Did you know that the knee joint is both the largest but also one of the most injured joints in the human body? In this post, we are going to share with you the challenges of knee osteoarthiritis and how to treat it!

In fact, studies shows that knee pain or knee osteoarthritis is often underreported, underestimated, and undertreated. Moreover, osteoarthritis of the knee is often ignored by medical practitioners until the disease is very advanced, as it is often considered as part of the ‘normal’ aging process.

Let’s dive right in!!

The knee joint is made up of the lower end of the femur, the upper end of the tibia, and the patella. The ends of these bones are covered with articular cartilage; a smooth, slippery substance that protects and cushions the bone.

In addition, there are two wedge-shaped pieces of cartilage called the meniscus that act as “shock absorbers”, helping to keep the knee in a stable position. The knee joint is surrounded by a thin lining called the synovial membrane. This membrane releases a fluid that lubricates the cartilage and reduces friction.

Although the knee joint is the strongest in the body, it also needs to bear the most direct body weight. Therefore, it is clear that the knee joint is one of the most affected joints due to its weight-bearing function.

Knee osteoarthritis is a degenerative, ‘wear -and-tear’ type of arthritis that occurs most often in people in their 50’s or older. Osteoarthritis is a condition where the cartilage in the knee joint gradually wears away. As the cartilage degenerates, the bones become frayed and rough, and the protective space between the bones decreases.

This results in bone rubbing on bone and produces painful bone spurs and further degeneration. Knee osteoarthritis usually progresses slowly, and the pain worsens over the time as the degeneration continues.

To add on, knee osteoarthritis and other rheumatic conditions seldom causes death but do unfortunately have a substantial impact on health. Recent studies show that, knee osteoarthritis leads to both individual and socioeconomic burden.

Both inflammatory and mechanical pain due to knee osteoarthritis are known to interfere with daily physical function and social activity. The pain severity can range from barely perceivable through to immobilizing, which further contributes to fatigue, poor mood, and reduced quality of sleep.

Thus, the substantial impact on health with people who suffer with knee osteoarthritis includes suffering from chronic pain, limitation in daily activities, participation restriction in social life and, in general, and overall poor quality of life.

Overall, almost everyone will experience some degree of osteoarthritis in their life. However, there are some frequently discussed risk factors that increase the occurrence of the knee osteoarthritis. The most common risk factors are:

• Age – The ability of cartilage to heal decreases as a person gets older. Over time, the knees’ cartilage becomes weaker and less flexible, making it more prone to thinning and damage.
• Heredity / Congenital defect – A genetic mutation that might make a person more likely to develop osteoarthritis of the knee. It may also be due to inherited abnormalities in the shape of the bones (particularly those surrounding by the knee joint).
• Gender – Women aged 55 and older are more likely to develop knee osteoarthritis than men of a similar age.
• Repetitive stress injuries / Joint trauma – Oftentimes this closely relates to the type of job of the individual. Occupations that involve stress to the joint, such as kneeling, squatting, or lifting heavy objects are more likely to develop osteoarthritis due to the constant pressure on the knee. Besides that, a fractured bone or surgery may cause damage to the knee joint, which may eventually lead to knee osteoarthritis. These symptoms may appear later after a longer period of time (also known as post-traumatic arthritis).
• Athletics – Athletes involved in sports may be at higher risk to develop osteoarthritis in their later age, especially if they do not take precautions in their younger years. However, it’s important to note that regular moderate exercise strengthens joints and can decrease the risk of osteoarthritis.
• Poor muscle tone / lack of exercise – Weak muscles and lack of exercise may put more stress on the knee cartilage and this stress leads to knee osteoarthritis.
• Obesity – Since the knees are the most weight-bearing joints, a person who is obese is twice as likely to develop knee osteoarthritis.

The common symptoms that experienced by the person who is suffering from knee osteoarthritis may include pain in the knee joint with increased activity, presence of swelling, feeling of warmth in the joint due to inflammation, morning stiffness in the knee joint, decreased mobility of the knee (getting in and out of chair will be difficult), and crepitus / crackly sound that can be heard when the knee moves.

Nonetheless, early recognition of the knee osteoarthritis signs and symptoms and appropriate treatment can slow or eliminate the progression of osteoarthritis.

Studies shows that 30.8% of Malaysian (population in Kuala Lumpur; aged 55 years and older) has suffered symptoms of knee osteoarthritis prevalence for at least a month over the past 12 months. This study also breaks down the prevalence of knee osteoarthritis by ethnicity in Malaysia. It reveals that knee osteoarthritis symptoms among the ethnics Malays was 37.7%, ethnics Indian 25.7% and ethnic Chinese 17.9%.

The prevalence of among ethnic Malays may in part be due to “floor culture” – he practicing of sitting cross legged on the floor. Aside from this, the rise in knee osteoarthritis among young old ethnic Malays can be correlated with the corresponding, alarming rise in obesity, diabetes mellitus and metabolic disorders in this group.

In a similar vein, studies have shown the prevalence of knee osteoarthritis among Indian Malaysians can also closely relate to the presence of two or more non-communicable diseases (NCDs). While for the ethnic Chinese, and the prevalence of knee is osteoarthritis is much lower and can be explained by lifestyle and occupation. However, researchers added that the results might be somewhat biased as the study has been performed among the urban population.

Treatment of Knee Osteoarthritis

Knee osteoarthritis can be treated conservatively, to relieve pain and return mobility to the knee(s). Conservative treatment plans will typically include a combination of pharmacological and non-pharmacological treatments.

The pharmacological approach among patients with knee osteoarthritis is mainly to relieve pain, however not all patients require medicine and for those who do, they may not need it all the time. The pharmacological approach often includes:

• Usage of non-steroidal anti-inflammatory drugs (NSAIDS) as an analgesic agent;
• Glucosamine Sulfatesulfate acts as a natural substance for the building block of proteoglycans; these normalize articular cartilage metabolism and also help to reduce inflammation.
• Chondroitin Sulfate found naturally in human cartilage, skin and arteries; this helps to slow down the progression of osteoarthritis on x-ray.
• Corticosteroids helps to alter the pain perception. While it shows a significant improvement for short-term benefit, continuous use of corticosteroids could facilitate muscle atrophy, joint destruction, or cartilage degenerations.
• Hyaluronic acid (HA) facilitates the restoration of normal intra-articular levels of HA which will be lacking in osteoarthritic joints.
• Platelet-rich-plasma (PRP) is considered as innovative and promising tool to stimulate repair of the damaged cartilage, therefore it may aid in the treatment of degenerative lesion of the articular cartilage and osteoarthritis. In addition, studies show that the combination of HA and PRP are more effective compared to HA alone in managing knee osteoarthritis.

The non-pharmacological and alternative medicine approach is a long-term process and requires continuous effort by the patient. The combination of a number of treatments is important to undertake here:

Lifestyle modifications consist of weight loss, modifying exercise routines from running or jumping exercises to swimming or cycling, and minimizing activities that aggravate the condition, such as full squats, climbing stairs, hiking, etc… Obesity is a major risk factor for developing knee osteoarthritis, as it puts direct pressure on the knee while weight bearing.

Thus, losing weight will significantly decrease the pain, improve the symptoms on the knee and reduces the progression of arthritis. As the symptoms reduce, complementary physical activities become easier. These lifestyle changes ultimately need to continue throughout life.

The main goal of physiotherapy / physical therapy is to reduce knee pain, maintain joint mobility, improve muscle strength, and finally decrease disability in people with knee osteoarthritis. These goals can be achieved by water or land-based exercises, aerobic walking, quadriceps strengthening and resistance exercise.

Physiotherapists will use modalities like transcutaneous electrical nerve stimulation (TENS), interferential current (IFC), pulsed electro stimulation and ultrasound therapy to have a large effect on pain relief and moderate improvement in function. In a study exploring the perspectives of patients with knee osteoarthritis on physiotherapy, most participants acknowledged that there is no cure for knee osteoarthritis.

However, the physiotherapy management helped in improving physical performance in term of balance, strength, pain reduction and decreasing of fear avoidance activities. In line with that, some participants expressed that physiotherapy could delay worsening of the arthritis and also prevent further deterioration.

Patient education / home exercise programs on the Do’s and Don’ts and self-management of knee osteoarthritis are crucial. Home exercise programs have been shown to improve the patients’ knee functional levels, decrease the severity of their pain and improve overall quality of life.

It further explained that therapists should develop various additional coping strategies to reduce the knee pain. These coping strategies focus on the modification of daily activities, short periods of rest between activities and self-management of the knee pain.

Finally, the use of braces or orthoses can be useful and have been reported to be effective in decreasing pain and joint stiffness. The brace helps to reduce compressive loading on the affected joint, as well as increase the joint proprioception and quadricep strength.

These conservative treatment approaches are quite effective in the early course of knee osteoarthritis (KL Grade 1,2, 3). However, in the advanced stages of knee osteoarthritis (KL Grade 4), surgical treatment like arthroplasty (TKA/R) and osteotomy are unfortunately needed as definitive treatment.

Total Knee Replacement (TKR)

Total knee replacement is a procedure whereby the diseased knee joint is replaced with artificial material. During this procedure, the end of the femur bone is removed and replaced with a metal shell, and the head of tibial bone is removed and replaced with a channeled plastic piece and metal stem.

The artificial components of a total knee replacement are referred to as the prosthesis.  The ligaments in the knee are either retained, sacrificed, or substituted by polyethylene posts.

In general, however, the lifetime of the total knee replacement prosthesis is undefined for several reason. However, studies estimate that the knee replacement would last at least 10 – 15 years. This is dependent on the preparation prior to surgery, the surgical techniques, anesthesia, and of course the quality of physical rehabilitation after surgery.

Another researcher stated that the knee functional score can improve significantly, although there are a few factors that affect the longevity of the prosthesis:

• Age of the patient – Younger patients undertaking total knee replacement in their 50s or younger have higher chance to require a revision knee replacement in their lifetime.
• Patient activities – Patients that continue activities that may place excessive stress on the knee replacement may cause the parts to wear out more quickly.
• Patient weight – Heavier patient place more stress on the joint replacement implant; thus, maintaining a normal body weight is crucial to ensuring the joint replacement lasts.
• Avoiding complications – Patients with invasive medical procedures may require additional antibiotics to prevent bacteria from getting into the joint replacement. Furthermore, patients with osteoporosis must ensure they are being adequately treated, as fractures can affect the joint replacement.

Rehabilitation Guideline

Thus, the rehabilitation guideline should be in line with patients’ progress and help to enhance the longevity of the prosthesis. Rehabilitation after total knee replacement mainly targets the recovery of knee range-of-motion (ROM), restoration of the knee and hip muscles, return to activity of daily living and participation in recreational activities for active patients.

There are multiple ways to regain strength and function, such as physical therapy, aquatic therapy, ice/cryotherapy, transcutaneous electrical nerve stimulation (TENS), neuromuscular electrical stimulation (NMES), and soft tissue manipulation. Rehabilitation will be achieved by designing individualized treatment based on patient and practitioner preference.

Below is an overall guideline for rehabilitation of total knee replacement patients:

• Cryotherapy and Compression

Cryotherapy and compression help to reduce pain, swelling and inflammation of the affected joint. Cryotherapy is a slow enzyme function and induces vasoconstriction to the operated side; hence, it reduces the nerve signal transmission and it induces a temporary anesthetic effect.

With this physiological effect, it helps to prevent edema by improving interstitial pressure and reducing the flow of fluid into the interstitial space.  It also helps to reduce the accumulation of hemarthroses in the joint. Studies have concluded that cryo-cuffs with pneumatic pressure are the most effective for post-operative pain relief and help to limit the accumulation of soft tissue swelling.

• Continuous Passive Motion (CPM)

Continuous passive motion (CPM) is a machine that repeatedly provides passive movement of the knee joint through controlled ROM with constant speed/pressure/movement. CPM helps to improve ROM and lead to fewer circulatory complications.

Use of CPM will allow patients to reach at least 0-90 degree knee flexion upon hospital discharge and 0 to 120 degree upon completing post-operative rehabilitation.

• Soft Tissue Manipulation

Soft tissue manipulation is a non-invasive technique aimed to stimulate soft-tissue regeneration through the application of pressure to the affected area(s). Soft tissue manipulation primarily focuses to reduce joint stiffness and pain.

• Neuromuscular Electrical Stimulation (NMES)

Neuromuscular Electrical Stimulation (NMES) helps to stimulate muscle contraction. Voluntary quadricep activation deficit can happen as a result of swelling, joint damage, and pain, therefore leading to decreased gait speed, impaired balance and increased risk of falling. The application of NMES gives a positive effect in early stage of rehabilitation by reducing the loss of quadricep activation.

• Exercise Therapy

Exercise plays an important role in the post-operative rehabilitation of patients with a total knee replacement. Exercise therapy includes passive knee ROM exercises, lower extremity stretches (for quadriceps, hamstring, and calf), ice application, gait re-training and functional training.

The exercise protocol may vary based on the therapist and the patient, as there is no “usual care” or “standard protocol”. The exercise protocol highlights basic strengthening exercises, range of motion stretches, reduces pain and normalizes gait mechanics. However, there is industry-wide consensus that post-operative exercise should consider patient-specific goals in order to have long-term focus and success.

• Aquatic Therapy

In aqua therapy, it is well known that the buoyancy of water attenuates the effects of gravity, shear and compressive forces in joints. In addition, the water resistance improves strength, particularly due to its intrinsic property to resist movement with speed.

The aquatic therapy can start as soon as 4 days up to 18 months after total knee replacement, taking into account the surgical wound and/or scar to avoid infection. The typical aquatic exercises done are stretching for the hip, knee, and ankle; single leg balance, mini-squats, cycle kicks and leg swings.

• Balance Training

Balance impairment will occur after total knee replacement as result of damage to the ligamentous structure that alters mechanoreceptors. Such alteration may have affected the joint proprioception and postural control, which influences the knee stability. The lack of knee stability affects the patient’s performance in terms of twisting, pivoting, walking on uneven surface and changing direction.

The balance can be re-achieved by incorporating lower extremity range of motion (ROM) exercises and functional task-oriented exercises with resistance bands, sidestepping, tandem walk and use of tilt board or balance beam.

Summary

The destruction of cartilage and progression of osteoarthritis can be prevented by doing low-impact exercises. Low-impact exercises improve joint health, relieve joint stiffness, and increase muscle and bone strength. By exercising, body weight can be maintained and further improve the symptoms.

Despite this, the overuse of joints can increase the occurrence of knee osteoarthritis, so the key is balance. Take a good rest if the knee joint swells or becomes achy. Likewise, certain certain nutrients help to reduce the risk ofdisease, such as omega-3 fatty acid and vitamin D.

Omega-3 fatty acid can be obtained from fish oil and nut oils, while vitamin D can be obtained from eating fatty fish such as salmon, tuna, milk and eggs, and our body produces its own vitamin D with the help of sunlight.

As a conclusion, knee osteoarthritis is preventable if there the appropriate lifestyle choices and precautions are taken. This study shows that knee osteoarthritis is not develop solely with age, but that lifestyle plays an important role in progressing knee osteoarthritis.

Thus, practicing a healthy lifestyle helps to reduce the risk of knee osteoarthritis. If the occurrence of knee osteoarthritis reduces, the requirement for total knee replacement also will reduce significantly.

If you want to know more about what Knee Osteoarthritis and Total Knee Replacement, feel free to give us a call at 03-50315946 or send us a Whatsapp or Make an Appointment. We at Rehamed Therapy are always here to help!