In a lively discussion, the panelists largely agree that physical therapy and exercise take center stage in treating severe OA of the knees among elderly patients. However, they do offer divergent views on the use and frequency of intraarticular injections. Without further delay, here is what they had to say.

Q: An 80-year-old patient with severe OA of the knees has hypertension and chronic renal failure severe enough to preclude the use of NSAIDs or surgery. How can I treat this patient?

A: Deborah A. Brown, APRN, BC, says conservative treatment for OA includes a multidisciplinary approach to improve function, decrease pain and improve one's quality of life. Using a pain rating scale such as a visual analog scale (VAS) of 1 to 10 for levels 1-5, Brown says clinicians should follow the American College of Rheumatology (ACR) guidelines for the initial treatment of OA. She says one may initiate acetaminophen dosing of up to 4 gm per day and use topical capsaicin four times a day. Supplemental treatment with glucosamine sulfate/chondroitin sulfate lacks sufficient data to support use, according to Brown.

While Michael Rudzinski, PA, considers topical agents like capsaicin or methylsalicylate, he says he would be cautious with all oral agents including NSAIDs and acetaminophen. Assuming a correct diagnosis and the lack of a specific, isolated, symptomatic, surgically correctable lesion or defect, Brian Peck, MD, says the basic treatments are physical therapy and exercise.

With this specific case study, Dr. Peck emphasizes that “pharmaceutical therapies are ancillary” and one should only use these to facilitate exercise or physical therapy, or to increase patient comfort.

Rudzinski emphasizes patient education and self-management. When the presenting patient with OA of the knees is overweight, Rudzinski says he will develop a plan with the patient and suggest appropriate resources to help him or her achieve ideal body weight. Brown agrees that educating these patients about weight loss and exercise is helpful.

When performing a physical exam of patients with severe OA of the knees, Dr. Peck says one of the first things a clinician will notice is weakness or outright atrophy of the quadriceps. Quadriceps weakness leads to instability and Dr. Peck says this instability leads to increased relative movement of the articular surfaces, exposing these patients to more rapid wear and tear of the already damaged articular cartilage. With the loss of articular cartilage, Dr. Peck says progressive joint space narrowing causes the fibrous supports of the knee (collateral ligaments, joint capsule, etc.) to become relatively lax, compounding the problem.

For these patients, Dr. Peck emphasizes the benefits of the isometric resistive quadriceps set. With this exercise, the patient attempts to lift a heavy, immovable object with a fully extended leg, hooking the foot or ankle under the object. Dr. Peck says the goal of this exercise is to contract the quadriceps and exercise it without stressing the knee joint itself.

He notes some people can do this effectively without the stationary object by simply holding their quadriceps in hard, full extension or by trying to lift the contralateral leg at the ankle. Clinicians can coach patients to hold the contraction until the muscle burns and repeat this 10 times, according to Dr. Peck, who advises doing this for three sessions a day.

These patients may use leg flexion machines but Dr. Peck strongly cautions patients against flexing the knee more than 30 to 45 degrees as this may cause further irritation of already overused cartilage.

Once these patients have mastered the quad set, Dr. Peck says they should perform similar resistance exercises of the abductors, adductors and flexors.

All of the panelists recommend a physical therapist referral in order to improve endurance, balance, strength and flexibility of the knees. They also note that assistive devices may include braces, canes or walkers. Brown and Rudzinski say orthotics may be helpful. Brown also suggests possible home modifications such as a raised toilet seat and coaches patients to avoid the use of stairs.

Dr. Peck says the injection of lidocaine and steroid into the knee is “extremely effective in most cases” for treating OA of the knee and avoids systemic side effects. Brown and Rudzinski would consider intraarticular injections for short-term relief of OA pain.

Brown and Rudzinski both cite current recommendations from the American Academy of Orthopedic Surgeons (AAOS) and the ACR. In regard to corticosteroid injections, Rudzinski says published recommendations from the AAOS urge clinicians to only use multiple injections if clear improvement has occurred but to limit the number of injections to three. Rudzinski says those recommendations advise no more than two intraarticular injections for any weightbearing joint. Brown says performing no greater than three intraarticular injections per year or every three months can help avoid cartilage damage. Dr. Peck disagrees, noting that injections of lidocaine and steroids can be repeated frequently without hastening cartilage damage.

“The old (mythology) about restricting such injections to some arbitrary number has no basis in fact,” maintains Dr. Peck. “For many patients, this is the mainstay of therapy and helps them lead more normal lives without surgery.”

If there is an increasingly frequent need for repetitive steroid/lidocaine injections, one may try hyaluronic acid injections. When one uses these in conjunction with physical therapy and pain control, they can be “remarkably effective for periods of up to a year,” notes Dr. Peck.

While Rudzinski would consider viscosupplementation, Brown says it would not be a viable choice in the aforementioned case study due to the bone joint destruction.

When it comes to pain control, some believe opioids are controversial or contraindicated for these patients. Rudzinski says he would be cautious with opioids and carefully analyze the risk/benefit ratio with the patient. However, Dr. Peck says practitioners who have experience in prescribing opioids can provide patients with a viable and effective alternative when other options such as NSAIDs are not available. Brown says opioid analgesics for pain greater than 5 on a VAS for “flares” is not unreasonable. However, she cautions they are not recommended for the elderly due to the risks of falling and constipation.

Q: How often can “cortisone” injections be given and which joints can be injected?

A: “Intraarticular injection of steroids (or other medications) is a time-tested, safe and effective way of treating individual joints affected by almost any sort of arthritis including OA,” explains Dr. Peck.
While the most commonly used medication for these injections is Depo-Medrol™, Dr. Peck says most rheumatologists currently prefer triamcinolone hexacetanide (Aristospan™). He adds that the smaller size of the suspended crystals makes it easier to push the suspension through thin needles and the suspension remains within the joint space for a longer period of time.

Brown believes intraarticular injections can “buy time” for patients who are not ready for joint arthroplasty, particularly those who need to lose weight, those who are too young and those who are not medically cleared for the procedure. Brown reiterates that most clinical recommendations limit intraarticular corticosteroid injections to no more than three times a year.

Rudzinski says the frequency of injection is dependent upon the specific patient and problem. He says he would restrict the injections to two or three per year, depending upon the specifics of the patient and his or her diagnosis, and whether the patient received a fairly good response to a previous injection.

Dr. Peck maintains “there is no credible evidence” that documents any need to limit intraarticular injections nor is there any evidence that shows these injections are detrimental to joint health. He also points out that some experimental evidence shows that when one injects steroids into joints undergoing an active inflammatory process, they develop less damage to articular cartilage than joints that were not injected.

Brown says the most commonly injected joints include the knees, hips, shoulders, ankles, elbows, fingers and wrists. Dr. Peck adds that some experience is needed to inject smaller joints, such as the PIPs, and deeper joints such as the sacroiliac joints. When it comes to degenerative joint disease of the spine, Brown says patients should be referred to a pain clinic for injections under the guidance of an MRI scan.