What noninvasive or minimally invasive procedures, excluding injections, are effective in patients with low-grade knee OA?
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Treatment combination is best
When we are treating low-grade OA, we tell our patients the optimal management requires both nonpharmacologic and pharmacologic modalities. The first thing in terms of nonpharmacologic modalities is patients have to be given correct information about their joint disease, which starts with the fact not all arthritis is the same. Getting properly diagnosed by a rheumatologist would be helpful because there are many different types of arthritis. Once patients are diagnosed with knee OA, they may need to adjust their lifestyle, exercise, the pacing of activities, and lose weight if they are overweight. Within physical therapy, there is water-based therapy and land-based therapy depending on level of activity. In addition, we have all types of bracing and footwear for conservative management. Alternative nonpharmacologic modalities are thermal units, transcutaneous electrical nerve stimulation units and acupuncture.
If those do not work, we have both topical and oral NSAIDs. Topical NSAIDs are usually in a cream form and are a good alternative if patients have other medical issues and may not want to take an oral NSAID. One can take an oral NSAID for relief, which are ibuprofen and naproxen in over-the-counter or prescription doses, as well. There are also weak opioids and narcotic analgesics that could be considered for refractory pain, but of course the risk-benefit ratio changes a little because opioids have an addiction potential regardless of whether they are weak or strong.
M. Elaine Husni, MD, MPH, is the vice chair of the department of rheumatic and immunologic diseases and director of the Arthritis Center at the Cleveland Clinic.
Disclosure: Husni reports she was on the executive team for the PRECISION study and receives research support from Sanofi Genzyme and Orthofix.
Cooling therapy targets nerves
Knee replacement surgery can be beneficial in properly selected patients with knee OA. However, due to BMI, comorbidities or other contraindications, surgery is not for everyone. A minimally invasive, thermal radiofrequency (RF) pain management alternative — COOLIEF Cooled Radiofrequency, or Cooled RF (Halyard Health) — that uses water-cooled technology has been used to safely treat pain in the knee, hip and back. The product was FDA-cleared this year as a way to relieve the chronic, moderate to severe knee pain caused by OA. It is clinically proven to provide patients with up to 12 months of pain relief, as well as with significantly greater and longer-lasting pain relief, improved physical function and its use is associated with higher patient satisfaction than intra-articular steroid injections.
Patients are given a local anesthetic to numb the area before a RF generator transmits a small current of RF energy through an insulated electrode or probe placed within tissue. Ionic heating, produced by the friction of charged molecules, thermally deactivates the nerves responsible for sending knee pain signals to the brain. As RF energy is delivered through water-cooled electrodes, thermal RF energy is safely transmitted and creates large-volume, spherically shaped treatment areas, which provide physicians with the flexibility to use the best approach angle to reach target nerves located within complex nerve courses. This technology facilitates short treatment times and, unlike surgery, does not involve an incision. As this minimally invasive, outpatient treatment requires no general anesthesia, patients can return home shortly after treatment.
Michele D’Apuzzo, MD, is an orthopedic surgeon at the Center for Advanced Orthopedics in Miami and assistant professor at Nova Southeastern University.
Disclosure: D’Apuzzo reports no relevant financial disclosures.