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14 Articles in Volume 15, Issue #6
Antihistamine for G-CSF–Induced Bone Pain
Book Review: Advanced Headache Therapy
Brain Drain: Lymphatic Drainage System Discovered in the Brain
Case History of Chronic Migraine: Update 2015 Part 2
Disturbed Sleep: Causes and Treatments
Is Topical Ketamine Ready For Prime Time?
Letters to the Editor: Central Sensitization, Microglia Modulators, Supplements
New App Helps Interpret Urine Drug Test Results
Osteoarthritis Update: 2015
Pain Catastrophizing: What Clinicians Need to Know
PPM Editorial Board: Tips for Treating Osteoarthritis
Practical Overview of Osteoarthritis
Status Report on Role of Stimulants in Chronic Pain Management
Treatment of Osteoarthritis

PPM Editorial Board: Tips for Treating Osteoarthritis

As a medical specialist in musculoskeletal medicine and physical medicine and rehabilitation, I have treated thousands of patients with osteoarthritis (OA) and other associated arthritides over my medical career. After reviewing the medical literature and empirical evidence available to the medical community, I am in strong support of the importance of exercise, nutrition, and occasional proper, well-informed treatments for these conditions.

Various studies have shown the virtues of moderate daily exercise for 30 to 60 minutes and the addition of natural antioxidants to daily dietary intake. The biggest problems I see in my athletic, sports-minded patient population is not whether they participate in exercise but rather overuse syndromes.1 Patients have trouble knowing when to slow down and try aquatic fitness/therapy, physical therapy, or non-impact exercising such as elliptical and stationary cycling until the overuse injuries have shown improvements. 

Most importantly, patients should always consult a trained, board-certified medical specialist to assist in recovery process and provide medical guidance when arthritic or overuse injuries/ailments persist.

—Elmer G. Pinzon, MD, MPH

Knoxville, Tennessee


Exercise is critical to the long-term management of OA.  “Use it or lose it” is especially true in this condition.  Choosing the right exercise is key. If it is too difficult or painful, then it is hard to maintain motivation, and there may be a risk of injury. If a patient is working with an instructor who is experienced with arthritis, gentle yoga can be very helpful. A “chair yoga” class also can be considered. Tai chi is another wonderful form of slow, controlled movement. My favorite form of exercise for patients with OA is aqua therapy or pool exercise. You need to have access to a pool that is 86o F or warmer. For all these exercises, you need to find an experienced instructor.

—Steven H. Richeimer, MD

Los Angeles, California


I concur with the other advisors’ comments, particularly on healthy lifestyle, weight loss, and emotional health factors.  Some additional pearls we have found useful:

  1. High-dose omega 3 fatty acids (2,700 mg EPA + DHA per day)2 work just as well as NSAIDs but without the adverse effects (gastrointestinal, cardiovascular, renal) and with added benefits for brain, cardiovascular system, bone, and skin.3,4 This may be taken for 1 to 3 months and then tapered down to a lower maintenance dose. The triglyceride form is better than the common ester form for absorption.
  2. N-Acetyl glucosamine (2-3 g/d), trade name Ultimate Glucosamine, works better than the older glucosamine sulphate/hydrochloride forms that need to be taken twice a day, and avoids the risk for higher blood sugar and blood pressure that can be associated with the older forms.
  3. We have had great success with viscosupplementation injections in mild to moderate OA. This applies to the FDA-approved higher molecular weight and cross-linked forms, as shown in a recent study by Strand et al5 that is more accurate than the study by Rutjes et al that lumped all viscosupplementation injections together.6
  4. We are seeing emerging success with platelet-rich plasma injections for OA of the knee, particularly in those who have failed standard cortisone injections and therapy. Success is augmented 3 to 4 times over dextrose prolotherapy and 9 times with the addition of adipose stem cells.7 More research and well-designed randomized controlled trials (RCTs) are needed, which we plan to do at our institution.
  5. Another option for patients who are too sick to have total knee replacement (TKR) and are unable to afford or are non-responsive to the above injections is intra-articular onobotulinumtoxin A (Botox).8 After chronic migraine, Botox has been studied in shoulder, knee, and hip pain. It is backed up by small randomized studies.9 Studies also support Botox use in the management of post-TKR pain due to flexion contractures.10 Our typical dose is 100 units using a 2:1 dilution. We recommend not mixing this with local anesthetic because that may denature the Botox molecule. Also avoid injecting bupivacaine hydrochloride (Marcaine, others) into the knee joint. This has been shown to damage cartilage cells and accelerate OA in the rat model.11
  6. Lastly, RCTs support the use of radiofrequency denervation for persistent knee pain in select patients having positive response to ultrasound-guided nerve blocks (much like the facet syndrome model).

—Gordon D. Ko, MD

Markham, Ontario


Here are pearls from my long time experience treating OA:

Heat & circulation: Start morning with hydrotherapy; shower for 5 minutes with a long beach towel wrapped around the body. Let the water drip on the towel while turning slowly in the shower. After 3 minutes, start doing gentle stretches of the neck, trunk, and limbs. Continue stretching for at least 3 minutes after the shower.

Nutrition & nutraceuticals: Have enough fluid intake (8oz) of a non-caffeine variety with each meal. Take 1 to 2 capsules of omega 3 essential fatty acids (over 2,500 mg/d) and 500 mg of vitamin C with each meal. If health allows, replace any sugars with honey and consider fresh garlic in main meals. A copper bracelet will replenish copper needs for production of healthy collagen.

Treatment and exercise: Use paraffin wax treatment liberally for any acute or chronic joint pain for at least 10 minutes twice a day. Gently exercise affected joints, with up to 20 repetitions of movement as tolerated, after the paraffin wax treatment.

Just remember—It’s not how long you live, it’s how long you live well!

—Gabriel Sella, MD, MSc, MPH

Martins Ferry, Ohio


I totally agree with my colleagues. Supervised exercise on a regular basis is important, as is learning how to pace oneself during exercise and all activities of daily living. There are very effective cognitive behavior treatment techniques that can be used in a more comprehensive program for these patients if they are having difficulty doing it on their own.

—Robert J. Gatchel, PhD, ABPP

Arlington, Texas


Patients with suspected osteoarthritic disorders should have vitamin D2 and D3 levels checked—most clinicians and laboratories don’t segregate these 2 items. Also, zinc levels are very important in uncovering immune deficiencies caused by the production of interleukin 6, a proinflammatory cytokine. In addition, pregnenolone, dihydroepiandrosterone sulfate (DHEA-S), and free corticol levels should be measured between 8:00 and 10:00 in the morning. 

As alternatives to medications, astraxanthin and curcumin (with piperine extract 10 mg) are powerful natural anti-inflammatory alkaloids that can stem the use of corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs) for the treatment of OA pain.

—John Claude Krusz, PhD, MD

Dallas, Texas


The expertise of this group is remarkable, and it is enjoyable to hear different ways colleagues are adding to the management of this common yet often underappreciated and undertreated condition.

My suggestion to clinicians and patients alike is start with an accurate diagnosis. All too often arthritis is “assumed:” therefore, either it is not managed effectively by the clinician or is avoided by the patient. How often have we seen patients with trochanteric pain syndrome avoid diagnosis because they do not want a hip replacement? Also, most patients referred for management of knee OA have not had weight bearing and bent-knee radiographs. Although we know pain correlates poorly with the picture, proper treatment of arthritis will be missed if the radiograph is interpreted as ‘normal’ or ‘minimal’ when, in fact, patients can have rather advanced disease.

—Joseph Ruane, DO

Columbus, Ohio


As a health care professional who has a passion for movement science, I am always searching for any treatment or intervention that might facilitate activity/exercise, whether it be biological or otherwise. Our company operates a medical exercise facility and we see OA-related pain more than any other condition. We have for many years understood that regular exercise is integral to the management of OA, so I will reiterate what others have already responded—that properly dosed and executed, exercise is a primary intervention in the management of OA.

Affecting joint nutrition by manipulating diet and/or supplementation as described is still a work in progress but also worth mentioning.

A very promising conservative treatment is one we are testing at our senior performance center in Michigan—pulsed electromagnetic field (PEMF) therapy. Our preliminary clinical findings are completely in line with the life sciences work that has been done on animal subject to date.12

Bottom line—In a very short time, I anticipate we will not be able to keep up with the demand for this treatment. In our senior population, this treatment takes on a different level of importance, allowing people with more active or advanced OA, who normally would not exercise due to pain, to come in for PEMF therapy, followed immediately by an exercise session.

In effect, this treatment also has helped us combat the social isolation often experienced by those suffering from debilitating musculoskeletal problems by giving patients both medically needed care and support.

—Tiziano Marovino, PT, DPT, MPH, DAAPM

Ypsilanti, Michigan

Last updated on: July 26, 2019
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