Osteoarthritis Pain

Osteoarthritis Pain Epidemiology and Impact of Osteoarthritis  Prevalence of arthritis and musculoskeletal disorders is difficult to estimate1  Osteoarthritis affects 40 million Americans1 – Estimated to affect 59.4 million people, or 18.2% of the US population, by 20201 – >20 million people experience pain from osteoarthritis2 – 7.1 million ambulatory care visits specific to osteoarthritis3 – Leading cause of work-related disability in people aged 16-72 years1 – 80% of people >75 years have osteoarthritis4 1. Lawrence RC et al. Arthritis Rheum. 1998;41:778-799. 2. Lipman AG. Curr Rheumatol Rep. 2001;3:513-519. 3. Hootman JM et al. Arthritis Rheum. 2002;47:571-581. 4. Manek NJ, Lane NE. Am Fam Physician. 2000;61:1795-1804. Joints Commonly Involved in Osteoarthritis  Osteoarthritis principally affects weight-bearing joints in the knees and hips, but it also affects the feet, ankles, distal interphalangeal joints, proximal interphalangeal joints, first carpometacarpal joints, cervical spine, and lower spine APS. Guideline for the Management of Pain in Osteoarthritis, Rheumatoid Arthritis, and Juvenile Chronic Arthritis. 2nd ed. Glenview, Ill: American Pain Society; 2002. Etiology and Pathophysiology of Osteoarthritis Synovial membrane Cyst formation and sclerosis in subchondral bone Shelving “fibrillated” cartilage Cartilage Osteophytic lipping Synovial hypertrophy Capsule Bone Thickened capsule Normal Osteoarthritis Osteoarthritis Diagnosis Assessment1,2  Medical and functional history1  Physical examination tool (eg, range of motion)  Functional assessment2 (eg, Health Assessment Questionnaire and Arthritis Impact Measurement Scales3) Signs and Symptoms3 Radiographic Evidence1,3  Morning stiffness (20-30 minutes)  “Gel” phenomenon (~20 minutes)  Occasionally local inflammation     Joint space narrowing Increased subchondral bony sclerosis Subchondral cyst formation Osteophytes 1. Swagerty DL Jr, Hellinger D. Am Fam Physician. 2001;64:279-286. 2. Kantz ME et al. Med Care. 1992;30(suppl):MS240MS252. 3. APS. Guideline for the Management of Pain in Osteoarthritis, Rheumatoid Arthritis, and Juvenile Chronic Arthritis. Glenville, Ill: American Pain Society; 2002. Nonpharmacologic Interventions for Osteoarthritis Primary Treatment Goal Patient/Family Education  Minimize symptoms1  Increase function and QOL1  Education about pain, pain management options, and self-management programs2  Personalized social support (phone)2,3  Reduce pain and psychological disability  Enhance self-efficiency and pain coping CognitiveBehavioral Therapy1 QOL=quality of life. 1. Hinton R et al. Am Fam Phys. 2002;65:841-848. 2. APS. Guideline for the Management of Pain in Osteoarthritis, Rheumatoid Arthritis, and Juvenile Chronic Arthritis. 2nd ed. Glenville, Ill: American Pain Society; 2002. 3. ACR. Arthritis Rheum. 2000;43:1905-1915. Physical Interventions for Osteoarthritis Exercise1,2  Range of motion and flexibility  Muscle strengthening  Aerobic (low impact, gravity limiting) Maintain Ideal  Follow a balanced diet plan Body Weight1,2  If BMI >30 kg/m2, follow weight management program Physical Modalities2 Orthotics1,2  Physical therapy  Occupational therapy  Assistive devices for walking and ADLs  Footwear and insoles, compression gloves, patellar taping, cane BMI=body mass index; ADLs=activities of daily living. 1. APS. Guideline for the Management of Pain in Osteoarthritis, Rheumatoid Arthritis, and Juvenile Chronic Arthritis. 2nd ed. Glenville, Ill: American Pain Society; 2002. 2. ACR. Arthritis Rheum. 2000;43:1905-1915. Complementary and Alternative Medicine for Osteoarthritis Dietary Supplements1,2 Physical Modalities1  Glucosamine sulfate  Chondroitin 4-sulfate     Heat/cold application TENS Acupuncture Magnets (insufficient evidence supporting use) TENS=transcutaneous electrical nerve stimulation. 1. APS. Guideline for the Management of Pain in Osteoarthritis, Rheumatoid Arthritis, and Juvenile Chronic Arthritis. 2nd ed. Glenville, Ill: Amerian Pain Society; 2002. 2. Clegg DO et al. N Engl J Med. 2006;354:795-808. Pharmacologic Treatments for Osteoarthritis Analgesics  Acetaminophen1-3  NSAIDs1-4  COX-2 inhibitors*1,2  Topical agents (eg, capsaicin,1,2 lidocaine patch 5%4)  Opioids – When all other analgesics have failed and as part of a biopsychosocial approach5 NSAIDs=nonsteroidal anti-inflammatory drugs; COX=cyclooxygenase. *Questions have been raised about adverse cardiovascular events. 1. ACR. Arthritis Rheum. 2000;43:1905-1915. 2. APS. Guideline for the Management of Pain in Osteoarthritis, Rheumatoid Arthritis, and Juvenile Chronic Arthritis. 2nd ed. Glenview, Ill: American Pain Society; 2002. 3. Lipman AG. Curr Rheumatol Rep. 2001;3:513-519. 4. Gammaitoni AR et al. Curr Med Res Opin. 2004;20(suppl 2):S13-S19. 5. Kivitz A et al. EULAR 20th Annual Meeting. 2003. Emerging Pharmacologic Treatment: Lidocaine Patch 5% Reduction From Baseline (%) -36 -38 -40 -42 -44 -46 -48 † * * Pain Stiffness Physical Function ‡ -50 Composite WOMAC Osteoarthritis Index Subscales 2-week, open-label trial. N=20; *P<.001; †P=.003; ‡P<.01. WOMAC=Western Ontario and McMaster Universities. Reprinted with permission from Galer BS et al. Curr Med Res Opin. 2004;20:1455-1458. Pharmacologic/Invasive Treatments for Osteoarthritis Injections  Intra-articular glucocorticoid (3-4x/y)1,2  Hyaluronic acid viscosupplementation3 Surgery  Total or resection arthroplasty, arthrodesis, arthroscopy, osteotomy (hip, ankle, knee)1 Other  Glucosamine sulfate, 1500 mg/d1 1. APS. Guideline for the Management of Pain in Osteoarthritis, Rheumatoid Arthritis, and Juvenile Chronic Arthritis. 2nd ed. Glenville, Ill: American Pain Society; 2002. 2. Hinton R et al. Am Fam Physician. 2002;65:841-848. 3. Manek NJ, Lane NE. Am Fam Physician. 2000;61:1795-1804. Intra-articular Injection of Hyaluronic Acid for Osteoarthritis  Mechanism of action is unknown  Animal studies show improvement in osteoarthritis and cartilage1  In vitro studies show beneficial molecular and cellular effects1 – Extracellular matrix, immune cells, inflammatory mediators  Clinical studies2 – Pain relief greater than placebo, comparable to oral NSAIDs, and comparable to or greater than glucocorticoid injections NSAIDs=nonsteroidal anti-inflammatory drugs. 1. Moreland LW. Arthritis Res Ther. 2003;5:54-67. 2. ACR. Arthritis Rheum. 2000;43:1905-1915. Future Treatments for Osteoarthritis Nonpharmacologic  Specific physical therapy programs  Continued improvement in complementary and alternative approaches Disease-modifying agents  Target-specific inflammatory mediators1  Target-specific genetic deficiencies2 – Interleukin-1 – Interleukin-6 – Tumor necrosis factor-  Cartilage growth factor (Tgf-S)3  Articular cartilage repair and transplantation4 1. Pelletier JP et al. Rheum Dis Clin North Am. 1993;19:545-568. 2. Goldring MB. Connect Tissue Res. 1999;40:1-11. 3. ACR. Cartilage Growth Factor (Tgf-S) in osteoarthritis. Available at: http://www.rheumatology.org/publications/hotline/archive/ 0394cartilagegf.asp. Accessed May 23, 2006. 5. Buckwalter JA, Mankin HJ. Arthritis Rheum. 1998;41:1331-1342.