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Why is it important to focus on multiple treatment options simultaneously?

12th October 2017

Because there is no stand-out, totally effective single treatment for osteoarthritis, people with the condition often find it best to put together a personal portfolio of treatments that will work together to help relieve pain and improve mobility. The combination that works for one person may not work for another, so it’s important to understand what’s available, how effective it is and whether it will help your personal condition.

Treatments range from movement and pressure therapies such as Alexander and acupuncture to nutritional supplements, pain relief, knee bracing, exercise, weight management, heat gels and more. We’ll take a look at which of these have some evidence behind them, and how to combine different approaches to work out an effective regime for you personally.

Complementary therapies involving touch, movement and pressure

Acupuncture and acupressure (a similar technique but without using needles) seem to be very effective at relieving pain in certain individuals and completely ineffective in others. If electrical stimulation is combined with the use of needles, the effectiveness rate goes up but this is effectively a transcutaneous electrical nerve stimulation (TENS) treatment which has long been established as effective for pain relief and which is discussed below.

Another approach is to take up a body-balancing method such as the Alexander technique and learn to use your body in such a way that you don't exacerbate your knee pain. Again, Alexander has many passionate adherents who have found enormous relief from arthritic pain by using it. Others can't persist with it at all. It does require quite a lot of discipline as you have to move your body in the required way all the time, not just during exercise sessions.

Chiropractors and osteopaths both use their knowledge of the way the body and its joints work to try to resolve mechanical problems in joints. These therapies can be quite intensive as the therapist attempts to manipulate joints into a better alignment. For some, this is a long-lasting treatment that provides great relief. For others, the rigour of the treatment session isn't worth it in view of the results.

Simple massage is often a very beneficial treatment because it can relax muscles that have become rigid and tense due to their proximity to a painful joint.

Exercise and weight loss

Whatever selection of treatments you eventually decide to adopt, exercise must be at the centre of them. Study after study has shown the benefits of exercise for people with arthritis. Part of the reason for this, is that the stronger the muscles around your joints are, the more they can take the strain and prevent excess load on joints such as the knee. However, with a joint that is already damaged it's important to build up slowly.

Sometimes people are put off starting an exercise programme because they already have significant pain. In this case, think about going to a specialised hydrotherapy pool. These are heated to a higher level than a normal public swimming pool, to help your body relax. In the water, you don't need to put any pressure on your joints and can concentrate on building muscle.


If you don't want to go out to exercise, then there are exercise programmes you can follow at home - ask your GP for an exercise sheet.

Everyone with a knee problem knows that they should probably lose some weight. The trouble is that once you have the problem, it will take a while to build up your exercise regime to the point where it’s helping you to control your weight. However, it's one of the key things that you can do to improve the problem and of all the solutions we're discussing here, weight loss and exercise are the ones with the most all-round benefits to your health.

Mind and body

It's now well recognised by the medical profession that having a long-term illness or significant chronic pain, is likely to cause depression. So don't feel at all ashamed about asking your doctor for an antidepressant if you need one. An improvement in your mood, and a more hopeful outlook can lead you to try and exercise, with the result that your mood improves further. Before you know it, you've managed to get yourself into a virtuous cycle of improvement.

If pills aren't for you, then perhaps consider some of the gentler forms of mind/body balancing. For example, yoga or tai chi, both of which combine gentle stretching with harmonious body movements. Mindfulness is another widespread approach in which you concentrate on the moment and this can be very helpful for people with osteoarthritis who may be worrying about what the future holds or depressed about what they can no longer do.

Medication

Because there is no cure for osteoarthritis when we talk about NHS medication we are usually looking at pain relief. Before prescribing a painkiller, your doctor will look at your medical history and also take a view on any other medications that you are taking. The general approach is to start with mild painkillers first until you reach a level at which the pain improves. You may be started on paracetamol - pay attention if the doctor advises taking it regularly. Many painkilling medications are more effective when taken in a continuous regime than with sudden bursts of higher doses.

The next step up is the Non-Steroidal Anti-Inflammatory Drugs (NSAIDs). The most commonly prescribed of these are ibuprofen, naproxen and diclofenac. NSAIDs do have some side effects, in particular, stomach problems, so your GP will want to go through your medical history before prescribing them for you.

Some NSAIDs are available as creams that you rub onto your painful joint, and according to NHS Choices, these are particularly helpful for knee osteoarthritis. If these don't help, capsaicin cream may be used. This acts as a nerve blocker but it may have to be used for a while before you notice any effect. The cream is actually made from chilies so you have to be careful about getting it in your eyes or mouth.

Opioids, such as codeine and tramadol are only prescribed for very severe pain. They have side-effects such as nausea, drowsiness and constipation, and again, there are various circumstances in which your GP will not want to prescribe them.

Corticosteroid injections and hyaluronic acid

Steroid injections are used when pain relief has not been effective. The steroid is injected directly into the knee to control the inflammation that is causing the pain. The response is very variable. Some people find little relief, whereas others have an excellent response and go on to have the injections regularly.

If you have tried every non-surgical treatment but have received little benefit, your doctor may recommend Viscosupplementation. This uses a substance called hyaluronic acid which is found naturally in joint fluid and which acts as a shock absorber and lubricant in the joint. You will receive up to five doses, delivered by injection directly into the knee joint. Again, there's a great variability in the response, but if you find this helpful you may be able to repeat the treatment every six months or so.

Nutritional supplements

The NHS says that glucosamine hydrochloride supplements have not shown evidence of helpful effects. However, there is some evidence that glucosamine sulphate and chondroitin sulphate may be slightly helpful. Neither supplement is routinely offered as part of NHS care.

Assistive devices

The most widespread of these, of course, is the simple walking stick. However, make sure that the stick you are using is at the right height. Your forearms should be level when you are using it.

A properly prescribed and fitted knee brace can work wonders, so it is also worth looking at this option, particularly if you hope to return to active sports. This normally comes in the form of an off-loading knee brace for use with uni-compartmental versions of the condition where it shifts the load from the affected side of the knee to the less affected side.

Transcutaneous electrical nerve stimulation (TENS) is a little more high-tech. It’s a clever little box that sends electrical impulses to an electrode that you stick onto your skin. The idea is that it numbs the nerve endings in the spine which control the pain you are experiencing.

Hot or cold packs are another basic remedy, but many find that they deliver effective relief, if only over the short term.

Putting it all together

Hopefully, the diversity of the treatments and approaches described above serves to demonstrate that the most effective approach to managing your knee osteoarthritis will be to assemble a package of exercise, pain relief, mood control, exercise, nutrition and assistive devices such as supports.

No one set of treatments will be ideal for everyone but in selecting an individual package that you believe will provide the most benefit to you personally, you are beginning to get control back over your condition. When the pain and immobility are at their worst you can feel that you are no longer in control of your life.

Another good thing about this eclectic approach is that if you find that one element no longer works well, you can drop it and add something else instead.

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