September 30, 2008
Bad News, Good News for Knees
By JEANNINE STEIN
By Jeannine Stein
Los Angeles Times
The prognosis for people with knee osteoarthritis isn't as bleak as it might seem in the wake of a study finding that arthroscopic surgery, once hailed as promising, might not be the best option.
That study, released in the Sept. 11 issue of the New England Journal of Medicine and widely reported in other news media, suggested that people who underwent the surgery didn't fare any better in the long run than their counterparts who received physical therapy.
During the surgery, small incisions are made through which a small camera and surgical instruments are inserted. Physicians can then repair or remove cartilage or flush the knee to remove debris - or do both procedures.
The trick is to find one or more treatments, amid the array that includes medication and physical therapy, that can ease the pain of worn cartilage. It can take some work.
"When patients come into my office, I give them a list of 17 options to help them manage their condition," says Dr. Ronald Grelsamer, a knee surgeon in the orthopedics department at Mount Sinai School of Medicine in New York. "At the very bottom is arthroscopy. It works for a little while, but it's not going to cure it. ... What I've found is that nothing works for everybody, and everything works for somebody."
Oral, nonsteroidal anti-inflammatories, such as Celebrex, can reduce inflammation and pain, as can cortisone injections. Hyaluronic acid injections can replace some of the viscous synovial fluids that lubricate the joints but that sometimes decrease with age. Acupuncture and massage also might alleviate pain. But as people get older and knees become more worn, the ultimate remedy could be a total knee replacement.
And although a New England Journal of Medicine study in 2006 found that glucosamine and chondroitin supplements fared no better than a placebo among 1,583 people in reducing knee pain by 20 percent, some doctors still recommend it.
"The average effect is quite small, and it can be slow-acting," says Dr. John FitzGerald, assistant professor of rheumatology at the David Geffen School of Medicine at the University of California, Los Angeles. "That study is open to interpretation. I think, on average it works a little bit for some people."
But much can be said for consistent exercise, which also can tamp down pain and improve mobility, according to health experts.
One study published in the Annals of Internal Medicine compared a physical therapy program of manual therapy and exercise with a placebo program of subtherapeutic ultrasound. It found that exercise improved scores for walking distance and function, pain and stiffness far greater than the placebo.
A good first line of defense, health experts say, is shedding some pounds. "You can get some long-lasting effects," FitzGerald says. Even a little makes a huge difference because walking and running can put extra force - equivalent to several times one's body weight - on the knees with every step. "Even with 5 to 10 pounds, which is a reasonable goal, people can expect a fairly significant improvement in knee pain."
The recommendation comes with a snag, however: When knees hurt, the motivation to exercise goes south.
"Unfortunately, you can't wait for the knee to get better to start exercising," FitzGerald says. "Start exercising, and then the knee will get better."
For patients who cannot exercise, however, neuromuscular electrical stimulation, or NMES, to improve quadricep strength in older adults with knee osteoarthritis has produced promising results, according to a study reported in a 2003 Journal of Rheumatology article.
Under Dr. Laura Talbot of The Johns Hopkins University, the researchers randomly selected subject from among 34 patients and sent small electrical impulses through the skin to the nerves and muscles to create involuntary muscle contractions. They used a portable electrical muscle stimulator three days a week over 12 weeks for quadricep training and strengthening. The research team concluded that a home-based NMES treatment plan appeared promising for increasing quadriceps strength in adults with knee osteoarthritis without making their symptoms worse.
Laura Bennett, a physical therapist who works with osteoarthritis patients at Good Samaritan Hospital in Los Angeles, has a use-it-or- lose-it philosophy when it comes to battling osteoarthritis.
"If we don't use it, we lose strength in our muscles and range of motion. We can compensate for a while, but if we become stagnant in our movements, then our joints don't get the fluid they need, which means they don't get the nutrition they need, then arthritis sets in, and it hurts to move, so we don't want to move."
Walking, swimming and water workouts are great for some people with arthritic knees, Bennett says. "Being in the water takes a certain amount of body weight off the knees and hips. Joints have an easier time moving, and the water gives muscles some resistance."
Walking time and intensity should progress gradually, she says. Many physical therapists will examine patients' muscle strength and flexibility from their feet to their hips and back, plus assess alignment and gait, possibly prescribing exercises and stretches to correct disparities and weaknesses.
"A lot of times with osteoarthritis it could be a muscle imbalance that's causing it, where one side might be weaker and one side is tighter, and people are not working at a biomechanical advantage," Bennett says. It's also not just the knees that are worthy of attention - other joints that support them, such as the hips and ankles, are important to shore up as well.
In examining movement patterns during walking or running, Christopher Powers, associate professor of biokinesiology and physical therapy at the University of Southern California, looks for "dynamic misalignment," checking to see if knees fall inward or if there's an abnormal rotation at the hip or foot. These, he says, can put undue torque and stress on the ligaments, joints and cartilage. Therapy, he adds, can take some of those stresses off the knee joint.
Because biomechanics vary from one person to the next, therapy programs need to be tailored but might include working with patients to change their gait - not always an easy task, considering that walking is something most people do automatically. "The patient has to be aware of what they're doing and why they're doing it," Powers says.
"Your muscles are kind of like shock absorbers, and when they're not working well, you start to rely on your passive shock absorbers, like your cartilage and bone."
Patients might be able to get referrals for licensed physical therapists from their doctors or hospitals. The American Physical Therapy Association also has lists of members on its Web site, www.apta.org.
try these therapies
Depending on the person, therapy might include a hamstring stretch that can be done sitting or lying down (stretching muscles helps increase joint flexibility). In that move, a belt is looped around one foot, and the straightened leg is lifted until a stretch is felt along the back of the leg. This can be repeated three times and held for 30 seconds on each leg.
External hip rotators, which are part of the kinetic chain that supports the knee, can be strengthened by lying on one side with knees bent, the top leg raised like a clamshell.
(No exercises should be attempted before consulting with a physician or licensed physical therapist.)
Originally published by BY JEANNINE STEIN.
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