Arthritis/ Inflammation/ Bursitis

HIP ARTHRITIS AND HIP BURSITIS

Hip Arthritis is a progressive disorder and is the common cause of pain in the hip. Arthritis causes inflammation of the hip joint. Common types of arthritis that can affect the hip are Osteoarthritis, Rheumatoid arthritis, Ankylosing Spondylitis, Systemic Lupus Erythematosus, Psoriatic arthritis. Hip osteoarthritis is caused due to gradual wear and tear of the cartilage present in the hip joint exposing the bone to bone contact that causes friction and pain in the joint. 

The doctor performs various tests to confirm the actual cause for hip inflammation and pain which may include blood tests, imaging tests X rays and in some cases MRI.The treatment for any type of arthritis is to first treat the inflammation, then the pain and associated symptoms of the condition. Nonsurgical treatment of arthritis and inflammation of the hip may include: Physical therapy, NSAIDS painkillers, Hip Corticosteroid injection, Symptom-modifying anti-rheumatic drugs (SMARDs) and Disease-modifying anti-rheumatic drugs (DMARDs). Lifestyle modifications to reduce the symptoms of arthritis of the hip include: losing excess weight, appropriate pain management & Minimize stress on the hip. Conventionally Total Hip Replacement Surgery is advised for severe arthritis which helps to reduce pain, improve quality of life and ability to perform daily activities with no restrictions.

Hip Bursitis A bursa is a small fluid filled cushion that reduces friction between a bone and muscle, skin or tendon. An inflammation in the hip bursa causes pain and swelling in the hip. There are major bursae of the hip that are located adjacent to the edges of the thighbone and pelvic bone. Inflammation of any of these bursae can cause tenderness, pain & stiffness around the hip joint. There are number of possible causes for hip bursitis including a hip injury or trauma, repeated pressure on the hip, infection, rheumatoid arthritis and age.

Alternative treatment methods at Beth Yehuwdah Arthritis Centre, Pullad and Daystar Clinic, Alappuzha

1) Platelet Rich Plasma in Osteoarthritis of Hip:

Platelet Rich Plasma is the recent trend in treating various joint conditions and is designed to stimulate repair of chronically inflamed synovium, torn ligaments in the affected joint and to reduce swelling and pain caused by the condition. PRP prolotherapy is a combination treatment where PRP is injected into the joint and/or bursa (cushions around the joint) and dextrose prolotherapy is given to the ligaments and/ or muscle attachments surrounding the joint.

This treatment may help a patient who does not want surgery and helps to overcome the disease condition with minimally invasive injection techniques. The treatment method stimulates the natural immune repair mechanisms of the body and delivers the building block essential to build and repair damaged tissues.

How does PRP work? Blood components are of four major types - plasma, platelets, white blood cells and red blood cells. Platelets assist in clotting and are also the “first-responders” of the body post injury; helping repair an injured region and in building up of new tissue and thereby promoting the healing process. Once platelets contact collagen in damaged tissues, the platelets release various biological growth factors (Table 1 as given below) to promote healing in soft tissues locally. Activated platelets commonly release the following growth factors:

Table 1: Various biological growth factors released by PRP when activated

PRP injection delivers a high concentration of autologous (patient’s own) platelets to the hip, where Osteoarthritis is present. Platelets present in the blood are the first responders to an injured area and helps build up new soft tissues. Introducing high concentration of platelets directly into the joint using PRP injection stimulates the healing process and faster recovery from the joint condition.          

Patient Benefits of PRP Prolotherapy:

• Minimally invasive treatment method
• Almost painless injection technique using very thin needles under local anesthesia
• For those who wish to avoid if not delay/ unfit for Joint Replacement Surgery
  Significantly reduces the symptoms associated with Osteoarthritis
• Reduced risk of adverse events
• Repairs and tightens ligaments improving joint stability and ease of walking
• Safe and effective treatment method
• Faster healing and recovery
• PRP Prolotherapy results in safe, significant, effective, progressive improvement of hip pain, function and reduction of stiffness.

Neural & Soft Tissue Infilteration Therapy (NESTIT)

Low Dose Steroid Infilteration/ Neural & Soft Tissue Infilteration Therapy (NESTIT):  Steroid tablets and injections of the group Corticosteroids, (which are very different from Anabolic steroids misused by some athletes) have been repeatedly proven medically for the last 70 years in the successful treatment of inflammatory conditions due to its potent anti-inflammatory effect. Though corticosteroids are very effective in reducing inflammation, they carry numerous potential side effects, which are undesirable. To circumvent this problem, and in order to utilize the potent anti-inflammatory effects of steroid injections, at the same time taking appropriate measures to considerably lower its side-effects, Dr Tejaz Koshy John in 2010 while working as an Orthopaedician in his private clinic in Guyana, South America developed NESTIT. NESTIT stands for (Juxta) Neural and Soft Tissue Infilteration Therapy. It consists of injecting small amounts of diluted anti inflammatory steroid solution indirectly near (juxta) nerve CCPs- (chronic constricting points) in the lower back/ hip/ neck/ shoulder regions, in order to reduce juxtaneural and perineural inflammation, as well as in certain soft tissue sites including but not limited to trigger points (painful muscle “knots”)/ myofascial syndrome and/or enthesitis (inflammation of soft tissue-bone junctions) and/or sites of nerve inflammation (neuritis/ radiculitis) and/or bursitis (inflammation of fluid filled cushions called bursa) and/or additional sites causing pain referrals (referred pain) to distant sites; in order to obtain a reduction in inflammation and pain in the concerned joint/ region/ limb. It is preferably given for those patients who have Rheumatoid Arthritis, Inflammatory Arthritis, Synovitis, Inflammatory Low Back Pain, Spondyloarthropathy & Nerve and Nerve root irritation. It is not a substitute for DMARDS (Disease modifying anti rheumatoid drugs), however when given with low dose DMARDS, in Dr Tejaz John’s clinical experience it may result in significant reduction of local inflammation, pain and improvement of joint function in most cases, also indirectly reducing side effects of high dose DMARDS.

NESTIT involves 

1. Administeration of low dose local steroid via infilterative type of injection technique rather than giving oral steroids (as cumulative daily dosage of oral steroids over a 6 week period could exceed the dose of local steroid injection by almost 5 to 10 times) or conventional single injection into joints directly.
2. Reduce the dosage of Steroid given via injection and the use of a sliding scale according to patient’s body weight and height to regulate dosage. A 40 kg woman of 4 feet 9 inches should not receive the same dosage as a 100 kg male of 6 feet height.
3. Dilute the low dose steroid injection upto 80% with sterile water and local anesthetic.
4. Administer relatively insoluble low dose steroid via multiple infilterations locally in inflamed tissues in very small amounts indirectly near (juxta) nerve CCPs- (chronic constricting points) in the lower back/ hip/ neck/ shoulder regions as per requirement, in order to reduce juxtaneural and perineural inflammation, as well as in certain soft tissue sites including but not limited to trigger points (painful muscle “knots”)/ myofascial syndrome and/or enthesitis (inflammation of soft tissue-bone junctions) and/or sites of nerve inflammation (neuritis/ radiculitis) and/or bursitis (inflammation of fluid filled cushions called bursa) and/or additional sites causing pain referrals (referred pain) to distant sites; in order to obtain a reduction in inflammation and pain in the concerned joint/ region/ limb.
5. Identification of high risk patients and risk stratification to reduce possibility of side effects, for eg. Patients suffering from serious heart & liver conditions tuberculosis, infections, significant osteoporosis, immuno-compromised patients, menstrual irregularities, already having Cushing’s syndrome, ongoing significant hair loss etc.
6. Regular monitoring of body weight and physical appearance for early detection of Cushingoid features, if it occurs (rarely), to delay/ avoid further injections.
7. Control of High Blood Pressure and Diabetes prior to giving injections.
8. Doing skin sensitivity tests to rule out allergic reactions to the drugs.
9. Explaining possibilities of common & rare side effects to the patient and taking precautions regarding other common side effects wherever possible.
10. Opting for/ Shifting to regenerative treatments like Platelet Rich Plasma and Dextrose Prolotherapy wherever there is secondary degenerative disease / soft tissue damage, once the severe inflammation subsides.

In Dr Tejaz John’s clinical experience, the patient benefits of Low Dose Steroid Infilteration/ Neural & Soft Tissue Infilteration Therapy (NESTIT) treatment are:

• Minimally invasive treatment method
• Almost painless injection technique using very thin needles under local anesthesia
• For those who are medically unfit/ those who want to avoid or delay Joint
• Replacement Surgery in Inflammatory Arthritis/ Bursitis.
  Significantly reduces the symptoms associated with Inflammation in cases of Arthritis/ Bursitis/ Enthesitis.
• Reduced risk of adverse events compared to oral steroid tablets which are taken daily, due lower dosage (very low steroid dosage compared to cumulative oral steroids over 6 week period).
• Reduced risk of side effects/ adverse effects due to prior risk stratification and identification of high risk patients vs. low risk patients by doing precautionary steps and tests prior to giving injection.
• Reduced incidence of post-injection pain due to highly diluted steroid solution.
• Reduces joint stiffness.
• More effective treatment method in inflammatory joint diseases.
• Faster recovery.
• NESTIT treatment results in significant, effective, progressive improvement of knee pain, function and reduction of stiffness if given in series.

To know more about Hip Arthritis/ Inflammation/ Bursitis treatment plans and cost, book an appointment now.