It's definitely horses for courses. No one knee osteoarthritis treatment works in everyone. There is no easy logical way to decide what to try, so use that gut feeling again.
Effective osteoarthritis remedies include large doses of nicotinamide, glucosamine sulphate and homeopathic remedies by mouth or topically, SAMe, acupuncture, green barley powder, aloe vera and lots of other naturopathic preparations.
It is likely that multiple treatments will be more helpful, but certainly more expensive. If cost is an issue, use one thing at a time and observe yourself closely for any effects.
The drugs most commonly prescribed are the NSAIDs (non steroidal anti inflammatory drugs.)
NSAIDs reduce inflammation and relieve pain, but also inhibit the very cells responsible for maintaining cartilage.
Quite apart from aggravating ulcers and heart failure etc., they aggravate the very condition whose symptoms they relieve.
They inhibit the formation of cartilage.
They also cause leaky gut, thereby increasing the inflammation component of osteoarthritis pain.
A couple of days at a time is usually fine, infrequently and only when in big trouble.
Diclofenac is short acting, so may be safer¹² than long acting NSAIDs. It also has analgesic properties. It is just as effective, and safer if used topically²² but you still only have one chance in 6 to 11 that it will be really helpful.
Stick to acetaminophen ( paracetamol,) if it appears to be useful²⁴. If you need more medication to relieve pain, try to use nsaids intermittently rather than all the time.
Doctors are very wary of prescribing narcotic (opium like) drugs for arthritis – but small doses are very useful. This is a major benefit of having a long term doctor who knows you well, and knows you are not a potential drug addict.
Different opiate drugs vary in the time each dose works for. Short acting ones like codeine, produce peaks and troughs of effect. Long acting preparations are more suitable for long term use.
Pain management specialists aim for something like 30 to 50% reduction in pain. Trying for better relief with larger doses may induce tolerance. This is when our body gets too used to a drug, and the beneficial effects are lost.
Initially, any opiate prescription will be on a trial basis, as with introduction of any new drug.
Opiates can increase your risk of falls, so assess your balance carefully when you try one. As soon as pain has been helped, it is really important to work on reducing any limp. Limping will have become a habit and it weakens your thigh quadriceps muscles. These will need strengthening to help prevent falls.
It is currently thought that knee osteoarthritis pain may have a neuropathic element, due to damage to the pain nerves themselves. Neuropathic pain may not respond well to opiates, but may respond to second line drugs...
The number needed to treat (sucessfully) for Valproate, Duloxetine and Carbimazepine is 5 to 6, and for Gabapentin it is 4. Knee osteoarthritis treatment with these drugs helps one person in 5-6 and one in 4 respectively.
Diazepam is not a pain killer, nor a muscle relaxant in commonly prescribed doses. It does relieve pain in "nocebo hyperalgesia" where expectations and prior conditioning turn anxiety into pain, via brain mechanisms involving cholecystokinin.
Fear of pain heightens one's experience of pain, here.Injection into the joint of artificial lubricant is also available for knee osteoarthritis treatment.
can be injected into the knee²¹ about every 4 months, without speeding up the loss of cartilage. This can be used in osteoarthritis or if the knee is the only joint still playing up once rheumatoid arthritis has settled on other treatment. This is generally very effective in relieving the pain for a few weeks.
Botulinum toxin injections have been shown to halve pain for 6 months in some cases, through their action on SNAP-25 protein in nerve endings.
Orthopedic surgeons can try to help¹¹ by shaving the rough cartilage down to a smooth surface. This procedure, no matter how sensible it sounds has been shown to speed up joint damage.
Trimming torn menisci and removal of loose bodies with knee arthroscopy, are useful.
Arthroscopic knee surgery may otherwise just bring forward the time when further surgery - total knee replacement, will be needed. TKR is usually successful in relieving pain and restoring function.
Cartilage transplants can be used, of cells cultured from ones own joint cartilage.
Think of this as walking smart rather than an admission of defeat. It can reduce the weight on your knee by 25%, and can be a very useful implement as well.
Some have a folding seat on the top, and some have a container inside for traditional liquid refreshment. Add your own personal touch and design your own.
Neoprene thermo-elastic material knee braces provide warmth and compression, and possibly help one know what ones knee is doing when the joint position sense is compromised.
Good quality hinged braces can reduce a tendency for one's knee to buckle sideways during weight bearing.
Stretch up any sore muscles, especially your glutei, adductors and hamstrings. Laying on your back, you should be able to lift each leg to vertical. If you can't, your hamstrings are tight and need stretching (assuming that your hip joints are fully mobile.)
Apply topical preparations.
Strengthen your quadriceps muscle. If it is possible, walk without a limp. If you "favor" a leg, its muscles rapidly waste from the disuse.
It is particularly important to get back to walking normally after an acute flare up resolves. Limping can easily become a habit
Lose some weight¹⁵. The knee is a weight bearing joint, and this is one of the causes of osteoarthritis here. Losing 5% of your weight is enough to help.
Years ago I was treating a man with an arthritic knee, with little success. He disappeared from the practice. I saw him quite some time later and he recounted how he’d got better. He had decided that his lawns needed aerating, and used a garden fork. He would push it in to the hilt using his foot, then angle it up slightly, to open up the subsoil. By the time he had finished his lawns, his knee was better.
There are other treatments of use at times. I had one old lady with knee arthritis who responded very well to neural therapy every few months. I use this when “brush allodynia” is found near the knee.
One old gentleman with severe knee osteoarthritis responded to intravenous calcium injections. There was very little cartilage left in his knee. The bone was taking all the weight.
This treatment temporarily reduces the rate at which bone is removed as part of its’ constant remodelling, allowing it to build up a little, and not complain so much about the weight it has to bear.
One gets demineralization in this subchondral bone in osteoarthritis.
Wearing flexible, thin soled shoes without heels may help¹⁶
Podiatrists can often help in knee osteoarthritis treatment, by improving the way the foot functions and thus reducing the strain on the knee. This deserves to be further up the list of options. Everyone with bad knee arthritis should see if a biomechanical podiatrist can help.
Applied Kinesiology is a discipline worth looking into as well. A kinesiology practitioner will deal with the way one has compensated by shifting body weight sideways and the function of muscles in the other leg.
Osteopaths may help the function of other joints such as ankle, hip and spine. Dysfunction there may adversely effect knee function.
Stretching the knee joint itself can help. I sometimes use a sudden stretch and there is equipment⁹ available to do it slowly and steadily.
My sudden technique is to sit with the foot on another chair, grasp the thigh just above the knee and after a couple of up and down movements to loosen the thigh muscles, just snap it down sharply to fully straight.
This sounds brutal, and I do pick my subjects; It however can give immediate relief.
SAMe is of proven benefit¹, equivalent to NSAIDs and without the side effects.
Lyprinol from the New Zealand green lipped mussel, may also be useful², but there are no trials comparing it with NSAIDs.
Saligesicᵀᴹ (Mediherb) is willow bark extract produced by the same process as used in the positive European trials³. It has the advantages of asprin without the upset tummy.
In the ESCOP monograph, (Salicis Cortex (Willow Bark) Fascicule 4 1997,) there are no time restriction nor special warnings on the use of willow bark extract - except for the usual prudent pregnancy and lactation warning.
Harpagophytum procumbens, (devil's claw, grapple plant,) has proven value in knee osteoarthritis treatment⁴.
Cinnamon is usually advised as an oral dose, such as half a teaspoon of powder with honey. One patient reported using a cinnamon stick in their sock overnight, with good effect on ankle arthritis. Aromatherapy?
Ginger extract can help¹⁴.
Uncaria tormentosa, (Cat's claw) and curcumin have been used traditionally, and have suitable actions.
Thorne have a curcumin compound called Meriva, better absorbed than the straight herb, and which has tested OK¹³ for efficacy and safety.
Proprietory herbal mixtures are available from naturopaths, one containing rosemary, hops and olive leaf - which takes 4 weeks to show benefits. Another mixture has hydroxyapatite, glucosamine, collagen, gelatin and silica. This works more quickly.
Food intolerance may be a factor in aggravating inflammation, so allergy elimination diets are always worth going through (as with any chronic illness.)
Copper bracelets have been around for a long time. This is from Dealon Bracelets...
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MSM improved pain and function in one trial⁷ of knee osteoarthritis treatment, using 3gm twice a day for 12 weeks.
The herb boswellia has been subjected to randomised, double-blind, placebo controlled trial⁸ and found to be an effective and well tolerated knee osteoarthritis treatment.
Leeches applied to the painful periarticular sites of the knee joint gave immediate pain relief in one trial¹<span style='font-size: 50%'>in Europe.
Leeches USA Ltd sells them commercially to plastic and reconstructive surgeons for use after surgery. http://www.leeches.biz/ is a site for buying them. Their use is widespread apparently, in Asia, Africa, and Arabic countries
Scutellaria baicalensis (Baikal Skullcap or huáng qín) and Acacia (Mimosa)catechu are in Cararthron in Australia, no doubt available elsewhere as well under different names.
Out of 13 unique studies considered, 10 studies were included in a meta-analysis of the efficacy of SAMe to decrease pain of osteoarthritis. One large randomized clinical trial showed an effect size in favor of SAMe of 0.20 (95 percent CI [-0.39, -0.02]) compared to placebo, thus demonstrating a decrease in the pain of osteoarthritis. Compared to treatment with nonsteroidal anti-inflammatory medication, treatment with SAMe was not associated with a statistically significant difference in outcomes (effect size 0.11; 95 percent CI [0.56, 0.35]).
The data from the two more rigorous trials, in conjunction with our re-analysis of original data suggests that (green lipped mussel) may be superior to placebo for the treatment of mild to moderate OA.
3. From Mediherb's sheet on Saligesic
Two randomized placebo-controlled clinical trials conducted in Germany and Israel found that standardized extract of willow bark supported the health of the musculoskeletal system particularly the knees, hip and lower back. Participants found that this willow bark extract helped their normal mobility and flexibility. The results were statistically significant. The daily dose contained 120-240 mg of salicin ( as in 2-4 tablets of Saligesicᵀᴹ.
4. Vandermander et al, p63, Herbal Medicinal Products for the treatment of Pain, Southern Cross University Press, 2000
5. The NIH Glucosamine Chondroitin Arthritis Intervention Trial J Pain Pallia Care Pharmac 2008 22(1) 39-43
6. Gruenwald J et al Advances in Therapy 2009 26(9) 858-71
7. Kim LS et al Osteoarthritis Cartilage. 2006 14(3) 286-94
8. Kimmatkar N et al Phytomedicine. 2003 10(1) 3-7
Michalsen A, Leech therapy for symptomatic treatment of knee osteoarthritis: results and implications of a pilot study.
Altern Ther Health Med. 2002 Sep-Oct;8(5):84-8.
11. Alexandra Kirkley et al A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee NEJM Sept. 11th 2008. 359 (11) pp 1097 - 1106
12. If you have had ulcers, high blood pressure, heart or kidney disease, OTC NSAIDs are not for you, for knee osteoarthritis treatment or anything else.
13. Belcaro G et al, Product-evaluation registry of Meriva®, curcumin-phosphatidylcholine complex, for the complementary management of osteoarthritis. PanMinerva Med. 2010;52 (Suppl. 1 to No. 1):55-62.
http://www.medicalnewstoday.com/articles/201305.ph. Read paper on line at http://www.altmedrev.com/publications/15/4/337.pdf
See also http://www.ncbi.nlm.nih.gov/pubmed/19678780 for another trial of a Curcuma domestica extract.
15. 1.Nicklas BJ, Legault C, Mihalko S, et al. The intensive diet and exercise for arthritis trial: 18-month clinical outcomes. Program and abstracts of the 2011 American College of Rheumatology Annual Scientific Meeting; November 5-9, 2011; Chicago, Illinois. Presentation 722.
16. Shakoor N, Block JA: Walking barefoot decreases loading on the lower extremity joints in knee osteoarthritis. Arthritis Rheum 2006, 54(9):2923–2927.
17. Shakoor N, Lidtke RH, Sengupta M, Fogg LF, Block JA: Effects of specialized footwear on joint loads in osteoarthritis of the knee. Arthritis Rheum 2008, 59(9):1214–1220.
18. Shakoor N, Sengupta M, Foucher KC, Wimmer MA, Fogg LF, Block JA: The effects of common footwear on joint loading in osteoarthritis of the knee. Arthritis Care Res (Hoboken) 2010, 62(7):917–923.
19. Trombini-Souza F, Kimura A, Ribeiro AP, Butugan M, Akashi P, Passaro AC, Arnone AC, Sacco IC: Inexpensive footwear decreases joint loading in elderly women with knee osteoarthritis. Gait Posture 2011, 34(1):126–130.
20. Sacco IC, Trombini-Souza F, Butugan MK, Passaro AC, Arnone AC, Fuller R: Inexpensive and minimalist footwear decreases joint loading in elderly women with knee osteoarthritis during stair descent. Arthritis Care Res (Hoboken) 2012, 64(3):368–374.
21. From the British Association of Manipulative Medicine newsletter October 1979, is the following...
"More effect and less detriment can be expected from para-articular corticsteroid administration; sites of tenderness and of pain produced by the needle point are chosen for multiple small injections. These are given with local anaesthetic and the limb is then tested under weight bearing in flexion and extension. If the patient can still identify a point of pain this too will require location and injection. Most members of this association have long discarded the blind intra-articular injection."
23 Ann Rheum Dis Published Online First 14 January 2015
24. It is not much use overall, but some people will do better than others on it. http://www.bmj.com/content/350/bmj.h1225
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Cholecystokinin (CCK) is called a gut-brain peptide hormone, as it has important actions in both. The name means gall-bladder stimulator as that was the first action attributed to it (under that name.) There is a lot of it in our brain and it has important actions regarding satiety, pain modulation and anxiety.
One artificial joint lubricant is Synvisc - sodium hyaluronate made from from chicken.
The menisci are semilunar cartilages (shaped like a waxing or waning moon,) which protrude in from the sides of the joint, between the bone ends. They are important for lubrication of the knee.
Proprioception (joint position sense) is very important for keeping one's balance - and avoiding joint damage in emergencies.
ESCOP stands for the European Scientific Cooperative on Phytotherapy.
GAIT stands for Glucosamine Chondroitin Arthritis Intervention Trial
MSM stands for methyl sulphonyl methane.
OTC NSAIDs means non steroidal anti-inflammatory drugs such as ibuprofen or diclofenac, obtained "over the counter" - bought without a prescription.