The Benefits of Hyaluronate Sodium For Knee Osteoarthritis Injections

knee injectionsIn general, the development of hyaluronate sodium for knee osteoarthritis dates back to the early to mid 1990’s. The full mechanism on how these compounds work has not been fully understood, but it is believed that they stimulate the cells in the joints to produce joint fluid and thus provide lubrication and cushioning within the joint. In the United States, these compounds have only been FDA approved for the use in the knee joint, but around the world they have been used successfully in a number of joints including shoulders, hands, hips and feet.

Knee Joint Injections

The first compound used was Synvisc. This has been produced from the rooster combs (the flesh on the top of their head) and was highly refined. Initially, it was administered in a series of five injections and has gradually been changed to a single injection. Orthopedic knee surgeons were the first to perform such injections and still probably perform the most of these injections. Since it was the first product on the market, many physicians are likely to use it.

From experience, however, it has significant drawbacks. The number one is that since it is refined from an animal product, there is a definite significant percentage of people who will have an acute inflammatory reaction to this injection. The reaction in the joint is not distinguishable from a joint infection and does often require further intervention, from checking the patient for infection, aspirating the joint, possible hospitalization, and further injection of the joint with steroid.

Since the early 2000’s, artificial hyaluronate sodium compounds have been genetically engineered and are absolutely pure compounds without any material that could cause an allergic response. All these compounds are somewhat similar and have similar effectiveness. Again, initially they came in a series of five injections, but they then refined it to a series of three injections, and now some are a single dose injection. The effectiveness in a variety of studies ranges for reducing knee pain from about 10 percent of people to 30 percent and a maximum of up to 50 percent. Injections often have to be repeated every six months to be most effective.

Who Would Benefit From Knee Injections?

The indications for these injections are osteoarthritis of the knee. Patient selection includes those who cannot take NSAID medications like ibuprofen, those who have not had long relief with steroid joint injections or are limited with steroid use, and those who have mild to moderated degenerative changes to the joint.

Once a patient is found to be a candidate for hyaluronate sodium joint injections, product selection is the next issue. In reality, this is the grey zone for recommendations, and experience with these products is helpful. Manufacturers of the products are pushing the single dose compounds, which these are convenient, however from providers it seems these may be somewhat less effective at producing results than those that are a series of three injections. Again, patient selection may be the most important factor but this is hard to tell definitively. The products that are a series of five injections do not seem to work better than those that are three injections. Further, none of the products are really better than the others when they are genetically engineered pure chemicals.

Choosing the hyaluronate sodium products for injection is based now on several practical issues. The first is to choose an artificial product that is pure. From personal experience, it is a nightmare to deal with an inflammatory reaction to one of these products and the only one that has this issue has been Synvisc, and you’d be best to avoid this injection unless you have a very experienced orthopedic surgeon who can assess your risk of a bad reaction. The best results are from genetically engineered pure products that are a series of three injections, since these tend to induce the cells in the knee to produce joint fluid on their own.

Single shot products may not be as good at inducing the knee cells to produce lubrication from a technical standpoint. The choices then are from three products that include Hyalgan, Euflexxa, and Supartz. These should all produce relatively equal results for the patients, but again on average if the knee osteoarthritis is not extreme, relief in about 30 to 50 percent of the patients is expected. All these products are FDA approved for the knee and the services to provide injections are usually covered by all insurances and are not considered experimental.

The last selection criterion is based on product cost and if an insurance carrier has a specific drug preference. The recommendation for a hyaluronate sodium supplementation product therefore would be one of the three products that include Hyalgan, Euflexxa, or Supartz unless the insurance carrier requires a single shot product, either Orthovisc or Monovisc.

Beyond the above discussion, all these injections should be done with some type of visualization procedure, either fluoroscopy or ultrasound to prove needle location and delivery to the joint space. Secondly, for those patients who want the state of the art treatment and who can pay cash, studies indicate that PRP injections have about a 50 percent success rate for pain relief for at least six months at a time. Furthermore, for the cash paying clientele, they can also use hyaluronate products as well as PRP in many of the joints in the body with about a 50% percent success rate.

Sleep and Caffeine May Play Key Role In Controlling Chronic Pain

sleep caffeineNew research out of Boston suggests that sleep and caffeine may play integral roles in controlling chronic pain flareups.

It’s probably not a huge surprise that sleep is beneficial for controlling chronic pain, as we’ve talked about the restorative benefits of sleep on our blog many times before, but the part about caffeine is interesting. Here’s what the researchers had to say.

Benefits of Sleep and Caffeine

For their study, researchers looked at the effects of sleep (or lack thereof) and caffeine on mice and their pain sensitivity. Researchers began by tracking normal sleep cycles and measuring brain activity, then they began to disrupt this healthy sleep cycle by giving mice toys and activities that entertained them and kept them awake (much like Netflix or our iPads do for humans).

“Mice love nesting, so when they started to get sleepy (as seen by their EEG/EMG pattern) we would give them nesting materials like a wipe or cotton ball,” says Dr. Alban Latremoliere, PhD and pain expert at Boston Children’s Hospital. “Rodents also like chewing, so we introduced a lot of activities based around chewing, for example, having to chew through something to get to a cotton ball.”

Researchers kept mice awake for up to 12 hours in one night or for six hours five nights in a row. They examined that fatigue, stress and pain sensitivity all increased during this time.

“We found that five consecutive days of moderate sleep deprivation can significantly exacerbate pain sensitivity over time in otherwise healthy mice,” says Dr. Chloe Alexandre, a sleep physiologist.

Caffeine’s Role

According to researchers, common painkillers did not help mice combat pain, and morphine was less effective in sleep-deprived mice, meaning chronic pain patients who are tired may have to up their morphine dose in order for it to be effective. However, researchers found that caffeine helped to block pain sensitivity.

This led researchers to conclude that a good night’s sleep combined with caffeine during the day (along with other good habits like regular exercise and a healthy diet) may be more effective for managing chronic pain than simply relaying on analgesic medications.

“Many patients with chronic pain suffer from poor sleep and daytime fatigue, and some pain medications themselves can contribute to these co-morbidities,” Dr. Kiran Maski, M.D. at Boston Children’s hospital who studies sleep disorders. “This study suggests a novel approach to pain management that would be relatively easy to implement in clinical care.”

Yoga And Acupuncture May Ease Chronic Pain Symptoms

Yoga Chronic Pain MinnesotaNew research published in the journal Mayo Clinic Proceedings suggests that activities like yoga, Tai Chi and other complementary health approaches may help alleviate discomfort associated with some types of chronic pain.

Lead author Richard L. Nahin, Ph.D., of the National Center for Complementary and Integrative Health (NCCIH) at the National Institutes of Health (NIH), suggested that activity options like Tai Chi and yoga may help prevent symptoms from chronic pain, especially when paired with other treatment options like regular exercise, a healthy diet and certain pain medications.

“For many Americans who suffer from chronic pain, medications may not completely relieve pain and can produce unwanted side effects,” said Nahin. “As a result, many people may turn to non-drug approaches to help manage their pain.”

Chronic Pain, Yoga and Tai Chi

For their study, researchers identified 150 randomized, controlled U.S. clinical trials conducted over the past 50 years that examined non-drug approaches to chronic pain. Specifically, the research targeted five common sources of pain, which were:

The treatment techniques analyzed were considered effective if patients reported that it led to improvements in pain severity and pain-related disability/function. After looking at the data, researchers found that both yoga and acupuncture were safe and effective for chronic back pain, while Tai Chi and acupuncture may be most beneficial for patients with osteoarthritis of the knee. Massage therapy was also somewhat beneficial for patients suffering from neck pain when it was managed with one-hour sessions 2-3 times per week.

“These data can equip providers and patients with the information they need to have informed conversations regarding nondrug approaches for treatment of specific pain conditions,” said David Shurtleff, Ph.D., deputy director of NCCIH. “It’s important that continued research explores how these approaches actually work and whether these findings apply broadly in diverse clinical settings and patient populations.”

At the end of the day, the study paints an interesting picture at some non-drug techniques that can be used in conjunction with other lifestyle interventions to provide relief. Simply getting massages or doing some yoga isn’t going to fully rid you of your pain, but it can play an important role in a total pain management plan. There is no magic pill to cure many of the above conditions, but with a multifaceted approach that involves treatment with a physical medicine pain specialist, relief can be found.

The Veteran’s Association and Chronic Pain

pain va minnesotaThis week there was another article on the pain management problems at the Veteran’s Association. As with all practices, the VA has had a long history of pushing opioids/narcotics as a main treatment strategy. Then suddenly a year ago, the VA decided these were not great management options and everyone had to be weaned to low dose or off these medications.

Options of management were not really given to anyone; it was just going to be the policy. This week, it was announced that one of their lead physicians has been awarded a grant to study options in weaning. Two options seem to be available, either with help of physical therapy and psychology, or possibly a slow wean by the pharmacist or with your physician.

Weaning Off Opioids

Pain is extremely complex. When a cause of the pain can be identified and treated, it is the best of all cases. Unfortunately, about a third of the population in general does suffer from chronic pain, and in many cases there is no reversible cause. Options to manage pain then become the course. Sometimes it is simple to manage and very successful. However there are oftentimes multiple generators of pain signals and it becomes difficult to develop a successful management routine. Treating pain does take a degree of compassion and it also often requires multiple strategies. Just saying no to drugs, especially to opioids, is a bit short sighted.

Addiction and abuse of opioid medications is extremely well documented. Overdose deaths are becoming rampant. Those who have pain are not resistant to having problems with opioid addiction. Furthermore, combining some medications, like those for anxiety or sleep with opioids significantly increases the risk of overdoses. Patients who have had problems with addiction to drugs, smoking or alcohol also have higher risks for addiction.  

There are many ways to treat painful conditions. One of the most important aspects of treatment of pain is working with a skilled, experienced, board certified expert in pain management. These are medical experts who hopefully have extensive ability to identify the causes of pain and develop multiple treatments to help manage the combination of problems causing the pain. They can help coordinate a variety of disciplines covering psychological needs, physical therapy, interventions and all the way through a variety of medications. As noted, there is not a single magic cure, especially not medication alone.

Unfortunately, the VA has seen a problem with opioid abuse and decided that this should be the focus of pain management. The goal appears to be to kill the devil, and get rid of this class of medications for most patients. Pain is much more complex than treatment with a single medication. Some people are dependent upon this as part of their overall management. At this time, there are not a lot of effective medications to treat pain. Research is making strides at better understanding the mechanisms involved in pain and the cells in the body that perpetuate the problems. Still we are definitely lacking solutions.

Instead of making opioids the enemy, maybe there is a better strategy. At this time we need to work on better treatments for pain instead of just eliminating medication options. Using pain management experts who can employ multiple strategies to properly diagnose and treat pain problems is what is needed. The recognition is needed that decisions on treatment options of pain should be made by pain experts, not by addiction experts administering a budget policy. Pain is truly complex and not simple to fully diagnose, manage, or treat.

Will Doctors be Replaced by Computers?

telemedicine minnesota computersTechnology and computers are taking over many tasks in society. For instance, in the past in grocery stores, a clerk typed in the price of an item into a cash register to sum up the total of items. Now, a scale is built into a barcode scanner and cashiers are not really needed.  In law offices, smart scan machines are reading legal documents and checking for errors, a job that used to be reserved for new lawyers. So if computers are invading the world, will doctors be necessary to see patients and determine the right treatment? The answer is complex.

The Future of Telemedicine

Computers are currently used for a multitude of tasks in the medical field.  There are robots that assist in surgery, and in some hospitals, robots are the carriers of medications and supplies throughout the premises. Specialized computers are now scanning X-rays and looking for abnormalities, as sometimes subtle changes are better spotted by computers than humans. In intensive care wards, computers often monitor the extensive data of each patient and can spot trends and suggest treatment options based on extensive data analysis. With increasing data in medicine, computers can often analyze any number of problems and help determine solutions based on the probabilities suggested by the information.

Telemedicine is also a burgeoning field. This can be a variety of medical activities from providing long distance consults with video chats through a remote clinic and provider or specialist, to a visit that is with a nurse, patient or a long distance provider. Remote monitoring of data by a specialist for an intensive care unit and remote reading of radiology imaging is also being done.

Computers can analyze information and find patterns in data if programmed well, however, they cannot yet substitute for the personal interactions of a patient and doctor. A computer still is unable to do a complete physical exam and understand subtle abnormalities portrayed by a patient. Assembling the information from a history, exam and studies, as well as interpreting responses to treatment performed to determine what may be beneficial next in management is also currently beyond the ability of a computer without extensive interaction with a physician.

Computers can be a great assistant in medicine. The human factor of personal interaction with a patient and performing a physical exam is essential in the ability to treat any patient. Many times I have reviewed a patient’s history and studies prior to a visit in order to form a tentative plan, and after the visit found a totally different problem with a need for a different treatment plan. The human factor is often essential in patient treatment, the compassion and the individualized management coordinating a plan. At this time computers may be an assistant but they are not ready to replace the doctor.