Nonsurgical treatments expand knee OA care options
Knee osteoarthritis accounts for about 80% of the burden of OA worldwide, and published studies show it contributes more than $27 billion in health care costs annually.
The increasing costs of health care coupled with increasing knee OA prevalence may lead to a tremendous societal economic burden in the future, according to an Arthritis Foundation report. The report also noted more than half of all individuals diagnosed with symptomatic knee OA are in the end stage of the disease when total knee replacement is often necessary to address joint degradation and associated symptoms.
However, when patients present in the early stages of knee OA, physicians are better able to address the disease with inexpensive, nonoperative treatments.
“I always tell my patients we should start with the cheapest, simplest, safest, least painful type of treatment so that we work our way up to more expensive, complicated, risky and painful things, like injections and, eventually, surgery,” Michael J. Stuart, MD, professor of orthopedics at Mayo Clinic in Rochester, Minnesota, told Orthopedics Today.
Nonoperative treatment for knee OA can benefit patients by decreasing pain, stiffness and fatigue, and improve their function by reducing the number of activity limitations, according to Leigh F. Callahan, PhD, professor of medicine and associate director of the Thurston Arthritis Research Center at the University of North Carolina, Chapel Hill. She said increasing physical activity can improve balance and proprioception problems, as well as strengthen the joint, which can also contribute to better outcomes when a patient eventually needs to undergo TKR.
“Not only can [patients] do a lot of things that can improve their quality of life without surgery, if they get to the point where surgery is still needed, behavioral interventions can help them improve those outcomes, as well,” Callahan, who is director of the Osteoarthritis Action Alliance, said.
Therapy, activity modification
According to Callahan, the top-line nonoperative treatments supported by the American Academy of Orthopaedic Surgeons, the American College of Rheumatology and the Osteoarthritis Research Society International include behavioral interventions, such as weight loss, physical activity and self-management education.
Among these nonoperative interventions, Brandon J. Erickson, MD, of the Rothman Orthopaedic Institute in New York, said weight loss is the most effective treatment for knee OA.
“We know that you carry about five times your body weight across your knee when you go up and down the stairs, and so when we take 1 pound off, it is usually about 5 pounds off the knee,” Erickson told Orthopedics Today. “It is important to maintain a healthy body mass index to make sure that the knee is as good as can be.”
Activity modification and physical therapy are also reliable treatment options for knee OA, according to Stuart, who said physical therapy should focus on education and instruction on a self-management program through handouts and literature, video instruction or sessions with a physical therapist.
“Essentially, physical therapy does not mean that you go in to see a physical therapist every day,” Stuart, who is an Orthopedics Today Editorial Board Member, said. “You learn what to do from a physical therapist. They are wonderful at evaluating, teaching and explaining. Then, maybe you come back and see them again for an assessment of your progress with an upgrade in your program,” he said.
In addition, Callahan noted many community-based physical activity programs have been approved for patients with OA, including the Arthritis Foundation’s Walk with Ease program, EnhanceBalance, the Fit and Strong! physical activity program and tai chi for arthritis.
“A number of these programs have been evaluated in people with arthritis and have been designated as arthritis-appropriate exercise-based interventions, ... which means they have been evaluated in large trials and shown to have improvements for people with OA and all types of arthritis,” Callahan said.
Erickson said lower extremity strength training can also help patients with knee OA and can include stretching the hamstrings and iliotibial band, as well as performing strengthening exercises, such as squats and leg press.
“Stationary bike and elliptical are also good,” Erickson said. “Running sometimes will exacerbate it a little bit, not that they are going to make anything worse, but it can sometimes make the knee flare up and can cause some pain. So, usually if the foot stays planted, or as we call them closed chain exercises, that usually does not exacerbate it as much as if they were pounding on it.”
Erickson recommends patients do clam shells, glute bridges and monster walks, which can help strengthen the hip and core muscles.
“The other thing that we will often times do aside from strengthening the knee is strengthen the hip and core muscles - the muscles ... muscles that help move your hip around and then your abs and back because if your gait is off because your hip hurts or you are not walking properly, if you can strengthen those muscles, it can take a little bit of load off of the knee and so it can feel a little bit better,” said Erickson.
Physical therapy can also help optimize a patients’ knee range of motion, which may be affected when they have knee OA, according to Erickson.
“Some people will not be able to get full range of motion because they have a little extra bone that grows in and around their knee. It can cause a bony block to motion, so there may be a point where they cannot get their full motion back, but we want to optimize their motion as best as we can,” he said.
Oral, topical NSAIDs
After weight loss and physical activity, Stuart noted the next tier of treatment includes oral or topical medication, which introduces some risk and cost to the patient.
“If you take too much nonsteroidal inflammatory drugs or acetaminophen, you can have serious side effects,” Stuart said, noting this may include bleeding ulcers, kidney or liver damage.
Risk-benefit analysis is discussed with each patient, he said.
Although topical NSAIDs may be safer compared with oral NSAIDs, Michael P. Schaefer, MD, FAAPM&R, R-MSK, said orthopedic surgeons may shy away from recommending these, despite that topical NSAIDs are recommended by the American College of Rheumatology as a nonoperative treatment option for knee OA.
“The problem with [topical NSAIDs] before was they were expensive in this country and almost always got insurance denials when we prescribed them,” Schaefer, division chief of PM&R in the department of orthopedics at University Hospitals Cleveland and associate professor of orthopedics at Case Western Reserve University, told Orthopedics Today. “But, in my opinion, they are safe compared to the oral NSAIDs and they are becoming less expensive.”
In select cases of knee OA where limb malalignment is present, an unloader brace can be used to transfer stress from “the bad compartment to a better compartment,” according to Stuart. However, he said the outcomes are unpredictable and depend largely on the patient.
“Some patients who choose to try an unloader brace find it helpful and are able to play golf, walk the dog or work without as much pain,” Stuart said. “But, other people don’t notice any improvement or don’t like wearing the brace, so it ends up in their closet or drawer.”
He said the same applies to wedge shoe orthotics, which change the loading of the knee similar to a medial unloader brace by lifting up the lateral border of the foot.
When prescribing wedge orthotics, Schaefer said he writes the proper orientation on the wedge to help prevent patients from wearing it on the wrong side.
“A number of patients come in wearing [the orthotic] on the wrong side. They do not understand the goal and make it feel more comfortable, [which is] the opposite way [of how it should feel],” Schaefer said. “The same thing with braces. You have to give them good instruction on how and what to use them [for],” he said.
Genicular artery embolization
In the past 5 to 6 years, genicular artery embolization has emerged as a nonoperative, minimally invasive, knee OA treatment, according to Sandeep Bagla, MD, a diagnostic and vascular interventional radiologist. The goal of genicular artery embolization is to counteract the processes that occur during inflammation and decrease the blood supply to the synovium, he said.
“During inflammation, there has been an increase in blood supply. Our goal is to decrease the blood supply and by doing an embolization, where you block the arteries or capillaries that go to the synovial tissue, you are decreasing blood supply to both the synovium, but also the corresponding pain fibers that are within the synovial lining,” Bagla told Orthopedics Today.
Generally used in patients with OA severity grades 1, 2 and 3, he said research on genicular artery embolization has shown patients experience better pain improvement and durability at 2 and 3 years after treatment compared with other nonoperative treatments. However, patients with grade 4 OA severity do not do as well long term, he said.
Indicated for pain, tenderness
“If you look at the ideal candidate for genicular artery embolization, it is people who have palpable knee tenderness, palpable synovial thickening and have increased pain, by they are not at the end stage of osteoarthritis,” Bagla said.
Although some risks are associated with genicular artery embolization, such as hematoma at the access site, anesthesia-related complications and local site infection, these risks are low and rare from a safety profile perspective, Bagla said.
Genicular artery embolization used to treat knee OA has been studied in a systematic approach and more research is underway, he said. Bagla added this additional research will not only advance the use of genicular artery embolization, but the technique will also allow it to be used in combination with other available therapies.
Radiofrequency (RF) ablation of the genicular nerves emerged in the last 5 years as a treatment modality for knee OA, according to Schaefer, who said it targets the superior medial, inferior medial and superior lateral genicular nerves of the knee.
RF ablation technology has evolved to provide better coverage of the nerve, making it more likely the nerve will be appropriately ablated, he said. In addition, RF ablation or cryoablation of the femoral-saphenous nerve can also be considered for patients with knee OA, according to Schaefer.
However, he said, RF ablation is usually reserved for patients who are not good candidates for TKR.
“[RF ablation] should not be used to replace arthroplasty or delay it for an extended period of time, but for the young patients, patients with high pain levels with so much radiographic osteoarthritis or medical risk factors that it makes surgery too risky, those are good options,” said Schaefer, who noted patients at University Hospitals are treated with the COOLIEF cooled RF (Avanos Medical) pain management system.
Low risks with RF ablation
In terms of risks, Stuart said the current research has not identified serious complications associated with the use of RF ablation, such as a neuropathic joint. Published results of RF ablation are better than placebo at 12 months and it may be an alternative to viscosupplementation injections, he said.
“I don’t personally perform this procedure, but tell patients that the results are unpredictable and they should check to see if their insurance will cover the cost,” Stuart said.
Although RF ablation should provide patients with up to 2 years of pain relief, the procedure often needs to be repeated in as soon as 6 months, Schaefer said.
“I am not aware of the data on the repeat ablation, but the clinical suspicion is repeat ablation is as effective and potentially additive, so it makes it less likely to return a third time,” he said.
Proper patient selection
With differing nonoperative treatments available to treat knee OA, Stuart said it is common for several treatments to be used in a staged fashion.
“I suggest a staged approach so that we can evaluate which treatment worked,” Stuart said. “For example, don’t start someone on a medication, give them an injection and put them in a brace simultaneously because, if they are improved, you don’t know why. I start with the simplest option and work up to the more complex and more expensive.”
Sources who spoke with Orthopedics Today noted choosing the best nonoperative treatment depends largely on patient selection and the level of activity to which a patient hopes to return.
A walk around the block is different than playing singles tennis three times per week, Erickson said. “They put different stresses on their knee,” he said.
Weight loss and physical therapy may be beneficial for patients with a low activity profile, Erickson said. However, patients who want to return to activity at a recreational level may need a combination of physical therapy and anti-inflammatory medication, he said.
Alternate training methods
Stuart said physicians should try to convince their more athletic patients to begin an alternate training methodology. This may include having athletes who participate in a lot of running to incorporate more low-impact or non-impact aerobic fitness exercise into their workouts. Athletes with unicompartmental or isolated OA with associated malalignment may benefit from shoe modification and bracing, he said.
Furthermore, athletes should be educated on ways to modulate inflammation, such as icing the knee after activities and using topical and oral NSAIDs, Stuart said.
“There may be a different approach to [treating] athletes, but it is the same disease process with the same prognosis,” Stuart said. “Essentially, you have to treat each patient individually, perform a total body assessment and get a feel for their goals, find out what they have tried in the past, then you take a focused and realistic approach,” he said. – by Casey Tingle
- Arthritis by the numbers. Available at: www.arthritis.org/getmedia/73a9f02d-7f91-4084-91c3-0ed0b11c5814/abtn-2020-final.pdf. Accessed March 30, 2021.
- Ong KL, et al. J Orthop Surg Res. 2020;doi:10.1186/s13018-020-01848-7.
- For more information:
- Sandeep Bagla, MD, can be reached at Vascular Interventional Partners NOVA, Prostate Centers USA, 1775 Tysons Blvd., 5th Fl., McLean, VA 22101; email: firstname.lastname@example.org.
- Leigh F. Callahan, PhD, can be reached at 3300 Thurston Bldg., Campus Box 7280, Chapel Hill, NC 27599; email: email@example.com.
- Brandon J. Erickson, MD, can be reached at 450 Mamaroneck Ave., Suite 200, Harrison, NY 10528; email: firstname.lastname@example.org.
- Michael P. Schaefer, MD, FAAPM&R, R-MSK can be reached at 11100 Euclid Ave., Cleveland, OH 44106; email: email@example.com.
- Michael J. Stuart, MD, can be reached at 200 First St. SW, Rochester, MN 55905; email: firstname.lastname@example.org.
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