Medicine/7. Clinical medicine

Prof. Vasiliyeva L.V., Starodubtseva I.A. (PhD)

NN Burdenko Voronezh State Medical Academy

Topical problems of nonpharmacological methods of therapy of patients with knee osteoarthritis:

Discussion of the results of investigation

Osteoarthritis being the most common rheumatic disorder causes a decline in the patients’ state of health; its deteriorating course and the resulting disability account for psychological problems and impaired social functioning of the affected population. (Nasonova V.A., Folomeyeva O.M., Amirdzhanova V.N., 2000)

It is common knowledge that in the presence of osteoarthritis pathologic changes occur mainly in the articular cartilage, subchondral bone, synovium and other soft tissues of the joint. Increased release of matrix-degrading enxymes in the articular cartilage, breakdown and loss of glycosaminoglycans may lead to morphologic changes such as pitting and thinning of the tissue with diminished ability to bear mechanical load.

In connection with the emergence of new medicines for osteoarthritis therapy and new treatment modalities a demand arose for the development of standardized criteria of effectiveness. The list of parameters, which might be included into the protocol of medical evaluation of osteoarthritis, is fairly large. Objective characteristics specific to the disease progression and well suited for routine use are required.

In recent years, a vigorous search for probable biological markers of degradation and restoration of articular tissues (mainly of cartilage and bones) has been carried out. Biological markers are expected to be representative of the above-mentioned changes, to serve the estimates in predicting the development of the disease and to serve the markers of the effectiveness of nosotropic therapy. Identification of new biological markers and in-depth study of known ones will offer a clearer view of osteoarthritis pathogenesis. The challenge now is to evaluate and monitor chondroprotective potentials of various treatments.

Currently there is no data available regarding circadian rhythms of cartilage biological markers. Furthermore, for every biological marker it is necessary to specify the blood portion - the plasma or the serum – in which it should be estimated. The results of the investigation show the concentrations of biological markers in plasma to be significantly different from those in the serum. Yet another important point is to determine a half-life for every biological marker since the interpretation of test results will present difficulties without these measurements.

Apart from the pathology (osteoarthritis, in particular) the concentration of biological markers depends on a number of factors: circadian rhythms, peristalsis, physical activity, hepatic and kidney disorders, age, gender and surgery.

Some biological markers are currently being evaluated in clinical practice, for example, glycosaminoglycans, cartilage oligomer matrix protein and so on. Other biological markers, perhaps, will be included in the list of routine biochemical tests. Blood biological markers more likely account for systemic metabolism than local changes in the osteoarthritis joint.

The present study evaluated glycosaminoglycans content in the blood sera of patients with osteoarthritis. The study population comprised patients of working age with primary osteoarthritis of various intensity and a concomitant pathology.

It has been established that the level of glycosaminoglycans within the male and female osteoarthritic individuals was higher than in healthy subjects. The comparative analysis of findings among the patients with osteoarthritis and healthy volunteers indicated significant hexose exceeding in the first and second groups independent of gender and age, which confirms the presence of a deteriorating process and the predominance of catabolic processes over anabolic ones. It has also been noted in the course of the study that high glycosaminoglycans content was associated with the severity of osteoarthritis.

The correlation analysis performed to reveal the relationship between the glycosaminoglycan level and the main medical and functional characteristics established an association between clinical signs (the assessment of pain using a visual analogue scale, scores of WOMAC and Lequesne questionnaires) and the parameters of glycosaminoglycans. The deterioration of algofunctional findings was followed by an increase in glycosaminoglycans.

The pharmacologic management of osteoarthritis is presently being discussed elsewhere. Conservative measures are expected to alleviate the degradation in para-articular tissues and joints and the resulting systemic pathologic changes. That is why apart from the combination therapy the clients should be instituted massage, physical exercise, physical therapy, postisometric relaxation etc. (Korzh N.A., Filippenko V.A., Dedukh N.V., 2000)

A number of authors believe that we should reconsider the administration of nonsteroidal anty-inflammatory drugs (NSAIDs) and pain relievers to patients with osteoarthritis. NSAIDs are most commonly prescribed medications reducing pain and maintaining joint mobility, however they have gastrointestinal toxicity especially among elderly population.

In this connection, nonpharmacologic measures are gaining in importance. They help reduce pain, maintain function and mobility, improve patients’ quality of life.

Treatment of osteoarthritic individuals with low intensity laser irradiation enables to relieve pain, stimulate trophism, oxygenate articular tissues through activated microcirculation, enhance restoration thus allowing to normalize joint function. However, the effect of low intensity laser irradiation on the level of glycosaminoglycans in osteoarthritic patients has not been studied yet.

The present research has demonstrated high effectiveness of low intensity laser irradiation in the treatment of patients with osteoarthritis using the biomarker glycosaminoglycan.

Besides, the biomarker under consideration was trialed as a guideline in the assessment of the disease severity or the staging of the pathological process along with radiography, laboratory tests, intensity of pain, restriction of joint mobility and maintenance of functional capacity of the patient.

The analysis of glycosaminoglycan dynamics under the influence of concomitant therapy with low intensity laser irradiation revealed a significant reduction of the glycosaminoglycan level to control estimates, which is consistent with the restorative effect of laser therapy.

Assessment of the effectiveness of the treatment given was based upon the patients‘ subjective feelings of pain alleviation and changes in the health status and the objective findings of the study.

In evaluating the effect of low intensity laser irradiation on the signs of osteoarthritis in the course of combination therapy the main criterion used was assessment of pain by visual analogue scale. The results of numerous investigations demonstrated its high information capacity (Bellamy N., 1993). The analysis of changes in the arthrological status and biochemical status and biometrical tests among osteoarthritic patients with the underlying reduction of glycosaminoglycan level detected that low intensity laser irradiation intervention significantly enhanced positive dynamics in all clinical characteristics related to the functional capacity in the patients’ and physicians’ opinions.

Comparative assessment of pain at rest by visual analogue scale in two groups of patients prior and following treatment demonstrated that the greatest efficiency was attained in the group receiving a combination therapy with low intensity laser irradiation and a standard intervention. A similar beneficial dynamics was noted with reference to pain with motion and on palpation and morning stiffness by visual analogue scale .

Clinical effectiveness of treating patients for osteoarthritis using low intensity laser irradiation was supported by WOMAC and Lequesne indices.

Comparative analyses of variation of WOMAC and Lequesne indices in response to therapy of osteoarthritic patients in the treatment and control groups revealed a continuously increasing ameliorating effect of low intensity laser irradiation before the completion of the study with statistically significant variations between the groups.

The estimation of low intensity laser irradiation effect on the articular syndrome in osteoarthritic patients showed that with the decreasing glycosaminoglycan level in the patients having the osteoarthritis stage III the greatest efficiency was noted in the patients having the first and the second stages of the disease. The result of the combination therapy was poorer in the patients with the osteoarthritis stage III and certain risk factors and conditions such as obesity, age over 65, history of traumas.

Laboratory tests have proved the anti-inflammatory action of low intensity laser irradiation concerning destructive changes. The comparative analysis of laboratory tests in the patients of the control group I and comparison group II showed the benefits of the combination therapy employing low intensity laser irradiation over routine therapy as to CSR, sialic acids and seromucoids.

For complementary assessment of pain syndrome dynamics the evidence of analgesics intake was used. It is known that NSAIDs have common side effects, such as dyspepsia, ulceration, perforation, bleeding, renal, hepatic and cardiovascular complications. Employment of low intensity laser irradiation in the combination therapy of osteoarthritis allowed to reduce pharmacological loading which provided a beneficial therapeutic effect. The reduced need and in some cases discontinuation of NSAIDs and glucocorticoids improved severe side effects of cardiovascular and gastrointestinal systems.

The innovative method of laser therapy of osteoarthritic patients, namely low intensity laser irradiation, has been clinically and pathogenetically grounded and used. The application involved cutaneous irradiation of knee-joints when the pulse beam was delivered successively by areas and through scan technique. In addition, supravenous laser irradiation of blood over the antecubital fossa was applied. The optimal irradiation dose has been used, the technique making allowances for all parameters of low intensity laser irradiation, which were tailored depending on the specific features of the clinical course and the presence of the associated pathology in every patient.

A one-year follow-up showed that low intensity laser irradiation had a prolonged aftereffect in comparison with standard therapy, which was manifested in the decreased rate of repeat hospitalizations and physician visits and periods of functional disability. This fact is of primary social and economic importance because it involves reduction of direct (cost of medications) and indirect (lost wage earning opportunities) costs as well as negative emotional responses to osteoarthritis and deterioration of the quality of life.

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