Osteoarthritis Resources

The Future of Knee Osteoarthritis Care

Best Practice, Innovation, and State of the Art

Introduction

One third of adults between the ages of 18 and 64 have arthritis,¹ and the lifetime risk of developing knee osteoarthritis (OA) by the age of eight-five is 45%.² The prevalence of knee OA is very high, and it’s continuing to rise. OA happens when cartilage, the smooth covering on the ends of our bones, starts to break down. This loss in cartilage can cause bone-on-bone contact during movement as well as undesirable bone growth, called bone spurs. These degenerative changes cause swelling, pain and stiffness, all of which contribute to a reduced quality of life.

There are many national and international organizations, including Osteoarthritis Research Society International (OARSI), National Institute for Health and Care Excellences (NICE), European League Against Rheumatism (EULAR) and the American Academy of Orthopaedic Surgeons (AAOS), that develop clinical guidelines describing best practices for patient care. These guidelines are based on scientific evidence and recommendations by experts in the area. Currently, standard treatment options for knee OA are based on the severity of the disease. Exercise, education and weight management are recommended as a first line of treatment for all patients with knee OA.³ There is strong evidence around exercise to reduce pain and maintain muscle strength.⁴ Weight management is also important because the load on the knee joint during activity is 2-7X higher than the actual amount of body weight applied.⁵ So, even a small reduction in body weight can greatly reduce the loading experienced in the joint.

For people who do not find relief from first line treatments, the recommended second line of treatment (in combination with first line treatments) is pharmacological pain relief.³ There are many medications that can be used to manage knee OA symptoms including oral, topical and injections. However, the long-term use of pain medications is associated with undesirable side effects and can cause health concerns.⁶ For people who have exhausted first and second line treatments, surgery is a treatment option for severe knee OA cases.³ Surgery can be effective for some patients, however, it is very invasive and costly, and over 50% of patients still experience pain after surgery.⁷ This could be due to many factors, including whether or not surgery was an appropriate intervention in the first place.

These treatment options are based on strong evidence and are the standard of care for knee OA patients today. However, there is exciting research happening on new and promising treatment options, including disease modifying drugs for OA, regenerative medicine approaches, and joint unloading techniques.

Disease Modifying OA Drugs

Traditional drugs recommended for knee OA are effective for addressing pain, but they do not delay disease progression or reverse joint damage. As well, because they are frequently associated with adverse side effects when used in the long-term,⁶ pharmacological researchers have started developing drugs that are intended to promote cartilage repair, prevent undesirable bone growth, reduce pain and minimize potential side effects. This class of drugs is called disease modifying osteoarthritis drugs (DMOADS). One of the more promising disease modifying OA drugs that is now being tested in humans is called “Sprifermin”. This drug is made up of a molecular compound that helps promote the growth of healthy cartilage. A study published last year showed that regular injections of Sprifermin resulted in improved cartilage thickness compared to a placebo, however the effect on clinical outcomes was uncertain.⁸ While these results are promising, more studies are needed to understand the effect of Sprifermin on patient symptoms, and to verify the long term safety and efficacy of the drug in humans.

Regenerative Medicine Approaches

Regenerative medicine is a field of research that uses the power of the cells found in our own body to heal and regenerate damaged tissues or organs, such as damaged cartilage in knees with OA. One regenerative medicine approach is called stem cell therapy. Stem cells can be harvested from your body, differentiated and grown into the desired cell type, and inserted back into your body. The goal of this therapy for knee OA is to heal and regenerate damaged cartilage in the knee joint. While research continues to advance in this area and shows promise for the future, there are still ongoing challenges in being able to produce cartilage that has the same characteristics as the original cartilage found in our bodies.¹⁰ Currently, there is a lack of clinical trial evidence to determine whether these procedures are safe and effective, and as of today, Health Canada has not approved any stem cell therapies for use in humans.¹¹

Joint Unloading Techniques

In contrast to DMOADs and Regenerative Medicine, joint unloading is a well-established core principle of conservative care for knee OA. Cyclical loading and unloading of the joint, for example when walking or climbing stairs, is critical for the maintenance of healthy cartilage. The normal distribution and amount of loading in the knee changes with knee OA, and research has shown that increased loads in the knee joint contribute to the initiation and progression of knee OA.¹² Joint unloading aims to reduce and redistribute these loads to avoid further damage and potentially encourage healing within the knee joint.

The knee joint has three compartments where bones meet: the medial tibiofemoral compartment, the lateral tibiofemoral compartment, and the patellofemoral compartment. Knee OA can affect any of these three compartments in the joint.

Knee braces for osteoarthritis have been around for decades and there are hundreds of options available. One of the most common types of knee braces are known as “uni-compartment offloaders”. They are designed to offload compressive forces from one side of your knee. They do this by applying a force to the side of your knee to “open up” the joint space on the opposite side and redistribute the forces normally going through the knee across a larger area. Uni-compartment offloader braces are cost-effective and minimally invasive treatments that can reduce pain, improve function, and potentially delay the progression of knee OA for the right patients.¹³ However, traditional knee braces have one main limitation: they are designed for use in patients with uni-compartmental knee OA affecting one tibiofemoral compartment (ie. one side of the knee). This makes up only 3-20% of all knee OA patients,^{14, 15} while the vast majority (over 90%) of patients are likely to have OA in two or all three compartments of their knee.¹⁶ This means that traditional knee braces are not optimized for the majority of patients with bi- or tri-compartmental knee OA, which may limit their effectiveness to reduce pain and improve knee function.  

Levitation Tri-Compartment Unloader Knee Brace

The benefits and limitations of traditional knee braces, together with the well-established clinical guidelines focused on exercise and weight loss to accomplish joint unloading formed the motivation for Spring Loaded Technology to develop a new type of brace. The Levitation Tri-Compartment Unloader knee brace was designed to reduce knee pain and improve mobility for patients with patellofemoral or multicompartment knee OA. Levitation’s novel brace uses a powerful silicone liquid spring that provides knee extension assistance to decrease compressive forces in the knee. It is the only brace designed to relieve knee pain and assist mobility by reducing forces in all three compartments of the knee, including the often affected patellofemoral compartment. By simultaneously reducing the loads experienced in both the tibiofemoral and patellofemoral knee joint compartments, Levitation aims to reduce pain, avoid further joint damage and potentially encourage healing within the knee joint. Patients with knee OA who experience pain during activities such as getting up from a seated position, going up or down stairs or walking uphill are likely to benefit from Levitation’s unique technology. 

Research conducted thus far on the brace shows that the unloading effect of the brace (when weight bearing) is similar to what would be achieved by losing 45 pounds of body weight.¹⁷ An independent study showed that the brace can reduce patellofemoral and tibiofemoral joint contact forces by over 40%.¹⁸ In a survey based study of current Levitation brace users, 95% of users reported reduced pain since using the Levitation brace.¹⁹ As well, studies with the military have shown that use of Levitation may improve physical performance of military personnel with knee injuries.

Among several other projects, we are now beginning research that will explore the potential benefits of the brace on joint loading and muscle activity using gait analysis and real-time imaging techniques at the University of Calgary. We are also planning a clinical trial to evaluate the efficacy of the brace to reduce pain and improve function in a large group of knee OA patients.

References

1. Jafarzadeh, S.R., Felson, D.T., 2018. Updated Estimates Suggest a Much Higher Prevalence of Arthritis in United States Adults Than Previous Ones. Arthritis Rheumatol. 70, 185–192. https://doi.org/10.1002/art.40355
2. Murphy, L., Schwartz, T.A., Helmick, C.G., Renner, J.B., Tudor, G., Koch, G., Dragomir, A., Kalsbeek, W.D., Luta, G., Jordan, J.M., 2008. Lifetime risk of symptomatic knee osteoarthritis. Arthritis Care Res. 59, 1207–1213. https://doi.org/10.1002/art.24021
3. GLA:D Canada. Treatment for Osteoarthritis.Accessed online from https://gladcanada.ca/index.php/treatment-for-osteoarthritis/ on 19 March 2020.
4. Fransen, M., McConnell, S., Harmer, A., Van der Esch, M., Simic, M., KL, B., 2015. Exercise for osteoarthritis of the knee (Review). Cochrane Database Syst. Rev. https://doi.org/10.1136/bjsports-2016-096104
5. Messier, S.P., Gutekunst, D.J., Davis, C., DeVita, P., 2005. Weight loss reduces knee-joint loads in overweight and obese older adults with knee osteoarthritis. Arthritis Rheum. 52, 2026–2032. https://doi.org/10.1002/art.21139
6. Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthr Cartil 2008;16:137–62. https://doi.org/10.1016/j.joca.2007.12.013.
7. Becker, R., Bonnin, M., Hofmann, S., 2011. The painful knee after total knee arthroplasty. Knee Surgery, Sport. Traumatol. Arthrosc. 19, 1409–1410. https://doi.org/10.1007/s00167-011-1625-7
8. Hochberg, M.C., Guermazi, A., Guehring, H., Aydemir, A., Wax, S., Fleuranceau-Morel, P., Reinstrup Bihlet, A., Byrjalsen, I., Ragnar Andersen, J., Eckstein, F., 2019. Effect of Intra-Articular Sprifermin vs Placebo on Femorotibial Joint Cartilage Thickness in Patients with Osteoarthritis: The FORWARD Randomized Clinical Trial. JAMA – J. Am. Med. Assoc. 322, 1360–1370. https://doi.org/10.1001/jama.2019.14735
9. Hochberg, M. et al. OP0059 Efficacy and safety of intra-articular sprifermin in symptomatic radiographic knee osteoarthritis: pre-specified analysis of 3-year data from a 5-year randomised, placebo-controlled, phase ii study. Ann. Rheum. Dis. 77, 80 LP – 81 (2018).
10. Escobar Ivirico, J.L., Bhattacharjee, M., Kuyinu, E., Nair, L.S., Laurencin, C.T., 2017. Regenerative Engineering for Knee Osteoarthritis Treatment: Biomaterials and Cell-Based Technologies. Engineering 3, 16–27. https://doi.org/10.1016/J.ENG.2017.01.003
11. Government of Canada. (2020) Health Canada Policy Position Paper – Autologous Cell Therapy Products. Accessed online from https://www.canada.ca/en/health-canada/services/drugs-health-products/biologics-radiopharmaceuticals-genetic-therapies/applications-submissions/guidance-documents/cell-therapy-policy.html on 19 March 2020. 
12. Andriacchi, T.P., Favre, J., Erhart-Hledik, J.C., Chu, C.R., 2015. A Systems View of Risk Factors for Knee Osteoarthritis Reveals Insights into the Pathogenesis of the Disease. Ann. Biomed. Eng. 43, 376–387. https://doi.org/10.1007/s10439-014-1117-2
13. Steadman RJ, Briggs KK, Pomeroy SM, Wijdicks CA. Current state of unloading braces for knee osteoarthritis. Knee Surgery, Sport Traumatol Arthrosc 2016;24:42–50. https://doi.org/10.1007/s00167-014-3305-x.
14. Heekin, R.D., Fokin, A. a., 2014. Incidence of Bicompartmental Osteoarthritis in Patients Undergoing Total and Unicompartmental Knee Arthroplasty: Is the Time Ripe for a Less Radical Treatment. J. Knee Surg. 27, 77–82. https://doi.org/10.1055/s-0033-1349401
15. Shahid, M.K., Al-Obaedi, O., Shah, M., 2018. Prevalence of Compartmental Osteoarthritis of the Knee in an Adult Patient Population: A Retrospective Observational Study. EC Orthop. 10, 774–780.
16. Duncan, R.C., Hay, E.M., Saklatvala, J., Croft, P.R., 2006. Prevalence of radiographic osteoarthritis – It all depends on your point of view. Rheumatology 45, 757–760. https://doi.org/10.1093/rheumatology/kei270
17. Budarick, A.R., MacKeil, B.E., Fitzgerald, S., Cowper-Smith, C.D., 2020. Design Evaluation of a Novel Multicompartment Unloader Knee Brace. J. Biomech. Eng. 142, 1–8. https://doi.org/10.1115/1.4044818
18. McGibbon, C.A., Brandon, S.C., Bishop, E.L., Biden, E.N., Cowper-Smith, C., 2020. Biomechanical study of a novel tri-compartmental unloader brace for the knee. In Preparation.
19. Budarick, A.R., Bishop, E. and Cowper-Smith, C., 2020. Evaluation of a new orthotic for multi-compartment knee osteoarthritis: a retrospective pilot survey. Submitted to Annals of Physical and Rehabilitation Medicine.

Gel Injections for Knee Arthritis

Stiff and sore joints are a reality for most of us as we get older. Normally, our body secretes natural lubricants that reduce friction between the joint surfaces. Knee osteoarthritis increases friction in the joint causing the protective layers of cartilage on joint surfaces to slowly break down. Gel injections for knee osteoarthritis contain hyaluronic acid which can provide relief by improving joint lubrication. Treatments aimed at decreasing joint friction are also known as viscosupplementation. According to experts¹², if you’ve tried exercising, dietary changes, and other painkilling drugs with no success, this treatment could be for you. 

Stem Cell Injections for Knee Arthritis

One of the primary effects of knee osteoarthritis is the degeneration of cartilage. Knee cartilage is crucial for normal joint function as it provides protective cushioning for the bony surfaces of the joint and stops them from coming into direct contact with one another. In many cases of moderate or severe osteoarthritis, the pain and disability associated with bone on bone contact is an important factor in the decision to undergo knee replacement surgery. Stem cell injections for knee arthritis may one day provide patients with a less invasive alternative to the common surgical procedures used today. Not only can stem cells potentially help relieve pain caused by knee osteoarthritis, they may also be able to slow, or even reverse the degeneration of cartilage. 

New Osteoarthritis Knee Brace Technology – An Alternative to Knee Surgery?

If your knee osteoarthritis has driven you to consider knee replacement surgery, keep reading. For many with moderate or severe knee osteoarthritis, surgery can seem inevitable. While knee replacement surgery is a well established and effective treatment option, reluctance to undergo the procedure is understandable. Knee replacements can be expensive and the recovery can be difficult. Fortunately, recent innovations in osteoarthritis knee brace technology may help you to reduce your consumption of painkillers and avoid or dramatically delay the need for surgery.

PRP Shots For Knee Arthritis – Are They Effective?

PRP (platelet-rich-plasma) therapy has been gaining popularity recently owing to its promise in a number of areas such as hair regeneration, wound healing, skin rejuvenation, and slowing the progression of arthritis. A variety of high-profile athletes have also touted the benefits of PRP for the knee joint. Many claim the shots have helped them during their recovery from sport-related injury. Currently, over 80,000 athletes are treated with PRP every year.¹ 

How to Choose the Best Knee Brace for Arthritis

Knee bracing solutions are increasing in popularity, particularly with the advent of tri-compartment unloading technology. This recent advancement in knee bracing technology now provides all knee osteoarthritis patients the opportunity to relieve their knee pain. There are more product choices than ever before and as a consequence, more diligence is required to ensure you select the product that best fits your situation. Choosing the wrong knee brace for arthritis can lead to frustration and disappointment as it will provide only a slight benefit. Choosing the right brace could afford you with life-changing increases in mobility, reduced pain, and confidence. What brace is right for you? It all depends on the pattern of knee arthritis you have.

Knee Pain When Walking – Is It All In The Shoes?

We all take our ability to walk for granted until we are set back by crippling pain. The average American walks 7000-13000 steps per day.¹ Over your lifetime, that’s a lot of steps! Each one of these strides applies pressure to our lower limbs and it all starts at the foot. The way in which the foot interacts with the ground can have a major influence on the stress applied to upstream joints, especially your knees. Consequently, the type of shoe you wear can influence any nagging knee pain when walking.

Knee Pain When Squatting? 3 Common Fixes.

Knee pain when squatting has many possible causes. Both joint inflexibility and poor muscle stability are usually contributing factors. You don’t have to be a yogi, but keeping your joints limber may help move stress away from your knees. Fortunately, it is possible to dramatically improve joint mobility in just one short stretching session. The bad news is that these mobility changes will disappear quickly if not maintained through consistent exercise. Getting into a proper routine is essential. Below are the key areas to focus on and simple exercises to try at home!

What to do if your Knee Hurts when Bending

More than a quarter of adults suffer from regular bouts of knee pain. It’s really no surprise as our knees handle a tremendous amount stress day-to-day.^1-2 Scientists have found that for every pound of bodyweight, our knees are subjected to up to seven pounds of pressure when they are bent or in weight-bearing.³ If you’re here, it is because you’ve noticed that your knee hurts when bending it, is painful walking down stairs and feels uncomfortable while squatting. The fix for this really depends on the diagnosis. Below are some common causes of knee pain.  

Water on the Knee – Symptoms, Causes and Solutions

Water on the knee is characterized by the accumulation of fluid and inflammation around the knee joint. When this occurs your knee may appear puffy and larger than usual. You may also find that it feels stiff and painful when you place weight on it and is sore to the touch. All of this can cause discomfort while walking up and down stairs, kneeling, and squatting. If you are experiencing symptoms of water on the knee you should consult your doctor to determine the best course of treatment for you.