Understanding and Treating Osteoarthritis

Osteoarthritis (OA), the disease responsible for the majority of later-in-life knee pain, tends to begin around middle age and comes to make itself known more loudly by the time the sixth decade rolls around. OA has long been considered a “wear and tear” joint problem associated with aging. But it’s more than that. Research has shown there are biological differences between cartilage that is merely getting older and aging cartilage with OA. For example, with OA there are greater amounts of certain molecules released. A study published on April 15, 2020, in Science Translational Medicine showed that blocking a particular enzyme in mice inhibited the progression of knee OA. While mice are not people, the finding suggests a pathway for developing future OA treatments and clinical trials.

“We believe that enzymes released with osteoarthritis are causing damage to the knee,” says interventional radiologist Siddharth A. Padia, MD, professor of radiology, UCLA Medical Center. “We are embarking on a new study later in 2021 to measure the enzymes before and after a procedure called genicular artery embolization (GAE) to see if it makes a difference in slowing the progression of arthritis.”

Meanwhile, there are several approaches to treating OA, depending on the severity of the disease. GAE, a promising new nonsurgical treatment, is detailed below.

Staged Treatment Options

Treatments start with the most conservative approaches and generally
track with OA severity. Stages of OA are ranked from 1 to 4. Stage 1 is when bony outgrowths (bone spurs) begin developing and are visible on x-rays. Pain, if any, is mild. The treatment recommendations include doit-yourself activities such as losing weight if overweight, following a self-guided exercise routine, and if pain occurs, the typical self-treatment protocol is RICE, an acronym for rest, ice, compression, and elevation.

Stage 2 also is considered rather mild, with more bone spurs and thinner cartilage visible on imaging (x-ray, MRI). Joints feel stiffer, especially after prolonged sitting. Knee braces, supportive knee sleeves, shoe inserts, physical therapy, and over-the-counter nonsteroidal anti-inflammatory medications (e.g., naproxen, ibuprofen) and pain medications (e.g., acetaminophen, aspirin, and topical products) become increasingly common at this stage.

As OA advances to stage 3, pain and joint swelling are more frequent, especially with activities such as knee bending, walking, and running. At
this point, all the previous recommendations may still be valid, but
they are less effective. The next step may include joint injections such as hyaluronic acid and steroids. While steroids can be quite effective and last up to six months, the window of benefit is short-lived. Steroids can harm
joints in the long run, so the number of injections a person can have is limited.

While hyaluronic acid isn’t damaging (the fluid provides some cushion for the joint), it may require several treatments. And everyone is different. Some people get relief for several months or more, while others may feel little or no benefit. There’s no way to know up front if the injections will work for you.

Stage 4, severe OA, is the stage where little to no cartilage remains.
The result is severe bone-on-bone pain and inflammation. Joint replacement is a common recommendation at this point. It’s a highly successful procedure, and replacements can last up to 20 years. Recovery and rehab may take many months. Studies show that the majority of people are pleased with the procedure. Pain is reduced and function returns in the vast majority of cases. Highly touted stem cell treatments show some promise but are still in trial stages.

Minimally Invasive GAE

Genicular artery embolization is making its way up through clinical
trials. It has been in use at UCLA since 2017, where it has treated people with moderate to severe pain. For example, a man in his 90s who wanted to avoid the general anesthesia required for knee replacement found the procedure to be quite successful. He previously had pain and trouble walking, but after the procedure he was able to walk comfortably and pain-free.

GAE is a nonsurgical treatment (using local anesthesia and twilight sedation) that has been shown to be both safe and effective in providing immediate and longterm pain relief in trials at UCLA and elsewhere. A new UCLA study further validated early results. Details were presented at the 2021 Society of Interventional Radiology Annual Scientific Meeting in March.

“Our primary objective in the trial was to assess safety, and the secondary objective was to assess efficacy,” says Dr. Padia, lead investigator. “There were no significant adverse events, just some minor skin discoloration, which was temporary. As far as efficacy, 68% of patients had significant reduction in pain and return to function sustained at 12 months when the trial ended.”

People in the study experienced benefits as soon as three days after the procedure. Using the common pain scale of 1 (no pain) and 10 (severe pain), average pain scores decreased from 8 out of 10 before GAE to 3 out of 10 after one month. Additionally, seven in 10 patients reported more than 50% reduction in pain scores at the one-year followup.

“People with knee OA have abnormally high blood flow to the inflamed area, and this procedure normalizes blood flow,” says Dr. Padia.

For this outpatient procedure, interventional radiologists navigate a catheter through a small incision in the hip into the arteries in the arthritic knee. They then inject tiny particles to reduce the blood supply to the inflamed and painful areas of the knee. According to Dr. Padia, the particles are routinely used in interventional radiology to treat a number of conditions, such as uterine fibroids, liver cancer, and enlarged prostates. The procedure takes just one to two hours to complete, followed by a two-hour recovery period. People can resume their normal activities immediately following the procedure, and a rehabilitation program is not routinely necessary. UCLA is planning trials using GAE to assess safety and efficacy for tennis elbow (lateral epicondylitis) and frozen shoulder (adhesive capsulitis) in qualified candidates in the near future. For more information on the knee procedure and upcoming trials, email [email protected]. Internet-Based Exercise Effective for OA Exercise can help reduce pain and restore some function in people with OA whether they’ve had a procedure such as GAE, joint injections, or joint replacement. Those with early-stage disease would do well to see a physical therapist (PT), who can design appropriate exercises for particular needs. Once pain has been an ongoing experience, working with a PT is definitely advised. Many people with knee pain tend to compensate with other muscles, which often results in a cascade of misalignments that can lead to pain in other body parts. Proper form is everything, and this is what movement experts can help with. Once that’s established, exercises can effectively be done in gyms and/or at home.

Researchers based in the UK wanted to find out if an OA exercise program delivered via the internet would benefit people with knee OA compared to “usual care,” which includes providing patients with disease information and self-management of recommended long-term exercise programs. Researchers recruited 551 people; average age was 66 and 67% were female. Half the group received the internet-based exercise intervention and the other half usual care. The study was conducted over a six-week period.

In addition to digitally-delivered exercises, the intervention group received educational sessions that covered the basics of osteoarthritis, its treatment, self-managing symptoms, the benefits of behavioral change and maintaining a healthy lifestyle. Each educational session was followed by a quiz to ensure that participants had understood the key messages. Adherence was encouraged by daily emails or smartphone notifications, or by the physiotherapist via asynchronous chat or telephone during the study period. The researchers found that the internet-based program significantly reduced pain and resulted in greater gains in strength and physical ability compared to the usual-care group. The superior outcome in the intervention group could partially be due to the daily delivery of individualized treatment, together with support, engagement, and nudging from health-care professionals. Nonetheless, the digital delivery of content proved to be a convenient and highly beneficial way to provide treatment to participants. The study appeared in the Feb. 23, 2021, issue of JAMA.

The post Understanding and Treating Osteoarthritis appeared first on University Health News.

Read Original Article: Understanding and Treating Osteoarthritis »