Non-Surgical Arthritis Management
Non-Surgical Arthritis Management
Most arthritis treatment involves different ways to decrease inflammation or distract from the pain that it causes.
Most arthritis treatment involves different ways to decrease inflammation or distract from the pain that it causes.
These can be grouped into three categories:
These can be grouped into three categories:
1. Activity modification
1. Activity modification
2. Medications
2. Medications
3. Gating
3. Gating
Activity Modification
Activity Modification
This is basically finding ways to decrease the force and motion across the hip, which then may decrease inflammation.
This is basically finding ways to decrease the force and motion across the hip, which then may decrease inflammation.
The part about activity modification that most people don't like, is that they like their activities. It's hard to ask people to give up what makes them feel good. If you are a runner or walker, it means mixing in swimming or cycling. If you like long distances, it means pulling back. If you carry a pack it means decreasing your load. It definitely helps, but in the end the time we have is short, and progressively decreasing your activity can have diminishing returns.
The part about activity modification that most people don't like, is that they like their activities. It's hard to ask people to give up what makes them feel good. If you are a runner or walker, it means mixing in swimming or cycling. If you like long distances, it means pulling back. If you carry a pack it means decreasing your load. It definitely helps, but in the end the time we have is short, and progressively decreasing your activity can have diminishing returns.
Using a cane or a walking pole to decrease the forces generated by the muscles acting across the hip can help significantly. The hip is a lever, and the force experienced at the joint can be greatly decreased by decreasing the work of the muscles that cross the hip. The cane is most effective when used in the hand opposite the effected hip.
Using a cane or a walking pole to decrease the forces generated by the muscles acting across the hip can help significantly. The hip is a lever, and the force experienced at the joint can be greatly decreased by decreasing the work of the muscles that cross the hip. The cane is most effective when used in the hand opposite the effected hip.
Weight loss is very effective at decreasing the force experienced by the hip. This is a global lifestyle modification. Decreasing portions, increasing vegetables and lean protein, and finding ways of burning more calories. I will frequently refer people for outside consultation to help with this, as it is not easy and not as simple as it sounds.
Weight loss is very effective at decreasing the force experienced by the hip. This is a global lifestyle modification. Decreasing portions, increasing vegetables and lean protein, and finding ways of burning more calories. I will frequently refer people for outside consultation to help with this, as it is not easy and not as simple as it sounds.
"Hip Therapy" by stretching or strengthening the muscles around the hip does not have an intuitive roll. It is akin to having worn out tires on your car and trying to make it better by driving it faster and farther than usual. Some patients report some transient benefit, but this may be secondary to gating or central endorphin release. It may work for a little while, but many report it increases their pain.
"Hip Therapy" by stretching or strengthening the muscles around the hip does not have an intuitive roll. It is akin to having worn out tires on your car and trying to make it better by driving it faster and farther than usual. Some patients report some transient benefit, but this may be secondary to gating or central endorphin release. It may work for a little while, but many report it increases their pain.
Medications
Medications
Inflammation is universal in all forms of arthritis and causes pain. The most effective medications include over-the-counter anti-inflammatories like Ibuprofen and Naprosyn. For some patients, they prefer and find greater efficacy in prescription medications like Celebrex and Mobic. In the end, the molecular basis for how they work is all the same, and each can be very effective. Anti-inflammatory medications are most effective when used continuously, and not just when there is pain.
Inflammation is universal in all forms of arthritis and causes pain. The most effective medications include over-the-counter anti-inflammatories like Ibuprofen and Naprosyn. For some patients, they prefer and find greater efficacy in prescription medications like Celebrex and Mobic. In the end, the molecular basis for how they work is all the same, and each can be very effective. Anti-inflammatory medications are most effective when used continuously, and not just when there is pain.
Caution must be exercised as prolonged use of any medication can have side effects. Stomach ulcers and bleeding are the most common for this family, in addition to being toxic to kidney tissue in high doses, and may result in some increase in cardiovascular events in some people. They are avoided in patients who take blood thinners. There is no free lunch.
Caution must be exercised as prolonged use of any medication can have side effects. Stomach ulcers and bleeding are the most common for this family, in addition to being toxic to kidney tissue in high doses, and may result in some increase in cardiovascular events in some people. They are avoided in patients who take blood thinners. There is no free lunch.
Acetaminophen is helpful. It is not a true anti-inflammatory, and is independent from the medications above. It acts in the brain and not at the site of inflammation, but it can be effective in decreasing the perception of pain, and in the end that is what matters. It is typically very safe, but again there is no free lunch, and acetaminophen is toxic to liver tissue in high doses and in people who have decreased liver function.
Acetaminophen is helpful. It is not a true anti-inflammatory, and is independent from the medications above. It acts in the brain and not at the site of inflammation, but it can be effective in decreasing the perception of pain, and in the end that is what matters. It is typically very safe, but again there is no free lunch, and acetaminophen is toxic to liver tissue in high doses and in people who have decreased liver function.
Cannabinoids (Marijuana) does have anti-inflammatory properties and has centrally acting analgesic properties. It has an increasing role in pain management. It is not well quantified and can be difficult to prescribe, but I have many patients who report efficacy. As there are fewer serious negative side effects than any of the classic pharmaceutical medications, I support its use in pain management.
Cannabinoids (Marijuana) does have anti-inflammatory properties and has centrally acting analgesic properties. It has an increasing role in pain management. It is not well quantified and can be difficult to prescribe, but I have many patients who report efficacy. As there are fewer serious negative side effects than any of the classic pharmaceutical medications, I support its use in pain management.
Narcotics and opioids have no role in treatment of arthritis pain. They increase sensitivity to pain over a short period of time and are addictive.
Narcotics and opioids have no role in treatment of arthritis pain. They increase sensitivity to pain over a short period of time and are addictive.
Gating
Gating
Gating decribes the neurologic mechanism of preempting or inhibiting the signal of one stimulus with another. Imagine nerves that carry pain signals as a train track. Only one train can occupy a track at a time. Additionally, if one of the engines is pulling the other way, the train won't get far.
Gating decribes the neurologic mechanism of preempting or inhibiting the signal of one stimulus with another. Imagine nerves that carry pain signals as a train track. Only one train can occupy a track at a time. Additionally, if one of the engines is pulling the other way, the train won't get far.
With gating we put alternate trains on the same track and others pulling the other direction. Pain signals traveling along specific nerve pathways can be blocked by other signals from another more acceptable stimulus in the area. It is neurologic trickery, but it is the result that matters.
With gating we put alternate trains on the same track and others pulling the other direction. Pain signals traveling along specific nerve pathways can be blocked by other signals from another more acceptable stimulus in the area. It is neurologic trickery, but it is the result that matters.
Gating methods include:
Gating methods include:
-Massage
-Massage
-Hot/Cold Therapy
-Hot/Cold Therapy
-Acupuncture
-Acupuncture
-Topical agents, Voltaren gel, Capsasin Cream, Aspercreme, Menthol rubs, CBD oils
-Topical agents, Voltaren gel, Capsasin Cream, Aspercreme, Menthol rubs, CBD oils
-Kenisiotape
-Kenisiotape
-Stretching/strengthening
-Stretching/strengthening
Gating methods are great because there is no downside besides cost.
Gating methods are great because there is no downside besides cost.
Injection
Injection
Injection modalities for treatment of hip arthritis are limited without much support for efficacy.
Injection modalities for treatment of hip arthritis are limited without much support for efficacy.
Steroids:
Steroids:
The mainstay is corticosteroid (steroid) injection. This treats the inflammatory component of hip arthritis and can be beneficial in some patients. Steroids inhibit tissue metabolism and repair, and may unfortunately exacerbate the progression of arthritis, as the remaining cartilage itself may be compromised by the effect of the steroid. Unfortunately, in the vast majority of patients with symptomatic arthritis, the duration of benefit of the steroid is limited. In my practice, steroid injection combined with local anesthetic is used primarily for confirmation of a primary diagnosis.
The mainstay is corticosteroid (steroid) injection. This treats the inflammatory component of hip arthritis and can be beneficial in some patients. Steroids inhibit tissue metabolism and repair, and may unfortunately exacerbate the progression of arthritis, as the remaining cartilage itself may be compromised by the effect of the steroid. Unfortunately, in the vast majority of patients with symptomatic arthritis, the duration of benefit of the steroid is limited. In my practice, steroid injection combined with local anesthetic is used primarily for confirmation of a primary diagnosis.
Platelet Rich Plasma (PRP):
Platelet Rich Plasma (PRP):
PRP may induce an inflammatory biologic response that may include some vascular ingrowth. There is not good literature to support its use and therefore PRP is usually not covered by insurance.
PRP may induce an inflammatory biologic response that may include some vascular ingrowth. There is not good literature to support its use and therefore PRP is usually not covered by insurance.
Stem Cell Therapy:
Stem Cell Therapy:
Theoretically this involves harvesting your stem cells (the cells in your body responsible for making/healing new parts when you need them) and injecting them into your hip joint. Current evidence does not support the use of stem cell therapy at this time. Generating new cartilage is more complex than just squirting cells randomly into the hip joint. There are anecdotal reports of transient benefit, but it is not supported by high quality studies. For this reason it is also not covered by any insurance programs or medicare.
Theoretically this involves harvesting your stem cells (the cells in your body responsible for making/healing new parts when you need them) and injecting them into your hip joint. Current evidence does not support the use of stem cell therapy at this time. Generating new cartilage is more complex than just squirting cells randomly into the hip joint. There are anecdotal reports of transient benefit, but it is not supported by high quality studies. For this reason it is also not covered by any insurance programs or medicare.
Surgery
Surgery
Surgery for the hip is considered after all other modalities have not provided satisfactory results. Hip arthroscopy and hip replacement are the two available interventions for hip pathology.
Surgery for the hip is considered after all other modalities have not provided satisfactory results. Hip arthroscopy and hip replacement are the two available interventions for hip pathology.
Patients who benefit from arthroscopic interventions are young with identifiable anomalies of the hip that are present prior to arthritic degeneration (loss of cartilage) of the joint itself.
Patients who benefit from arthroscopic interventions are young with identifiable anomalies of the hip that are present prior to arthritic degeneration (loss of cartilage) of the joint itself.
All other forms of arthritis that are beyond medical management are treated with hip replacement (arthroplasty).
All other forms of arthritis that are beyond medical management are treated with hip replacement (arthroplasty).
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