Seventy-year-old Mrs Y.R. weighed 80 kilos and complained of six-month-old pain and stiffness in both knee joints. It restricted her mobility, especially climbing down the stairs, and her daily functioning too. She was having increasing difficulty doing her household chores.
Physical examination showed that her thigh muscles were very tight. Bending the leg at the knee was painful and restricted because of her tight quadriceps (muscle on the front of the thigh). The hamstrings (muscle on the back of her thigh) and the calf muscles too were stiff and painful.
An X-ray of the knee joint was done, which showed only mild degenerative changes in the knee joint, suggestive of very early osteoarthritis in both knees. The pain in her knees was disproportionate to the X-ray findings. The tight muscles and severe spasm of the muscles of the thigh and calf were probably the cause of pain, as they were causing stress on the knee joint as well as on the nerves supplying the knees.
Currently, there is no cure for osteoarthritis of the knee. Treatment needs to focus on decreasing pain and improving functionality. The recommendations are that treatment should be tailored to the individual patient, with a combination of nondrug and drug therapies.
What are some non-drug therapies for osteoarthritis?
These are generally the preferred line of management in patients with osteoarthritis of the knees, as these therapies are not only safe but have long-lasting effects.
The mainstay of this line of treatment is exercises. Exercises should be mainly targeted at strengthening the muscles of the thigh (quadriceps in front and hamstrings behind) and the calf muscles at the back of the leg. These muscles are not only weak but they are often very tight leading to stiffness of the joint, making bending the knee and climbing down steps difficult and painful.
The tightness of the muscles is because of muscle shortening. So, in addition to muscle strengthening exercises, muscle shortening needs to be addressed as well. For achieving this, a combination of dry needling and stretching of the relevant muscles should be done.
There is evidence that specific joint exercises play a major role in decreasing pain and improving function in these patients. The role of physiotherapists in the medical management of patients with osteoarthritis of the knee is, thus, very crucial. They assess muscle strength, joint stability and mobility and recommend appropriate exercises to decrease pain and improve functionality. They also help in providing suitable assistive devices such as canes, crutches or walkers to improve ambulation.
Since the knee joint is a weight-bearing joint, weight reduction would be of great benefit in these patients as it would decrease the stress and strain on the joint. But this is easier said than done, the main reason being that decreased mobility itself hampers regular walks and any such attempts at weight reduction. If necessary, a nutritionist’s services may need to be enrolled to help reduce body weight through diet control.
Acupuncture has been shown to be a viable adjunct and a useful alternate therapy for arthritis of the knee. The main advantage that acupuncture has over anti-inflammatory drugs is the complete lack of side-effects, as it is incredibly safe and is an outpatient treatment.
Since many patients with severe osteoarthritis may have mood disturbances due to their disability, this aspect needs to be addressed as well. Most of these people may not have major depressive episodes but are likely to have low level depression or dysthymia. A combination of Cognitive Behavioural Therapy and supportive psychotherapy would be helpful.
The distorted thoughts related to disability, and discouragement due to lack of wellness thereof, are targeted. Activity scheduling is done so that a routine is built. The patient is encouraged to engage in all kinds of activities from self-care to exercises to indulging in hobbies and socialization. Sympathetic and caring family members are urged to spend time with the patient so that loneliness and discouragement do not creep in. Efforts to promote socialization of the patient are also done. They are persuaded to use their assistive devices and go to nearby gardens or society hubs to interact with their friends.
Can over-the-counter drugs help?
It is advisable that analgesic drugs be used only when there is severe pain. Paracetamol is the first line drug for mild to moderate knee-joint pain. If it is effective, it is the preferred drug for long-term management, as its side-effect profile is superior to those of anti-inflammatory drugs such as ibuprofen and diclofenac sodium.
The latter may be more useful in severe knee-joint pain, especially if there is associated swelling. For those patients who wish to avoid taking analgesic drugs orally, cold packs and topical or local application of capsaicin or anti-inflammatory agents like gels or sprays containing anti-inflammatory drugs are advocated.
This excerpt has been taken from Conquering Pain: How To Prevent It, Treat It, And Lead A Better Life by Dr Mary Abraham and Dr Vandana V. Prakash.