242019May
Alternative Treatment for Osteoarthritis

Alternative Treatment for Osteoarthritis

Alternative treatment for osteoarthritis consists of implementing ways to reduce pain and restore joint function without surgery. After decades of treating patients with osteoarthritis, in our experience there are conservative steps you can take to preserve the joint including, hyaluronic acid injections (viscosupplemetation), Platelet Rich Plasma therapy, physical therapy, and dietary supplements.

Osetoarthritis is a degenerative disease that affects any joint in your body. Osteoarthritis occurs when the cartilage between your joints breaks down, causing stiff, swollen, and painful joints. While most everyone will feel pain and limited function of the joint, replacement surgery is only necessary when there is a complete loss of joint function.

There are two types of osteoarthritis: primary and secondary.
Primary osteoarthritis is caused by general wear and tear often diagnosed in older individuals beginning around age 55.

Secondary osteoarthritis has a specific cause such as an injury, obesity, genetics, and inactivity.

The main characteristics of OA are:

  • Cartilage loss
  • Changes in the subchondral bone (bone underlying the cartilage)
  • Changes in tendons and ligaments
  • Mechanical misalignment
  • Eventual loss of the joint function

No matter if you have primary or secondary osteoarthritis, the physical feeling is the same between the two. Some of the items you experience when you have osteoarthritis include:

  • Pain after physical activity
  • Joint swelling
  • Joint stiffness
  • Loss of joint flexibility/function
  • Changes in the joint appearance/joint deformities

As a rheumatology practice, we focus on alternative treatment for osteoarthritis with the goal of preserving the joint and avoiding surgery.

With this goal in mind, we are guided by three main principles of therapy:

  1. Control of pain and inflammation
  2. Prevention of cartilage degeneration
  3. Restoring joint function

With these three principles in mind, the items in the chart below are the options available in each principle.

Viscosupplementation therapy—injections of Hyaluronic Acid

After ten years of performing viscosupplementation, we have come up with a list of the best practice standards that we adhere to when considering joint injections including: contraindications, who are the best candidates, which joints are most successful, injection principles, and post-injection guidelines.

Indications

  • Joint pain
  • Osteoarthritis

Contraindications
If these items are present, it is not recommended that an injection be performed as the outcome will not be successful. These items are what we consider “temporary contraindications” meaning once they are addressed and under control an injection can be performed.

  • Ongoing joint inflammation (active synovitis)
  • Crystal-induced arthropathy (disease of the joint) (gout/pseudogout)
  • Infection

Predictors of a good outcome—who will benefit?
In our clinic, by following the predictors below, we typically see a success rate of 70-75%

Mild to moderate joint deformities
The more intact the joint, it is more likely the injection will be effective.

Absence of large synovial effusions
Synovial fluid is a liquid that lubricates our joints and keeps them moving smoothly. Synovial effusions are excess pools of synovial fluid around the joint. If there is an effusion, it will need to be drained prior to an injection. HA is more effective in dry joints because the solution does not get diluted and also goes directly to the problem area more efficiently.

Well-preserved periarticular muscle mass
The muscles around the joint are in good condition.

Minimal joint instability
The joint is held in proper place by the surrounding musculoskeletal tissues.

On which joints does viscosupplementation work best?
In the United States, hyaluronic acid injections are only approved for knees, but at IFSMED, we have seen successful use with several other joints.

The highest rate of success (in order):

  1. Temporomandibular joint (TMJ)
  2. Base of thumb (1st CMC joint)
  3. Knees

Moderate success 50-50%

  1. Hips
  2. Ankles

Low success rate less than 10-25%
Shoulders

Outcome Optimization
In order to have the best possible outcome the following items should be considered and or followed.

Pre-viscosupplementation intra-articular steroid injection—in certain instances, after basic measures to lower inflammation have been followed, inflammation of the joint may still occur. In these instances a steroid injection can be used in the joint to lower inflammation.

Inject into a ‘dry joint’—prior to injection, the joint should be inspected under ultrasound to see if any fluid needs to be drained. As previously mentioned, if injected into a wet joint, the product will get diluted and its effectiveness goes down.

Selection of the right viscosupplementation agent—our preferred choice is Euflexxa.

Minimum of three injections—once a week for three weeks

Ultrasound guidance of joint injections—in our opinion, you should not get the injection if your doctor does not use ultrasound to visually see inside the joint (further explanation below).

Post-injection joint immobilization—for the first 48 hours don’t do much activity—not even standing for more than an hour. You do not want to place any undue stress on the joint and the drug can get pushed out of the joint.

Physical therapy—performing rehabilitation exercises with a qualified professional will quicken recovery time, strengthen supporting muscles, and improve range of motion.

Dietary supplements—there are several supplements that offer pain and inflammation management, cartilage boosters, and lubricants (discussed below).

Ultrasound Guided Injections—an invaluable diagnostic tool
We do not perform any injection without the use of ultrasound. It provides numerous benefits that give an exact picture of what is happening inside a joint that you just simply cannot get by looking at the surface.

Using ultrasound provides a safe, non-invasive tool that allows for:

  • Better assessment of joint anatomy
  • Discovery of unexpected findings (things you may not know you have that can only be seen under ultrasound)
    Crystals (calcium pyrophosphate, urate, etc.)
  • Active synovitis or active tendinitis
  • Hidden effusions
  • Guaranteed drug delivery to the joint space with pinpoint accuracy
  • Visual confirmation–as a patient, you can watch the drug going into the right space

Below is an example of ultrasound guidance for drainage of fluid.

Image on top shows fluid on the knee and the needle going right where it is supposed to go to drain fluid.
After drainage picture on the bottom. After draining, you can see the joint is dry and ready for HA injection.

Comparing surgery to an alternative treatment for osteoarthritis

Surgery
Much more prone to infection
Long recovery time
Range of motion will not be totally normal
Lasts 5-15 years

Viscosupplementation
Hyaluronic Acid is a natural lubricant, our own body makes HA
Stimulate production of your own lubricant
Covers the surface of the bones and cartilage, improving the mechanics of the joint
Possess anti-inflammatory properties
3 injections once per week for 3 weeks
Can perform as many injections as needed for many years
Lasts for up to 6 months

Steroids
Artificial product—greater chance of a reaction with an artificial product compared to a natural one
Decrease inflammation of joint, leading to decreased pain
Lasts for shorter period of time
Potential loss of subcutaneous fat around injection area
Can’t inject again and again, maximum of 3-4 injections, could lead to ulcers.

Platelet Rich Plasma (PRP) Therapy

The idea behind PRP is that when platelets attach to solid surfaces, they release growth hormones and growth factors. These attract stem cells and create a scar-like tissue that covers the defects in cartilage.

  • Platelet attachment to collagen fibers results in their activation and massive release of growth factors
  • Released growth factors stimulate cartilage matrix synthesis and suppress inflammatory responses
  • Published data indicate that PRP therapy benefits patients with knee and hip OA

Video of PRP procedure at IFSMED

Physical Therapy

While there are exercises you should do to help strengthen your bones, this section will focus on different modalities within the physical therapy umbrella that can help.

Bone Spurs—why talk about bone spurs? The main cause of bone spurs is the joint damage associated with osteoarthritis.

Bone spurs are bone growth that forms on the edges of bone. When they are painful, you will want to remove them.
What causes bone spurs?

Theory 1: when you lose cartilage, you develop a cartilage defect and the joint becomes unstable. Bone spurs create an extra structure to stabilize the joint.

Theory 2: Bone grows continuously, when you have a cartilage defect, the electrical currency within the bone and surface of the cartilage become disturbed leading the current to grow bone in strange areas.

How do we deal with bone spurs?

Iontophoresis with acetic acid— Shaving bone spurs will not work as they will come back. We prefer iontophoresis with acetic acid. While acetic acid dissolves calcium buildup; iontophoresis is a process that uses an electrical current to increase the acetic acid’s penetration into the skin.

In the image below, one electrode with acetic acid is placed on the troubled area (black) and a neutral electrode (red) is placed nearby. Plug the device in and use for 10 minutes. Ultrasound is used as a follow up to soften the bone. For additional treatment, one can also follow this up with class IV laser therapy.

alternative treatment for osteoarthritis

Class IV laser therapy
Class IV laser therapy is a non-invasive use of laser energy with infrared laser to decrease inflammation. Hot laser is especially effective, and will take 8-10 treatments to begin to notice a difference.

Laser has been shown to:

  • Reduce pain, inflammation, and enhance tissue healing of muscle, ligaments, and bones
  • Increase circulation and oxygenation of tissues
  • Increase red blood cells to area and increase venous and lymphatic return
  • Generate a photochemical response (helping cells produce ATP/energy) in damaged or dysfunctional tissue
Alternative treatment for osteoarthritis

Class IV Laser

In our practice, iontophoresis combined with laser therapy has proven to be 80-85% effective.

Supplements for OA

Dietary supplements can be used as a part of an alternative treatment for Osteoarthritis maintenance. They usually do not work right away, they need to be taken at high doses, but once they kick in, you can take for much longer than pain medication with a much better safety profile.

Cartilage Matrix Optimizers—thicken cartilage—improve mechanics of the joint

Viscoelasticity—lubricants

Inflammation Control

When it comes to managing painful joints with osteoarthritis, there are cases where surgery is the best option, but for those who do not want surgery, they can explore an alternative treatment for osteoarthritis.

The alternative route may take some different combinations to find out what works best for you, but once perfected, it can be a viable option to live many years of activity pain free.

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