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Other Treatment Options (non biological)

Macquarie Stem Cells has provided this information to ensure we are not being biased, there are a range of treatment options for you. So, we have reviewed significant amount of literature to present accurate and balanced information. We do not provide these treatments, we only provide biological treatment options for your osteoarthritis to repair damage that has been caused.

Medication Use

Pain Killers (Analgesic Medications)

Paracetamol (acetaminophen) somewhat alleviates the pain of mild to moderate osteoarthritis. There is strong scientific evidence confirming this. Additionally, Paracetamol has been proven to be more effective in combination with tramadol or another weak opioid than as monotherapy [1]. Some studies have found approximately 20% of low grade OA patients taking tramadol, stop taking their medication due to insufficient relief [1].

There is strong scientific evidence that Tramadol is as effective as weak opioids for musculoskeletal pain. However, the adverse events of Tramadol are to the same extent as opioids [1].

Current analgesic medications have shown limited effectiveness for long-term osteoarthritis. The adverse events associated with analgesics often prohibit long term use for patients [2].

Medication is unlikely to be a complete solution for people with Osteoarthritis, and even when pain relief is achieved, nonmedical interventions, such as physiotherapy, occupational therapy, orthotics, or psychological treatment, might be needed to restore normal function and well-being [2].

Opioids

Studies have shown opioids reduce severe osteoarthritis pain by approximately 24% [1]. Weak opioids reduce mild to moderate osteoarthritis and low back pain by approximately 40% and they are as effective as NSAIDs for osteoarthritis pain [1].

Opioids can cause unpleasant adverse effects. Majority of the common side effects can include constipation, fatigue, dizziness, nausea and vomiting for over 50% of patients utilising these medications [1]. Opioids such as Carbamazepine and Gabapentin (Neurontin) have shown the ability to help with neuropathic pain as well as arthritic pain [1].

NSAIDs (Anti Inflammatory Medications)

NSAID’s, fully known as “nonsteroidal anti-inflammatory drugs”, have been studied in depth. Previous literature shows, they are able to reduce the pain of osteoarthritis by at least 30% [1]. Combining NSAIDs with other analgesics and/or opioids (as guided by your doctor) have shown complement pain reduction [1]. NSAIDs can have similar adverse events as analgesics and opioids have previously shown, however they can also increase the risk of cardiovascular events [1].

Topical Analgesics Creams (heat creams and anti-inflammatory creams)

Topical analgesic creams are often used for a variety of conditions involving acute or chronic pain. Most common use is around sprains and muscle aches [3]. They have presented some effect in helping with early stages of osteoarthritis pain involving the hand or knee joints, as well as minor neuropathic pain [3].

Studies observing persistent 6 to 12 week use of topical analgesic creams in the application of chronic osteoarthritis in the hands and knees confirm limited effect [3].

Anti-depressants

Unfortunately, depression is common among patients suffering from long-term osteoarthritis. Studies have observed over 2000 patients and approximately 30% of these patients were identified to have potential depression [9]. As general health declined for these patients, the impact of depression had become worse.

Amongst all of the patients who were deemed to have potential depression, only 50% of them received treatments to improve their mental health [9].

This means, osteoarthritis can potentially lead to depression and depression needs to be diagnosed then treated to improve patient’s quality of life.

In relation to pain relief, antidepressants have shown efficacy in managing pain [1] but they are far more useful in treating mental issues caused due to OA.

Conclusion of Medication Use

All of these options as discussed above have been deemed as a cost-effective option for managing chronic pain. These options can come with severe side effects if used for long periods of time [1], [2]. In some cases, eliminating pain only masks signals and causes further damage in the long run.

 

Diet – Supplements & Exercise

Diet & Weight

Supporting your joint health with basics such as diet and physical exercise improves the treatment options for patients with OA beyond traditional rehabilitation, medications, and surgical strategies [6].
Diet plays a role between the anabolic and catabolic processes which occur in our bodies. Specifically looking at the joints, the blood vessels carry nutrients to the, muscles, tendons, chondrocytes and the synovial membrane, therefore the poor diet means poorer delivery of nutrients. This can potentially reduce the effectiveness of any other treatment you may be going through [6].

Diet plays a big role in osteoarthritis, studies have found associations with not only excess weight impacting on joint’s wear and tear but also a relationship between total fat and saturated fatty acids intake with increased progression of osteoarthritis [7].

In a similar situation, by consuming MUFA (mono-unsaturated fatty acids) and PUFA (poly-unsaturated fatty acids) progression of osteoarthritis can potentially be slowed down [7].

The inflammatory characteristics of patients diet is very important and incorporating anti-inflammatory foods  into your diet has shown to improve joint function, and keep destructive inflammation levels to a minimum, therefore improving long term wear and tear of the joint [8].

Best-practice guidelines for osteoarthritis emphasize self-management including weight control and exercise. Unfortunately this has not been a primary factor in our health education system [8]. Patients are encouraged to combine a healthy, low inflammatory diet with any other intervention they are performing for their osteoarthritis. Advice about low inflammatory foods can be obtained via the internet but it is best to get a tailored program from a nutritionist.

Supplements

Turmeric/Curcumin

Turmeric is a plant of the ginger family and curcumin is a chemical compound of turmeric. Curcumin has demonstrated management of by controlling the release of inflammatory cytokines. It can work as a general low grade anti-inflammatory and also by controlling the inflammation levels it has exhibited some benefits to slow down OA progression [56].

Olive Oil & Fish Oil

Much like the turmeric, oil supplements can have anti-inflammatory properties. One double blinded, randomized clinical trial has demonstrated the topical application of olive oil improved pain and physical function in patients affected by knee osteoarthritis [6].

Fish oil presents similar characteristics in comparison to olive oil, publications have identified a decrease in inflammatory destruction of cartilage tissue [6].

Methionine

Methionine is an essential amino acid for humans. Some researchers have found methionine promotes anabolic processes (rebuilding) of cartilage [6]. Some studies have shown patients who have received methionine supplements had a greater benefit in the long term compared to treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) [6].

Type II Collagen

Type II collagen is a nutritional supplement derived from chicken sternum cartilage. Literature shows patients with osteoarthritis that are using this supplement have increased the mobility and the functionality of the joints with some reduction in pain levels [6].

Glucosamine

Glucosamine is a product that occurs naturally in the fluid around the joints. Studies have presented the value of glucosamine in rebuilding cartilage. Research results are have shown glucosamine to be effective in management of arthritis.

Conclusion of Supplement use

Supplementations can be an ongoing strategy for managing and preventing osteoarthritis as a complement to traditional clinical treatment. Nutritional balances with diet can regulate the balance between anabolic (rebuilding) and catabolic (destructive) processes in joint tissue. This can result in improved function, reduced pain and increased longevity of joint wear [6].

However, there is criticism regarding the quality and validity of the majority of these studies that have been focusing on supplements. At this stage, the majority of the publications/ trials which have also been conducted are by the manufacturing companies [1]. This has caused a concern of sponsorship bias. Many of these studies also have a low number of participants, short-term of follow up and non-defined dosing [5].

They appear to be a low cost and high safety method of treating osteoarthritis (as long as it is controlled by a nutritionist). They may be worth-while in including to the patients list of interventions to try.

 

Physiotherapy, Exercise & Hydrotherapy

Physical therapy managed and supervised by a professional has shown to alleviate chronic pain 20–30% more effectively than no treatment [1].  Physiotherapy including traditional physical activity can be more cost-effective in alleviating chronic pain as compared to using analgesic medications [1].

Pain appears to be the greatest barrier to patients engaging in and sticking to physical activity programs including professional physiotherapy. Unfortunately some individuals prefer short term pain relief of analgesic medications as a replacement to physiotherapy. This has led to poor joint support and function in the long term. The benefits of exercise in the management of osteoarthritis are well established and they need to be engaged in as a pre-dominant joint support for osteoarthritis [4].

It is important for people suffering from osteoarthritis to continue physiotherapy with the support of professional as opposed to self-managed exercises. It is easy for individuals to develop poor techniques and fall into bad training habits. These habits can cause further damage.

If the individual finds physiotherapy is too “forceful” hydrotherapy is a great option. The buoyancy of the water helps reduce the load your joints are under. This can help patients develop their muscles and tendons in a manner that is less stressful.

 

Other Strategies

Relaxation therapy

Yoga

Yoga is a mind and body type therapy involving controlled movements, postures and breathing. Yoga has been demonstrated to have significant improvement for pain relief and physical function in studies [10]. Osteoarthritis sufferers who adhere to yoga on a regular basis have shown improved symptoms, physical function, sleep quality, and quality of life in comparison with people who do not engage in regular yoga [12].

Chair Yoga

Chair yoga is just like normal yoga, but a chair is used as external support. One specific study has observed an 8-week chair yoga program. This study has shown reduction in pain, fatigue, and improvement in gait speed. The effects on pain interference had been sustained 3 months post 8 week program.  Ongoing chair-yoga is potentially a viable option for people to consider using to maintain pain relief benefits [11].

Tai Chi

Tai Chi is a slow focused series of movements used as a form of exercise. It is accompanies by accompanied by deep breathing for control and a sense of relaxation. Tai Chi has demonstrated significant improvement for quality of life, pain relief and physical function [10].

Conclusion of relaxation therapies

There are many different mind and body exercises available. The type of exercises is related to the individuals’ preference, there is no set guide that applies to everyone.  These exercises and movement patterns appear to be promising in reducing pain, aiding in physical function and quality of life for people who suffer from osteoarthritis [10]. It is recommended these activities to be undertaken in conjunction with other alternative therapies.

Some studies have shown mind and body focus controlled exercises have provided patients with the ability to control pain during other unrelated invasive medical procedures [13].

 

Cognitive Behavioural Therapy

Cognitive behavioural therapy, alternatively known as unwanted behaviour therapy, focuses on altering patterns of habit that we may have fallen into. This type of therapy has shown improvements in social and physical function. Additionally, the individuals whom have gone through this therapy have shown up to 25% improvements in coping with chronic pain in comparison to similar patients whom have not exercised cognitive behavioural therapy [1].

Cognitive behaviour therapy can include removal of poor functioning habits such as smoking, lifting techniques, walking pattern/stride, sleeping patterns and much more. Smoking, poor sleep and stress are all associated with low-grade inflammation and hyper-immune response [8]. By understanding and educating individuals with this type of therapy, it is another good step to controlling your arthritis restrictions.

Electrical Stimulation Therapy

Electrical stimulation therapy such as;

  • H-TENS – high frequency transcutaneouselectrical nerve stimulation
  • L-TENS – low frequency transcutaneouselectrical nerve stimulation
  • NMES – neuromuscular electrical stimulation
  • PES – pulsed electrical stimulation
  • IFC – interferential current
  • NIN – non-invasive interactive neuro stimulation

The intent of electrical stimulation therapy is to send frequent pulses of light electricity to the areas of pain, this allows the nerves to “get used to the pain” and expect it. Overtime, nerve function can dim the pain signals it is receiving, thus decreasing pain.

Meta-analysis of medical publications has looked at 27 trials and they have assessed 6 kinds of electrical stimulation therapies as listed above. Amongst all of these electrical stimulation therapies, they have concluded IFC to be the only option that stands above the rest. It has shown significant effect in controlling the intensity of pain [14].

Acupuncture

Acupuncture is the insertion of fine needles in the skin at specific points.  There have been multiple studies looking at acupuncture and the ability of this therapy to control pain. Meta-analysis of these studies confirms acupuncture can provide pain relief but only in the short term. It has been more successful in helping improve muscle function as opposed to direct pain relief [15].

Additionally to the point mentioned above, scientific evidence focuses acupuncture on spine related issues such as lower back, neck and shoulder pain as effectively as other treatments [1].

Balenotherapy

Balenotherapy known as mud or mineral baths therapy.

Studies have looked at a group of 21 patients suffering from knee osteoarthritis. Focusing on mud therapy and the after effects on patient’s joint pain and function, the study reveals improved the knee function and OA-related pain. These studies have reported a better health-related quality of life and some studies indicate improvements to pain relief by up to 30% [1].  These published documents consider Balenotherapy to have a therapeutic effect on the individual by creating a mode of deep relaxation. Deep relaxation has been linked to having a systemic anti-inflammatory effect and promotes immune regulation. [16].

However, systemic reviews consider multiple studies to be biased with minimal scientific evidence to back up their claims. Overall evidence is insufficient to show that balenotherapy is more effective than no treatment, and comparisons to other modes of relaxation therapy are not considered [17]. Balenotherapy can be a cheap and safe option to achieve deep relaxation, individuals can consider this approach into their weekly routines.

 

Injections

Corticosteroid injections

Corticosteroids work by suppressing inflammatory signals that are sent by our immune system. This can have a positive and a negative impact on our joints. Inflammation is destructive to tissues in the body, by suppressing inflammation it can save potential damage. The use of these steroids for acute injury and acute inflammation has shown to be effective. In relation to osteoarthritis where inflammation is not acute and it is chronic, the corticosteroid injections can suppress growth of tissues; in the long run this can further increase degeneration and lead to severe damage.

There have been multiple studies looking at the use of corticosteroid injections. Most studies suggest a good short-term benefit generally between 1 to 3 months [22].  One very good study found that regular three-month injections of corticosteroid injections for two years resulted in no significant change in pain and function in comparison with saline. Aside from poor improvements, this study noted a significant adverse effect on the patient’s joints. There were significant losses in cartilage for all patients whom received corticosteroid injections as opposed to saline [18].

Systematic reviews in literature conclude corticosteroid injections can be effective in controlling pain and improving function on short term [21]. It is of greater benefit for individuals who have acute inflammation as opposed to chronic inflammation. Long term use of these injections should be approached with caution as they can cause more harm than good. They should only be used in cases where it is deemed 100% necessary.

Prolotherapy

Prolotherapy is not extremely common; it involves injection of a mild irritant solution directly on the site of the arthritis or injury. This can create a mild, controlled injury that stimulates the body’s natural healing mechanisms to lay down new tissue on the weakened areas.

Many studies have been evaluated and results are in agreeance. Prolotherapy has shown improvement for pain, function and range of motion of the joint. This is applicable in short and long term [24].

Systematic reviews reveal Prolotherapy is useful for mild to moderate osteoarthritis and tendinopathy (tendonitis). The mechanism of repair is not well understood at this stage and literature assumes there is a systemic multifactorial effect that takes place. However, evidence suggests Prolotherapy is safe in treating symptomatic low grade osteoarthritis in carefully selected patients [23], [24].

Ozone therapy

Ozone therapy focuses on increasing the amount of oxygen present in our body. In treatment of osteoarthritis it is commonly provided as an injection of ozone directly into the joint.

One randomized, blinded and placebo controlled clinical trial assessed 98 patients with symptomatic knee osteoarthritis. This study revealed ozone was more effective than placebo. Additionally the ozone injections proved to relieve pain, improve function and in-turn increase the patient quality of life [25].

Another study compared ozone injections with hyaluronic acid in the short-term. There were 3 arms in this study;

  1. HA injections of 23 patients,
  2. Ozone injections of 23 patients and
  3. Combination of both injections 24 patients.

Results of this study concluded a combination of ozone and HA yielded significantly better outcomes [26].

Lubrication / Viscosupplementation Injections

Lubrication injections such as hyaluronic acid, is a gel-like fluid that is injected into the joints of patients with arthritis. Hyaluronic acid is a naturally occurring substance found in the synovial fluid surrounding joints. This acts as a lubricant in order to enable bones to move smoothly without harsh grinding. The gel-like substance also has shown to have shock absorbing properties.

Metal analysis of publications observing 12 randomised controlled trials containing 1794 patients indicate, the injection of HA into a joint provide a decrease in pain and increase in function. In comparison to corticosteroid injections, corticosteroids appear to be superior in controlling pain in the first month post injection. However, the HA injections last much longer than corticosteroids, the effect of HA continues to last from 3 to 6 months post first injection [20]. The immediate short term effects appear to be higher in the group of patients whom have received HA injections, but the long term side effects for corticosteroid injections significantly outweigh the short term side effects presented by hyaluronic acid injections [19],[20].

Overall, the viscosupplementation injections can potentially relieve pain for up to 6 months. This is longer than the pain relief derived from nonsteroidal anti-inflammatory drugs and corticosteroid injections. HA injections administered at the early stages of arthritis may be more beneficial than when given later in the more advanced stages of arthritis [31]. Individuals should consider combining viscosupplementation injections with conventional therapy as it can be more effective than a single pronged approach [31].

 

Surgical Options

Radiofrequency denervation

Radiofrequency denervation is also known as radiofrequency neurotomy and radiofrequency rhizotomy. Radiofrequency energy is inserted through a probe of a needle to burn the nerve. This disrupts nerve function in an attempt to force the nerve drop the signals processing ability. Nerves can grow back and repair themselves and this is not a permanent solution for pain relief.

This treatment is often applied to areas of the spine. Limited scientific evidence suggests this can provide short-term relief of chronic neck and back pain but there are serious complications with the treatment [1].

When applied to other joints such as knees, systematic reviews of 13 publications identify a high success rate of treating chronic pain, lasting between 1 to 12 months post treatment. The reviews have also confirmed serious adverse events are unlikely if the therapy is applied away from the spine [29], [30].

Joint Arthroscopy

Arthroscopy involves opening up a joint via keyhole surgery and cleaning out any debris that may be present. During this procedure, it is often used to shave areas of cartilage to “buy more space”, trim loose sections and potentially repair torn areas of the cartilage.

Meta-analysis reviews of 13 randomised trials as well as 12 general observational studies present a high certainty that pain reduction is very minor post arthroscopy and lasts up to 3 months [38]. Joint function is similar, very minor short term improvements and 2 years post treatment, there is no difference at all. Overall, individuals who undergo joint arthroscopy do not have good benefits in pain relief or function in comparison to more conservative arthritis management strategies [38].

One of the reviews looked at supplementation, hyaluronic acid injections and PRP injections in comparison to joint arthroscopies. The outcome indicated PRP injections were the most effective of all the options listed above. There were no advantages in having joint arthroscopy even when examining those patients with combined cartilage tears and osteoarthritis [37].

On a final note, studies have also considered the cost factors associated with arthroscopies. The observations reveal arthroscopic surgeries are not an economically viable option [36]. There are many other treatments available with a greater cost to benefit ratio.

Joint fusion

To fuse a joint, means the joint is locked into one position. This is only applicable to extremities of the body, such as ankles, wrists, fingers and in some cases the discs of your spine. Larger more mobile joints such as knees, hips, shoulders will not be suitable.

It is commonly known, joint fusion is the very last approach aside from joint replacement. Typically patients will have tried all options and failed all medical treatments. Secondary to failed previous surgeries or bone infection, this is often the only way to achieve a stable and painless joint [34].

Studies have demonstrated pain relief for patients, contrary to pain relief joint function has almost ceased for patients post joint fusion [35].

Osteotomy

Osteotomy is a surgical procedure where the bone is cut and then re-aligned, lengthened or shortened depending on the specific requirement of the patient. This procedure is only required if there are structural imbalances with alignment or height in patients joints. This can lead to premature wear and tear of the joint and debilitating pain.

The best way to address this imbalance is by an osteotomy procedure or joint replacement. With regard to patient age and level of activity, osteotomy may be a good option. Studies reviewing osteotomy procedures indicate good outcomes in relation to decreasing the rate of cartilage wear and tear as well as patient outcomes associated with pain and function.

Osteotomy studies have shown that patient outcomes can be greater with the combination of alternative therapies [32]. One study evaluated 5-year outcomes after lower limb realignment (osteotomy), the results indicated change in load distribution during walking. This has resulted in long-term improvements in relation to wear, tear as well as symptoms associated with misalignment [33].

Joint replacement

Joint replacement is the bottom line of osteoarthritis, this is a process whereby the patient’s original joint is cut out and removed completely, then replaced with a ball and socket type metal fabricated structure. This structure is physically held inside the bone with glue and it is sutured into the tendons.

Replacements are not suitable for all patients and all joints, however once performed they can be very effective in relieving pain and improving joint function [2].

Despite large improvements in pain and function of joints post replacement, individuals do not increase their level of activity, in many cases they tend to decrease. It is suspected this is due to a preventative thought processes [39]. Statistic reveal, approximately 15% of cases of joint replacements, this surgery have not met the patients’ expectations [40].

HIP REPLACEMENT revisions are on the rise from 2.0% to 12.6% over the long term 10 year interval.

The risk of the first joint replacement failing is greatest between 7 to 10 years post-surgery [41]. The table below indicates joint replacement revision risk as the years increase.

Table courtesy: National Joint Replacement Registry of Australia 2015

KNEE REPLACEMENTS revision rates appear to be similar to the hip joints, they have raised by 2.6% to 11.2% over the past 10 years [41]. The table below indicates joint replacement revision risk as the years increase.

Table courtesy: National Joint Replacement Registry of Australia 2015

The most common reasons for patients to undergo second joint replacements are listed below [41];

  • Loosening/lysis (28.7%)
  • Infection (22.4%)
  • Pain (20.9%)
  • Instability (6.3%)

Younger patients under the age of 70 have a higher rate of second replacement compared to older patients [41].

Individuals should think carefully prior to proceeding with a joint replacement procedure. This procedure is certainly able to alleviate pain and increase function of the joint at a cost of completely removing the individual’s original joint. Just like any other surgical procedure, replacements can fail. They are likely to last 10 – 15 years [41]. Joint replacements can often only be revised 2 times. If the joint replacement fails for the 3rd time, patients may face serious consequences. Joint replacements are suitable best for patients who are at an age where they are not very active but also suitable for the surgical aspect of the procedure.

It is highly recommended, patients seek multiple opinions from health practitioners and they have tried all other methods of treating/managing arthritis prior to accepting a joint replacement.

 

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