Osteoarthritis is a progressive degenerative disease with the tendency to worsen over time. The disease is characterized by articular cartilage degeneration, subchondral damage and bone remodeling. The most common joints are the knee and hip joint. Current numbers in the US alone are staggering. The estimates of osteoarthritis patients are in the millions with some estimates as high as 90 million adults. One in four adults have some form of arthritis with osteoarthritis the most prevalent.
The current treatment of OA is to control the symptoms until the severity of the disability and pain mandates surgical intervention. Early therapy may delay and alleviate the progression of the disease and negate the need for surgery.
Symptomatic Treatment for Osteoarthritis
- Lifestyle modification
- Exercise programs
- Pharmacological Therapy
- Injection Therapy
Lifestyle Modification can minimize the symptoms and is the cornerstone of any treatment program for osteoarthritis.
- Weight loss and maintain a healthy weight
- Healthy Diet of select non inflammatory foods- Dark Leafy greens, spinach, kale, broccoli, collard greens, Nuts, olive oil, berries, garlic, green tea
Avoid- Pasta, wheat products, butter, margarine, most meats, sugar, shadow vegetables, tomatoes, gluten, dairy and fatty foods
- Control blood sugar
- Make sleep a priority
- Stop smoking
- Avoid or limit alcohol
- Eat fish at least twice a week- fatty fish high in levels of Omega 3 and Vit D
- Protect joints against trauma
- Embrace Movement as a sedentary lifestyle will make the symptoms worse
Exercise programs are mandatory. The best therapy is swimming where the stress is alleviated from the joints.
Contact sports should be avoided
Exercise on hard surfaces should also be avoided
Physical Therapy can help initially and educate as to further programs and the limitations that should be avoided
Non-Steroidal Medications have been given for years for osteoarthritis. It is now well documented that NSAIDS can cause stomach upset, ulcers, cardiovascular problems, bleeding problems, kidney and liver damage. Short term use of this group of medications is now recommended.
Acetaminophen is used for short term relief of pain. Higher and long -term use can cause liver damage.
Antidepressants are now used for chronic pain. This class of drugs has a multitude of severe side effects with the most common including headache, nausea, dry mouth, insomnia, GI problems, sexual dysfunction, dizziness and insomnia
Due to the systemic administration of oral drug therapies and their significant side effects of gastrointestinal, cardiovascular, hepatic and renal, injections have a more direct effects on target tissue with reduced side effects systemically.
- Hyaluronic Acid
- Oxygen Ozone
Intra-articular corticosteroids are the most common approach in the injectable treatment of osteoarthritis of the knee. The rationale for its use is the immunosuppressive activity acting at different levels of the inflammatory cascade. Corticosteroids block the synthesis of pro-inflammatory molecules such as interleukin-1, leukotrienes, prostaglandins and catabolic proteins such as metalloproteinases.
In a meta-analysis of 27 randomized controlled trails, corticosteroids were found to be more beneficial in pain reduction than controls, but this difference was short lived and lost completely in the 13 week follow up. At the 13-week junction, there was no statistical difference between corticosteroids and controls. Therefore, the quality of evidence in support of corticosteroids for the treatment of OA of the knee was graded as low.
The side effects of corticosteroids are well known, and repeated injections can degrade the cartilage, bone and tissues of an OA joint.
Hyaluronic Acid is a natural occurring glycosaminoglycan that provides joint lubrication and cushioning. It is a natural shock absorber and provides stability for the glycans of the extracellular matrix of the joint space. In normal adult knees, HA concentration ranges from 2.5 to 4.0 mg/ml whereas in the osteoarthritic knee this value decreases by approximately 50%.
The benefits of supplementation with hyaluronic acid can last up to 26 weeks. The benefits in terms of pain relief and functional improvement have been recently rediscussed by the Osteoarthritis Research Society International and they assigned a level of recommendation of 1B/2 to the use of HA for the treatment of OA of the knee.
Intra-articular HA is recommended for the long-term treatment of osteoarthritis of the knee with a more favorable safety profile than repeated corticosteroids.
The American Academy of Orthopedic Surgeons has neither endorsed nor discouraged HA use. However, the AAOS still endorses the use of corticosteroids for osteoarthritis of the knee.
Polydeoxyribonucleotides are composed of polymers of various chain lengths. These substances are capable of binding large amounts of water capable of restructuring the cartilage surface. They also aid in chondrocyte survival with reduced degradation of proteoglycans.
These substances have significant anti-inflammatory properties by decreasing proinflammatory mediators such as IL-6, tumor necrosis factor-alpha and others.
PDRN offers mechanical protection towards the damaged cartilage, helps replace synovial fluid, and restores the natural microenvironment of the joint. According to a meta-analysis, PDRN has shown improvement of activities of daily living and has equal functional improvement to HA.
In a study done in Great Britain, Hyaluronic acid when combined with Polydeoxyribonucleotides had a greater efficacy than either substance alone and the results were longer lasting. This combination could be used and would result in a longer interval between injections. Studies are currently ongoing.
Ozone was a molecule discovered in the mid-19th century consisting of three atoms of oxygen in a dynamically unstable structure. The ozone was proven to be a powerful anti-inflammatory and immune modulatory substance. It reduces oxidative stress and stimulates fibroblastic joint repair while promoting cartilage growth. Ozone therapy leads to an increase oxygen delivery by promoting vasodilation and angiogenesis.
Although still considered controversial, ozone therapy has shown better pain relief, joint function and quality of life than corticosteroid injections.
Ozone therapy is a safe procedure with almost zero side effects, and it is bacteriostatic, fungicidal and viricidal therefore the risk of infection is minimal.
In most trials, treatment with hyaluronic acid is still superior to ozone therapy leading to its lack of widespread consensus.
Platelet Rich Plasma
Platelet rich plasma is an autologous blood derived product with platelet concentrations greater than the bodies baseline. Platelet Rich Plasma relies on the ability of platelets to release biologically active proteins when encountering damaged tissues. The growth factors and cytokines released by the alpha granules contained on the platelets promotes tissue healing and regeneration. The PRP effects can be attributed to the effect on the signaling pathways.
The Wnt family of proteins plays a central role in inflammation cascades and stimulation of the release of catabolic molecules such as metalloproteinases which are responsible for cartilage degradation and deterioration of articular surfaces. The Wnt pathway is also significantly involved in Type 2 collagen degradation and chondrocyte apoptosis. Platelets modulate the effects of this pathway and block this inflammatory degradation of the tissues.
Most studies have demonstrated that PRP is superior to HA especially in cases of low- grade degradation. In cases of high-grade degradation of the joint, the outcomes are quite similar to viscosupplementation.
Mesenchymal Stem Cells
MSC treatment consists of intra-articular injections of stem cells associated with a group of cells with immune-modulatory and anti-inflammatory stromal molecules. Many adult tissues are populated with MSC but in clinical practice, they are usually harvested from the bone marrow or adipose tissues. MSC have the capacity to differentiate into mesenchymal derived tissue such as osteoblasts, chondrocytes and adipocytes that possess anti-inflammatory, pro-angiogenetic and anti-apoptotic function as well as reparative and regeneration.
Bone Marrow Mesenchymal Cells are obtained from the iliac crest by needle aspiration and then concentrated. BMAC has shown to have a positive effect on function and pain however its regenerative effects and superiority compared to viscosupplementation and corticosteroids are still to be proven.
Stromal Vascular Fraction (Adipose tissue usual site of origin) contains at least 300-500 times more cells when compared to BMAC. SVF products differ in terms of preparation methods. Originally SVF was obtained by enzymatic digestion with collagenase and trypsin but following safety and regulatory concerns other methods were developed.
The FDA in July 2020 released a document entitled “Regulatory Considerations for Human Cells, Tissues, and Cellular and Tissue Based Products: Minimal Manipulation and Homologous Use”
This defines Homologous Use as “that the HCT/P is intended for homologous use only, means the repair, replacement, reconstruction or supplementation of a recipients’ cells or tissues with an HCT/P that performs the same basic function or functions in the recipient as the donor.
Minimal manipulation is considered processing, such as cutting, grinding, shaping, culturing, enzymatic digestion and decellularization.
Because of these new regulations and more contained in this document, the use of stem cells by donors or the manipulation of the patients own tissues can be considered in violation of this new regulation and not currently recommended by many institutions.
Integrative Practice Solutions has been instructing physician practices in the use of viscosupplementation for years. We have formulated the patented Advanced Arthritis Relief Protocol™. Developed with the information we have gathered from hundreds of physicians and thousands of osteoarthritic cases treated over the past decade. Fluoroscopic guidance, unloading bracing and physical therapy both in office and at home, added to viscosupplementation, has enhanced our outcomes for superior care in these patients and added to the quality of life in these individuals without the need for surgery.
Juventix Regenerative Medical, our sister company, is an industry leader in the regenerative medical field. Our Platelet Rich Plasma Kits are FDA approved and designed for the ease, and safety of use and cost effectiveness. Our Regenerative Devices include a LED Activator, Bio-Incubator and Photo modulator. All are state of the art for regenerative applications using the patients’ autologous blood and therefore no side effects or allergic responses.
In 2022, a patient with osteoarthritis of the knee has many proven treatment options. Don’t rush into arthroscopic surgery or even total knee replacement. Refrain from multiple steroid injections or long term NSAID use. These procedures and drugs can have significant side effects. Discuss other modalities and treatment protocols with your healthcare professional.
Dr. Robert McGrath
Platelet Rich Plasma: New Performance Understandings and Therapeutic Considerations in 2020
Int J Mol Sci 2020 Oct;21(20): 7794. PMID 33096812
Randomized Double Blind Comparison of a Fixed Co-Formulation of Intra-Articular Polynucleotides and Hyaluronic Acid Versus Hyaluronic Acid Alone in the Treatment of Knee Osteoarthritis: Two Year Follow Up
BMC Musculoskeletal Disorders 18 Jan 2021 doi.org/10.1186/s12891-021-04648-0
Injections in the Osteoarthric Knee: A Review of Current Treatment Options
Effort open rev 2021 Jun: 6(6):501-509 PMID 34267940