07/09/2017
CHRONIC KNEE PAIN & PAIN RELIEF-
DR VIJAY CHAVAN. MD (anaesthesiology),FIPM
DR RASHMEE CHAVAN. MD (anaesthesiology),FIPM
Chronic Knee Pain is a one of the commonest problems of our society. Lets discuss today the knee pain because of chronic osteoarthritis.
Chronic pain of Osteoarthritis (degenerative) of the Knee & pain relieving procedures.
While age is a major risk factor for osteoarthritis of the knee, young people can get it, too. For some individuals, it may be hereditary. For others, osteoarthritis of the knee can result from injury or infection or even from being overweight.
Osteoarthritis, commonly known as wear-and-tear arthritis, is a condition in which the natural cushioning between joints i.e. cartilage ,wears away. When this happens, the bones of the joints rub more closely against one another with less of the shock-absorbing benefits of cartilage. The rubbing results in pain, swelling, stiffness, decreased ability to move and, sometimes, the formation of bone spurs.
Osteoarthritis is the most common type of arthritis. While it can occur even in young people, the chance of developing osteoarthritis rises after age 45. Women are more likely to have osteoarthritis than men.
The most common cause of osteoarthritis of the knee is age. Almost everyone will eventually develop some degree of osteoarthritis. However, several factors increase the risk of developing significant arthritis at an earlier age.
• Age. The ability of cartilage to heal decreases as a person gets older.
• Weight- Weight increases pressure on all the joints, especially the knees. Every pound of weight you gain adds 3 to 4 pounds of extra weight on your knees.
• Heredity. This includes genetic mutations that might make a person more likely to develop osteoarthritis of the knee. It may also be due to inherited abnormalities in the shape of the bones that surround the knee joint.
• Gender. Women ages 45 and older are more likely than men to develop osteoarthritis of the knee.
• Repetitive stress injuries. These are usually a result of the type of job a person has. People with certain occupations that include a lot of activity that can stress the joint, such as kneeling, squatting, or lifting heavy weights (55 pounds or more), are more likely to develop osteoarthritis of the knee because of the constant pressure on the joint.
• Athletics. Athletes involved in soccer, tennis, or long-distance running may be at higher risk for developing osteoarthritis of the knee. That means athletes should take precautions to avoid injury. However, it's important to note that regular moderate exercise strengthens joints and can decrease the risk of osteoarthritis. In fact, weak muscles around the knee can lead to osteoarthritis.
• Other illnesses. People with rheumatoid arthritis, the second most common type of arthritis, are also more likely to develop osteoarthritis. People with certain metabolic disorders, such as iron overload, uraemia, gout or excess growth hormone, also run a higher risk of osteoarthritis.
Symptoms of osteoarthritis of the knee may include:
• pain that increases when you are active, but gets a little better with rest
• swelling
• feeling of warmth in the joint
• stiffness in the knee, especially in the morning or when you have been sitting for a while
• decrease in mobility of the knee, making it difficult to get in and out of chairs or cars, use the stairs, or walk
• creaking, crackly sound that is heard when the knee moves
The diagnosis of knee osteoarthritis will begin with a physical exam. Medical history is also important to make sure the diagnosis of Osteoarthritis or something else, may be causing your pain. Also find out if anyone else in your family has arthritis. Additional testing may require, including:
• X-rays, which can show bone and cartilage damage as well as the presence of bone spurs
• magnetic resonance imaging (MRI) scans
MRI scans may be ordered when X-rays do not give a clear reason for joint pain or when the X-rays suggest that other types of joint tissue could be damaged. Doctors may use blood tests to rule out other conditions that could be causing the pain, such as rheumatoid arthritis, a different type of arthritis caused by a disorder in the immune system.
The primary goals of treating osteoarthritis of the knee are to relieve the pain and return mobility. The treatment plan will typically include a combination of the following:
• Weight loss. Losing even a small amount of weight, if needed, can significantly decrease knee pain from osteoarthritis.
• Exercise. Strengthening the muscles around the knee makes the joint more stable and decreases pain. Stretching exercises help keep the knee joint mobile and flexible.
• Pain relievers and anti-inflammatory drugs. This includes over-the-counter choices such as paracetamol ( in dose upto 3000 mg per day,Orally), ibuprofen ,NSAID. Don't take over-the-counter medications for more than 10 days without checking with consultant doctor. Taking them for longer increases the chance of side effects. If over-the-counter medications don't provide relief, your consultant may give you a prescription anti-inflammatory drug or other medication to help ease the pain.
• Injections of corticosteroids or hyaluronic acid into the knee. Steroids are powerful anti-inflammatory drugs. Hyaluronic acid is normally present in joints as a type of lubricating fluid.
• Alternative therapies. Some alternative therapies that may be effective include topical creams with counterirritants, acupuncture, or supplements.
• Using devices such as braces. There are two types of braces: "unloader" braces, which take the weight away from the side of the knee affected by arthritis; and "support" braces, which provide support for the entire knee.
• Physical and occupational therapy. If you are having trouble with daily activities, physical or occupational therapy can help. Physical therapists teach you ways to strengthen muscles and increase flexibility in your joint. Occupational therapists teach you ways to perform regular, daily activities, such as housework, with less pain.
• SPECIAL INVASIVE PROCEDURES for CHRONIC KNEE PAIN
Genicular nerve block.
A genicular nerve block is the injection of a local anesthetic to block the nerves that transmits pain from the knee.
ANATOMY
Introduced in 2011, genicular RFA is performed using bony landmarks to target the superior lateral (SLGN), superior medial (SMGN) and inferior medial (IMGN) genicular nerves under fluoroscopic guidance. The anatomical basis for genicular RFA was solely derived from cadaveric dissections.
•SMGN in majority of knee/thigh dissections was not reliably found in its reported anatomic location. On the medial side, the most consistent and largest nerve is the terminal branch of the vastus medialis muscle. After originating from the femoral nerve, it travels medially within the vastus medialis as it gives multiple motor branches. At the level of adductor hiatus, the terminal articular branch separates from the vastus medialis, courses distally, anterior to the adductor magnus tendon, and bifurcates at the level of adductor tubercle under the medial retinaculum. The articular branch of the nerve to vastus intermedius enters deep to the muscle proximally, and travels on the anterior surface of femur beneath the muscle to innervate suprapatellar recess.
•IMGN was reliably found in its reported anatomic location, however its termination point did not appear to be in the knee capsule itself.
•SLGN was reliably found in anatomic dissection originating from the sciatic nerve approximately 3cm proximal to its bifurcation. It courses laterally deep to biceps femoris, then bifurcates to the level of popliteus and lateral gastroc tendon origin and joins the superior lateral genicular vascular bundle to innervate superior lateral joint capsule. Due to its consistently small size however, ablative lesion from RFA may commonly miss this nerve
The variability of efficacy in genicular nerve RFA questions the consistency of the anatomical relationship of the genicular nerves to their reported bony landmarks.
Purpose of a genicular nerve block?
A genicular nerve block is a diagnostic procedure to determine if the pathologic changes (i.e. arthritis, meniscal tears, etc) and inflammation within the knee joint is the source of your knee pain. It also confirms that the knee pain will respond well to the actual treatment procedure. If a genicular nerve block works, it will give you relief for several hours. After that, the pain is expected to return to normal. This test is always performed twice (usually a week or two apart) because two successful tests are required to move onto treatment. If both diagnostic tests are positive, then we schedule a treatment called radiofrequency (RF) ablation. In this procedure, the same nerves are cauterized, which typically leads to pain relief for 12-18 months (please see the link for Genicular Radiofrequency Ablation to learn more about this procedure). If this process works well for one knee, it can be performed on the other knee if needed.
Procedure
Patient will be placed on the procedure table. The injection site is sterilized with anticeptic solution. The site to be injected is anaesthetised with a local anesthetic, and a needle is directed to the target area. C arm guidance is used to ensure proper placement and positioning of the needle. When the needle is properly positioned near the genicular nerve, local anesthetic is injected to numb that nerve. This will be repeated at multiple sites around the knee to block all genicular nerves.
The injection can be painful and therefore provide the option of receiving IV sedation. IV sedation, combined with local anesthetic, can make the injection nearly pain free. It allows the patient to remain very still during the procedure, which can also make the injection easier, faster, and more successful. If patient decide to have IV sedation,he or she must have a driver to get you home safely afterwards.So it’s a OPD & a day procedure.
Risks and Side effects
The complication rate for this procedure is very low. Whenever a needle enters the skin, bleeding or infection can occur.
You may have an allergic reaction to any of the medications used.
Patient may experience any of the following side effects up to 4 hours after the procedure:
• Leg muscle weakness or numbness may occur due to the local anesthetic affecting the nerves that control legs (this is a temporary effect ). If patient have any leg weakness or numbness, walk only with assistance in order to prevent falls and injury.Leg strength will return slowly and completely.
• Dizziness may occur due to a decrease in patients blood pressure.
• Mild headaches may occur.
• Mild discomfort at the injection site can occur. This typically lasts for a few hours but can persist for a couple days. If this occurs, take anti-inflammatories or pain medications, apply ice to the area the day of the procedure. If it persists, apply moist heat in the day(s) following.
The side effects listed above can be normal. They are not dangerous and will resolve on their own. If, however,patient experience any of the following, a complication may have occurred and you should either contact your doctor.
• Severe or progressive pain at the injection site(s)
• Leg weakness that progressively worsens or persists for longer than 8 hours
• Severe or progressive redness, swelling, or discharge from the injections site(s)
• Fevers, chills, nausea, or vomiting.
Duration of pain relief
Patient should feel relief from your usual pain within 20 to 30 minuites. Again, this is only expected to last for several hours, at the most.
Long-Term Pain Relief After Radiofrequency Nerve Ablation of the Genicular Nerve: Knee osteoarthritis (OA) pain can be managed conservatively with physical therapy and medications while joint replacements are reserved for more severe joint disease with intractable pain symptoms. Modalities like intra-articular corticosteroid injection may provide a long-term pain relief & many times can cause some degree of harm. Interruption of nociceptive pathways via genicular nerve radiofrequency is a technique that can potentially provide long-term pain relief in this group of patients.
PROLOTHEARAPY
Series of sugar-water injections ease knee OA pain? Doctors have differing opinions about the therapy’s effectiveness and safety.
Most treatments for osteoarthritis (OA) address only symptoms and may create other challenges. Weight loss and exercise programs may be difficult for people to follow successfully. The side effects of pain medications may cause other health problems. Pain consultants looking for less risky and more accessible, effective options are giving new scrutiny to an older treatment, prolotherapy, for its potential to improve knee OA symptoms.
Prolotherapy is injection of an irritant solution (often a form of sugar called dextrose) into joints, ligaments, and tendons. A typical treatment program involves 15 to 20 injections given monthly for three to four months, followed by occasional, as-needed shots.
While the therapy has been in use for 75 years, researchers and doctors still aren’t sure how the injections improve pain and other symptoms. And many remain skeptical it even works at all.
Prolotherapy, one theory is that injecting dextrose at certain concentrations triggers a natural healing process, stimulating repair of damaged tissues.
Questions Remain -More research is needed to confirm the effectiveness and long-term safety of prolotherapy for knee OA. As of 2014, prolotherapy is offered most often offered in sports medicine and orthopaedic practices, many of which emphasize the potential benefits of “regenerative” injectables, which also includes platelet-rich plasma and growth factors. Doctors are increasingly using injectables for OA, from alternative options like prolotherapy to more traditional corticosteroid and hyaluronic acid injections.
“Like platelet-rich plasma, prolotherapy suffers from a lack of well-thought-out, methodologically sound, large randomized trials, particularly with long-term follow-up,”However, experience treating hundreds of individuals with positive, safe results makes many passionate & enthusiastic about the therapy.
Who Should Try It?
Usually for patients who have tried two or more therapies, such as supervised physical therapy and weight loss, and who still have pain and other symptoms that limit their activities. “As with all medical procedures, a clinical visit including a detailed history, exam and eligibility screening criteria, helps identify patients most likely to benefit from prolotherapy.Prolotherapy can be expensive.
Prolozonetherapy for Knee Osteoarthritis
THE BASICS________________________________________
Prolozone is a technique that marries concepts from neural therapy, Prolotherapy, and ozone therapy. It involves injecting various combinations of lignocaine, anti-inflammatory medications, vitamins, minerals, proliferatives, and a mixture of ozone/oxygen gas into degenerated or injured joints, and into areas of pain. The result of this combination is nothing short of remarkable in that damaged tissues can be regenerated, and otherwise untreatable pain can be permanently cured.
OZONE = TRIATOMIC OXYGEN
Oxygen is an atom that cannot exist in a stabilized form as a single atom. This is because it does not have enough electrons to balance it out. So in order to provide stability, two oxygen atoms bond together in close proximity and share electrons. This molecule, called O2, is what is generally referred to when the word “oxygen” is used. O2 is the stable form of oxygen that exists in the atmosphere.
When an energetic force, such as electricity (lightening) or ultra-violet light (solar exposure), is imposed upon a molecule of O2, the two oxygen atoms are temporarily split apart into single oxygen atoms. Then, in a matter of nanoseconds these highly unstable oxygen atoms will pair up again and reform back into O2 molecules. But a small percentage of them will unite in a ménage-a-trio known as ozone. Thus, ozone, referred to as O3, is a gaseous molecule which consists of three oxygen atoms all sharing the same electrons.
This is exactly what happens in a corona discharge ozone generator. Oxygen (O2) molecules go into the generator and are exposed to an electric spark. What emerges from the other end is a mixture of oxygen and ozone. The parameters of the generator can be set to produce a given amount of ozone in that mixture. In clinical circumstances the concentration of ozone in the final gas mixture is between 1-3%. In the therapeutic sections of this article I will be using the word “ozone” to refer to this mixture of ozone and oxygen.
Ozone is a relatively unstable molecule. This is because there just are not enough electrons to go around to keep three oxygen atoms stabilized. There are enough for two atoms, but not three. This instability is exactly why ozone is so powerful—because it is driven to give off the extra oxygen atom so that it can be reduced to the stable O2 form. This of course requires getting electrons, and the best place for a single oxygen atom to get an electron in a cellular environment is from the double bonds found in lipids and amino acids. The reaction looks like this:
O3 + -C=C- → -C-O3-C- → -CO-CO2→ -C=O + -C-O2
HOW DOES PROLOZONE WORK?
________________________________________ There is a localized decrease in BLOOD SUPPLY.In other words, it is a localized area of tissue here the articular cartilage,that is trapped in a state of reduced oxygen utilization. Restore oxygen utilization, and the tissue will function normally again.
This same principle also applies to cases of cerebral infarct. Between the area of dead brain tissue and healthy tissue, there is a localized penumbra of brain tissue that is trapped in a state of decreased oxygen utilization. This tissue is not dead, but it is non functional. Restoring oxygen utilization to these cells with hyperbaric oxygen will often result in significant clinical improvement. I believe that Prolozone works by improving oxygen utilization in a localized area of damaged connective tissue, allowing it to heal, and to restore full function.
WHAT CAUSES CHRONIC PAIN________________________________________ We damage our connective tissues all the time. This is normal. In fact, it is controlled damage that is at the very heart of why exercise is so beneficial. When the tissue is damaged, stem cells and blast cells are called to the area of injury. Growth factors are stimulated, and very soon the damage is repaired. You sprain your ankle, and then it heals. You break your neck, and then it heals. That is, unless it doesn’t.
Why is it that some injuries never heal, and go on to become areas of chronic pain and dysfunction? What happened to the healing mechanisms that always worked before? It’s the same process as myocardial hibernation and cerebral penumbra of injury. These localized areas fail to heal because of a localized decrease in oxygen utilization. Reverse this, and an area of chronic pain will become normal again. Reverse this, and an area of chronic degeneration will begin to regenerate exactly as it was supposed to in the first place.
Here’s another question. Why does chronic pain and degeneration only occur in joints and ligaments instead of other tissues? And why do people heal so much more reliably when they are young than when they become older? The answer in both cases has to do with decreased oxygen utilization.
Ligaments and joints are notoriously known as areas of decreased oxygen tension. The oxygen tension in a healthy ligament is often only 1/10th that of the tissue only several millimeters away from it. The same is true for joints. These areas are setups for developing a situation that involves a localized area of decreased oxygen utilization.
But as we grow older, does our circulation improve, or does it decrease? Of course it decreases. So the natural decrease in oxygen utilization that is seen in the healthy ligaments and joints of the young become even further compromised with aging. So here’s the scenario for chronic pain and tissue degeneration that seems to correlate well with what I have clinically seen from using Prolozone in thousands of patients over these past 20 years.
There is a naturally occurring decrease in circulation to ligaments and joints. This condition is further compromised with aging. The result is a naturally occurring localized decrease in oxygen utilization in these tissues. Then along comes a trauma. The trauma produces edema and inflammation causing a further localized decrease in oxygen utilization. This decrease in oxygen utilization produces a localized increase in lactic acid production, free radical damage, and necrosis which serves as the foundation for sensory irritation and injury, all of which causes chronic pain.
Both the initial trauma and the ensuing edema and inflammation result in a decrease in circulation. This compromises the delivery of oxygen and important nutrients to the localized area of damage, and decreases oxygen utilization even more. The trauma also compromises cell membrane potential, which both causes decreased oxygen utilization, and in turn is caused by decreased oxygen utilization. So, even though stem cells and blast cells are there, and growth factors are being released, healing does not occur. None of these mechanisms can be effective because of a lack of adequate oxygen utilization. Thus, a vicious cycle, which dub “The Circle of Chronic Pain” results: decreased oxygen utilization leads to a decrease in cell membrane potential and an increase in free radical damage, which leads to tissue damage and increased inflammation and edema, which perpetuates the trauma, which leads to a further decrease in oxygen utilization. All of which adds up to chronic pain and degeneration. Break that cycle, and the cells and tissues can begin to do what they usually do so well—heal themselves. That is precisely what Prolozone does.
Each component of Prolozone has a specific biological purpose. Procaine acts to re-establish cellular membrane potentials. Anti-inflammatory agents decrease edema and swelling. The inclusion of vitamins and minerals provides necessary substrates for oxygen utilization that in damaged tissues are often deficient. And finally, oxygen utilization is directly stimulated by ozone.
OTHER LOCALIZED EFFECTS OF OZONE-As a powerful oxidizing agent, ozone also has several other effects that are important for tissue repair and regeneration. One is by stimulating growth factor production and release. The stimulation of growth factors, especially endothelial factors are important for tissue regeneration to occur.
But ozone therapy can do more than just stimulate growth factor production and release. It also activates the membrane receptors through which growth factors exert their effects. And finally, there is evidence that ozone therapy can mediate the effects of the various growth factors.
Ozone- its a GAS!
One last note about the effect of injecting a gas. Unlike injecting a liquid, which will just pool in the area of injection, gases expand when injected, and dissect along areas of inflammation. This fact is exploited in the Prolozone technique by injecting large volumes (10-30cc) of gas into each treated area. The effect is that very large areas, and difficult to reach areas are treated with only one injection. This decreases the number of injections needed to treat a given area, and also greatly decreases the chance of missing the area of primary involvement term it as “Target practicing with a shot gun.”
WHAT A PROLOZONE PATIENT CAN EXPECT-The first thing that most patients notice after a Prolozone treatment is an almost immediate 50-80% decrease in pain. This is in part due to the effect of the procaine. But ozone itself has a significant ability to directly relieve pain.Next, chronic areas of degeneration such as in osteoarthritic knees, hips, and ankles will regenerate. Although more research is needed to fully document this effect, some physicians have already taken pre and post treatment x-rays that have shown an increase in cartilage thickness in knees treated with Prolozone. And fortunately, other than a rarely occurring and temporary increase in pain in the area injected, no significant side effects from Prolozone have ever been demonstrated. Other than the possibility of an allergy, there are no contraindications to its use.
________________________________________
Prolozone is so effective, I virtually never use these other modalities as they are classically used. Additionally, Prolozone offers some advantages over classical proliferative therapy.Ozone directly stimulates the down regulated oxygen utilization in damaged areas of the body that is at the heart of why these areas don’t heal. Prolotherapy does not have this action. Secondly, Prolotherapy is typically very painful, with the pain from the therapy often persisting for days to weeks after a treatment. In contrast, patients receiving Prolozone feel immediate improvement, with very little or no pain at all during or after the treatments.
Prolotherapy requires many injections, whereas Prolozone only requires a few. This means that Prolozone is faster, and typically much less expensive.
Because Prolozone involves the injection of a gas in large volumes which expands into a large area of surrounding tissue, it is not as critical to pinpoint each Prolozone injection as it is when using proliferatives. Thus, it is easier to master.
Since Prolozone does not work as a proliferative, the use of anti-inflammatory medications is not contraindicated, and can in fact be synergistic.
Prolozone is especially effective when used intra-articularly. It can stimulate the regeneration of damaged cartilage in knees, shoulders, ankles, and hips.
Is Surgery Used to Treat Knee Osteoarthritis?
When other treatments don't work, surgery is a good option,but try to keep it as a last choice.There are some examples,where knee pain remained same or even worsened after TKR surgery.Although incidence is uncommon,one must keep this fact in mind.
Joint replacement surgery, or arthroplasty, is a surgical procedure in which joints are replaced with artificial parts made from metals or plastic. The replacement could involve one side of the knee or the entire knee. Joint replacement surgery is usually reserved for people over age 50 with severe osteoarthritis. The surgery may need to be repeated later if the joint wears out again after several years, but with today's modern advancements most new joints will last over 20 years. The surgery has risks, but the results are generally very good.
Although surgery is generally effective for patients with advanced disease, some older individuals with comorbidities may not be appropriate surgical candidates. In addition some patients do not wish to consider surgery and prefer non- surgical options. In these patients, radiofrequency (RF) neurotomy of the genicular nerves & prolozone therapy might be a successful alternative to surgery.
