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Physical Therapy for Osteoarthritis

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  • Arthroscopic knee surgery for osteoarthritis and/or torn meniscus is one of the most unnecessary surgeries performed.
  • Research has shown arthroscopic knee surgery works no better than placebo surgery, and when comparing treatments for knee pain, physical therapy was found to be just as effective as surgery, but at significantly reduced cost and risk
  • Recent research also shows exercise is just as effective as surgery for people with a chronic pain in the front part of their knee, known as chronic patellofemoral syndrome (PFPS), which is also frequently treated with arthroscopic surgery
  • In one recent study, 84 percent of patients reported significantly less pain and elbow tenderness at six months following treatment with platelet rich plasma (PRP), a component of whole blood that contains a number of growth factors that takes advantage of your body’s natural healing process
  • Natural tips for pain relief and cartilage loss are listed, including: exercise, optimizing your vitamin D, K2, and sulfur levels. Natural pain relieving agents you can try include astaxanthin, omega-3, hyaluronic acid and curcumin, among others
 

Physical Therapy as Good as Surgery for Osteoarthritic Knees and Torn Meniscus

April 05, 2013 | 261,625 views
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By Dr. Mercola

Arthroscopic knee surgery for osteoarthritis is one of the most unnecessary surgeries performed today, as it works no better than a placebo surgery.

Proof of this is a double blind placebo controlled multi-center (including Harvard’s Mass General hospital) study published in one of the most well-respected medical journals on the planet, the New England Journal of Medicine (NEJM)1 over 10 years ago.

Despite this monumental finding, some 510,000 people in the United States undergo arthroscopic knee surgery every year.2 And at a price of anywhere from $4,500 to $7,000 per procedure, that adds up to billions of dollars every year spent on this surgery.

Osteoarthritis of the knee is one of the primary reasons patients receive arthroscopic surgery. This is a degenerative joint disease in which the cartilage that covers the ends of the bones in your joint deteriorates, causing bone to rub against bone.

Arthroscopic knee surgery is also commonly performed to repair a torn meniscus, the crescent-shaped fibrocartilaginous structure that acts like a cushion in your knee.

Many might think that this problem, surely, would warrant surgery. But recent research3 shows that physical therapy can be just as good as surgery for a torn meniscus, adding support to the idea that when it comes to knee pain, whether caused by osteoarthritis or torn cartilage, surgery is one of the least effective treatments available...

Physical Therapy as Good as Surgery for Torn Cartilage and Arthritis

The featured study, also published in NEJM,4 claims to be one of the most rigorous studies yet comparing treatments for knee pain caused by either torn meniscus or arthritis. According to the Washington Post:5

“Researchers at seven major universities and orthopedic surgery centers around the U.S. assigned 351 people with arthritis and meniscus tears to get either surgery or physical therapy. The therapy was nine sessions on average plus exercises to do at home, which experts say is key to success.

After six months, both groups had similar rates of functional improvement. Pain scores also were similar.

Thirty percent of patients assigned to physical therapy wound up having surgery before the six months was up, often because they felt therapy wasn’t helping them. Yet they ended up the same as those who got surgery right away, as well as the rest of the physical therapy group who stuck with it and avoided having an operation.”

Another study6 published in 2007 also found that exercise was just as effective as surgery for people with a chronic pain in the front part of their knee, known as chronic patellofemoral syndrome (PFPS), which is also frequently treated with arthroscopic surgery.

The study compared arthroscopy with exercise in 56 patients with PFPS. One group of participants was treated with knee arthroscopy and an eight-week home exercise program, while a second group received only the exercise program. At the end of nine months, patients in both groups experienced similar reductions in pain and improvements in knee mobility.

A follow-up conducted two years later still found no differences in outcomes between the two groups.

In an editorial about the featured study,7 Australian preventive medicine expert Rachelle Buchbinder of Monash University in Melbourne urges the medical community to change its practice and use physical therapy as the first line of treatment, reserving surgery for the minority who do not experience improvement from the therapy.

“Currently, millions of people are being exposed to potential risks associated with a treatment that may or may not offer specific benefit, and the costs are substantial,” she writes. “These results should change practice. They should also lead to reflection on the need for levels of high-quality evidence of the efficacy and safety of surgical procedures similar to those currently expected for nonoperative therapy.”

Placebo Surgery Works as Well for Osteoarthritis as Arthroscopic Surgery

Buchbinder points out the importance of sham surgery to determine the true value of operative treatments. Unfortunately, many surgeons are reluctant to take on such research. Many doctors consider them unethical because patients could undergo risks with no benefits. But it has been done. The study I mentioned at the start of the article that was published in 2002,8 evaluated arthroscopic surgery for osteoarthritis. A total of 180 participants were randomly assigned to either have the real operation or sham placebo surgery in which surgeons simply made cuts in their knees.

Those in the placebo group received a drug that put them to sleep. Unlike those getting the real operation, they did not have general anesthesia to avoid unwarranted health risks and complications. In the end, the real surgery turned out to be no better at all, compared to the sham procedure. According to the authors:

“At no point did either of the intervention groups report less pain or better function than the placebo group. For example, mean scores on the Knee-Specific Pain Scale were similar in the placebo, lavage, and débridement groups... at one year [and] at two years... Furthermore, the 95 percent confidence intervals for the differences between the placebo group and the intervention groups exclude any clinically meaningful difference. In this controlled trial involving patients with osteoarthritis of the knee, the outcomes after arthroscopic lavage or arthroscopic débridement were no better than those after a placebo procedure.”

Outcomes in Tennis Elbow Significantly Improved by Novel Therapy

People suffering from chronic tennis elbow may also want to consider the alternatives to arthroscopic surgery. According to the largest multi-center study to date on the use of platelet rich plasma (PRP) treatment for lateral epicondylar tendinopathy (“tennis elbow”), 84 percent of patients reported significantly less pain and elbow tenderness at six months following the treatment, compared to those who received a placebo.

What is PRP?

Platelet Rich Plasma (PRP) is a component of whole blood that contains a number of growth factors that takes advantage of your body’s natural healing process. A small amount of your own blood is drawn, and using a centrifuge machine, the blood is spun to separate and concentrate the specific platelets and growth factors sought. The PRP is then injected into the site of injury to help jumpstart the natural healing process. The treatment has garnered some attention for its potential in treating problems such as:

Osteoarthritis of the knee Shoulder injuries Hip, spine and neck injuries
Rotator cuff tears Chronic plantar fasciitis Anterior cruciate ligament (ACL) injuries
Ankle sprains Tendonitis Ligament sprains

 

The research was presented at the 2013 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS). According to Medical News Today:9

In this study, 230 patients suffering from chronic tennis elbow who had failed traditional therapies were treated at 12 U.S. medical centers. Patients were randomized and received either an injection of PRP made from their own concentrated blood platelets, or a placebo, administered with an analgesic at the site of pain.

At 12 weeks, 55.1 percent of PRP patients reported improved pain scores compared to 47.4 percent in the control group, and 37.4 percent reported less elbow tenderness versus 48.4 percent in the control group. At 24 weeks, 71.5 percent of the PRP patients had improved pain scores compared to 56.1 percent in the control group, and 29 percent reported less elbow tenderness compared to 54 percent in the control group. At six months, 83.9 percent of the PRP-treated group reported significantly less pain and elbow tenderness, compared to 65.9 percent of the active control group.”

If You Have Joint Pain, Exercise is an Important Must

The notion that exercise is detrimental to your joints is a misconception, as there is no evidence to support this belief. Instead, the evidence points to exercise having a positive impact on your joint tissues -- if you exercise sufficiently to lose weight, or maintain an ideal weight, you can in fact reduce your risk of developing joint pain due to osteoarthritis rather than increase your risk. Exercise can also improve your bone density and joint function, which can help prevent and alleviate osteoarthritis (a major cause of joint pain) as you age.

For example, previous research10 has shown that people with rheumatoid arthritis, which causes joint pain, stiffness and deformities, who did weight training for 24 weeks improved their function by up to 30 percent and their strength by 120 percent. Unfortunately, many with joint pain are missing out on these potential benefits. Research11 published in 2011 found that over 40 percent of men and 56 percent of women with knee osteoarthritis were inactive, which means they did not engage in even one 10-minute period of moderate-to-vigorous activity all week...

Exercise, along with a healthy diet, can help you to jumpstart weight loss if you're overweight, and this can lead to tremendous improvements in your joint pain. According to a 2012 article by Harvard Health Publications:12

"Each pound you lose reduces knee pressure in every step you take. One study13 found that the risk of developing osteoarthritis dropped 50 percent with each 11-pound weight loss among younger obese women. If older men lost enough weight to shift from an obese classification to just overweight — that is, from a body mass index (BMI) of 30 or higher down to one that fell between 25 and 29.9 — the researchers estimated knee osteoarthritis would decrease by a fifth. For older women, that shift would cut knee osteoarthritis by a third."

Special Considerations for Exercising With Joint Pain

There are some factors to consider, particularly if your pain worsens with movement, as you do not want to strain a significantly unstable joint. Pain during movement is one of the most common and debilitating symptoms of osteoarthritis, and typically this is the result of your bones starting to come into contact with each other as cartilage and synovial fluid is reduced.

If you find that you're in pain for longer than one hour after your exercise session, you should slow down or choose another form of exercise. Assistive devices are also helpful to decrease the pressure on affected joints during your workout. You may also want to work with a physical therapist or qualified personal trainer who can develop a safe range of activities for you. Your program should include a range of activities, just as I recommend for any exerciser. Weight training, high-intensity cardio, stretching and core work can all be integrated into your routine.

My most highly recommended form of exercise is Peak Fitness, and this program can be used by virtually everyone. However, if you've already developed osteoarthritis in your knee, you'll want to incorporate exercises that strengthen the quadriceps muscle at the front of your thigh. And, rather than running or other high-impact exercise, you may be better off with non-weight-bearing exercises like swimming and bicycling.

Natural Tips for Pain Relief and Cartilage Loss

Cartilage loss in your knees, one of the hallmarks of osteoarthritis, is associated with low levels of vitamin D. So if you're struggling with joint pain due to osteoarthritis, get your vitamin D levels tested, then optimize them using appropriate sun exposure or a safe tanning bed. If neither of these options are available, supplementation with oral vitamin D3 along with vitamin K2 can be considered.

Sun exposure is your best option though, because when your skin produces two types of sulfur in response to sun exposure: cholesterol sulfate, and vitamin D3 sulfate. Sulfur plays a vital role in the structure and biological activity of both proteins and enzymes. If you don't have sufficient amounts of sulfur in your body, this deficiency can cascade into a number of health problems, including impacting your joints and connective tissues.

In addition to making sure you're getting high amounts of sulfur-rich foods in your diet, such as organic and/or grass-fed/pastured beef and poultry, Dr. Stephanie Seneff, a senior scientist at MIT, recommends soaking your body in magnesium sulfate (Epsom salt) baths to compensate and counteract sulfur deficiency. She uses about 1/4 cup in a tub of water, twice a week. It's particularly useful if you have joint problems or arthritis.

Methylsulfonylmethane, commonly known by its acronym, MSM, is another alternative that may be helpful. MSM is an organic form of sulfur and a potent antioxidant, naturally found in many plants, and is available in supplement form. As for glucosamine and chondroitin, two animal products marketed as food supplements for the relief of joint pain, the results from studies evaluating these supplements have been mixed, and many do not appear to be getting any significant relief from either of them.

Pain Relieving Supplements

For joint pain, I recommend avoiding anti-inflammatory drugs like non-steroidal anti-inflammatories (NSAIDs) and analgesics, like Tylenol, which are often recommended to osteoarthritis patients. Chronic use of these types of medications is associated with significant side effects such as kidney and/or liver damage. Safer, and very effective, options to help relieve joint pain include:

  • Astaxanthin: An anti-inflammatory antioxidant that affects a wide range of inflammation mediators, but in a gentler, less concentrated manner and without the negative side effects associated with steroidal and non-steroidal anti-inflammatory drugs. And it works for a high percentage of people. In one study, more than 80 percent of arthritis sufferers improved with astaxanthin.
  • Eggshell membrane: The eggshell membrane is the unique protective barrier between the egg white and the mineralized eggshell. The membrane contains elastin, a protein that supports cartilage health, and collagen, a fibrous protein that supports cartilage and connective tissue strength and elasticity.
  • It also contains transforming growth factor-b, a protein that supports tissue rejuvenation, along with other amino acids and structural components that support the stability and flexibility of your joints by providing them with the building blocks needed to build cartilage.

  • Hyaluronic acid (HA): Hyaluronic acid is a key component of your cartilage, responsible for moving nutrients into your cells and moving waste out. One of its most important biological functions is the retention of water… second only to providing nutrients and removing waste from cells that lack a direct blood supply, such as cartilage cells.
  • Unfortunately, the process of normal aging reduces the amount of HA synthesized by your body. Oral hyaluronic acid supplementation may effectively help most people cushion their joints after just 2 to 4 months.

  • Boswellia: Also known as boswellin or "Indian frankincense," this Indian herb is one treatment I've found to be particularly useful against arthritic inflammation and associated pain. With sustained use, boswellia may help maintain steady blood flow to your joints, supporting your joint tissues' ability to boost flexibility and strength.
  • Turmeric / curcumin: A study in the Journal of Alternative and Complementary Medicine found that taking turmeric extracts each day for six weeks was just as effective as ibuprofen for relieving knee osteoarthritis pain. This is most likely related to the anti-inflammatory effects of curcumin -- the pigment that gives the turmeric spice its yellow-orange color.
  • Animal-based omega-3 fats: These are excellent for arthritis because omega-3s are well known to help reduce inflammation. Look for a high-quality, animal-based source such as krill oil.

Make Surgery Your Last Option Rather than Your First...

The steps outlined above should help to significantly slow down any further deterioration or loss of motion in your joints, and provide you with drug-free pain relief. And remember, whether you have osteoarthritis in your knees or a torn meniscus, arthroscopic knee surgery has been shown to be no better than placebo surgery, and physical therapy and exercise has repeatedly been shown to be just as effective as surgery, and perhaps even more so in some cases.

So please, carefully weigh your options; the risks and the benefits. As reported in the featured article,14 NOT resorting to the “fix” promised by surgery may actually be the magic you’re looking for:

“Surgery costs about $5,000, compared with $1,000 to $2,000 for a typical course of physical therapy... Robert Dvorkin had both treatments for injuries on each knee several years apart. Dvorkin, 56, director of operations at the Coalition for the Homeless in New York City, had surgery followed by physical therapy for a tear in his right knee and said it was months before he felt no pain.

Then several years ago he hurt his left knee while exercising. 'I had been doing some stretching and doing some push-ups and I just felt it go ‘pop.’' he recalls. 'I was limping, it was extremely painful.' An imaging test showed a less severe tear and a different surgeon recommended physical therapy.

Dvorkin said it worked like a charm — he avoided surgery and recovered faster than from his first injury. The treatment involved two to three hour-long sessions a week, including strengthening exercises, balancing and massage. He said the sessions weren’t that painful and his knee felt better after each one. 'Within a month I was healed,' Dvorkin said. 'I was completely back to normal.'”