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Dr Orrange received her BA in Biology at the University of California San Diego and a Masters Degree in Health Sciences at the Johns Hopkins University School of Public Health She received her MD from the USC Keck School of…
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Oh My Aching Knee. A Stepwise Approach to Treating Osteoarthritis.
In 2000, 25 million Americans had osteoarthritis. When arthritis becomes symptomatic in the knee, and it does in 13% of adults over the age of 55, it can impair mobility and be disabling.
Doubts about the safety of some recently prescribed medications like Vioxx and our lack of options for treatment of knee pain from osteoarthritis lends itself to frustration for many of us.Treament is often pain meds and anti-inflammatories, waiting, and eventual referral to knee replacement surgery.
There is a great demand for nonpharmacologic therapy and I think there are good options to consider before starting on meds and surgery. What are the current treatment and management options for arthritis of the knee?
Most studies for osteoarthritis are done looking at the effect of drug treatment and surgery and other conservative measures are often overlooked: exercise, braces, weight loss, and orthotics for example. It seems to make sense that we should start with the above mentioned interventions and leave the medications and drugs if those fail.
Having that in mind here is a stepwise approach to the treatment of osteoarthritis of the knee and hip with the goal being to reduce pain and improve mobility.
First: This is not easy but start with nonpharmacologic therapy including education, exercise, appropriate footwear, weight loss, appliances like insoles (lateral wedged insoles, etc) and knee braces. Exercise includes regular aerobic, muscle-strengthening and range of motion exercises which can be done on your own or taught to you by a physical therapist. Exercises in water can also be effective. If your primary care physician doesn’t help you find these options try and find an orthopedic surgeon to send you in the right direction.
Second: Start gently when you do need pharmacologic therapy. Acetaminophen (Tylenol) is a good start and usually comes in 500 mg or 650 mg tablets for arthritis and up to 4 grams a day can be taken. If this works for you it’s a good and safe long term option and works especially well if taken at night to help fight off the morning stiffness and pain.
Third: Topical applications of NSAIDS (non steroidal anti-inflammatories) and capsaicin work well and are safe to use. The topical preparations like Voltaren you rub on twice a day and they do work well for knee osteoarthritis and you skip most of the side effects of oral medications.
Fourth: When Tylenol doesn’t work it is reasonable to go to an NSAID (ibuprofen, motrin, advil, naproxen) and if they bother your stomach you can think about adding a stomach protecting agent (proton pump inhibitors like prilosec) or switch to a COX-2 inhibitor like Celebrex.
Fifth: When the fourth step doesn’t work for you, it is reasonable to ask about going to opiod analgesics (mixed with Tylenol or not).
Sixth: Other slow acting drugs for osteoarthritis are also reasonable to try: Glucosamine, chondroitin, hyaluronic acid, diacerein do appear to provide some symptomatic relief with low toxicity.
Seventh: Injections of steroid or hyaluronate acid into the joint can be considered for a flare that is unresponsive to NSAIDS and pain medications.
Eighth: Surgery. If you are young a joint-preserving surgery may be attempted but for most joint replacement has to be considered in patients with radiographic evidence of Osteoarthritis who have refractory pain and disability.
What has your experience been?
Dr O.
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Displaying comments 14-1 of 14
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Thank your for this information. I know that osteoarthritis is also a wide-spread disease here in Europe. I have it since many years, combined with fibromyalgia and CFS. The fact that I also have a metabolism problem through which I gained double the weight of before did not make it easier for my joints. For 8 years I was on disability pension. But then I found the Magnetic Field Therapy, which is widely used by physicians all over Europe. Using the MFT keeps me pain-free for many years now. I know that there are several models available on the market. The best I have found was developed by a team of over 30 scientists of 2 European universities. But I know there are also MFT systems available in North America. I hope this would help some of your patients as well.
I personally have used the Voltaren cream. It works very well. I cannot take the oral forms due to Gerd.
Joan
Bonnie Minsky MA, MPH, LDN, CNS
Melissa Diane Smith's book Against the Grain was an informative and enjoyable read to help me understand the negative effects of wheat gluten on the human body.
I hope my comments help others.
What actually helped me the most, ironically, was walking. At first, I started slow walking in the water at the community pool. Then I did a fast walking-in-water routine, a strenuous workout that helped trim my hips. This was an added bonus!
Then, I started a leisurely pace of walking around the block, a walk block at a time. I seldom experience pain in my knees or hips any more. If I spend a few hours sitting in the same position, as when I'm knitting or on the computer, my knees and hips start to feel achy. That's when I put a leash on the dog and go for a walk to the park.
Exercise has really been the most beneficial thing to do for my arthritic joints and getting that fresh air is so much nicer when you know you have a hot bath waiting to come home to afterward.Ahhh!