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knee pain

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Focus on reducing pain and improving mobility

By David Dunaief, M.D.

Dr. David Dunaief

Osteoarthritis has been diagnosed in over 54 million Americans, with 43.5 percent of them reporting symptoms that limit their activities and significantly impact their quality of life (1). Historically, the disorder was thought to be solely a wear-and-tear degeneration of the joint(s). However, Osteoarthritis (OA) also involves inflammation with the release of cytokines and prostaglandins — inflammatory factors — which cause joint destruction and pain (2).

The joints most commonly affected include the ankle, knee, hip, spine and hand. OA may affect joints asymmetrically, meaning that it affects a joint on only one side of the body.

Mainstays of treatment include analgesics and COX-2 inhibitors (Celebrex). Common analgesics used are acetaminophen and NSAIDs, such as ibuprofen (Advil), naproxen sodium (Aleve). A benefit of NSAIDs is that they have anti-inflammatory effects. Meanwhile, COX-2 inhibitors may also improve joint mobility.

There are adverse effects with NSAIDs, including increased gastrointestinal (or GI) bleed and, with long-term use, an increase in cardiovascular events, such as heart attacks, with the elderly being most susceptible.

Neither medication type, however, structurally modifies the joints. In other words, they may not slow OA’s progression nor rebuild cartilage or the joint space as a whole. Are there therapies that can accomplish these feats and, if so, what are they? We will look at hyaluronic acid, glucosamine and chondroitin, and lifestyle modifications such as exercise and weight loss.

Chondroitin sulfate beneficial for hand OA

The results with the use of glucosamine and chondroitin have been mixed, depending on the joints affected. In the FACTS trial, a randomized controlled trial, chondroitin sulfate by itself showed significant improvement in pain and function with OA of the hand (3). The dose of chondroitin used in the study was 800 mg once a day. The patients, all of whom were symptomatic at the trial’s start, also saw the duration of their morning stiffness shorten.

There was also a modest reduction in structural damage of hand joints after three months, compared to placebo. The benefit was seen with prescription chondroitin sulfate, so over-the-counter supplements may not work the same way. Patients were allowed to use acetaminophen, and there was no change in dose or frequency throughout the trial.

Crystalline glucosamine sulfate

In knee OA, crystalline glucosamine sulfate showed reduction in pain and improvement in functioning in a randomized controlled trial (4). When assessed by radiologic findings, it also slowed the progression of structural damage to the knee joint. In other words, the therapy may have disease-modifying effects over the long term. The glucosamine formulation may work by inhibiting inflammatory factors such as NF-kB. The trial used 1500 mg of prescription crystalline glucosamine sulfate over a three-year period. Again, it’s not clear whether an over-the-counter supplement works the same way.

Glucosamine and/or chondroitin for knee OA

In a meta-analysis (group of 10 studies), glucosamine, chondroitin or the combination did not show beneficial effects — reduced pain or mobility changes — in patients when compared to placebo (5). It was not clear whether supplemental or prescription-level therapies were used in each trial — or whether that makes a difference. This study was published prior to the crystalline glucosamine sulfate trial of the knee, discussed above, which did show statistical significance.

There is not much downside to using glucosamine and/or chondroitin for OA patients. However, use caution if taking an anticoagulant (blood thinner) like Coumadin, since glucosamine has anticoagulant effects. Also, those with shellfish allergies should not use glucosamine. If there is no effect within three months, it is unlikely that glucosamine and/or chondroitin are beneficial.

Hyaluronic acid

In a meta-analysis (a group of 89 trials), the risks outweighed the benefit of hyaluronic acid, a drug injected into the joint for the treatment of OA (6). Viscosupplementation involves a combination of hyaluronic acid types that act as a shock absorber and lubricant for the joints. Some of the studies did show a clinical benefit. However, the authors believe that adverse local events, which occurred in 30 to 50 percent of patients, and serious adverse events, with 14 trials showing a 41 percent increased risk, outweigh the benefits. Since there are mixed results with the trials, it is best to discuss this option with your physician.

Impact of weight loss and exercise

Obesity treatment with a weight-loss program actually has potential disease-modifying affects with OA (7). It may prevent cartilage loss in the medial aspect of the knee. The good news is that, even with as little as a seven percent weight loss in the obese patient, these results were still observed. The study’s average weight loss was nine to 10 pounds, and results were seen on a dose-response curve — the greater the weight loss, the thicker the knee cartilage.

Writing in The New England Journal of Medicine, Dr. David Felson observed there is an inverse relationship between the amount of muscle-strengthening exercise, especially of the quadriceps, and the amount of pain experienced in the knee joint. It is very important to do nonimpact exercises such as leg raises, squats, swimming, bicycling and on elliptical machines.

Fortunately, there are a number of options to prevent, treat and potentially modify the effects of OA. With weight loss in the obese patient, quality of life can dramatically increased. Glucosamine and/or chondroitin may be of benefit, depending on the joints affected. The benefits are potential improvements in pain, mobility and structural-modifying effects, which are worth the risk for many patients. When taking glucosamine and/or chondroitin in supplement form, ConsumerLab.com may be a good source for finding a supplement where you get the dose claimed on the box. I would also use formulations in the trials that showed results, even in supplement form.

References:

(1) MMWR Morb Mortal Wkly Rep. 2017 Mar 10;66(9):246-253. (2) Rheumatology. 2011;50(12):2157-2165. (3) Arthritis Rheum. 2011 Nov;63(11):3383-91. (4) Ther Adv Musculoskel Dis. 2012;4(3):167-180. (5) BMJ. 2010;341:c4675. (6) Ann Intern Med. 2012;157(3):180-191. (7) Ann Rheum Dis. 2012;71(1):26-32.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com.