Knee Arthritis Treatment Options
CLINICAL
Part 1
Jeffrey Tucker
DC, DACRB
In this article, I discuss some of the treatment options for a patient with knee osteoarthritis (OA). Following my history and physical examination, I like to discuss the patients’ realistic treatment goals. Then I talk about current treatment options for their knee pain.
Arthritis can be categorized by four basic criteria:
1.Degenerative, which is the most common (e.g., osteoarthritis)
2.Inflammatory (e.g., rheumatoid, psoriatic)
3.Infectious (e.g., STD, Lyme disease)
4.Metabolic (e.g., gout)
Infectious and metabolic are treatable and often curable; degenerative and inflammatory are manageable but not yet curable.
Any type of movable joint can get arthritis. Patients describe it as an ache; it hurts to move, and they have loss of motion. Doctors know about the synovial pouch, and that it is cushioned by articular cartilage. What patients hear is, “It’s inflamed.” We know that chronic inflammation in the synovium deteriorates cartilage, eventually exposing the underlying subchondral bone to greater and more asynchronous forces. These cause both softening of the bone as well as stimulation of bony growths, i.e., osteophytes, spurs, and sometimes cysts.
Inflammation impairs neural input to the muscles around the joint(s). The consequence of this is the change in the muscles’ co-contraction of agonists and antagonists. Changes in strength and stability, along with poor support and increased impact forces to the articulating surfaces, lead to further deterioration of the joint.
Weakening of muscles, increased joint laxity, and diminished proprioception (poor firing of the muscles) can create dysfunctions along the entire kinetic chain. For example, we’ll see the instability of the OA knee and how that affects the hip joints and the lumbar spine, as well as how it compromises higher areas of the musculoskeletal system. In this article, I don’t intend to go through the movement assessments I use, but in my office, I do spend time observing movement analysis to determine if a joint is not working properly. The typical abnormal or faulty knee movement pattern I see is the knee(s) moving inward on the “small knee bend” test (about 30 degrees of knee flexion). Just bringing awareness to the patient of the proper tracking mechanism of the knee when it is in flexion (while standing) has been enormously helpful to recovery. The basic self-biofeedback treatment is to have the patient stand in front of a mirror, perform small knee bends, and track the center of the patella over the second toe (repeatedly).
Treating and managing knee arthritis
Knee OA may be both the least and the most preventable form of arthritis. I’ve practiced strategies to help decrease chronic inflammation (swelling), and help promote bone and cartilage regrowth. Arthritic knee-pain management techniques are best treated using a combination of modalities. However, don't forget to consider the exclusion of other variables for knee osteoarthritis, such as:
Knee alignment (1)
Foot structure and function (2)
Leg length inequality (3)
Heavy physical work (4)
Obesity (5)
Muscle imbalance (6)
Previous arthritic knee procedures (7)
High-heel wearers (8)
My practice style is to prescribe a specific treatment plan and give it a fair trial. First, treatment for any form of arthritis depends on its proximate causes. If I sense inflammation, I try to reduce the inflammation using modalities and, if needed, weight loss. According to information cited in an article published online in the Merck Manuals Professional Edition, “Exercise can sometimes arrest or even reverse hip and knee OA,” and, “Moderate weight loss in overweight patients often reduces pain and may even reduce progression of knee OA” (9). If my patient is overweight or obese, I currently recommend a ketogenic weight-loss program. In my office, I have hired a fulltime weight-loss specialist. Losing 5 to 10% of body fat may reduce systemic and/or local inflammation, pain, and restore some function. There are pills and injections that reduce inflammation and pain, but most of our patients still want to know what else they can do. We can offer our attempts to restore range of motion, generate nerve signals to keep muscles “alive” for that time when either remission occurs or inflammation is well-managed, and eventually work to restore function.
Many patients self-prescribe medications such as acetaminophen and NSAIDs for OA. Some patients present after steroid injections have already been provided. As a chiropractor, I’m more into talking about Boswellia serrata (anti-inflammatory and a pain reliever); turmeric (reduces joint pain and swelling); capsaicin (topical cream and ointment); arnica (a homeopathic remedy); collagen helpers, such as glucosamine and chondroitin; Epsom salt baths (adding two cups of Epsom salt to a warm bath); vitamin D (reduces inflammation); and fish oils (inflammation resolution). I also make my own CBD topical creams for my patients.
Other care recommendations could involve relative rest or activity modification. First, we should modify either the frequency, intensity, duration, or, most importantly, the type of cardio exercise the patient performs. Instead of walking on an arthritic lower extremity, try cycling or the elliptical.
I recommend mind-body techniques, such as writing for 10 minutes every night. I have patients set a timer for 10 minutes, start with a blank piece of paper, and then write down everything that comes to mind as it relates to the pain. I tell them, “Just keep writing until the timer goes off. Whatever stream of thought comes to your mind, write it down. After the timer goes off, rip up the paper and throw it away. You don’t even have to read the page.” This concept falls under the brain neuroplasticity changes we are trying to offer.
Restoring function and therapeutic exercises are going to need to be discussed with each patient. Implementation of a broad exercise program could include yoga, cardiovascular, strength, flexibility, and balance training. I have to modify each according to the abilities of the patient. Be even more specific and discuss the options of water walking, water aerobics, or stationary or outdoor bikes. If they like walking, I recommend shorter, more frequent walking times. I have patients do one deep knee bend (flexion past 90 degrees) each morning. If they can do one rep without pain, I slowly have them perform three to five more and continue building up reps by only adding three to five a day. I ask patients to test the deep knee bend in the morning after being awake for about an hour or two. Restoration of squats is a guide and a goal. If they have positive pain in the morning, I want to know what they did the day before and what they ate the day before. Certain foods or activities could have been an inflammatory offender. We patiently wait until they can return to a designated number of reps or until the pain diminishes. Keep in mind that flexion is not always the trigger; some patients need to avoid or modify knee extension. In the case of a flare-up, I modify the strength-training routine to use lesser resistances (elastic tubes versus free weights) or even the type of contraction (isometric versus isotonic). Isometric exercises can be performed at a self-regulated tension within a range of motion that does not cause pain. I always look to strengthen unaffected joints or peripherally affected muscles to support continued functionality overall. I emphasize the quadriceps and gluteals. Core work is still valuable for those with OA of the knee or hip.
I always look for muscles that need stretching, which seems to help the involved joints. Assisted stretches, such as proprioceptive neuromuscular facilitation (PNF) stretching or long-duration manually assisted hamstring stretches, are worthy of an entire office visit alone.
I often find that most patients who have had previous physical therapy or chiropractic care prior to coming to see me have not explored balance and stability work. I start with simple tools and maintain “safety first.” I have not had any patients who could not start on a stability pad; performing simple, static balance movements helps facilitate function once the pain and swelling abate. Should a joint replacement be in the client’s future, this kind of work will pay off dearly.
In part two, I will discuss stem cell therapy and regenerative therapies.
References:
1. http: //ard.bmj. com/content/72/2/23 5. abstract
Ann RliemnDis 2013;72:235-240 The Journal ofBone and Joint Surgery (American). 2008;90:1961-1969. http://jbjs. org/article. aspx? articleid=2 8820
2. Arch Phys Med Rehabil 2006;87:1436-41 http://www.ncbi.nlm.nih.gov/pmc/ai1icles/PMC3482996/
3. Ann Intern Med 2010; 152 287-295 http://www.annals.Org/content/152/5/287.abstract7etoc
4. Rheumatology 2010 49: 308-314 http://rheumatology.oxfordjournals.org/cgi/content/
ab str act/49/2/3 08?etoc
5. Rheumatology 2010 49: 308-314 http://rheumatology.oxfordjournals.org/cgi/content/ ab str act/49/2/3 08?etoc
6. Clinical Biomechanics Volume 20, Issue 1, January 2005, Pages 97-104
http://www.sciencedirect.com/science/article/pii/ S026800330400186X
7. Arthritis & Rheumatism. 2006; 54(3):795-801 http://onlinelibrary.wiley.com/doi/10.1002/art.21724/ abstract
8. Archives of Physical Medicine and Rehabilitation Volume 86, Issue 5, May
2005, Pages 871-875
http://www.sciencedirect.com/science/article/pii/ S000399930401398X
9. Kontzias A. Osteoarthritis (OA) - Musculoskeletal and Connective Tissue Disorders - Merck Manuals Professional Edition. Merck & Co., Inc. Revised February 2017. Accessed March 13, 2018.
Angeles, Jeffrey Tucker, CA. He DC, is the DACRB, President practices of the in AC West A Rehab Los Council (CCPTR.org).
Dr. Tucker's website is www.DrJeffreyTucker.com
