Download DEGENERATIVE JOINT DISEASE

8/15/2012
CASE:
DEGENERATIVE
JOINT DISEASE
A 66-year-old woman who is overweight reports bilateral
knee pain of gradual onset during the past several months
that increasingly has limited her activities. Last week, when
walking down the stairs, she nearly fell when her knee gave
way. She does not recall having injured her knee, and she
has no morning stiffness and no pain in other joints. She has
tried taking up to eight extra-strength (500 mg each)
acetaminophen tablets daily without success and has never
had ulcers or stomach bleeding.
OSTEOARTHRITIS OF THE KNEE
DIFFERENTIAL
DIAGNOSIS
Trauma: ligamentous sprains
Meniscal injury
Osteoarthritis
Patellofemoral pain syndrome
Pes anserine bursitis
Inflammatory: rheumatoid arthritis, Reiter syndrome
Septic arthritis
Midlumbar radiculopathy
Crystal-induced inflammatory arthropathy: gout, pseudogout
Popliteal cyst
WHY ME?
Risk Factors:
• Obesity
• Age > 55 yrs
• Female
• Prior injury/Sports Activities
(wrestling, cycling, recreational
parachuting, soccer, football)
• Muscle weakness
• Skeletal asymmetry/malalignment
(valgus or varus deformities)
Tumor
CLINICAL
PRESENTATION
• Joint pain (medial > lateral)
associated with activity
(climbing stairs, walking
distances, going from seated
to standing position)
• Decreased range of motion
• Morning stiffness that lasts <
30 minutes
• Weakness or instability
• Crepitus
• Effusion
THE KNEE EXAM
HTTP://WWW.YOUTUBE.COM/WATCH?V=FNUGYNYVHQE
Inspection: gait, varus or valgus alignment, swelling,
erythema
Palpation: joint line tenderness, swelling, warmth, crepitus
Specific Testing:
Lachman’s:
http://www.youtube.com/watch?v=htJiomxxJ7Q&feature=fvw
rel
McMurry’s:
http://www.youtube.com/watch?v=uKvQ_6C3U_o&feature=rel
mfu
Anterior and Posterior Drawer tests, Valgus and Varus Stress
tests, patellar apprehension test.
1
8/15/2012
PATHOPHYSIOLOGY
PHYSIOLOGIC
CHANGES
Two theories of how OA starts:
1.
Injury to cartilage, either single event or repetitive microtrauma,
that initiates inappropriate repair response.
2.
Fundamental defect in cartilage – example type II collagen gene
defect.
Injury > activation of protease, collagenase, and cytokines > cartilage
degradation.
•
Hyaline articular cartilage is lost > Joint space narrowing.
•
Capsular stretching
•
Bone remodeling (subchondral bone cysts and osteophytes)
•
Synovitis is present in some cases.
•
Ligamentous laxity also occurs.
•
Malalignment of joint
•
Weakness of periarticular muscles
DIAGNOSIS
CRITERIA FOR OA OF THE KNEE:
Presence of knee pain, plus at least 3 of 6 characteristics
-
Greater than 50 years of age
-
Morning stiffness for < 30 minutes
-
Crepitus on active ROM of knee
-
Boney Tenderness
-
Boney Enlargement
-
No palpable warmth
Sensitivity 95% and Specificity 69%
*American College of Rheumatology
DIAGNOSIS
CRITERIA EXPANDED:
ESR< 40
Rheumatoid Factor Titer
< 1:40
Synovial Fluid consistent
with OA: clear color, WBC
< 2000
Sens 92% and spec 75%
Imaging: Indicated if pain
is nocturnal or is at rest or
doesn’t improve with
conventional therapy.
Findings do not correlate
well with symptoms of OA.
2
8/15/2012
NONPHARM TX
NONPHARM TX
•ACR Strongly Recommends
•ACR Conditionally Recommends
• Participate in aerobic and/or resistance land-based exercise
• Participate in aquatic exercise
• Lose weight (for persons who are overweight)
•
•
•
•
•
•
•
•
•
•
•
WEIGHT LOSS
Participate in self-management programs
Receive manual therapy in combination with supervised exercise
Receive psychosocial interventions
Use medially directed patellar taping
Wear medially wedged insoles if they have lateral compartment OA
Wear laterally wedged subtalar strapped insoles if they have medial
compartment OA
Be instructed in the use of thermal agents
Receive walking aids, as needed
Participate in tai chi programs
Be treated with traditional Chinese acupuncture
Be instructed in the use of transcutaneous electrical stimulation
EXERCISE AND DIETARY WEIGHT LOSS IN OVERWEIGHT AND OBESE OLDER ADULTS
WITH KNEE OSTEOARTHRITIS: THE ARTHRITIS, DIET, AND ACTIVITY PROMOTION
TRIAL
Strong associations
• Framingham: men 1.5, women 2.1
ADAPT study
•
•
•
•
•
N=316 over 18 mths
Healthy lifestyle vs Diet, Exercise, D+E
Aerobic + Resistance Exercise 1 hr, 3x/wk
Diet – 4.9%, D+E 5.7%, Cont 1.2%
5.7%=11.5 lbs
Arthritis & Rheumatism
Volume 50, Issue 5, pages 1501-1510, 6 MAY 2004 DOI: 10.1002/art.20256
http://onlinelibrary.wiley.com/doi/10.1002/art.20256/full#fig2
EXERCISE
2006 meta-analysis
• 16 studies
• Modest, yet clinically important influence on wellbeing
EXERCISE
Weakness of quadriceps muscle
Improve stability of joints
Improve pain
High/low intensity aerobic
2009 meta-analysis
• 32 studies
• Land-based exercise has short-term benefits
Water vs Land
Tai Chi
3
8/15/2012
MALALIGNMENT
Medial knee more common
• Genu varum
Unloader brace
Neoprene sleeve
1999 study
$350 vs $30
Mean aggregate absolute scores on the
WOMAC
MALALIGNMENT
Mean absolute scores for pain on
the thirty-second stair-climbing test.
PHARM PHRIENDLY
Wedged insoles
• Thicker laterally
• Decreases medial load
RCT showed no reduction in pain
PHARM TX
PHARM TX
ACR strongly recommends
ACR conditionally recommends NOT to use
•
•
•
•
•
Acetaminophen
Oral NSAIDs
Topical NSAIDs
Tramadol
Intraarticular corticosteroid injections
• Chondroitin sulfate
• Glucosamine
• Topical capsaicin
ACR has NO recommendations
• Intraarticular hyaluronates
• Duloxetine
• Opioid analgesics
4
8/15/2012
NSAIDS VS
ACETAMINOPHEN
2009 Cochrane meta-analysis, 15 RCTs
•
•
•
•
•
•
•
•
4000 mg Tyl vs various NSAIDs
Tylenol better than placebo… barely
NSAIDs better than Tylenol… barely
GI adverse effects: NSAID 19%, Tyl 13%
Withdrawal due to GI: RR 2.0
GI AE: RR 1.47
COX2 no GI probs
No difference in serious GI, renal, CV AEs
Overall Pain: Tyl vs Placebo
• But mean study length was 6.6 weeks
WOMAC: Tyl vs Placebo
ACETAMINOPHEN GI
EFFECTS
2011, 13 week study
Overall Pain: Tyl vs 1200 mg Ibu,var NSAIDs
• 3 g Tyl vs 1200 mg Ibuprofen, mono and combo
• Similar drop in HGB at end
• Worse in combination
UTD: ≥2 g/day
Overall Pain: Tyl vs 2400 mg Ibu,var NSAIDs
HX OF GI BLEED
GUIDELINES ANYONE?
Still desire NSAID…
American College of Rheumatology
ACR says…
• Mild OA: Tyl > NSAIDs
• Mod/Sev OA: consider NSAIDs
European League Against Rheumatism
GI ulcer but no bleed in 1 year
• COX-2 or NSAID + PPI
GI bleed in last year
• COX-2 + PPI
• Tyl primary. NSAIDs for Tyl failure
Canadian Consensus Guidelines
• Mod/Sev: NSAIDs
• Mild: may consider Tyl
No NSAID preference
5
8/15/2012
INJECTIONS
GLUCOCORTICOID
INJECTIONS
•Steroids
2004 meta analysis, 10 studies
•Roosters (farm friendly)
Improvement up to 2 weeks
• NNT 1.3 to 3.5
No significance at 16-24 wks
• But RR 2.09, NNT 4.4
1 study – no difference in joint space, 2 yrs
50 mg Pred equiv or 20 mg triamcinolone
INTRAARTICULAR
HYALURONAN
2005 meta-analysis, 22 studies
$500/injection
• Decr rest pain at 2 to 6 wks
• Decr pain at 10 to 14 and 22 to 30 wks
• Poorly designed or industry sponsored
• Not recommended
2006 Cochrane, 28 studies
Cash only
Series of 3 to 5 shots
• Same as IA steroids at 1 to 4 wks
• Slower in onset
• Better at 5 to 13 wks
SMALLER NEEDLES,
DIFFERENT JUICE
ACUPUNCTURE
2007 meta-analysis, 11 RCTs
Vs sham
• Statistically sig difference vs sham
• “no or minimally clinical relevant effects”
Vs wait list or usual care
• Significant and “Marked clinically relevant effects”
• Sustained at 6 mths
6
8/15/2012
ACUPUNCTURE
GLUCOSAMINE/CHONDROITIN
Same authors
Glucosamine:
2010 Cochrane
An amino sugar which is converted into cartilage
proteoglycans that stimulate chondrocyte metabolism and
may slow progression of disease process.
Vs sham
• Significant but not clinically relevant
Vs waiting list
• Significant and clinically relevant
• Gotta be placebo
Dose: 500mg TID
Chondroitin:
A glycosaminoglycan that inhibits action of degradative
enzymes.
Dose: 1000 – 1200mg daily
GLUCOSAMINE/CHONDROITIN
OPIOIDS
2006 - Glucosamine/chondroitin Arthritis Intervention Trial (GAIT) - 24 wk,
randomized, double-blind trial
ACR says…
Participants: 1583 > 40yrs with knee pain for > 6 months and radiologic
evidence of OA
IF
Five Groups:
No other Tx response and…
1. 500 mg of glucosamine hydrochloride three times daily
Does not desire or…
2. 400 mg of sodium chondroitin sulfate three times daily
3. 500 mg of glucosamine plus 400 mg of chondroitin sulfate three times
daily
4. 200 mg of celecoxib (Celebrex, Pfizer) daily
5. Placebo
Is not a candidate for orthoplasty…
THEN
Follow APS/AAPM recs
Results: Not clinically significant relief from glucosamine and chondroitin as
compared to placebo. Outcome measured was % decrease in pain.
2009 – Cochrane Review: 25 RCT of 4963 participants. No statistical
significance in reduction of pain, stiffness, or function.
OUR PATIENT
•
•
•
•
•
•
•
Failed trial of Acetaminophen
NSAIDs PRN, with food
PPI?
PT for quad strengthening
Weight loss & Exercise
Neoprene sleeve > brace
Intraarticular corticosteroids
REFERENCES
Up To Date: “Pharmacologic therapy of osteoarthritis” Last updated 10/16/11.
Up To Date: “Nonpharmacologic therapy of osteoarthritis” Last updated 10/20/11.
Clinical Practice, N Engl J Med 2006:354;841 – 848
Ringdahl E, Pandit S. Treatment of Knee Osteoarthritis. Am Fam Physician. 2011 Jun 1;83(11):1287-1292.
Messier SP, Loeser RF, Miller GD, et al. Exercise and dietary weight loss in overweight and obese older adults with knee osteoarthritis: the Arthritis, Diet,
and Activity Promotion Trial. Arthritis Rheum. 2004;50(5):1501.
Devos-Comby L, Cronan T, Roesch SC. Do exercise and self-management interventions benefit patients with osteoarthritis of the knee? A metaanalytic
review. J Rheumatol. 2006;33(4):744.
Fransen M, McConnell S. Land-based exercise for osteoarthritis of the knee: a metaanalysis of randomized controlled trials. J Rheumatol.
2009;36(6):1109.
Baker K, Goggins J, Xie H, Szumowski K, LaValley M, Hunter DJ, Felson DT. A randomized crossover trial of a wedged insole for treatment of knee
osteoarthritis. Arthritis Rheum. 2007;56(4):1198.
Kirkley A, Webster-Bogaert S, Litchfield R, et al. The effect of bracing on varus gonarthrosis. J Bone Joint Surg Am 1999;81:539-48.
T.E. Towheed, L. Maxwell, M.G. Judd et al. Acetaminophen for osteoarthritis. Cochrane Database Syst Rev (1) (2006) CD004257
Doherty M, Hawkey C, Goulder M, Gibb I, Hill N, Aspley S, Reader S. A randomised controlled trial of ibuprofen, paracetamol or a combination tablet of
ibuprofen/paracetamol in community-derived people with knee pain. Ann Rheum Dis. 2011;70(9):1534.
Arroll B, Goodyear-Smith F. Corticosteroid injections for osteoarthritis of the knee: meta-analysis. BMJ. 2004;328(7444):869.
Arrich J, Piribauer F, Mad P, Schmid D, Klaushofer K, Müllner M. Intra-articular hyaluronic acid for the treatment of osteoarthritis of the knee: systematic
review and meta-analysis. CMAJ. 2005;172(8):1039.
Bellamy N, Campbell J, Welch V, Gee TL, Bourne R, Wells GA. Viscosupplementation for the treatment of osteoarthritis of the knee. Cochrane Database
of Systematic Reviews 2006, Issue 2. Art. No.: CD005321. DOI: 10.1002/14651858.CD005321.pub2.
Manheimer E, Cheng K, Linde K, Lao L, Yoo J, Wieland S, van der Windt DAWM, Berman BM, Bouter LM. Acupuncture for peripheral joint osteoarthritis.
Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD001977. DOI: 10.1002/14651858.CD001977.pub2.
Manheimer E, Linde K, Lao L, Bouter LM,Berman BM. Meta-analysis: acupuncture for osteoarthritis of the knee. Ann Intern Med. 2007;146(12):868-877.
7
8/15/2012
REFERENCES
http://ohsusportsmedicine.blogspot.com/2009/01/knee.html
New England Journal of Medicine. Osteoarthritis of the Knee. 2006.
New England Journal of Medicine. Glucosamine, Chondroitin Sulfate,
and the Two in Combination for Painful Knee Osteoarthritis. 2006.
American Family Physician. Treatment of Knee Osteoarthritis. June
2011.
http://www.fammed.wisc.edu/integrative/modules/osteoarthritis
UpToDate. Diagnosis and Classification of Osteoarthritis. Updated April
2012.
UpToDate. Clinical Manifestations of Osteoarthrits. Updated March 2012.
Towheed T, Maxwell L, Anastassiades TP, Shea B, Houpt JB, Welch V,
Hochberg MC, Wells GA. Glucosamine therapy for treating
osteoarthritis. Cochrane Database of Systematic Reviews 2005, Issue 2.
Art. No.: CD002946. DOI: 10.1002/14651858.CD002946.pub2.
8