osteoarthritis treatment

If you have Osteoarthritis, you are not alone!

And we can help!

It is estimated that 1 in 8 Canadians has Osteoarthritis(OA) and OA is considered one of the leading causes of disability among adults.

It is estimated that 1 in 8 Canadians has Osteoarthritis.

OA is considered one of the leading causes of disability among adults (Miller 2020) and these numbers are rising as our population is aging.

Knee OA disability rates increased 75% between 1990 & 2013 and it is expected to continue to rise.

“By the year 2030, an estimated 67 million adults (25% of the projected total adult population) aged 18 years and older will have doctor-diagnosed arthritis, compared with the 52.5 million adults in 2010-2012.” (McAlindon 2014)

At Resolution Physiotherapy & IMS Clinic in Barrie, we are excited to have Orthopaedic Surgeon, Dr. Raaj Vora on our team as well as Physiotherapists who have post-graduate training in the rehabilitation of Osteoarthritis.

If you have OA pain that is slowing you down, contact us today so we can help get you back to life with increased function and less pain!

What is Osteoarthritis?

“Osteoarthritis (OA) is one of the leading causes of disability in the adult population. OA is most often a slow progressive joint disorder, characterized by joint pain, cartilage degeneration, and decreased joint function.” (Altman 2019)

“A healthy joint requires not only a fine-tuned balance of molecular signals regulating homeostasis but also the ability to respond to damage, restoration, and remodeling. Biomechanical, metabolic, and biologic changes, as well as trauma and isolated cartilage lesions, may lead to the loss of this homeostasis, resulting in degeneration of the articular surface and, ultimately, to osteoarthritis (OA).” (Kon 2018)

To put it simply, OA occurs when there is and imbalance between cells that cause inflammation (called IL-1b cells) and cells that reduce inflammation (called IL-1a cells). In a normal knee joint, the balance between these 2 cells is equal meaning that there is no inflammation in the joint. With OA, this balance is altered where the percentage of inflammation causing cells is much higher and this leads to inflammation in the joint which causes a breakdown of the articular cartilage, increased joint compression, bone spurring, reduced mobility and pain.

With the population aging, and the prevalence of OA increasing, it is important that modern medicine addresses this imbalance with the goal of modifying the course of the disease as well as improving quaity of life for our clients. Up until now, treatment has focussed on treating the symptoms without being able to alter the biochemistry of what is happening in the joint.

At Resolution Physiotherapy, we are very excited as there are now new treatments available, including nSTRIDE (see below for detailed description) which are not only improving pain and function, but are also changing the biochemistry in the joint which may result in an alteration in the OA disease process as a whole.

What are risk factors for Osteoarthritis?

There are a number of risk factors for OA.
If you have OA, it is likely that you have one or more of the following (Richmond 2013, Heidari 2011):

• Age — Advancing age is one of the strongest risk factors for OA, and OA is uncommon under the age of 40. About 13% of women and 10% of men aged 60 years and older have symptomatic knee OA (Heidari 2011).

• Gender — For reasons unknown, women are two to three times more likely to develop OA than men

• Family history: If other members of your family have or did have OA, your risk of developing OA increases.

• Obesity — People who are obese are at high risk of developing OA. Losing weight may reduce this risk.

• Occupation — OA risk is higher with occupations that require repetitive sitting or kneeling, or that involve heavy lifting, prolonged standing or walking

• Injury — Previous joint injury or trauma, including ACL or meniscal injury increases the risk of future OA

• Sports — The risk of OA may be increased in people who participate competitively in sports that predispose to joint injury, especially when OA develops before the age of 45

Which joints are most commonly affected by Osteoarthritis?

“Any joint can be affected by osteoarthritis (OA) but the disease occurs most commonly in joints that have experienced repetitive stress or injury.

Knee: The knee is the most common lower-limb joint affected by OA. People with OA often experience knee pain when doing routine activities such as walking and going up and down stairs.

Hip: OA of the hip can be deceptive. Some people feel pain in the groin area, while others feel pain in the buttocks, front of the thigh, sides of the hips, or lower back. Some of these pain symptoms are not necessarily due to OA of the hip. They may be due to conditions in other areas causing pain in the hip region, known as “referred” pain. Likewise, patients can be surprised when their doctor tells them the problem is their hip joint when they experience pain elsewhere.

Hand: OA of the hand is commonly linked to a family history of the condition. What causes osteoarthritis? In the fingers, symptoms include pain and swelling of the joints. In the thumb, pain is most commonly experienced at the base of the thumb and worsens with gripping and pinching movements.

Foot and ankle: OA can affect the ankle and the joints within the foot, commonly the joint at the base of the big toe. This causes pain when walking and can result in swelling or deformity at the joint that can lead to the formation of bunions. In addition to the big toe, bunions can have a “knock on” effect when the angle and displacement of the big toe results in the second toe putting pressure on the third toe. Bunions have the potential to compound foot pain and deformity.

Back and neck: The first sign of OA is typically stiffness or pain. In general, once the source of the pain is identified, an OA diagnosis is straightforward. Unfortunately, an OA diagnosis of the back and neck is not always straightforward. Although back pain is very common, definitively diagnosing the source of back pain is a challenge. Is the cause OA (a joint problem) or is it something else (a disc or injury-related problem)? The challenge arises because osteoarthritic changes in the spine seen on x-ray and other imaging studies do not always cause pain. Since the incidence of OA increases with age, you may indeed have OA in your older back but the source of your pain may be another condition, injury, or disease.” (OARSI https://www.oarsi.org/which-joints-does-osteoarthritis-affect, McAlindon 2014)

What symptoms will you have with OA?

Symptoms and severity of symptoms can vary dramatically amongst people who have OA but common symptoms of OA include (OARSI https://www.oarsi.org/patients):

• Joint pain that usually occurs when using the joint or at the end of the day after using the joint

• Stiffness that occurs more frequently first thing in the morning; or stiffness later in the day after sitting for periods of time but which lasts for less than around 30 minutes once you get moving

• Joint noises such as cracking, crunching, grinding sounds when the joint moves

• Swelling, when your joint appears larger and feels warm to touch, can be caused by the inflammation associated with OA leading to joint fluid buildup

• Instability, when the joint may feel weak or likely to give way when you put pressure on it

How is Osteoarthritis diagnosed?

Our Physiotherapists can diagnose OA by reviewing your medical history and your current symptoms, including the level of discomfort or pain you are experiencing, especially when engaging in certain types of activities. Your Physiotherapist will also do a thorough examination that includes examination of your joints to assess for tenderness, ease and range of motion, presence of swelling, joint sounds such as cracking and grating, joint stability, and whether you have any boney alignment changes.

Although imaging studies, such as x-ray, are not necessary to make a diagnosis of OA, they may be required to confirm your diagnosis and the severity of your degenerative changes prior to receiving interventional treatments from Specialists at Resolution Physiotherapy.

What treatments are available for OA at Resolution Physiotherapy?

At Resolution Physiotherapy, we offer both Conservative and Interventional Treatments for OA, which have been shown to improve pain and function.

Conservative Treatments include Physiotherapy, Knee OA Bracing, and Therapeutic Exercise including the research validated GLAD program

Interventional treatments include N-Stride, an exciting new treatment which can improve pain for up to 3 years with a single injection, as well as PRP, Hyaluronic Acid, & Cortisone Injection, treatments which provide shorter term relief of Osteoarthritic related pain.

Conservative Treatments for Osteoarthritis

Physiotherapy

Recent studies have shown that nonoperative, Physiotheapy treatment may delay or even prevent the need for surgery at 5-7 years in more than 50% of patients with knee OA (Gwynne-Jones 2020). Other studies have demonstrated that Manual Physiotherapy can reduce pain and stiffness with daily activity, improve function, reduce the need for medication and injections, and delay total joint arthroplasty (Allen 2019).

Our Physiotherapists have completed extensive post-graduate training and use Advanced Manual Physiotherapy and modalities to reduce pain, improve mobility and function for our clients with OA, including:

• Joint mobilizations

• Gunn IMS

• Active & Passive Myofascial Release techniques

• Active Cupping

• Radial Shockwave Therapy

Therapeutic Exercise

Therapeutic Exercise has consistently been shown to be effective at reducing pain and improving function with Osteoarthritis.

Our Physiotherapists use client specific video exercise programs to maximize performance and success for our clients, as well as the GLAD OA exercise program, which is a research validated exercise program specifically to reduce pain and improve function with OA.

Interventional Treatments for Osteoarthritis

Resolution Physiotherapy is excited to team up with Orthopaedic Surgeon, Dr. Raaj Vora, who will be offering intra-articular injections with the goal of reducing pain, improving function, and delaying the need for surgical interventions for our clients.

nSTRIDE - Autologous Protein Solution

nSTRIDE is an exciting new treatment developed with the goal of reducing pain, increasing function, as well as slowing the progression of cartilage breakdown and delaying the need for surgery with Osteoarthritis.

nSTRIDE uses an Autologous Protein Solution (APS) which is created using a client’s own blood. The blood is then processed using the unique nStride system which, in a matter of minutes, creates a solution that has an extremely high concentration of good anti-inflammatory proteins.

When nSTRIDE APS is then injected directly into the knee joint, it alters the ratio of proteins within the joint, resulting in a significantly higher concentration of anti-inflammatory and beneficial proteins in the joint. In laboratory testing, it has been shown that these anti-inflammatory proteins can block and slow the degradation of cartilage which occurs with Osteoarthritis.

“Up until now, there have been no OA treatments which have changed the course of the disease.” (Kon 2018)

nSTRIDE is the first interventional treatment for OA that could potentially alter the course of the disease progression (van Drumpt 2016) in addition to significantly reducing pain and improving function for clients with Osteoarthritis.

nSTRIDE APS has been shown to:

• Significantly reduce pain associated with Knee OA for up to 2 years with a single injection (70% of those injected experienced a 70% reduction in pain) (Kon 2018, Kon 2017, van Drumpt 2016, King 2016)

• Significantly improve function in the knee joint associated with OA (Kon 2018, Kon 2017, van Drumpt 2016, King 2016)

• To be safe and effective for patients with mild to moderate OA following a single injection (Kon 2018, Kon 2017, van Drumpt 2016, King 2016)

• Protect cartilage in a meniscal-tear model (King 2017)

• Stimulate cartilage cell proliferation (Matsuka 2013)

• Inhibit pro-inflammatory proteins production and catabolic destruction of cartilage, thereby protecting cartilage tissue (King 2017, Matsuka 2013)

• Produce a serum with a much higher ratio of anti-inflammatory to pro-inflammatory proteins (1000:1) so that there is a much higher amount of anti-inflammatory proteins - this balance is theorized to contribute to long-term pain relief due to the “potential disease-modifying properties of APS improving joint homeostasis and cartilage quality” (vanDrumpt 2016)

Hyaluronic Acid

In a healthy knee, there is a thick, slippery substance called synovial fluid inside the joint that provides lubrication, allowing bones to glide easily against one another. This lubrication helps reduce wear and tear by keeping the bones slightly apart from one another and acting as a shock absorber.

In individuals with osteoarthritis, hyaluronic acid (HA), which is an important component of synovial fluid breaks down and is no longer produced at a rate high enough to keep the joint properly lubricated. This reduction of hyaluronic acid can lead to joint pain and stiffness.

HA injections have been shown to:

• produce a small, statistically significant improvements in knee pain and knee function (Miller 2020)

• be more effective than Corticosteroid injection for reducing knee pain and improving function with knee OA at 6 months (He 2017)

• produce the same effect as Corticosteroid injection for reducing knee pain and improving function with knee OA at 3 months (He 2017)

• have less risk of adverse events in the form of gastrointestinal concerns when compared with oral NSAIDs (Miller 2020, Bannuru 2014)

Given the favorable safety profile of HA over NSAIDs, HA may be a viable alternative to NSAIDs in knee OA care, especially for older patients at greater risk for systemic adverse events. (Bannuru 2014) HA will also produce longer term pain relief than Corticosteroid injection (He 2017).

Platelet Rich Protein (PRP)

Platelet-rich plasma, or PRP, is a substance that’s thought to promote healing when injected. PRP is produced from a client’s own blood that is centrifuged so that the blood separates into components. Plasma is the component that is isolated with PRP and it contains special “factors,” or proteins, that help your blood to clot. PRP also contains proteins that support cell growth.

PRP is used in orthopaedic and sports medicine practices to treat bone, tendon and ligament injuries (O’Connell 2019).

The use of PRP in the treatment of degenerative knee OA has increased in recent years due to it being a relatively safe treatment and that it is easily produced in a clinical environment.

Studies on PRP have shown that:

• Intra-articular PRP injections in active patients with knee OA show significant improvements in pain reduction, improved symptoms and quality of life at 6 and 12 months post-injection (O’Connell 2019, Meheux 2016)

• At 6 months post injection, PRP and HA had similar effects with respect to pain relief and functional improvement in knee OA (Dai 2017)

• At 12 months PRP is more effective than HA for improving pain and knee joint function in all stages of knee OA (O’Connell 2019, Dai 2017)

• Three injections per month yielded significantly better outcomes in the short-term (Huang 2017)

• PRP injection can increase patellofemoral articular cartilage volume (Raeissadat 2020)

• Younger and more active patients with a low degree of cartilage degradation achieved better results following PRP treatment (Meheux 2016)

PRP is a better option than HA for longer term pain relief and functional improvement with OA but the higher cost and risk for adverse events with PRP over HA must also be taken into consideration. Despite the apparent positivity in the use of PRP for treatment of knee OA, the lack of standardization of PRP has made it difficult to generalize the effectiveness of PRP treatment (O’Connell 2019).

At Resolution, we strive to deliver the best product available. We extract high density platelets to ensure the patient is receiving the best treatment available. 

Corticosteroid Injection

Corticosteroids is a cost effective treatment that has both anti-inflammatory and immunosuppressive effects, but their mechanism of action is complex. Corticosteroids act directly on steroid receptors and interupt the inflammatory response related to OA. This leads to rapid decreases in swelling and pain in inflamed osteoarthritic joints.

Corticosteroid injection has been shown to:

• reduce pain and inflammation and pain over a short duration (1-6 weeks) (Kijowski 2019, Law 2015, Ayhan 2014)

• have low risk of adverse events on the short term (Kijowski 2019)

• have a higher risk of adverse events including possibly increasing the rate of progression of OA, increased cartilage degeneration and bone loss over the long term (Kijowski 2019)

• the beneficial effects of IA corticosteroid appear rapid but may be of short duration (Kijowski 2019, Law 2015, Ayhan 2014)

Corticosteroid injection is a cost effective option for rapid reduction of inflammation and pain in OA but consideration must be made regarding the risk of long term adverse events and that HA or PRP may yield longer lasting effects.

References:

Altman, Roy, et al. "Anti-inflammatory effects of intra-articular hyaluronic acid: a systematic review." Cartilage 10.1 (2019): 43-52.

Ayhan, Egemen, Hayrettin Kesmezacar, and Isik Akgun. "Intraarticular injections (corticosteroid, hyaluronic acid, platelet rich plasma) for the knee osteoarthritis." World journal of orthopedics 5.3 (2014): 351.

Bannuru, Raveendhara R., et al. "Relative efficacy of hyaluronic acid in comparison with NSAIDs for knee osteoarthritis: a systematic review and meta-analysis." Seminars in arthritis and rheumatism. Vol. 43. No. 5. WB Saunders, 2014.

Dai, Wen-Li, et al. "Efficacy of platelet-rich plasma in the treatment of knee osteoarthritis: a meta-analysis of randomized controlled trials." Arthroscopy: The Journal of Arthroscopic & Related Surgery 33.3 (2017): 659-670.

Gwynne-Jones, Julia, et al. "The outcomes of non-operative management of patients with hip and knee osteoarthritis triaged to a physiotherapy-led clinic at minimum 5-year follow-up and factors associated with progression to surgery." The Journal of Arthroplasty (2020).

Huang, Po-Hua, et al. "Short-term clinical results of intra-articular PRP injections for early osteoarthritis of the knee." International Journal of Surgery 42 (2017): 117-122.

He, Wei-wei, et al. "Efficacy and safety of intraarticular hyaluronic acid and corticosteroid for knee osteoarthritis: A meta-analysis." International Journal of Surgery 39 (2017): 95-103.

Heidari, Behzad. "Knee osteoarthritis prevalence, risk factors, pathogenesis and features: Part I." Caspian journal of internal medicine 2.2 (2011): 205.

Kijowski, Richard. "Risks and Benefits of Intra-articular Corticosteroid Injection for Treatment of Osteoarthritis: What Radiologists and Patients Need to Know." (2019): 664-665.

King, William, et al. "Human blood‐based anti‐inflammatory solution inhibits osteoarthritis progression in a meniscal‐tear rat study." Journal of Orthopaedic Research 35.10 (2017): 2260-2268.

King W, van der Weegen W, Van Drumpt R, Soons H, Toler K, Woodell-May J, “White bloodcell concentration correlates with increased concentration of IL-1ra and improvement in WOMAC pain scores in an open-label safety study of autologous protein solution.” Journal of Experimental Orthopaedics. 2016;3:9.

Kon E, Engebretsen L , Peter Verdonk P, Nehrer S and Filardo G. “Clinical Outcomes of Knee Osteoarthritis Treated with an Autologous Protein Solution. A1-year Pilot Double-Blinded Randomized Control Trial. American Journal of Sports Medicine, Oct. 2017.

Kon E, Engebretsen L , Peter Verdonk P, Nehrer S and Filardo G. “Two-year Clinical Outcomes of An Autologous Protein Solution Injection For Knee Osteoarthritis.” ICRS 14th World Congress, presented, 2018.

Law, Tsun Yee, et al. "Current concepts on the use of corticosteroid injections for knee osteoarthritis." The Physician and sportsmedicine 43.3 (2015): 269-273.

Matuska, Andrea, et al. "Autologous solution protects bovine cartilage explants from IL‐1α‐and TNFα‐induced cartilage degradation." Journal of Orthopaedic Research 31.12 (2013): 1929-1935.

McAlindon, Timothy E., et al. "OARSI guidelines for the non-surgical management of knee osteoarthritis." Osteoarthritis and cartilage 22.3 (2014): 363-388.

Meheux, Carlos J., et al. "Efficacy of intra-articular platelet-rich plasma injections in knee osteoarthritis: a systematic review." Arthroscopy: The Journal of Arthroscopic & Related Surgery 32.3 (2016): 495-505.

Miller, Larry E., Michael Fredericson, and Roy D. Altman. "Hyaluronic Acid Injections or Oral Nonsteroidal Anti-inflammatory Drugs for Knee Osteoarthritis: Systematic Review and Meta-analysis of Randomized Trials." Orthopaedic Journal of Sports Medicine 8.1 (2020): 2325967119897909.

O’Connell, Brendan, Nicholas Martin Wragg, and Samantha Louise Wilson. "The use of PRP injections in the management of knee osteoarthritis." Cell and tissue research 376.2 (2019): 143-152.

Raeissadat, Seyed Ahmad, et al. "MRI Changes After Platelet Rich Plasma Injection in Knee Osteoarthritis (Randomized Clinical Trial)." Journal of Pain Research 13 (2020): 65.

Richmond, Sarah A., et al. "Are joint injury, sport activity, physical activity, obesity, or occupational activities predictors for osteoarthritis? A systematic review." journal of orthopaedic & sports physical therapy 43.8 (2013): 515-B19.

van Drumpt, Rogier AM, et al. "Safety and treatment effectiveness of a single autologous protein solution injection in patients with knee osteoarthritis." BioResearch open access 5.1 (2016): 261-268.