Top Five Treatment Tips for Osteoarthritis
CHRONIC PAIN
Donald C. DeFabio
DC, DACBSP, DACRB, DABCO
“There is a higher prevalence of OA in people who are overweight and have a sedentary lifestyle”
WHILE OSTEOARTHRITIS (OA) is common, according to the World Health Organization, OA is an inevitable consequence of aging. This is great news since chiropractic owns lifestyle and prevention, so let’s put decreasing our patient’s risk for developing OA on the list of the many resources we can provide. This article will look at the top five interventions, including topicals that you can easily implement to manage OA and reduce its progression.
Chiropractic Adjustments
Motion is life. The osteoarthritic joint tends to be stiff, and the soft tissues around the joint also lose their elasticity. Both limit movement. In addition, a joint that is not arthritic but has reduced movement has a higher propensity to develop OA.
Chiropractic adjustments maintain motion in joints that are not arthritic and can improve motion in joints that do have osteoarthritic changes. Articular cartilage is soft and needs nutrition obtained by synovial fluid. Keeping a joint moving enhances dispersion of synovial fluid throughout the joint, maintaining healthier articular cartilage.
The caveat here is to use the chiropractic technique of your choice that will encourage motion without creating inflammation in and around the joint. Adjust the joint to regain and maintain as much motion as possible without passing that fine line where the joint becomes swollen and inflamed. It is not about the technique; it is about the intensity of the adjustment. Do not inflame an arthritic joint with excessive manual procedures. Once the joint becomes inflamed, degenerative change accelerates, so it must be avoided at all costs.
Nutrition and Lifestyle
There is a higher prevalence of OA in people who are overweight and have a sedentary lifestyle. Therefore, the first intervention with our patients is to reduce excess weight, decrease inflammation, and encourage activity. With an overweight symptomatic OA patient, perhaps the first place to start would be an anti-inflammatory diet. Stop the grains, hydrogenated oils, and high-glycemic foods and increase above-ground vegetables, lean meat, and water. If the patient is also diabetic, limit fruit and all carbohydrates.
Increasing omega-3 fatty acids found in green vegetation, cold water fish, chia, flax, and hemp seeds and decreasing omega-6 fatty acids found in grains and seed oils, such as corn, vegetable, canola, and soy, reduces the inflammatory cascade. A modified Mediterranean diet limits total carbohydrate load to less than 100g per day. This is highly effective in reducing both weight and blood sugar issues. However, before you make any drastic changes in diet, consider the medications the patient may be taking to ensure no rapid changes in blood sugar or blood pressure occur.
You can stack the modified Mediterranean diet with simple nutraceuticals, such as fish oil, glucosamine, chondroitin, collagen, and anti-inflammatory herbals. If you currently use a nutritional supplement line, look for their joint formula and start there. If not, pick a reputable company, start with their joint formula and inflammation protocol, and then stack those supplements with anti-inflammatory food choices.
Supports and Bracing
Exercise and movement of the osteoarthritic joint follow a fine line. Too much activity will cause the joint to become inflamed and painful, but not enough movement causes the joint to become stiff, painful, and progressively weak. Remember, degenerative changes occur rapidly when the joint is inflamed, so joint inflammation must be limited as much as possible. Wearing supports and braces to protect a joint from excess motion or load helps maintain movement and function with both ADLs and recreational sports. Braces and supports used in conjunction with exercise do not lead to muscle atrophy.
It is important that the brace fits properly and offloads the desired structure. For example, a patient with irritation of the medial knee with a valgus deformity needs a brace with a medial hinge/buttress; they need something to offload the medial compartment. However, a patient with patellar tendinopathy may simply need an open-patella knee sleeve. Soft supports offer compression and may also provide warmth, which is soothing. That is a good combination to help maintain movement without limiting motion and is indicated in joints that have good aligmnent. Joints that demonstrate abnormal aligmnent issues due to OA may require more aggressive bracing.
To determine if a brace or support is reimbursable through insurance, check for an HCPCS code and verify that specific code with the patient's insurance carrier. Many braces are reimbursable through insurance but most supports are not.
Modalities
Many traditional and newer, advanced modalities are great for managing pain and restoring function in OA. Traditionally, paraffin baths, ultrasound, and diathermy that provide heat to those stiff and tight joints is analgesic and enables better ROM. Again, if the joint is inflamed, don't introduce heat because it will create excessive inflammation, driving further degenerative change.
More recently, we know that therapeutic laser therapy can provide analgesia and accelerate mitochondrial function, which is beneficial in OA. Also, radial shockwave therapy can be highly effective in and around an osteoarthritic joint that is not inflamed to help restore motion and reduce pain. A newer technology called Winback Tecar therapy is very effective for the management of OA and for soft tissue healing and recovery. It works by producing a deep endothermic heat and is completely safe over metal implants and joint prostheses.
Regardless of your modality of choice, there are many choices for managing the inflammatory phase and treating the chronic stiffness phase of OA. The modern modalities that have recently surfaced are highly effective and worth considering as an addition to your armamentarium of modalities.
“Select a topical that has one active ingredient, and if it works, perfect! If not, progress to a topical with a separate single active ingredient.”
Topicals
The American Geriatric Society recommends using topical agents for localized neuropathic and non-neuropathic pain as a front-line measure for the management of pain in the elderly. Topical analgesics are an excellent choice because they have minimal systemic absorption, will not interfere with other medications, have a high rate of compliance, and can be easily self-dosed.
Most topical analgesics are counterirritants that act on the TRPV receptors. For example, capsaicin acts on the TRPV1 receptors and creates a sensation of heat. It is highly pungent and currently only available in 5% concentration, but prescription agents are being developed with doses up to 10%. Oil of wintergreen is essentially salicylic acid, or liquid aspirin, and is an effective topical with a less offensive odor. It is a Cox-1 inhibitor and should not be used with patients who have a sensitivity to aspirin. Menthol is another common and highly effective counterirritant, providing a cooling sensation that stimulates the TRPM8 receptors.
The menthol concentration will vary from 1% to 16%. Through my experience, I have had the best result with 10%. While active ingredient concentration is important, other factors to consider are the quality of the ingredients and how well the topical is formulated, i.e., presence of penetration-enhancing elements, stability, and performance on the skin.
Often, a company will stack several topicals together in one product, which makes it very difficult to determine which of the active ingredients are the most effective for the patient. Select a topical that has one active ingredient, and if it works, perfect! If not, progress to a topical with a separate single active ingredient. This will target your topical dosing and application as opposed to buying a topical that has six different counterirritants with homeopathics and CBD. Frankly, you don't know which one of those compounds is working, and you probably are paying for others that are not needed. Personally, I keep a menthol-only (Stopain Clinical) and CBD-only (which is unscented, too) in my office, which works well to handle my patient demographic.
Approximately 73% of people have arthritis after 55 years of age, 60% of those are female and the knee is the most frequently affected joint followed by the hip and hands. But according to the WHO, this can be reduced. The keys to OA management and prevention are simple — an active lifestyle, choosing appropriate foods, anti-inflammatory and joint-protective nutraceuticals, using modalities to accelerate cellular metabolism, maintaining joint ROM with CMT, and using topicals to control pain. That may be just what the doctor ordered to reduce your patients’ risk of having a joint replacement due to OA.
Dr. Donald DeFabio is a chiropractic motivational speaker and teaches relevant rehab and rehab diplomate seminars throughout the U.S. His e-book, The Six Keys to In Office Rehab, is available free on his website, www.DeFabioDifference.com, where you can also find his upcoming speaking engagements. Dr. DeFabio’s exercise protocols can be found on his YouTube channel, which has over 41,000 subscribers. He can be reached at [email protected] for questions, to schedule a presentation, and to register for his workshops.
