Prolotherapy for Osteoarthritis of the Knee

Knee X-rayThe National Institute of Health Division of Alternative and Complimentary Medicine has said that if a treatment works, and its results can be reproduced, then it is not alternative therapy.  Such a wise mantra is at the heart of a study published in the May/June issue of the Annals of Family Medicine and recently reviewed in MedPage.

David Rabago, MD, of the University of Wisconsin in Madison and his associates looked at whether prolotherapy is beneficial for those patients suffering from arthritis of the knee. Prolotherapy involves the injection of sugar water or dextrose into joints for the relief of pain. It has been used in different joints for over 75 years but most of the research studies available on its use suffer from poor scientific design and reproducibility.

This study involved 90 adults with knee arthritis in one or both knees for at least five years.  The mean age of the enrollees was 57 years with 2/3 of the enrollees being women and ¾ overweight or obese.  The enrollees were separated into groups. One group received dextrose injections, another received saline or salt water, and a non-injection exercise group. The injections were given at weeks 1, 5, 9, 13 and 17. 

Prolotherapy required them to make multiple punctures around the knee at various tendon and ligament sites. 22.5 mL of either concentrated dextrose or saline placebo were injected into the knees followed by an intra-articular injection of 6mL of additional fluid.   A third arm of the study included patients given no injections but instructed in a home exercise physical therapy program. 

In the dextrose group, 17 patients received injections in only one knee and 13 had treatment in both knees. In the placebo saline group, 15 had a single knee treated while 13 had both knees treated.   During the study, 14 patients in each group used oral non-steroidal inflammatory drugs to relieve pain and discomfort.  All patients receiving injections reported mild to moderate pain after the procedure and up to 2/3 used oral oxycodone before or after the procedure.

The patients used the Western Ontario McMaster University Osteoarthritis Index to score their pain, function and stiffness. There was a significant difference in the improvement of those receiving the dextrose injections as compared to those receiving saline injections. Ninety-one percent of those receiving the dextrose injections said they would recommend the treatment to others.

This was a preliminary study which showed the effectiveness of an alternative therapy in treating a common and chronic condition. It is clear that these findings necessitate a larger study which can look at the correct dosage to inject and to explore how the sugar injections actually work. It appears to be a relatively inexpensive way to relieve chronic pain and is worthy of further study!

Fitness in Mid-life Leads to Less Illness in Later Life

Woman with DumbbellsAt doctor/patient visits, physicians stress the importance of developing and following a healthy lifestyle. That healthy lifestyle includes eating correctly and in moderation, controlling your weight, going for periodic benchmarking checkups and getting regular and consistent exercise. An untold number of research studies have supported these recommendations.  Medpage, the online medical journal of the University Of Pennsylvania School Of Medicine printed two reviews of studies which confirm the findings.

Ambrish Pandey, MD, of the prestigious University of Texas Southwestern Medical Center in Dallas, Texas with his colleagues presented data that links fitness in your fifties with a reduced risk of cardiovascular heart failure in later life.  They looked at 9,050 men and women with an average age of 48 and followed them for a period of eight years. They evaluated their fitness at entry into the study and eight years later. They followed patients for 60,635 patient years.  

Their findings were quite simple. Those people who exercised regularly and improved their fitness over time had less heart disease and heart failure. They proved that your risk of cardiovascular disease in your sixties and seventies was modifiable based on your fitness level and effort to improve it and sustain it.

Susan Lakoski, MD, of the University of Vermont in Burlington looked at fitness in men in their fifties and concluded that “physical fitness reduces the risk of lung and colorectal cancer”.  She pointed out that if fit men developed cancer they tended to have a higher survival rate than unfit men. Interestingly, her study suggested that weight was NOT the issue.  Overweight men who were fit did well, while unfit lean men did not do as well.

It is refreshing to have data to back up the recommendations we make to our patients – find some form of exercise they enjoy and keep doing it, frequently and repeatedly if you wish to have fewer health issues to deal with as you age.

The Benefits of Exercise and Fitness

Woman with DumbbellsThe highly acclaimed Cooper Clinic has been following 20,000 patients’ fitness levels for the last 40 years. They recently published an article in the Annals of Internal Medicine proclaiming that fitness in the middle years of life lowers your risk of developing dementia in your senior years. The Cooper Clinic has been following these patients for evaluation of cardiovascular fitness and development of heart disease but decided to use the same data to review who, if any, developed dementia by their 70th, 75th, 80th and 85th birthdays. All participants initially were screened with exercise treadmill testing. They found that those who were the fittest were 36% less likely to be diagnosed with dementia after age 65 than the least fit.

David Geldmacher, MD, of the University of Alabama at Birmingham, told MedPage Today that the potential benefit of exercise to reduce dementia risk is worth bringing up with patients, even though recommendations for exercise are made routinely for cardiovascular health reasons. Many patients are willing to forego exercise with the belief that sudden death by a heart related illness isn’t such a bad way to expire. On the other hand the thought of living with a chronic debilitating disease like dementia is highly undesirable and exercise might be an acceptable lifestyle change to prevent that process. Knowing that fitness can reduce the Alzheimer risk may give them further motivation to follow through with an exercise and fitness plan.

In an unrelated but equally fascinating study, researchers at the Durham Veterans Affairs Medical Center in Durham, North Carolina found that Caucasian men who participated in regular exercise at a moderate level were less likely to have prostate cancer on biopsy of suspicious areas of the prostate. If the biopsy did reveal prostate cancer the grade of the cancer tended to be lower indicating a more favorable prognosis. This study of 164 Caucasian men and 143 black men did not show any fitness protection for black men who exercised regularly. The authors went on to point out the small size of the study and the fact that the level and frequency of exercise was self-reported not measured or monitored by the research team. Other factors such as heredity, diet and lifestyle issues may be factors as well. They recommended further study to determine the exact relationship between exercise and prostate health or disease.

Both these studies strongly support the concept that regular exercise of a moderate level probably has strongly favorable influences in multiple areas of health. I will continue to urge my patients to get some form of regular exercise that they enjoy on a daily basis while the researchers confirm the long term benefit of regular exercise and fitness.

Exercise Induced Muscle Soreness May Not Benefit from Regular Use of NSAID’s

The June 11, 2012 issue of MedPage carries coverage of the meeting of the European League Against Rheumatism where work by Matthias Rother, MD, PhD suggested that taking Ketoprofen or even Celecoxib (Celebrex) for exercise induced muscle soreness may not be a great idea.

The study looked at 64 healthy volunteers who were asked to walk down stairs totaling 400 vertical meters – similar to walking all the way down from the top of a 100-story building.  Forty of the volunteers were randomized to take 200 mg of Celebrex or a placebo twice a day. Twenty-four of the participants were randomized to take Ketoprofen or a placebo.

The patients in the Ketoprofen reported no improvement in pain.  In fact, their pain lasted longer (122 hours) than the placebo groups pain (105 hours).  Patients taking the Celecoxib had a mild pain improvement – so mild that it was not felt to be statistically significant.  This led the researchers to conclude that NSAID’s did not provide significant pain relief to justify their use in post-exercise muscle soreness. They went on to say that muscle inflammation and soreness are part of the inflammatory reaction following exercise that is “essential for recovery.”

This was a small study and it is hard to conclude anything. I will still recommend RICE therapy (Rest, Ice, Compression, Elevation) immediately following post injury or exercise.  Celecoxib (Celebrex) did reduce pain by 12- 13%, so, possibly the dosage and frequency of administration of the NSAID needs to be looked at as well. If my patients do not have a medical reason to avoid NSAIDs, they will still be advised to try them for work and exercise related aches and pains.