What is knee osteoarthritis?
Osteoarthritis (OA) is the most common form of arthritis (Vioreanu, 2014). OA is a degenerative, ‘wear and tear’ type condition while largely effects the protective cartilage in the joint which may affect the the ability of the knee joint to take weight during upright activities like walking and climbing stairs. Symptoms can also include achy pains, sometimes sharp from either the inner or outer knee, sometimes both. You may also feel a stiffness or weakness in the knee which may affect your confidence. Other problems may include intermittent swelling, fully straightening or bending the knee as well as feelings of ‘crepitus’ or grinding (Vioreanu, 2014). The incidence of OA tends to increase with age, with over 50% of the population having OA by the age of 65 (Vioreanu, 2014).
What can be done to help – what do the medical experts suggest?
The National Institute for Clinical Excellence have published updated guidelines in 2014 suggesting:
- Local heat or cold therapy
Exercise including local muscle strengthening and general aerobic fitness
Joint mobilisation and stretching
Weight loss for those who are overweight or obese
The use of transcutaneous electrical nerve stimulation (TENS)
Paracetamol and/or topical non-steroidal anti-inflammatory drugs (NSAIDs)
As Chartered Physiotherapists, we are well positioned to provide these treatments with the exception of prescribing medication (if needed) which would require a visit to your GP. Surgery or non-conservative treatment can be offered for those who fail to respond after a reasonable amount of time to so called ‘conservative treatment’ as described above. This involves an onward referral from physiotherapy to an orthopaedic consultant who will consider further mediation, injections or surgery depending on the severity of the arthritis.
Another set of useful international guidelines for knee OA are provided by the American Academy of Orthopaedic Surgeons Guidelines (2013) for non-operative treatment of Knee Osteoarthritis. Their key recommendations are as follows:
- Low impact aerobic exercise (e.g. cycling, swimming, walking, yoga)
- Weight Loss for those with Body Mass Index of greater than 25
- Non-Steroidal Anti-inflammatory drugs (NSAIDs) such as Mobic, Naprosyn, Arcoxia, Mobic, Celebrex, Voltaren and Neurofen
- Supervised Physiotherapy aimed at improving strength, balance and, flexibility (Vioreanu, 2014)
What does clinical experience suggest most beneficial?
Clinically, we find the use of a combined approach including medical acupuncture/electroacupuncture, manual mobilisation and stretching of the knee surrounding muscles, alongside appropriately prescribed therapeutic exercises provide the best results for a patient experiencing symptoms of knee OA.
- Medical Acupuncture/Electroacupuncture involves the use of fine needles (and additional electrical stimulation) applied to the surrounding knee muscles including the quadriceps, hamstring, calf and gluteal muscles which has been shown to improve the pain and physical dysfunction associated with osteoarthritis of the knee (White et al., 2007, Selfe & Taylor, 2008; Manheimer et al., 2010; Cao et al, 2012; Berman et al., 2004). Although the NICE guidelines and AAOS guidelines do not advise the use of acupuncture as an adjunct to treating OA, large randomised trials have shown significant benefits in terms of pain and function and similar results have also been observed when used by us in the clinic.
- Therapeutic exercise: clinically, providing a comprehensive lower limb strengthening and flexibility programme proves most effective in terms of providing long-term symptom management. Exercises focus on the quadriceps, hamstring, calf, gluteal and abdominal muscles to optimise the function of the knee joint. We are currently running a knee and hip class which is ideal for anyone suffering from knee pain (or hip pain) which may be due to OA and focuses on the aforementioned muscle groups to improve overall function: (http://mmphysiopilates.com/dublin/join-a-class.html).
Take home message?
There are many possible treatment approaches for arthritic knees. The most beneficial and highly recommended options (according to evidence, as well as clinical observation) are conservative treatments including NSAID’s, physiotherapy (including electroacupuncture/acupuncture, manual therapy and therapeutic exercise), low impact aerobic exercise and weight loss where appropriate. Most of our clients achieve good results with the approach. However, if symptoms remain severe and your function is not improving following a trial of 4-6 sessions of conservative treatment, onward referral to an Orthopaedic Consultant may be required. Interventions at this stage may include further medication, injections, knee alignment surgery, knee replacements or arthroscopic surgery.
Mr. Mihai Vioreanu (2014). URL: http://www.mihaivioreanu.ie/blog/the-young-arthritic-knee#sthash.hdSXSj4R.dpuf
National Institute for Care and Excellence (NICE), 2014. Osteoarthritis: care and management. Clinical guideline. URL: http://www.nice.org.uk/guidance/cg177/resources/osteoarthritis-care-and-management-35109757272517
American Academy of Orthopaedic Surgeons (AAOS), 2013. Treatment of osteoarthritis of the knee. Evidence-based guideline second edition. URL: http://www.aaos.org/research/guidelines/TreatmentofOsteoarthritisoftheKneeGuideline.pdf
Selfe, TK & Taylor, AG (2010). Acupuncture and Osteoarthritis of the Knee. A Review of Randomized, Controlled Trials. Cochrane Database Syst Rev. 20;(1):CD001977.
Manheimer E, Cheng K, Linde K, Lao L, Yoo J, Wieland S, van der Windt DA, Berman BM, Bouter LM (2012). Acupuncture for peripheral joint osteoarthritis. Saudi Med J. 33(5):526-32.
Cao L1, Zhang XL, Gao YS, Jiang Y (2004). Needle acupuncture for osteoarthritis of the knee. A systematic review and updated meta-analysis. Ann Intern Med. 21;141(12):901-10.
Berman BM, Lao L, Langenberg P, Lee WL, Gilpin AM, Hochberg MC (2004). Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: a randomized, controlled trial. Ann Intern Med. 21;141(12):901-10.