Osteoarthritis Management in Bangladesh

Introduction

1.1 Background

Musculoskeletal conditions affect the muscles, bones and joints. They are common often long

term conditions which can result in an ongoing loss of quality of life. Collectively,

musculoskeletal conditions are the greatest cause of disability in the UK, accounting for close

to a third of all years lived with disability.

Osteoarthritis (OA) is the most common musculoskeletal condition in older people. Around a

third of people aged 45 years and over in the UK, has sought treatment for OA. It affects the

joints, causing them to become painful and limiting their movement. The condition occurs in

different sites, but often affects the knee, hip or finger joints. The overall impact of OA on a

person with the condition varies depending on the joints involved, the level of pain, and extent

of loss of function. When the hands are affected, OA can prevent people being able to

undertake daily activities. OA in the hips or knees can restrict mobility, limit walking, climbing

stairs, bathing and personal care, etc. In severe cases, it is a substantial barrier to people’s

mobility and independence, and significantly compromises their wellbeing and quality of life.

OA has a significant impact on our society because it is the most prevalent musculoskeletal

disorder. In Bangladesh, knee Osteoarthritis is one of the familiar disabling diseases affecting

both elderly male and female (Rashid et al., 1997). Knee, the most complicated joint in the

human body, is most frequently affected and the number of patients with disabling OA of the

knee is rapidly increasing day by day. Most of the available literature shows that there is no

effective treatment for OA, and individuals with this disease have little benefit from prescribed

medications (Holman and Lorig, 2004). OA of the knee is the most often occurring disease of

all other joint diseases (Felson, 2005). One statistics give a general indication to the prevalence

of OA; about 10,392,681 people are affected by OA in 2004 (Statistics by Country

Osteoarthritis, 2005).

1.2 Osteoarthritis

Osteoarthritis is the result of mechanical and biological phenomena that upset the equilibrium

between the synthesis and degradation of cartilage and that affect all of the articular (synovial,

Osteoarthritis Management in Bangladesh Page 1

synovial fluid, subchondral bone, capsule, ligaments) and periarticular (tendons and muscles)

structures.

Fig 1.2.1 : A normal Joint

Fig 1.2.2: A joint with mild Osteoarthritis

Fig 1.2.3: A joint with severe Osteoarthritis

The prevalence of osteoarthritis increases with age and life expectancy. Its frequency is

strongly correlated with age. It is rare to find anyone over 65 years of age who does not have

one or several arthritic lesions. Figures of around 70% have been proposed. We should just


remember that one in every two cases of OA is visible on radiography, that one radiographic

case of OA in two is symptomatic. OA is not a fatality linked to age; certain joints and certain

subjects show more resistance than others. The preferential sites are the spine, knee, hands, and

hip. Some forms of OA affect multiple sites (generalized Osteoarthritis). The cartilage is one of

the target tissues of OA.

It is essential to have a good understanding of cartilage to understand the degenerative process

of OA and the mode of action of the main treatments. It is a highly differentiated connective

tissue, with no vessels or nerves. Its structure is perfectly adapted to two functions: absorption

and distribution of forces and sliding of the joint surfaces with a very low coefficient of

friction. Cartilage has only one cell type and its richly hydrated (70-80%) and unsaturated

(50%) extracellular matrix is composed of Collagen fibers (resistant to traction) and aggregates

of proteoglycans fixed to a long filament of Hyaluronic acid (resistant to compression). The

ensemble forms a viscoelastic structure controlled via the mobilization of water molecules that

move under the effect of mechanical forces towards the joint space and vice versa. The

properties of cartilage, as with its cellular and physicochemical composition, alter with age.

The chondrocytes no longer seem able to maintain the equilibrium between the synthesis and

degradation of the cartilage. OA therefore becomes a risk.

1.3 Classification of Osteoarthritis

Chitnavis and Carr (2002) classified OA based on etiology which is familiar to clinicians and

subdivided OA into’ Primary’ for which the cause of disease production is unknown and

‘Secondary’ which is related to some factors such as injury and deformity.

1.3.1 Primary osteoarthritis

This is less common type of Osteoarthritis. It is also called nodal generalized OA. It occurs

without any cause and predominantly affects women.

1.3.2 Secondary osteoarthritis

Thomson, Skinner and Piercy (1991) stated that secondary osteoarthritis arises as

consequences of various conditions like:

Trauma after severe injury resulting in fractures of the joint surfaces

Dislocation

Infection.


1.4 Causes of Osteoarthritis

Many factors can increase risk of OA. It’s often a mixture of these that leads to the condition:

1.4.1 Age

OA usually starts from the late 40s onwards. It is not fully understood why it’s more

common in older people, but it might be due to muscles weakening and the body being less

able to heal itself, or joint slowly wearing out over time.

1.4.2 Gender

For most joints, especially the knees and hands, OA is more common and more severe in

women.

1.4.3 Obesity

Being overweight is an important factor in causing OA, especially in knee. It also increases

the chances of OA slowly becoming worse.

1.4.4 Joint injury

A major injury or operation on a joint may lead to OA in that joint later in life. Normal

activity and exercise don’t cause OA, but doing very hard activities over and over or

physically demanding jobs can increase the risk.

1.4.5 Joint abnormalities

Congenital abnormalities (or if developed in childhood) can lead to earlier and more severe

OA than usual (eg. OA of the hips).

1.4.6 Genetic factors

Nodal osteoarthritis, which particularly affects the hands of middle-aged women, runs

strongly in families, although it’s not yet clear which genes are involved. And some rare

forms of OA which start at an earlier age are linked with genes that affect collagen. Genetic

factors play a smaller, but still important, part in OA of the hip and knee.

1.4.7 Other types of joint disease

Sometimes OA is a result of damage from a different kind of joint disease, such as

Rheumatoid arthritis or Gout.


Table 1.4.1: Risk factors for Osteoarthritis development

1.5 Sites where Osteoarthritis Develop

OA can affect any joint, especially if it has been badly injured. The most commonly affected

joints are:

Knee

Hip

Spine

Big toes

Hand.


Fig 1.5.1: Site of Osteoarthritis can develop

1.6 Symptoms of Osteoarthritis

The main symptoms of OA are:

1.6.1 Pain

The pain tends to be worse when one moves joint or at the end of the day. If one has severe

osteoarthritis, he / she may feel pain more often.

1.6.2 Stiffness

Joints may feel stiff after rest, but this usually go away after get moving.

1.6.3 A grating or grinding sensation (crepitus)

Joint may creak or crunch as one move.

1.6.4 Swelling

The swelling may be hard (caused by osteophytes) or soft (caused by synovial thickening

and extra fluid), and the muscles around joint may look thin or wasted.


1.6.5 Not being able to use your joint normally

Joint may not move as freely or as far as normal. Sometimes it may give way because your

muscles have weakened or your joint has become less stable. Exercises to strengthen your

muscles can help to prevent this.

1.6.6 Symptoms will often vary for no clear reason

Some people find that changes in the weather make the pain worse, especially damp

weather along with falling atmospheric pressure. Others find the pain varies depending on

how active they’ve been. In more severe cases, the pain might not go away. It might cause

difficulties in ones daily activities.

1.7 Diagnosis

Definitive diagnosis is mainly accomplished through careful analysis of the history of the

patient and observation of joint alterations by X-ray and physical examination (Hilt and

Cogburn, 1994). Osteoarthritis of the knee can be diagnosed mainly in two ways:

1.7.1 Radiological diagnosis

Plain radiographs (X-rays): Can help in the diagnosis and may be the only special test

required in the majority of cases. X-ray may shows:

Narrowing joint space

Sub-articular sclerosis

Bone cysts

Bone density is either normal or increased (Osteoarthritis, 2006).

Arthroscopy: Arthroscopy may show cartilage damage long before X-ray changes appear

(Solomon, Warwick and Nayagam, 2001).

MRI: It can demonstrate early cartilage change (Kumar and Clark, 2002).


Fig 1.7.1.1: X-ray on knee Osteoarthritis

Fig1.7.1.2 X-ray on knee Osteoarthritis

1.7.2 Pathological diagnosis

Blood test: White blood cell count is usually less than 500/mm2 and is composed

predominantly of mononuclear cells. In inflammatory aspirates the WBC count is usually

greater than 2,000/mm2 and the predominant cell type is usually the Neutrophil (Hinton et

al., 2002). The ESR and Rheumatoid factor and antinuclear antibodies are negative (Kumar

and Clark, 2002).

Physiotherapy diagnosis: Clarke’s sign (to assess presence of patelo-femoral dysfunction)

and Apprehension test (to assess patellar subluxation & dislocation) (Magee, 1997).

1.7.3 Prognosis

There have been few longitudinal epidemiological studies documenting the natural course

of OA and participants of clinical trials are rarely followed for more than six months. The

studies that have been performed, and anecdotal reports, suggest that OA has a very


variable course. Most patients experience a slow, progressive deterioration, characterized

by episodic exacerbations of pain that insidiously increase in frequency, intensity and

length, resulting in muscle weakness and fatigue, joint stiffness and reduced function. The

risk factors for progression have not been identified (Hurley et al., 2002)


Management

2.1 Non-therapeutic Management

There is no cure for osteoarthritis as yet, but there is a lot that you can do to improve your

symptoms and reduce the chances of your arthritis becoming worse.

2.1.1 Exercise

It is very important to keep joints moving. You will need to find the right balance between

rest and exercise – too much activity may increase your pain but too little can make your

joints stiffen up. Little and often is usually the best approach. There are two main types of

exercise that you will need to do:

2.1.1.1 Strengthening

It will improve the strength and tone of the muscles that control your joint. This will

help to protect your joint and make it more stable. It’s also been shown to reduce pain.

Thigh (quadriceps) exercises will help to stop your knee giving way if you have

osteoarthritis of the knee, reducing the chances of stumbling or falling Because knee

and hip osteoarthritis may come to affect both sides of your body, and because both legs

work as a unit when you walk, it`s helpful to:

Do strengthening exercises on both legs

Do hip exercises if you have knee osteoarthritis (and vice versa).

2.1.1.2 Aerobic

The benefits of regular aerobic exercise can include:

Better sleep

Better general health and well-being

Exercise raises the levels of pain-relieving hormones called Endorphins.

A physiotherapist can advise on the best exercises for you, but you`ll need to do them every

day to get the most from them.


Fig 2.1.1.2.1: Different types of exercise

2.1.2 Swimming

Physiotherapist may recommend hydrotherapy, which is special exercise done in a warm

water pool.

2.1.3 Weight management

Overweight increases the strain on your joints especially your knees. Being overweight not

only increases your risk of developing osteoarthritis but also makes it more likely that your

arthritis will get worse over time. Because of the way your joints work, the force put

through your knees when you walk, especially on stairs and slopes, can be several times

your actual body weight. Losing even a small amount of weight can make a big difference

to the strain on your weight-bearing joints. A balanced, reduced-calorie diet combined with

regular exercise may be recommended.

2.1.4 Reducing the strain on your joints

Apart from keeping an eye on your weight, there are a number of other ways you can

reduce the strain on your joints:

2.1.4.1 Pace your activities through the day

Don`t tackle all the physical jobs at once. Break the harder jobs up and do something

gentler in between. A chart can help you to plan your daily activities and monitor when

they cause extreme tiredness (fatigue) or affect your symptoms.


2.1.4.2 Wear low-heeled shoes with soft, thick soles

Thicker soles will act as shock absorbers for your feet, knees, hips and back. High heels

will alter the angle of your hips, knees and big toe joints and put extra strain on them.

2.1.4.3 Use a walking stick

Therapist or Doctor can advise on the correct length and how to put your weight

through the stick instead of your affected joint; walking stick helps to reduce the weight

and stress on a painful hip or knee.

2.1.4.4 Use the handrail for support when climbing stairs

This is particularly important if you have osteoarthritis of the knee.

2.1.4.5 Keep your joints moving

In particular, don`t keep an OA knee bent for too long as this will come to affect your

muscles. Think about modifying your home, car or workplace to reduce unnecessary

strain on your joints. An occupational therapist can advise you on how to protect your

joints and on special equipment or gadgets that will make your daily tasks easier.

2.1.4.6 Learn to relax your muscles and get the tension out of your body

A physiotherapist or occupational therapist can advise you on relaxation techniques.

2.1.4.7 Apply warmth to a painful joint

Heat lamps are popular, but a hot-water bottle or reheatable pad are just as good. This

can be helpful if you have a flare-up of pain when you`ve done a bit too much. More

evidence to support the use of knee braces for osteoarthritis is becoming available.

Several types of brace can help to stabilise your kneecap and make it move correctly.


2.2 Therapeutic Management

At present, there is no cure for OA. The primary strategy for pharmacological management is

to control pain and improve function and quality of life. When OA pharmaceuticals are

prescribed, the trade-offs between the risks and the benefits must be assessed because side

effects are common and the long-term efficacy of these drugs is often variable.

2.2.1 Capsaicin cream

It is a topical preparation derived from chillies and is available in various concentrations.

Capsaicin cream causes a reduction in sensation through its effect in depleting a chemical

(substance P. neuropeptide) associated with sensory nerve transmissions. There was only

one low quality study on topical capsaicin, hence the recommendation that there is weak

evidence to support its use in the treatment of OA of the knee or hip.

Evidence statement

A low quality placebo controlled RCT with 200 participants with OA of the hip (n=33),

knee (n=66), shoulder and hand reported statistically significant reduction in VAS

measured pain for 0.025% capsaicin cream used in combination with 1.33% GTN cream

when applied four times daily over the affected joint for 6 weeks; however, no effect size

was reported. There was no difference in improvement in pain reported for use of capsaicin

or GTN when used alone compared to placebo.

Participants using capsaicin and/or GTN creams were reported to be more likely to prefer

therapycontinuation than those using placebo; however, non-completers were not included

in the analysis. This study included small numbers of participants with OA of the hip

(n=33) and knee (n=66) in each group, and was probably underpowered to analyse

differences between the four groups.The participants using capsaicin had higher baseline

discomfort scores associated with application (averaged over the first 5 days) than other

groups; however, this settled with continued use. No other potential adverse events were

reported.

2.2.2 Paracetamol (Acetaminophen)

Paracetamol is the oral analgesic of choice for management of OA. It reduces pain but has

minimal effect on inflammation; it is used more often in mild to moderate OA. Paracetamol


is generally well tolerated with few side effects when used at the recommended dose of up

to 4 g/day for up to 12 months. Effectiveness of paracetamol is related to adequate dosage

and patients should be encouraged to take medication regularly according to the directions

to reduce pain episodes. An excellent volume of evidence of excellent consistency provided

support for the recommendation that GPs prescribe paracetamol as a first line

pharmacological treatment for patients with OA.

Evidence statement

A good quality SR including 15 RCTs with 5986 participants with hip or knee OA provided

evidence for the effectiveness of Paracetamol for between 7 days and 12 months, when

provided in regular divided doses to a maximum dose of 4 g/day, in treating pain (SMD –

0.13, 95% CI: –0.22 to –0.04) in people with hip and knee OA compared to placebo. The

NNT was 4–16. Paracetamol was found to be as safe as placebo. In 10 comparator

controlled RCTs, Paracetamol was less effective than NSAIDs (WOMAC total SMD –0.46,

95% CI: –0.73 to –0.19), but there was a higher risk of gastrointestinal adverse events (RR

1.47, 95% CI: 1.08–2.0) among patients using traditional NSAIDs.

A moderate quality RCT including 581 participants with mild to moderate hip or knee OA

provided evidence of benefit of Paracetamol (4 g/day) & Naproxen (750mg/day) compared

to placebo in reducing WOMAC pain for 6–12 months, but no difference in effectiveness

between the two active agents.102 A low quality RCT with a small number of participants

(n=20) with knee OA reported similar effectiveness of Paracetamol (mean improvement

40.7 mm) and Rofecoxib (42.5 mm) compared to placebo for VAS pain and for WOMAC

function for 3 months.

2.2.3 Oral NSAIDs

NSAIDs are recommended for treatment of acute pain due to their anti-inflammatory and

antinociceptive effects. When inflammation of a joint is present, and Paracetamol is not

sufficient for pain relief, COX-2 inhibitor may be added. Due to the range of adverse events

related to these medications, particularly in elderly patients, the lowest dose should be

prescribed for the shortest duration. Using Paracetamol in conjunction with a NSAID may

achieve effective pain management with a lower NSAID dose, as may the use of an

intermittent dose taken before aggravating activities, rather than a continuous dose. An


excellent volume of evidence of good consistency provided support for recommendation

that GPs prescribe NSAIDs for the pharmacological treatment of patients with OA.

Evidence statement

NSAIDs efficacy

There is evidence from a good quality SR of 23 trials with 10,845 participants with OA

knee pain to support a small benefit (10.1 mm VAS scale) for oral NSAIDs, including

Cyclo-oxygenase agents, in reducing the intensity of pain at 2–13 weeks follow up. On

average, people with knee OA who were on NSAIDs were 15.6% better off than

placebo. This benefit may not be of clinical importance as the minimally important

clinical difference for knee OA has been estimated to be a change from baseline of at

least 17–22%. In addition, benefit was not seen at longer time periods (1–4 years).

Harms were not reported. One good quality RCT including 13,274 participants with OA

of the hip, knee or hand reported evidence to support equivalent efficacy of Celecoxib

200 or 400 mg per day in divided doses, compared to Diclofenac 50 mg twice daily, or

Naproxen 500 mg twice daily over duration of 12 weeks. There were fewer ulcer

complications in the Celecoxib group (0.8/100 patient years traditional NSAID, 0.1/100

patient years Celecoxib, OR 7.02, 95% CI: 1.46–33.8), and no difference in the number

of cardiovascular Thromboembolic events. However, the number of such events was

low and the study was not powered to detect such differences. Patients requiring daily

use of anti-ulcer medications were excluded from the trial.

A low quality placebo controlled RCT including 511 participants with hip or knee OA

reported differential benefit of treating knee or hip OA with improvement in WOMAC

pain (ES knee 0.8, ES hip 0.5), stiffness (ES knee 0.8, hip 0.55) and physical function

(ES knee 0.78, hip 0.51) compared to placebo when measured at 6 weeks. Adverse

events were not reported.

NSAIDs safety

There is evidence that use of oral NSAIDS is associated with a number of side

effects109 including GIT adverse effects (risk of Perforation or bleeding 1/50–100

patient years110), increase in blood pressure, aggravation of cardiac failure, renal

failure and drug interactions, and that this risk is increased by older age, concomitant


medication use and duration of use. However, there are no head-to-head trials or cost

effectiveness analyses of COX-2 medications versus traditional NSAIDs used in

conjunction with effective anti-ulcer preparations such as Misoprostol, H2 receptor

antagonists, PPIs or Antacids.

A low quality SR reported the risk of Atherothrombosis associated with traditional and

COX-2 NSAIDs. There is evidence to support a moderately increased risk (1.86, 95%

CI: 1.33–2.59) of myocardial infarction with COX–2 NSAIDs (0.6%/year) compared to

placebo (0.3%/year). There is evidence to support equal risk (1.16, 95% CI: 0.97–1.38)

among COX-2 (1.0%/year) and traditional NSAIDs (0.9%/year) for serious vascular

events with some heterogeneity between Naproxen (0.92), Ibuprofen (1.51) and

Diclofenac (1.63).

A moderate quality RCT involving 34,701 participants (pooled data from three studies)

aged over 50 years reported on cardiac thrombotic events in participants taking

NSAIDs, the majority of whom (24,913) had OA of the hip, knee, hand or spine. When

treated for an average period of 18 months, there was similar cardiac thrombotic event

rates for Etoricoxib (1.24/100 patient years) prescribed at doses of 60–90 mg/day and

Diclofenac (1.3/100 patient years) prescribed in a divided daily dose of 150 mg/day,

resulting in a hazard ratio of 0.95 (95% CI: 0.81–1.11). The rates of upper GIT

perforation, bleeding, obstruction and ulcers were lower with Etoricoxib compared to

Diclofenac (0.67 vs. 0.97/100 patient years). There was no placebo group. Participants

were able to use prophylactic low dose aspirin and PPIs, or Misoprostol was

recommended for patients at high risk of upper GIT clinical events. Subgroup analyses

of these patients in relation to outcomes was not provided.112 Evidence from a

moderate quality RCT involving 287 participants with arthritis and a history of ulcer

bleeding after using NSAIDs, but at a stage when their ulcers had healed (negative for

H. pylori), showed that combination treatment of 75 mg Diclofenac twice daily plus 20

mg of Omeprazole daily (n=143) had a reduced risk of recurrent ulcer compared to

Celecoxib 200 mg twice daily plus a daily placebo (n=144) for 6 months. Probability of

recurrent bleeding during the 6 month period was 4.9% (95% CI: 3.1–6.7) for Celecoxib

compared to 6.4% (95% CI: 4.3–8.4) for Diclofenac plus Omeprazole (difference –

1.5%, 95% CI: –6.8–3.8). Renal adverse events, including hypertension, peripheral


oedema, and renal failure occurred in 24.3% of participants in the Celecoxib group and

30.8% of those receiving Diclofenac plus Omeprazole. A number of GIT events were

questionably excluded as adverse event cases. There was no placebo group and

participants with active ulcers were excluded, which may have contributed to the

favourable results. Evidence from a moderate quality RCT involving 273 arthritis

participants who had a history of previous, now healed gastric ulcer as a result of taking

non-selective NSAIDs (negative for H. pylori) showed that combination treatment with

400 mg/day Celecoxib and 20 mg Esomeprazole twice daily (n=137) was more

effective than 400 mg/day Celecoxib and placebo (n=136) for 12 months for prevention

of recurrent ulcer bleeding. 13 month cumulative incidence of recurrent ulcer bleeding

was 0% in the combined treatment group and 12 (8.9%) in the controls (95% CI:

difference: 4.1–13.7; p=0.0004). Discontinuation of treatment and the incidence of

adverse events were similar in the two treatment groups.

A low quality SR including 114 double blind RCTs involving 116 094 participants with

different comorbidity status (OA being most common) provided evidence on the safety

of oral NSAIDs. Analysis of 127 trials (40 Rofecoxib, 37 Celecoxib, 29 Valedecoxib/

Parecoxib, 15 Etericoxib and 6 Lumiracoxib) found that Celecoxib was associated with

lower risk of both renal dysfunction (RR 0.61, 95% CI: 0.40–0.94) and hypertension

(RR 0.83, 95% CI: 0.71–0.97) compared to rofecoxib. No significant increased risk was

established for Valedecoxib/Parecoxib, Etericoxib or Lumiracoxib.

Note: Rofecoxib and Lumiracoxib have been withdrawn from use.

2.2.4 Topical NSAIDs

Topical NSAIDs have an analgesic and anti-inflammatory effect related to suppression of

local prostaglandin synthesis. Topical NSAIDs are applied to the skin over the affected

joint and absorbed into the tissue, producing an increased concentration of the drug at the

local site while minimizing systemic drug levels. The benefit is a reduced risk of side

effects and medication interactions compared to oral NSAIDs. A satisfactory volume of

evidence of satisfactory consistency provided support for the recommendation that GPs

recommend short term use of topical NSAIDs for patients with knee OA.


Evidence statement

There is evidence from one low quality SR, including four RCTs (no quality assessment

provided) with 811 participants with knee OA, treated for 4–12 weeks, of a very small

benefit (ES –0.28, 95% CI: –0.42 to 0.14) for topical NSAIDs (Diclofenac and Eltenac) in

reducing pain associated with knee OA compared to placebo or vehicle. Adverse effects

reported included self limited local skin reactions (dryness, rash, pruritus). There is

evidence from a good quality RCT with 238 participants with knee OA, that Diclofenac gel,

applied 4 times/day for up to 1 minute each time for 3 weeks compared to placebo, was no

different at 1 week but provided a small benefit with reduced pain on movement (reduced

VAS score 4 mm) and reduced total WOMAC score (6 mm) during the second week, and

that this response was sustained in week 3.

2.2.5 Weak and strong Opioids

Opioids have a modest effect in managing moderate to severe OA pain in patients for

whom Paracetamol is ineffective, and who do not respond to, or have contraindications for,

NSAIDs. However, most of the research on opioid use has been in short term trials and long

term efficacy has not been shown. Because of the high rate of adverse effects that impact

upon patients’ quality of lives, the modest benefit to be gained from opioid therapy should

be considered carefully.

The use of weak opioids (eg. codeine) should also be considered cautiously as these

preparations are less effective than strong opioids with the same adverse effects.

An excellent volume of evidence of excellent consistency provided support for the

recommendation that GPs consider weak or strong opioids for management of moderate to

severe OA pain in some patients.

Evidence statement

There is evidence from a moderate quality SR of weak (Codeine, Propoxyphene, Tramadol)

and strong (Oxycodone, Oxymorphone, Fentanyl, Morphine) opioids used for up to 13

weeks for benefit in reducing pain intensity and improving physical function when used in

treating hip and knee OA compared to placebo. There was a high proportion of patients

reporting adverse effects including nausea (30%), constipation (23%), dizziness (20%),


somnolence (18%) and vomiting (13%), resulting in discontinuation of therapy in 25%

patients taking strong opioids and 19% taking weak opioids compared to placebo (7%).

There is evidence of small benefit of Tramadol for 7 days to 3 months duration, when

provided in divided doses of up to 400 mg/day, in treating persistent moderate to severe OA

hip and knee pain. The NNT for benefit was six. The use of Tramadol in mild to moderate

pain is limited by drug interactions and CNS adverse effects. Tramadol was associated with

a greater risk of adverse events compared to placebo (NNH for minor adverse events was

five; major adverse events eight). Tramadol had greater risk of adverse events than

Diclofenac or Dextropropoxyphene but a lower risk compared to Pentazocine. There is

potential multiple drug interactions. In particular, the combination of Tramadol with other

serotonergic drugs must be avoided due to the risk of serotonin syndrome (refer to NPS

Analgesic choices in persistent pain). The most commonly reported adverse events were

nausea, vomiting, dizziness, constipation, somnolence, tiredness and headache.

There is evidence of small benefit of Oxymorphone (an opioid analgesic medication) when

used for at least 2 weeks, and provided in doses of 20–50 mg twice daily, in treating

persistent pain of at least moderate intensity in patients with hip and knee OA, who have

had suboptimal response to simple analgesia. There was a high withdrawal rate due to

adverse events.

There is evidence of moderate benefit for the knee and small benefit for the hip, of

transdermal fentanyl (an opioid analgesic medication) used for 5 weeks duration when

provided in doses of 1–4 patches (25 µg) every 72 hours, in treating persistent pain of at

least moderate intensity in patients with hip and knee OA awaiting joint replacement

surgery who have had suboptimal response to simple analgesia. Use of transdermal fentanyl

was associated with a higher rate of adverse events and withdrawal symptoms compared to

placebo.

2.2.6 Intra-articular corticosteroid injection

Indicated for short term symptom management when the patient has an acutely painful,

swollen joint. Generally synovial fluid is aspirated from joint to reduce swelling prior to the

administration of the corticosteroid directly into the joint cavity. The procedure allows for a

greater concentration of medication at the site of action, with a lower risk of systemic side


effects. Due to possible cartilage damage from repeated IA injections, the number of

corticosteroid injections is generally limited to 3 times per year for large weight bearing

joints and 4 times per year for smaller joints. Intra-articular injections to the same joint are

usually administered at no shorter than 3 monthly intervals. An excellent volume of

evidence of good consistency provided support for recommendation that GPs recommend

IA corticosteroids for short term symptom management in patients with knee OA.

Evidence statement

One good quality systematic review of 28 RCTs with 1973 participants with knee OA

provided evidence for short term (1–34 weeks) benefit for pain reduction and patient global

assessment, but not physical function of IA corticosteroid preparations. The NNT to

improve pain and patient global assessment was 3–4. Nine trials compared corticosteroid

injection with hyaluronan and hylan derivatives. HA products demonstrated a similar but

slower onset but were more durable with clinical benefit being detected at 5–13 weeks post-

injection. There is limited data comparing different corticosteroid preparations. The authors

were unable to recommend one preparation over another. There were no major adverse

effects reported. Compared to placebo there was no greater number of participants reporting

post-injection flare.26 One moderate quality RCT of 101 participants with hip OA provided

evidence for short term (28 days) benefit on pain on walking (ES 0.6) for a single IA

injection of 1 mL methylprednisolone and two placebo injections, compared to three

placebo injections and three injections of 2 mL HA. There were no serious adverse events.

2.2.7 Viscosupplementation (hyaluronan and hylan derivatives) for knee OA

Viscosupplementation is the procedure of administering synthetic hyaluronic acid or hylan

(HA) products into the joint via IA injection. Hyaluronic acid is a naturally occurring

substance in the body that contributes to the elasticity and lubrication of synovial and

cartilage within the joints. In patients with OA, the concentration and molecular weight of

naturally produced HA is reduced, providing a rationale for supplementing natural HA by

viscosupplementation. The aim of viscosupplementation is to relieve pain and improve

mobility by restoring the protective functions performed by HA. Various HA products are

available, and research suggests there may be differences in efficacy between particular

products. HA products are produced with either low or high molecular weights, which

influences the number of injections and amount of medication administered in the


viscosupplementation course. An excellent volume of evidence of good consistency

provided support for the recommendation that viscosupplementation provides some benefit

for patients with OA of the knee.

Evidence statement

There is evidence from one good quality SR of 76 RCTs of moderate quality that found

varying levels of benefit for pain, function and global assessment for 5–13 weeks for

viscosupplementation compared to placebo in treating knee OA. The SR reported

viscosupplementation was equivalent to ongoing use of NSAIDs and superior to placebo.

The results need to be interpreted with caution, as there was heterogeneity manifested by

differences in the magnitude of clinical impact as measured by WMD of clinical effect

across product class as well as studies. No major safety issues were detected. There is

inadequate evidence about differences in benefit between products. There is some evidence

for similar, but more sustained benefit of HA products compared to corticosteroid injection.

A moderate quality RCT with 106 participants with knee OA reported reduced pain at 3

weeks with a 6 week course of weekly IA injections of HA compared to placebo, but this

was not sustained at 6 weeks or 12 weeks.

A low quality RCT with 60 participants with knee OA reported benefits in reducing pain

and improving function for both IA injection of hylan (three injections given once weekly

over 3 weeks) and TENS (applied five times per week for 20 minutes at 150 Hz) but no

difference between the two groups. The improvements were noted up to 6 months after

treatment; however effect sizes were not stated. Adverse events were not reported.

A low quality RCT with 157 participants with knee OA reported no difference in benefit

between mean VAS improvement of high molecular weight HA given over 3 weeks (26

mm) and low molecular weight HA given over 5 weeks (27 mm). Adverse events (most

common pain at the injection site) were reported in approximately one-third of participants

in both groups.

2.2.8 Glucosamine hydrochloride and glucosamine sulphate

Glucosamine is found naturally in articular cartilage and has a role in cartilage formation

and repair. Glucosamine has been used in the management of OA as an analgesic and for


restorative properties; although no good quality research supports the role of glucosamine

in cartilage repair. Research on effectiveness of glucosamine has produced varied results

that may be related to length of therapy and/ or severity of OA. Glucosamine is available

over-the-counter in Australia as glucosamine sulphate or glucosamine hydrochloride dietary

supplements. The usual dosing is 1500 mg/day in three divided doses. Research suggests

improvement in symptoms requires at least 4 weeks of therapy, and this is generally well

tolerated with no significant adverse events reported. Gastrointestinal upsets, sleepiness,

headaches and skin reactions have been reported in some people.134, A good volume of

evidence was available on glucosamine use in OA, however there were significant

inconsistencies in the findings.

Evidence statement

There is conflicting evidence of benefit for glucosamine sulphate and glucosamine

hydrochloride in the treatment of the symptoms of OA of the knee. There is insufficient

evidence to support benefit for preventing progression of knee OA cartilage loss. In all

reported studies, glucosamine was safe compared to placebo.

A moderate quality SR included 20 studies. Subgroup analysis of the best designed studies

(eight with adequate allocation concealment) found no benefit of glucosamine sulphate or

glucosamine hydrochloride over placebo when used in variable doses between 400–1500

mg/day for up to 6 months for treatment of OA knee. The review reported that subgroup

analysis of one product, the Rotta preparation (10 studies), demonstrated small

improvements in pain and function using the Lequesne index but no benefit as assessed by

the WOMAC pain, stiffness or function subscales. However, the two Rotta studies with the

largest number of participants were negative and analysis of other products did not

demonstrate benefit. The pooled results demonstrated a small benefit (0.61 improvement

out of 10 for pain) for glucosamine which is unlikely to be of clinical importance, and the

results need to be interpreted with caution in view of inclusion of poor quality RCTs.

A recent good quality RCT involving 318 participants with knee OA provided some

evidence for a small benefit of glucosamine sulphate (1500 mg/day) for treatment of knee

OA compared to placebo or paracetamol (3 g/day) when measured using the composite

Lequesne or WOMAC composite scores, but no benefit for reducing pain as measured


using the WOMAC pain scale. The difference of 1.2 points in Lequesne scale between

glucosamine sulphate and placebo (the overall scale being 1–24) may be of doubtful

clinical significance. In addition, evidence for effectiveness of chondroitin sulphate in

treatment of OA knee is lacking (see below).

One moderate quality large RCT compared glucosamine hydrochloride (1500 mg/day),

alone or in combination with chondroitin sulphate (1200 mg/day) to placebo and celecoxib

(200 mg/day). Glucosamine alone, or in combination with chondroitin sulphate, was found

to have no benefit over placebo in reducing pain for patients with knee OA. The response to

combined therapy was higher in a subset of patients with moderate to severe OA, however

these results need to be interpreted with caution as this was a post-hoc subgroup analysis.

2.2.9 Diacerein

Diacerein and its active metabolite rhein are anthraquinones related to senna compounds.

They inhibit the synthesis of IL-1â in human OA synovium in vitro, as well as the

expression of IL-1 receptors on chondrocytes. No effects have been reported on TNF or its

receptors.


2.3 Surgical Management

When non-therapeutic and therapeutic management strategies are not effective at controlling

OA symptoms, surgical options should be considered.

2.3.1 Joint replacement

Joint replacement is a critical and permanent intervention for patients who have few other

options. Patients who experience severe daily pain and show extensive narrowing of joint

space are eligible for joint replacement surgery. While this is an expensive treatment

option, cost effective analyses have indicated that the costs from long term medication use

and lost productivity outweigh the price of surgery in patients with severe symptoms.

2.3.2 Osteotomy

It is the cutting and reshaping of bones with the purpose of altering the area of the joint

which bears weight. A Cochrane Review found that osteotomies reduced pain and

improved function, though there is no evidence whether an osteotomy is more effective

than conservative treatment. There is also evidence that osteotomies may eliminate or delay

the need for joint replacement surgery

2.3.3 Arthroscopic debridement and lavage

Arthroscopic debridement and lavage are two processes that involve removing damaged

cartilage, bone, and excess debris surrounding the joint. This is still a very controversial

process and a Cochrane Review found that the treatment did not improve pain or function

when compared to a sham surgery. However, for specific population of patients, the surgery

may be beneficial and more research is needed to identify these subgroups.


Management in Bangladesh

3.1 Non-therapeutic Management

Osteoarthritis is the most common form of chronic arthritis, with radiological evidence of OA

in more than 50% of people over 65 years of age. Approximately 10% of men and 18% of

women suffer symptomatic OA. The situation of Bangladesh is, the overall point prevalence of

musculoskeleletal pain is 26.3%. All kind of non-therapeutic management tools like different

types of exercise including Strengthening, Aerobic, and Swimming etc are main, weight

management are available in Bangladesh. Education and training facility regarding those

exercises are also available and people are practicing. Tai chi is a Chinese exercise that

involves slow, fluid movements designed to improve cardiac and respiratory fitness, flexibility,

balance, and muscle strength. Traditional tai chi may also improve psychological wellbeing and

relaxation. This exercise is not available currently in Bangladesh. We should introduce it to our

population. Also there is no awareness program across the country about Osteoarthritis. We

should take some action about Osteoarthritis awareness to people who are lives in rural area.

3.2 Therapeutic Management

Currently available pharmacologic interventions are directed at symptomatic relief. Research

continues into potential disease-modifying interventions in OA. This review will discuss

pharmacotherapy of OA with available evidences for symptom relieving therapy, disease or

structure modifying therapy, nutriceuticals and experimental therapies.

3.2.1 Capsaicin cream

Available in a 20g tube.

3.2.2 Non-steroidal Anti-inflammatory Drugs

Almost all kind of NSAIDs including Oral, Topical and Injection are available. Leading

Pharmaceutical companies are producing quality products.

3.2.3 Weak and strong opioids

There are many company producing Opioid drugs including Morphine, Tramadol. So OA

treatment with Opoid drugs in Bangladesh is possible.


3.2.4 Glucosamine hydrochloride and Chondroitin sulfate

Leading Pharmaceutical companies are producing this product.

3.2.5 Diacerein and Glucosamine hydrochloride

Combination of Diacerein and Glucosamine for the treatment of OA and joint pain is

available. Diacerein is a new anti inflammatory drug developed specially for the treatment

of Osteoarthritis. It directly inhibits IL-1 beta synthesis and release in vitro and down

modulates IL-1 induced activities and have been shown to possess disease modifying effect

in experimental models of osteoarthritis and in human subjects with finger joint and knee

osteoarthritis.

3.3 Surgical Management

Critical surgeries like joint replacement are now possible in Bangladesh. Ex-Director of the

National Institute of Traumatolgy and Orthopedic Rehabilitation (NITOR) Prof. Dr. Abdul

Awal Rizvi said they were doing hip and knee replacement surgeries regularly at the hospital at

a much cheaper cost. "You don't need to go outside, we can do it in Bangladesh," Rizvi told on

a press conference in the capital. Experts say, patients suffering from excruciating joint pain

due to arthritis need joint replacement to keep them mobile and active. Prof. Dr. Ram Dew

Ram Koiry, President of Bangladesh Orthopedic Society (BOS), said the number of patients

suffering from arthritis was increasing with the rising trend of aged population. He said urban

people suffer most than rural because their change in lifestyle leads to joint damage.

NITOR Director said it would cost only Tk 10,000 for a hip replacement surgery, excluding the

prosthetic implant price of which ranges between Tk 30,000 to Tk 80,000. He adding that even

in neighboring India it would cost at least Tk 200,000 excluding travel and accommodation.


Research with New Therapeutic Target

4.1 IL-1 receptor antagonist (IL-1Ra):

The potential methods of intervention in OA include growth factor and cytokine manipulation.

Cytokines, such as IL-1 and TNF-á, are produced by the synovium and contribute to

inflammation within osteoarthritic joints. Moreover, there may be deficient expression of

naturally occurring anti-inflammatory compounds such as IL-1Ra by the chondrocytes of

patients with OA. In some cases, increased nitric oxide production by OA articular

chondrocytes may inhibit IL-1Ra synthesis. In a dog model of OA, IL-1Ra therapy reduced the

expression of collagenase-1 in cartilage. The severity of cartilage lesions is also diminished. In

a rabbit model of OA, transfer of the IL-1Ra gene to joints prevented OA progression.

4.2 The MAP kinase inhibitor

The mitogen-activated protein (MAP) kinases are intracellular signaling proteins which play a

central role in controlling the activity of pathways that regulate production and activity of

multiple mediators of joint tissue destruction. The MAP kinase inhibition has the potential to

slow disease progression in osteoarthritis and also might reduce pain; however, safety concerns

have limited the use of general MAP kinase inhibitors in humans.

4.3 NF-kappaB inhibitors

NF-kappaB transcription factors can be triggered by a host of stress-related stimuli including

pro-inflammatory cytokines, excessive mechanical stress and ECM degradation products. Thus

the NF-kappa B activating kinases are potential therapeutic OA targets. However, work

remains in its infancy to evaluate the effects of efficacious, targeted NF-kappa B inhibitors in

animal models of OA disease.

4.4 Gene therapy

The control of genes such as TIMP and MMPs would, in theory, provide the opportunity to

modulate the patient’s disease. As previously noted, gene expression of IL-1Ra has already

been tried in rabbits and dogs, as well as in an equine model of OA using an adenovirus vector.


4.5 Chondrocyte and stem cell transplants

Chondrocyte and stem cell transplants into articular cartilage defects have been tried as well.

Chondrocytes transplanted into human cartilage explants survived up to 45 days in vitro in one

trial. Transfection of chondrocytes with the galactosidase gene has been successful both before

and after transplantation.


Discussion

Osteoarthritis is accepted as a major public health problem. As estimated by the World Health

Organization, it is one of the major causes of impaired function that reduces quality of life

worldwide. The magnitude of this problem is likely to rise due to the increasing life expectancy

and the increasing rates of obesity among the population. The goal of OA treatment is to

control symptoms, prevent disease progression, minimize disability, and improve quality of

life. Traditional treatment paradigms for OA have conceded the inexorable progression of the

disease and concentrated on pain management. Still non-pharmacologic therapy is the corner

stone for OA management. Pharmacologic therapies are mainly aimed at symptomatic relief.

The future holds promise for drugs that may genuinely modify structure, but these will require

careful evaluation so that they may be appropriately positioned in the management of OA.

Many people struggle with OA, thinking that nothing can be done to help. This isn’t the case.

By taking a strategic approach to identifying people with, or at risk of, osteoarthritis and

supporting them to manage the condition, much can be done to help people with osteoarthritis

improve their quality of life. OA is a top cause of disability in older people. The goal of

treatment in OA is to reduce pain and improve function. There is no cure for the disease, but

some treatments attempt to slow disease progression, you can manage how it affects your

lifestyle. Some tips include: Properly position and support your neck and back while sitting or

sleeping, Adjust furniture, such as raising a chair or toilet seat, Avoid repeated motions of the

joint, especially frequent bending, Lose weight if you are overweight or obese, which can

reduce pain and slow progression of OA, Exercise each day, Use arthritis support devices that

will help you do daily activities. The goal of OA treatment is to control symptoms, prevent

disease progression, minimize disability, and improve quality of life. The management can be

divided into non pharmacologic interventions, pharmacologic interventions, and surgical

options. Pharmacologic interventions can be further subdivided into symptomatic therapy and

potential structure or disease-modifying therapy.

There are, at present, no specific pharmacologic therapies that can prevent the progression of

joint damage due to OA. Acetaminophen is the first line of therapy, although most of the

patient requires NSAIDs. Risk of gastrointestinal bleeding and cardiovascular risk need to be

considered, especially for elderly. With inflammatory components, intra-articular


glucocorticoid injection gives short term benefit. Compared with corticosteroid injections,

hyaluronan injections have similar clinical effects. But it is more costly. So far research with

potential structure and disease-modifying drugs in osteoarthritis includes tetracyclines,

glycosaminoglycan polysulfuric acid, pentosan polysulfate, diacerein, glucosamine and others.

Scientists are looking for new therapeutic targets like IL-1 receptor antagonist (IL-1Ra),

mitogen-activated protein kinases inhibitors, NF-kappaB inhibitors. Gene therapy, Chondrocyte

and stem cell transplants showed some promise in animal models.

The current control strategy mainly consists of palliative pain treatment, as there are several

medicines on the market that alleviate pain and improve function in OA patients. In severe

cases, joint replacement surgery has been proven effective in relieving the painful and

debilitating effects of the disease, though the high cost and use of advanced resources mean

these procedures are not available in many countries around the world. There are currently no

therapies available that can reverse or halt the progression of osteoarthritis; larger studies are

needed to evaluate the clinical and cost effectiveness of the few therapies that have shown

promise in animal trials.

Because there is such a wide variety of risk factor for this disease, it is unlikely that OA can be

prevented entirely. Protective factors such as exercise, healthy diet, and occupational injuries

can all be addressed, but many risk factors such as gender, age, and genetics are not modifiable.

The physical disability arising from pain and loss of functional capacity reduces quality of life

and increases the risk of further morbidity. Though there is a wide range of devices and

palliative medicines available that relieve pain and improve quality of life for patients, there is

no pharmaceutical product that halts or reverses the onset of OA.

Thus, as the population ages, the disease burden of osteoarthritis will naturally increase

accordingly unless primary prevention efforts such as healthy diet and exercise are scaled up

around the world diagnostics and secondary prevention methods are developed that detect the

onset of OA very early, perhaps through testing genetic or biochemical markers, and therapies

are developed that stop or even reverse the progression of OA when it is identified. Otherwise,

people around the world will continue to develop the currently-incurable disease, OA.


Conclusion

Osteoarthritis is a chronic progressive disease that is one of the leading causes of disability

among elderly populations throughout the world. It causes pain, disability and impaired

movement, which places a large burden (both in terms of health and economics) on individuals,

communities, and health systems. While there are several therapies available for symptomatic

treatment that mitigate pain, there are no medicines that can reverse or halt the progression of

the disease. This pharmaceutical gap must be addressed in order to reduce the burden of OA.

The study confirm that Bangladesh have most of the facilities for the treatment of OA. The

awareness program should be introduced as soon as possible. Government should take action

for people`s consciousness about OA specially in rural areas of Bangladesh. The Joint

Replacement therapy is only available in the capital; beside this the service is available in few

of the hospitals. We should increase the number of hospitals for provide the service.


Literature Review

Treatment of osteoarthritis is updated from conservative to surgery. Proper treatment is vital

need to cure the patients presenting with OA. Appropriate management is the mainstay for the

complete recovery of the OA. The associated pathologies should be cured accordingly. “Updated Management of Osteoarthritis: A Review by MJ Islam, MA Yusuf, MS Hossain, M

Ahmed”, Journal of Science Foundation, July 2013, Vol. 11, No. 2 , ISSN 1728-7855.

As the global population continues to age, the burden of osteoarthritis will increase

dramatically. Some progress has been made in biomarkers for osteoarthritis diagnosis, but

much more research still needs to be done before they can be used in a clinical setting. Meta-

analyses of clinical trials show that avocado-soybean unsaponifiables significantly reduce pain

associated with osteoarthritis and may be an effective complementary treatment that could be

used in conjunction with traditional pharmaceuticals. While they are expensive operations, total

hip and knee replacement surgeries have been shown to be cost effective in the long term. More

research should be conducted on how to introduce low cost joint replacement surgeries into

hospitals in low and middle income countries. ”Priority Medicines for Europe and the World "A

Public Health Approach to Innovation"Update on 2004 Background Paper Written by Saloni

Tanna, Pharm.D. MPH, By Rachel Wittenauer, Lily Smith, and Kamal Aden January 28th

2013’’.

In this study there were 35 cases and 35 number of control that means case: control was 1:1 and

hospital based unmatched setting. Intended of this study to determine the risk factors of

developing osteoarthritis with considering the variables like socio- demographic and socio-

economic variables, using high heeled shoe, past history of painful knee swelling, bare foot

walking, BMI, occupation, heavy activity more than four hour, stair climbing, sitting on the

floor for home activity, prolong standing, positive family history of knee or other joint diseases,

regular weight bearing and sustained knee bending. The important way for prevention of knee

osteoarthritis including the modification daily activity for reduces risk factors. The investigator

suggested careful about the occupational posture during work which might be reduced the risk

of knee osteoarthritis. Always maintain the correct working position during daily living

activities and correct the faulty ergonomics design of the house which also reduces the risk of

knee osteoarthritis, because investigator found that sitting on the floor for home activity one of


the risk factor of the knee osteoarthritis in the study. “Risk factors of developing knee

osteoarthritis, Md. Ashek Elahee, Department of Physiotherapy CRP, Savar, Dhaka-1343

Bangladesh February, 2012”.

Osteoarthritis is one of the ten most disabling disease in adults. Though it is not a curable

disease, but regular physical activity plays a vital role in maintaining the physical wellbeing.

Ifthe patient receive physiotherapy regularly and maintain therapeutic activities at their

homethen 80% symptoms will be subsided. This study proved that physiotherapy is effective

for the patient with osteoarthritis of knee joint. ”Outcome of Physiotherapy management for

osteoarthritis of knee joint: A retrospective survey by Sharmina Akther Mukta, Department of

Physiotherapy CRP, Savar, Dhaka-1343 Bangladesh August, 2012”.

A prospective randomized clinical trial was conducted on 162 patients of osteoarthritis of knee

were included in the study. The patients were divided into two groups- Group A and Group B.

The Group A was treated with shortwave diathermy, exercise, naproxen and activity

modification and the Group B was treated with shortwave diathermy, exercise and naproxen.

Improvement was found more in Group A than Group B after 4th week (95% CI was -2.59 to

6.56). Then it was found that the improvement was gradually increased in Group A than Group

B and finally, it was found that there was highly significant improvement in Group A than

Group B after 6th week (95% CI was -3.45 to -0.70). This study suggests that activity

modification play an important role for the treatment of the patients with osteoarthritis of knee. “Effects of activity modification on the patients with osteoarthritis of the knee , M. A. Shakoor,

Md. Abu Taslim and Md. Shahadat Hossain, Bangladesh Med Res Counc Bull 2007; 33: 55-59”.

This report presents new data revealing the overall extent of osteoarthritis in the UK. It is based

on data collected in the Consultations in Primary Care Archive (CiPCA) and analysed by the

Arthritis Research UK Primary Care Centre at Keele University. Estimates of the future extent

of osteoarthritis in the UK, carried out by Arthritis Research UK, are also included. “Osteoarthritis in general practice, Arthritis Research UK, July 2013”

The survey was carried out in a rural community, an urban slum, and an affluent urban

community with samples of 2635, 1317 and 1259 adults, respectively. Through door-to-door

surveys, trained interviewers identified subjects with musculoskeletal pain. A socio-culturally

adapted and validated Bengali version of the COPCORD (Community Oriented Program for

Control of Rheumatic Disorders) questionnaire was used. Trained internists and


rheumatologists examined the positive respondents using an English COPCORD examination

sheet to identify respondents with definite rheumatic disorders and to reach a diagnosis. “Haq

SA, Das BB, Rahman F, et al. Prevalence of rheumatic disorders in a Bangladeshi urban

community: COPCORD study. APLAR 2002 Abstracts Proceeding Book. 10 th APLAR. Bangkok,

Thailand, December 1 – 6, 2002, p 182”

The summary of recommendations is not intended to stand alone. Medical care should always

be based on a physician’s expert judgment and the patient’s circumstances, values, preferences

and rights. For treatment procedures to provide benefit, mutual collaboration with shared

decision-making between patient and physician/allied healthcare provider is essential. “Treatment of osteoarthritis of the knee evidence-based guideline, 2nd edition Adopted by the

American Academy of Orthopedic Surgeons, Board of Directors May 18, 2013”.


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