May 2013

Out on a limb: Yes, treat the symptoms

Jordana-twitterJordana Bieze Foster, Editor

In the healthcare community there’s a lot of talk about the importance of treating the underlying cause of a disease rather than just the symptoms. But sometimes treating the symptoms can be pretty darned important too.

This is particularly true in the case of knee osteo­arthritis, for which a number of interventions have been found to effectively relieve pain and improve function, but none have yet been found to effectively slow disease progression.

Most frustrating is that some interventions—including braces, wedged orthoses, and footwear—have been associated with significant decreases in knee adduction moment, which is a surrogate measure of knee loading. If a device really reduces knee loading, one would think it would also slow disease progression. Unfortunately, so far, researchers have had a hard time demonstrating that.

But that doesn’t mean those interventions aren’t worthwhile. Far from it.

Pain is an incredibly strong determinant of quality of life. Pain is often associated with depression and anxiety, and even pain that doesn’t technically affect a patient’s ability to function probably still affects that patient’s ability to function well. And knee osteo­arthritis pain affects function in pretty much anyone with an interest in walking, even if only to get to the next room.

So any intervention that helps relieve knee OA pain will automatically make a knee OA patient’s life a little better. That in itself is worth something.

But there are other benefits as well. Reducing a patient’s pain may make that patient more likely to exercise, which has additional positive trickle-down effects. Strength gains associated with exercise can further improve pain and function. And, in obese or overweight patients with knee OA, weight loss achieved by adding exercise to diet leads to greater pain relief and function gain than weight lost through diet alone.

Even patients whose disease has progressed to the point where they need total knee arthroplasty (TKA) can still benefit from symptom management. Research suggests that performing selective strength exercises prior to TKA can significantly improve outcomes after surgery—but many practitioners say their end-stage knee OA patients are in too much pain to participate in such prehabilitation programs. If an intervention can reduce a patient’s pain so that prehabilitation is feasible, that’s yet another reason to keep that intervention in the clinical arsenal.

Of course, the benefits of almost any intervention have trade-offs. Pharmaceutical analgesics can be associated with various side effects, including gastrointestinal and cardiovascular adverse events. Braces and other devices come with issues related to comfort, convenience, and aesthetics. And there’s always the issue of cost to consider, as well.

Certainly finding an intervention that slows or reverses disease progression is the holy grail of knee OA research. Until that happens, practitioners will have to manage their patients’ symptoms using the interventions that are currently available. Those interventions may not be ideal. But they can still make a huge difference in a patient’s life.

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