January 19, 2020 By Dr Anuj Agrawal

Arthritis- Ten treatments you should consider before surgery

Arthritis- Ten treatments you should consider before surgery

Arthritis refers to diseases involving ‘inflammation’ of joints causing pain, swelling and deformity. Though arthritis includes more than 200 diseases, but the term is most commonly used for osteoarthritis, which is age-related wear and tear of the joint, and this article too shall mainly focus on that.

Osteoarthritis of knees and hips is a leading cause of disability worldwide, causing difficulty in day-to-day activities such as walking, sitting and climbing stairs. Though surgery, in the form of joint replacements, is the most successful treatment for disabling arthritis, there are other treatments available which can be effective in mild to moderate disease.

1. Education, yoga and tai chi

Understanding of any disease is important to let an individual develop insight into his/her condition and better cope with it. Educational and self-management programs help the patient set realistic treatment goals and work with a positive mindset to achieve them with sustained efforts. Traditional Indian and Chinese mind-body practices such as yoga and tai chi are becoming increasingly popular and have a positive impact on pain and disability due to arthritis. Cognitive behavioral therapy by psychiatrists too helps improve health-related quality of life.

2. Exercises and weight loss

Physical activity has an important role in maintaining the movements of joints and providing nutrition to the articular cartilage. Aerobic exercises such as walking, swimming and cycling are useful for both cardiovascular and musculoskeletal health. Balance and strengthening exercises (specific for the joint) help in improving joint pain, stability and gait.

Weight loss is strongly recommended for overweight and obese individuals to decrease the loads transmitted to the joint, improve pain and slow down disease progression. Weight loss should be achieved by a combination of dietary measures and exercises. Weight-loss medications and bariatric surgery should be considered by severely obese individuals.

3. Nutritional supplements

Adequate dietary intake of calcium, vitamin D and proteins is advisable to maintain the health of bones and joints. Protein and related (glycosaminoglycan) supplements, such as glucosamine, chondroitin sulphate and collagen, are widely used for arthritis, as these substances are important constituents of joint cartilage. Though these might help decrease pain in some individuals, there is no evidence that these supplements affect disease severity or progression. Collagen supplements require large doses (around 10 g) and can be expensive.

Some foods and spices such as garlic, ginger, turmeric and avocadoes can be useful in arthritis patients to help decrease joint inflammation and improve cartilage health, though their benefit is more for inflammatory arthritis (e.g. rheumatoid arthritis) rather than osteoarthritis. Turmeric (or its active compound curcumin) particularly has good anti-inflammatory properties.

4. Herbal remedies

Pain medications can be harmful when taken over a long period, and traditional and herbal remedies are popular for arthritis as safer, though less effective, alternatives. Rosehip, Devil’s claw and Boswellia (Indian olibanum or shallaki) are popular herbal supplements used in arthritis, either individually or in combination. S-adenosyl methionine (SAMe) is a dietary supplement also used to improve pain and function in arthritis, though it only has a modest benefit.

5. Hot/cold packs

Local measures, such as application of hot or cold packs, are beneficial to decrease joint inflammation and improve pain. Such packs can be applied for 15-20 minutes several times in a day for best results. Hot packs are usually preferable over cold packs for chronic arthritis. Manual therapies such as massage and manipulation are not much useful for arthritis.

6. Acupressure and other physical therapy

Acupressure and acupuncture are effective techniques for pain relief, though the benefit is short-lasting. They have shown inconsistent benefit in arthritis and are not promising. Electrophysical therapies have not been shown to be much useful for arthritis, and are best used as adjuncts to exercises. TENS (transcutaneous electrical nerve stimulation), a popular electrophysical therapy, is no more recommended for arthritis. Ultrasound, laser and pulsed vibration therapy are only beneficial for small joints of the hands and feet.

7. Braces and walking aids

Supportive and corrective splints and braces can be beneficial in hand and knee arthritis. Knee caps are not much beneficial, but corrective knee braces can help improve the positioning (tracking) of knee cap and alignment of the knee and provide relief. However, such braces can be quite bulky and inconvenient and mostly used in patients who are not willing or fit for surgery. Walking aids, such as a simple stick, can help offload the joint and reduce pain. Shoe modifications and insoles have no lasting benefit and should be avoided.

8. Topical analgesics

With advancements in nanotechnology and drug-delivery systems, targeted delivery of pain medications (analgesics) by topical application (on the affected area) in the form of local gels or sprays has become more effective than before. Topical application of NSAIDs (commonly diclofenac) is effective for arthritis of superficial joints such as knee, hand and foot. Absorption of the medication in blood is minimized (around 5%) by topical application, and hence the potential for adverse effects is reduced. Capsaicin is another agent commonly used in topical formulations, which acts chemically on nerve endings (counterirritant) to reduce pain.

9. Oral analgesics

Oral medications are greatly effective in reducing pain and swelling associated with arthritis. Acetaminophen (or paracetamol) is the first-line drug with moderate analgesic potency and excellent safety profile for long term use. For more severe pain, NSAIDs (non-steroidal anti-inflammatory drugs) and weak or atypical opioids are indicated. NSAIDs are the most effective drugs for arthritis, but can have adverse effects on heart, kidney and liver on prolonged usage. Gastrointestinal adverse effects are minimised with some NSAIDs (COX2 inhibitors) such as etoricoxib, etodolac and diclofenac. Tramadol is an atypical opioid, and preferred over other opioids as it has less abuse potential. But the body gradually develops tolerance to it, decreasing its analgesic efficacy. Flupirtine and oxaceprol are a few alternatives to NSAIDs that have moderate efficacy and better safety.

10. Injections into the joint

Steroids are very potent anti-inflammatory agents, but oral steroids are not used for osteoarthritis as they cause severe adverse effects. However, steroids can be injected into the joint (intraarticular) to greatly relieve pain and swelling, with minimal adverse effects. Steroid injections are indicated to relieve flare-ups of arthritis. Hyaluronic acid injections aim to provide lubrication and relief to arthritic joints. They don’t have any adverse effects, but are significantly costlier then steroids. They have been found to provide limited, short-lasting pain relief in early arthritis. Cost-benefit ratio of these injections is not favorable, and currently their use is not recommended for arthritis.

Injections of platelet-rich plasma (PRP) derived from one’s own blood and stem cells are thought to help regenerate cartilage, but such an effect has not come forth in studies and their use is no more recommended. Some other regenerative injection therapies are being tried for arthritis. Prolotherapy is one such therapy for injured soft tissues and joints, and involves injecting a potential irritant such as dextrose in or around the joints. It has shown inconsistent results for arthritis and needs further evaluation.