Research progress on treatment measures for joint function in non-surgical patients with knee osteoarthritis

Zhixia Liu; Shiyu Song; Quanying Zhang; Dongqin Wang

doi:10.1016/j.jor.2024.11.023

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64 (); 64-67

doi:

10.1016/j.jor.2024.11.023

Research progress on treatment measures for joint function in non-surgical patients with knee osteoarthritis

Zhixia Liu^a, Shiyu Song^a, Quanying Zhang^b,, Dongqin Wang^b

a The First Clinical College of Xinxiang Medical College, China

b The First Affiliated Hospital of Xinxiang Medical University, China

⁎Corresponding author: Quanying Zhang. liuzxlsh@163.com

Received: 2024-9-26, Accepted: 2024-11-24, Published: 2024-11-25

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

As human lifespan increases and the proportion of obese people increases, the prevalence of knee osteoarthritis continues to increase. Its main clinical manifestations include joint pain, snapping, and decreased joint function. Due to the slow progression of the disease in KOA, patients have been troubled by the disease for a long time, affecting their quality of life. Therefore, the main purpose of treatment is to relieve symptoms and restore joint function. At present, most clinical studies focus on the joint function of postoperative KOA patients. However, in real life, there are still KOA patients who do not meet the surgical standards, and there are relatively few studies on this part. Therefore, this article reviews the relevant concepts, influencing factors and intervention measures for joint function in patients with non-surgical knee osteoarthritis in recent years, to provide a theoretical reference for subsequent research on improving joint function in patients with non-surgical knee osteoarthritis, and to improve patient's quality of life.

Keywords

Non-surgical

Knee osteoarthritis

Joint function

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1 Introduction

Osteoarthritis (OA) is a disease caused by a variety of factors, characterized primarily by damage to articular cartilage and the proliferation of bone at the edges of joints. It is often accompanied by subchondral bone sclerosis, synovial inflammation, and soft tissue changes around the joint.¹ It is estimated that 10 %–20 % of individuals over the age of 60 suffer from OA.² Among all affected joints, knee osteoarthritis (KOA) accounts for more than 83 % of the total disease burden.³ Its clinical symptoms mainly manifest as knee joint pain, stiffness, swelling, and limited mobility, which may lead to disability in the advanced stages. The knee joint is one of the most complex joints in the human body, composed of the distal femur and the proximal tibia, and includes ligaments, menisci, and other accessory structures.⁴ Under normal conditions, the knee joint works in conjunction with surrounding tissues to flex and extend flexibly. However, due to the mild early symptoms and slow progression of KOA, many people do not pay enough attention. Over time, patients will experience significant joint pain and crepitus, leading to a decline in joint function. However, in real life, there are patients who have not met the criteria for surgery and only receive corresponding treatment measures to alleviate their current discomfort. Therefore, for these patients who have not reached the surgical indications or are only in the early to middle stages of knee osteoarthritis, providing them with appropriate guidance to alleviate pain and improve their quality of life is essential. This article aims to review the current status, influencing factors, and treatment measures of joint function in non-surgical knee osteoarthritis patients, and to provide solutions and a reference basis for the recovery of joint function in non-surgical knee osteoarthritis patients. Through these efforts, we hope to help patients better manage their conditions, improve their quality of life, and provide guidance for future clinical practice and research.

2 The current state of domestic and international research on joint function in non-surgical patients with knee osteoarthritis

In 2023, the European League Against Rheumatism updated its treatment recommendations for non-pharmacological therapy of hip and knee osteoarthritis, suggesting that patients gradually transition from low-intensity exercises to high-intensity exercises, and encouraging patients with knee osteoarthritis (KOA) to incorporate exercise into their daily activities.⁵ Taglietti⁶ demonstrated that after 8 weeks of aquatic exercise therapy, KOA patients experienced significant improvements in joint pain and joint function, with follow-up surveys at 3 months showing that the treatment plan involving aquatic exercises could enhance patients' joint function. Cheung⁷ conducted a randomized controlled trial dividing KOA patients into groups practicing Hatha yoga, aerobic strengthening exercises, and health education, to compare the effects of Hatha yoga and aerobic strengthening exercises on KOA patients. The results showed that both Hatha yoga and aerobic strengthening exercises effectively improved symptoms and function in KOA patients, with the efficacy of Hatha yoga being superior to that of the aerobic strengthening exercise group. In China, the "Expert Consensus on the Diagnosis and Treatment of Knee Osteoarthritis in Traditional Chinese Medicine," published in 2015, recommends that KOA patients engage in various forms of exercise therapy under the guidance of professional doctors, such as straight leg raises, jogging, Tai Chi, and Baduanjin.⁸ Huang⁹ applied Baduanjin to KOA patients, using exercise as a means of rehabilitation training, and the results indicated that Baduanjin not only improved patients' knee extensor function and joint mobility but also had a high satisfaction rate among patients. Research from both domestic and international sources advocates for the promotion of exercise therapy as the preferred method for treating the joint function of non-surgical KOA patients. By employing different forms of exercise, the muscle strength around the knee joint is enhanced, thereby restoring patients' joint function. In China, some scholars use unique traditional Chinese medicine therapies to alleviate the discomfort symptoms of KOA patients and achieve the purpose of treatment.

3 Influencing factors in the occurrence of knee osteoarthritis

3.1

3.1 Age and gender

Age is a widely recognized risk factor for the development of knee osteoarthritis (KOA) among experts and scholars.¹⁰ As people age, the risk of developing KOA also increases. This may be related to the increased vulnerability of the knee joints in the elderly, such as decreased muscle strength, laxity of the ligaments around the knee joint, and wear and tear of the articular cartilage. Under the influence of these factors, the stability of the knee joint is reduced. Research by Chinese scholar Wang¹¹ indicates that about 48.7 % of individuals aged 50 to 60 have KOA, the prevalence rate is 62.2 % among those aged 60 to 70, and 63.1 % among individuals over 70 years old. Additionally, the incidence of KOA is higher in women than in men. Studies have shown that the radiographic prevalence of KOA in women is about 3.5 times that of men, and the prevalence of symptomatic KOA is 5.2 times higher in women than in men, with women significantly exceeding men.¹² This may be associated with the fluctuating hormone levels in women and the practice of women squatting to urinate.¹³

3.2

3.2 Obesity

In the study by Wallace,¹⁴ it was found that individuals with a higher Body Mass Index (BMI) have an increased risk of developing KOA. Furthermore, changes in body weight are directly linked to the risk of joint damage. Riddle¹⁵ through long-term follow-up of KOA patients, revealed a dose-response relationship between changes in body weight and corresponding pain and functional impairment. After a 3-year follow-up, the study data showed that a weight loss of more than 10 % in patients can significantly enhance knee joint function and reduce the level of knee pain. In contrast, a weight gain of 10 % can exacerbate knee pain and decrease joint function.

3.3

3.3 Occupational activities

The health of articular cartilage and surrounding tissues of the knee joint depends on moderate joint loading. Therefore, excessive loading that exceeds the joint's tolerance may lead to the occurrence of KOA. Research by Cooper¹⁶ indicates that squatting or kneeling for more than 30 min daily or frequently lifting items exceeding 25 kg, can increase the risk of developing KOA by five times. In Kujala's¹⁷ study of male athletes, weightlifters had the highest incidence of KOA, reaching 28 %, while football players had an incidence of 26 %. It is evident that various types of occupational activities are significant influencing factors in the incidence of knee osteoarthritis.

4 Treatment measures for joint function in non-surgical knee osteoarthritis patients

4.1

4.1 Exercise therapy

Exercise therapy, proven in research to be a reliable and convenient treatment for KOA without the need for specific facilities and with low economic cost, is recommended as a first-line treatment for KOA by multiple guidelines domestically and internationally. The Osteoarthritis Research Society International updated its "Non-surgical Treatment Guidelines for Knee Osteoarthritis" in 2014, recommending land-based exercises, aquatic exercises, and strength training as non-pharmacological treatment methods for KOA patients.¹⁸ As an adjunct to physical therapy, exercise can prevent cartilage deformation and prevent the loss of trabecular bone in the metaphysis.¹⁹ Therefore, patients can improve joint mobility, enhance balance, and increase muscle strength around the knee joint through exercise training, thereby further improving knee joint function.²⁰ Bennell found that after 30 months of isokinetic muscle strength training, the incidence of knee joint space narrowing in patients was reduced by 26 %, and improvements were observed in knee flexion-extension range, quadriceps strength, and knee pain intensity.²¹ Other studies have shown that exercise training not only improves joint function but also has positive effects on patients' cardiopulmonary function, stable posture, and mental health.²² Therefore, exercise training is an effective adjuvant therapy, playing an important role in the treatment of patients with knee osteoarthritis. Although exercise therapy is widely applied to postoperative patients in China, more attention should also be given to the functional exercise of non-surgical knee osteoarthritis patients. Thus, applying appropriate exercise therapy to patients with early to mid-stage knee osteoarthritis can help alleviate discomfort symptoms and enhance knee joint function.

4.2

4.2 Traditional Chinese medicine treatment

Traditional Chinese Medicine (TCM) offers a variety of treatment methods for Knee Osteoarthritis (KOA) and has numerous successful treatment cases.²³ The main therapeutic approaches include acupuncture, tuina (Chinese therapeutic massage), needle knife therapy, and the use of Chinese herbal medicine. For instance, Ju²⁴ randomly divided patients into two groups, with 30 patients in the control group receiving celecoxib capsules orally and 30 patients in the treatment group receiving electroacupuncture treatment at different acupoints such as Yanglingquan, Liangqiu, and Zusanli. After two weeks of treatment, the pain levels and joint functions of the patients in the treatment group were superior to those in the control group. Moreover, the American College of Rheumatology guidelines suggest that acupuncture be used to treat KOA patients when drug therapy is ineffective, fully acknowledging the effectiveness of acupuncture treatment.²⁵ Some researchers use tuina techniques to treat KOA, mainly based on the concept of "bone and muscle work together" and "muscles serve the bones," adjusting the tension balance of the muscles and fascia around the knee joint, playing an important role in maintaining the mechanical balance of the bone and muscle structure around the knee. Yuan²⁶ randomly divided 74 KOA patients into a control group and a treatment group, with the control group receiving oral celecoxib and the treatment group receiving tuina therapy. The results showed that the WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) scores of the patients in the treatment group were better than those in the control group, and their joint functions were improved. At the same time, Wang's²⁷ research results also indicated that the overall treatment effectiveness of KOA patients receiving a combination of tuina and acupuncture was significantly higher than that of those receiving oral Western medicine alone, suggesting that the combination of TCM tuina and warm acupuncture has a definite therapeutic effect on KOA, effectively reducing patients' pain and enhancing the range of joint motion.

4.3

4.3 Pharmacological treatment

The appropriate use of chondroprotective drugs (such as chondroitin) can help repair the damaged articular cartilage in patients with knee osteoarthritis. In addition to their anti-inflammatory and analgesic effects, these chondroprotective drugs can also slow down the progression of the patient's condition.²⁸ The principle is that chondroitin is a major component of the extracellular matrix of articular cartilage and plays an important role in generating significant osmotic pressure. In this way, it can provide resistance and elasticity to the cartilage to withstand tensile stress under load-bearing conditions.²⁹ Research by Rovati³⁰ shows that although the treatment course of chondroitin is relatively long, the drug's efficacy tends to increase gradually throughout the study period. Even after discontinuing the medication after it takes effect, the duration of the therapeutic effect is longer than that of nonsteroidal anti-inflammatory drugs (NSAIDs), and it has a lasting promoting effect on the recovery of knee joint function. Moreover, it has fewer side effects, whereas long-term use of NSAIDs can cause gastric damage, so patients with gastric problems are not recommended to use such drugs. In clinical practice, different drugs can also be used in combination to treat patients. For example, Long³¹ divided 88 patients with knee osteoarthritis into a study group and a control group, with 44 cases in each group. The study group used hydrochloric acid glucosamine in combination with anti-osteoporosis drugs, while the control group used anti-osteoporosis drugs alone. After two months of treatment, the therapeutic effect of the study group was significantly higher than that of the control group, and the improvement in pain levels and joint function in the study group was greater than that in the control group, indicating that the efficacy of the combined medication is superior to monotherapy.

4.4

4.4 Physical therapy

Patients with Knee Osteoarthritis (KOA) can also use physical therapy methods during the treatment process, which mainly include ultrasound therapy, pulsed electromagnetic field therapy, laser therapy, and whole-body vibration therapy, etc. These methods primarily work by enhancing local blood circulation and reducing inflammatory responses, effectively alleviating muscle tension and local pain.³² Studies have indicated that low-intensity pulsed ultrasound therapy is both safe and effective for KOA patients, and can significantly relieve pain and restore knee joint function.³³ Tavakoli³⁴ also found that low-intensity pulsed ultrasound can inhibit chondrocyte apoptosis, aiding in the repair of articular cartilage. However, some experts³⁵ believe that ultrasound therapy does not play a role, and the differences may be related to the varying severity of the conditions of the subjects selected for the study. Therefore, further research is needed to determine whether ultrasound has a reparative effect on articular cartilage. Whole-body vibration therapy, on the other hand, uses mechanical vibrations to stimulate proprioceptors, triggering involuntary muscle contractions, as a form of strength training to activate muscle function.³⁶ Zhang³⁷ found that whole-body vibration therapy can activate the flexor and extensor muscle groups around the knee joint in KOA patients, with the most significant therapeutic effects observed at a low vibration frequency with the knee flexed at 60°.

4.5

4.5 Other therapies

Some researchers have also used methods such as Tai Chi and Wu Qin Xi to treat KOA patients, aiming to alleviate symptoms and gradually restore joint function. Ghandali³⁸ conducted a single-blind randomized trial to implement Tai Chi as a therapeutic method, and after secondary analysis, a reduction of 9–11 points in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was observed, promoting the recovery of patients' joint function, a result consistent with the conclusions of domestic researchers. Domestic experts selected 120 subjects and used a combination of isokinetic muscle strength and the subjective Berg Balance Scale to study the effects of Wu Qin Xi on knee muscle strength and balance in middle-aged and elderly female patients.³⁹ After comparison, it was found that the knee muscle strength of middle-aged and elderly female patients was enhanced, the rate of muscle strength decline was slowed down, and the patients' balance ability was improved.

5 Conclusion

A comprehensive review of domestic and international research findings indicates that exercise therapy is the preferred treatment method for the recovery of knee joint function, followed by pharmacological and physical therapies. Although there are various treatment options available, patients can, under the guidance of a physician, choose suitable treatment methods based on their condition and financial status. Moreover, from the early detection of knee osteoarthritis to hospitalization for surgical treatment, patients must endure a long period during which they are continually troubled by the disease. Most clinical researchers primarily focus on the joint function of postoperative KOA patients, while there is relatively less research on the majority of KOA patients who have not met the criteria for surgery. Therefore, it is necessary to conduct research on non-surgical knee osteoarthritis patients to alleviate their clinical symptoms, restore joint function, and thereby improve their quality of life.

CRediT authorship contribution statement

Zhixia Liu: Conceptualization, Project administration, Writing – original draft. Shiyu Song: Investigation, Writing – original draft. Quanying Zhang: Supervision, Writing – review & editing. Dongqin Wang: Supervision, Writing – review & editing.

Ethical statement

There were no ethical concerns associated with the completion of this study as this review used previously published data.

Funding statement

No funding was obtained for the creation of this review.

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Show Sections

[1] Foster N.E., Eriksson L., Deveza L., Hall M., . Osteoarthritis year in review 2022: epidemiology & therapy. Osteoarthritis Cartilage. 2023;31(7):876-883.
[Google Scholar]

[2] Pereira D., Peleteiro B., Araújo J., Branco J., Santos R.A., Ramos E., . The effect of osteoarthr-itis definition on prevalence and incidence estimates: a systematic review. Osteoarthritis Cartilage. 2011;19(11):1270-1285.
[Google Scholar]

[3] Vos T., Flaxman A.D., Naghavi M., et al . Years lived with disability (YLDs) for 1160 sequelaeof 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2163-2196.
[Google Scholar]

[4] Tong B., Chen H., Wang M., et al . Association of body composition and physical activity with pain and function in knee osteoarthritis patients: a cross-sectional study. BMJ Open. 2024;14(1)
[Google Scholar]

[5] Moseng T., Vliet Vlieland T.P.M., Battista S., et al . EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis: 2023 update. Ann Rheum Dis. 2024;83(6):730-740.
[Google Scholar]

[6] Taglietti M., Facci L.M., Trelha C.S., et al . Effectiveness of aquatic exercises compared to patient-education on health status in individuals with knee osteoarthritis: a randomized controlled trial. Clin Rehabil. 2018;32(6):766-776.
[Google Scholar]

[7] Cheung C., Wyman J.F., Bronas U., McCarthy T., Rudser K., Mathiason M.A., . Managing knee osteoarthritis with yoga or aerobic/strengthening exercise programs in older adults: a pilot randomized controlled trial. Rheumatol Int. 2017;37(3):389-398.
[Google Scholar]

[8] Lin J.M., Quan R., Dong Y.W., et al . Application status analysis of "expert consensuson Diagnosis and treatment of knee osteoarthritis in traditional Chinese medicine (2015 edition)" in the study of knee osteoarthritis. J Tradit Chin Orthop Traumatol. 2023;35(7):11-15+29.
[Google Scholar]

[9] Huang F., Chen W., . Study on the applied effect of Baduanjin in rehabilitation nursing exercise of knee osteoarthritis. Chin Community Doct. 2021;37(5):158-159.
[Google Scholar]

[10] Rehman Y., Korsvold A.M., Lerdal A., Aamodt A., . No difference in patient-reported outcomes with cruciate-retaining, anterior-stabilized, and posterior-stabilized total knee arthropla-stydesigns. Bone Joint Lett J. 2023;105-B(12):1271-1278.
[Google Scholar]

[11] Wang J.H., . Progress research on the pathogenesis and treatment of knee osteoarthritis. Med Inf. 2019;32(4):57-59.
[Google Scholar]

[12] Kim I., Kim H.A., Seo Y.I., Song Y.W., Jeong J.Y., Kim D.H., . The prevalence of knee osteoarthrits in elderly community residents in Korea. J Kor Med Sci. 2010;25(2):293-298.
[Google Scholar]

[13] De Zwart A.H., Dekker J., Roorda L.D., et al . High-intensity versus low-intensity resistance training in patients with knee osteoarthritis: a randomized controlled trial. Clin Rehabil. 2022;36(7):952-967.
[Google Scholar]

[14] [Google Scholar]

[15] Riddle D.L., Stratford P.W., . Body weight changes and corresponding changes in pain and f-unction in persons with symptomatic knee osteoarthritis: a cohort study. Arthritis Care Res. 2013;65(1):15-22.
[Google Scholar]

[16] Cooper C., McAlindon T., Coggon D., Egger P., Dieppe P., . Occupational activity and osteoarthritis of the knee. Ann Rheum Dis. 1994;53(2):90-93.
[Google Scholar]

[17] Kujala U.M., Kettunen J., Paananen H., et al . Knee osteoarthritis in former runners, soccer players, weight lifters, and shooters. Arthritis Rheum. 1995;38(4):539-546.
[Google Scholar]

[18] McAlindon T.E., Bannuru R.R., Sullivan M.C., et al . OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage. 2014;22(3):363-388.
[Google Scholar]

[19] Zeng C.Y., Zhang Z.R., Tang Z.M., Hua F.Z., . Benefits and mechanisms of exercise training for knee osteoarthritis. Front Physiol. 2021;12
[Google Scholar]

[20] Raposo F., Ramos M., Lúcia Cruz A., . Effects of exercise on knee osteoarthritis: a systematic review. Muscoskel Care. 2021;19(4):399-435.
[Google Scholar]

[21] Bennell K.L., Hinman R.S., . A review of the clinical evidence for exercise in osteoarthritis of the hip and knee. J Sci Med Sport. 2011;14(1):4-9.
[Google Scholar]

[22] Garber C.E., Blissmer B., Deschenes M.R., et al . American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining ca-cardiorespiratory-tory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43(7):1334-1359.
[Google Scholar]

[23] Li J., Li Y.X., Luo L.J., et al . The effectiveness and safety of acupuncture for knee osteoarthritis: an overview of systematic reviews. Medicine (Baltim). 2019;98(28)
[Google Scholar]

[24] Ju Z.Y., Wang Y., Chen C.L., Cui H.X., Ding J.Y., Wang K., . Clinical study on electroacupuncture for knee osteoarthritis. SH J TCM. 2017;36(9):1111-1115.
[Google Scholar]

[25] Hochberg M.C., Altman R.D., April K.T., et al . American College of Rheumatology 2012 re-commendations for the use of nonpharmacologic and pharmacologic therapies inosteoarthritis of the hand, hip, and knee. Arthritis Care Res. 2012;64(4):465-474.
[Google Scholar]

[26] Yuan P., Si F.J., . Tuina in treating knee osteoarthritis based on concept of holism: a rando-m positive controlled clinical study. SH J TCM. 2018;52(10):60-62+66.
[Google Scholar]

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Research progress on treatment measures for joint function in non-surgical patients with knee osteoarthritis

Abstract