What to do with my arthritic knee?
A challenging area of clinical medicine is the treatment of aging. One of the most common areas that I dealt with related to aging was the degenerative knee. Osteoarthritis (OA) is one of the most common joint problems and a major cause of disability and medical costs to our health care systems. In addition, many studies and personal and clinical experience have shown that this has a significant effect on quality-of-life (QOL) measures.
Knee OA is one of the most common conditions of OA, which affects many as we age, causing pain, disability and restricting activity. Patients with OA of the knee can present in their 30’s with a history of knee trauma in high school or in their 70’s with no specific trauma history. Regardless of the age, this is often a frustrating problem for us as we age.
Education and tools for self-management are essential and important groundwork for everyone with OA of the knee. The understanding of the problem and process is often necessary to be able to progress further with treatment. The initial treatment for everyone with OA of the knee includes exercise. Numerous studies demonstrate the positive effect of any strengthening of the muscles around the knee with subsequent decrease in pain and increase in QOL. The exercises could include simple chair exercises, walking, t’ai chi or other specific leg strengthening exercises. A favorite of many patients, with access, is pool therapy – both swimming and water aerobics. Finding a way to move without increasing pain, while improving strength, is an essential part to treatment.
Multiple other interventions may be helpful and rarely harmful. These include weight management, various knee sleeves, knee braces, walking sticks and shoe inserts although these are very individual in patient response. Weight management is essential to decrease the mechanical stress but challenging for the overweight patient with a painful knee.
Pharmaceutical options include topical medications (capsaicin or NSAIDs), acetaminophen, COX-2 inhibitors, non-selective NSAIDs, Hyaluronic acid products, and intra-articular glucocorticoids. Each of these interventions have limited efficacy and potential side effects but can be helpful for varying time lengths in the treatment of symptoms.
A recent interesting review article (Xing 2017) on intra-articular platelet-rich plasma (PRP) injections prompted this discussion of non-surgical treatment of knee OA. Biological treatments can include PRP, stem cells and more targeted pharmacological therapy for OA, and disease-modifying osteoarthritis drugs (DMOADs). The use of biological treatments, like PRP, is interesting, but the literature is limited because of less than optimal study design and frequent bias. In addition, the clinical heterogeneity of the patient population is an important limitation. Patients with different ages, levels of OA, other comorbidities and BMI are often in the same studies, which limits the applicability of the study.
In theory, PRP is a concentrate of platelets, which assist tissue repair through growth factors, potentially to improve healing and decrease the inflammation in the knee. In their review, Xing et al used an unusual research model and combined several research tools/instruments to evaluate the risk of bias and the quality of the previous studies. This limited their study to two previous reviews because of the evidence for bias and heterogeneity of the studies. Their overall conclusion was they could recommend PRP for the knee with OA with relative confidencealthough they cannot recommend a particular PRP system. Given these results and the difficulty in studying this treatment, the appropriate use of PRP still needs to be determined.
As someone who has followed the studies of non-surgical treatment for knee OA with interest, OA of the knee remains a difficult problem. Overall, initial treatment should include strength training in a manner that does not increase pain or disability, the consideration of bracing/sleeves, weight management and limited/judicious use of pharmaceutical options after discussing with your physician. We will watch with interest as the data/research continues in regards to biologics in the future.
Bernad-Pineda M, et al. Quality of life in patients with knee and hip osteoarthritis. Rev Esp Cir Ortop Traumatol. 2014.
Buttgereit F, et al. Non-surgical management of knee osteoarthritis: where are we now and where do we need to go, RMD Open,2014.
Fransen M, et al. Exercise for osteoarthritis of the knee: A Cochrane systematic review. British Journal of Sports Medicine, 2015.
Osteoarthritis Research Society International (OARSI), Non-Surgical Management of Knee Osteoarthritis Summary, 2014.
Xing, D., et al. Intra-articular platelet-rich plasma injections for knee osteoarthritis: An overview of systematic reviews and risk of bias considerations. International Journal of Rheumatic Diseases, 2017.