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11 Articles in Volume 6, Issue #4
Assessing Secondary Gain In Chronic Pain Patients
Chronic Overuse Sports Injuries
Introducing Low Level Laser Therapy to Pain Management
Managing Diabetic Peripheral Neuropathic Pain (DPNP)
Moral Virtue and the Pain Physician
Non-pharmacologic Therapy for Chronic Opioid-dependent Sickle Cell Pain
Osteoarthritis of the Knee
Smoking and Low Back Pain
Temporal Tendinitis Migraine Mimic
The Underutilization of Intrathecal Treatment
Tumblin’ Dice–Why Does Random Matter?

Osteoarthritis of the Knee

Pain management options for alleviating pain and increasing mobility for patients with this disease.

Osteoarthritis is the most common form of arthritis, afflicting more than 21 million people in the United States. As America continues to age, some estimates suggest that as many as 70 million or 20 percent of Americans will suffer from some form of arthritis by 2030.1 Osteoarthritis (OA) of the knee is one of the five leading causes of disability among seniors, and the risk for disability is just as great as that from cardiovascular disease. Pain drives the treatment of osteoarthritis and, after years of dealing with increasing discomfort, many patients eventually have total knee replacement surgery. With gradually thinning cartilage and changing joints, joint cartilage eventually deteriorates and daily activity for patients with OA Knee becomes very painful. Treatment options may include prescription drugs, diet and exercise changes, and joint fluid therapy.2

According to the American Academy of Orthopedic Surgeons (AAOS), osteoarthritis may develop in knees that have experienced trauma, infection, injury or, more commonly, arise de novo without precipitating cause as people age. Factors like heredity, weight, age and gender can predetermine an individual for osteoarthritis. For example, women over the age of 50 are more likely to develop OA than men over the age of 50. Also, those with occupations that require kneeling or squatting are more prone to develop OA. It is also more prevalent in soccer players, tennis players, and long-distance runners.2

Disease Progression

In a normal knee, cartilage provides a smooth surface so bones can move easily across each other. There is a high concentration of hyaluronan in the synovial fluid that nourishes, cushions, and lubricates the joint. In a knee with OA, the cartilage begins to deteriorate in the early stages of the disease, and the joint space between the bones narrows considerably. This results in the formation of bone spurs by the surrounding bone called osteophytes. At this stage, the synovial fluid has a very low concentration of hyaluronan and is not able to protect the joint. Gradually the joint changes and the articular cartilage continues to fade until the bone ends scrape against each other and the joint becomes deformed. This is when activity for OA patients is the most strained and painful.3 See Figure 1 for comparison of a healthy joint to one ravaged by OA.

Often, patients experiencing mild to moderate pain may report the symptoms to their doctor. Physicians often ask a few questions to determine the source of the pain:

  • Is your knee stiff in the morning?
  • Does your knee hurt when you move?
  • Does your knee hurt when you are not moving?
  • Do you hear a crackling sound or have a grating feeling?
  • Is the skin around your knee red and swollen?3

X-rays (see Figure 2) are also used to see how far the disease has progressed and, if a patient is found to have OA of the knee, they will join 21 million other Americans on the route to finding the right course of treatment.4

Figure 1. Inside Osteoarthritis of the Knee .

Pain Management Modalities

Because there is no cure for osteoarthritis, treatment is focussed on alleviating pain and improving the quality of life and mobility of the patient. The American College of Rheumatology recommends a sequence of treatments depending on the severity of pain caused by osteoarthritis.5

Exercise and Weight Loss. One of the main causes of osteoarthritis is stress on the knee joints caused by obesity and too much pressure on the body. A regime of a healthy diet and exercise can help a patient lose weight and lessen the pain pressure on the patient’s knees. In fact, even if one doesn’t currently have osteoarthritis, weight loss of as little as 11 pounds can reduce the risk of developing knee osteoarthritis by 50%. Physicians may prescribe a light exercise regime of low-impact sport for 30-60 minutes, three times a week. Some patients may also choose to brace their knee during exercise for added comfort. Moderate physical activity at least three times a week can reduce the risk of arthritis-related disability by 47%.4

Analgesics and Anti-Inflammatories. If exercise and diet changes don’t alleviate discomfort, many patients turn to over-the-counter pain medication and anti-inflammatories for relief. While at first, acetaminophen, aspirin or ibuprofen may be a good source for pain relief; most OA Knee sufferers will eventually need more potent analgesics to control their pain. COX-2 inhibitors, the latest in nonsteroidal anti-inflammatory drugs (NSAIDs), are drugs that inhibit an enzyme involved in inflammation but spare COX-1, which limits gastrointestinal toxicity. The only COX-2 inhibitor still on the market in the United States is Celecoxib. Rofecoxib and Valdecoxib were taken off of the market in September 2004 and April 2005, respectively.6

Corticosteroids are another common form of treatment for osteoarthritis. This is a medication that is injected into a joint that is swollen and painful, as opposed to being taken orally. These drugs are primarily targeted towards lessening inflammation and decreasing pain over a short amount of time. These steroid injections can only be administered three or four times a year to the same joint, and there are several side effects involved such as fluid retention, weight gain, nervousness, and high blood pressure.7

Knee Replacement Surgery. Many physicians argue that a total knee replacement is the only way to return the most quality of life to patients with osteoarthritis of the knee. However, surgery is very costly. The cost of a total knee replacement and the hospital stay can amount to $30,000.8 A study presented at the 73rd Annual Meeting of the American Academy of Orthopedic Surgeons (AAOS) predicts that the demand for such surgeries is expected to increase 673 percent by 2030, and there may not be enough orthopedic surgeons to perform these surgeries.9 This dramatic increase is because of the aging population and prevalence of overweight and obese Americans. Such a demand for surgeries and for orthopedic surgeons would inevitably burden the current health care system and patients would have to wait longer for surgery.

Patients are often told, however, to exhaust every alternative of pain relief therapy before they undergo a total knee replacement. Complications can include infection, nerve damage and, if the prosthesis used to replace the joint loosens, the surgery may need to be performed all over again.8 According to the AAOS, joint replacement is still one of the most successful procedures conducted by orthopedic surgeons today and, if a patient commits to the surgery, outcome studies have shown an immediate and dramatic benefit to the patient. The average age of those getting total knee replacements in 1999 was 69, and the average hospital stay was about 4.5 days. Women are much more likely to have the knee replacement surgery than men, but at a more advanced stage of osteoarthritis than men do.10

Figure 2. iagnostic x-ray for osteoarthritis.

Joint Fluid Therapy (JFT). If exercise, physical therapy and pain relievers don’t offer the patient the pain relief they need, and a total knee replacement is not an option, joint fluid therapy is an attractive option for many OA Knee sufferers with mild to moderate pain. Joint Fluid Therapy is an FDA approved treatment for osteoarthritic knee pain using intra-articular injections of hyaluronic acid. It provides relief from arthritis pain for many patients by injecting hyaluronan into the knee. Hyaluronan is a natural substance similar to that found in particularly high amounts in joint tissues and in the synovial fluid that fills the joints. The body’s own hyaluronan acts like a lubricant and shock absorber in the synovial fluid of a healthy joint.3

Joint fluid therapy is administered by removing the diseased joint fluid and replacing it with a fluid having improved viscosity and elastic properties. It was developed as a response to the finding that as OA of the knee was progressing, joint fluid became thinner with diminished lubrication and protection properties. In 1987, SUPARTZ, manufactured by Seikagaku Corporation and distributed in the United States by Smith & Nephew since 2001, became the first hyaluronan treatment approved for the relief of OA pain in the world. Today, it is the most prescribed JFT treatment worldwide, with over 155 million injections sold. Because it is injected directly into the knee, it does not interfere with other medications the patient may be taking, and it shows no more incidences of side effects than the place bo control group.3

SUPARTZ was recently approved by the FDA to give the physicians more choice when prescribing a form of JFT treatment. Although joint fluid therapy is still indicated for five weekly injections, the amendment to the directions for use and the precaution section of the labeling now allow physicians to choose as few as three weekly injections for their patients with osteoarthritis knee pain if the physician judges the patients would experience benefit. While JFT is not for every osteoarthritis patient, it has proven to provide significant pain relief to patients who have tried other drug and non-drug therapies.3

Studies suggest that most patients experiencing relief do so after the full series of five injections however, some patients may experience benefit with three injections given in weekly intervals. The actual amount and duration of pain relief varies from patient to patient. A physician administers injections directly into the knee once a week. The doctor may administer a local anesthetic prior to the injection to minimize any possible discomfort associated with the injection. For 48 hours after receiving an injection, the patient should avoid activities such as jogging, tennis, heavy lifting, or long periods of standing. As with any JFT, pain and swelling of the injected joint may occur after treatment.3

Patients are candidates for JFT if they meet these criteria:

  • knee pain is due to osteoarthritis
  • patient is not getting adequate pain relief from walking or physical therapy
  • patient is not getting adequate pain relief from ibuprofen, acetaminophen, naproxen sodium and other COX-2 inhibitors or NSAIDs like Celecoxib3

Patients are not candidates for JFT if they are allergic to products from birds such as feathers, eggs, and poultry since products like SUPARTZ are made from rooster combs.3

Other OA Treatments

Other treatments of osteoarthritis include alternative therapies like acupuncture and magnetic pulse therapy, but most trials and studies of these methods have not been conclusive enough for patients to rely solely on these treatments. Other alternative treatment options requiring additional studies include topical NSAIDs and Vitamins C, D or E.11

Discussion

As the baby boomers move into their retirement years, the nation’s health care system will need more and more effective ways to manage pain and treat patients in a cost effective way. Expensive pharmaceutical drugs and increasingly sophisticated medical technology, together with longer life expectancy of seniors, contribute to the growing cost of health care.12 Studies show that baby boomers have a heightened awareness of medical issues and research, with 48% of adults closely watching the news coverage about the voluntary withdrawal of Rofecoxib from the market. This population is not afraid to ask for more explanations from their doctors and to get second opinions. They typically know their medical options when they are diagnosed with something like osteoarthritis.13

In 2003, Medicare covered 35 million enrollees ages 65 and over, and six million enrollees under age 65 with disabilities. This comprises 14% of the total U.S. population. By 2030, the number of people on Medicare is expected to almost double, with a projected 77 million enrollees.

One of the hardest health care challenges for older Americans is paying for their prescription drugs. Older Americans with Medicare pay 15 percent more for prescriptions than many patients in insurance programs and as people age they tend to spend more and more money on prescription drugs.14 In the case of osteoarthritis pain management, joint fluid therapy does not interfere with other medications and it lessens seniors’ reliability on pain medications. SUPARTZ, for example, is one of the treatments that is covered by both Medicare and most insurance policies. Note that procedures for reimbursement vary depending on the payer and the policy, and many require that a doctor provide joint fluid therapy at the office.

Conclusion

The aging population and increasing cost of health care will greatly impact our future health care system and the methods we use to treat conditions like osteoarthritis. With numerous treatment options for OA, decisions about treatment should ultimately be made between the patient and the physician and consider factors such as the degree of pain and incapacitation, potential drug interactions, as well as medical reimbursement. The characteristics of joint fluid therapy makes this a popular option for increasing mobility and quality of life. n

Last updated on: December 20, 2011
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