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
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:
- 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.
- 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.
- 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
- 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.
- 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
- 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
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