Knee Pain and Weight Management: Strategies Advised by Singaporean Physicians

Advertise with a purpose of improvement. Although some might claim that you have a more challenging road because you need to lose weight, you might say that the task is more difficult and you might even be a little disheartened. But that doesn’t mean it can’t be done and it doesn’t mean you won’t start feeling the effects (positive ones) on your knee pain. Improvement always starts with an idea. This may be sparked from an event, from reading something, or from a visit to the knee pain doctor Singapore. If you start looking into your knee pain, weight, and the effects of the two, you might start to believe that it’s more than just a coincidence. Then and there, you’ve already started to improve. This idea may then turn into action, whether it be to seek further advice from a health professional, a change of diet, a weight loss attempt, or all of the above. Taking action is the next step on the road to improvement. Now I can’t say how you will go, everyone is different. But the idea of improvement is to always go forward. And while improvement is an ambiguous term that can vary between individuals, the joint between weight and knee pain will very much be clarified. At the end of the day, you want your knee pain to be less if not non-existent, and your desire will be easily applied to the joint. Desire is the catalyst of change, and if you desire to improve pain in your joints, understanding the connection between your weight and your knee pain will be a key part of that journey.

Overview of Knee Pain

Knee pain is a significant and common problem in Singapore, affecting 30% of adults over the age of 45. The knee is the largest joint in the body, and it is a hinge joint made up of bone, cartilage, ligaments, and tendons. The joint is supported by the muscles of the legs and is essential for mobility and certain movements such as walking, running, and jumping. Knee pain can be either acute or chronic. Acute pain is most often the result of trauma or an injury, such as a torn ligament or a meniscus tear. Chronic pain can be caused by a number of different ailments, including osteoarthritis, rheumatoid arthritis, gout, and infections. This essay will discuss the link between knee pain and being overweight, the effects and implications of knee pain for the patient, the treatment of knee pain, and the effect on knee pain in regards to lower limb function.

Importance of Weight Management

Management of chronic knee pain consists of a combination of therapies including medications, physical therapy, steroid injections, weight loss, and if indicated, surgery. On a national basis, therapies to treat osteoarthritis (analgesics and NSAIDs, weight loss, physical therapy) have grown steadily over the past 10 years. Some treatment modalities such as use of narcotics, intra-articular hyaluronate injections and arthroscopy have grown despite lack of evidence to support efficacy and are best discouraged. The percentage of adults with knee osteoarthritis using narcotics has doubled over the past decade, and the CDC has recently organized a workgroup to develop best practices for pain management therapies to include guideline adherence and education. A multidisciplinary team approach using non-pharmacologic and pharmacologic modalities is important for both short and long-term management of knee pain, and an understanding of available treatment options and their safety and efficacy will help patients make treatment decisions. Open communication between patients and healthcare providers regarding realistic treatment outcomes is recommended. Although there is no cure for knee osteoarthritis, lifestyle modifications and medical treatments can effectively control pain and disability.

Strategies for Weight Management

Healthy eating habits promote a healthy weight as well as reduce the risk and severity of knee OA. One documented weight loss study supports the above statement. The Intensive Diet and Exercise for Arthritis (IDEA) trial is the first randomized controlled trial in older overweight and obese adults with knee OA comparing two different forms of exercise and weight loss. The exercise protocol was very successful but did not result in significant weight loss, with a mean weight loss of 1.8kg. This is in comparison to the diet-only group, who had a mean weight loss of 4.6kg over 18 months. The significant weight loss resulted in an improvement of 50% in their KOOS quality of life score. High-quality evidence (Grade A) supports weight loss and self-paced walk programs for improvement in symptomatic relief of knee OA and physical function. Weight loss of 5% of initial body weight over 20 weeks has been recommended. This can be achieved through the reduction of calories by 500-1000 calories per day. More rapid weight loss doesn’t provide any additional benefits in the management of knee OA. Medical nutrition therapy and orlistat used in conjunction with calorie restriction may have 5-10% weight loss over 6 months and have shown some effectiveness in the improvement of symptoms of knee OA. No specific diet has been recommended for weight loss and symptomatic relief of knee OA. Diets with various macronutrient distributions have been used in weight loss studies with success. There is also insufficient evidence to suggest that weight loss achieved through a specific diet has further benefits on symptoms of knee OA. Due to potential comorbidities of knee OA and obesity, it is essential to monitor patients who are participating in weight loss programs that may affect their pharmacological management of other diseases. In conclusion, healthy eating habits should promote calorie reduction and healthy foods, weight loss and self-paced walk programs for symptomatic relief of knee OA, weight loss of 5% of initial body weight over 20 weeks, and medical monitoring of weight changes on other diseases.

Healthy Eating Habits

Eating a healthy diet is an essential part of weight management. The general rule of thumb for losing weight is to eat fewer calories than you burn. This can be done by reducing the amount of food you eat, increasing the amount of exercise you do, or a combination of the two. Eating a wide variety of healthy foods can also help you to get all the nutrients you need. This includes eating from all the food groups including grains, lean meats, low fat dairy products, and eating plenty of vegetables, legumes and fruits. It is also helpful to limit the amount of high fat and high sugar foods that you eat.

Specialists suggest some strategies for weight management that can help ease strain on the knees and prevent new knee damage. Some common sense strategies are eating a healthy diet, watching portion size, and being active. But sometimes common sense is not common practice. The following guidelines can help you both lose weight and maintain healthy joints.

Regular Physical Activity

The benefits of physical activity in weight management are substantial. It has also been shown that the combination of aerobic exercise and strength training is more effective in body fat reduction and promoting weight loss. It also helps in reducing the risk of developing cardiovascular disease and diabetes, both of which are associated with obesity. More recently, research has indicated that weight maintenance is even more successful when physical activity is increased to 60 minutes a day. This level of activity aids in the prevention of weight regain and can be a beneficial factor in maintaining a healthy weight in the long term.

Physical activity is any bodily movement produced by skeletal muscles that results in an expenditure of energy. This includes sports, exercise, household activities, walking, and how much we move in the workplace. It is an important part of weight management as it directly affects the balance of calories in the body. Regular physical activity increases the number of calories used, and a combination of moderate-intensity activities, such as walking, and vigorous-intensity activities, such as sports, has a greater effect in burning calories.

Portion Control

There are many different approaches to weight loss. One can attempt dieting, increasing the level of physical activity, incorporating pharmacotherapy, and even surgical intervention. Unfortunately, and in the long run, most methods seem to be unsuccessful. Weight regain after a weight loss attempt is the rule rather than the exception, with about two-thirds of those who lose weight regaining the weight within a year and the majority of those individuals regaining the weight within five years. This has led to a perspective that obesity is a chronic condition and necessitates chronic treatment. Weight loss maintenance has become the goal to successful obesity management and is being reflected by the use of the term “weight management”. Weight loss maintenance is defined as sustained weight loss for a significant period of time, be it a year or more. The reasoning behind weight maintenance as opposed to weight loss is that long-term weight loss is often not achieved and short-term benefits are only few. Data from various studies has shown that a 10% reduction in body weight is often followed by regaining of weight and results in a net loss of only 2-3% in body weight. Hence, it is clear that the emphasis should be placed on weight loss maintenance rather than short-term weight loss, with an increase in the net loss of body weight.

Impact of Weight Management on Knee Pain

An interesting study from Wake Forest University in the USA compared the progression of knee OA in two groups of overweight and obese people over a period of 4 years. The progression of knee OA was determined by the loss of joint space width from X-ray images. The group of people who lost an average of 11 pounds showed far less progression of knee OA. For every 1-pound loss in weight, it is said that there is a 4-fold reduction in load exerted on the knee for the duration of normal daily activities. This is because with every step, the load on the knee is equivalent to 3-4 times the body weight. This known fact is what led to the simple and effective force = 3 times body weight ÷ 3 (each knee) = body weight.

Weight loss has been reported since early times to be beneficial for reducing pain in your knees. Recent studies have strengthened the association between weight loss and a reduction in knee pain. The American College of Rheumatology and the Arthritis Foundation recommend that a weight loss of 5.1% of body mass can significantly improve the symptoms of knee OA. When you stop and think about it, walking on a level surface puts a force equivalent to 1½ times your body weight on your knees. That means a person who is 10 pounds overweight has an extra 15 pounds of pressure on his knees with each step. This increased pressure can cause the destruction of the meniscus and speed up the breakdown of joint cartilage, ultimately resulting in osteoarthritis. Weight loss can halt this destructive process.

Reduction of Joint Stress

Weight loss is potentially the most effective, least expensive, and the safest method to reduce knee joint stress. Respectably, the body weight stabilizes during early adulthood and then increases for men and women, until about the age of 50-60 years after which weights tend to decrease due to illness and loss of muscle mass. Epidemiological studies, particularly from America, show a clearly positive relationship between body mass and symptomatic knee osteoarthritis. Obese persons have a 5 times increased risk of developing symptomatic knee OA compared to non-obese persons. This relationship is stronger in women and significant in non-weight bearing knee OA but is consistent across all studied groups. Weight loss is beneficial in overweight women with a previous knee injury and is effective in preventing and treating knee OA. A prospective study has also shown that weight loss has a beneficial effect on knee joint force pattern during walking. This study documented a direct relationship between weight and medial compartment knee force, which was significantly reduced with weight loss.

When the foot is on the ground, there are two to three times body weight stresses on the knee. This has been calculated by comparing forces at the knee joint to a subject’s body weight. Any increase in this, such as occurs with stair climbing or rising from a chair, also markedly increases the knee joint force. It has been suggested that forces across the knee in excess of three times body weight can produce joint damage. This has been used as a standard to advise patients in activities modifications to reduce joint stress.

Reducing joint stress is important in preventing and managing knee arthritis. It is a limiting factor in knee osteoarthritis (OA) progression. Reducing stress on the knee may also prevent, and is certainly beneficial for, postoperative patients.

Improvement in Mobility

Obesity is a well-documented prognostic factor with regards to knee disability and is constitutive of a primarily physical mechanism. Weight is a strong independent predictor of onset and progression of disability. The chances of developing disability in mobility are significantly less in non-obese people. Obesity is also related to the prevalence of knee pain, the most common site of pain from osteoarthritis, and has been identified as an important risk factor for the disorder. Obese women are nearly 4 times more likely to develop symptomatic osteoarthritis of the knee, a condition strongly associated with disability. If it is accepted that a loss in ability to perform activities of daily life signifies onset of disability, it can be postulated that improvement is the reverse. In the context of knee OA, disability has been operationally defined as difficulty in climbing up stairs, and it has been shown that this is particularly related to knee pain and muscle weakness.

Recommendations by Singaporean Physicians

Consultation with knee pain specialists involves a detailed history and comprehensive examination of the individual’s knee. This may be followed by investigations such as blood tests, X-rays, or an MRI. The process is to help rule in and out the various differential diagnoses and provide an accurate diagnosis of the specific cause of the knee pain. Knowing the cause of the knee pain is crucial in the successful treatment to resolve the pain. This is because different conditions will require different forms of treatment. For example, gout needs medications and dietary modification to reduce the uric acid level in the body; a ligament injury may need surgical reconstruction to provide knee stability; a degenerative osteoarthritic knee may require a knee replacement. If the treatment does not match the condition, there is unlikely to be much improvement in the knee pain.

Consultation with Knee Pain Specialists

Weight loss in overweight and obese individuals has been shown to improve pain and function in those with symptomatic knee OA. Large epidemiological studies have shown an association between weight loss and a reduced risk of developing symptomatic knee OA in women, and weight change in either direction is a strong predictor of OA incidence in the knee. Weight loss also has a dose-dependent association with symptomatic improvement in individuals with knee OA; a loss of 10% for example, has been shown to produce a fourfold reduction in load at the knee during daily activities.

Patients with symptomatic knee OA and an elevated BMI should be encouraged to lose weight and supported in their efforts to do so. At present, the most effective method for weight loss is through dietary change combined with increased physical activity. Walking, the first-line treatment for knee OA, is limited by pain and disability. Walking speed decreases linearly as function worsens, and gait abnormalities are common in patients with knee OA. Prolonged joint loading during ambulation may also contribute to disease progression. High-impact aerobic activity and sports that involve twisting and pivoting motions should be discouraged, as these activities exert excessive joint stress and are associated with an increased risk of OA progression and symptomatic complications. In the lower extremity, a step reduction of 10% reduces the load per step on the knee joint by approximately 10%.

Patients with knee pain who struggle to lose weight on their own should seek consultation with a physician who specializes in weight management. In the physician’s clinic, patients can receive the support and guidance that the primary care setting may not have the resources to provide. A weight management specialist can provide an adequate follow-up over time, which sustained weight loss requires, and can monitor for the development of obesity-related comorbidities that may require further care. These factors are particularly relevant in the management of knee osteoarthritis (OA), and often time and resources in the primary care setting are inadequate to effectively address comorbid obesity and weight-related joint stress in patients with this chronic disease.

Personalized Weight Loss Plans

Weight loss is a common recommendation for overweight or obese persons with knee pain. Obesity not only causes knee pain by mechanical overloading, but also increases the risk of OA in people who are at high risk by hereditary. Weight loss through a low-intensity exercise and dietary intervention reduced over four years the risk of symptomatic osteoarthritis in overweight women by nearly 60%. There is also evidence that the risk of OA decreases with increasing physical activity. This is partly by preventing obesity, but also by strengthening the musculature about the knee, which has been shown to decrease the risk of knee OA development. Unfortunately, although weight management advice should be a key part for managing overweight or obese persons with knee pain, it is often not carried out. This can be due to many reasons including lack of patient motivation, it being a sensitive issue, negative attitudes and behaviors from healthcare providers, fear of pain or further damage to the knees, and general lack of support and resources. Two qualitative studies were conducted to determine the attitudes and perceived barriers to weight loss in adults with knee pain. In both studies adults with chronic knee pain were interviewed. In the first study of adults of varying BMI, six focus groups were created and it was found that although most people were aware of the benefits of weight loss, they thought it was too difficult and hardly anyone was addressing it. All groups reported that they believed weight loss would reduce knee pain and slow disease progression, with some aware of the direct link between obesity and OA. While most individuals attempted to lose weight in the past, the reasons for their temporary or no success were mainly due to lack of motivation and social support. They also reported reluctance to go to exercise centers or do certain activities that would further damage their knees.

Multidisciplinary Approach to Treatment

Most of the physicians consider a multidisciplinary approach to be necessary for effective management of knee pain in overweight patients. This involves the collaboration of the family physician, orthopaedic surgeon, physiotherapist, and dietitian. The family physician plays a key role as the coordinator as he is usually the first person the patient consults regarding his knee pain. He is responsible for making the diagnosis, ruling out other causes of knee pain, and coordinating treatment plans with the other specialists. The orthopaedic surgeon will be able to assess the patient for possible surgical indications. The physiotherapist formulates an appropriate exercise program to address the patient’s knee pain and aid weight loss, and the dietitian helps to identify and change eating habits that led to weight gain by providing nutritional education and a diet plan that is both safe and effective for the individual’s long-term weight management. All these combined efforts are aimed at helping the patient achieve an ideal body weight, which is essential in relieving the symptoms of knee osteoarthritis and preventing further joint damage.

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