Your health: New tools for improved management of Knee Osteoarthritis

By Jeffry Beer, MD

Issue of Nov. 7, 2008 / 9 Cheshvan 5769

Osteoarthritis (OA) can result in irreversible cartilage loss in patients of all ages. However, it is more commonly seen in patients of older age. A diagnosis of OA can potentially set the stage for many years of pain, stiffness, inactivity, and immobility.

Traditionally, this progressive deterioration required joint replacement surgery; however, an integrated program of innovative treatments can slow or prevent disease progression, relieve joint pain and stiffness and alleviate the need for surgery. In addition, although not currently available, much research is being devoted to treatments that are designed to replace or regrow the worn cartilage that is the hallmark of OA.

An individual with OA is best served by a comprehensive outpatient program that provides careful clinical evaluation and diagnosis as well as treatment to meet unique patient needs.

Physical therapy remains a cornerstone of treatment. Strengthening and conditioning of the muscles that surround the knee, together with flexibility and range of motion program exercises are essential to decreasing the transmission of large forces across the knee joint.

Such efforts have been shown to decrease pain and may slow or prevent further progression of the disease process. The Arthritis Foundation has a number of programs, including a tai chi exercise program, which can be helpful in patients attempting to manage symptoms of OA.

There is evidence from the medical literature that weight loss is beneficial in decreasing pain, improving function and preventing disease progression. In selected patients, nutrition counseling may be essential to maintaining a healthy lifestyle.

Some studies have shown that acupuncture may be helpful in decreasing knee pain in patients with OA. Such modalities may be appropriate for select patients.

Conflicting evidence is noted regarding the potential benefits of supplements such as glucosamine and chondroitin. Although it may be helpful to reduce pain in some and it is usually well tolerated with minimal side effects, it has not been shown in human studies to cause the regrowth of joint cartilage.

Hyaluronic acid (HA) represents a relatively new treatment option to enhance joint function and relieve pain. Primarily, injections of HA are thought to improve the quality of joint fluid, providing more efficient lubrication and better shock absorption within the joint. Currently FDA approved to treat OA of the knee, the effectiveness of HA is other joints is being investigated. Better tolerated than steroid injections, HA also avoids the systemic side effects of those agents. Although significant improvements may be realized with the use of HA, such benefits are usually temporary; repeated courses of injections may be performed at intervals of six months or longer.

Minor side effects, such as injection site soreness, are rare and usually self-limited. No long-term adverse effects have been seen with HA use. There are currently five different brands of HA available on the market. The most recent introduction is a synthetic preparation that can be used in patients with avian allergies.

These injections are performed as a series of three or five injections, depending on the product used. Most physicians will perform “blind” injections, utilizing skin landmarks and palpation techniques to determine proper placement. Despite this, there is a growing body of literature to suggest that even in experienced hands, these injections are inaccurate and may miss their target in 25 to 30 percent of cases. To minimize this, the use of x-ray (fluoroscopy) or ultrasound images to guide the injection is a preferred approach.

For many patients, the use of HA injections can mean significant pain reduction and greater mobility. Some patients have been able to resume activities previously curtailed because of OA. Most can expect to realize at least a mild to moderate degree of relief.

Although still in experimental stages, there is ongoing investigation into the use of stem cells to regrow worn cartilage in patients with advanced OA. Such treatments are likely to be of major benefit in the years to come and one day may make the use of joint replacement surgery obsolete. Despite this, significant challenges exist to the use of this technology and it may be some time before we begin to see this in clinical practice.

By combining both traditional and innovative treatment approaches for treating the symptoms of OA, a comprehensive program of care provides effective nonsurgical options to help patients overcome the debilitating effects of this condition and reserves surgery for those patients for whom conservative treatment measures have failed.

Jeffry Beer, MD is an associate at Long Island Spine Rehabilitation Medicine, PC (www.lispine med.com), where he specializes in the nonsurgical treatment of joint and spine disorders. He regularly performs joint injections with the use of fluoroscopic guidance. He can be reached at (516) 393-8941.Your