RECENT ADVANCES IN OSTEOARTHRITIS KNEE PAIN TREATMENT

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Osteoarthritis (OA) is the commonest disease affecting synovial joints and occurs in 40% of the population over 65 years is the most common cause of knee pain.   Though hip, ankle, shoulder and small joints of hand and feet may be involved, the commonest joints to be affected are knee joints. It’s a degenerative disease that must be accepted as an inevitable consequence of trauma and ageing. Some genetic predisposition is also seen.

OA is now seen as a dynamic, essentially reparative process with genetic predisposition and exciting prospects of medical intervention. It is now known as a disease of the synovial joint affecting

  • subchondral bone
  • synovium
  • meniscus
  • ligaments
  • cartilage

As OA is primarily due to breakdown of articular cartilage with poor repair both mechanisms are targets of therapeutic maneuvers.

OA Knee Pain Management

OA has a variable progression with some patients rapidly progressing to disability, whereas others may continue to have mild symptoms for long term. Treatment should be tailored to fit the clinical severity of the disease.    The principal goals of management are:-

♦ Education of the patient about OA

♦ Pain relief

♦ Achieving and maintaining optimal joint and limb function

♦ Reducing adverse factors to beneficially modify the osteoarthritis process and its outcome

OA Knee pain Non pharmacological management

  • Activities that cause excessive loading of involved joint should be avoided.
  • Weight reduction in obese patients
  • lower extremity strengthening exercises for 20-30 minutes daily,
  • use of canes, walker
  • mechanical aids in the form of shock absorbing footwear with good mediolateral support arch support & calcanial cushion are effective in reducing pain and disability.
  • Lateral heel wedges in OA of medial tibiofemoral compartment & patellar tapping for patellofemoral OA are useful.
  • Application of heat like hot water bath and trans cutaneous nerve stimulation (TENS) may also reduce pain and stiffness of the joints.

Pharmacological Management

Medicine used in Osteoarthritis can be classified as  :-

  1. Symptom modifying drugs which reduces pain over short periods. (NSAIDS, Paracetamol, Capsaicin cream)
  2. Symptomatic slow acting drugs for OA (SYSDOA).  This include Hyaluronic acid (Viscosupplementation) and Neutraceuticals (Glucosamine sulphate and Chondroitin Sulphate)

Viscosupplementation :    This refers to intra articular injection of Hyaluronic acid into the joints of patients with OA.

Viscosupplementation is based on the premise that the synovial fluid in OA is less viscous due to reduced concentration of hyaluronan and decrease in its chain length and molecular weight.  Intra articular injections of hyaluronan have the potential to restore the rheological properties of synovial fluid in the osteoarthritic joint and stimulate the endogenous synthesis of a higher molecular weight and more functional hyaluronan.   It is hoped that this will clinically translate into improved mobility and decreased pain.

 The potential disease-modifying role of this treatment requires confirmation by further studies. It should not be used in patients with allergy to avian products since it is derived from rooster comb.   Side effects are generally mild and transient, comprise local reactions at injection site with pain, tenderness and erythema.

Neutraceuticals :    Glucosamine and Chondroitin sulfate have recently become popular for treatment of OA. They are sold as nutritional supplements in US and do not have USFDA approval.    Two randomized controlled double blind trials in Belgium and Czech Republic suggested that this drug (1.5 g daily) has a substantial symptom and structure modifying effect in patients with mild to moderate OA knee.

IL-1 Inhibition in Osteoarthritis

IL-1 has been shown to accelerate the degradation of cartilage matrix by inducing proteolytic enzymes, interfering with the activity of growth factors such as insulin-like growth factor or decreasing the synthesis of key matrix components such as aggrecan.   Diacerein is a slow-acting drug which interferes with the post receptor pathways following IL-1 stimulation in chondocytes and inflammatory cells. It is to be given for not less than six months at a dose of 50 mg twice a day.

An intra-articular Corticosteroid injection can be given in cases of inflammatory OA or OA knee with effusion once in 4-6 month intervals. Tidal irrigation of the knee using large-bore needles may give comfort to those who do not respond attributable to the placebo effect.

PRP therapy: It is one of the therapies to repair cartilage and ligaments.

Genicular Nerve RFA

Surgery

Osteotomy and joint preserving surgical procedures should be considered in young adults with symptomatic OA, especially in the presence of dysplasia or varus/valgus deformity. Joint replacement has to be considered in patients with radiographic evidence of hip/ knee OA who have refractory pain and disability.

Future Prospects

1.         Intraarticular injection of Interleukin 1 receptor antagonist can slow the progression of disease. It has been found safe and well tolerated in clinical trials.

2.         Cartilage regeneration: Autologous chondrocyte transplantation and attempts at cartilage repair using mesenchymal stem cells and autologous osteochondral plugs are currently being used experimentally.

3.         Gene therapy: The underlying concept is to deliver OA genes that have products with ant arthritic properties.   Synovium and articular cartilage are two attractive sites for the delivery of anti-OA genes.

For more details mail us at www.painxtotal@gmail.com or WhatsApp Dr. Anurag Aggarwal @9958830005 or visit our clinic Aggarwals Gynae & Spine Pain Clinic, Indirapuram, website: www.painx.in

 

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