Transcription:
Non Operative Treatments of Arthritis

Melanie Cole (Host): If you feel pain, stiffness in your body, or have trouble moving around, you might have arthritis. If this pain is starting to affect your quality of life, you may look to nonsurgical options to help you. My guest today, is Dr. Alon Antebi. He’s an Orthopedic Trauma Surgeon and a member of the medical staff at Palmdale Regional Medical Center. Dr. Antebi, define arthritis for us because it’s really got such a large definition. Narrow it down a little bit for us.

Dr. Alon Antebi (Guest): Sure, so arthritis is probably one of the most common diagnoses an orthopedic surgeon would make both in the clinical setting as well as in the hospital. It’s probably the number one reason why most patients go see an orthopedic surgeon. When you make the diagnosis of arthritis, patients are like, “Ah, it’s just arthritis,” but they really don’t know what that means.

There are different forms of arthritis. The most common form of arthritis here — at least in the United States — is osteoarthritis. The second most common form is what we call inflammatory arthritis, and that goes into different variations of inflammatory arthritis, and the most common form of that is rheumatoid arthritis, which most patients are aware of. There are other forms as well, such as Lupus. People with lupus can get inflammatory arthritis as well.

Osteoarthritis is the most common reason and the most common type and form of osteoarthritis. This is a type of arthritis where you get from essentially wear and tear. However, you can also get arthritis from having a previous trauma. If you are 18-years-old and tear your ACL in your knee and having a reconstruction or surgery for it – or even if you don’t have surgery for it, the biomechanics of that knee will not be the same as God defined it and therefore, in the future – ten, fifteen, twenty years later – that knee will become arthritic from a trauma that you sustained twenty years ago.

Most people don’t have trauma to their joints. It’s just wear and tear, and a lot of it has to do with the design of their joints. Even though you may look at a person and look that they have a hip, and they have a knee, and they have a shoulder, they may not necessarily be designed anatomically perfect. It’s kind of like the analogy that I give a patient. When they buy a car from the factory, if one of the tires is not perfectly mounted and perfectly balanced, instead of that tire lasting 20- or 30,000 miles, it will only last 5,000 miles because the tire wasn’t mounted right. It’s the same thing with the human body. If the joint was not designed perfectly, there would be early wear and tear because most people put about anywhere between 8- to 10,000 steps a day when they just walk and live their life.

Melanie: So, previous, wear and tear, autoimmune for rheumatoid, is there a genetic component to either – any of the types of arthritis – is one more likely to have that genetic component? Do other things like weight, obesity, bone density, do any of these contribute to an arthritic situation, as well?

Dr. Antebi: Sure, I think genetics definitely plays a role in it, but there is really no scientific proof. For example, I’ll see a patient who is in her 60s and come in with arthritis in the knee and the hip, and then she’ll say, “Oh, yeah. It must be genetic because my mom had two hip replacements and a knee replacement.” There really is no hardcore genetic component.

However, one of the conditions that we used to call congenital hip dysplasia, which is a formation of a bad forming hip, which later leads to arthritis in the hip. Now, we don’t call it congenital; we call it developmental meaning something that you may have developed in utero while you were sitting in your mom’s womb in a funny position, which caused your hip not to form right. And then, 20, 30, 40 years later, we realize that you had it, and now you develop arthritis because the joint wasn’t necessarily formed correctly.

Obesity – again, obesity does not necessarily cause arthritis. It’s the same thing as I said before, the analogy – if you have a truck, and the tire is not mounted right on the truck, and now you added 5,000 lbs. of bricks for that truck to carry. It will definitely cause the tire to wear out sooner, but you are already biomechanically at a disadvantage having the extra weight. We see earlier arthritis in heavier people just because they are carrying more weight. The body wasn’t designed to carry an extra 50 lbs. or 100 lbs. your whole life, and if you do, then you will develop arthritis earlier.

Melanie: Then let’s get right into some of the first-line of defense. We somebody has got it in their hip, or their knee, or maybe they tore their ACL, or they have some reason that they’ve got arthritis as you’ve described. What’s the first-line of defense? Are you looking towards medicational intervention? Do you ice, brace, heat? What modalities do you like, Dr. Antebi?

Dr. Antebi: Sure, sure. A lot of it depends on the degree of arthritis and the age. The first thing that we need to do is we need to do a clinical exam, get the history from the patient. Have they been having pain for a month or is this something that’s been going on for a long time? We would work up a diagnosis as to how bad this is.

The first thing, the mainstay, is getting an X-ray in the office. Let’s get the X-ray and let’s see how much space you have in your joint -- whichever joint that is, whether it’s a hip, a knee, or the shoulder. It could even be a hand, or a finger, or whatever it is – so, we would first get an X-ray. Most of the time we can diagnose arthritis on an X-ray. If not, then at that point we get to fancier modalities like MRI or CT scans.

Once we diagnose arthritis, a lot of it depends on your symptoms. Is this something that bothers you once a week, it only bothers you when you exercise, or it just bothers you every day with every step? We kind of have to get the degree of how bad this is bothering you. And have you tried anything at home? Have you tried putting ice? Have you tried putting heat? Have you tried taking over the counter Tylenol or ibuprofen to help your pain?

Depending on what the patient says and where is it coming from will depend on what we will do. If they have not started anything at all and we diagnose them with arthritis, then we can talk to them about activity modification, we can talk about weight loss – if they need to have some weight loss – we can talk about different foods that they eat in addition to starting some baseline medication like an anti-inflammatory medication. We would try those things, give it a month or two, and then see how they respond. They would come back for another visit, and then at that point, if their pain is not any better, we can proceed to different modalities.

If they come in and now they’re in their 60s or 70s, and their arthritis has been lingering for several years, and they’ve tried all this other stuff that we talked about like over the counter brace, medications over the counter, they’ve tried weight loss, they’ve tried physical therapy, and nothing helps. At that point, we can talk about doing injections. There are various forms of treatments – again, these are nonoperative treatments that we can perform in the office. We can talk about those as well.

Melanie: So, let’s do that because people hear cortisone injection in my shoulder, but they only can get one every six months – speak about the different types of injections, Doctor --

Dr. Antebi: Sure.

Melanie: And when it’s appropriate to have – whether it’s platelet-rich plasma or cortisone, or whether you’re doing immunotherapy, whatever it is – speak about these different types of injections and when they’re appropriate to be used?

Dr. Antebi: Sure. The first-line of injection would be cortisone, and it’s something that’s relatively inexpensive, and it usually does work, but you’re putting something artificial into the joint. It’s there as a potent anti-inflammatory to help the pain in that joint. It doesn’t work for everybody, and each person may have a different response. It may work for six months in one patient and only six days in another patient. We never know what kind of response each patient is going to have, so I usually suggest trying it and see if it helps. And also, the degree of arthritis – does somebody have a Stage what I’d say 10/10 or are they a 2/10? The person who has less arthritis may respond better than the person who has more severe arthritis. Cortisone is an option.

In regards to how many times we can do it? Well, I always tell patients that if you have pain today and we inject your knee, and you respond, and you get four to five months out of it, it’s worth trying again in the future. However, if you only get a three or four-day response to pain relief, I would not try it again. A lot of the modalities that we use and reuse depends on how the patient responded the first time.

Now, moving on from cortisone, there’s also a medication called viscosupplementation. Viscosupplementation looks like a clear gel that we inject. It’s hyaluronic acid. There are various companies on the market that make this medication. Depending on the medication, sometimes we do three injections, five injections, and now there are some formularies where you would only do one injection of this type of medication.

The Academy of Orthopedics -- which is our governing body of orthopedic surgeons – recently came out with a large multicenter study that basically shows that this stuff is no better than placebo. Whether you get it or not, it doesn’t really matter because it doesn’t really help. Now a lot of insurance companies are backing away having to pay for these medicines. However, I still use them for patients who are “Hey, this is what I want,” and we try it again – try the three shots and if they get better, great. If not, then we have to move to the next step.

What is the next step? After cortisone and viscosupplementation, now we’re dealing with a whole different type of treatments. A lot of these treatments are not covered by insurance companies, and this is where we get into regenerative therapy if you will. There are a lot of studies out there – you can find studies that show that it works, that it doesn’t work – the first thing is PRP. PRP stands for Platelet-Rich Plasma. This is a procedure that initially came out where it was mainly meant for injecting tendons, soft tissue, epicondylitis, Achilles tendonitis, shoulder tendonitis, and now, people are injecting and using them for various modalities like osteoarthritis. People are using it for hair rejuvenation and erectile dysfunction. It’s all over the place. This is usually a cash-pay in the office. It’s a procedure where we take the person’s blood in the office, and we put it in the centrifuge. We’re able to separate the various components of the blood, and what we’re looking for is the platelet-rich plasma portion of the blood. It comes into a concentrated bullet of several cc’s, and then we inject that into the specific area where the person has pain.

I have been doing this procedure now, for approximately two years, in the office and definitely have seen a pretty amazing response with patients. Again, it’s not a panacea; it’s not something that every patient responds to, but I have definitely seen better clinical results than the first two things that we talked about, which was cortisone and the viscosupplementation.

Do you have any other questions?

Melanie: Well, I do. I just want to know where you feel nutrition – because people have heard about chondroitin and they’ve heard about Omega-3s and eating plenty of fatty fish – is there anything that we do eating-wise – people have even said pineapple is a great anti-inflammatory. Do you ever – do your patients ever ask you about various nutritional or alternative kinds of supplements?

Dr. Antebi: Yes, there is a lot of data out there – one thing in medicine, you can find anything in medicine to support anything that you want, and you can find something in medicine to counteract that study, as well. There is a lot of talk out there, for example, on the consumption of cinnamon, turmeric acid supplementation, in addition to the use of chondroitin and glucosamine. What I tell patients is this. I’m like, listen if you’re willing to spend the money and try something for a month and see if you get the clinical results. What ends up happening is sometimes patients will take two or three things. They will take the turmeric; they’ll take the cinnamon, they’ll take the chondroitin. They may feel better, but we don’t know which component of those things actually worked. Or is it another placebo? Just because they waited a month taking something, if they wouldn’t have taken anything and waited a month, would they have gotten better? You know what I’m saying?

Melanie: Yes.

Dr. Antebi: We really never know. I definitely don’t advise not to take them. These are considered medical foods. They’re not really medications per se. You don’t need a prescription for these, and a lot of people just don’t like taking medicine – they don’t like taking pills, and they do look for alternative treatments. 

The other thing that’s really on the market right now, which is costing people – depending on where you go -- for example, I’m very close to Los Angeles and Santa Monica, and people are getting stem cell treatments. These stem cells could either come from fat, your bone marrow, or placental tissue. Again, there is really no hard data to show that any of this stuff works, but when people are desperate in pain, they’ll pay anything to try to get out of pain if they can afford it and to try to do something that’s not operative. Again, there is no hard data to show that any of this stuff works. The people who are selling this stuff will tell you it’s the next best thing. However, there are a lot of financial incentives for selling those things.

Melanie: So, people really need to go into this with caution and their eyes wide-open. And Doctor, wrap it up for us because you are just such an amazing guest. You teach us so well about these things. Give us a little wrap up about arthritis and nonsurgical treatments and when it’s really time to come see an orthopedic surgeon to discuss some of these options.

Dr. Antebi: Sure. Arthritis is probably the most common reason why somebody would have joint pain in this country. I think with the use of – like you said earlier, diet, exercise, weight loss, and simple over the counter anti-inflammatories – this is something you can do at home before you ever see a doctor. If a month goes by and your pain is still persistent, at that point, I would make an appointment to see an orthopedic surgeon. At that point, you can get worked up and start these other modalities, including prescribed medications as well as injections. Surgery should always be your last option. If a doctor offers you an option for nonoperative treatment with an injection – whether it costs money or not and whether you can afford it or not -- I would try that first before proceeding to any surgical intervention.

Melanie: Thank you so much, Dr. Antebi. A pleasure as always. You’re listening to Palmdale Regional Radio. For more information, please visit PalmdaleRegional.com. Physicians are independent practitioners who are not employees or agents of Palmdale Regional Medical Center. The hospital shall not be liable for actions or treatments provided by physicians. This is Melanie Cole. Thanks so much, for listening.