Non-Surgical Management of Osteoarthritis
What is Osteoarthritis
Osteoarthritis (OA) is a chronic, progressive, degenerative disease of the articular cartilage. OA is not the inevitable end point of ageing. In many cases it affects only one knee and is precipitated by an injury to the ACL and / or menisci. Bilateral OA (both knees) is more likely to be related to genetics, weight and alignment.
OA generally begins at a point or points and gradually expands from that point. As arthritis worsens more cartilage is lost and eventually the joint will wear down to bone, at least in some areas and the lubricating and cushioning function of the cartilage is lost. The cardinal features of OA are pain with activity, stiffness and swelling. Stiffness is caused by osteophytes that are bony growths around the margin of a worn joint that occupy space needed for movement. Some individuals have a tendency to grow very large osteophytes (this is called hypertrophic OA) and can end up with very restricted movement.
Non-Surgical Treatment Options
Surgery is the last line of treatment for OA. The mainstays of non-surgical management are weight loss and exercise. If you are overweight and have mild to moderate knee OA your first priority is to lose weight. This is done primarily in your kitchen. Exercise should be non-impact. Otherwise it will make the pain worse. For knee OA there is no substitute for a bike. Every treatment modality listed below works better if you are lean as do all the surgical options. This may not be what you want to hear but it is good advice nonetheless.
Validated, evidence-based exercise programmes specifically designed for knee osteoarthritis are available from credentialed physiotherapists. The GLA:D programme is one example of this. For more information on this follow the link below.
OA is a huge problem nationally and involves big money. There are enormous vested interests involved and sorting the science from the BS is not easy. Treatment options can be broadly broken down into ingestables and injectables.
Glucosamine and Chondroitin
Platelet rich plasma
You may have noticed stem cells are not included. Planktonic stems cells do not repair cartilage, are very expensive and have no role to play at present. Stem cells need to be implanted in a matrix to make cartilage. Stem cell injections are not and will not be covered by Medicare because there is not enough quality science to support the cost. All of the options listed above are cheaper and more likely to help.
Paracetamol has a small effect on knee OA symptoms. Longer acting preparations or no better than the standard drug. It does not slow disease progression.
NSAIDs have a moderate effect on knee OA symptoms. They have very real risks of kidney, gut and circulatory side-effects especially with prolonged use and in the elderly. They should be combined with a proton pump inhibitor drug (reduced stomach acid prevention) in the elderly and if there is a history of gastric ulcers. They are best used to treat flareups rather than manage day to day symptoms.
Naproxen has the best cardiovascular risk profile. Diclofenac potassium (not sodium) probably works best for knee OA. Cox 2 selective NSAIDs (celecoxib / meloxicam) have best gut risk profile but don't work as well for OA. They do not slow disease progression.
Glucosamine / Chondroitin
These are supplements rather than drugs. (A drug is a poison that interferes with a natural process whereas as supplement aims to augment a natural process). They are constituent components of articular cartilage. They may have a moderate effect on knee OA symptoms but have to be taken regularly and are very safe except for those allergic to shellfish. They may slow disease progression.
Corticosteroids have a powerful anti-inflammatory effect. An injection of steroid into the knee works best if the knee has fluid in it (called an effusion). An effusion indicates a significant inflammatory component to the symptoms rather than simply a mechanical one. It is best used to treat a flareup rather than the baseline symptoms. It can cause a precipitous rise on blood sugar levels in diabetics. It does not slow disease progression.
Hyaluronin is a natural component of joint fluid that aids with lubrication. They have been around for 30 years. They have a minimal and temporary effect on knee OA symptoms. They are expensive, unpredictable and not covered by Medicare. The do not slow disease progression.
Platelet Rich Plasma (PRP) Injection
PRP is a concentrate of a persons own blood platelets. Platelets contain many chemicals that can modulate inflammation and when injected in the knee the platelets activate and release these chemicals. PRP was initially developed as a treatment for Achilles tendonitis (for which it does nothing). PRPs have been a scientific dogs breakfast for years with non-standardised preparations being used willy-nilly for all sorts of conditions. In the last 3 years a body of good scientific evidence has been evolving to support the use of leukocyte poor PRP (not leukocyte rich) for moderate knee OA. All this evidence was based on 3 injections a week apart. The injections are reasonably expensive and not covered by Medicare. PRP may slow down disease progression and is superior to hyaluronin and equivalent to NSAIDs.