A case of advanced stage gonarthrosis treated with prolotherapy
A 70 year old, obese female presented with complaints of pain in both the knees. She was a known case of osteoarthritis for over 5 years. She had a recent flare up of pain with a positive patella tap sign on examination. The pain did not improve with stepped therapy using paracetamol then nonselective non-steroidal anti-inflammatory agents (NSAIDs). Her pain was gradually worsening and for that she was seen regularly seen in the clinic. She complained of severe pain after prolonged walking or stair climbing, and rarely, it disturbed her sleep during night. Almost two years ago, she was treated with physiotherapy and intra-articular steroid and later, a year ago, the same doctor applied hyaluronic acid injections but in vain. She was prescribed with various medications including paracetamol (500 mg), caffeine (30 mg), codeine (10 mg) and dexketoprofen trometamol (25 mg). It was risky to go for surgical intervention due to her underlying chronic ailments, about which her previous doctor had already informed her. Therefore, finally she was recommended to our clinic.
These symptoms are most consistent with which of the following conditions?
- Bony metastatic disease
- Spinal canal stenosis
- Vertebral fracture
Osteoarthritis (OA) is one of the very common ailments affecting musculoskeletal system (1). Gonarthrosis (osteoarthritis of the knee) refers to the progressive, wear and tear disease indicated by inflammation of the knee joint causing injury to the articular cartilage. The symptoms like pain, stiffness and restricted motion of the joint are thought to be occurring from the imbalance between the collagen synthesis and the damage of the articular cartilage (2). Overall OA is of great concern across the globe, and estimated to affect almost 50 percent of the population aged over 65 years. In addition to age, sex, inheritance, it also bears a close association with obesity, injuries, sedentary lifestyle and dietary factors (3). It is one of the most common forms of arthritis seen in primary care practice, and the second most common rheumatologic problem and is a most frequent joint disease. About 13% of women and 10% of men aged 60 years and older have symptomatic knee OA, indicating a lower prevalence in men as compared to women (4). The risk of arthritis and OA is up to seven times higher for obese people, compared with their underweight/normal weight peers (5). Globally, knee OA was ranked as the 11th highest contributor to global disability and 38th highest in disability-adjusted life years (6). Also, this is the most common cause of locomotor disability in the elderly (7), and consequently, it is the leading indication for the joint replacement surgery (8). Knee and hip joints usually cause the most morbidity (9); however, knee arthritis is about twice as common as arthritis of the hip and thus of great concern (10).
The treatment of gonarthrosis aims to reduce the pain, improve and maintain joint mobility, and limit the functional impairment. The management of osteoarthritic pain involves pharmacological, surgical and complementary modes of therapy. Intra-articular (IA) treatments for knee osteoarthritis are often promoted as an option when oral medication fails. Surgery is usually reserved for patients when all other methods do not work.
She did not have a history of prior knee injuries, or pain in the other joints. She had a history of chronic obstructive pulmonary disease (COPD) for 8 years, diabetes for 15 years, and high blood pressure for 24 years. She was prescribed various drugs by treating physicians for her elevated blood pressure, and blood glucose. She was obese for the last 30 years of her life. There was no positive family history of rheumatoid arthritis, fibromyalgia or hypertension.
Examination and Laboratory Investigations
Her general examination was normal. Blood pressure was reported to be 140/80, electrocardiogram showed normal findings and the heart sound was normal. Physical examination showed tender knees with limited motion and the stress test was positive. The other peripheral joints were normal and there was slightly restricted movement in the spine, which was normal for her age. The pain level was noted to be severe (Scala 1), using the Visual Analog Scale. Using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scale, the levels of pain, stiffness, and loss of physical function were noted to be 25, 10, and 80 points, respectively. While the total WOMAC points were 115, imaging studies of the knees showed medial tibiofemoral joint space narrowing and osteophyte formation. Laboratory investigations including, blood assessment (RA factor/CRP) and the other biochemical tests were turned out to be normal. Serum uric acid levels were within the normal range, indicating the absence of the gout and the serum calcium levels were at the lower limit of normal (9 mg/dl).
The patient was treated in six sessions of the knee prolotherapy and one session per month was applied. Vital parameters including the heart rate, blood pressure and pulse oximeter measurements were monitored. Anesthesia was given and 4 cc of 25% dextrose+4 cc of 0.2% lidocaine solution was injected intra-articularly and 0.5 cc of 15% dextrose+0.5 cc of 0.2% lidocaine solution was injected around the joint. Medications including NSAIDs and steroids were discontinued. Complimentary approaches including stretching exercises, physiotherapy, and weight reducing plan were continued. Patient’s evaluation after all the six sessions showed VAS score Scala as 2 indicative of almost no pain. Other parameters including pain levels, stiffness level, loss of physical function and total WOMAC were noted to be 5, 2, 15, and 22 points respectively, indicating a great improvement. Radiological findings after a year showed improved levels of osteoarthritis (grade I), which was grade IV earlier and improved range of motion (115 degree).
Usually, NSAIDs, along with exercise and weight loss approach are used as a first-line treatment for arthritis-related pain. 10 The dietary supplements like glucosamine and chondroitin have been recommended to alleviate the pain, but it is associated with minor side effects, including nausea, diarrhea, and headache (10). The continuous use of at least two analgesics for prolonged period may result in progressive renal impairment (11). The development of acute renal failure after exposure to conventional, non-selective NSAIDs have been reported in a population based study. Moreover, it may also cause hypertension, peripheral edema and electrolyte imbalance such as sodium retention, and hyperkalemia (12).
Prolotherapy is a complimentary, injection-based approach for chronic arthritis-related pain. It is a technique of injecting a small volumes sclerosing of solution/s in painful ligaments, tendons and surround space. These injections are given over multiple treatment sessions (13). The results of 3-arm, blinded, randomized controlled trial by Rabago D et al, showed the sustained improvement of pain, function, and stiffness scores for knee osteoarthritis on using prolotherapy, when compared with blinded saline injections and at-home exercises (14). Dextrose prolotherapy alone and dextrose+morrhuate sodium may result in safe, significant, sustained improvement of knee pain, function, and stiffness scores in adults with moderate to severe knee arthritis when compared to baseline status (15,16).
It is not rare to use injection therapies to treat arthritis of the knee as a most appropriate non-surgical approach. In such treatments, usually either corticosteroids or hyaluronic acid are used. The prolotherapy has shown clinical and radiological improvements and thus can be applied in a clinical practice to treat gonarthrosis.
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