Date of Award

7-26-2020

Document Type

Open Access Thesis

Degree Name

MS in Physician Assistant Studies (PA)

Department

Physician Assistant Studies

First Advisor

Alicia Quella PhD PA-C

Abstract

Objective: To compare the efficacy of other modalities and interventions versus standard first-line therapy of nonsteroidal anti-inflammatory drugs for pain management in patients with symptomatic knee osteoarthritis

Methods: Perform literature reviews outlining patients suffering from Grade II or higher KOA using the Kellgren-Lawrence classification system and currently experiencing symptoms of pain, stiffness, and impaired physical functioning. Use data and results from various studies to compare improvement of symptoms from these modalities versus improvement of NSAIDs alone.

Results: Weight loss and physical activity should remain the mainstay of early osteoarthritis treatment to help slow disease progression and symptoms of KOA. Duloxetine has been shown to be non-inferior to treatment with NSAIDs and improved patient physical functioning and quality of life. Oral and intra-articular corticosteroids remain superior or equal in pain reduction but have a shorter duration of action and greater adverse reactions when taken long term. Ozone therapy is best used in post-operative pain management or severe flares of osteoarthritis to quickly reduce pain and inflammation, long term therapy is not recommended over NSAIDs. Glucosamine does not decrease pain related to KOA but when used concomitantly with NSAIDs can increase physical function, quality of life, and also slow disease progression. LP-PRP injections have greater efficacy and resulted in lower WOMAC total scores at three, six, and twelve-month intervals when compared to ozone, hyaluronic acid, and corticosteroid injections. LP-PRP injections also have greater or equal efficacy of hyaluronic acid plus oral NSAIDs at one year. PRP therapy also has some evidence to suggest disease modifying potential. Hyaluronic acid injections resulted in less joint line tenderness and better physical functioning when compared to NSAID therapy alone, however, reduction in pain was not statistically significant. Prolotherapy was shown to be equally effective as PRP injections at pain reduction but requires serial injections. Benefit of prolotherapy is its safety profile and cost effectiveness. Finally, stem cell therapy resulted in lower WOMAC total scores when compared to hyaluronic acid injections. T2 MRI mapping indicates the ability of mesenchymal stem cells to regenerate cartilage and slow disease progression.

Conclusion: NSAIDs remain the most efficient means of pain reduction but do not result in statistically significant increases in physical function or quality of life. Hyaluronic acid can increase the patients physical functioning if used alone or in combination with NSAID therapy. Oral glucosamine sulfate, if taken daily, can reduce the progression of osteoarthritis but provides no pain relief if taken alone or without NSAIDs. Oral or intra- articular corticosteroids should be reserved for severe flares of pain in which the patient is unable to perform daily activities secondary to disability. Adverse reactions and possible further joint degeneration remain the biggest concern. Duloxetine should be considered in patients suffering chronic and refractory pain related to KOA and can be used in addition to NSAIDs to provide long term relief. Clinically the use of ozone therapy is not relevant and pain reduction can be achieved in other modalities, use of ozone is best reserved for post-operative management to reduce inflammation. PRP injections are clinically relevant and provide statistically significant reductions in pain and disease progression. Use should be considered in patients who have failed other conservative KOA treatments. Finally, the use of mesenchymal stem cells does alter disease progression and reduce pain, but clinically its use is not relevant because the harvesting and cost are greater than other effective therapies currently. More evidence is needed to support its clinical use. In conclusion, alternative modalities should be considered if therapy with NSAIDs is not providing adequate reductions in pain or the goals of the patients are not being met. The aforementioned modalities are safe and effective adjuvant therapies to manage patients with symptomatic KOA.

Identifier

SC 11.PAS.2020.Schmitz.N

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