I. What is knee osteoarthritis?
Osteoarthritis OA (OA): a joint disease caused by a variety of factors that lead to fibrosis, chafing, ulceration, and loss of articular cartilage. Cartilage destruction with secondary osteophytes chronic arthritis, also known as degenerative arthritis, proliferative arthritis, hypertrophic arthritis, age-related arthritis.
Second, the causes of osteoarthritis
Sports injury
Overweight
Advanced age
Heredity
Diagnostic criteria: (American College of Rheumatology (ACR) criteria; European League Against Rheumatism (EULAR) criteria; Chinese Orthopaedic Society criteria 2007 edition)
Knee pain more than 1 month X-ray shows joint space narrowing, cartilage, lower bone sclerosis, cystic changes, bone superfluous formation joint fluid clear, viscous, white blood cells < 2000/ml age ≥ 40 years old morning stiffness < 30min with bone friction sound
IV. Treatment goals
Control pain, reduce disability, improve joint function, improve quality of life, avoid adverse reactions
V. Core treatment plan
2007 Chinese Orthopaedic Association (COA) – “Guidelines for the diagnosis and treatment of osteoarthritis
2008 National Institute for Health and Clinical Excellence (NICE) – National Clinical Guidelines for the Management of OA
2008 American Academy of Orthopaedic Surgeons (AAOS) – Clinical Guidelines for the Management of Knee OA
2010 Osteoarthritis Research Society International (OARSI) – Guidelines for the Treatment of OA of the Hip and Knee
2012 American College of Rheumatology (ACR) – ACR Recommendations for the Non-Pharmacologic and Pharmacologic Treatment of Osteoarthritis of the Hand, Hip, and Knee
2013 American Academy of Orthopaedic Surgeons (AAOS) – Evidence-Based Medical Guidelines for Osteoarthritis of the Knee, Second Edition
VI. Basis of Treatment
Non-pharmacological treatment.
1. Exercise therapy
Low-intensity aerobic fitness exercise
Joint function and flexibility exercises
Core strength training: only small to moderate effect, but its efficacy has been comparable to that of painkillers and NSAIDs.
Aerobic exercise and home-based quadriceps strength exercises can reduce pain and improve motor function. Aerobic walking programs in combination with other treatments can improve joint stiffness, strength, mobility, and endurance in OA patients in the short term. In patients with bilateral knee OA, the efficacy of exercise therapy, ultrasound therapy, and electrotherapy was evaluated using a six-minute walk test, which showed that all three treatments relieved pain and improved joint function, but the six-minute walk test showed that exercise therapy was the most effective. Balance exercises can be performed in moderation, but twisting and high-impact exercises are not recommended.
2. Weight control
A large sample (n=823) prospective 22-year follow-up study found that those with a BMI ≥30 had a 7-fold higher risk of knee OA than those with a BMI <25. Overall weight loss of at least 5% in overweight individuals, or at a rate of 0.25% per week for 20 weeks, can significantly reduce knee pain and improve joint function. Therefore, weight control is a highly recommended treatment. However, low energy weight loss recipes can lead to loss of muscle tissue and strength in the lower extremities.
3. Self-management and health education and information
Multiple guidelines are strongly recommended as one of the core treatments; however, after the ACR re-evaluated using the GRADE system, the recommendation level is listed as a conditional recommendation rather than a strong recommendation.
4. Physical therapy and acupuncture, electrical stimulation
Although physical therapy can lead to radiologically demonstrated aggravation of osteochondral hyperplasia, it is not related to the degree of joint space narrowing, and the latest MRI study evidence shows that physical therapy can increase the volume of knee cartilage and decrease cartilage damage. Traditional Chinese acupuncture and transcutaneous electrical stimulation have been shown to provide relief for some pain, but not for all pain management. aaos does not recommend this approach.
5.Improve the force line or patellar motion trajectory
Knee brace, difficult to promote
Wedge inserts
Joint load reduction, mobility support
Adhesive bandage pushing and pulling to fix the skin on the surface of the patella, indirectly pulling the patella medially to improve the outward shift of the patellar trajectory in OA patients.
6.Psychological intervention
Factors can affect the patient’s tolerance of pain, and the use of cognitive behavioral therapy to train the patient’s coping skills for pain can reduce the patient’s perception of pain and relieve stress.
Drug treatment
1.First-line drug therapy for symptom relief
2.Other oral medications for symptom relief
3.Intra-articular injection therapy
4.Over-the-counter (OTC) nutritional therapy
5.Topical drug use
a) Transdermal absorption, direct action
b) Definite action and mild systemic reaction
For example: emulsions, creams, patches
Systemic analgesic drugs
Acetaminophen (paracetamol, Benadryl, Tylenol, Piriton): acetaminophen is preferred (4g/d, OTC single dose <650 mg)
NSAIDs : ACR strongly recommends the use of topical formulations of NSAIDs over 75 years of age
Tramadol opioids: tramadol, duloxetine, or intra-articular hyaluronic acid injections are recommended when available.
Co-administration of PPI’s
Other oral medications used for palliative disorders
Opioid analgesics, or dulcolax under certain conditions
Duloxetine (5-hydroxytryptamine and norepinephrine reuptake inhibitor): may be considered in patients with depression and neuropathic pain symptoms (radiating, burning pain, pins and needles)
Intra-articular injection therapy
Corticosteroids
Hyaluronic acid
The great controversy of intra-articular injection therapy
The ACR guidelines do not explicitly recommend HA injections for patients with OA, and the latest version of the NICE and AAOS guidelines do not recommend HA injections.
”Although some independent studies found statistically significant differences in clinical efficacy, the degree of improvement in efficacy did not reach a minimum clinically significant change value when meta-analysed” (Minimal clinically important difference ;MC II)
”More research should be done to identify which patients hyaluronic acid works for and which patients are more sensitive to it” – David S. Jevsevar: Chair, AAOS Evidence-Based Quality and Value Control Committee
Over-the-Counter Nutritional Therapy
Glucosamine, chondroitin, collagen hydrolysates (CHs), and unsaponifiable avocado soya unguents (ASUs): are a class of agents that provide direct cartilage protection and symptomatic relief in patients with OA. However, the new NICE and AAOS guidelines clearly oppose them because there is no strong evidence to support their use as conventional therapy.
VII. Summary
Core treatment: exercise therapy and weight control
Preferred drug acetaminophen
Topical formulations of NSAIDs are safest
The path to localized exploration of osteoarthritis guidelines.