Lifestyle and Integrative Medicine Strategies for Managing Knee Osteoarthritis

By Ziya “Z” Altug, PT, DPT, MS, OCS

Osteoarthritis (OA) is a slowly evolving articular disease that affects the underlying bone, soft tissue, and synovial fluid.¹ Osteoarthritis typically affects the hands and large weight-bearing joints, such as the hips and knees. Some risk factors for OA include aging, obesity, overuse or abuse of joints, trauma, instability of joints, excessive mobility, and/or immobilization.² Symptom descriptors may include dull ache, insidious onset, and slow progression. Weight-bearing activity is an aggravating factor, rest is an alleviating factor, night pain may be present and/or early morning stiffness.³ Finally, knee OA may be classified as medial, lateral, or patellofemoral compartments.⁴

The following are some intervention strategies that may be considered for individuals with knee OA.

Strategy #1: Include Sustainable and Fun Activities and Exercises

Patients with knee OA may benefit from low joint-loading activities such as calisthenics, stationary cycling, swimming, tai chi, or walking, or moderate joint-loading activities such as cross-country skiing, doubles tennis, hiking, or weight lifting to help manage knee pain.⁵ It is also important to encourage patients to engage in hip and leg strengthening and range of motion, flexibility, aerobic, and balance training exercises to help improve function in daily life and reduce knee pain.^6-10

Research shows that short bout walking is an effective way of improving physical activity.¹¹ For example, the short bout approach for knee OA may include a walking program that consists of 5 to 10 minutes of walking in the morning before starting work and another short bout walk after work as an easy way to increase activity. Then at lunch, an individual could walk for another 5 to 10 minutes. This approach could add 15 to 30 minutes of physical activity into an individual’s daily activities. Another therapeutic approach is to utilize aquatic exercises to help unload and reduce stress to the knees.^12,13 Also, a person may try Ai Chi, where the elements of tai chi and qigong are performed in an aquatic setting.¹⁴

Finally, a person with OA may be advised to use motivational phrases such as “motion is lotion” or “movement is medicine.”¹⁵ This strategy may help empower individuals to move throughout their day and increase home program compliance.

Strategy #2: Try Mind Body Movements

Various studies show that yoga classes,^16,17 tai chi,¹⁸ and qigong (Baduanjin)¹⁹ may help reduce pain and improve quality of life in individuals with knee OA.

Strategy #3: Improve Nutrition

A study by Xu and colleagues in 2020²⁰ concludes that “Adherence to a Western dietary pattern was associated with increased radiographic and symptomatic knee osteoarthritis (KOA) progression, while following a prudent pattern was associated with reduced progression. In general, for people already diagnosed with KOA, eating a diet rich in fruits, vegetables, fish, whole grains, and legumes may be related to decreased radiographic and symptomatic disease progression.” For this reason, a registered dietitian or nutritionist should be a part of the rehabilitation team.

Strategy #4: Reduce Weight

An article by Felson and colleagues in 2000²¹ indicates that weight loss can affect joint forces in the knee. This could be a key fact to share with patients as a motivational tool. Felson and colleagues state that, “for each one-pound increase in weight, the overall force across the knee in a single-leg stance increases two to three pounds. This load effect probably explains most of the increased risk for osteoarthritis of the knee and hip among overweight persons.”

Strategy #5: Manage Mental Stress

A study by Lee and colleagues in 2017²² concludes that, “Mindfulness is associated with depression, stress, self-efficacy, and quality of life among knee OA patients. Mindfulness also moderates the influence of pain on stress, which suggests that mindfulness may alter the way one copes with pain.” For example, suggested stress management strategies may include meditation, mindful walking, gardening, aromatherapy (such as lavender), and gentle exercises (such as walking, yoga, tai chi, or qigong). Moreover, providing individuals with phrases such as “my mind is quiet,” “my legs feel relaxed,” or “I feel comfortable” may prove to help a person relax and feel comfortable. The phrases may be given to individuals to repeat to themselves as a part of their home program.²³

Finally, progressive muscle relaxation (PMR, see “Muscle Relaxation Routine” in gray box), originally developed by Edmund Jacobson,²⁴ may help with relaxation and managing knee pain.²⁵

Strategy #6: Optimize Sleep

A study by Gilbert and colleagues in 2021²⁶ finds that “Poor sleep quality is associated with less physical activity in persons with or at risk for knee osteoarthritis.” Patients may be provided sleep hygiene guidelines that include:^27-29

• Make sure the bedroom is quiet, dark, and cool.
• Make sure the bed and pillow are comfortable.
• Turn the alarm clock away from the bed.
• Create a regular bedtime ritual (such as wash face, brush teeth, meditate, or light reading).
• Use the bed for sleep and avoid using the bed for activities such as television, computer, or phone use.
• Do not smoke as smoking is a stimulant that disturbs sleep and negatively affects many other functions.
• Avoid caffeinated foods and beverages close to bedtime (preferably at least 3 to 5 hours before bedtime).
• Avoid alcohol near bedtime as alcohol may fragment sleep.
• Avoid heavy meals near bedtime.
• Avoid spicy food near bedtime (at least 2 to 3 hours before bedtime).
• Avoid intense exercise near bedtime as it may act as a stimulant.
• Minimize stimulating mental activities before bedtime (such as emotional discussions, reading intense books, or watching intense movies or the news).

Strategy #7: Consider Various Integrative Therapies

The following are some integrative strategies that may be used for managing knee OA:

• Cupping is a form of instrument-assisted manual therapy.³⁰
• Tui Na is a traditional Chinese medicine massage.³¹
• Self-acupressure is a form of traditional Chinese medicine based on a similar philosophy to acupuncture.^32,33
• Electroacupuncture is a modern version of acupuncture using electricity.³⁴

Strategy #8: Consider Various Self-Help Strategies

Patients may be taught how to use self-massage^35,36 and kinesiotaping^37,38 as a self-management strategy before a walking or exercise program to improve home program compliance. Also, guiding patients to select appropriate footwear may help manage knee pain.^39,40

Strategy #9: Consider Assistive Devices and Knee Braces

To improve quality of life and increase function in daily activities, patients may benefit from the use of a single point cane (or other assistive device),⁴¹ soft knee brace,⁴² or a knee unloader brace⁴³ to manage knee pain.

Strategy #10: Include Psychosocial Support Strategies

Include psychosocial support for patients through group-based activities, peers, family, and spouse for pain management and improved quality of life.^44-46

Conclusion

Interprofessional collaborations and shared decision-making⁴⁷ with the patient can help establish a therapeutic alliance to help uncover strategies for short-term symptom relief and develop meaningful long-term goals to improve overall quality of life.

Ziya “Z” Altug, PT, DPT, MS, OCS is a board-certified doctor of physical therapy with over 30 years of clinical experience treating musculoskeletal injuries. He uses lifestyle and integrative medicine strategies as a part of his therapeutic interventions. His book, Integrative Healing: Developing Wellness in the Mind and Body is available on Amazon. He is a member of the American Physical Therapy Association and the American College of Lifestyle Medicine. He can be reached at https://www.linkedin.com/in/zaltug/.