Osteoarthritis:Two Non-Pharmacological Options

Introduction
 
Osteoarthritis (OA) is a chronic, degenerative disease of synovial joints, characterized by progressive articular cartilage degradation, subchondral bone remodeling, osteophyte formation, synovial inflammation, changes in periarticular muscles, and alterations in joint biomechanics. Clinically, patients typically present with joint pain (often worse with weight-bearing or movement), stiffness after inactivity, reduced range of motion, crepitus, swelling, and functional limitation. Symptoms tend to develop insidiously and may worsen over time, occasionally punctuated by acute exacerbations.

Epidemiology
 
OA is among the leading causes of disability globally. According to recent estimates, there are more than 600 million people living with OA worldwide, with age-standardized prevalence steadily increasing over recent decades (Zhang, X. et al., 2025, Wang, Z. et al., 2024). Knee OA is especially common; its global lifetime risk is approximately 9.3%. Hip OA, hand OA, and other joint-specific OA forms also contribute to the total burden (Litwic et al, 2013, WHO, 2023). Regionally, prevalence is higher in high-sociodemographic index (SDI) and high-income regions, including much of Europe. For instance, a systematic review of hip OA found a radiographic prevalence of around 12.6% in Europe (versus lower estimates in other regions). Across Europe, prevalence varies by region (Eastern, Central, Western), with    around 7–8% (for total OA) and higher incidence and disability in Western Europe. The disease accounts for large numbers of years lived with disability (YLDs) and its burden is increasing, driven by population aging, obesity trends, and increased survival from other diseases.

Risk Factors
 
Osteoarthritis is etiologically heterogeneous. Key non-modifiable risk factors (Allen, K.D. et al., 2022) include:

• Age: incidence and prevalence rise sharply with advancing age.
• Sex: women are at higher risk than men, particularly for knee and hand OA, especially post-menopause. (WHO, 2023)
• Genetic predisposition: multiple genetic loci and familial aggregation have been identified.

 
Important modifiable risk factors (Bortoluzzi,A. et al., 2018) include:

• Obesity / high body mass index (BMI): increases joint loading and may contribute via systemic inflammation.
• Prior joint injury or repetitive joint overuse (work- or sports-related trauma).
• Biomechanical factors: malalignment (varus/valgus in knees), joint shape abnormalities, muscle weakness and poor joint support.
• Metabolic factors: comorbidities including metabolic syndrome, diabetes, dyslipidemia. Emerging data suggest systemic contributors beyond purely mechanical stress.

 
Additional risk modifiers include lower socioeconomic status, some dietary factors, possibly vitamin insufficiencies, and lifestyle (physical inactivity). However, evidence is variable for these.

Clinical Presentation and Natural History
 
The onset of OA is gradual. Early disease may show radiographic changes without symptoms; conversely, symptomatic disease may precede severe structural damage. Pain, stiffness (especially mornings or after rest), crepitus, and limited joint mobility are typical. Over time, progressive joint destruction may lead to deformity, loss of function, disability, reduced quality of life, and often comorbidities due to sedentary behavior (cardiovascular disease, obesity, mood disorders).

Current Treatment Modalities
 
Standard management of osteoarthritis is multimodal and often tiered, combining non-pharmacologic with pharmacologic approaches, and in advanced disease, surgical interventions. The main modalities include:
 

1. Patient education and lifestyle modification: weight loss, diet, physical activity.
2. Exercise therapy: strength training, aerobic conditioning, flexibility, neuromuscular, and balance training.
3. Physical modalities: bracing, orthotics, assistive devices, manual therapy.
4. Pharmacologic treatments: analgesics (acetaminophen), nonsteroidal anti-inflammatory drugs (NSAIDs), topical agents; intra-articular injections (corticosteroids, hyaluronic acid) in selected cases.
5. Surgical options: osteotomy, joint replacement (e.g. total knee or hip arthroplasty) when conservative measures fail and quality of life is severely impaired.

 
While these approaches can ameliorate symptoms and improve function, pharmacologic and surgical interventions carry risks and costs. NSAIDs are associated with gastrointestinal, cardiovascular, and renal adverse effects; joint replacement surgery has operative risks, recovery burdens, and limitations in access. Because of these issues, there is increasing interest in safer, non-pharmacologic strategies that can be deployed earlier in the disease course.
 
In the following discussion, I will focus on two under-utilized but promising non-pharmacologic interventions for osteoarthritis: structured exercise programs (of various types) and low-dose radiation therapy. I will examine the evidence base for efficacy, mechanisms of action, dosing and safety, and discuss why low-dose radiation therapy is more commonly employed in European practice than in the United States. The goal is to assess how these modalities might complement or offer alternatives to pharmacologic treatments, especially for patients seeking long-term, low-risk, sustainable relief and functional improvement.

Structured exercise program

​The best current science and major clinical guidelines treat regular, structured exercise as the core (first-line) therapy for osteoarthritis and age-related joint pain, while recommending caution about routine, long-term use of systemic analgesics (especially oral NSAIDs) in older adults because of real safety risks. The guidelines, evidence, mechanisms, and practical implications are summarized below:

Major guidelines
 

• International and national guidelines put therapeutic exercise (individualized, structured, often strength + aerobic + neuromuscular work) at the center of non-surgical management for knee/hip OA and many older adults with joint pain. Examples: NICE (UK), OARSI, and the American College of Rheumatology (NICE Guidelines , 2022, Bannuru, R.R. et al., 2019, Kolasinski, S.L. et al., 2020).
• Geriatric prescribing guidance (AGS/Beers) flags regular, scheduled oral NSAID use as potentially inappropriate in many older adults because of dose-related gastrointestinal, renal and cardiovascular harms; it advises avoiding chronic use unless benefits clearly outweigh risks and monitoring closely if used (2023 American Geriatrics Society Beers Criteria® Update Expert Panel).

Evidence from systematic reviews and trials
 

• Exercise reduces pain and improves function. Large systematic reviews, Cochrane updates, and an individual-participant-data meta-analysis/IPD-meta (Holden et al. 2023) show that therapeutic exercise produces small but statistically significant improvements in pain and physical function versus non-exercise controls (short-term benefits are clearest). The IPD meta-analysis quantified short-term pain improvement at about −6.4 points on a 0–100 scale (95% CI −8.45 to −4.27); benefits persist but become smaller over medium/long term. People with higher baseline pain/function impairment tend to gain more (Lawford B.J. et al., 2024).
• Type of exercise. Multiple trials/meta-analyses find benefit from land-based therapeutic exercise overall; resistance (strength) training, neuromuscular/proprioceptive training, and aerobic activity all show benefit. No single exercise type is universally “best” — prescription should be tailored (strength + functional training is commonly recommended) (Young, J.J. et al., 2023, Lim, J. et al., 2024).
• Comparative landscape. Network meta-analyses that compare many treatments (pharmacologic and non-pharmacologic) find that many interventions can reduce OA pain, but heterogeneity and risk-of-bias make direct ranking difficult; nevertheless, exercise stands out as a low-risk, broadly beneficial option (Smedslund, G. et al., 2022).

Mechanism of action
 

• Muscle support & biomechanics: Strengthening peri-articular muscles reduces joint loading and improves joint control.
• Central and peripheral pain modulation (exercise-induced hypoalgesia): a single bout and regular training change pain processing (reduced pain sensitivity).
• Anti-inflammatory and metabolic effects: regular exercise lowers some pro-inflammatory cytokines (and reduces adiposity), which helps chronic, low-grade inflammation that contributes to OA pain. Reviews summarize these central and peripheral mechanisms (Hall, M. et al., 2020, Vaegter, H. B. & Jones, M. D, 2020, Kong H. et al., 2022).

An excellent explanation by a physiotherapist

Efficacy vs safety
 

• Oral NSAIDs (ibuprofen, naproxen, diclofenac, COX-2 inhibitors): effective analgesics for OA pain in many trials, but they carry real risks in older adults — dose-related increased risk of gastrointestinal bleeding, acute kidney injury/decline in renal function, and increased risk of acute myocardial infarction or other cardiovascular events in some settings. Because older adults often have comorbidities and take other drugs (anticoagulants, ACE inhibitors, diuretics), the absolute harms rise (Bally M. et al., 2017, Modig, S.& Elmståhl, S., 2018, 2023 American Geriatrics Society Beers Criteria® Update Expert Panel ).
• Topical NSAIDs: meta-analyses and reviews show topical NSAID preparations produce meaningful local pain relief with lower systemic adverse events than oral NSAIDs — often a reasonable first pharmacologic option for localized knee or hand OA pain (Rannou, F. et al., 2016, Wang, Y. et al., 2022).
• Paracetamol (acetaminophen): high-quality systematic reviews find minimal to no clinically important benefit of regular paracetamol for hip/knee OA pain. Long-term/parenteral use is not risk-free (liver injury, and other potential harms). Many guidelines now place paracetamol low in the treatment algorithm (or recommend it only for short-term “rescue” use) (Leopoldino, A.O. et al, 2019, McCrae, J. C. et al., 2018).
• Net clinical view (evidence + safety): pharmacologic agents can help short-term pain control, but the risk:benefit in older adults must be evaluated individually. This is precisely why guidelines emphasise exercise (benefit + exceptionally low systemic risk) as the foundation of care, and recommend cautious, often short-term or topical use of analgesics when needed (NICE Guidelines, 2022, Bannuru, R.R. et al., 2019).

Practical applications
 
Practical, evidence-based steps clinicians/guidelines recommend that reflect the science above:

1. Make exercise the core therapy. Start a tailored program combining local muscle strengthening (eg. quadriceps for knee OA), aerobic conditioning (walking, cycling, swimming), and balance/functional training. Supervision (physiotherapist or guided classes) improves adherence and outcomes (NICE Guidelines, 2022, Lawford B.J. et al., 2024).
2. Address weight if overweight. Combined exercise + weight loss improves pain more than either alone in overweight patients (NICE Guidelines, 2022).
3. Reserve oral NSAIDs for short, targeted use under medical supervision (lowest effective dose, shortest duration; consider GI protection and monitor renal function and BP). Avoid routine long-term scheduled oral NSAIDs in many older adults unless clinician judges benefits outweigh the risks (2023 American Geriatrics Society Beers Criteria® Update Expert Panel).
4. Prefer topical NSAIDs for localized OA pain when medication is needed — similar pain relief with lower systemic exposure (Rannou, F. et al., 2016, Wang, Y. et al., 2022).
5. Use paracetamol only as short-term rescue (not as the main long-term strategy) given small benefit and potential harm with long-term use. (Leopoldino, A.O. et al, 2019, McCrae, J. C. et al., 2018)

 
In summary, exercise is evidence-based first-line therapy for osteoarthritis and age-related joint pain: it reduces pain and improves function, carries low systemic risk, and has broader health benefits (cardiovascular, balance, fall prevention). Systemic analgesics (oral NSAIDs, long-term paracetamol) can help short-term but carry non-trivial harms in older adults and therefore should not be the primary long-term strategy without careful clinician oversight; topical options and time-limited oral use (lowest effective dose, monitoring) are safer choices when medication is necessary.

4–6-week evidence-based starter plan
 
The plan was designed for older adults with joint pain due to osteoarthritis or overuse and grounded in the research and recommendations discussed above. The focus is on:

• reducing pain and stiffness,
• improving strength, balance, and joint control,
• avoiding overuse or further inflammation.

 


General Principles Before Starting
 

1. Medical check: Confirm with your clinician that moderate activity is safe for you (especially if you have cardiovascular, balance, or orthopedic issues).
2. Pain rule: Some mild discomfort (≤3/10) during exercise is acceptable, but pain should not worsen or linger >24 hours after.
3. Frequency target: 5–6 days per week of some activity (mixing strength, mobility, and aerobic).
4. Warm-up and cool-down: 5 minutes of gentle motion before/after every session (slow marching, arm swings, ankle circles).
5. Equipment needed: Resistance bands, a sturdy chair, light weights (or water bottles), and comfortable shoes.

 
Please note if your attending physician prescribed specific exercises to be done under the supervision of a physical therapist. You should consult and coordinate with the physical therapist for any additional personal exercise program.

4–6 Week Starter Plan for Joint Health

Week	Focus	Strength / Neuromuscular (3×/week)	Flexibility & Mobility (Daily)	Aerobic Conditioning (3–5×/week)
1–2	Foundation & Activation	• Sit-to-Stand from chair (2×10 reps) • Mini squats holding chair (2×10) • Standing hip abduction (side leg raises) (2×10/side) • Wall push-ups (2×10) Heel rises (2×10) • Resistance band rows (optional)	• Knee/hip range-of-motion circles (5 min) • Hamstring and calf stretch (30s×2) • Gentle yoga or tai chi flow (10 min)	• Brisk walking, cycling, or water walking • Start with 10–15 min, progress to 20 min
3–4	Strength Progression & Endurance	• Sit-to-Stand → add light weights • Step-ups on low step (2×10) • Side-lying leg lifts (2×10) • Mini lunges (supported) (2×8/side) • Band external rotation for shoulders (2×10)	• Continue ROM stretches • Add quadriceps and hip flexor stretches (30s×2) • Add gentle balance drills (heel-to-toe walk, single-leg hold)	• Increase aerobic time to 25–30 min/session • Add one interval day (30s brisk / 90s slow × 5)
5–6	Functional & Maintenance Phase	• Chair squats (3×10) • Step-ups (3×10) • Hip bridge (2×10) • Standing balance + arm movement (eyes open/closed) • Resistance band rows (3×10)	• Full stretching routine (10 min/day) • Include yoga or tai chi session 2×/week	• 30–40 min continuous low-impact aerobic work (walking, cycling, pool, elliptical) • Maintain at least 150 min/week total

Key Modifications & Tips
 

• Pain flare: Replace high-load moves with isometric holds (e.g., wall sits, straight-leg raise).
• Swelling/inflammation day: Use gentle range-of-motion exercises or pool walking instead of strength work.
• Progression: Increase repetitions by 2–4 every 2 weeks or add light resistance band tension.
• Joint load reduction: Water-based exercise or recumbent cycling reduce compressive forces on knees and hips.
• Balance benefit: Add Tai Chi or yoga once weekly — supported by trials showing improvement in OA pain and proprioception.

Mechanistic Summary

• Strengthening muscles (quadriceps, glutes, core) reduces stress on joints by redistributing mechanical loads.
• Aerobic exercise improves circulation, reduces systemic inflammation (IL-6, TNF-α), and promotes synovial fluid turnover.
• Mobility and balance training maintain joint range and reduce the risk of falls and maladaptive compensatory gait.

​Recommended Videos & Highlights
 
YouTube videos on exercises for osteoarthritis abound. Here are my favorites addressing common osteoarthritis of the knee, hip and shoulders. Many of the exercises in the 4-6 Week Starter Plan will be demonstrated in the videos discussed below.

Knee

Video	What It Demonstrates Well / Why Useful  ​
Exercises for Seniors with Knee Pain (SilverSneakers) (YouTube)	Gentle strengthening and stabilizing moves, with options to use a chair for support. Good for early or mild knee discomfort.
The Best Knee Arthritis Exercises for Pain Relief (Jeffrey Peng MD) (YouTube)	Focuses on exercises useful for osteoarthritic knees; show a variety of movements targeting quadriceps, hamstrings, etc.
Gentle Knee Workout (yes2next) (YouTube)	Seniors, Beginner Exercisers
Easy Knee Strengthening Exercises for Seniors and Beginners (SpineCare / Dr. Rowe) (YouTube)	Covers seated and standing moves; good for people who may have limited mobility or pain with standing-only routines.
20 Minute Knee Pain Exercises // Strengthen & Stretch for Immediate & Long Term Relief! (SeniorShape Fitness) (YouTube)	Balanced blend of strengthening + stretching in a 20-minute session — useful as a standalone daily routine.
Transform Weak Knees: 5 Chair Exercises for Seniors (yes2next) (YouTube)	Chair-based routine — good fallback when your knee is sore or you're recovering but still want to maintain muscle and mobility.
Exercises for Knee Pain // Strengthening Movements & Stretches (SeniorShape) (YouTube)	Shows progression from standing to floor work, combining strength + stretch.

Hip

Video	What It Demonstrates Well / Why Useful  ​
Hip Arthritis Pain Relief Exercises (Jeffrey Peng MD) (YouTube)	A set of exercises for hip pain from arthritis: half-squats, hamstring curls, straight leg raises, hip abduction/adduction, and gentle stretches.
Tailored stretching: Hip exercises (for arthritis and joint pain) (Arthritis UK) (YouTube)	A gentle 15-minute physiotherapist-led session, focusing on mobility, stretching, and hip activation.
6 Hip Arthritis Exercises (Rehab Science) (YouTube)	Shows mobility drills + strengthening options for the hip in osteoarthritis or post-surgery settings.
Best Exercises for Hip Osteoarthritis (Dr. Kristie Ennis) (YouTube)	Balanced routine focusing on mobility and strength.
Hip Arthritis? Try These Hip Strengthening Exercises (Upright Health) (YouTube)	Mixes strengthening, mobility, and commentary on pain vs radiographic changes.

Shoulder

Video	What It Demonstrates Well / Why Useful
10- Minute Shoulder Arthritis Exercises: Real Time Follow Along Routine (Virtual Hand Care) (YouTube)	A beginner-friendly, no-equipment routine with movements like shoulder shrugs, external/internal rotation, extensions, flexion.
Tailored stretching: Shoulder exercises (for arthritis and joint pain) (Arthritis UK) (YouTube)	A 15-minute guide by physiotherapists showing gentle movements (arm lifts, table slides, door press, etc.).
Exercises for osteoarthritis of the shoulder (Arthritis Society Canada) (YouTube)	Stretches, ROM, stabilizer exercises and scapular control.
Shoulder Arthritis Stretches & Exercises (Ask Doctor Jo) (YouTube)	Includes pendulums, band/resistance movements, scapular retraction, active assist stretches.
Shoulder Exercises for Arthritis // Dumbbell Shoulder Workout (Age Fitness with Tess) (YouTube)	Slightly more advanced, adding light dumbbells for strengthening, when pain allows.

​Tips for Using These Videos Effectively & Safely
 

1. Start slowly & short. Even if the video is 20–30 minutes, you can pick 2–3 exercises initially until your tolerance in the affected joint builds.
2. Use support. Use a chair, wall, or stable object during standing moves to guard against slips or imbalance.
3. Consistency over intensity. Better to do 10 min daily than 30 min once and cause soreness.
4. Monitor response. If pain worsens (especially sharp pain, swelling, “giving way”), scale back immediately or skip that movement.
5. Mirror your own program. Use the videos to guide your form and variety, but keep your tailored 4–6-week program in mind.
6. Record or note the time stamps. If a particular exercise is especially good (e.g. mini-squats, heel raises, side leg lifts), note where in the video it is so you can return to it easily.

Low-Dose Radiation Therapy (LDRT)

​LDRT as a treatment for osteoarthritis fell into disfavor in the United States decades ago (since the 80’s) due to concerns about secondary malignancies, advances in pharmacological treatment, and negative results from two significant randomized controlled trials (as cited below). Nevertheless, emerging data from the most recent meeting of the Association for Radiation Oncology (ASTRO) have rekindled interest. Reviewing the subject is certainly timely  for the benefit of the osteoarthritis community.

Nature of the Radiation Used
 
To be clear, low-dose radiation therapy (LDRT) for osteoarthritis (OA) is ionizing X-radiation, not radiofrequency or laser energy.

• X-rays (photon radiation) are used — the same physical type as diagnostic X-rays but with much lower energies than modern external beam (megavoltage) therapy used for cancer.
• Typical LDRT for benign and degenerative conditions employs orthovoltage (medium-energy) X-rays or low-megavoltage photon beams from linear accelerators (linacs).

 
The energy, wavelength, and frequency ranges employed are summarized in the table below.

Parameter	Typical LDRT (OA) Range	Context
Photon energy	100–250 keV (kiloelectronvolts) — often 120–150 kV in orthovoltage units	Historically called “deep X-ray therapy.” Adequate penetration for superficial to moderate-depth joints (hand, knee, ankle).
Wavelength	~0.012–0.005 nm (using λ = hc/E)	Shorter than diagnostic X-rays (40–120 keV), longer than megavoltage beams used in oncology.
Frequency	~2.5 × 10¹⁹ to 6 × 10¹⁹ Hz	In the high X-ray band of the electromagnetic spectrum.

​Purpose-built instruments are used for delivering the orthovoltage X-ray whereas low-megavoltage photons beams are derived from repurposed linear accelerators with calibrated dose planning system.

Mechanism of action
 
Low-dose radiotherapy (LDRT) is hypothesized to reduce pain in osteoarthritis (OA) by producing anti-inflammatory and immunomodulatory effects at doses well below those used in oncologic practice. Proposed mechanisms include altered polarization and reduced activity of inflammatory macrophages, decreased secretion of pro-inflammatory cytokines, modulation of endothelial adhesion molecules, and effects on nociceptive signaling within periarticular tissues. These biological effects have been demonstrated in preclinical models and are used to explain the rapid (weeks) to delayed (months) symptomatic improvements reported in clinical series (Weissmann, T. et al. ,2023, Dove, A. P. H. et al., 2022).

Typical dose and fractionation used in Europe
 
Patterns of care in Europe are relatively consistent: common regimens deliver 0.5–1.0 Gy per fraction with total doses in the ~3–6 Gy range, typically given as 2 fractions per week over 2–3 weeks (for example, 6 × 0.5 Gy = 3 Gy total; or 6 × 1 Gy = 6 Gy total). Some centers report variation (very low single-fraction schemes and higher cumulative doses in specific indications), but the 0.5 Gy/fraction × 6 fractions schedule is among the most frequently cited. National practice patterns (especially in Germany) historically have used these low-fractionation regimens for benign skeletal disorders (Dove, A. P. H. et al., 2022, Micke, O. et al., 2017).

​Summary of evidence from randomized trials, observational series, and recent data

• High-quality sham-controlled RCTs (negative): Two well-conducted, double-blind, sham-controlled randomized trials from the Netherlands found no clinically meaningful benefit of LDRT over sham in symptomatic hand OA (6 × 1 Gy vs sham) and in knee OA. Long-term follow-up of these parallel trials showed no delayed effect. These RCTs tempered enthusiasm generated by earlier observational reports. (Minten, M. J. M. et al., 2018, Mahler, E. A. M. et al., 2019).
• Large observational and registry series (positive): Numerous European retrospective and prospective series, and national patterns-of-care studies (particularly from Germany), report substantial pain relief and functional improvement in most treated patients; these studies also often report favorable safety profiles in older adults. Such series underpin routine LDRT use for benign musculoskeletal pain in parts of Europe. However, observational designs are susceptible to placebo effects, regression to the mean, and selection bias. (Keller, S. et al., 2013, Wiśniowska, A. et al., 2025).
• Recent/nascent randomized data (mixed/emerging): In 2025 several groups presented randomized data at international meetings (and professional society press releases) reporting benefit from modern LDRT regimens (for example, 3 Gy total delivered in 6 × 0.5 Gy) versus sham for mild–moderate knee OA. These presentations—summarized in ASTRO material and contemporary news coverage—suggest the field is evolving and that newer regimens or patient selection strategies may yield positive results; however, many of these reports are initially conference abstracts or press releases and require full peer-reviewed publication before they should change standards of care. (Kim,B. H. et al., 2025, ASTRO News Release).

 
To recapitulate, the older RCTs (hand and knee OA) did not show benefit over sham and therefore argue for caution; large observational series and long European experience support potential efficacy in practice; and very recent controlled data (2024–2025 conference reports) raise the possibility that particular doses, fractionations, or patient subgroups may benefit. The balance remains uncertain pending peer-reviewed publication and independent replication

Safety considerations
 

• Dose-relative risk: LDRT for OA uses doses that are a small fraction of oncologic therapy; nevertheless, any ionizing radiation carries theoretical carcinogenic potential. Epidemiologic and modeling studies suggest the absolute risk of radiation-induced malignancy from contemporary LDRT protocols is small, especially in older adults, but non-zero—risk is higher the younger the patient and the closer irradiated tissues are to radiosensitive organs or active bone marrow. Policy statements and reviews therefore emphasize individual risk–benefit assessment (McKeown, S. R. et al., 2015, Mazonakis, M. & Damilakis, J. 2017). 
• Short-term adverse events: Reported acute toxicities are uncommon and mild (transient skin erythema, fatigue). Serious immediate toxicity is rare at the low doses used for benign disease (Dove, A. P. H. et al., 2022).
• Long-term safety: Longitudinal data from large European cohorts show low absolute numbers of potentially radiation-related cancers after decades of follow-up, but uncertainty remains because long latency and confounding make precise risk quantification difficult. Expert guidance therefore typically recommends cautious use in patients <40 years of age, avoidance in pregnancy, and careful documentation and counseling about uncertain long-term risks. Professional bodies (radiation oncology and radiology colleges) advise that LDRT for benign disease be governed by local protocols and multidisciplinary oversight (van den Ende, C. H. M. et al., 2020, RCR Recommendation, 2023).
• Other practical cautions: avoid repeat courses unless clear benefit occurred previously and the risk–benefit remains favorable; consider proximity to major organs/bone marrow when planning fields; and ensure modern planning/beam-shaping techniques to minimize unnecessary exposure. (Dove, A. P. H. et al., 2022, DEGRO Guidelines for Radiotherapy of Benign Diseases, 2022)

Current Clinical Practice
 

• European practice: LDRT is an accepted, commonly used option for selected patients with painful OA and other degenerative musculoskeletal conditions in parts of Europe (notably Germany and Central Europe), often when conservative measures (exercise, weight loss, analgesics, injections) have failed or are contraindicated. (Weissmann, T. et al. ,2023, Wiśniowska, A. et al., 2025)
• North American practice: Historically LDRT was abandoned in the U.S.; renewed interest in specialized radiation oncology centers has grown only recently. Because of mixed RCT data and regulatory/coverage issues, LDRT is not yet a broadly endorsed standard in many North American guidelines. Emerging randomized evidence presented in 2025 may change practice if peer-reviewed reports confirm benefit and safety (Cleveland Clinic, 2023, Haelle, T., 2025).

​Conclusion
 
Evidence for LDRT includes decades of European experience and many observational studies showing pain relief, but two high-quality sham-controlled trials (hand and knee OA) found no benefit versus sham. More recently randomized data presented at meetings suggest certain modern schedules might be effective, but those reports await full peer review. The therapy uses doses far lower than cancer treatment and short-term side effects are uncommon. The principal long-term concern is a small but uncertain risk of radiation-related malignancy, particularly relevant for younger patients. Given this mixed evidence, LDRT would be considered only if the patient remains symptomatic despite guideline-based conservative care and understands the benefits and risks. A radiation oncology consultation will best address technical planning, expected timeline for benefit (often weeks to months), and follow-up.

Educational videos on LDRT and Osteoarthritis

US Radiology Centers offering LDRT
 
Reservation about LDRT notwithstanding, a quick non comprehensive search of the web yielded multiple clinical sites across the US offering the service for osteoarthritis and other non-malignant conditions:
 
UCLA Health Radiation Oncology (Los Angeles, California, and surrounding areas)
Loyola Medicine (Maywood, Illinois)
New York Cancer & Blood Specialists (NYC / metro NY)
Mount Sinai Health System (NYC)- Anthony Nehlsen MD, Radiation Oncology
Astera Cancer Care — Monroe Township, NJ
Hunterdon Regional Cancer Center (Hunterdon Healthcare), Flemington/Hunterdon County, NJ
RWJ Barnabas Health / Regional radiation oncology programs (NJ)
Allegheny Health Network (AHN) (Western Pennsylvania)
Radiation Oncology Services- Charleston Area Medical Center
Compass Oncology (Portland, Oregon, and Vancouver, Washington area)
Erlanger (Chattanooga, Tennessee area)
Mayo Clinic (Rochester, Minnesota area)
 
If you are interested in LDRT for osteoarthritis, consultation with your primary care doctor or specialists (rheumatologists, sport medicine practitioners) is a prerequisite before any action steps.

References
 
Allen, K. D., et al. (2022). Epidemiology of osteoarthritis. Osteoarthritis and Cartilage, 30(2), 184–195. https://doi.org/10.1016/j.joca.2021.04.020
 
ASTRO. (2025, September 28). Low-dose radiation therapy offers substantial relief to people with painful knee osteoarthritis [News release]. San Francisco, CA: ASTRO.
 
Bally, M., Dendukuri, N., Rich, B., Nadeau, L., Helin-Salmivaara, A., Garbe, E., et al. (2017). Risk of acute myocardial infarction with NSAIDs in real-world use: Bayesian meta-analysis of individual patient data. BMJ, 357, j1909. https://doi.org/10.1136/bmj.j1909
 
Bannuru, R. R., et al. (2019). OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis and Cartilage, 27(11), 1578–1589. https://doi.org/10.1016/j.joca.2019.06.011
 
Bortoluzzi, A., Furini, F., & Scirè, C. A. (2018). Osteoarthritis and its management: Epidemiology, nutritional aspects, and environmental factors. Autoimmunity Reviews, 17(11), 1097–1104. https://doi.org/10.1016/j.autrev.2018.06.002
 
Cleveland Clinic. (2023, November 7). Low-dose radiation therapy reemerging for osteoarthritis. https://consultqd.clevelandclinic.org/low-dose-radiation-therapy-reemerging-for-osteoarthritis
 
DEGRO-AG. (2022). Radiotherapy of Benign Diseases.
 
Dove, A. P. H., Cmelak, A., Darrow, K., McComas, K. N., Chowdhary, M., Beckta, J., & Kirschner, A. N. (2022). The Use of Low-Dose Radiation Therapy in Osteoarthritis: A Review. International journal of radiation oncology, biology, physics, 114(2), 203–220. https://doi.org/10.1016/j.ijrobp.2022.04.029
 
Fan, Z., Yan, L., Liu, H., et al. (2023). The prevalence of hip osteoarthritis: A systematic review and meta-analysis. Arthritis Research & Therapy, 25(1), 51. https://doi.org/10.1186/s13075-023-03033-7
 
Haelle, T. (2025, September 24). Low-dose radiation therapy making a comeback for osteoarthritis. Medscape News & Perspective. https://www.medscape.com/viewarticle/xxxxxxx
 
Hall, M., Dobson, F., Plinsinga, M., et al. (2020). Effect of exercise on pain processing and motor output in people with knee osteoarthritis: A systematic review and meta-analysis. Osteoarthritis and Cartilage, 28(11), 1501–1513. https://doi.org/10.1016/j.joca.2020.07.009
 
Holden, M. A., Brown, J., Abbott, J. H., et al. (2023). Moderators of the effect of therapeutic exercise for knee and hip osteoarthritis: A systematic review and individual participant data meta-analysis. The Lancet Rheumatology, 5(7), e386–e400. https://doi.org/10.1016/S2665-9913(23)00122-4
 
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