“There’s no one-size-fits-all solution for osteoarthritis of the knee”

The most important factors in therapy for knee osteoarthritis are the manifestations of pain and the biomechanics of the knee, says Prakash Jayabalan, MD, PhD. Solutions have to be tailored to the patient and the condition. Our interview with Dr. Jayabalan, who specializes in osteoarthritis and currently practices in the USA, emphasizes the importance of an individual therapy approach, which when appropriate includes bracing as an adjunct to other treatment modalities.

life: What are your goals when pursuing conservative treatment for your patients with osteoarthritis of the knee?

Dr. Jayabalan: Most of my patients with knee OA come to me because of the pain they’re experiencing, so pain relief is clearly the focus. Equally important, and connected with this, is to change their biomechanics for improved joint function. The knee needs stability, strength and relief, which can be accomplished through targeted weight loss and consistent training.
It’s always important to evaluate the knee and to strengthen the muscles with exercises tailored to each patient’s condition. Apart from medication and injections, supports and orthoses can help to reduce pain and relieve the knee.

What are the biggest challenges in treating these patients?

Dr. Jayabalan: The main problem, of course, is that no existing treatment or available device is capable of preventing progression of osteoarthritis of the knee.
A complicating factor is that the classic knee OA patient is typically older and with a higher BMI, limiting their ability to perform appropriate training and exercise. Since pain limits OA patients, pain management is extremely important.
From a clinical and mechanical perspective, osteoarthritis of the knee is a highly complex condition that affects many structures in the knee joint, not just the layers of cartilage. The bones, ligaments and muscles also need attention, which is also why there’s not just ‘one treatment for all’ approach for knee osteoarthritis. Instead I am deeply convinced that knee OA should be treated on an individual basis, always tailored to the existing findings and the specific patient: What are the patient’s goals and expectations, and which treatment methods would leave the patient most satisfied? Of course, you must also consider what is realistically achievable and which treatments offer the greatest chances of success, including a consideration of the patient’s everyday routine. For example, asking a patient who generally only walks one thousand steps per day to start exercising by immediately training at ten thousand steps per day won’t be a successful strategy.

What role do knee supports and orthoses play in conservative treatment?

Dr. Jayabalan: We can achieve positive results using supports and orthoses for osteoarthritis of the knee; but the crux is satisfaction and acceptance among the wearers. Patients often perceive braces and supports as large, bulky and obstructive for their daily routine, especially for athletic activities. When a patient is fitted with a comfortable support or orthosis it can be very beneficial for their sense of stability and have the potential to improve their movement habits.
There are solid physiological advantages to bracing. Supports and orthoses can relieve the knee joint, improving the functional interplay of the individual structures. They help to protect against excessive strain, protecting against pain and giving patients confidence to get moving and stay more active. Bracing can be an important part of improving the stability and confidence patient’s may feel in performing their everyday functions.

How could the recommendation and acceptance of supports and orthoses for conservative treatment be further improved from a clinical perspective and from the patient’s point of view?

Dr. Jayabalan: From a clinical perspective, controlled long-term studies with biomechanical measurements to assess the effects could significantly improve the recommendation of knee supports and orthoses. In my opinion, the currently existing evidence for supports is not differentiated enough, particularly in terms of the investigation period. After all, a support or orthosis doesn’t have an instantaneous effect in all respects. For instance, sustainable improvements in mobility only become evident over a longer time period. Ideally there would be a study with measurable results providing potential evidence of the long-term effects of a knee support, for example for joint relief. That could be a relatively simple, easy to conduct study with a duration of between six and twelve months.

And thanks to these studies, the patients would see that they have an option that has been demonstrated to reduce symptoms and slow down their functional decline. This would also be highly beneficial in managing patients’ expectations when it comes to immediate effects. Then maybe there would not be so much focus on pain medications (either oral or injectables) alone, which is one of the most common treatments for knee OA here in the United States. One clear advantage of bracing is that it represents low risk for the patient as a non-invasive treatment modality.

In your opinion, what are the requirements that knee OA braces have to fulfill?

Dr. Jayabalan: The fit and comfort of bracing is a decisive factor. Off the shelf products are generally not sufficiently comfortable to wear off the shelf and a “one size fits all” approach is also inappropriate for the same reason. A single product cannot be the solution for the biomechanical problems faced by all patients. On the contrary, this tends to lead patients to believe that all orthoses are large and bulky, restrictive and poorly fitting.
Diversity and options for customization and adjustment are extremely important. This also helps patients’ acceptance and satisfaction with their products, since they know they are getting something designed to fit them personally: tailored to their diagnosis, their knee and their everyday needs.

The Bauerfeind portfolio includes supports with proprioceptive effect for patients with mild to
moderate osteoarthritis of the knee, mechanically relieving orthoses for patients with moderate
to severe OA, and products that combine the two (GenuTrain OA). How would you assess
this range?

Dr. Jayabalan: Intuitively, a product range with various solutions addressing different levels of disease severity, makes sense in terms of creating an individualized therapy plan based on patient needs. In terms of generating additional clinical evidence, I would encourage longer-term studies tracking and analyzing biomechanical effects as well as patient reported subjective perceived quality
of life improvements.

Images: iStockphoto.com/ttsz, Bauerfeind