I coined the term POLITE Method for how I treat my patients. The ‘P’ is for improving posture and creating a plan of treatment.
The ‘OL’ is optimal loading. This means figuring out self-management activities for knee pain that are not too easy and not too difficult.
The ‘I’ in instruments that I use in the office for knee pain such as laser, DMS, and shockwave therapy that give effective short- and long-term pain relief benefits.
‘T’ is for taping the knee and I’ll teach you how to apply simple kinesio-tape to the knee for pain relief.
‘E’ is for education regarding the progressive nature of osteoarthritis (OA) and for pain management education; joint-sparing exercise advice including daily walking, balance tips, and falls prevention; and emotional and cognitive skills to improve quality of life; Eating for weight loss for those who are overweight or obese. Weight loss has been shown to improve mobility and reduce pain. For every one pound of weight lost, there is a 4-pound reduction in the load exerted on the knee for each step taken during daily activities. A weight loss of only 15 pounds can cut knee pain in half for overweight individuals with arthritis.
A low-carbohydrate diet has been shown to reduce weight in obese patients by ?10% and lead to improvements in self-reported scores for overall progress and functional ability.
If you like my POLITE approach call 310-444-9393 for an appointment.
2007-2009. For men and women, the prevalence of age-adjusted arthritis increased significantly with increasing BMI (P <.001 for trend). The age-adjusted prevalence of OA among people who were obese (25.2% for men and 33.8% for women) was nearly double that of people who are underweight/normal weight (13.8% for men and 18.9% for women). Source: CDC. Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation— United States, 2007-2009. MMWR. 2010;59(39):1261-1265.
Treatment options for OA
In patients with knee OA, my approach tends include shoe inserts. These are good adjuncts to supplements, laser, Deep Muscle Stimulation (DMS), injectables, taping, and exercise therapy. I recommend swimming, recumbent bicycles, rowing machines and elliptical trainers. I teacgh my clients a lot of low load, easy to do stretches and strenghtening exercises. Weight loss is really important here.
On laser therapy for treating patients with knee OA: It depends on the patient and the severity of his or her OA. For example, if the patient is older and has a severely arthritic knee, a total knee replacement will probably be necessary. If a patient has OA and joint effusion, I might recommend laser, aspiration and corticosteroid injection.
If I have a patient with symptoms of OA who may have incurred an injury such as an ACL tear, I will use warm laser and DMS.
If you have undergone an arthroscopic procedure, but not yet fully out of pain, I will use laser.
I often use glucosamine and chondroitin sulfate with high dose omega 3’s.
I like topical menthol products such as BioFreeze. These have evidence of efficacy.
There are dangers of using cortisone, which has been administered for years as an injection in the joints. If any of my patients ask for cortisone because it worked when administered to them 10 years ago, I would educate them on safer long-term options. The most common recommendation I have for most of my patients is to eat less carbs and exercise more. I love the anti-inflammatory diet coupled with UltraInflamX by Metyagenics and high dose omega 3 fish oils. Through weight reduction and a low-impact exercise program, many patients will achieve dramatic improvements in their arthritis pain.
My goal for patients is to decrease pain and inflammation, maintain or improve function and retard disease progression if possible. In this regard, preventing damage to subchondral bone, cartilage, joint space narrowing and osteophyte formation is the goal.
The contraindications for NSAIDs include gastrointestinal (GI) bleeding or adverse effects to the kidneys or liver. Some patients worry about taking a glucosamine product because they have diabetes, but I inform them no data support this concern.
I might recommend UltraInflamX by Metagenics alot. I like garlic, ginseng and gingko — but these affect bleeding time. If used in conjunction with NSAIDs, the risk of GI problems increases.
Everyone with chronic pain can safely start the Anti-inflammatory diet – no sugar, alcohol, gluten, dairy, preservatives, & chemicals. The minimum supplements I recommend you should be taking are high amounts of EPA/DHA (EPA-DHA 720, three softgels up to three times daily with food), Vitamin D3 (IsoD3 5,000 i.u. daily) and digestive enzymes (Metazyme, one tablet during each meal). Order from Metagenics 800-692-9400.
Additional Supplements for chronic pain:
Quercetin (Resveratin Plus 12 capsules daily). Order from XYMOGEN 1-800-647-6100
UltraInflamX Plus 360 medical food is a shake that contains Turmeric, Ginger, Rosemary extract, as well as other vitamins and minerals plus 15 grams of protein. Two scoops in water or juice 1 – 2 times daily. Order from Metagenics 800-692-9400
Kaprex is for joint relief and contains hops, iso-alpha acids, Olive Leaf extract and Rosemary Leaf extract. Dose is two softgels three times daily. Order from Metagenics 800-692-9400.
Chronic pain depletes serotonin, GABA and dopamine and other catecholamines (which in turn amplify pain perception); so nutrients that address serotonin (such as Tryptophan, 5HTP, and vitamin D) and dopamine and catecholamines are useful. Trancor and Symphora (4 each per day). Order from Metagenics 800-692-9400
Acute Trauma: Traumeel tablets – take 1 tablet every 15 minutes for 3 hours then cut back to 1 every hour for day 1; 1 every 2 hours on day 2 and 1 3 per day until you come in for a visit. This is easily purchased in health food stores.
Peripheral neuropathy, including diabetic neuropathy:
Take Insinase which contains Alpha Lipoic Acid 540 mg BID and Acetyl-L-Carnitine HCL 400 mg BID. Order from Metagenics 800-692-9400.
Osteoarthrits & RA:
Combinations of Magnesium, Calcium, Valerian root and Hops are essential. See my list for chronic pain and include UltraInflamX 360.
Capsaicin (Capsicum frutescens) cream:
Capsaicin is the main component in hot chili peppers (also known as cayenne). Applied to the surface of the skin, it is believed to deplete stores of a substance that contributes to inflammation and pain in arthritis. Several studies have shown that capsaicin cream provided much better pain relief than a placebo but no improvement in joint swelling, grip strength, or function for people with OA. Pain reduction generally begins 3 to 7 days after applying the capsaicin cream to the skin. Apply the cream 4 times daily.
This is another topical pain reliever used in pain management. This is especially good for sore or strained muscles; shoulderand arm pain; neck, hip, and leg pain; back pain; arthritis pain; painful joints; diabetic neuropathy; tendonitis; and bursitis. Biofreeze needs to be applied 4 times daily.
KinesioTaping procedures are an invaluable aide in everything from chronic edema (swelling) reduction to reduction of muscle tension/pain.
My two favorite modalities for chronic pain continue to be the Deep Muscle Stimulator (DMS) and warm laser.
The FDA has approved duloxetine hydrochloride (Cymbalta, manufactured by Eli Lilly) an antidepressant, to treat chronic back pain and osteoarthritis pain. The FDA granted the new indication based on results of four double-blind, placebo-controlled, randomized clinical trails in which patients randomized to duloxetine reported a greater reduction compared with the placebo group.
In addition to its use for treatment of depression, duloxetine is approved for treatment of diabetic peripheral neuropathy, generalized anxiety disorder, and fibromyalgia.
Are you ready for this?: The most common side effects reported in the back pain and osteoarthritis trials were nausea, dry mouth, insomnia, drowsiness, constipation, fatigue, and dizziness. Other serious side effects, which occurred in less than 1% of patients, included liver damage, allergic reactions such as hives, rashes and/or swelling of the face, pneumonia, depressed mood, suicide, and suicidal thoughts and behavior. I have patients who come in with insomnia, drowsiness, constipation, fatigue, and dizziness as there chief complaints – who needs additional side effects.
Here’s my thoughts – try the anti-inflammatory diet, UltraInflamX 360, and fish oils for 12 weeks and feel the improvement without the side effects.
ROME — Contrary to some earlier findings, obese patients with knee osteoarthritis who lost substantial weight showed signs of structural improvement in their damaged joints, according to two studies reported here. In 44 extremely obese patients whose…
full story http://www.medpagetoday.com/MeetingCoverage/EULAR/tb/20768
Repetitive exercises are another way to help arthritic knees:
•Use a skateboard. Sit down in a chair. Place your foot on the skateboard. Slide your foot back and forth.
•Use a furniture mover. Use these on carpeted surfaces. Do the same thing as with the skateboard.
•Use a rocking chair. Rocking chairs create small, light motions in the hip, knee and spine. They really work.
•Swing your legs in water while sitting on the edge of a pool. For this to work, you have to swing your legs very slowly. Otherwise, you’ll fatigue the muscles too fast.
•People often ask if they can use cycling as a way to improve their joint health and the answer is, it depends! It depends on how much motion you have in your knee, how irritable your knee is, and how easily you can control the resistance on the bike. Cycling can create body weight or higher loads on your knee so it’s usually not my first choice. But, it is an option. And, only on a stationary bike.
•I suggest ten-fifteen minutes per session and aim for three sessions per day. The key is to move slowly and feel very little fatigue in the muscles. The purpose is not to strengthen your muscles; it’s to improve the fluid in your knee.
Regarding Glucosamine, the original Italian studies circa 1988 were using 1200mg GluS04 and 600mg ChonS04 daily for 6 weeks. These studies claimed that people with osteoarthritic knees felt a 50% symptom reduction. Arthroscopy of that group revealed evidence of increased meniscal thickness. Histo revealed increased Chondrocyte size and histo density.
The JOG (Joints on Glucosamine) study used Glucosamine Hydrochloride at 1500 mg/day. Glucosamine hydrochloride has been shown to be ineffective in other studies. Glucosamine sulphate is the active form that is most helpful. My experience is that clients need to be on at least 3-4 grams/day for an initial 3 week dose to be effective. At week 4-6 they can take 2-3 grams daily. A maintaince dose is 1500 mg. I do like to change this supplement out every 10-12 weeks.
Using glucosamine hydrochloride has been a common theme of studies showing lack of benefit.
Ideal treatment for joint pain should include Pycnogenol, a pine bark extract with anti- inflammatory effects. Pycnogenol has been shown to help knee osteoarthritis, conditions that need enhanced blood flow, symptoms of menopause, and diabetics manage blood sugar levels.
Dr. Tucker recommends combining Pycnogenol (150 mg of Pycnogenol daily), glucosamine and chondroitin sulphate ( 1500 mg daily), with omega-3s( 2-3 grams daily) to reduce inflammation related to knee OA.
I had a question from a Doctor about what nutritional recommendations I use for patients with Osteoarthritis. Here is my response.
Make sure they are consistent for at least 3 months on an Anti-inflammatory diet. Depending on the client I use either the Mediterranean Diet or Paleo Diet.
The following are supplements from my Metagenics site (www.meta-ehealth.com/site/office/index.jsp) that I recommend:
If it is a light to moderate case:
Kaprex — 1-2 softgel twice daily
Non-responders by day 5, move to 6 softgels daily
Time to benefit: 2 to 10 days.
Kaprex is an herbal supplement that provides natural joint relief that is easy on the gastrointestinal (GI) tract. It works by interfering with signals in the body that initiate the production of damaging compounds that cause minor pain and negatively impact cartilage and other joint tissues.
Chondro-Relief Intensive Care – 2-3 capsules twice daily
Chondro-Relief Intensive Care supports healthy joint function with Glucosamine HCI, Chondroitin Sulfate, Methyl-Sulfonyl-Methane (MSM), P. Canaliculus, Hyaluronic Acid, and Avocado/Soybean Unsaponifiables (ASU) in addition to other antioxidants that support healthy connective tissue.
EPA-DHA 6:1 Enteric Coated — 2 softgels three times daily. Omega 3 fatty acids are important for patients with chronic inflammatory conditions.
D3 5,000 — 1 tablet two times daily. Get there blood level checked & then dose up or down.
If it is a moderate to severe case:
UltraInflamX Plus 360 — 2 scoops twice daily. They make a shake in the morning & afternoon. It is a Medical food for inflammation and biotransformation.
Chondro-Relief Intensive Care – 2-4 capsules twice daily
EPA-DHA 6:1 Enteric Coated — 2 softgels three times daily. Omega 3 fatty acids providing a ratio appropriate for patients with chronic inflammatory conditions.
D3 5,000 — 1 tablet three times daily.
I have clients use Capsaicin cream and rub it on the involved area at least four times per day.
Laser therapy is effective for degenerative osteoarthritis
Stelian J, Gil I, Habot B et al. Improvement of pain and disability in elderly patients with degenerative osteoarthritis of the knee treated with narrow-band light therapy. J Am Geriatr Soc. 1992; 40: 23-26.
In an Israeli study the effect of laser therapy in degenerative osteoarthritis (DOA) of the knee was investigated in a double blind study among 50 patients. One group received infrared (GaAlAs) and one red (HeNe) laser. Only the first group could be blinded, while the latter was open. Patients were treated twice daily, 15 minutes each time, for 10 days. The patients treated themselves after instruction. Total dose for each session was 10.3 J for red and 11.1 for infrared. Continuous mode was used for 7.5 minutes, pulsed for 7.5 minutes, rationale not stated. There was a significant pain reduction in the laser groups as compared to the placebo groups. There was no significant difference between the red and the infrared group. The Disability Index Questionnaire also revealed an improvement in the laser groups. All patients in the placebo group required analgesics within two months after laser therapy while the patients in the laser group were pain free ranging from 2 months to 1 year.