About one in seven people will eventually develop osteoarthritis of the knee, and the proportion is likely to rise as the population gets older and the obesity epidemic takes its toll on our aging knees. Unfortunately, there is no cure and no clear winner among the many drugs used to treat the condition. Part of the problem is that there have been few studies comparing treatments.
Recently researchers from Tufts and Brown universities attempted to fill in some of the blanks by doing a special analysis of 137 placebo-controlled studies on knee arthritis in order to evaluate the relative efficacy of four leading drugs and two common types of injections. The results, published in the Annals of Internal Medicine, contained some surprises”
Acetaminophen, the most commonly recommended and used drug for arthritis (Tylenol is one brand), was least effective in relieving knee pain after three months – only minimally better than placebo.
Best of the oral drugs for pain relief was diclofenac (prescription only), followed by ibuprofen and the naproxen. Celecoxib (Celebrex, prescription only) was just slightly more effective than acetaminophen. There was little or no difference in the effect of drugs on stiffness and function, largely because of limited data.
Most effective for pain were injections of either corticosteroids or hyaluronic acid into the joint, compared to an injected placebo – and even more effective when compared to an oral placebo.
Interestingly, injected placebos provided much more pain relief than oral placebos and were at least as beneficial as the oral drugs. It’s well known that the placebo effect plays a large role in treatments for arthritis and other kinds of pain. That is, positive expectations about a treatment – even if it actually is just a sugar pill or saline injection – can trigger an improvement in symptoms. Injected placebos may be more effective because patients expect more from them, or it may be that injecting any fluid into the joint provides some relief.
BOTTOM LINE: If you have knee arthritis, discuss your treatment options with your healthcare provider. People respond differently to treatments partly because arthritis pain can have different causes. Many providers still advise patients to start with acetaminophen, since it will help some of them and is least risky when taken as directed. However, acetaminophen overdosing (more than 4,000 milligrams a day) can cause sever liver damage, as can lower doses when combined with alcohol. If oral drugs don’t help enough, ask about knee injections.
And don’t forget exercise and weight loss (if you are overweight), which can go a long way in reducing arthritis symptoms.
What are some symptoms of arthritis and how can I protect my joints from arthritis?
Generally, the pain associated with arthritis develops gradually, although sudden onset it also possible. The joint may become stiff and swollen, making it difficult to bend or straighten the joint. Pain and swelling are worse in the morning or after a period of inactivity. Pain may also increase after activities such as walking, stair climbing or kneeling. The pain may often cause a feeling of weakness in the knee, resulting in a "locking" or "buckling". Many people report that changes in the weather also affect the degree of pain from arthritis.
Your first sign of hip arthritis may be a bit of discomfort and stiffness in your groin, buttock or thigh when you wake up in the morning. The pain flares when you're active and gets better when you rest.
Canes, crutches, walkers or splints may help relieve the stress and strain on arthritic joints. Learning methods of performing daily activities that are the less stressful to painful joints also may be helpful. Certain exercises and physical therapy may be used to decrease stiffness and to strengthen the weakened muscles around the joint.
What are some treatment options for arthritis?
The goals of treatment are to provide pain relief, increase motion, and improve strength. There are several kinds of treatment:
Many over-the-counter medications, including aspirin, ibuprofen, and naproxen (common anti-inflammatory drugs) may be used to effectively control pain and inflammation in arthritis. Acetaminophen (Tylenol) may be used to effectively control pain. Prescription medications also are available if over-the-counter medications are not effective.
The physician chooses a medication by taking into account the type or arthritis, its severity, and the patient's general physical health. Patients with ulcers, asthma, kidney, or liver disease may not be able to safely take anti-inflammatory medications.
Injections of cortisone directly into the joint may temporarily help to relieve pain and swelling. It is important to know, however, that repeated frequent injections into the same joint can damage the joint and have undesirable side effects.
As mentioned above, certain exercises and physical therapy may be used to decrease stiffness and to strengthen the weakened muscles around the joint.
In general, an orthopaedist will recommend surgery for arthritis when other methods of non-surgical treatment have failed to give relief. The physician will choose the type of surgery by taking into account the type of arthritis, it severity and the patient's physical condition.
What is the post-operative course and recovery like? How will my daily activities be affected by surgery?
After total hip or knee replacement you will often stand and begin walking the day after surgery. Initially, you will walk with a walker, crutches or a cane. Most patients have some temporary pain in the replaced joint because the surrounding muscles are weak from inactivity and the tissues are healing, but it diminishes steadily over time.
Exercise is an important part of the recovery process. Your orthopaedic surgeon or the staff will discuss an exercise program for you after surgery. This varies for different joint replacements and for differing needs of each patient. After your recovery from surgery, you may be permitted to play golf, walk and dance. However, more strenuous sports, such as singles tennis or running, may be discouraged.
The motion of your joint will generally improve after surgery, but only if you follow your post-op joint motion exercise program at home.
What can I expect during recovery at home?
You will have stitches or staples running along your wound or a suture beneath your skin on your skin on your hip or knee. The stitches or staples will be removed approximately 10 days after surgery. A suture beneath your skin will not require removal. Avoid soaking the wound in water until the wound has thoroughly sealed and dried and all sutures or staples are removed. A bandage may be placed over the wound to prevent irritation from clothing for support stockings.
Some loss of appetite is common for several weeks after surgery. A balanced diet, often with an iron supplement, is important to promote proper tissue healing and restore muscle strength.
Exercise is a critical component of home care, particularly during the first few weeks after surgery. Your activity program should include:
A graduated walking program to slowly increase your mobility, initially in your home and later outside.
A return to other normal household activities, such as sitting and standing and walking up and down stairs.
Specific exercises several times a d ay to restore movement and strengthen your joint. You probably will be able to perform the exercises without help, but you may have a physical therapist help you at home the first few weeks after surgery.
Driving usually begins when your knee or hip bends sufficiently so you can enter and sit comfortably in your car and when your muscle control provides adequate reaction time for braking and acceleration. Most individuals resume driving about five to six weeks after surgery.
Are there any advances in Joint Replacement Surgery? YES!!!
Minimally invasive hip and knee replacement.
New technology for imaging and computer-assisted implant placement has been developed. It continues to be modified as experience with smaller incision surgery grows. This will allow more precise reconstruction of the hip or knee.
In addition, new implant designs and materials are being developed to both facilitate minimally invasive surgery of the hip and knee and to prolong the life-span of replacements.
Contact Dr. Reff to find out about arthritis pain relief options.