Available online on 15.09.2024 at http://jddtonline.info

Journal of Drug Delivery and Therapeutics

Open Access to Pharmaceutical and Medical Research

Copyright   © 2024 The  Author(s): This is an open-access article distributed under the terms of the CC BY-NC 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited

Open Access  Full Text Article                                                                                                                                              Case Report

Management of Knee Osteoarthritis (KOA) with Integrative Therapy: A Case Report

Uzair Yousf Mir ¹*, Shaik Adeena Parveen ¹, Safia Abbasi ¹, Hamid Ali ², Mohd Nayab ³, Abdul Azeez ³,        Abdul Nasir Ansari ⁴

PG Scholar¹, Department of Regimenal therapies, NIUM, Bengaluru, Karnataka, India.

Assistant Professor², Department of Amraze Jild Wa Tazeeniyat, A & U Tibbia College & Hospital Karol Bagh, New Delhi 

Associate Professor³, Department of Regimenal therapies, NIUM, Bengaluru, Karnataka, India.

Professor and Head⁴, Department of Regimenal therapies, NIUM, Bengaluru, Karnataka, India

 

 

INTRODUCTION

Knee osteoarthritis (KOA) is a common chronic debilitating disease that imparts a substantial socioeconomic burden to society and healthcare systems.¹ The condition is characterized by joint pain, functional impairment and significant reduction in quality of life.² Knee osteoarthritis is the most common joint disease and a major cause of functional limitation and pain in adults.³ KOA affects more than 650 million individuals worldwide and is a leading cause of disability.⁴ The prevalence of knee OA has dramatically risen in recent decades due to consistent increase in life expectancy and obesity worldwide. The estimated prevalence of KOA is around 23.9% in the general adult population.⁵ KOA being a degenerative disease, leads to loss of articular cartilage, bone remodeling (osteophyte formation), subchondral sclerosis and subchondral cysts. Articular cartilage is a shock-absorbent connective tissue that provides a smooth surface to minimize friction upon joint movement. The above changes lead to joint dysfunction and hence pain worsened upon activity, stiffness and loss of function. However, more recent studies have shown that the pathogenesis is much more complex with metabolic and inflammatory aspects to it.^6,7 As far as the management of KOA is concerned, it is generally divided into conservative (non-operative) and surgical (operative) measures. Conservative management broadly compromises pharmacological and non-pharmaco-logical options and is conventionally the first line treatment to avoid or delay the need for surgical management.^8,9,10It includes Patient education, physical exercise, and weight loss (for overweight or obese individuals). However, less than 40% of patients with knee OA receive this kind of intervention.¹¹ In Unani system of medicine, KOA comes within the domain of Waja-ul-Mafasil, which is an Arabic term which denotes pain in joints, especially the joints of upper or lower limbs. According to the joint involved, they are named as Waja-ul-Katif (shoulder pain) Waja-ul-Miraq (elbow pain), Waja-ul-Khasira (hip pain), Waja-ul-Kaab (ankle pain), Waja-ur-Rukbah (knee pain), Waja-uz-Zahr (low backache) etc.^12,13 Joints are more susceptible organs to get accumulated with morbid matters owing to their spacious structure, cold and dry temperament (Barid Yabis Mizaj), low metabolic rate etc.The most common etiological factor responsible for the development of Waja-ul-Mafasil is raw phlegm (Balgham-e-Kham) produced due to inappropriate metabolism (Gair Tibbi Istihala). Thus, the morbid material collected in the joint spaces is not eliminated properly, which gradually affects the joints and thereby  produces pressure and inflammatory symptoms like pain, stiffness, swelling, redness, etc. Keeping etiology in mind, Unani physicians have been successfully managing KOA using the principles of Izalae Sabab (removal of cause) and Tadeele mizaj (correction of temperament) with various drugs having properties such as Musakkin (analgesic), Muhallil (resolvent), Qabiz (astringent), Raade (Repellent), Murakhkhi (local relaxant) Mukhaddir (anaesthetics), Munawwim (hypnotics) and regimes such as Hijama (Cupping), Irsal-e-Alaq (Leech Therapy), Fasd (Venesection/Phlebotomy),¹⁴ Natūl (Irrigation),^15,16 Dalk (Massage) with myriads of oils like Roghan-e-Baboona, Roghan-e-Dhatura, Roghane-Surkh, Roghan-e-Suranjan, Roghan-e-Gule Aak, Roghan-e-Malkangni, Roghan-e-Haft-Barg, Roghan-e-Kuchla, Roghan-e-Hina, Roghan-e-Zanjabeel, Roghan-e-Shibbat,^17,18,19 Takmeed (Fomentation),²⁰ Zimad (Paste), Riyazat (Exercise), Hammam,^21,22 etc. We present a case of KOA with a poor response to NSAIDs and other therapeutic measures. We combined unani pharmacological therapy with regimenal therapy (massage therapy and steam fomentation) to provide a safe and effective early treatment option.

CASE REPORT

A 55-year-old female, who presented to Department of Regimenal therapies, National Institute of Unani Medicine, Bengaluru with complaints of progressive bilateral knee pain since 5 years. The patient had history of bilateral knee OA. The patient had taken NSAIDs intermittently for pain management for 3 years however from last 2 months, symptoms have worsened and patient felt more stiffness in the morning and complaints of exaggeration of pain while walking for more than 20 minutes and standing continuously for more than 30 minutes. The pain was intermittent throbbing and dull in nature, present around both the knees. Pain in right knee was more than pain in left knee. The patient had radiographs which indicated osteoarthritis in both knees. Radiographs showed Kellgren and Lawrence (KL)²³ grading 2 in left knee joint and KL grading 3 in right knee joint. Patient expressed the main concern of pain in the bilateral knee. Crepitus was heard in both knees. Tests and assessments were performed at baseline and post intervention to determine the intensity of pain, knee joint range of motion and manual muscle strength. After obtaining informed consent, the patient underwent clinical assessment using multiple assessment para-meters like Numerical pain level scale (NPRS),²⁴ Active Range of Motion (AROM)²⁵ and Manual Muscle Test²⁶ prior to the intervention at baseline V₀. The patient was asked to rate his knee pain on NPRS scale, where 0 indicates no pain at all and 10 indicates extreme pain. The patient had NPRS score of 08/10 and 04/10 in right and left knee joint respectively as shown in Table 1. As far as the Active Range of Motion(AROM) is concerned, there was lack of knee extension as shown in    Table 2. The Oxford Muscle Scale was used to quantify the power or strength of muscles wherein measurement is scored on a 0 to 5 scale, with 5 representing maximal strength. The MMT scores are shown in Table 3. The assessment was done at baseline (V₀) and after completion of integrative therapy (V₁), i.e., on the 28^th day.

TABLE 1: Showing NPRS Score at V₀ (Baseline).  

NPRS	Score at V0
Right knee	08/10
Left knee	04/10

 

TABLE 2: Showing AROM Score at V₀ (Baseline).

AROM	Range of Motion  at V0
Right Knee Flexion	110°
Left Knee Flexion	120°
Right Knee Extension	-5°
Left Knee Extension	-3°

 

TABLE 3: Showing MMT Score at V₀ (Baseline).

MMT	MMT score at V0
Right Hip Extension	5
Left Hip Extension	5
Right Hip Abduction	5
Left Hip Abduction	5
Right Knee Flexion	4
Left Knee Flexion	4
Right Knee Extension	4
Left Knee Extension	4

 

METHOD OF PREPARATION OF OIL USED FOR MASSAGE:

Oil of Celastrus paniculatus Wild (Roghan e Malkangni) was prepared as per guidelines of NFUM (National Formulary of Unani Medicine). Crude fresh Celastrus paniculatus seeds were collected from the local market and oil was obtained by the process of cold pressing.²⁷  

Dosage: 15-20 ml of oil was used.

PROCEDURE OF REGIMENAL THERAPY:

After a detailed assessment, the patient was given the first session of massage with lukewarm oil of Celastrus paniculatus Wild. (Roghan e Malkangni) over bilateral knee joints for about 20 minutes. After massage, with the aid of an automatic electrical steam machine, steam fomentation was done over the same area for another 20 minutes, early morning with a frequency of one session per day for one month. Oil of Celastrus paniculatus Wild (Roghan e Malkangni)  was prepared as per the guidelines of the NFUM from crude Celastrus paniculatus seeds by cold pressing process in the pharmacy of the NIUM. Unani physicians have employed this oil for many diseases, especially those, which are caused by cold temperamental humors like facial paralysis, hemiplegia, thigh pain etc.^28,29 Before and after the completion of each session, vital parameters such as blood pressure, pulse, and respiratory rate were recorded. After completion of treatment, patient reported an improvement in symptoms that was also reflected by assessment parameters post- intervention as shown in Table 4, 5, and 6.

TABLE 4: Showing NPRS Score at V₁ (Post intervention).

NPRS	Score at V1
Right knee	05/10
Left knee	03/10

 

TABLE 5: Showing AROM Score at V₁(Post intervention).

AROM	Range of Motion  at V1
Right Knee Flexion	115°
Left Knee Flexion	127°
Right Knee Extension	-1°
Left Knee Extension	0°

 

TABLE 6: Showing MMT Score at V₁ (Post intervention).

MMT	MMT score at V1
Right Hip Extension	5
Left Hip Extension	5
Right Hip Abduction	5
Left Hip Abduction	5
Right Knee Flexion	4
Left Knee Flexion	5
Right Knee Extension	4
Left Knee Extension	5

DISCUSSION

Unani System of Medicine is Graeco-Arabic medicine found by Hippocrates and Galen and refined by Arabian and Persian doctors such as Rhazes (al Razi) and Avicenna (Ibn-e-Sina), Al-Zahrawi, and Ibn Nafis throughout the Middle Ages. Buqrat (460-377 BC), also known as Hippocrates, was a descendant of Aesculapius and is regarded as the “Father of Unani Medicine”^30,31

 In Unani System of Medicine, diseases are thought to disrupt the body’s normal temperament and humor equilibrium. So Regimenal therapy (Ilaj bit Tadbeer) and pharmacology (Ilaj bil-Dawa) have been used since ancient times with the intention of restoring humor equilibrium and correcting aberrant temperament. This study is the first documented case to show the impact of integrative therapy, coupling pharmacotherapy with regimenal therapy in the management of KOA. The oral medication prescribed was Habbe Suranjan owing to its anti-inflammatory and antioxidant properties³². Unani physicians have been prescribing this medication for arthalgia from time immemorial.^33,34,35 The patient was advised to take two tablets twice daily after food for 30 days. The tablet was manufactured in the pharmacy of NIUM as per National Formulary of Unani Medicine (NFUM) guidelines. The ingredients and composition of  Habbe Suranjan^36,37 are listed in Table 7. The ingredients possess analgesic and anti-inflammatory properties ^33,34,35.

TABLE 7: Showing Ingredients of Habbe Suranjan 

Ingredients	Composition	Dose
Suranjan Shireen	Colchicum autumnale	80g
Turbud	Ipomoea turpethum	95g
Aelwa/ Sibr	Aloe barbadensis	35g
Habb- al-Neel	Ipomea hederacea	35g
Gugul / Muqil	Commiphora mukul	15g
Mastagi	Pistacia lentiscus	15g
Tukhm soya /Shibt	Anethum sowa	35g

 

In Regimenal therapy, patient was given massage, 20 minutes daily over bilateral knee joint with lukewarm Roghan e malkangni for 30 days, followed by steam fomentation for 15 minutes. At the time of recruitment, the patient was in pain and was not able to walk or stand for prolonged time. After intervention, the inflammation subsided and patient felt relief in pain and stiffness. The patient reported amelioration of symptoms and an improvement in assessment scores. The assessment scores depicted a significant difference before and after treatment as shown in Figures A, B and C below.

 

 

 

Figure A: Bar diagram showing NPRS scores before and after treatment.

Figure B: Bar diagram showing degrees of AROM before and after treatment.

 

Figure C: Bar diagram showing MMT scores before and after treatment.

 

 

The case study results indicate that integrative therapy has potential anti-inflammatory and analgesic benefits and can be employed for KOA. The soothing effect offered by integrative therapy may be attributed to the anti-inflammatory and analgesic properties of the Habbe suranjan and Roghan e malkangni.^33,34,35. Massage (Dalk) and steam therapy  further helped in relieving of symptoms by increasing blood flow and reducing inflammation³⁸, relaxation of surrounding muscles and reducing muscle spasm^39,40, release of pain-relieving chemicals, such as endorphins and opioids⁴¹ , reducing nerve sensitivity and pain transmission^42,43 and improving joint mobility and reducing stiffness.⁴⁴ This case report shows that an integrative approach involving pharmacotherapy and regimenal therapy can improve symptoms of KOA.

Financial Support

All authors declare that no specific financial support was received for this study.

Ethical Clearance

This study is approved from Institutional Ethical Committee for Biomedical Research.

Acknowledgement 

I am thankful to my co-authors for their patience and support and also to the participant who extended her willingness to be part of the study and supportive staff of the hospital in providing necessary infrastructure.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

REFRENCES

1. Dantas LO, de Fátima Salvini T, McAlindon TE. Knee osteoarthritis: key treatments and implications for physical therapy. Brazilian journal of physical therapy. 2021 Mar 1;25(2):135-46 https://doi.org/10.1016/j.bjpt.2020.08.004 PMid:33262080 PMCid:PMC7990728

2. Lim WB, Al-Dadah O. Conservative treatment of knee osteoarthritis: A review of the literature. World journal of orthopedics. 2022 Mar 3;13(3):212 https://doi.org/10.5312/wjo.v13.i3.212 PMid:35317254 PMCid:PMC8935331

3. Raposo F, Ramos M, Lúcia Cruz A. Effects of exercise on knee osteoarthritis: A systematic review. Musculoskeletal care. 2021 Dec;19(4):399-435. https://doi.org/10.1002/msc.1538 PMid:33666347

4. Global, regional prevalence, incidence and risk factors of knee osteoarthritis in population-based studies. Cui A, Li H, Wang D, Zhong J, Chen Y, Lu H. EClinicalMedicine. 2020;29-30:100587. https://doi.org/10.1016/j.eclinm.2020.100587 PMid:34505846 PMCid:PMC7704420

5. Lim WB, Al-Dadah O. Conservative treatment of knee osteoarthritis: A review of the literature. World journal of orthopedics. 2022 Mar 3;13(3):212. https://doi.org/10.5312/wjo.v13.i3.212 PMid:35317254 PMCid:PMC8935331

6. June RK, Liu-Bryan R, Long F, Griffin TM. Emerging role of metabolic signaling in synovial joint remodeling and osteoarthritis. J Orthop Res. 2016;34:2048-2058. https://doi.org/10.1002/jor.23420 PMid:27605370 PMCid:PMC5365077

7. Mobasheri A, Rayman MP, Gualillo O, Sellam J, van der Kraan P, Fearon U. The role of metabolism in the pathogenesis of osteoarthritis. Nat Rev Rheumatol. 2017;13:302-311. https://doi.org/10.1038/nrrheum.2017.50 PMid:28381830

8. Lim WB, Al-Dadah O. Conservative treatment of knee osteoarthritis: A review of the literature. World journal of orthopedics. 2022 Mar 3;13(3):212 https://doi.org/10.5312/wjo.v13.i3.212 PMid:35317254 PMCid:PMC8935331

9. An updated algorithm recommendation for the management of knee osteoarthritis from the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) Bruyère O, Honvo G, Veronese N, et al. Semin Arthritis Rheum. 2019;49:337-350. https://doi.org/10.1016/j.semarthrit.2019.04.008 PMid:31126594

10. Zhang Z, Huang C, Cao Y, Mu R, Zhang MC, Xing D, Fan D, Ding Y, Guo J, Hou Y, Jianhao L. 2021 revised algorithm for the management of knee osteoarthritis-the Chinese viewpoint. Aging clinical and experimental research. 2021 Aug;33:2141-7. https://doi.org/10.1007/s40520-021-01906-y PMid:34189714 PMCid:PMC8302513

11. Dantas LO, de Fátima Salvini T, McAlindon TE. Knee osteoarthritis: key treatments and implications for physical therapy. Brazilian journal of physical therapy. 2021 Mar 1;25(2):135-46. https://doi.org/10.1016/j.bjpt.2020.08.004 PMid:33262080 PMCid:PMC7990728

12. Khan A. Al Iksir (Urdu translation by Kabīr-al-Dīn HM). New Delhi: Idara Kitab-us-Shifa. 2011.

13. Razi Z. Kitab-al-Hawi. Vol 11th. New Delhi: CCRUM. 2004.

14. Majusi A. Kamil-al-Sana (Urdu translation by GH Kanturi). Vol 2nd. New Delhi: Idara Kitab-us-Shifa. 2010

15. Sina I. Al Qanoon Fi-al-Tib (Urdu translation by GH Kanturi). Vol 3rd. New Delhi: Idara Kitab-us-Shifa. YNM.

16. Tabri R. Firdous-ul-Hikmat. New Delhi: Idarar Kitab-ulShifa. 2010.

17. Mohammad Kabiruddin. Al-Quarabadeen. 3rd Ed. NewDehli: CCRUM. 2006.

18. Mohammad Kabiruddin. Bayaze Kabeer. New Dehli: Idara Kitab-us-Shifa. 2010.

19. Anonymous. Qarabadeene Majidi. New Delhi: All India Tibbi Conference Ajanta offset & Publication. 1996. 34. Perlman AI, Ali A, Njike VY, Hom D, Davidi A, GouldForgerite S, et al. Massage therapy for osteoarthritis of the knee: a Randomized Dose-Finding Trial", PLoS ONE. 2012; 7(2): 1-9. https://doi.org/10.1371/journal.pone.0030248 PMid:22347369 PMCid:PMC3275589

20. Tabri R. Firdous-ul-Hikmat. New Delhi: Idarar Kitab-ulShifa. 2010.

21. Sīnā I. Kulliyā-ī-Qānūn (Urdu translated by Kabīr al-Dīn HM). New Delhi: Ejaz Publishing House. 2006. 39.

22. Hamid A. Ilaj-bil-tadbeer (regimental therapy): A noble method of treatment in Unani medicine: A review. Int. J. Med. Res. 2018;3(3):01-6.

23. Kondal S, Kulkarni V, Gaikwad A, Kharat A, Pant A. Automatic grading of knee osteoarthritis on the Kellgren-Lawrence scale from radiographs using convolutional neural networks. arXiv preprint arXiv:2004.08572. 2020 Apr 18.

24. Vaughan CL, Carver AC. Pain Assessment and Management. Neuropalliative Care: A Guide to Improving the Lives of Patients and Families Affected by Neurologic Disease. 2019:239-55. https://doi.org/10.1007/978-3-319-93215-6_17 PMCid:PMC6872941

25. Norkin CC, White DJ. Measurement of joint motion: a guide to goniometry. FA Davis; 2016 Nov 18.

26. Talley NJ, O'connor S. Clinical examination: a systematic guide to physical diagnosis. Elsevier Australia; 2010.

27. National Formulary of Unani Medicine, Central Council for Research in Unani Medicine, Ministry of AYUSH, Family Welfare and Health, Govt of India, New Delhi, 2006; 197.

28. Khan Azam. Muhit-i-Azam, vol 4. (Urdu translation by Central Council for Research in Unani Medicine), Ministry of AYUSH, Family Welfare and Health, Govt of India, New Delhi, 2018; 512-15.

29. Ghani Najmul. Idara Kitab al-Shifa, New Delhi, 2011; 1211: 1212

30. Parveen A, Parveen R, Akhatar A, Parveen B, Siddiqui KM, Iqbal M. Concepts and quality considerations in Unani system of medicine. Journal of AOAC International. 2020 May;103(3):609-33. https://doi.org/10.5740/jaoacint.19-0284 PMid:31547901

31. Ghazanfar K, Dar SA, Nazir T, Akbar S. Subchronic oral toxicity study of Habb-e-Suranjan in albino Wistar rats. Journal of Complementary and Integrative Medicine. 2018 Aug 28;15(3):20170144. https://doi.org/10.1515/jcim-2017-0144 PMid:29590082

32. International BR. Retracted: Unani Formulation Habb-e-Suranjan: A Treasure of Biological Activities. BioMed Research International. 2024;2024 https://doi.org/10.1155/2024/9858134 PMid:38230016 PMCid:PMC10791445

33. Kabeeruddin M. Bayaz-e-Kabeer, Part II. IdaraKitabu-ushShifa, New Delhi. 2010; 50

34. Majusi AA. Kamil-us-Sana'ah, Vol. II, (Urdu translation).IdaraKitabu-ush-Shifa,New Delhi. 2010; 505

35. Arzani A. Qarabadeen-e-Qadri. (Urdu Translation) Central Council for Research in Unani Medicine. Govt. of India, Ministry of Health & F. W. (Dept. of AYUSH)), New Delhi. 2009; 613-636.

36. Qarabadeen-e-Majeedi -Delhi: All India Unani Tibbi Conferance, 1986; 85

37. National Formulary of Unani Medicine,New Delhi : Department of Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy (AYUSH), Ministry of Health & Family Welfare, Government of India, 2008;5(6):7,17,191-193

38. Field, T. Massage therapy research review. Journal of Bodywork and Movement Therapies, 2014;18(2):169-176. https://doi.org/10.1016/j.jbmt.2013.12.002 PMid:25042302

39. Hertling, D., & Kessler, R. M. (2006). Management of common musculoskeletal disorders. Lippincott Williams & Wilkins..

40. Lee, S. C., et al. Effects of steam therapy on muscle relaxation and pain in patients with knee osteoarthritis. Journal of Bodywork and Movement Therapies, 2018;22(2):249-255.

41. Moyer, C. A., et al. Affective touch and physiological responses to massage. Journal of Bodywork and Movement Therapies, 2018;22(2):241-248.

42. Schmid, A. B., et al. Mechanisms of pain relief by massage. Journal of Pain Research, 2018;11:1275-1286

43. Singh, P., et al. Evaluation of the effect of steam fomentation on pain and nerve conduction velocity in patients with knee pain. Journal of Clinical and Diagnostic Research, 2017;11(9):OC01-OC03

44. Taniguchi, K., et al. Effects of massage on joint mobility and pain in patients with knee osteoarthritis. Journal of Bodywork and Movement Therapies, 2018;22(3):537-543.