The Challenge of Knee OA and the Potential of Manual Therapy

Knee osteoarthritis is a major public health problem that primarily affects the elderly. Almost 10 percent of the United States population suffers from symptomatic knee osteoarthritis by the age of 60. In fact, OA is prevalent worldwide, especially with an increasingly aging society. It is one of the leading causes of pain and dysfunction in the joints among the aging population.1 Despite this, there are no approved interventions that ameliorate structural progression of this disorder.

OA is a degenerative joint disorder characterized by articular cartilage degradation, osteophyte formation, synovium hyperplasia, subchondral bone cysts and sclerosis. Its pathogenesis remains unclear, making it a challenge to manage. Even with all the technological advances in imaging and improvements in joint replacements, we are lacking effective nonsurgical methods of management, especially in the early stages of the disease. As far as prevention and or preventing progression, there are no practical options.

Diagnosis: A Major Challenge

At present, the diagnosis of OA of the knee primarily depends on clinical symptoms and radiographic findings. Conventional radiography is still being used as a standard imaging technique for the evaluation of known or suspected OA in clinical practice and research. (Figure 1)

Kellgren-Lawrence radiographic grading criteria is generally the assessment tool used in the evaluation of OA in the knee. This is a problem because most individuals are clinically asymptomatic in the early stages of OA, and often pathological degradation of the articular cartilage already exists before the symptoms arise.

So, What's the Takeaway?

The definition and diagnosis of OA is evolving with improvements in risk-factor measurement, using advanced imaging, systemic and local biomarkers and improved methods for measuring symptoms, which help to understand the mechanisms and identify potential areas for intervention or prevention. Regenerative medicine, despite tremendous interest, has yet to able to demonstrate the efficacy of this modality for definitive structural improvement that would last for years or decades, and obviate or delay the need for joint arthroplasty.

All these modalities are still only symptomatic relief, which don't seem to justify the high cost. We are still just managing the symptoms, rather than reducing disease progression. So, why not take a more conservative biomechanical approach than surgery, at least in the earlier stages of disease? Not everyone needs a joint placement, and they don't come with a warranty.

Chiropractic Intervention

Manual therapy, which includes joint mobilization and manipulation, combined with stretching and strengthening exercises to affect the components of the full kinematic chain of the lower extremity, including the lumbar segments, has proven beneficial.10-11 This is a form of conservative biomechanical therapy – really a chiropractic treatment. This type of manual therapy, along with exercise, muscle strengthening, and nutritional / weight-management consulting, should be an option for most patients, particularly in the earlier stages of disease (Kellgren Grade 1-3).12-13

Research on the clinical efficacy of chiropractic manual therapy techniques for the spine is well-documented.14 However, much less attention has been focused on chiropractic interventions directed toward the peripheral joints. Individualized manual therapy, along with the prescription of an aerobic walking and quadriceps-strengthening exercise program, has been documented to significantly improve knee pain and function.15

Application of chiropractic knee techniques can significantly reduce the symptoms associated with knee OA.16 Macquarie Injury Management Group Knee Protocol (MIMG) is a chiropractic approach that includes two techniques: myofascial mobilization and myofascial manipulation.17 It was introduced by the MIMG group, Australia. The protocol consists of a noninvasive myofascial mobilization procedure and an impulse thrust procedure specific to the patellofemoral articulation. Maitland and Mulligan mobilizations are two other protocols used in osteoarthritis treatment.

The takeaway: Much can be offered with manual therapy for the patient who has good bony and ligamentous integrity, but also happens to suffer from osteoarthritis of the knee.