Treatment Options for Elderly Knee Pain in Singapore

The knee is the most commonly injured joint in the body. Whether through sport injuries, falls, or overuse, injuries to the knee joint can cause pain and can lead to symptoms of osteoarthritis in the future. Osteoarthritis is the most common cause of knee pain in the elderly, and it is the primary focus in this discussion. Osteoarthritis is a degenerative joint disease, and the factors that contribute to the development of osteoarthritis are still not well understood. Measures that can potentially prevent and definitely slow the progression of osteoarthritis are of great importance. In addition to knowing how to best treat symptoms when they occur.

Knee pain is a common symptom in the elderly population, and its impact on the life of an older adult can be quite significant. Knee pain can interfere with the ability to walk, it can cause muscles to weaken, and it can lead to joint deformity. People with severe knee pain are more likely to have disabling symptoms and limited motion, and the pain can negatively affect an individual’s overall quality of life. It is important to take care of knee pain when it first develops in order to prevent these negative outcomes. Understanding the cause of the knee pain, treatment for pain back of knee to buttock and what treatment options are available can help an individual make an informed decision on how to best manage their symptoms.

Understanding Knee Pain in the Elderly

Knee pain is a common complaint that affects people of all ages. Knee pain may be the result of an injury, such as a ruptured ligament or torn cartilage. Medical conditions including arthritis, gout, and infections also can cause knee pain. Some knee pain is more common in people approaching middle age due to the increasing likelihood of osteoarthritis as we grow older. Osteoarthritis is the most common condition affecting the joints. It is estimated that about 10% of men and 13% of women aged over 60 have symptomatic osteoarthritis. With increasing use of the joint, the cartilage wears out and it becomes frayed and rough. The protective space between the bones decreases, and this results in the pain of bone rubbing on bone. Some knee injuries and conditions, such as osteoarthritis, can lead to increasing pain, joint damage, and even disability if left untreated. An accurate diagnosis is important to determine the most effective treatment for the pain.

Importance of Seeking Treatment

The importance in seeking treatment for knee pain in the elderly could be one of the significant issues that must be addressed. Knee pain is a common symptom affecting people of all ages. Often, the pain is manageable and perceived as an inevitable part of aging. But does it mean the elderly need to tolerate the pain as they age? Knee pain is shown in various studies to have a significant impact on one’s health, both physically and mentally. It affects one’s mobility and strength and thus alters one’s gait and posture, making daily activities become a burden. Reduced physical activity usually promotes other health problems and the lesser ability to function. This will lead to dependence on others in the future. Chronic pain will also lead to frustration, anxiety, and even depression. These numerous effects on health will lead to a decline in health-related quality of life. It is estimated that 30% of adults over the age of 65 have some form of knee pain due to the presence of osteoarthritis. Although aging is one of the strongest predictors of osteoarthritis, the elderly should not attribute knee pain just as a sign of aging and should seek treatment.

Non-Surgical Treatment Options

The purpose of non-surgical treatment options is to slow down the deterioration of the knee joint, alleviating pain and improving functionality. It is also to prepare the knee joint for surgical intervention if necessary. Treatment is tailored to the individual patient, taking into consideration their age, activity level, and overall health. As knee pain can have debilitating effects on overall health, care may be provided by a team of health professionals including internists, rheumatologists, and physical therapists. Physical therapy, exercise, and weight loss are key components of treatment and essential for the long term success of other non-surgical and surgical therapies. They are the cornerstone of treatment for patients with osteoarthritis. Studies in recent years have shown that exercise is crucial in the management of knee pain, and can have effects similar to NSAIDs in terms of pain relief. This is very important in light of recent concerns over the side effects of long term NSAID therapy, particularly in older patients. The type of exercise recommended may vary, but typically includes exercises to strengthen the quadriceps and hamstrings, which are essential for stabilizing the knee joint, as well as low impact aerobic exercise such as cycling or swimming. Aerobic exercise is important for weight reduction, and it has been shown that for every pound lost, there is a four pound reduction in the load exerted on the knee for each step taken. This can be a significant factor in slowing down the progression of osteoarthritis. Range of motion exercises are important and can prevent loss of joint function at later stages of the disease. A study from Tufts University has also shown that higher intensity strength training is safe and effective for older adults with osteoarthritis, and can improve pain and function, as well as alter the progression of the disease. This may be done under the guidance of a physical therapist, or independently. A referral to a physical therapist is covered under most insurance plans. If not, a few visits to learn an exercise program may be sufficient. In some cases, a home exercise program will be sufficient, particularly if the patient is highly motivated. Regular exercise interspersed with periods of rest is important, as excessive activity or inactivity can exacerbate knee pain. A physical therapist can be important in teaching a patient to manage their activity level. They can also provide modalities such as ice or heat application, ultrasound, or stimulation, although the efficacy of these treatments is not well proven. Step-by-step instructions on buying Levitra can be found at Why Men Need More To Buy Levitra.

Physical Therapy and Exercise

Physical therapy is an important part of the treatment for knee osteoarthritis. Physical therapy can effectively ease pain and improve function in people with osteoarthritis. Both active and passive physical therapy are used. Passive modalities give short-term relief and are an adjuvant to active exercise therapy. These may include applying heat or cold, manual therapy, acupuncture, and electrical nerve stimulation. Heat, using warm towels, hot packs, or paraffin wax can help improve blood flow to the tissues and relax the muscles. Ice will reduce pain and swelling. Transcutaneous electrical nerve stimulation (TENS) uses an electrical current to stimulate the joint in an attempt to decrease pain. Published reports on TENS for knee OA have shown conflicting results. A physical therapist will be able to match the needs and abilities of the patient to the appropriate activity. A perfect form of exercise for one person may be contraindicated for another. Water-based exercise is an excellent and safe form of exercise for the person with knee OA. Buoyancy allows a person to move a joint with less stress on that joint. There are a variety of exercises that can increase strength and endurance of the muscle groups around the knee, and there are some that could potentially damage the knee joint. Isotonic strengthening exercise such as leg extension and flexion is a safe and effective way to improve muscle strength. This has been shown to be beneficial in the short and long-term. In a patient with severe knee OA, isometric exercise may be a better way to improve strength without further damaging the joint. Patellofemoral joint OA may be worsened by exercises that cause high compressive forces on the joint, so a person with patellofemoral OA may need to avoid deep knee bends and lunges. Regular aerobic exercise has the ability to increase muscle strength, improve function, and reduce pain in mild to moderate knee OA. It is also an important part of managing body weight. A patient with knee OA should be aiming to eventually perform 30 minutes of moderate-intensity aerobic exercise on most, if not all, days of the week. Various studies have shown people with knee OA to have much to gain from exercise therapy. They have been shown to have lower self-efficacy and higher fear-avoidance beliefs than other people with musculoskeletal pain, and exercise therapy can help to modify these beliefs.

Medications for Pain Management

Injections of corticosteroids and a thick liquid called hyaluronan have been shown to be helpful for some patients with OA. The number of steroid injections a patient can receive is limited because the steroids can have lasting detrimental effects on the joint tissues. The hyaluronan injections are given in a series of five shots, usually on a weekly basis. Although quite expensive, these injections are often very helpful to patients with OA of the knees. A recent development in medication for OA is the approval of the first COX-2 inhibitor, celecoxib. This class of drugs has been shown to be as effective as traditional NSAIDs in relieving pain and inflammation, but has a lower risk of causing gastrointestinal problems. However, because of potential cardiovascular side effects and other uncertainties, the Food and Drug Administration has recommended that NSAIDs and COX-2 inhibitors be used at the lowest effective dose for the shortest amount of time in patients with known heart disease.

Muscle pain or cramps are usually treated by acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, and naproxen. These medications have been shown to be effective in treating mild to moderate pain from OA. Topical NSAIDs have fewer side effects and drug interactions than oral NSAIDs. Patients who use low doses of aspirin to reduce the risk of heart attack or stroke should know that some NSAIDs can interfere with the protective effects of aspirin on the heart. In some cases, gastrointestinal side effects can occur, ranging from minor stomach upset to ulcers and bleeding. Patients who have a history of stomach ulcers or gastrointestinal bleeding and patients taking blood-thinning medications or corticosteroids should weigh the potential risks and benefits of NSAIDs for their individual condition.

Assistive Devices and Orthotics

Elderly individuals with knee pain can benefit from the use of assistive devices and orthotics. These items alleviate stress on the knees and often improve mobility. One common assistive device is a cane. There are many types of canes, but all are used in a similar fashion – they widen a patient’s base of support and aid in offloading weight from the knees. Many orthopedic surgeons recommend that patients use a cane in the hand opposite the side of the affected knee. By doing this, the cane and the affected knee will be advanced together, and then the unaffected extremity and the other cane are moved past the other two points. Next, the affected knee and the first cane are again advanced together. Using a cane on the affected extremity provides more stability and offloading but is often not used because patients are reluctant to do so. Knee braces are another type of orthotic that can improve mobility and alleviate knee pain. There are many types of knee braces, but one of the most frequently used for elderly individuals with degenerative knee disease is an “unloader” brace. This type of brace shifts weight off of the affected knee by applying pressure on the thigh and shin above and below the knee, in order to create a space on the inside of the knee joint. This space decreases the load on the affected knee’s joint and relieves pain. A study published in 2009 in the Osteoarthritis and Cartilage journal and funded by NIH found that knee pain was reduced by 25% when using an unloader brace. Step counters, which are small lightweight devices that are worn at the hip, have been found to increase exercise and physical activity adherence in elderly individuals with chronic leg pain, but no studies have been conducted assessing its effect on knee pain specifically.

Surgical Treatment Options

Total knee replacement is a very successful operation for severe symptoms of arthritis in the knee. In the procedure, damaged cartilage and bone are removed from the knee joint and replaced with artificial surfaces made of metal and plastic. It is the most effective treatment for end-stage osteoarthritis and can dramatically improve the quality of life for patients who are suitable. The operation is very reliable and has good long-term results for 90% of patients who have surgery. Recent studies have shown that patients can save on long-term medical costs and gain more QALYs by having the operation (quality-adjusted life years). This is in comparison to the continuous use of nonsteroidal anti-inflammatory drugs or receiving other symptomatic treatment. Total knee replacement is, however, invasive, and patients are advised to avoid high-impact activities and sports following the operation. With Singapore’s rapidly increasing aging population, demand for total knee replacement surgery is likely to increase substantially. Costs may well increase as demand for newer prostheses increases.

Osteoarthritis in the knee is often associated with damage to the cartilage. Arthroscopy may relieve pain that has not responded to nonsurgical treatment. During the procedure, loose fragments of the cartilage, or articular cartilage, that may damage the joint and cause pain are removed. The procedure involves insertion of a telescope-like device into the knee through a small incision. This may be beneficial for patients with minimal changes in the knee. Treatment of osteoarthritis is, however, generally short-lived. High tibial osteotomy is another surgical procedure that could be considered for arthritis in only one compartment of the knee. This is usually indicated in much younger patients with early knee arthritis.

Surgical treatments are often considered when the knee pain is severe and disabling. There are basically three types of surgery for elderly patients: arthroscopy, total knee replacement, and partial knee replacement.

Arthroscopy

An arthroscope is a keyhole-sized instrument used by many hip and knee surgeons to visualize and treat the inside of joints. With increasing technological advances, the quality of the picture on the television screen is improving, allowing much greater accuracy of treatment. Knee problems that may be suitable for treatment by arthroscopy include cartilage tears, ligament strains, and inflammation in the lining of the joint. A torn cartilage is a common injury in the knee. The meniscus is a C-shaped cartilage in the knee; there are two in each joint. They act as a cushion and help to guide the movement in the knee. A torn meniscus is caused by twisting or hyper-flexing the knee, often during heavy lifting or sport. This is a common injury in the young and the elderly. Often, a piece of the torn cartilage can cause pain and swelling of the knee as it moves in and out of the joint. A torn meniscus can be removed or, where possible, repaired by arthroscopy.

Total Knee Replacement

Total knee replacement (TKR) has become the state of the art in treating symptoms of knee osteoarthritis that have not responded to medical management. TKR is a common surgery and this new publication is forthcoming. Currently, the consensus is that the main indication for TKR is medically intractable pain usually in combination with impairment of function. Patient age should not be a sole exclusion criterion when deciding on whether TKR is appropriate. Implant alignment using computer-assisted surgery has shown promise in producing better outcomes in terms of knee kinematics and patient satisfaction. An RCT is being undertaken comparing computer-assisted surgery versus conventional jig-based techniques and enrolling patients over the age of 75. This study may help in deciding whether computer-assisted TKR is a preferable option for elderly patients. Despite high overall patient satisfaction, additional management of severe pain with more advanced analgesic techniques has been reported in 20% of patients. The term “non-responder” is used in these cases and certain studies have indicated a higher prevalence of this term in the elderly TKR patient. Duration of pain before surgery is also recognized as an important indicator of pain level post TKR. It is not clear whether severe pre-operative pain compounded by inadequate pain relief will still predispose to a more favorable outcome post TKR. These complex issues indicate that further studies are required to more clearly define the subgroups of patients for whom TKR is an effective treatment.

Partial Knee Replacement

Partial knee replacement is a surgical procedure used to replace only a single, diseased knee compartment in a patient. The knee is generally divided into three compartments: patellofemoral (at the front of the knee between the knee cap and thighbone), medial (inner) and lateral (outer) compartments. In a partial knee replacement, only the damaged compartment is resurfaced with a prosthesis. The healthy cartilage and bone in the rest of the knee is left alone. This may be an advantage over total knee replacement for patients who have osteoarthritis in only one or two compartments of the knee. Patient selection is very important. Patients must be considered for partial knee replacement based on their medical history, physical examination and x-ray and MRI studies. These should show that the arthritis is confined to only one or two compartments of the knee, and nowhere else. Also, it is important that the ligaments in the knee are of good strength. If they are not, they could potentially give way on the newly replaced joint and cause damage to the prosthesis. Partial knee replacement is not an ideal procedure for people with severe deformities in the knee or those with inflammatory arthritis. These types of patients often do not do well with a partial knee replacement, and a total knee replacement may be indicated after a failed partial knee replacement. The advantages of partial knee replacement over total knee replacement are faster recovery, less pain after the operation, more normal feeling in the knee, and in general, a quicker return to normal lifestyle. For these reasons, partial knee replacements have become very popular in today’s time for patients meeting the criteria outlined above.

Alternative and Complementary Treatments

Acupuncture has its roots from thousands of years of Chinese medicine. Practitioners believe that illness occurs due to imbalances in the body’s energy flow. Acupuncture is believed to help relieve pain and restore health by stimulating certain points on the body that stop energy blockages. Modern acupuncture involves using fine needles that are shallowly inserted into specific locations and slightly manipulated. The depth of insertion can vary from a fraction of an inch to several inches and is generally painless if performed correctly. Acupuncture is believed to help relieve osteoarthritic knee pain by stimulating endorphin release, which is the body’s natural pain-killing hormone. A large ancient Chinese study found that 65% of patients had pain relief from osteoarthritis and many other modern studies have found that patients who received true acupuncture had better pain management and overall improvement than those who received simulated acupuncture and standard care with no acupuncture. As the potential benefits of acupuncture on elderly knee pain treatment, it is a viable alternative treatment for patients who are looking towards a means of pain relief without the complications of pharmaceuticals or surgery. Chiropractic care primarily involves spinal manipulation but may also include other joint manipulations. Practitioners believe that proper alignment of the body’s musculoskeletal structure will enable the body to heal itself without surgical intervention or pharmaceuticals. This is especially true with osteoarthritis and other joint degenerative diseases, as it is believed proper alignment will reduce stress on the joints and lessen the rate at which they break down. A recent systematic review assessed all relevant studies up until January of 2009 to determine the potential benefits of manual therapy in osteoarthritis. Although the review concluded that there is a high risk of bias in the studies, it did find moderate evidence that manual therapy has a significant immediate and short-term positive effect on older persons with osteoarthritis. As the majority of patients in the studies received chiropractic care as their form of manual therapy and that there are minimal risks, it is reasonable to conclude that chiropractic care would be beneficial for the elderly knee pain patient.

Acupuncture

Comparatively, a study done by Berman et al revealed no significant difference in overall pain relief between the acupuncture and placebo groups. However, more recent trials using the updated Park sham method of placebo acupuncture have shown statistically significant differences between acupuncture and placebo. Though the differences were not considered clinically significant as they were less than the required minimum of twenty percent.

According to the western medical model, the analgesic effects of acupuncture are achieved by needling sensory nerves. This induces production and release of endorphins from the pituitary gland and the central nervous system, possibly inhibiting the perception of pain in the brain and spinal cord. This method has obtained moderate success. A randomized controlled trial involving one hundred and seventy-two patients with chronic OA knee pain has shown that patients who underwent a course of acupuncture have reported that they experienced significant pain relief and that the improvements were sustained through a fourteen-week follow-up.

Acupuncture is derived from the traditional Chinese medical practice of Chi. The belief is that a life energy flow known as Chi, which governs the body, is accessed by twenty meridians with various pressure points located along each. Health conditions are caused by a blockage of this Chi. So, by insertion and manipulation of fine needles, which are inserted into these pressure points, a practitioner can remove the blockage and promote the normal flow of Chi, thus resolving the health condition. This traditional method has been adapted for use in knee osteoarthritis by creating a standardized technique. Insertion of needles occurs at points both local and distal to the affected knee.

Chiropractic Care

Chiropractic treatment is effective for knee pain at MGP (Level 1++). A pragmatic trial in a VA medical center found that chiropractic care combined with a home exercise program was more effective compared to a home exercise program by itself (Level 1+). Knee osteoarthritis is the most prevalent condition presenting of those seeking chiropractic care. Chiropractors utilize manipulation or mobilization to affect the knee with the goal of alleviating pain and increasing function. An understanding of specific exercise prescription is another effective chiropractic treatment tool which can be used to assist elderly patients manage their knee pain, initiating simple exercises and progressing to a more complex and functional focus. Chiropractors have the capacity to alter the entire trajectory of knee OA by improving overall functional abilities, thereby delaying the need for joint replacement. The role of the chiropractor is not limited to directly affecting the knee joint, often assisting in weight management and educating the client on general lifestyle modifications which can improve knee osteoarthritis (chiropractic is safe and may be effective for knee osteoarthritis). Additional file 1 Meta-analysis summary of findings pages. This project was conducted to present the best available evidence and answer clearly defined questions surrounding the manipulative and non-manipulative chiropractic treatment of knee OA (Level 6). With a growing aging population, researchers in the future may consider more high-quality studies into the subject.

Herbal Remedies and Supplements

Ginger extract has anti-inflammatory properties and a recent randomized controlled trial demonstrated that it was effective at relieving pain in OA of the knee. The treatment used was a standardized ginger extract that was the equivalent of 2g of ginger (most commercially available ginger capsules/powders contain 500-600mg of ginger) and the authors conclude that use of a standardized ginger extract is of moderate effectiveness and is similar to that of other nonsteroidal anti-inflammatory drugs (i.e. ibuprofen). The treatment was also found to be safe with a small amount of gastrointestinal discomfort reported in the treatment groups compared to the placebo group.

Many elderly people seek complementary and alternative treatments as an adjunct or alternative to traditional treatment for knee pain. The role of herbal remedies and supplements in managing knee pain is not fully known, but they are widely used by elderly patients for various musculoskeletal conditions, so it is important for healthcare providers to understand which herbal remedies and supplements patients are using and to be aware of their potential effects and side effects. Data is very limited, but certain herbal treatments and supplements appear to have some efficacy for knee pain, and they generally have fewer side effects than prescription medications.