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Non-operative treatment guide for osteoarthritis

Osteoarthritis (OA) is one of the most common forms of arthritis. The joint pain and stiffness caused by OA can make it difficult to work, play sports and perform daily activities.

Osteoarthritis is a condition of the bone or joint in which there is loss of cartilage (soft, spongy tissue covering the bone for protection) resulting in the release of inflammatory products causing irritation of the joint lining (synovium) leading to pain and swelling. As a result of continued joint impact, there may be an increase in bone formation leading to reduced joint range of motion.

How Patients Can Reduce the Painful Symptoms of OA

Weight Loss

For every additional pound of weight above ideal body weight (IBW), the knee or hip has four times  the additional force across the joint. For example, if you are 20 pounds over IBW, there is an additional 80 pounds of force across the joint (20 x 4). If you take an average of 5000 steps per day, then there will be 400,000 pounds of additional force every day on your joint.

What this means for you is that for every pound of weight lost, there is a four pound reduction in knee-joint load per step.

(Messier S, Gutekunst D, Davis C, DeVita P. Weight loss reduces knee-joint loads in overweight and obese older adults with knee OA. ARTHRITIS & RHEUMATISM Vol. 52, No. 7, July 2005, pp 2026–2032.)

Motion is Lotion

Exercise is crucial if you have arthritis. Motion in the joint creates increased release of hyaluronic acid which helps to lubricate your joint. Your muscles act as “shock absorbers” for your joints, so increased strength = increased shock absorption.

Knowing just how much activity to do when you’re hurting can be tricky. After all, research has shown that moderate activity can help prevent the progression of arthritis and improve overall function. But while mild muscle soreness after a workout is normal, sharp pain during or immediately after can signal injury.

20- to 30-minute weight-training sessions two to three times a week are sufficient. You should start reaping noticeable benefits within four to 12 weeks, such as improved energy and muscle tone. Within six months, most people increase their strength 40 percent or more. Give your body at least one recovery day between sessions.

Tai Chi

The martial art of Tai Chi is all about slow, rhythmic, meditative movements designed to help you find peace and calm.

A study by Wang et al suggested that Tai Chi is a potentially effective treatment for pain associated with osteoarthritis of the knee. In a prospective, single-blind, randomized, controlled trial, 40 patients with symptomatic tibio-femoral osteoarthritis who performed 60 minutes of Tai Chi twice weekly for 12 weeks experienced significantly greater pain reduction than did control subjects who underwent 12 weeks of wellness education and stretching. The Tai Chi cohort also had significantly better WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) physical function scores, patient and physician global visual analog scale scores, chair stand time, Center for Epidemiologic Studies Depression Scale scores, self-efficacy scores, and Short Form 36 physical component summaries.

Glucosamine and Chondroitin

Glucosamine and Chondroitin are components of normal cartilage. In the body, they are the building blocks for cartilage and appear to stimulate the body to make more cartilage. There are conflicting studies on glucosamine and chondroitin, some demonstrating a beneficial effect on osteoarthritis pain, and others showing no benefit.

The supplements, which are available in pharmacies and health food stores without a prescription, are well-tolerated and appear to be safe. However, there are no long-term studies to confirm their long-term safety and effectiveness. Keep in mind that the U.S. Food and Drug Administration (FDA) regulates supplements, but treats them like food rather than drugs; supplement manufacturers are not required to prove their products are safe or effective before selling them in the marketplace.

Anti-Inflammatory Diet

This is not a diet in the popular sense. It is not intended as a weight-loss program (although people can and do lose weight on it), nor is it an eating plan to use for a limited period of time. Rather, it is way of selecting and preparing anti-inflammatory foods based on scientific knowledge of how they can help your body maintain optimum health.

Along with influencing inflammation, this natural anti-inflammatory diet will provide steady energy and ample vitamins, minerals, essential fatty acids dietary fiber, and protective phytonutrients.

  1. To get maximum natural protection against age-related diseases (including cardiovascular disease, cancer, and neurodegenerative disease) as well as against environmental toxicity, eat a variety of fruits, vegetables and mushrooms.
  2. Choose fruits and vegetables from all parts of the color spectrum, especially berries, tomatoes, orange and yellow fruits, and dark leafy greens.
  3. Choose organic produce whenever possible. Learn which conventionally grown crops are most likely to carry pesticide residues and avoid them.
  4. Eat cruciferous (cabbage-family) vegetables regularly.
  5. Include soy foods in your diet.
  6. Drink tea instead of coffee, especially good quality white, green or oolong tea.
  7. If you drink alcohol, use red wine preferentially.
  8. Enjoy plain dark chocolate in moderation (with a minimum cocoa content of 70 percent).

Anti-inflammatory Supplements

Tumeric: Traditionally used in Chinese and Indian Ayurvedic medicine to treat arthritis turmeric/curcumin blocks inflammatory cytokines and enzymes, including NFkB/Cox 1/Cox 2 resulting in reduced prostaglandins and leukotrienes. May take without similar adverse effects as NSAIDS (ibuprofen, Naprosyn, Mobic).

A systematic review and meta-analysis was conducted using data reported by RCTs. The primary efficacy measure was pain intensity or functional status. A total of eight RCTs met our inclusion criteria that included 606 randomized patients. Curcuminoids were found to significantly reduce pain (SMD: -0.57, 95% CI: -1.11 to -0.03, P = 0.04). This pain-relieving effect was found to be independent of administered dose and duration of treatment with curcuminoids, and was free from publication bias. Curcuminoids were safe and well tolerated in all evaluated RCTs.

(Sahebkar A, Henrotin Y. Analgesic Efficacy and Safety of Curcuminoids in Clinical Practice: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Pain Med. 2016 Jun; 17(6): 1192-202). Recommended dose of 400-600mg TID. A quality supplement by New Chapter is Zyflamend. (http://www.newchapter.com/zyflamend/zyflamend-whole-body)

Green Tea: Its use in the treatment of arthritic disease as an anti-inflammatory agent has been recognized more recently. The constituents of green tea are polyphenolic compounds called catechins, and epigallocatechin- 3 galate is the most abundant catechin in green tea. Epigallocatechin-3 galate inhibits IL-1–induced proteoglycan release and Type 2 collagen degradation in cartilage explants. In human in-vitro models, it also suppresses IL-1β and attenuates activation of the transcription factor NF-κB. Green tea also inhibits the aggrecanases, which degrade cartilage.

The usual recommendation is 3 to 4 cups of tea a day. If the patient is taking green tea extract, a dosage of 300 to 400 mg is typical.

Omega-3: EFA, found in fish oil, can directly reduce the degenerative enzymes aggrecanase and matrix metalloproteinase, as well as IL-1, TNFα, and COX-2 to reduce the inflammation in synovial cartilage.

A recent study of 250 patients with cervical and lumbar disc disease who were taking NSAIDs revealed that 59% could substitute fish oil supplements as a natural anti-inflammatory agent for the NSAIDs. The recommended dosage is a total of 1.5 to 5 g of EPA and DHA per day, taken with meals. Typically, persons on a regimen of anticoagulant medications should not take omega-3 EFAs because of the possibility of increasing the bleeding potential.

Pycnogenol: Like white willow bark, this is a nutraceutical material that has been used since ancient times. Pycnogenol is derived from the bark of the maritime pine tree (Pinus maritima) and has been used for more than 2000 years. It contains a potent blend of active polyphenols that includes catechin, taxifolin, procyanidins, and phenolic acids. It is one of the most potent antioxidant compounds currently known.[120]

Pycnogenol inhibits TNFα-induced NF-κB activation as well as adhesion molecule expression in the endothelium. Vigorous sports activity dramatically increases oxygen consumption, by 10- to 20-fold over the resting state. Hence, an increased number of free radicals is generated during exhaustive exercise.

Pycnogenol is thought to counteract the deleterious effects of these free radicals and improve blood flow to muscle, as was demonstrated by Pavlovic in a double-blind cross-over study of 24 recreational athletes. A small 2007 University of Arizona study found pycnogenol reduced osteoarthritis pain by 43 percent and stiffness by 25 percent. Two 2008 studies showed significant improvements in joint pain, stiffness and function that persisted after the supplement was stopped. But a 2012 review concluded that these studies were poorly designed and underpowered.

How Doctors Can Help Reduce Symptoms of OA

Prescription or Over-the-Counter Analgesics or NSAIDs

Analgesics: Pain relievers, or analgesics, such as acetaminophen (e.g. Tylenol), or tramadol (e.g. Ultram) are used to relieve pain, but do not alleviate inflammation or swelling. Because they have few side effects, analgesics are recommended for patients experiencing mild to moderate pain.

NSAIDs (Non-Steroidal Anti-Inflammatory Drugs):  This group includes such painkillers as aspirin, ibuprofen (e.g. Advil), naproxen (e.g. Aleve), cox-2 inhibitors) are used to reduce swelling and inflammation, and are recommended for patients experiencing moderate to severe pain.

Remember, OA joint pain is a chronic condition that may require long-term treatment. As with all NSAIDs, it’s important to use the lowest effective dose for the shortest time possible. You and your doctor can develop a treatment plan that’s right for you. Drug therapy is used to manage physical symptoms, with a focus on relieving pain and slowing progression of the disease.

Topical Analgesics: Topical analgesics are creams that can be applied directly to the skin over the affected area. The primary ingredients in these creams are usually counterirritants, such as wintergreen and eucalyptus, which stimulate the nerve endings and distract the brain from joint pain. Topical analgesics are available in most drug stores, and can be used in combination with most oral pain medications.

Voltaren® Gel is a nonsteroidal anti-inflammatory drug (NSAID) used for the relief of joint pain of osteoarthritis in the knees, ankles, feet, elbows, wrists, and hands. Voltaren® Gel has not been studied for use on the spine, hip, or shoulder.

Physical Therapy

Referral to a Physical Therapist to guide you in a strengthening and balance program. A literature review by Runhaar et al indicated that the mechanisms by which exercise reduces pain and improves function in cases of osteoarthritis may include the development of increased upper leg strength, the reduction of extension impairments, and the improvement of proprioception.

Swimming, especially aerobic aquatic programs through the Arthritis Foundation, can be helpful. Certain studies also indicate that a home exercise program for patients with OA of the knee provides an important benefit

Guided Injections

Steroid Injections: Corticosteroids are medications that mimic the effects of the hormone cortisol, which is produced naturally by the adrenal glands. Cortisol affects many parts of the body, including the immune system. It helps lower levels of prostaglandins and downplays the interaction between certain white blood cells (T-cells and B-cells) involved in the immune response. Corticosteroids stimulate this effect to control inflammation.

Steroid injections are great for acute pain relief. Your physician may administer them every 3-6 months. They have the potential to transiently increase your blood glucose and may accelerate cartilage breakdown.

(Dragoo JL1, Danial CM, Braun HJ, Pouliot MA, Kim HJ. The chondrotoxicity of single-dose corticosteroids. Knee Surg Sports Traumatol Arthrosc. 2012 Sep;20(9):1809-14. doi: 10.1007/s00167-011-1820-6. Epub 2011 Dec 21.)

Visco-Supplementation:  EUFLEXXA is a hyaluronic acid (HA) product that is manufactured from a natural source of HA. HA is a natural substance that is found in the human body as well as in animals and bacteria. In the human knee, HA is a thick, slippery fluid that helps cushion, lubricate, and protect the bones and joint tissue.

In patients with OA of the knee or hip, the HA gets thinner over time and becomes less able to provide protection. EUFLEXXA is used to relieve OA knee pain in people who do not get enough relief from simple pain medications such as acetaminophen, ibuprofen, or naproxen or from exercise and physical therapy.

Do not take this product if you have had any previous allergic reaction to EUFLEXXA or hyaluronan products.

Platelet-Rich Plasma (PRP) Therapy: Sometimes called PRP therapy or autologous conditioned plasma (ACP) therapy, attempts to take advantage of the blood’s natural healing properties to repair damaged cartilage, tendons, ligaments, muscles, or even bone.

Although not considered standard practice, a growing number of people are turning to PRP injections to treat an expanding list of orthopedic conditions, including osteoarthritis. It is most commonly used for knee or hip osteoarthritis, but may be used on other joints or tendons as well. Platelet-rich plasma is derived from a sample of the patient’s own blood.

The therapeutic injections contain plasma with a higher concentration of platelets than is found in normal blood. Plasma is the liquid component of blood; it is the medium for red and white blood cells and other material traveling in the blood stream. Plasma is mostly water but also includes proteins, nutrients, glucose, and antibodies, among other components.

Like red and white blood cells, platelets are a normal component of blood. Platelets alone do not have any restorative or healing properties; rather, they secrete substances called growth factors and other proteins that regulate cell division, stimulate tissue regeneration, and promote healing. Platelets also help the blood to clot; a person with defective platelets or too few platelets will bleed excessively from a cut.

A 2016 study comparing PRP to visco-supplementation demonstrated improved pain score and function at the 12-month follow-up in the PRP group. Other WOMAC and SF-36 parameters improved only in the PRP group.

(Raeissadat SA1, Rayegani SM2, Hassanabadi H3, Fathi M4, Ghorbani E5, Babaee M5, Azma K6. Knee Osteoarthritis Injection Choices: Platelet- Rich Plasma (PRP) Versus Hyaluronic Acid (A one-year randomized clinical trial). Clin Med Insights Arthritis Musculoskelet Disord. 2015 Jan 7;8:1-8. doi: 10.4137/CMAMD.S17894. eCollection 2015)

Stem Cell Treatments: May be discussed during clinic visit and as detailed in a separate hand-out.

Referral to an Arthritis Specialist

Your primary care physician can refer you to a doctor with additional training in arthritis to help you explore the correct treatment course for you.

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