Innovative Therapies for Knee Pain: Emerging Trends in Singapore

In recent years, methods of treating various knee pathologies have been advancing at a rapid rate. These treatments aim to reduce disability and prevent long-term implications of knee injuries. Some notable treatments include viscosupplementation for early knee osteoarthritis, platelet-rich plasma (PRP) injections for knee osteoarthritis and soft tissue injuries, and injection of mesenchymal stem cells to regenerate articular cartilage. These injection therapies all aim to enhance tissue healing and regeneration, thereby preventing further progression of degenerative joint diseases. In the field of ACL reconstruction, research has shown promise for healing of partial ACL tears with the aforementioned PRP or stem cell injections, hence avoiding the need for complete ligament reconstruction. There have been various new methods of meniscal repair such as meniscal scaffolds and trephination for access to the avascular zone of the meniscus. These are aimed to avoid the early-onset osteoarthritis associated with meniscectomy. Step by step, more evidence is emerging to support the efficacy of these treatments, hence shifting the standard of care for the respective knee injuries.

The prevalence of knee pain Singapore has increased significantly in the last two decades. This is largely due to an aging population as well as an increased incidence of sports-related injuries in the younger population. Knee pain can be attributed to a myriad of causes, which significantly influence treatment modalities. Osteoarthritis is the most common cause in the elderly population. It is estimated that 25% of people over the age of 55 have knee osteoarthritis, and a portion of these cases are a direct result of sports-related injuries in earlier life. Anterior cruciate ligament (ACL) injuries are prevalent in the athletic population. They are up to 8 times more common in females than males and may be associated with meniscal tears. These injuries have the potential to cause significant long-term implications such as early onset osteoarthritis. Patellofemoral pain syndrome is also commonly seen in the young athletic population. Treatment of knee pain is largely influenced by the duration and severity of pain, as well as impact on function and quality of life.

Non-Surgical Therapies for Knee Pain

For individuals with osteoarthritis, exercise therapy has been shown to be very effective at reducing pain and improving physical function. It should be seen as a first-line treatment. Physiotherapy at the Osteoarthritis Research Society International agrees that “Exercise therapies are the most effective intervention for decreasing pain and improving physical function in patients with symptomatic osteoarthritis.” This statement was developed off the findings of 51 trials.

We can also prescribe specific strengthening exercises that can target certain muscle groups around the knee or hip joints. Recent evidence has shown that hip abductor and external rotator muscle weakness can be a contributing factor to the development of knee osteoarthritis. It makes sense to treat these specific weaknesses as improvements can reduce the likelihood of the condition developing or possibly slow down its progression.

Physical therapy can involve many components such as weight loss, aerobic exercise, and specific strengthening exercises. Weight loss can be one of the most important factors in decreasing pain from osteoarthritis. It is estimated that for every 1kg lost, there is a 4kg reduction in load exerted on the knee. It makes sense to combine weight loss with aerobic exercise and further reduce loads on the knee. Alternative forms of aerobic exercise such as water-based exercises or cycling can also reduce the load on the knee while providing beneficial effects from exercise. Aerobic exercise not only leads to improvements in general health but can also lead to improvements in pain and functional ability for people with knee osteoarthritis.

Physical Therapy

A common physical therapy program for OA patients is to improve quadriceps muscle strength. Increased strength in this muscle group can help to decrease pain and improve function of the knee joint. This has been shown to be an effective method of therapy for OA in younger patients, although it is under-utilized in the older population who tend to have more severe atrophy in this muscle group. Although beneficial, there is no definite evidence that muscle strengthening exercises can alter the structure of the joint.

Physical therapy, often started even before the diagnosis of OA is certain, can be an effective treatment choice. Physical therapists are trained to help people with medical problems affecting mobility. They can help patients maintain or restore an active lifestyle and can provide education about self-management of OA.

Medications

There are many different medications available for treating knee pain. Which medication your knee pain specialist prescribes will depend in part upon the severity of your pain. Acetaminophen is generally the first medication that will be tried. Although it is not very effective for relieving inflammation, it is a good first-line painkiller. However, it is important to ensure that you do not exceed the recommended dosage. Exceeding the dosage can be very harmful to your liver. Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat knee pain. These medications are effective painkillers and are also very effective at reducing inflammation. An example of an NSAID is ibuprofen, which can be bought without prescription and is relatively inexpensive. However, long-term use of NSAIDs can cause stomach upset, increased risk of ulcers, and increased risk of bleeding. This can be particularly dangerous for older people. If you need to take an NSAID for a prolonged period, your doctor may prescribe a different NSAID which is less likely to cause stomach problems and may also put you on medication to protect your stomach. Another way of reducing the risk of developing stomach problems caused by NSAIDs is to take them with food. Topical NSAIDs, in the form of gels or creams applied to the skin over the painful joints, are also available. These are less likely to cause stomach problems and are very effective for some people. If you are unsuitable for treatment with NSAIDs, there is another type of medication called paracetamol, which can be taken on its own or in combination with opioids such as codeine. Opioids are very effective painkillers, but there is a risk of developing dependence on these medications and also side effects such as drowsiness and constipation. Therefore, they are usually only used for severe pain and it is rare for them to be a long-term solution. A newer type of medication for knee pain is a type of NSAID called a COX-2 inhibitor. This is a type of NSAID which is less likely to cause stomach problems. However, there have been concerns about the safety of these medications because they can cause heart problems and there have been instances of drugs in this class being withdrawn from the market. Therefore, if you are prescribed a COX-2 inhibitor, it is important that you have regular check-ups with your doctor.

Surgical Interventions for Knee Pain

Surgical intervention is usually the last option considered for anyone with chronic knee pain as it is costly, involves some risks, and requires a long post-operative rehabilitation period. Newer and minimally-invasive procedures make the decision for surgery less daunting. An initial mode of surgery is usually a knee arthroscopy. This is a low-risk procedure used to diagnose and treat knee problems. The procedure involves an examination of the inside of the knee with an arthroscope (a narrow fiber-optic telescope). A small incision is made and the joint is filled with saline to provide a clear view. The arthroscope is then inserted through the incision and a diagnosis of the knee is made. Problems can be corrected by inserting instruments through other small incisions. This is usually done under local anesthesia and the recovery time is minimal. Step locking in the knee? Remove a meniscal tear. Swelling and pain? This can be due to synovitis or plica and this can be removed. Arthroscopy has been found to be effective for unexplained pain giving the patient a diagnosis and treatment has in some cases been found to delay the progression of osteoarthritis. For severe knee pain from arthritis, there’s evidence that arthroscopic surgery is not effective when compared with non-surgical treatments. But this is not the case for people with meniscal tears. In these cases, the knee can be pain free and provide many more years of function, if the meniscal tear is repaired or resected. This is especially important in the younger population with the meniscus being a crucial shock absorber in the knee. Ongoing research is being done to reduce the risk of arthritis after a meniscectomy. This is being done by the replacement of the meniscus with a variety of implants. This may save a lot of people from suffering painful arthritic knees.

Arthroscopy

At the start of the procedure, the knee is pumped up with normal saline to allow the surgeon to clearly see and assess the condition of the knee through the arthroscope inserted into small skin incisions. Typically, an arthroscopy will involve inspection of the whole joint including the articular cartilage, meniscus, ligaments, and the synovium membrane, with the intention of diagnosing the cause of the problem in the knee. Treatment of particular conditions during arthroscopy involves using small surgical instruments which are inserted into the joint through additional small incisions. These may involve cutting or trimming tissue, and in cases such as meniscus tears or ligament injury, a variety of very strong and lightweight synthetic materials may be used to repair the damage. The type of surgery conducted and the outcome of arthroscopy is generally very subjective and depends on the nature and severity of the knee problem.

Arthroscopy is a popular choice for the treatment of disorders of the knee following accurate diagnosis of the knee problem. It is to be considered when the outcome of conservative management of conditions such as physiotherapy, exercises or medications do not improve the knee problem. Arthroscopy is a surgical procedure in which a small fiber optic telescope (arthroscope) is inserted into the knee joint to evaluate and treat a variety of conditions. It is a minimally invasive procedure and is generally conducted as a day surgery. The advantage of arthroscopy over traditional open surgery is that the joint does not have to be opened up fully. Because of this, it is felt that arthroscopy is associated with less pain, quicker healing, and overall recovery from the procedure.

Partial or Total Knee Replacement

When this procedure is appropriate, most replaced knees are actually quite straight. But frequently, the cartilage loss is not uniform. One portion of the knee may have good alignment and stable ligaments, while another has already significantly collapsed and is very unstable. Orthopedic experts know that this unstable condition is what causes the progressive and rapid joint destruction. High deformity or instability is the primary indicator for joint replacement. So depending on the state of your knee, joint replacement may or may not be the best option. For those for whom it is appropriate, partial knee replacement may be an option. This is for those who only have damage in one area of the knee. This procedure is done arthroscopically, where only the damaged part of the knee cartilage is replaced with plastic or metal parts. This allows the patient to retain more of their original knee. The recovery is much faster than total knee replacement and less painful. Usually, patients are in outpatient surgery and have to use crutches for a few weeks. Full recovery to your original state should take about 6-8 weeks, aside from the risk of the cut in the skin becoming infected or inflamed. Device wear or loosening is physical, as the knee becomes unstable and starts giving again. If this is the case, then it would be appropriate to switch from partial to full knee replacement. This is when both surfaces of the knee joint are replaced. Usually, this surgery is done on those who are older and less active because the artificial knee may wear out over time, and overly active patients may cause it to wear out faster. Total knee replacement is for those who don’t have other options and are most likely bone on bone at the joint.

Knee pain becomes so severe that it can lead to significant disability. It can interfere with mobility and daily activities. It may occur while resting or sleeping. Knee replacement surgery is a treatment that can help with this problem. It can relieve pain and disability and allow you to live a more active life. Knee pain is often caused by osteoarthritis. This is a condition where the articular cartilage covering the ends of the bones gradually wears away, causing pain and stiffness. This pain and stiffness may be heightened by inflammation of the synovial membrane and a decrease in the muscles around the knees.

Cartilage Restoration

Microfracture is a simple surgical technique. It is a cost-effective way to treat cartilage injuries by creating a new cartilage growth from the body. This can be done in two ways but for knee cartilage injuries it is done by keyhole surgery. By creating small holes in the bone that’s the foundations of the articular surface, blood and stem cells from the bone marrow will migrate into the damaged area creating a new cover of fibrocartilage. Rehabilitation from microfracture is very important; the first 6 weeks is non weight-bearing and during this time a CPM machine may be used to prevent the new cartilage from hardening too quick. Full recovery can be achieved within 3-6 months. Although microfracture is seen as a good way to reduce knee arthritic problems for patients, fibrocartilage is not as tough or as durable as the articular cartilage, so frequent failure and progression to osteoarthritis can occur.

The notion that damaged articular cartilage is not reparable has ended. For years, patients and their orthopaedic surgeons thought that once the articular cartilage in the knee is injured or worn away, there were very few treatment options short of total knee replacement. For the younger patient with an isolated area of cartilage damage, this was a particularly discouraging prognosis. During the last 20-30 years, a surge of knowledge about the structure and function of articular cartilage has led to the development of several new procedures aimed at restoring the articular surface.

Emerging Trends in Singapore

Stem cells are the building blocks of our body and are capable of forming diverse body tissues such as tendons, ligaments, cartilage, and muscles. Stem cells, as the name indicates, are those cells capable of repairing and revitalizing the dead or injured tissues of our body. In a pioneering or major attempt to bring knee pain treatments in Singapore to a revolutionary era, stem cell treatment for chronic or acute tendon and articular injuries is offered. Autologous Mesenchymal Stem Cells (a-MSC) are isolated from the patient’s own hip bone by means of a needle and specially processed in the laboratory in a controlled environment. This is done to avoid contamination and at the same time optimize the cell quality and yield. These cells are then carefully injected or implanted into the injured tissues under ultrasound or x-ray guidance. The all-new procedure is capable of healing all the injured tissues with minimal scarring.

The time when you are undergoing more stress on your knees than their bearing capability, it is surely the best care you are in need of. There can be infinite causes for knee pain. It differs from one person to another. The solution for knee pain can vary according to the cause as well. The conventional methods followed till date for knee pain therapies include painkiller medicines, cortisone injections, lubricants, knee braces, physiotherapy, arthroscopy, or abdominal and knee joint replacement. Now it is the time to change or step forward from these conventional methods to some other advanced therapies. So here we are, to help you out with some useful information on the advanced knee therapies available in Singapore, most probably recent or currently in use. The therapies involve pioneering treatment plans using pioneering medicines and the most advanced evidence-based analytics. These therapies are truly proficient in reducing or relieving pain, improving function, and at the same time delaying or preventing knee joint degeneration.

Stem Cell Therapy

Advances in regenerative medicine offer the potential of providing a lasting resolution of chronic knee pain by addressing the cause of the pain, which is often damage to the articular cartilage. Autologous chondrocyte implantation is a proven biological technique for regenerating articular cartilage. Over the past several years, a considerable amount of research has been conducted to find a suitable biologic agent to combine with the technique of microfracture, which produces a different form of fibrocartilage from that produced by the natural healing response of the body. Microfracture is a bone marrow stimulation technique that will be discussed further in the section on subchondral therapies. As the search continues, the strongest prospect appears to be the development of some form of gene therapy to insert into the chondrocytes to make them produce suitable hyaline cartilage. This section will address the current status of regenerative therapies and the future outlook for these therapies in the treatment of early knee osteoarthritis.

Platelet-Rich Plasma (PRP) Therapy

In comparison to treatment with cortisone or NSAIDs, patients treated with PRP have demonstrated overall quite good improvement in symptoms. The most improvement has been demonstrated in patients with a duration of symptoms less than six months. With PRP, there is a far less probability of side effects compared with traditional medications, where there is a high incidence of gastric irritation and potential ulcer formation. High-dose cortisone injections are best avoided as the side effects and potential for complications far outweigh the benefits to the patient’s rehabilitation and quality of life.

The process, involving injection of autologous PRP into the knee, relies on the growth potential of PRP on the tendon cells and recruitment of cells to the local tissues. The growth potential is highly important on damaged tissues, often with degenerative changes, where healing response is generally slow or incomplete. The biological healing properties of PRP can change the course of the traditional management: a protracted exercise in physiotherapy, anti-inflammatory medications, cortisone injection, or in some cases, arthroplasty or joint replacement. The process of PRP can often be a first-line treatment for some of the elderly patients and a cure for the younger patients.

Regenerative Medicine

Osteoarthritis (OA) is a degenerative joint disorder and is a major issue for elderly patients in Singapore. With the projected increase in OA cases, stem cell therapy can be an attractive option for an effective treatment.

At present, the most effective cellular regenerative therapy for knee injuries and, by extension, knee joint OA is a same-day procedure involving the harvesting of fat stem cells from the patient. This sample is then sent to a lab where the stem cells are separated and concentrated before being reinserted into the patient’s knee. Effectively, this procedure is essentially an injection, but what it lacks in complexity in procedure, it makes up for in rehabilitation and recovery time. It has been noted that recovery from this procedure is faster than that of surgery, and notice of pain relief can be as early as a week. This can be seen as an attractive option for elderly patients who are not suited to a surgery rehabilitation program.

Now, stem cells are the body’s raw materials, but in the context of science, they are early-stage cells that can multiply into a specific type of cell/tissue. Stem cells are a key element in regenerative medicine. This would be done using stem cells found in embryos or fat and bone marrow found in adults to build connective tissues (cartilage, tendons, and ligaments).

Regenerative medicine is one of the most exciting therapies to be emerging in medicine today. Treating damaged tissues and organs in patient and non-invasive procedures is a concept that fills the gap of medical fields’ long-term goal of curing. Mostly focusing on degenerative conditions caused by age, disease, and damage, degenerative conditions put a large amount of burden on the affected individual as well as the health economy in a country. Singapore is, in context, experiencing the age and disease-related burden. With regenerative medicine specifically targeting these conditions, it can be seen as an attractive therapeutic option.

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