Everything You Need To Know About Non-Surgical Management of Osteoarthritis
There are so many options out there for the treatment of osteoarthritis (OA), which is the wear and tear type of arthritis, it is hard to know what options are available to you.
Ideally, prevention and maintaining healthy joints is the key, and that requires consistent work at maintaining the strength of the muscles around our joints to create smooth and stable movements in the ways that joints were intended to move.
Additionally, we want to move our joints in ways that the loads and forces are evenly distributed through the joints, and not in a way that is off balance or lopsided. This will cause more wear and tear in some parts of the joint versus other parts of the same joint.
We additionally don’t want to apply too great of a load through the joints. A commonly believe is that running is hard on the knees. There is a lot of evidence that an activity like running prevents the development of OA when done for fitness and at the recreational level. The risk of development of OA happens when the runners’ mechanics don’t allow the joint to manage the loads effectively and gently, like a good set of shocks on a car.
So, we invite you to take a read of this blog to get a well rounded view of arthritis treatment options. It is a long one, but a good one based on a thorough literature review that we completed while writing this. To skip to a specific section, please use these quick links:
Giving a joint with some external support with an engineered brace
Give your joints some lubrication with a viscosupplmentation injection
Osteoarthritis defined.
Osteoarthritis, when broken down into its parts, just means joint (“arth”) inflammation (“itis”). The “osteo” kind comes from wear and tear over time, whereas the “rheumatoid” kind comes from a person's immune system attacking the cells inside the joint. We will only be discussing the “osteo” kind today.
Joints are designed to move a certain way. To best explain it, take a look at the video below:
Dr Rich Trenholm explains the basics of why people get osteoarthritis and the best treatments for it. For more information about our multidisciplinary Sport and Exercise Medicine and Rehabilitation clinic in Huntsville, Ontario, visit www.reactivatemuskoka.com
A clear understanding of the objectives and outcomes behind a patient's treatment is one of the most important things to determine at the outset of the treatment plan.
Every person’s arthritis is mechanically different. So, having your joints evaluated by experts in the rehabilitation field can not only determine how advanced your arthritis is, and what treatment options exist for you, but also what factors contributed to and continue to contribute to your arthritic progression. The more can control those variables and factors that are leading to your arthritis, the more we can slow the progression of your arthritis.
Unfortunately, we cannot turn back time. We cannot undo what damage has been done to the knees but we can control what happens from this point forward.
Why do people get osteoarthritis, in a nutshell
Joints are designed to move a certain way. Some joints, like the shoulder and the hip joint, move in three directions as they are "ball and socket" joints. On the other hand, joints like the knee and finger joints are what we would call "hinge" joints. They move forward and back, and there is no rotational movement with these joints. That is, unless there is a hinge joint (knee) that is stuck between two ball and socket joints (hip and ankle complex). I mention the ankle complex as there are three joints in the ankle that allow the ankle to move in three dimensions (front and back, side to side, and rotation). When there is excessive movement at the rotational joints, then the hinge joint, which doesn't tolerate rotation well, gets twisted and torqued in the middle. This twisting and torquing, over time, applies "wear and tear" to the joint and as a result degenerative changes in the form of osteoarthropathy occur.
You are wondering what "osteoarthropathy" is...well, it is the degenerative change to the joint, but when you get inflammation of this condition, you get the "-itis" tacked on the end, and you get osteoarthritis.
A clear understanding of the objectives and outcomes behind a patient’s treatment is one of the most important things to determine at the outset of the treatment plan. Every person’s arthritis is mechanically different. So, having your joints evaluated by experts in the rehabilitation field cannot only determine how advanced your arthritis is, and what treatment options exist for you, but also what factors contributed to and continue to contribute to your arthritic progression. The more we can control those variables and factors that are leading to your arthritis, the more we can slow the progression of your arthritis.
Diagnosing osteoarthropathy and osteoarthritis
One thing that I wanted to quickly touch on in this article was the relationship between what you see on an x-ray and what is actually the source of pain. Most x-rays are done in what we would call non-weight-bearing positions. This means that a person is lying on the table in the x-ray department and an x-ray gets taken. Unfortunately, most of us doOne thing that I wanted to quickly touch on in this article was the relationship between what you see on an x-ray and what is actually the source of pain. Most x-rays are done in what we would call non-weight-bearing positions. This means that a person is lying on the table in the x-ray department and an x-ray gets taken. Unfortunately, This does not provide an accurate picture of actually what exists when we are walking around, which is a weight-bearing position. So in order to truly look at the severity of the OA, x-rays need to be done in a weight-bearing position or the knees, hips and ankles along with traditional views.
What is the deal with meniscal tears?
The other thing that is often found on imaging are tears to the meniscus in the knee, and the labrum (another kind of meniscus) in the hip and shoulder. Once these are found on imaging, it often allows patients to say “Aha! That’s the reason for my pain!” when in fact most of the patients, as we age, develop what is called degenerative tears to the cartilage in our joints. This is caused by the combination off high loads going through the joints in abnormal patterns at poorly controlled speeds.
Imagine having a car that is going down a bumpy road. A brand new car will float along with great shocks taking a lot of the bumps. This is what it is like to have joints balanced and strong enough to manage the loads that are applied to it. But over time, driving too fast and making hard turns to cause the shocks to wear down and more of the bumps are felt by the car and the wear and tear are now on the body and chassis of the car. Over time this breaks down and you need a new car.
the squeaky wheel needs the grease
So, often the reason is that the pain is coming from the abnormal and uncontrolled movements of the joints in ways that they weren’t designed to and as such these structures get Loaded in ways that they weren’t designed to be. That is way too if the most powerful treatments for pain related to asked you arthritis or weight loss and correction of the biomechanical issues that lead to an unstable and poorly responsive joint.
So, what are the best available options for treating OA without having to resort to a joint replacement surgery?
First Steps First, Figure Out Why You Have Arthritis
Pain does come from arthritis, but it also comes from the abnormal stresses and loads that are being placed on the joint structures, such as cartilage, ligaments, muscles and tendons that support the joint. Often with proper support and alignment that can be achieved through physiotherapy to improve the alignment and then progress onto regular physical exercise, and controlling the way and how fast forces going through the joint, we can control the pain, and slow down the progression of your arthritis. How do we figure out what ways your body moves that is abnormally loading your joints? Well, having a physician or allied health professional (physiotherapist, chiropractor, or massage therapist to name a few) stand back and watch how you move. How your body corrects for imbalances, which you probably aren’t even aware of, which loads your joints unevenly.
step two. Reduce The Loads Going Through The Joint: Weight Reduction.
Your body's weight is pulled down by the earth's gravity through your joints. The more weight that you have, the more gravitational pull will happen, and the greater the forces that your joints will experience. The greater the forces that a joint is loaded with, the more stress it applies to the bone and cartilage that make up the joint. But joints are just bones stacked on top of each other.
Even small reductions in weight make a big difference. If you are sitting, your knees experience 2 times your body weight, when you walk it experiences 3 to 4 times your body weight. When you walk it is 5 to 6 times, and if you run it is upwards of 10 times your body weight. Add in things that put your knees in deep flexion, such as stairs, ladders, or walking on inclines, then he forces go up even higher. So, small changes make a big difference. Let's take, for example, a 200lb person. When they are sitting, their knee is experiencing 400lbs of pressure. Standing 600lbs. Walking 1000lbs. Running, now you are looking at 10000lbs of pressure. So dropping your weight by 10lbs can significantly lower the forces. You do the math.
number three. Keep Your Joints Healthy By Staying Fit and Strong: Strength and Conditioning with Regular Physical Activity.
In order to prevent the bones from slipping and moving around more than they should, there are ligaments that act as safety straps to hold the joint together should the bones try to move too far away from each other.
But the first line of defence is the muscle units (each muscle unit is made up of a tendon that attaches at one place, a tendon that attaches at another, and the muscle that contracts are in between the two tendons). Every joint has muscles that work in opposition to each other, to counterbalance each other. For every ying, there is a yang. Such as the quads have the hamstrings. The biceps have the triceps. And so on.
However, if the muscles are not balanced in relation to each other, then one muscle group is pulling more effectively than the other, which allows the joint to move. This movement allows the forces to be applied through the joint in places that it shouldn’t be.
Not only do you have balancing issues, but if your muscles that are around a joint are not strong enough to manage the loads and forces you are asking it to manage, then eventually the pounding and jostling that the joint has to endure will result in excessive wear and tear.
step four. Using A Hands-On Approach: Manual Therapies
While therapies that include acupuncture and massage therapy won’t correct the arthritic process going on inside the joint, these treatments might provide pain relief by helping reduce increased muscular tension around the joint, which would increase the pressure inside the joint.
Massage therapy would help relax muscular tension and lengthen the muscles, and both massage and acupuncture could complement exercise and movement-based therapies by making the muscles more responsive to exercises that would help the muscles around the joint become more efficient and effective stabilizers.
Number five. A Little Help From Engineering: External Braces
Braces come in all shapes and sizes and can be custom made to fit your body size and shape, or they can be bought off the shelf at most pharmacies and sports stores. Most of the off the shelf braces provide little to no structural support to a joint.
However, it makes you more aware of the joint, which in turn might help people properly engage muscles around the joint and load a joint properly. Think of them as the fabric that gives a joint a nice hug while they are being worn.
Custom made braces are structurally designed to “offload” parts of the joint in order to relieve pressure where OA might exist. They also work to balance out the forces across the entire joint surface rather than forces being lopsided in a joint, which will eventually lead to progressive arthropathy.
Orthotics are a form of an external brace as well. By changing the alignment of the foot and ankle, the pattern through which forces go through the lower extremity and eventually the pelvis and back, changes. This helps some people, but often the loads and the abnormal mechanical patterns that the orthotic is trying to control are too great for them to be terribly effective.
Medical, But Not Surgical Options
Returning To Our Roots: Herbal Supplements
In short, there have been a lot of studies on herbal supplements. Most of the studies, while they claim to have significant improvements with pain and disability that come with OA, most of the studies aren’t very well done or don’t have a lot of people in the studies, to draw meaningful conclusions.
There was a recent, well-designed study called a systematic analysis, that analyses a number of scientific studies and compiles the results, looked at the various herbal supplements and remedies to treat OA in order to reduce pain and improve function. They found that most of the studies were too small, had too much bias, or were flawed in other ways to really draw any conclusions. However, there were a few that showed that these supplements may provide some benefits:
Tumeric with Curcumin
Boswellia Serrata Extract
Pycnogenol (Pine Bark Extract)
Methosulfonylmethane (MSM)
For those who have exhausted the established options, supplements may look appealing and some may be worth a short-term trial. It’s important to remember that with studies of supplements and drugs alike, as the quality of evidence improves, the treatment effects often diminish or disappear. Still, based on the existing evidence, for your own evaluation, it seems reasonable to try products for which there is the best evidence. This is an area where the evidence continues to emerge, so if you’re experiencing OA, cautious skepticism about the “latest and greatest” supplement seems to be reasonable.
Taming The Flame: Topical, Oral or Injectable Anti-Inflammatories
This group of over the counter or prescription-based medication works to reduce the inflammatory effect that is associated with arthritis. It also helps with pain that is associated with OA, however, it doesn’t do anything to change the rate of progression of OA.
Topical anti-inflammatories tend to be widely used as they are readily available with most of them being available over the counter. However, the science for most over the counter preparations suggests that these topical NSAIDs only penetrated less than 4mm. So, they might be good for shallow joints like the hands or feet, but to get into the bigger and deeper joints like hips, knees, ankles, and shoulders it is unlikely to get into the joint. That being said, it could provide pain relief to the muscles and tendons around the joints that are working overtime to support an arthritic joint. There are, however, a few that are prescription that is more effective, and penetrate deeper than the over the counter versions (Multiprofen CC is a great Canadian product that your doctor can order for you).
Oral anti-inflammatories can be hard on your stomach, intestinal system, your kidneys, and in some cases, your heart. Although effective, especially for those people who have multiple joints affected by OA, sometimes taking a pill that circulates around your entire body to get to one spot might not be appealing to some.
Injectable anti-inflammatories, or steroid injections, are usually high dose single-shot injections that are injected directly into a joint affected by OA. These injections are generally well-tolerated, but after an injection there tends to be a day or two where the pain and stiffness may be a bit worse. So it is a good idea to time the injection to be done at a time when you can take it easy on the injected joint, and only do what you need to do as that will help with this “post-injection flare”. The pain relief that these injections provide lasts on average about 4 to 6 weeks. For a number of people, the length of this treatment effect can last longer if that 4 to 6 week period is used to actively rehabilitate the joint, the muscles that stabilize the joint, and the nerves that supply these muscles so that the muscles become active again.
Adding A BIt of Lubricant To Your Joint: Viscosupplementation Injections
This relatively new treatment injects a gel-like substance called hyaluronic acid into an arthritic joint and acts to “wake up” the cells in the joint (called the chondrocytes) to make the synovial fluid. The synovial fluid is what lubricates joints to keep things moving smoothly.
Contrary to what you might think, these injections only last in your joint for a few days, but their effect can last upwards of 6 months, and sometimes years. However, you have to wait for it as the peak effect is somewhere around the 60-day mark. However, physicians are now combining the injection of viscosupplements with a steroid injection to “bridge the gap” and get pain relief sooner rather than later.
There are a number of different brand names, and there are small differences between them all, but in general, they are relatively the same, work the same, and have the same efficacy. Our clinic carries a Canadian brand called NeoVisc and Multivisc Dex, which can be purchased at our clinic. Your primary care provider can inject your joints with “Visco”, or one of our physicians at Reactivate can inject your joint.
There is always a catch, however! There are two key factors that contribute to the success of these injections in attempting to reduce pain and improve function:
The injection has to go in the right place for them to work properly. This applied to steroid injections as well. Even though a joint space of the knee is large, it can still be missed with a primary care provider that might not be super comfortable doing these injections. Additionally smaller joints in the hand, or hard to reach joints like the hip or ankle, take more expertise to ensure that the injection goes in the right place.
The earlier in the OA process you get these injections, the more they are likely to work and the effect will last longer. Because these injections “wake up” the chondrocytes, if the severity of the OA is too great, then those chondrocytes aren’t viable anymore, and so there is nothing to wake up. So, don’t use these injections as a last resort. They should be close to being the first line. Don’t let the word “injection” turn you off.
Things On The Horizon: New and Emerging Treatments
There are a number of new treatment options that are being offered at various clinics for the treatment of OA, however the research for these treatments is not robust enough and the study sizes big enough to say whether or not they are beneficial, and don’t carry significant risk to the patient.
This includes the injection of a patient's own adipose (fat) cells into the joint. Fat cells have a high concentration of “stem cells” which are the basic cells that most of our body parts were made from. However, these cells aren’t specific to the joint, and the attempt to regenerate the cartilage cells so that they can once again produce the slippery synovial fluid to lubricate the joint.
The same goes for another treatment called PRP, or platelet-rich plasma. This injection takes a patient's blood, and they isolate the plasma part of the blood where all of the immune cells are. Unfortunately, for OA, PRP is not well supported in unbiased scientific studies.
Parting Thoughts and Putting It All Together
As you can see, there is a plethora of non-surgical options on how to treat OA without having to resort straight to a knee replacement. The sooner in the disease process of OA you get help, straighten out and balance the muscles around the joint, add a bit of lubricant to the joint to help it glide better, the more quality days of your life you will have. You will actually delay the need to have surgery for a joint replacement, either temporarily or indefinitely.
But the most common element that is left out of all of the equations above is you. The patient. Without your willingness to participate, do the things that are needed to be done, and spend the time and effort actively participating as a member of your rehabilitation team, the less likely all of these options will be successful for you. You will get out of it what you put into it.
So, come and see any of our incredible Sport and Exercise Medicine and Rehabilitation team members at Reactivate Muskoka to get control of your pain, improve your function, and start living your best life.
