Conservative care for knee osteoarthritis

The people we see at our clinic are typically people who have been suffering from chronic pain for many, many years. Their joints pop, grind, crack, and are generally considered to be “noisy.” They have a long medical history of prescription anti-inflammatory medications use, stronger prescription anti-inflammatory medications, painkillers, physical therapy, massage therapy, chiropractic care, cortisone shots, nerve blocks, and finally a surgical recommendation. Some patients have even had the surgery and they continue to suffer from chronic pain issues and they start the cycle of treatments over again.

Why does this happen to them and millions of people just like them? The answer: These treatments do not actually fix the root cause of the patient’s problem.

Let’s start with a 2022 paper in the journal Rheumatology Reviews (1). In this collaborative opinion from international researchers, a review is offered on the current conservative care treatment options for knee osteoarthritis. “Osteoarthritis is the most prevalent type of arthritis worldwide, resulting in pain and often chronic disability and a significant burden on healthcare systems globally. Non-steroidal anti-inflammatory drugs (NSAIDs), analgesics, and intra-articular corticosteroid injections are of little value in the long term, and opioids may have ominous consequences. Radiotherapy (low-dose radiation) for knee osteoarthritis has no added value. Physical therapy, exercises, weight loss, and lifestyle modifications may give pain relief, and improve physical functioning and quality of life. However, none of them has articular cartilage regenerating potential.”

Let’s focus on that last sentence. “None of them has articular cartilage regenerating potential.”

I don’t go to the doctor because nothing can help me and I will just have to live with

Some patients spend years with painful osteoarthritis without seeking a doctor or doctors guided and suggested medical treatments. This would include the times of acute flare-ups when they are experiencing persistent severe pain and disability. Then why do patients seek or not seek medical care? Researchers in the British Medical Journal (1) sought to investigate and answer this question.

The research team received responses to a self-complete questionnaire from 863 people ages 50 and over (55% female; average age 70 years, range: 58 years old to 93 years old).

The most important determinants of the patient’s decision to consult the doctor for joint pain were:

the extent to which pain disrupted everyday life 31%
what the patient thought the doctor would say to them – the possibility that nothing could be done and that the patient would just have to live with it 24%

Anticipating that the doctor will regard joint pain as ‘part of the normal aging process that one just has to accept’ is a strong disincentive to seeking help, potentially outweighing other aspects of quality of care.

Alongside the recognition and management of disrupted function, an important goal of each primary care consultation for osteoarthritis should be to avoid imparting or reinforcing this perception.

When patients did seek treatment, what did they find most effective?

An October 2021 paper in the Archives of Rheumatology (2) surveyed patients whose complaints included mostly knee pain, lumbar pain, and cervical spine-neck pain. Prior to the survey treatment modalities which were prescribed to patients were:

Oral drugs (79.7%)
Topical drugs (73.8%),
Home-based exercise program (62.6%), and
physical therapy (outpatient) (61.3%).

However, based on their own personal needs, patients preferred:

Outpatient physical therapy program (45.9%),
oral drugs (33.1%),

According to the researchers: “The treatment preferences of our patient group were mostly drugs, outpatient and inpatient physical therapy programs, and home-based exercises depending on the reasons such as previous benefit from treatment, long-term effects, easy access to treatment, and concerns about side effects.”

The standard medical treatment for osteoarthritis involves the use of non-steroidal anti-inflammatory drugs (NSAIDs). Unfortunately, however, it has been recently shown that these medications may promote further deterioration of the joint. Therefore, although these medications may be helpful in reducing pain, they may not be beneficial in the long run. At the minimum, everyone would concur that they do nothing to help the repair process of the soft tissue injury.

Over the past several years additional information has accumulated in regards to the use of glucosamine, chondroitin sulfate, and collagen II. These products are available without a prescription from health practitioners or the local health food stores. They have been shown to be effective in pill form or via injection. Glucosamine can be extremely helpful in reducing pain from osteoarthritis and can also help prevent further deterioration of the joint.

Another useful medicine for joint pain is Capsaicin. This is available either as a generic or proprietary cream (known as Zostrix). When applied to a painful joint on a regular basis, joint-related pain and muscle spasms are decreased to a significant degree. Side effects, other than warmth, are very rare. These creams literally work to decrease the amount of pain chemicals that are present in the tissues surrounding the joint.

A November 2022 paper published in the journal Osteoarthritis Cartilage (3) assessed the effectiveness of vitamin D supplementation on knee osteoarthritis in 236 patients over 45 years old who had knee pain. The researchers found that compared to the control group, vitamin D supplementation did not make a significant difference in pain or function.

There is a lot of recent research coming out of China on the use of glucosamine in the treatment of osteoarthritis.

A July 2022 study (4) found that “the clinical efficacy of chondroitin combined with glucosamine in the treatment of knee osteoarthritis was significantly higher than that of conventional therapy (conservative care treatment or that of chondroitin or glucosamine alone).” Patients showed patients had positive results for joint pain, tenderness, swelling, and dysfunction.”

In July 2022, Pakistani researchers (5) found that “Manual therapy and resistance exercise training are effective in the management of knee osteoarthritis, however, glucosamine and chondroitin sulfate supplementation for 4 weeks showed no additional benefits.”

How well does a placebo really work?

A May 2022 study (8) was led by doctors at the Institute of Medical Psychology, Ludwig Maximilian University of Munich to see if a placebo helped elderly patients with knee osteoarthritis, and, if it did, how much? There has been much in the medical research over the years to suggest that patients did get better with placebo because they believed in the treatment.

In this study, sixty patients (55% females; average age about 67) were divided into one of two placebo treatment groups or no treatment. Let’s explain that: The one group of placebo treatments were given suggestions during treatment. These suggestions included one group “to decrease pain” and the other group “to improve mood.”

The patients who were given suggestions to improve pain actually did. The patients who were given suggestions to improve their mood did not. But how much did a placebo actually work? In neither group function, stiffness, knee mobility, stress, state anxiety, quality of life, and self-efficacy did not change differently between groups. However, the one group did experience less pain. The suggestion of the research? “Placebo treatment improved knee pain in elderly patients with symptomatic knee osteoarthritis, while functional disability and mobility of the knee did not change. The content of the verbal suggestion was of minor importance. Placebo administration may be considered as supportive analgesic treatment (placebo as a pain killer) in elderly patients with symptomatic knee osteoarthritis.”

Of course, there are ethical issues here when offering placebos as treatments.

Irenka and Cymbalta

A May 2022 paper in the journal Arthritis & Rheumatology (6) tested the effectiveness of Irenka and Cymbalta (duloxetine drugs typically prescribed for major depressive disorder, anxiety, diabetic peripheral neuropathy, and chronic musculoskeletal pain) in patients with chronic pain from osteoarthritis.

132 patients were randomized into treatment groups. A total of 66 patients were randomized to receive duloxetine in addition to usual care, and 66 patients did not receive duloxetine but had conventional care. Duloxetine was gradually discontinued after 3 months when patients experienced no effect and/or when patients had intolerable side effects.

Usual care was education, lifestyle advice, diet, physiotherapy, and analgesics. Intraarticular injection of glucocorticoids and referral to secondary care were also allowed. The researchers found: “no (added beneficial) effect of duloxetine added to usual care compared to usual care alone in patients with chronic knee or hip osteoarthritis pain.”

1. Coxon D, Frisher M, Jinks C, Jordan K, Paskins Z, Peat G. The relative importance of perceived doctor’s attitude on the decision to consult for symptomatic osteoarthritis: a choice-based conjoint analysis study. BMJ Open. 2015 Oct 26;5(10):e009625. doi: 10.1136/bmjopen-2015-009625. [Google Scholar]
2 Kutsal YG, Eyigör S, Karahan S, Günaydın R, İrdesel J, Sarıdoğan M, Borman P, Sarı A, Gökkaya KO, Safer VB. Incorporating patient preferences into osteoarthritis treatment. Archives of Rheumatology. 2021 Dec;36(4):577. [Google Scholar]
3 Jin X, Ding C, Hunter DJ, Gallego B. Effectiveness of vitamin D supplementation on knee osteoarthritis-A target trial emulation study using data from the Osteoarthritis Initiative cohort. Osteoarthritis and Cartilage. 2022 Nov 1;30(11):1495-505. [Google Scholar]
4 Wang Z, Wang R, Yao H, Yang J, Chen Y, Zhu Y, Lu C. Clinical Efficacy and Safety of Chondroitin Combined with Glucosamine in the Treatment of Knee Osteoarthritis: A Systematic Review and Meta-Analysis. Computational and Mathematical Methods in Medicine. 2022 Jul 25;2022. [Google Scholar]
5 Babur MN, Siddiqi FA, Tassadaq N, Tareen MA, Osama M. Effects of glucosamine and chondroitin sulfate supplementation in addition to resistance exercise training and manual therapy in patients with knee osteoarthritis: A randomized controlled trial. [Google Scholar]
6 van den Driest JJ, Schiphof D, Koffeman AR, Koopmanschap MA, Bindels PJ, Bierma-Zeinstra SM. No Added Value of Duloxetine in Patients With Chronic Pain due to Hip or Knee Osteoarthritis: A Cluster-Randomized Trial. [Google Scholar]
7 Siddiq MA, Clegg D, Jansen TL, Rasker JJ. Emerging and new treatment options for knee osteoarthritis. Current rheumatology reviews. 2022 Feb 1;18(1):20-32. [Google Scholar]
8 Olliges E, Stroppe S, Haile A, Reiß F, Malhis M, Funke SA, Meissner K. Open-Label Placebo Administration Decreases Pain in Elderly Patients With Symptomatic Knee Osteoarthritis–A Randomized Controlled Trial. Frontiers in psychiatry. 2022;13.

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