♪ Bob and Brad ♪
♪ The two most famous physical therapists ♪
♪ On the internet ♪
- Hi folks, Brad Heineck, physical therapist.
- Hi, I'm Christ the Pharmacist.
- And I'm exactly 1/2
of the Bob and Brad Physical Therapy channel,
and Bob is not here today, but he's gonna be back.
We've got Chris here.
He's done I don't know how much research
on this topic with knee replacements
and what you need to know
if you've got a knee that's questionable,
and do you need it replaced or what are the options.
It's all gonna be answered right here.
Before we go on any further,
there is no giveaway today.
- No giveaway. - It's Saturday.
- It's a Saturday. - so we can skip that.
- Sleeping it in, checking a little Bob and Brad.
- Chris, let you take it away,
I'm gonna give some advice on the exercises
and stuff I know a lot about,
and whenever I'm gonna chime in.
- Yeah. - Carry on!
- All right, well, today we're talking about
osteoarthritis of the knee.
- Osteo. - Osteo.
- That's different than the rheumatoid?
- Yeah. Rheumatoid is more of a immune response.
All right, and yeah, so we were talking about,
so with rheumatoid arthritis,
that's the one that's your immune system
is attacking the joint per se. - Sure.
- This is the wear and tear
that we all, at some point or another as we age,
are going to develop. - Sure.
- It's that wear and tear.
It's kind of the tissues around the knee.
I mean, specifically the cartilage starts to wear down.
That's our shock absorber.
I don't know if we wanna look at anybody, Sam or not.
- Well, yeah, we can look at that right now.
So, on the knee, the cartilage, we're looking at...
Sam, I'm sorry about this, but we gotta see this.
Right on the bottom of the tibia
or the top of the tibia here
is where the two bones articulate
or that's where they rub together,
and then these surfaces here,
and these surfaces are nice and white and shiny
when they're healthy.
With arthritis, it's kinda like they're rusty
and they start to develop pits
and they're not shiny anymore.
And when the bones, the joints go together,
instead of nice and smooth, it starts to grind.
It makes noises. We call that crepitus.
And pain is almost always associated with it.
- Yeah, and so then that continually devolves
really in bad cases of it, so it's something.
So, you know, what do we do?
I mean, that's kind of the big million dollar question.
I mean, are we all doomed to have knee replacement surgery?
And the answer is no. - Right.
- And so that's the good thing.
I mean, that's where you come in,
where you're so adept at everything that you can do
from an exercise and strengthening aspect.
But you know, a lot of it comes down
to, what else can we do that are maybe non-drug related?
So it's gonna be weight loss. - Right.
- You know, if we get a BMI over, you know, 30,
I mean, there's a seven times higher chance
that you can develop knee osteoarthritis.
- So like if you're 5'6" and you weigh 180 pounds,
you know, your joints are taking quite a bit more
than if you were thinner. - Yes, applied physics.
- But you know, a lot of people include my, you know,
weight loss is very hard, very challenging.
It may not happen to a lot of people for other reasons
and just because it's difficult for many reasons.
- Correct.
And so, I mean, it's like, so, what's next?
Then it's strengthening that leg
so that we can take care of that joint.
- And actually it's a therapist point of view,
before we get into some of the other option,
if you do have arthritis in your knee,
it hurts when you walk, it feels better when you sit down,
you need to check your range of motion.
I'm not gonna get into this in too much detail,
but look at your range of motion.
You need to have full extension.
The knee needs to be fully straight,
compared to your sore knee,
hopefully your other knee is not so bad.
If this one straightens out all the way
and this one doesn't,
it's very common with the painful knee.
We have videos, nice videos that show
how to stretch the knee
and this is one of the exercises.
Simply stretch it gently like I'm doing here
and you also wanna look at the range of motion
and make sure it's flexes are bends all the way.
Okay?
And then when you get that full range of motion,
you wanna do exercises
that keep the joint moving without weight bearing.
In other words, a stationary bike.
You could just put a towel on the floor
and rub back and forth.
You know, there's the Knee Glide made specifically for that,
particularly on carpet or you can put it on an angle
which makes quite a difference when you have a sore knee.
So those are a couple options.
But if you Google Bob and Brad arthritic knee pain
or arthritic knee exercises,
we've got a number of videos that should come up
and you can look at those
and it'll go through those exercises in detail
and get your knee feeling better or ranged out.
And either way before surgery,
you definitely want to have that.
Pre-op they call that.
But if you're just trying to maintain and avoid surgery,
you still need to do that. - Yes. Absolutely.
- Go ahead. I'm sorry, Chris. - Oh, no, no, no.
I think that's important to interject all those things
because at the end of the day,
it's really about the joint
and joint integrity and preservation.
See, what I mean? - Sure.
- And you heard me say
that not everybody's gonna end up with a knee replacement.
I mean, we can do a lot of different things.
We talked about briefly controlling the weight if we can.
You know, otherwise strengthening exercises,
which I think is absolutely paramount and critical.
But actually, how we eat and feed ourselves
is actually pretty good.
So there's a variety of different things
and actually be kind of cool to do a video
with Jordan on this.
- Oh, sure. - Osteoarthritis diet.
But there's a lot of foods out there
and please feel free to Google it.
You can look at foods that help prevent inflammation
and also nourish your cartilage.
So we often used to think that cartilage,
it couldn't regenerate itself, but that's really not true.
It regenerates very slowly like a glacial pace.
So it's not gonna be anything quick
that can really just go ahead
and just "I'm gonna eat so well
that my cartilage goes back to its normal spongy status."
It doesn't really do that,
but we can do things to slow it down
or kind of regain some of that integrity of it.
- So we probably don't wanna get into details of a diet,
but in general, is there some...
- Yeah, it's gonna be, you know...
Yeah, it's gonna be your fish,
so it's gonna be like your salmon and your sardines,
'cause they're gonna have the omegas in there.
It's gonna be your green, leafy vegetables
like kale and spinach and broccoli, those types of things.
They're anti-infs, so things like beets and blueberries.
They all kind of work together synergistically.
So you wanna have a very complete diet.
- Right.
- And that helps to kind of give your body
the things that it needs to protect itself
to reduce inflammation.
And when you eat kind of an anti-inflammatory diet,
it helps to prolong and nourish those joints,
and all of body, not just our knees,
but we're talking about the knee today.
So I think that's very important.
And then... - And if you eat that way,
your joints are gonna become more healthy
and you're probably gonna lose some weights.
- Exactly. - It's a win-win situation.
- It is. And so it kind of...
Yeah, it's a self-fulfilling prophecy in a lot of ways.
But you know, still there's times
where, let's say, you're a runner,
you tweaked it when you're a kid playing football or tennis.
You know, there's a lot of reasons why.
Genetics withstanding.
Male versus female,
and I think that's an interesting thing too,
is that most osteoarthritis in the knee is 60% female.
- Oh, really? - Yeah.
So there's a high- - Because they work harder.
- They definitely work harder and they're totally stronger.
But at the end of the day, you know,
it's also a little bit of just how their bodies are designed
with the hip angle. - Sure.
- And I don't think we'll get too in depth in that
'cause that'll puts you to sleep.
- It is what it is. Yeah. - But it's something that...
At least we see that with the statistic.
I mean, you're looking at 600,000 knee replacements a year,
roughly. - Yep.
- And so, I mean, it's certainly, but we...
That's only 6000,000 people per year.
I mean, there's a lot of people that are walking around.
- That's just in the States, right?
- Yes. That's a US figure.
So with that, you know, so what do we do?
Well, we move on, we do the physical therapy,
we try pain relievers like ibuprofen and Tylenol or Relieve
those things are useful.
- And those are okay, I'm assuming.
- They're okay. Yep.
And they definitely help,
but again, they begin to out and outta gas.
So then now it's like,
what do we do to try and preserve this, calm things down?
So let's say you got a wedding you need to go to
and you don't want to have knee replacement surgery
and you want to prolong it,
or maybe we can prolong it so that we get healthy
so that we don't have to have the surgery.
So those are options that are on the table.
So there's two main things
that doctors uses in their toolbox
and it's gonna be your hyaluronic acid shots
or your corticosteroid shots or the steroid shots.
- Okay.
Now I'm just gonna say... - Yep.
- You just said that you're in pharmaceutical terms.
- Yeah. - Let's say that what people
- Yeah.
- May recognize. - So a lot of times,
I think doctors kind of talk about
the rooster shot or the rooster comb shot.
- Okay.
- So brand name being like Synvisc,
but there's about five or six other manufacturers out there.
Some actually use the rooster comb,
but other ones have found different ways
to make the medication to minimize poultry allergies
and things like that.
- And those, I understand,
actually try to regenerate the cartilage
- Yeah. - Or add to it.
- And I think they aren't gonna really regenerate it,
but it's gonna help to lubricate it.
So if I had a can of WD-40
and I could spray it in your joint,
and that's what these, specifically called,
viscosupplementation.
So we'll talk about the hyaluronic acid
or rooster shot first.
That one, you know, it's a mix bag of nuts.
You know, all these shots are really designed
for mild to modest osteoarthritis.
- Okay.
- So when it's severe, you can't do it.
If you've got an infection, you can't do it.
- Okay.
- So there's limiting factors in these things.
So I mean, when you are bone on bone,
these shots won't do any good. - Sure.
- So when you still got a little cartilage left,
that's hanging on,
I mean, hyaluronic acid shots or rooster shots
can last up to six months. - Sure.
- And it's serious depending upon the product
your doctor chooses for you. - Right.
- So there's a one, and a three, and a five shots series,
so it just kind of depends on the product that's utilized.
They're covered by insurance, which is good,
'cause they're about 1,200 bucks a pop.
- So Medicare in the United States
- So Medicare in United States
- Will cover that. - Covers it.
And I would imagine that over in Europe,
there's probably a similar type thing,
but I'm not very well versed in that
so I don't wanna throw words in anybody's healthcare system.
- So that really is a conversation
between you and your doctor
'cause there's all these little variables and
- Yep.
- You need to decide, is that it?
Or do you wanna go more unto that or what the option is?
- Well, I think we can...
Well, I think just to keep it with organized.
So the hyaluronic acid or rooster shots,
they help once they find where they need to put it.
- Okay.
- And they'll do a very extensive workup for you
and figure out what's going on.
They're gonna put it into the knee joint itself.
- So they use a needle.
- Yep. They use a needle and they squirt it in.
It's usually about five, six milliliters,
which is just about a teaspoon full of liquid.
So it's just a teeny tiny amount.
- Okay. - So it's not much.
A little bit goes a long way.
And so they place that,
and sometimes they'll use ultrasound
to show where the needle needs to go
- Sure. - and place it.
And sometimes that knee can be pretty swollen.
So sometimes they might pull a little bit of fluid out
to make room and put that in.
It also is twofold.
It also pulling some of that pressure off
actually allows that knee to feel a lot better too.
- So they pull fluid out,
your bodily fluid out, - Yep.
- 'Cause it's all swollen.
- Yeah, it's effusion swelling.
- Gives you room to put in the medicine.
- Put in the medicine, so it's actually important step.
So it's just something that you're mentally aware
that you know these steps may be coming.
- Sure.
- Not everybody has that happen.
Sometimes it's not quite that inflamed,
so it's not necessary. - Sure.
- Again, your doctor very well versed.
They are so strong in these areas.
- Yeah, I agree.
- Again, it's above my pay grade.
(both chuckles)
But the reality of it is it's just something
that you will have to probably be prepared for,
at least mentally. - Right.
- But when they inject that in there,
depending upon the product that they use,
whether it's the one shot, the three or the five,
if you're coming back ,it's every week for three weeks,
it's every week for five weeks, or the one time shot.
So your doctor gonna determine
which one of those is most appropriate for you,
- Sure. - allergies and withstanding.
And so they're gonna place that in there
and you have to have rest for two days after this shot.
- Okay. - You can't just go out,
"I got my shot, I'm all lubed up.
I'm ready to run a marathon."
It's not happening.
So it's actually very important
to listen to your doctor's advice with the healing process
to make sure that that sets properly,
helps to bathe and nourish the existing cartilage
that's left, - Sure.
- and help to create that good lubrication
like we saw in the knee joint itself.
- Right. - And so, it can last.
And actually the unique thing
about the hyaluronic acid or rooster shots
are the pain relief is, in many cases,
more durable or longer lasting
than what you get from the steroid,
which is the next drug we're gonna talk about.
- Right. I just wanted to make mention
'cause I had my other in. - Yep.
- Her weight is not healthy. - Yep.
- She's got other issues. Surgery's not an option for her.
And they talked about this shot
and then they talked about the steroid.
- Yep.
- And after a little discussion,
and my mom wanted me there
because "Oh, the therapist, he'll know what to do,"
so it was my decision, not hers
- Yep. - in her mind.
But it was pretty easy in her case,
we decided the next option.
- Yep. - The steroid.
- Yeah. The steroid shot. It's a corticosteroid.
And the reason that those are, in many cases, favored
over the hyaluronic acid shots
are it provides more immediate pain relief early on.
The hyaluronic acid shots take a little time to develop
like in their wheelhouse maybe.
- So you're talking about weeks?
- Yeah, like about four weeks
and then it can last up to six months.
- Sure. - So it just kind of depends.
So again, it's bathing and nourishing the joint.
But for a lot of patients,
and a lot of the research suggests,
it's inconclusive or inconsistent relief.
So it's not everybody,
it's not for everybody and it's not for every circumstance
and your doctor will recognize that very clearly.
- Yeah. - And give you the options
like they did like with your mom.
- Yeah.
- So the next option that we talk about
is the steroid shot or the glucocorticosteroid shot,
and that's the one that helps to reduce inflammation
and by reducing inflammation, swelling in there,
it calms that down to allow, hopefully,
our body's natural healing processes to kind of take place.
- Sure.
- But we have to be careful
when we're doing a steroid shot in any joint,
but we're talking about the knee today,
because too many of them can actually degrade the tissue,
the bone, the cartilage, and even the tendons.
- Sure.
- So the example that we always see in a lot of cases,
at least with the tendons,
are, we've seen a dry rubber band.
So you know how stretchy, you know how elasticy
a nice rubber band is.
You can pull out and you're gonna get it.
But you know...
Too bad, we don't have a- - I thought I had one back.
Oh, it'd be like this. - Yeah.
So you can kind of see that.
That's nerve tissue by the way. (laughs)
But if it were your cartilage,
it kind of behaves the same way
or if it's tendon, it behaves the same way.
But when we use too many of these steroid shots
and the magic number is four. - Okay.
- You don't want to go more than four in a year.
So you keep three to four months in between those shots
- Okay.
- to help to allow the drug to metabolize out
and make sure it doesn't make it brittle.
- So it's like an old rubber band in the sun.
- Old rubber band and it just pulls apart.
- And it breaks. - Yep.
And it may actually decrease the ability
for the body to regenerate its own cartilage
and it degenerate on the bone itself.
- Sure.
- So, questions your doctor will screen you for
making sure there's no infection,
making sure there's no allergies to certain components.
It's kind of funny to be allergic.
There are some people that are allergic to steroids,
which is a strange irony
'cause people get steroids to treat allergies
in a lot of cases. - Sure.
- But there are small circumstances.
So again, you would be acutely aware of that
because you would've experienced something quite negative.
So your doctor will screen you to make sure it's appropriate
and moving forward, we're gonna say you are,
they're gonna place it again very carefully.
- Yeah.
- And put it and they'll use maybe a little bit...
You know, might pull some fluid out
and then they're gonna put it into your joint.
- Sure.
- And a lot of times they mix it
with a pain reliever called lidocaine
and it helps to numb it.
So a lot of times,
patients experience almost immediate relief
and that's a little bit of a slippery slope
because all of a sudden,
"Wow, my knee feels really good, doc.
I'm gonna go mow the lawn."
Or whatever.
And again, the answer to that is no.
You want to take a couple of days off
to allow that shot to take place and let some healing begin.
And then you can began to strengthen, exercise, enjoy.
- Right.
- So we have to be real careful with that too.
You know, the side effects
with both the hyaluronic acid shots or the rooster shots
and the steroid shots are almost similar.
So sometimes, you wanna report to your doctor
if you get a little bit of irritation, get some redness.
Sometimes with the steroid shot,
you can get some blanching of the skin
if it's placed closer to the surface.
So some little tweaky things
that people notice from time to time.
But generally very safe, very effective choices
to try and help to reduce that inflammation, improve pain
and hopefully stave off or even maybe not have surgery.
I mean, your mom responded unbelievably well.
- She did.
She went in, the doctor was very good,
explained it to me and to my mother
so we both could understand it.
She got the shot, right. I mean, it wasn't even scheduled.
We were just there for knee pain.
- Yep. - And I thought
he's gonna say, "Come back next week
and we'll give the injection."
He did it right there. - Yep.
- It was almost pain free for her.
- Yeah.
- I thought it was one of those things
where you kinda bite the bullet while they inject,
but it wasn't.
- These guys and gals are so skilled.
- Yeah.
- They're so good at what they do
and they just understand anatomy and physiology so great
that they really can't...
I mean, they're there to help heal.
I mean, that's their job.
And I think that they utilize the tools in the shed
to maximize it.
I mean, sometimes the inevitable is gonna happen
where the damage just is too great
and we have to have the replacement.
But you know, there's a lot of people like your mom
that are in that quasi-state
and you know, the other thing that we have to look at
is whether we use the hyaluronic acid shot
or the steroid shot,
healing can begin. - Sure.
- So if we're working on that strengthening,
we can prolong or maybe even avoid that surgical result.
So I think that's really critical to take home.
- In her case, it was last fall, she got the shot.
Within a week, she was feeling better
and she hasn't mentioned knee pain since.
- Yeah. - So it's a-
- Proofs in the pudding.
- Yeah, I'm very happy with that
- Oh, yeah. - And so good.
Well, were we gonna cover something else with this?
- I don't know that we were. (chuckles)
- Well, no, I just-
- I mean, we could talk about like platelet enrichment
if you want. - Oh, is that an option?
- It's an option, but it's little bit on the fringes.
- So we're talking about is PRP?
- Yep. - Yeah. P-
- So, I didn't know we wanted to include...
I mean, we can.
so basically what they do is-
- Well, people are tuning out anyways.
They got what they wanted, but if they wanna see that,
'cause I just got introduced to that
with my shoulder issue - Yep.
- and I watched continually last night about it
- Yep. - for hip issues.
So it's like, "Oh, this is new, but it's out there."
- It's new. It's out there.
The research is kind of all over the map.
There's not a lot of consistent ways
that doctors have been doing it.
So I think if they can find a more consistent way
to deliver it, I think it's got promise.
Because what they do, they centrifuge it out,
they oxygenate the blood, they put the platelets back in.
- So they actually take your own blood out.
- They're using your parts. - Right.
- And that's what's nice
because you're not gonna be allergic to yourself.
- Sure.