Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

NSAIDs are medications that reduce inflammation and pain by blocking an enzyme called cyclooxygenase (COX) in your musculoskeletal system. The COX enzyme uses breakdown products from your cell walls for the production of prostaglandins.  Prostaglandins are chemicals that increase pain and inflammation.  There are two COX enzymes – COX-1 which is found in your gastrointestinal tract and COX-2 which is found only in your musculoskeletal system.  Some medications affect both COX-1 and COX-2, leading to stomach upset, while some medications only affect COX-2 (in the musculoskeletal system). These can be used in the form of pills or creams.  The benefit of creams is that they are less likely to affect other areas of your body such as your kidney or heart.

Medications - Different NSAID treatments
Medication (Brand Name) Dosage Benefits Prescription Topical /  Oral
Ibuprofen (Advil) 200 – 800 mg once every 8 hours with food Works Quickly

Easy to adjust the dosage

Take with Breakfast, Lunch and/or Dinner

No Oral
Naproxen (Alleve, Naprosyn) 250 – 500 mg twice daily with food Longer lasting

Take with Breakfast and/or Dinner

No Oral
Meloxicam (Mobic) 7.5 – 15 mg once daily with food Longer lasting – once daily.

Take with breakfast or dinner

Less likely to cause abdominal symptoms
(more COX-2 than COX-1)

Yes Oral
Celecoxib (Celebrex) 200mg once daily or 100mg twice daily Longer-lasting – once or twice daily

COX-2 selective – less likely to have abdominal effects

Yes Oral
Diclofenac (Voltaren, Pennsaid) 2 – 4 g twice daily Less likely to cause systemic side-effects (safer)

Medication delivered directly to the affected area

No Topical

Side Effects: NSAIDs are generally safe.  However, patients with a history of heart disease, kidney disease, high blood pressure, ulcers, or GI bleeding may want to consider avoid NSAIDs as the use of these medications may worsen these problems.

Tylenol (Acetaminophen)

Acetaminophen works via multiple mechanisms and is not completely understood. It works as a partial COX inhibitor without the anti-inflammatory behavior as NSAIDs. Acetaminophen may also affect endocannabinoid receptors. Researchers have not been able to fully elucidate the way that acetaminophen works. We do know that it works more on the central nervous system to limit the experience of pain. It is an inexpensive over-the-counter pain-reliever. Tylenol is generally considered to be a very safe medication. It is however processed by the liver and should be avoided in patients with liver disease.

Corticosteroid Injections (Steroid Injections)

Cortisol is a hormone naturally produced by the body during stress (fight or flight response). This is done to suppress the inflammatory response during stress. Cortisone is a strong anti-inflammatory that works in a similar fashion, suppressing the inflammatory system, and thus naturally producing pain generators. By giving via an injection directly into the knee joint, steroid injections are a great way to reduce pain from a recent arthritis exacerbation or provide temporary relief. Many patients have a lasting effect. Usually, these injections can be provided every 3 months. Many patients will find great success with treatment that occurs on an annual or semi-annual basis.

Injections

Weight Loss (Minimizing Obesity)

Decreasing your weight reduces the stress on your joints. Every pound carried on your body is equivalent to 4 pounds on your knees.

Weighing a patient before total hip or total knee replacement

Exercise and Physical Therapy

Building muscle is an incredibly effective way to improve the pain in your joints. Working with therapists can help develop muscles involved in hip and knee function. This improvement in strength reduces the stress put across your joint. Stretching helps with making your joints more flexible and less stiff.

Physical and Therapy

Walkers and Canes

Gait aids provide improved mobility and support for patients that need them.

What to expect during the first month after knee replacement surgery

Activity Modification

High-impact activities such as jogging on joints that are worn out may cause pain and possibly damage to your cartilage. Having reasonable expectations of your arthritic joint may allow you to have a pain-free experience.

Running

Viscosupplementation or Hyaluronic Acid Injections (Gel Shots)

These types of injections may provide cushion or lubrication to the joint.Hyaluronic acid is a substance that is naturally found in the knee and may make it easier for the knee to obtain painless motion. The FDA has approved these medications for knee injections. There have been several medical journal studies that have been published on these types of injections. Some studies have shown improvements in pain for up to 6 months ago at a time, while some have shown no improvements

Water

Anti-Rheumatic Medications

These medications have been game-changers in patients’ lives and pain control. Patients who have gout, rheumatoid, or other inflammatory arthritis should consider evaluation by a rheumatologist for co-management of their pain.

Anti-Gout Medications

The treatment options for gouty arthritis are mainly divided into one of three groups: uric-acid-lowering medication, urate-lowering medications (allopurinol, febuxostat, probenecid), and prophylactic medications. Dietary changes are recommended to patients suffering from gouty arthritis; the intake of food that adds uric acid content in blood needs to be minimized, i.e., red meat, liver, kidneys, sugary drinks, and foods rich in fructose.

Radiofrequency Ablation

Radiofrequency ablation is a technique by which a probe is inserted near a nerve and delivers radiofrequency energy, causing ionic heat to create a lesion into the nerve. By creating a lesion in the nerve, it prevents the transfer of pain signals from your arthritic knee. This prevents you from feeling the pain. Radiofrequency ablation requires anesthesia for the insertion of the probe. Some patients notice pain relief for up to two years.

TENS Unit

TENS units (Transcutaneous Electrical Nerve Stimulation) are often provided in physical therapist office to help with stimulation of muscle for muscle building and pain relief. Some patients have noticed that purchasing a portable take-home unit provides them with pain relief without the use of medications or procedures. TENS unit delivers electricity to electrode pads that are applied to the skin. This electrical stimulation will cause muscle contractions. Some patients notice an improvement in their overall pain control through this process.

Platelet Rich Plasma (PRP) injections

Platelet Rich Plasma (PRP) is a newer type of injection often not covered by insurance.  Your blood will be drawn by the staff and then placed into a centrifuge. The centrifuge will then separate the platelets and the anti-inflammatory molecules from the blood. This concentration is called platlelet rich plasma or PRP for short.  PRP injections have been shown to improve symptoms in patients with mild to moderate arthrtisi for up to 6 months to 2 years.

Platelet Rich Plasma (PRP) Centrifuge

Braces

Knee braces are an easily accessible, low-risk option for the treatment of arthritis. There are many different types of knee braces, including hinged braces, neoprene sleeves, and offloading braces.  Talk with Dr. Morton about how bracing might help with your arthritis.

Patellofemoral Brace

Alternative Medical Treatments

Stem cells and embryonic tissue are injected by some practitioners to reduce inflammation. Some patients find that stem cells bring a significant, long term relief. Please let Dr. Morton know if you are receiving these types of injections.

Cannabidiol (CBD) or medical marijuana

Marijuana is a plant that has CBD and THC components. Marijuana is a substance that is often used recreationally.  There are some medical uses of marijuana including pain relief.  One of the side effects of marijuana is drowsiness. Cannabidol (or CBD) is an extract from marijuana that is possibly related to decreasing pain without the associated drowsiness. Talk with Dr. Morton if you are considering CBD use or require a medical marijuana card.

Acupuncture

Acupuncture is associated with decreased pain. It may stimulate nerves which may lead to the release of endorphins from the pain. These endorphins may reduce the experience of pain.

Chiropractic Manipulation and Massage Therapy

Chiropractic manipulation and massage therapy have provided some patients with relief of pain in their knees. Unfortunately, there has been a minimal demonstration of prolonged pain relief with these techniques for arthritis.

Glucosamine and chondroitin are considered natural components within cartilage in the knee.  Consumption of these supplements may improve the health of cartilage within the body.

Tumeric is a natural anti-inflammatory that patients often consume with a regular diet. Many patients who are supplementing with turmeric or consuming in their regular diet may find improvement in their pain over long-term use.

Low-Level Laser Light Treatment

Low-Level Laser light treatment is a low-risk treatment that some patients have found to improve their pain. There is some research that shows that penetration into the soft tissue with low-level light causes a slight inflammatory response. This inflammatory response in turn creates a physiologic response that promotes cellular regeneration.