This month, BioDrugs published the latest systematic review and meta-analysis of hyaluronic acid (HA) in the treatment of knee osteoarthritis (OA)(1). After reviewing 74 randomized controlled trials, their results show that HA improves pain by 40 to 50%. The authors were unable to definitively determine whether one brand is more effective than the next. Hyaluronan, an endogenous lubricant and shock absorber, is abundantly present in young, healthy joints, but is less concentrated and smaller in size in osteoarthritic joints. The reduction in lubrication and shock absorption in osteoarthritic joints can be remedied by intraarticular viscosupplementation.
HA More Effective than Corticosteroids: HA and corticosteroids have both become staples of conservative OA management, but studies show that HA has improved long-term effects compared to hexacetonide (2) and methylprednisolone acetate (3). While corticosteroids tend to produce faster pain relief, HA has more lasting effects with greater symptomatic relief at six months. At six months, arthroscopic findings show that HA proves superior to corticosteroids in reducing the grade and extent of cartilage damage.
Guided Injections Prove More Effective: The majority of studies in the current meta-analysis use traditional, palpation-guided injections, which likely decreased the potential effectiveness of HA. Accuracy of injection is important in both HA and corticosteroid treatments, and palpation-guided injections traditionally have significant rates of inaccuracy. For instance, Sibbitt and colleagues found that ultrasound-guided injections, compared to palpation-guided injections, increase the responder rate 38%, increase therapeutic duration 32%, and reduce outpatient costs 33% (4). At Care Medical Center, to ensure maximum effectiveness, we use fluoroscopy to guide knee injections.
Conservative Management Should Include Supervised Exercises: Home exercise plans are another staple in conservative management of knee OA. Home exercise (5) and physical-therapy-supervised exercise (6) have been shown to improve walking speed, reduce pain, and significantly reduce the need for knee surgeries, but head-to-head comparison between PT-supervised exercise and a very well-designed home exercise program shows that adding eight to ten physical therapy visits doubles the pain improvement and significantly improves patient satisfaction (7). It stands to reason that improving the muscular function of the knee will only add to and protect the lubrication and shock absorption remedies achieved through viscosupplementation.
Please Refer Your Patients to Care Medical Center’s Knee Arthritis Program:
When you have patients conservatively managing osteoarthritis of the knee, please remember Care Medical Center. Our Knee Arthritis Program combines onsite physical therapy with MD-delivered, fluoroscopic-guided Hyalgan injections. Guided HA injections maximize the effectiveness of viscosupplementation while incorporating a rehabilitation and home exercise program that creates synergistic effects offering maximum symptom relief available in conservative therapy and often resulting in significant cost savings for patient and payers. Medicare and insurance both cover our Knee Arthritis Program – including the FDA Approved Hyalgan injections.
1.Colen S, van den Bekerom M, Mulier M, Haverkamp D. Hyaluronic acid in the treatment of knee osteoarthritis: a systematic review and meta-analysis with emphasis on the efficacy of different products. BioDrugs. 2012; 26 (4): 257-268.
2.Jones A, Pattrick M, Doherty S, Doherty M. Osteoarthritis and Cartilage (Osteoarthritis Research Society). 1995; 3 (4): 269-273.
3.Frizzier L, Ronchetti I. Intra-articular treatment of osteoarthritis of the knee: an arthroscopic and clinical comparison between sodium hyaluronate (500-730 kDa) and methylprednisolone acetate. J Orthopaed Traumatol. 2002; 3: 89-96.
4.Sibbitt W, Band P, Chaves-Chiang N, et al. A randomized controlled trial of the cost-effectiveness of ultrasound-guided intraarticular injection of inflammatory arthritis. The Journal of Rheumatology. 2011; 38 (22): 252-263.
5.Thomas K, Muir K, Doherty M, et al. Home based exercise programme for knee pain and knee osteoarthritis: randomised controlled trial. BMJ. 2002; 325 (7367): 752.
6.Deyle G, et al. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee. A randomized, controlled trial. Ann Intern Med. 2000; 132: 173-81.
7.Deyle G, Allison S, Matekel R, et al. Physical therapy treatment effectiveness for osteoarthritis of the knee: a randomized comparison of supervised clinical exercise and manual therapy procedures versus a home exercise program. Phys Ther. 2005. 85 (12): 1301-17.
For Your Health,
Dr. Ryan Moorman