Feed: The Arthritic Knee - AggScore: 72.9
Summary: The Arthritic Knee
You've got osteoarthritis but do you have the information you need to combat your pain? Find it here, and inform yourself about the surgical and non-surgical treatment options for the arthritic knee.
Different Aspects of Arthritis Knee Pain
It has long been known that the perception of pain is multi-factorial. In the case of knee osteoarthritis it is more than the wear of the joint surface that leads to the experience of pain.
Red heads have been shown to be more sensitive to pain and
there are differences in perception between men and women.
Women are more sensitive to pain (but are just as good as men
at tolerating it).
A recent Korean study looked at knee x-rays and the level of
reported pain in over 650 people. Those diagnosed with
depression experienced more pain than others with the same
level of osteoarthritis.
It has been suggested that a comprehensive treatment should
address both the depression and the osteoarthritis. The role of
chronic pain in potentially contributing to the depression
should also be investigated.
Living with pain is difficult and the more that is understood,
the better the available treatments will be.
For more on the Korean study, click here.
Date Published: Jul 23, 2011 - 4:44 am
More Stem Cell Research
There are many reasons to delay major surgical intervention until the benefits significantly outweight the risks. One of these is that the passage of time allows for the development of new treatments.
A simple point worth considering: There is likely to be more research into osteoarthritis treatment in the next 5 years than there was in the last 15.
Why?
Money, that's why.
Multinational companies spend their research and development funds on areas most likely to produce a return on their investment. Easy problems are solved first, then more difficult problems are addressed in order of their market size. The good news for sufferers of osteoarthritis is that the large baby boomer population is reaching retirement age. The number of people with knee osteoarthritis is rising exponentially and with it potential profits for the company that comes up with a minimally invasive treatment that is effective for the majority of patients.
Stem cell research is one area showing a lot of promise in the treatment of many diseases. On top of the first human arthritis stem cell research in the UK, another study is looking at the ability of stem cells to repair meniscal tears - a common sporting injury that often leads to early onset osteoarthritis. Both of these studies are of limited size and both involve the surgical implantation of cells but they represent important steps on the path to the goal treatment of a simple injection that has major benefits (for more on this study, click here.)
Every year you are able to delay a knee replacement gives researchers more time to develop new treatments. This is why I am a big advocate of (essentially risk-free) delaying tactics such as weight loss, quads exercises, and unloader knee braces.
Date Published: Jun 29, 2011 - 5:33 am
Lateral Heel Wedges
Medial compartment osteoarthritis often leads to a varus
deformity commonly known as being knock-kneed. This alters the
biomechanics of the leg and the angle causes an increase in the
percentage of body weight taken through the worn half of the
knee.
For this reason many treatments for unicompartmental knee
osteoarthritis look at addressing this deformity.
These include:
Lateral Heel Wedges.
Lateral heel wedges are thought to work by raising the outside
border of the heel that in turn unloads the medial compartment of
the knee.
A recent study in Melbourne, Australia looked at the effect of
patients wearing these wedges for a period of 12 months.
They found that those wearing the lateral wedges (5 degree
inclination) had no difference in pain scores to those in the
control group who had zero degree insoles.
The authors also looked to see if there was any difference in the
progression of arthritis but again found no difference in
cartilage loss or the presence of bone marrow lesions.
The conclusion: Lateral Heel Wedges provide no symptomatic or
structural benefits when worn for a period of 12 months.
This is in agreement with the Knee Osteoarthritis Guidelines
published by the American Academy of Orthopedic Surgeons in 2008
(see AAOS Knee Arthritis Guidelines) who included
heel wedges in the list of treatments that have been shown to be
ineffective.
For more information on the Australian study, click here.
Date Published: May 27, 2011 - 10:43 pm
Chondroitin - New Research
Chondroitin has long been found combined with Glucosamine in supplements claiming to help those suffering from osteoarthritis. The majority of the studies done have been either on Glucosamine alone or on Glucosamine plus Chondroitin.
A new paper published in The Annals of the Rheumatic
Diseases has looked at Chondroitin in isolation and the
effect it has on the progression of osteoarthritis.
What makes this study different is the outcome measures used to
examine the effect of Chondroitin. Previous studies have used
subjective measures (such as reported pain and ability to
sleep) with objective functional measurements (such as timed
walking tests, ability to climb stairs).
As the object of this paper was not to see if the supplement
decreased pain or improved activity but if it changed the
disease process, MRI scans were used to "keep score".
The scan measured changes in cartilage volume, lesions in the
subchondral bone (an important predictor of severity) and
synovitis as well as noting any reported changes in symptoms.
The study was randomized, double blinded and placebo controlled
and the total number of patients was 69.
The treatment dose was 800mg of Chondroitin once a day.
The results showed that the treatment group:
- Had less cartilage loss at both 6 and 12 months
- Had less subchondral bone marrow lesions at 12 months
- Had no difference in reported symptoms
-------------------
It can be difficult to find Chondroitin supplements on their
own. I was unable to find any 800mg (or 400mg) Chondroitin but
was able to find 600mg here. I am personally going to give this a
go for at least 12 months. I am particularly impressed by the
changes in the bone marrow lesions and although I do not
currently have any myself, I consider anything that may prevent
them of high importance.
It is much easier to find Chondroitin combined with
Glucosamine, I was able to find this product (3 caps = 1500mg Glucosamine /
750mg Chondroitin) with one years supply only costing $50.
This works out significantly cheaper than getting Chondroitin
on its own (as there is much more competition in this market).
Having said that, I am a follower of the evidence and will
stick with the Chondroitin until a study comes along to show
the benefits of the combination are better than the single
supplement. The evidence to date on Glucosamine has been
borderline and although it is a safe supplement I am unaware of
a study such as the one mentioned above that shows a strong
positive effect from its use.
This study produced some exciting results and it should inspire
a lot of follow up research. It is enough for me to go from
taking nothing more than fish oil to giving Chondroitin a one
year trial.
To read more on the Chondroitin article, click here.
Date Published: Mar 13, 2011 - 4:19 am
Prehabilitation - Exercise in the lead up to surgery
It is never too late to start exercising.
I spend a lot of time educating people about the benefits of
exercise. Increased strength and function, decreased pain and the
potential slowing of the disease process are all good reasons to
do a knee exercise program.
Physical therapists have long noted that those with good
quadriceps muscles on average recover quicker following knee
replacement surgery. Those who have decided to go ahead with a
joint replacement should not cease normal activities or feel they
have nothing to gain from the lead up to their surgery.
A recent study in the Journal of Strength and Conditioning
Research looked at the effects of 'Prehabilitation' - an
exercise program done in the period before surgery.
Although the exercises were only done for between 4 and 8 weeks
prior to surgery, the exercise group outperformed the control
group in both leg strength and ability to perform functional
tasks.
It really is never too late to start and anyone on a waiting list
for surgery or who feels that the time for them to consider it is
close should be looking to exercise.
Exercise has consistently shown to offer benefits from diagnosis
through to post-operative rehabilitation.
It does take will power and persistence but offers good results.
Despite this, thousands of people ignore exercise and spend a
fortune on unproven remedies.
Sometimes you need to do the work to get ahead. If you have been
unable to get started with an exercise program due to pain in
your knee, seek the help of a physical therapist and see what you
can achieve.
For more on the 'Prehabilitation' article, click here.
Date Published: Jan 25, 2011 - 9:32 pm
Doctors Not Following Guidelines for Knee Arthritis.
A January 2011 article to be published in Arthritis Care and Research suggests that doctors are ignoring the latest evidence-based guidelines and continuing to prescribe analgesics and refer patients for surgery.
This behavior is consistent with the "traditional" treatment of
osteoarthritis - Take painkillers until the pain becomes
unbearable then have the joint replaced.
This ignores the strong evidence supporting conservative
non-pharmacological management of osteoarthritis. These
treatments can be used during the period between diagnosis and
end stage disease and aim to delay or prevent the need for
surgery.
My personal opinion is that this occurrence is in part due to the
culture of today. Treatments proven to benefit knee arthritis but
requiring will power and hard work (exercise and weight loss
programs), are less popular than "easy" treatments (oral pain
medication and arthroscopic surgery) despite their relatively
ineffectiveness.
Motivation is the key to success and this will be the challenge
to governments looking to reduce the cost of osteoarthritis
treatment. The analgesia-surgery model is unsustainable
financially and it seems illogical to ignore treating the middle
stage of the disease.
Lifestyle programs incorporating weight loss and exercise plus
the use of assistive devices such as unloader knee
braces will be the focus of future treatment programs as cost
effectiveness becomes increasingly important.
I still see the occasional patient who asks for the facts, does
every one of the proven treatments, and does very well. The
majority however want the magic wand waved over them and all to
be fine.
For more, read the article here.
Date Published: Jan 07, 2011 - 3:04 am
Stem Cell Research - What Do Humans and Leopards Have in Common?
The potential of Stem Cells is being investigated for the treatment of many conditions and osteoarthritis is no exception.
Many believe that stem cells offer the best hope of growing new
cartilage to cover the defects caused by osteoarthritis. There
have been a number of animal studies published that look
promising and now human trials are beginning.
In the UK, a new study is due to begin at the end of 2010. It
will be looking into the effects of adding stem cells to
traditional chondrocyte cells that are used in Autologous
Chondrocyte Implantation surgery. It is hoped the addition of
these cells will lead to a graft that more closely resembles
normal articular cartilage.
For more information on this see:
In other news, just as human trials are beginning, so are Snow
Leopard trials. In Australia, Sydney's Taronga Zoo has recently
operated on one of its endangered Snow Leopards who was crippled
by osteoarthritis. It is hoped the stem cells will restore
function to a progressively degenerative knee.
It will be a few years before we learn of the outcome on research
into stem cell treatments but it will be an exciting time for all
of those suffering from degenerative joint disease.
Date Published: Nov 22, 2010 - 4:20 am
Periprosthetic Fracture
Knee replacements are tough. The metal components are much stronger than natural bone and the high density platic spacers are also very resilient.
Unfortunately, if you apply a force to your bone that would have broken it before your knee replacement, it will probably break it afterwards. The main difference now is that many of the methods used to fix fractures around the knee can't be used as the knee replacement gets in the way.
This raises an interesting question that was discussed at the recent Australian Orthopaedic Association conference. Knee replacements increase function and decrease pain, allowing people to return to activities they had previously ceased. So should you return to high risk sports such as snow skiing just because you can?
It has been noted that the number of sports that surgeons are happy for their patients to return to has been increasing but there has been no evidence to back this decision. It has been hypothesized that some surgeons are promoting the return to more extreme sports as a form of advertizing. Given that there are known difficulties for traumatic injury treatment following knee replacement, and the unknown effect of some sports on the life of a replacement, it is a fair question to ask.
Of course one of the main benefits of knee replacement surgery is allowing people to return to activities that had been denied them. Everyone should make an informed decision on the benefits and risks of any activity but when the risks are unknown a higher degree of scepticism should be employed. The goal of a knee replacement should be remembered - to allow everyday activities without pain. As younger people investigate the option of a total knee replacement, this issue is likely to receive more attention.
We may well be able to quantify the risk of certain activities in the future, but until then it is "buyer beware".
Date Published: Oct 30, 2010 - 4:32 am
Knee Replacement after High Tibial Osteotomy
A new German study has just been published looking at the outcomes of knee replacements done after a High Tibial Osteotomy compared with uncomplicated first time joint replacements.
Previous studies looking at this question had found higher rates of complications and an increased duration of surgery.
The findings from this study are:
No significant difference in length of operation
No significant difference in complication rate.
X-ray assessment at follow up showed no significant difference between the groups.
The High Tibial Osteotomy group had a lower range of motion. The average works out at 9.5 degrees less movement
The follow up time for the study was an average of 7 years making it difficult to comment on failure rates in the long term. The medium term results were on the whole fairly similar with the exception of joint range of motion.
For the whole study, click here.
Date Published: Sep 15, 2010 - 4:58 am
Tibial Plateau Fracture - Factors Affecting Outcomes
Tibial plateau fractures are associated with an increased risk of osteoarthritis. These fractures are intra-articular - the fracture passes through the smooth surface of the joint. After the fracture is healed there is generally an area of irregularity, even a good result is not as smooth as the joint was prior to injury.
With the thousands of steps we take each day any small step in the surface is thought to increase the rate of wear. The result is post traumatic osteoarthritis.
Some areas of the body tolerate intra-articular fractures better than others. Studies have shown that the tibial plateau is more forgiving than some areas. Other factors seem to have a significant say in the development of arthritis.
These include joint stability, the survival of the meniscus, and the presence of angulation at the knee (varus or valgus deformity).
Many people suffering a tibial plateau fracture will go on to need a total knee replacement. If the fracture does not damage any ligamentous structure, the meniscus survives and there is no angulation at the knee, the risk may be modest. Major fractures also damaging supporting soft tissue structure are likely to have a much poorer outcome.
Click here for more information.
Date Published: Sep 10, 2010 - 4:18 am
Why Does Weight Loss Matter So Much In Knee Arthritis
It is obvious that the more weight you carry, the harder your joints will work but most people don't understand how much of a difference it makes.
Take walking for example. The impact of our feet hitting the ground in walking creates a force equal to around three times our body weight. All of your weight is transferred through a single leg (while the other is in the air stepping forward) and we take thousands of steps a day.
What about running? The increased impact with the ground raises the forces to around 5 times body weight. This is a significant amount. Every extra 20 pounds of weight you carry means an extra 100 pounds of force through your knee every step you take when running.
And jumping? Does it get worse?
Yes - Landing from a jump brings the force through the knees up to the order of seven times body weight.
When you look at numbers like these it is easy to understand why weight loss is one of the most effective treatments of osteoarthritis.
Date Published: Aug 25, 2010 - 4:30 am
Knee Arthritis - Stem Cell Therapy
Stem cells are getting a lot of press coverage as scientists look to use them to treat a wide variety of diseases. Stem cells are receiving this focus as the have the ability to turn into many other types of cell. Researcher looking into osteoarthritis hope to be able to harness their power to rebuild the articular cartilage that has been worn away.
There has been some excitement lately as a British team have announced they will commence a human trial at the end of this year bringing theory into practice.
They plan to combine stem cells with an existing treatment for knee osteoarthritis, Autologous Chondrocyte Implantation. ACI is the harvesting of cartilage cells via keyhole surgery and growing them in a laboratory. They are later implanted into the joint to cover the defect.
The new study will look at adding stem cells to the cartilage cells as well as looking at adding both stem cells and bone marrow cells to the cartilage mix. It is hoped that the new technique will demonstrate a longer term solution to knee joint pain caused by osteoarthritis. The study will run throughout 2011 and will include around 70 patients.
More information can be found here.
Date Published: Jul 21, 2010 - 5:34 am
Total Knee Replacement - Quads Are Important
When it comes to the stage where only a total knee replacement will do, quadriceps strength is vital.
Having helped hundreds of people to get home after a knee replacement, I have noticed certain factors obviously affect the ease of recovery.
Weight is important. It is easy to put on a few extra pounds when every step hurts. You are less likely to remain active while your eating remains about the same. Extra weight puts more stress on the knees and also make recovering from surgery more difficult.
Attitude is important. Motivated people handle the discomfort immediately post-op better and realize that the best time to get the knee moving is in the first few days, despite the pain.
Pain relief is important. Skilled doctors, sympathetic to their patients needs can greatly affect the short term outcomes through effective pain relief. The number one reason for slow recovery is pain. Take this away or control it and results improve dramatically.
Quadriceps strength is important. Your quads straighten the knee, keep you upright, and support the knee joint. It is normal for the quads to become weaker over time with osteoarthritis as pain leads to less activity and results in the associated loss of strength.
Any improvement in quads strength you make in the lead up to a knee replacement will make your recovery easier. The sooner someone is able to lift their leg straight up off the bed, the sooner they are likely to go home. I encourage anyone on a waiting list for a knee replacement to make the most of their time.
Even extremely painful knees can usually find a simple exercise to increase strength.
For some ideas of where to start, see my previous post on exercise here.
If you are considering a knee replacement, your first step should be the introduction of an exercise program. It will be the best thing you have ever done for your knee.
Date Published: Jun 19, 2010 - 7:53 am
Knee Osteoarthritis Becoming More Common In Younger People
The incidence of knee arthritis is rising in young people and researchers are trying to find out why.
Osteoarthritis is thought of as a disease of the elderly but although more common with advancing age, young people can also feel the pain of arthritis.
It has been known for many years that fracturing a bone through the joint surface leads to the early onset of osteoarthritis. Now it is being suggested that other injuries such as rupturing the Anterior Cruciate Ligament (ACL) can also greatly increase the risk. A significant impact, even one insufficient to fracture the bone, can cause damage to the articular cartilage. It has been estimated that around half of those rupturing their ACL will develop early onset osteoarthritis within 5 - 10 years.
Another reason for early arthritis is the growing rate of obesity in society. The knees are particularly sensitive to the increased load caused by gaining weight. The mechanical effect of obesity has been described as the chronic overloading of weight bearing joints that results in an increased rate of cartilage wear.
Osteoarthritis is a serious condition and surgeons are reluctant to replace joints in young people due to the replacements limited lifespan. Young people need to work at all of the non-surgical treatment options to reduce their pain until they are older. Weight loss, muscular strengthening, medication and off-loading braces are all options for the younger arthritic knee.
For more on the latest research into early onset osteoarthritis, click here.
Date Published: May 28, 2010 - 11:20 pm
Arthritis Knee Braces Ease Pain
A new study has been published investigating the effectiveness of off-loading knee braces for osteoarthritis of the knee.
The study looked at 49 individuals with knee arthritis and the
effect the brace had after 6 months of use.
The results showed that wearing the brace helped 31% of
participants take less over-the-counter anti-inflammatory
medication and 35% took less prescription anti-inflammatory
drugs.
Users were also able to restart recreational sporting activities
that they had previously enjoyed.
This all sounds great but there are a few things to note. The
results need to be taken with a grain of salt because in the
study, the braces were provided by one company (Ossur) who
also financed the study and the associated media briefing. The
study also had a small sample size of less than 50 which
decreases the statistical power of the results. A larger,
independent study would offer stronger support but it is another
example of the growing body of evidence in favor of off-loading
knee braces for osteoarthritis.
For more information on the study click here.
Date Published: May 01, 2010 - 5:22 am
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