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Sports Medicine at Sea 2011
Evaluation and Management
of Osteoarthritis
R b tS
Robert
Sallis,
lli MD
MD, FAAFP
FAAFP, FACSM
Co-Director; Sports Medicine Fellowship
Department of Family Medicine
Kaiser Permanente Medical Center
Fontana,, California
• Joint problems
affect some 43
million Americans.
• Most common
cause off disability
di bilit iin
adults
• More
M
costly
tl th
than
diabetes and
cancer.
cancer
• Numbers are
increasing.
Osteoarthritis
• Most common joint disorder, with
predilection for those over 50.
• Slowly
Sl l progressive,
i
causing
i continued
ti
d
breakdown of articular cartilage and
changes in subchondral bone.
• Common synonyms are
osteoarthrosis (OA) and
degenerative joint disease (DJD).
– Osteoarthrosis may be better term since
inflammation is usually mild.
mild
– Degenerative changes are the
predominant factor contributing to
disability.
disability
Occupational Hazard for Athletes?
The hands of a former NFL
f tb ll player
football
l
• Cedric
C di H
Hardman
d
– 13 year pro football
career defensive
d f
i end
d
– SF 49ers and Oakland
Raiders
– 2 time All Pro
– 49ers
49
currentt all-time
ll ti
sacks leader
– Raider
Raider’s
s Super Bowl XV
champion
• “No relief, there’s never any
relief. Day in, day out, I feel
like crap. Don’t believe
anything people say about
those golden years of your
life. They suck”
Overview
• Review pathophysiology,
epidemiology
gy and risk
factors for OA.
• Discuss a practical
approach to the
diagnosis of OA.
• Summarize current
treatment modalities for
OA from a clinical
perspective and present
a rational treatment plan.
Pathophysiology of OA
• Combination of mechanical, cellular
and biochemical processes in the
j i t
joint.
– Loss of articular cartilage
– Bone overgrowth (osteophytes
(osteophytes, sclerosis)
• Articular cartilage is aneural – pain
must arise from other structures
structures.
– Stretched nerve endings in the covering
of the bone (periosteum).
– Inflamed joint capsule lining (synovitis )
or microfractures in underlying bone.
– Joint instability
instabilit leading to stretching of
joint capsule, tendons or muscle.
Epidemiology of OA
• Over 40 million suffer with OA in
U.S. (increasing as baby boomers
age).
• 70-90% older than 75 have at least
one joint
j i t iinvolved.
l d
• Total cost of arthritis exceeds 2%
off GNP.
GNP
• Men & women equally affected:
–B
Before
f
50,
50 prevalence
l
off OA in
i mostt
joints greater in men than women.
– After 50, women more affected in
hand, foot and knee; Men more in hip.
Classification of OA
• Idiopathic Osteoarthritis
– Localized - commonly affects hands,
hands feet
feet, knee
knee,
hip, and spine.
– Generalized - involves 3 or more joint sites
sites.
• Secondary Osteoarthritis (specific
conditions increase risk):
– Other bone/joint disorders like osteonecrosis,
RA gout,
RA,
gout septic arthritis
arthritis, Paget’s
Paget s, CPPD.
CPPD
– Other diseases like diabetes, acromegaly,
hypothyroidism neuropathic (Charcot)
hypothyroidism,
arthropathy, and frostbite
Risk Factors for OA
•
•
•
•
•
•
•
•
Age
A
Obesity
Injury
j y or conditions
Genetics
Gender
Education (lower education level)
Physical Inactivity
Ethnicity (Whites > Blacks >
Hispanics)
• Physical and anatomic factors
(unequal leg length, flat feet, bowed
legs or knock knees)
knees).
• Congenital joint abnormality (Slipped
Capital Femoral Epiphysis, LegCalve Perthe s)
Calve-Perthe’s)
• Work and leisure activity (risk for
injury)
Joints Commonly Involved in OA
90% o
of Cases
Involve 3 Joints
• Knees (41%)
• Hands
H d (30%)
• Hips (19%)
Diagnosis of OA
• Made largely by history & exam
and confirmed with imaging.
• Signs and symptoms: hallmark is
pain and stiffness in one or only a
few joints.
–P
Presentt for
f months
th to
t years; Slowly
Sl l
progressive; Worsens with activity.
– Symmetric joint involvement.
– Morning stiffness; usually resolves in
<30 min. “Gelling” after periods of
inactivity.
– Prolonged
P l
d stiffness
tiff
and
d jjoint
i t
enlargement often evident with
progression
– Crepitus
C it ((grating
ti sensation
ti iin jjoint)
i t) iis
late symptom.
Exam Finding
g with OA
• Boney deformity
– Heberden’s (DIP) and
Bo chard’s (PIP) nod
Bouchard’s
nodules
les
– Osteophytes
– Muscle atrophy
• Painful motion
– Painful IR with hip OA
– Painful to squat with knee
OA.
– Painful pinch with thumb
OA.
OA
• Neurological signs
(altered sensation,
reduced strength or
reflexes).
Muscle atrophy
Radiographic Changes of OA
• X-ray findings with OA
include:
– Joint space narrowing and
osteophyte formation.
– Pseudocysts
P
d
t and
d iincreased
d
density of subchondral bone.
• Can provide objective
evidence of disease.
– Absence does not exclude
diagnosis.
– Can have x-ray changes of OA
b t no symptoms
but
t
or disability.
di bilit
Treatment Goals for OA
• 4 Main Goals
– Control pain and swelling
– Minimize disability
y
– Improve the quality of life
– Educate patient about their role in the
management
•S
Subjective
bj ti complaints
l i t and
d objective
bj ti
findings help guide the design of
appropriate therapeutic goals.
OA Treatment Should be
Individualized to:
• Patient's
Patient s expectations
• Level of function and activity
• Joints involved and the
severity of patient's disease
• Occupational and vocational
needs
• Nature of any coexisting
medical problems
Treatment Options for OA
• Non-pharmacologic
measures
• Oral medications
– Acetaminophen and
NSAID s
NSAID’s
– Narcotic analgesics
– Antidepressants
– Supplements
• Topical Treatments (ice,
heat, creams)
• Injectables
– Cortisone
– Hyaluronic acid
• Surgical treatment
Treatment of OA
• Paradigm shift in OA treatment over
past few years – non-pharmacologic
measures (not drugs) have become
the keystone of treatment.
• Previouslyy NSAID’s were focus.
– Studies showed only modest
effectiveness.
– Potential serious adverse effects
effects.
• Drugs should be used as adjuncts
((not alternatives)) to other measures.
– Benefits of non-pharmacologic measures
and drugs often additive
– May permit reduction in dose of NSAID
NSAID’ss
or analgesics used.
Non-Pharmacologic
Non
Pharmacologic Measures
• Exercise and
weight loss
• Thermal modalities
• Education
• Joint
J i t protection
t ti
• External supports
• Rehabilitation and
sports activity
y
Exercise and Weight Loss
• Exercise – can improve general
health and be therapeutic.
– OA is major reason for inactivity in
elderly – health benefits of
exercise lost.
– “Functional”
Functional exercises involving
ADL’s best (climbing stairs,
getting out of chair).
– Non weight bearing with bike or
water exercise.
• Weight loss – helps pain with
knee or hip OA
OA.
– Decreases risk for developing OA.
– Next to age, obesity biggest risk
f OA.
for
OA
Thermal Modalities
• Heat – helps pain and spasm –
use prior to stretching.
g
– Moist heat better than dry.
– Hot paraffin or heat mitten for hands.
– Deep heat given by ultrasound or
diathermy (microwave or shortwave)
• Cold – helps relieve muscle aches
after exercise.
– May help control swelling.
swelling
– Apply by ice packs, ice massage or
local spray.
Education and Joint Protection
• Patient education – that gives encouragement,
reassurance, advice on exercise and measures to
unload joint (cane
(cane, footwear) helps in selfself
management.
protection – of arthritic jjoint from stress
• Joint p
decreases pain and preserves cartilage.
– Walking transmits 3.5x body weight across joint, while
squatting transmits 9x (choose swimming over running
over tennis).
– Instability in knee OA common – helped with therapy
program or controlled
t ll d exposure tto movements
t th
thatt
challenge stability.
– Ambulatory assistive devices – such as canes and
walkers can support gait.
Fitting a Cane
• When placed vertically
alongside
l
id ttoes, ttop off
cane should be aligned
with
ith ulnar
l
styloid.
t l id
• Force on the cane
should be directed
downward.
• Should be placed in
contralateral hand.
External Supports
• Functional knee braces (unloader
brace) – helpful for medial
compartment arthritis.
arthritis Produce
valgus thrust to unload medial
compartment.
• Elastic bandages – can reduce
pain and feeling of giving way.
Loose fitting bandages better.
• Patella taping – can reduce pain
and improve function in
patellofemoral compartment OA.
• Wedged insoles / orthotics – may
reduce loading on medial or
lateral knee compartment.
• Splinting for hand OA – helps
relieve pain for base of thumb OA.
Unloads
medial
compartment
Other Non-Pharmacologic Measures
• Contractures – of soft tissues
and tendons around joint with
OA are common.
common Can prevent
by passive ROM and
stretching
g and active ROM
exercises.
• Tai Chi – ancient Chinese
f
form
off conditioning
diti i exercises
i
shown to reduce falls in
elderly.
y
• Acupuncture – may relieve
pain and improve function
(d t nott conclusive).
(data
l i )
Medications
• None shown to halt the
progression of OA.
• Common meds used:
– Acetaminophen and
NSAID’s
– Tramadol
– COX-2 inhibitors (Coxibs)
– Narcotic analgesics
– Topical Creams (Capsaicin
cream, Bengay, NSAID’s)
– Antidepressants
A tid
t
– Supplements
NSAID’s and Acetaminophen
• How did NSAID’s fall from grace?
– Efficacy of anti-inflammatory dose of NSAID (Motrin 800
TID) shown no better than analgesic dose (400 TID) or
ACET (1gm QID).
– Based on safety
safety, efficacy and cost,
cost 1995 ACR guidelines
recommended ACET as 1st line treatment for OA.
– ACR recommends NSAID if signs of joint inflammation (no
good data to support).
– Black Box warning (all NSAIDs) for CV & GI effects (2005).
• ACET and NSAID effects may be additive (can use
lower dose of NSAID).
• NSAID’s
NSAID’ and
d ACET only
l modestly
d l effective
ff i iin OA –
symptom control rarely complete.
Acetaminophen (Tylenol)
• Nonprescription analgesic that is
drug of choice for OA pain.
• Dose up to 4 g/day
– 1000 mg four times a day.
– 650 mg every 4 hours.
• Adverse effects generally mild
mild.
– Hepatotoxicity is rare; usually a/w
excess alcohol use
use.
– There is suggestive evidence (not
definitive) that chronic use has dosedose
dependent, long-term nephrotoxicity.
NSAID’s
• Indicated for inflammatory OA or non-inflam failing
to respond to ACET; or for moderate to severe pain.
– Most often use oral
– Topical preparations available (Diclofenac gel or patch).
• 2004 meta
meta-analysis
anal sis (15 RCT’s)
– ACET superior to placebo in relief of OA pain, but less
effective than NSAIDs.
– GI side effects more common with NSAID’s; ACET and
COX-2 about same GI risk.
• Diclofenac (Voltaren) gel first topical NSAID
– Mainly for hand & knee OA when can’t take oral NSAID.
– Efficacy no better than placebo after 2 weeks.
– Black box warning for CV and GI risk.
Classification of NSAID’s
• Non-selective COX Inhibitors:
– Propionic acid derivatives (Ibuprofen, Naproxen)
– Acetic acid derivatives (Indomethacin, Sulindac,
Diclofenac, Nabumetone)
– Salicylic Acid derivatives (Aspirin,
(Aspirin Diflunisal)
– Nonacetylated salicylates (Salsalate)
– Enolic acid ((Oxicam)) derivatives ((Piroxicam,,
Meloxicam)
– Fenamic acid derivatives (Meclofenamic acid,
Tolfenamic acid)
• Selective COX-2 inhibitors:
– Celecoxib FDA alert (Rofecoxib & Valdecoxib withdrawn)
• If one not working, try one from a different class.
COX-2 Inhibitors (Coxibs)
• These NSAID’s selectively inhibit COX-2 and spare
COX-1.
– Lower incidence of upper GI irritation (lost if taking ASA)
ASA).
– Despite lay press claims, efficacy in OA no greater than
nonselective NSAID’s.
– Cost
C t off these
th
drugs
d
much
h hi
higher.
h
– Traditional NSAID plus PPI (to protect stomach) just as
good for those with GI upset and much cheaper.
• Vioxx and Celebrex may slightly (.3-.5%) increase
risk of MI.
– Sept 04’
04 Merck withdraws Vioxx from market.
– Celebrex shown to have similar risk (NEJM, 3/05) – on
market with black box warning.
– Bextra removed from market 4/05 due to life-threatening
life threatening
skin reactions.
Selecting an NSAID
• Immense variability in patients' response to
the wide variety of NSAID’s used.
– Start with OTC (aspirin, ibuprofen or naproxen).
– Low dose ibuprofen
p
((<1600 mg/day)
g y) may
y have
less serious GI toxicity.
– Nonacetylated salicylates (salsalate), sulindac,
and nabumetone appear to have less renal
toxicity.
– Salsalate & nabumetone less antiplatelet activity.
– Avoid long-term indomethacin with hip OA
(? accelerated
l t d jjoint
i td
destruction).
t ti )
– Avoid COX-2 if hx of CVD or risk factors
Tramadol
• Analgesic with uncertain MOA
– Side effects similar to weak
opioids (constipation); rate of GI
upset may be higher.
– Seizures additional risk (esp if on
antidepressants or neuroleptics)
• Used alone or in combo with
ACET; may also be added to
NSAID or COX-2.
– Tramadol + ACET roughly
equivalent to Tylenol #3 for OA
pain.
Other Medications
• Narcotic
N
ti analgesics
l
i
– Consider when ACET and/or
NSAID’s not providing adequate
analgesia.
– Concerns about tolerance and
dependence.
– Tramadol nice alternative.
• Antidepressants
– Good for chronic pain (depression
common).
– Amitriptyline and Imiprimine most
used.
used
• Topical Creams
– Capsaicin cream, Bengay.
– Shown to relieve pain in OA of
hand and knee.
Supplements
• Glucosamine – likely effective.
• Chondroitin – may be effective,
often combined with Glucosamine.
• SAM-e – mayy be as effective as
coxib.
• Selenium – no benefits shown.
• Folic Acid – may be effective for
hand OA (combined with B-12).
• Zinc – more study needed.
• Vitamin C – more studyy needed.
Injections for OA
• Corticosteroid injections can be
helpful in OA.
– Adverse effects usually minor (skin
dimpling, depigmentation, infection is
rare).
– Systemic corticosteroids have no
place in treatment of OA.
• Hyaluronic acid injections
(Hyalgan Synvisc)
(Hyalgan,
– Presumed to supplement
endogenous HA in joint (key
component of synovial fluid)
fluid).
– Efficacy similar to steroid injection.
– Severe local reactions reported.
– Expensive
E
i – classed
l
d as a d
device,
i
nott
a drug.
Surgery for OA
• Joint debridement / levage – for
loose body, cartilage flap or
meniscal tear.
– Not helpful if no mechanical
symptoms.
– $3 billion a year spent on these
procedures.
• Osteotomy – wedge of bone
removed to shift weight off
damaged area of joint.
• Arthrodesis – jjoint fused to
relieve pain (used in spine and
small joints of hand and foot).
• Joint replacement – treatment of
last resort to relieve pain of OA.
EBM Recommendations For Tx Knee OA
From BMJ Clinical Evidence
• Beneficial Treatments
– Exercise and physiotherapy (pain relief and improved
function)
– NSAIDs (oral) for short term pain relief
• Likely to be Beneficial Non-surgical Treatments
–
–
–
–
–
–
Corticosteroids (intra
(intra-articular
articular — short-term
short term pain relief)
Hyaluronan (intra-articular)
Joint bracing
NSAIDs (topical) for short-term pain relief
Simple oral analgesics (short-term pain relief only)
Taping
EBM Recommendations For Tx Knee OA
From BMJ Clinical Evidence
• Likely to be Beneficial Surgical Treatments
– Knee
K
replacement
l
t
– Osteotomy
• Trade off between Benefits and Harms
– Opioid analgesics
• Unknown Effectiveness
–
–
–
–
–
–
Acupuncture
Capsaicin
Chondroitin
Education (to aid self management)
Glucosamine
Insoles
My Approach to Treating OA
• Rest until pain free; exercise to
tolerance (cross train).
– Weight loss
– Thermal treatments
– PT, braces, cane etc.
• A
Acetaminophen
t i
h up tto 4 gm/d,
/d
consider adding NSAID (different
class if no response).
)
• Glucosamine 500 mg TID,
Chondroitin 400 TID, SAM-e 200400 TID ($$)
($$).
• Cortisone injections.
• Elavil HS ((help
p with sleep),
p)
Tramadol for severe pain.
• Surgical options last resort.
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