Cutting-edge Solutions: Innovations in Knee Pain Treatment by Singaporean Doctors
“Anatomically, the knee joint is the largest and the most complex joint in the human body. It is used for everything involving leg movement, such as standing, walking, running, jumping, and turning. The knee is built for durability, bearing the body’s weight. But increasing the weight of our bodies as we grow older sometimes creates knee pain and injury. Knee pain is a very common problem, about one in four adults experience it. It may occur as the result of an acute injury, such as a ruptured ligament or torn cartilage. Medical conditions including arthritis, gout and infection can also cause knee pain. Some acute injuries such as a torn meniscus or a small fracture can lead to the development of painful arthritis in later years. In some cases, knee pain may be so severe that it may hinder sleep and daily activities. No matter what the cause, the end result is the limitation of mobility. The general movement of the knee is greatly affected when we are hindered by severe knee pain. This leads to the weakening of the thigh muscles and a further increase in the stress to the knee. Knee pain has become a crippling ailment to millions of people in recent years. It has become the most common cause of chronic pain. The rapid increase in our aging population has greatly contributed to the growing number of individuals suffering from knee pain. In particular, the more active and aggressive lifestyles of the baby boomers have resulted in a higher number of sports injuries, ultimately leading to the development of knee pain. The baby boomers have refused to take chronic pain and physical limitation as an acceptable way of life as did their predecessors. As a result, they have sought medical care to remedy what ails them. At present, the concern for knee pain has shifted to focusing on ways to improve function and provide relief as quickly and safely as possible. This is the new millennium and people are not willing to be sidelined by knee pain. They want quick and effective solutions that will allow them to return to their normal everyday activities.”
Overview of Knee Pain
The first step to determine the nature of the pain. Aching in different parts of the knee might indicate different problems, and we could feel the pain at the back, front, or sides of the knee. Moreover, the knee may also swell as a result of an injury. In some cases, if the injury is more severe and acute, the patient can feel or hear a popping or snapping noise during the injury.
Knee pain is a common complaint for many people with a wide variety of potential causes. Since the knee is so complex and made up of many parts, the knee pain can be the result of an injury or other health conditions. An injury is the most common cause of knee pain. Sudden (acute) injuries may be caused by a direct blow to the knee or from abnormal twisting, bending the knee, or falling on the knee. Examples of sudden injuries include ligament sprains or tears, torn cartilage, and broken bones.
Importance of Effective Treatment
Current treatment of knee pain often utilizes pharmaceutical intervention or physiotherapy. However, a recent consumer survey suggests that patients are becoming increasingly dissatisfied with pharmaceutical treatment, largely due to concerns over addiction and side effects. On the other hand, many feel that physiotherapy does not yield significant results and is poorly covered by healthcare plans. As a result, patients are spending large sums of money for treatments that are less than satisfactory. Left with these options, more and more people turn to drastic measures such as surgery, hoping that it will offer a quick fix to their problem. The perception that surgery will cure knee pain is not entirely correct. In some cases, knee pain is still present post-surgical intervention and the recovery process can be slow. As surgical techniques advance, this may change. However, from a global perspective, surgery is not a practical form of treatment for an issue that is so prevalent.
Knee pain is a common public health issue, yet it is often trivialized more as an inconvenience than a hindrance. Knee pain detrimentally affects the quality of life, not only for the elderly but also for adolescents and young adults. The range of pain can be from mild to severe and can be acute or chronic. As the population ages and as the prevalence of obesity increases, the burden of knee pain will significantly increase. It is estimated that by the year 2030, 67 million Americans will have doctor-diagnosed arthritis, which is a common cause of knee pain. This is almost a 40% increase from current statistics. In order to prevent the future epidemic of knee pain, we must first understand that knee pain can no longer be ignored and effective treatments must be sought.
Role of Singaporean Doctors
Singaporean doctors have contributed to finding a safer and more effective means of pain relief for knee osteoarthritis in the form of high voltage electrical stimulation (HVES). This was developed by the Clinical Technology Centre in Nanyang Technological University. HVES has always been known to be effective for muscle strengthening, and studies have shown that it may also be effective for pain relief. NTUC healthcare also has a research program that is looking into using HVES for quadriceps strengthening in knee osteoarthritis. In short, the idea is to facilitate muscle strengthening with simultaneous pain relief, taking advantage of the former to achieve the latter. An improvement in quadriceps strength has the added bonus of aiding rehabilitation and possibly slowing down disease progression.
At present, the most common means of pain relief are via NSAID medication or steroid injections. Unfortunately, although both methods are effective in alleviating pain, they are not ideal as both carry the risk of severe side effects and complications to the patient’s general health.
Unlike systemic diseases, which can be combated medically, painful degeneration to the knee in the form of osteoarthritis often ends up requiring a total knee replacement, the severe end of the spectrum. It is estimated that a patient will need about 8 to 10 years of pain relief before a knee replacement becomes a viable and attractive option. This period is of theoretical significance and tactical to all knee pain doctor Singapore who treat knee pain, but there are currently no satisfactory medical or surgical methods to achieve pain relief.
Singapore ranks among the world’s finest in the field of medical research and practice. In recent years, there has also been a growing number of Singaporeans who pursue medical education and specialization. The field of orthopaedic medicine and surgery is no exception, and Singaporean orthopaedic surgeons have been providing many “cutting-edge solutions” for knee pain treatment. An analysis of the innovations will demonstrate the diverse and important roles that Singaporean doctors play in developing effective knee pain treatment.
Advanced Treatment Techniques
Regenerative medicine is a branch of translational research that involves the process of “replacing or regenerating human cells, tissues or organs to restore or establish normal function”. This area of knee treatment is still relatively new, however, there are several types of regenerative medicine therapies being tested today. Platelet-rich plasma (PRP) therapy is a treatment that uses injections of a concentration of a patient’s own platelets to accelerate the healing of injured tendons, ligaments, muscles, and joints. In essence, this treatment has been developed for the patient’s body to better heal itself. A study showed PRP treatments to have significant positive effects in osteoarthritic knee patients in regards to pain relief and improved function. More research and longer-term results are needed before this treatment is widely offered for conditions of knee pain.
Minimally invasive procedures are becoming more advanced and often require little to no use of general anesthesia, allowing the patient to go home the same day. Knee arthroscopy is the most common outpatient procedure. The surgeon makes a small incision and inserts a tiny camera viewing the knee on a video screen. Small incisions are made to insert the appropriate instruments to correct the problem. Arthroscopy can be used to correct a variety of problems within the knee such as torn cartilage or reconstructing a torn ACL. High tibial osteotomy is a surgical procedure performed to relieve pressure off of the knee by transferring weight from the damaged side of the knee to the undamaged side of the knee. This is accomplished by cutting the bone and realigning the knee into a straighter position. The procedure can be done quickly and is designed for patients requiring knee surgery that are looking to maintain an active lifestyle. The benefits of minimally invasive procedures are that they are less traumatic on the body with quicker recovery time compared to traditional open surgeries.
Minimally Invasive Procedures
Partial knee replacements use smaller incisions and less invasive techniques to treat the affected area without disturbing the healthy bone and tissue surrounding it. This is in contrast to a total knee replacement where the whole knee joint is affected. This is particularly useful for patients suffering from unicompartmental knee osteoarthritis (affecting only one part of the knee joint). High tibial osteotomy is used in younger, more active patients and involves cutting and realigning the bone of the tibia. This is to relieve pressure and prevent further damage to a certain part of the knee joint. Autologous chondrocyte implantation is used to treat isolated cartilage defects in younger patients. It involves taking a sample of normal hyaline cartilage and growing chondrocytes in a lab. These are then implanted in the area of damaged cartilage.
Minimally invasive surgery is defined by making smaller incisions and reducing muscle damage. It has the potential benefits of speeding up the recovery process, reduced blood loss, less scarring, and a shorter hospital stay. This can be suitable for the athletic patient who may not want a transfer of tissue away from its original place (as in ACL reconstruction) and has higher expectations of a quicker return to their chosen activity. There are a number of contemporary techniques that fall into the category of “minimally invasive surgery.” These include partial knee replacements, knee osteotomies, and autologous chondrocyte implantation.
Regenerative Medicine Therapies
Cell-based therapy is a technique that involves direct intra-articular injection of chondrocytes (autologous/microfracture), stem cells, and more recently expanded cells in culture. This method looks at directly replacing the damaged cells with healthy cells. This treatment has been shown to be beneficial, but it needs to be well controlled as there is a risk that these cells may form into fibrocartilage instead of hyaline cartilage. This can be achieved through the tuning of the cells to form the desired cartilage type or through combining the cells with a scaffold to provide an environment that would lead to the desired cell differentiation.
In recent years, regenerative medicine therapy (RMT) has become a very popular treatment for osteoarthritis (OA) and chronic knee pain. The main objective of RMT is to provide relief or delay the onset of OA through biological regeneration of articular cartilage and menisci. The concepts involved are quite similar to our body’s natural healing ability, but they are more advanced and focus on repairing instead of forming scars, which can become a source of pain. There are a few strategies and areas of research in RMT, and the most common ones utilized clinically now are cell-based therapy, growth factor treatment, and scaffolds with incorporation of biologics. Data supporting effectiveness in various RMT treatments are emerging; however, more long-term trials are needed.
Robotic-Assisted Surgeries
Traditionally, knee replacements involve cutting a large incision down the middle of the knee. Several Singaporean hospitals have been offering robotic knee replacement surgeries for the past few years, and there are clear benefits that have the potential to improve outcomes for patients. Robotic surgery is a type of minimally invasive surgery. “Minimally invasive” means that instead of operating on patients through large incisions, we use miniaturized surgical instruments that fit through a series of quarter-inch incisions. During a robotic-assisted surgery, the patient’s bone is removed using the robot, but only that which is damaged—good bone is conserved for the future need of a revision procedure. “It’s very precise because not only is the incision small, but the replacement can be put in exactly where it needs to be,” said Dr. Lim of Gleneagles Hospital. This is because bone and joint deformities can be preserved in the virtual environment created by the robot before the actual replacement is undertaken. Robotic systems also track data of patient outcomes. “Data tracking should theoretically allow for accurate surveillance of implant locations and provide feedback on long-term implant survivorship, functional outcomes and quality of life measures,” said Dr. Victor Seah of Tan Tock Seng Hospital. While there is evidence that robotic surgery may improve accuracy and monitor outcomes, the cut to patient-benefit is still unproven. Robotic knee replacement surgery is best suited for patients who are of a younger age and an active lifestyle, and the hope is that with further technology and research, it will be able to extend the life of the knee implant for these patients.
Collaborative Approach for Comprehensive Care
The key to the successful management of a patient with knee problems is the formation of a good rapport between the treating physicians and therapists and the patients themselves. This concept of a multidisciplinary team approach was discussed by Mr. Kevin Ng, principal physiotherapist at the Jurong Health Campus. He emphasized that successful treatment of complex knee problems cannot be carried out in a silo. It requires physicians, surgeons, and therapists to collaborate their skills and knowledge while constantly engaging in dialogue with the patient as to their progress and respective goals. This would allow for a more seamless progression from injury stages, to surgery, and post-surgery rehabilitation. High-level communication between this multidisciplinary team can also avoid unsuitable patients having inappropriate surgical management and any misunderstandings or conflicting strategies that can occasion an adverse event.
The first thing that we need to know is what is a normal knee. Hence, Sports and Exercise Medicine (SEM) doctors and physiotherapists need to understand the biomechanics and pathomorphological issues relating to problems of the knee. Thereafter, a decision can be made as to whether the patient can be successfully managed conservatively, referred to have keyhole surgery/osteotomy to correct a problem, or whether a reconstructive procedure will be the best option. These possibilities should be discussed with the patient in light of the recently published article in the British Medical Journal by a team at the University of Oxford who validated an informed decision-making procedure for patients with osteoarthritis of the knee.
Lawrence Koh, medical director of Singapore Sports and Orthopaedic Clinic (SOSC) and moderator of the AM Nair Lecture, prefaced the session by stating that the meeting was not about “how to turn surgical knees into normal knees” but how to navigate patients with the various problems of the knee through to an eventual good conclusion.
Multidisciplinary Team Approach
The most high-profile and successful examples of multidisciplinary care in health are seen in the field of sport. At the elite level, athletes have access to a wide array of health professionals with the shared goal of optimizing athletic performance. This team will generally consist of sports physicians, orthopedic surgeons, physiotherapists, dieticians, nutritionists, psychologists, and various consultants in specific areas of musculoskeletal medicine. The management of the athlete is thorough and comprehensive, with the athlete being passed through various team members to give input into diagnosis, treatment, rehabilitation, and prevention strategies. A good example of this being successful is seen in the injury management of English Premier League Football Clubs, where the injured player can often spend more time with the club physiotherapist and sports physician than with the treating surgeon. While this level of care is typically reserved for the elite or professional athlete, similar principles can be applied to deliver best practice evidence-based care for any individual with knee pain.
The complex, interrelated, and multifaceted nature of knee pain requires a wide range of expert assessment and management skills to be applied to the individual patient. The traditional medical model of single practitioners working in isolation will be unable to meet the complex health needs of these patients. Instead, a collaborative, team-based approach has been shown to be more effective in delivering best evidence medical care. This model of care promotes the thorough assessment of patients, provides a wider variety of treatment options, and allows for input from various health professionals to ensure the most appropriate management is delivered. This approach is integrated and seamless, with various team members coming together to form a treatment plan that is constantly reviewed and adapted. This is compared to a referral-based system in which care is fragmented and lacks coordination between various practitioners and therapists.
Personalized Treatment Plans
An important feature of the ideal process is the ability to modify the initial treatment plan according to follow-up assessment of the patient’s progress. This requires regular review. Satisfied with the current care, good decisions are made with greater satisfaction and optimal results. All types of patients benefit from a good diagnosis and rational prognosis, but the potential for precision with personalized care makes it especially relevant to people with sports injuries or early arthritis who hope to prolong an active lifestyle.
Taking into account these considerations, the best way to construct a treatment plan for knee pain is highly variable. The process begins with identifying a specific diagnosis and assessing its severity and impact on the patient’s function and quality of life. This allows a prognostic judgment on the likely natural course of the condition, and the expected benefit from various treatment options. Ideally, the treatment is then tailored to the individual patient’s needs, taking into account their personal preferences and circumstances. This notion of matching treatments to the needs of individual patients can be considered a broad definition of ‘personalized’ healthcare. It is implicit in all good medical practice, but the reality often falls short of the ideal.
With so many types of knee pain, it is impractical for a research paper to discuss every possible condition and the recommended course of treatment. The evidence is strongest for the general benefits of weight loss and exercise for osteoarthritis and an operation (anterior cruciate ligament reconstruction) followed by exercise therapy for traumatic anterior knee pain due to ligament injury. At the other end of the spectrum from the relatively disabling osteoarthritis or ligament injury, many people, particularly the young or middle-aged, have knee pain that is not severe and does not greatly affect their function. In these situations, there might be no need for any specific treatment, or perhaps only some advice on exercise therapy.
Rehabilitation and Physiotherapy
Rehabilitation and physiotherapy research encompasses a variety of methods to determine the most effective ways to improve knee treatment outcomes. There is not only research into which exercises are most effective post-arthroscopic surgery, but also on injury prevention and reducing the risk of developing knee osteoarthritis. With an expected rise in the number of people with knee osteoarthritis in the next 20 years, research into effective methods of treatment and prevention is highly relevant in preventing future suffering and a high economic cost.
Rehabilitation and physiotherapy form the cornerstone of any treatment plan for knee injuries. It is particularly important in the successful treatment for osteoarthritis and after surgical intervention. An exercise programme focusing on flexibility, strength, and coordination is usually a first step. This may be undertaken under the supervision of a physiotherapist or done at home. Techniques to reduce pain and swelling, such as ice therapy or electrical stimulation, may also be used. Following knee surgery, the patient will undergo a more structured physiotherapy programme, often at a clinic and progressing to exercises in a pool and then at a gym. Postoperative rehabilitation times can vary, for a simple arthroscopy may only be a few weeks, whilst a full knee replacement may take 3 months plus. High-quality rehabilitation has shown to substantially improve a patient’s recovery and functional outcome in both the short and long term.
