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Osteoarthritis and Exercise Rochelle M. Nolte, MD CDR USPHS/USCG Objectives • Understand factors involved in the etiology and epidemiology of osteoarthritis • Understand how exercise helps prevent osteoarthritis • Understand how exercise is used in the treatment of osteoarthritis Etiology of Osteoarthritis • Disease of the synovial joints – Primary changes of OA begin in the cartilage – Most pronounced in load bearing areas of articular cartilage – Fibrocartilaginous repair is inferior to original hyaline cartilage – Other tissues affected include: subchondral bone, synovium, meniscus, ligaments, muscle Etiology of Osteoarthritis • Articular cartilage is composed of: – Proteoglycans • Provide compressive stiffness and ability to withstand load – Collagen • Provides tensile strength and resistance to shear Etiology of osteoarthritis • Articular cartilage (1-2 mm thick) – Provides a smooth bearing surface • With synovial fluid as a lubricant, the coefficient of friction for cartilage on cartilage is 15X lower than rubbing 2 ice cubes together – Prevents the concentration of forces when bones are loaded Etiology of Osteoarthritis • Growth of cartilage and bone at the joint margins leads to osteophytes which can restrict movement • Chronic synovitis and thickening of the joint capsule further restrict movement • Periarticular muscle wasting is common and plays a major role in sx and disability Symptoms of osteoarthritis • PAIN (Articular cartilage is aneural) – OA pain is not from the cartilage • Stretching of nerve ending in periosteum covering osteophytes • Microfractures in subchondral bone • Stretching of joint capsule • Synovitis • Ligament stretching or muscle pain • STIFFNESS (esp. after inactivity) Physical exam findings of OA • Bony or soft tissue swelling • Bony crepitus • Synovial effusions (usually small) • Mild warmth • Periarticular muscle atrophy • Bony hypertrophy (advanced OA) • Joint subluxation (advanced OA) Laboratory findings in OA • THERE ARE NO DIAGNOSTIC LAB TESTS FOR OSTEOARTHRITIS • OA is not a systemic disease, therefore: – ESR, Chem 7, CBC, and UA all WNL • Synovial fluid • Mild leukocytosis (<2000 WBC/microliter) • Can be used to exclude gout, CPPD, or septic arthritis if diagnosis is in doubt Radiology findings in OA • Often great disparity between the severity of radiographic findings and severity of symptoms and functional ability • 90% of people >40 have x-ray changes • 30% are symptomatic • During early OA radiographs may be normal Radiology findings in OA • Joint space narrowing may be earliest sign – Secondary to loss of articular cartilage • Subchondral sclerosis • Subchondral cysts • Osteophytes • Change in joint contour secondary to bony remodeling and joint subluxation Epidemiology of OA • OA of the knee is the leading cause of chronic disability in the elderly in developed countries • In patients over the age of 55: – Hip OA is more common in men – IP and 1st MCP OA is more common in women – Knee OA (with sx) is more common in women Epidemiology of OA • In patients under the age of 55: – Joint distribution of OA is equal between men and women • Due to genetics or joint usage????? – Mother and sister of a woman with DIP OA are 2 & 3 X more likely to have the same – Racial differences in prevalence and pattern of joint involvement also point to genetic basis Epidemiology of OA • Age is the most powerful risk factor for OA • Women < 45 years of age: 2% with OA • Women 45-64: 30% with OA • Women >65: 68% with OA Epidemiology of OA • There is no convincing data to support an association between nonspecific nonprofessional athletic activities and osteoarthritis – (excluding major trauma) • Neither long-distance running nor jogging has been shown to cause osteoarthritis Epidemiology of OA • Obesity is a risk factor for knee (and hand) osteoarthritis – In the highest quintile of BMI • Relative risk of developing OA in the next 36 years was 1.5 for men and 2.1 for women • For SEVERE OA, the RR rose to 1.9 for men and 3.2 for women – Weight loss of 5kg was associated with a 50% reduction in the odds of developing OA Epidemiology of OA • Disability in subjects with knee OA – More strongly associated with QUADRICEPS WEAKNESS – than with joint pain or radiographic severity • Demographics associated with increased likelihood of being symptomatic: women, unemployed, divorced, poor social support Risk factors for OA • Age • Major joint trauma • Sex • Repetitive stress • Race – Vocational • Genetic factors – Recreational • Obesity • Congenital defects • Prior inflammatory joint disease • Metabolic disorders Risk factors for OA • Systemic – Age – Gender – Ethnicity – Genetics – Hormonal status – Bone density – Metabolic/nutritional status Risk factors for OA • Local – Obesity – Major trauma – Joint deformity – Physical disability – Muscle weakness – Occupational/sports stress Prevention of OA • Physiological effects of physical activity are most marked in those parts of the body that are used most during exercise • Physical activity is the best way to ensure the maintenance of functional capacity • Endurance-type activity using rhythmic movements of large muscle groups are the best studied Prevention of OA • Exercise reduces the pain and functional disturbance in OA of the knee (SOR A) – Data insufficient for conclusions about the type of exercise that should be preferred • Sudden overloading, incorrect joint loading, and various injuries predispose people to OA • Preventing excessive wt gain helps Prevention of OA • Current studies – Isokinetic exercise for improving knee flexor and extensor muscles in healthy adults to assess safety and effectiveness – Will also assess in adults with neurological, orthopedic, and rheumatologic conditions Management/Treatment of OA • Goals – Educate patient about disease and management – Improve function – Control pain – Alter disease process and its consequences Management/Treatment of OA • No known cure for OA • HOWEVER – Impaired muscle function – Reduced fitness • Affect pain and dysfunction • Are amenable to therapeutic exercise Management/Treatment of OA • Pharmacologic • Topical – Acetaminophen – Capsaicin – NSAIDS – Methylsalicylate • Cox-2 specific inhibitors – NSAIDS • With PPI or misoprostol • Intra-articular – Nonacetylated salicylate – Corticosteroids – Tramadol – Hyaluronic acid – Opioids Treatment/Management of OA • Pharmacologic – Acetaminophen • Grade A/Level I for short-term pain relief • Pain decreased 4 points (100 point scale) compared to placebo • Relatively inexpensive compared to NSAIDS • Relatively safe compared to NSAIDS • Usually studied in doses of 2-4 g/d • Liver toxicity is major concern Management/Treatment of OA • Pharmacologic – NSAIDS • Grade A/Level I for short-term pain relief • Shown to provide better pain control than acetaminophen, especially with more severe pain • No difference in functional improvement • Greater GI toxicity than acetaminophen • No difference in efficacy among NSAIDS Management/Treatment of OA • Pharmacologic – Tramadol • Pain decreased 8.5 points compared to placebo • 39 had minor side effects (18 with placebo) • 21 had major side effects (8 with placebo) – Opioids • Grade B/ Level I for pain control in OA • Must balance side effect profile for risk/benefit Management/Treatment of OA • Pharmacologic – Topical Capsaicin • Inconclusive evidence – Topical NSAIDs • + short-term pain relief in very limited short-term studies only compared to placebo. • No studies comparing to PO medications Management/Treatment of OA • Pharmacologic – Intra-articular steroids • Grade A/Level I for short-term pain relief – Intra-articular hyaluronic acid • Grade A/Level I for short-term treatment Treatment/Management of OA • Pharmacologic – Intraarticular corticosteroids • Superior to placebo for pain control for 2-3 weeks • At 4-24 weeks, no evidence of improvement in pain • No evidence of improvement in function – Hyaluronic acid • More effective than corticosteroids 5-13 weeks post-injection (pain, ROM, function) Treatment/Management of OA • Pharmacologic – Hyaluronic acid (HA) • Better than placebo • Comparable effectiveness to NSAIDs – Fewer systemic adverse events – More local reactions • Longer-acting than IA steroids • No major safety issues • SOR B (76 heterogeneous trials) Treatment/Management of OA • Pharmacologic – Herbal therapy • Avocado soybean unsaponifiables (ASU’s) with promising results in 2 studies on: – Functional index, pain, NSAID use, and global evaluation • Reumalex (willow bark preparation) inconclusive • Tipi tea inconclusive Management/Treatment of OA • Possible structure/disease modifying stuff – Glucosamine – Diacerein – Cytokine inhibitors – Cartilage repair – Bisphosphonates – Degradative enzyme inhibitors • Tetracyclines, metalloproteinase inhibitors Treatment/Management of OA • Pharmacologic – Glucosamine 20 studies with >2500 patients • If only high quality studies evaluated: – No benefit over placebo on pain • If all studies included: – Pain may improve by as much as 13 points • 2 RCT’s using Rotta preparation: – Demonstrated slowing of radiological progression of OA over a 3 year period Treatment/Management of OA • Pharmacologic – Diacerein • Pain improved 5 points compared to placebo • Over 3 years, – Slowed progress of OA in the hip compared to placebo – Did not slow progress of OA in the knee • Diarrhea is most common side effect – 42 out of 100 had diarrhea in the first 2 weeks – 18 discontinued because of side effects (13 in placebo) Management/Treatment of OA • Non-pharmacologic • Non-pharmacologic – Patient education – Assistive devices – Self-management – Patellar taping programs – Appropriate footwear – Weight loss – Lateral-wedged – PT/OT insoles – ROM exercises – Bracing – Muscle strengthening – Joint protection and energy conservation Management/Treatment of OA • Non-pharmacologic (Exercise) – Walking program v. control. Level I/Grade A (RCT n=1089) for improvement in: • Pain • Functional status • Stride length • Aerobic capacity • Energy level • Medication use • Disability transferring from bed and bathing Management/Treatment of OA • Non-pharmacologic (Exercise) – Whole-body functional exercise v. control. Level I/Grade A (RCT n=864) for: • Pain • Functional status • Mobility • Walking • Work • Disability in Activities of Daily Living (ADL’s) Management/Treatment of OA • Non-pharmacologic (Exercise) – Home strengthening program for knee v. control. Level I/Grade A (controlled clinical trial n=81) for: • Pain • Functional status • Energy level • Range of motion (ROM) in flexion • Other studies: group exercise program as effective as one-on-one Management/Treatment of OA • No differences between high and low intensity aerobic exercise in people with OA for: – Functional status – Pain – Gait – Aerobic capacity • Therapeutic range (btwn suitable and excessive exercise) may be narrow in some patients Management/Treatment of OA • Non-pharmacologic (brace) study (SOR B) – Valgus knee brace better than: – Neoprene sleeve better than: – Control group according to pain scale – While score changes were statistically significant, clinical significance is questionable – Study only lasted 6 months. <500 patients Management/Treatment of OA • Non-pharmacologic (insole) study (SOR B) – Laterally wedged insoles may decrease knee OA pain – Laterally wedged insoles decrease the amount of pain medication taken – Pain decreased by one point (100 point scale) in laterally wedged insoles. Decreased by 5 points in neutrally wedged insoles. However, pain medication use decreased more in laterally wedged insole patients and patients wore the laterally wedged insoles for a longer period of time Management/Treatment of OA • Non-pharmacologic (exercise programs) – Exercise programs improve health and function (SOR A) – People tend to stick with a home exercise program more than exercising at a center (SOR B) – The specific type of exercise that is best needs more research Management/Treatment of OA • Thermotherapy – Heat had no benefit on swelling over cold or placebo – Cold did not significantly improve pain – Cold did slightly improve swelling – Ice 20 min/d 5d/wk for 2 weeks did show improved muscle strength, ROM, and a decrease in time to walk 50 feet Management/Treatment of OA • Ultrasound was of no benefit for: – Pain – Range of motion – Functional status Treatment/Management of OA • Transcutaneous electrical nerve stimulation (TENS) for knee OA – Active and “acupuncture like” TENS for at least four weeks reduced pain and knee stiffness (SOR B) • Electrical stimulation – Showed improvement in measurements, but – Clinical significance from the patient’s perspective is questionable Treatment/Management of OA • Surgery – Valgus high tibial osteotomy (HTO) for treatment of medial compartment OA • No study comparing HTO to conservative txment – Partial knee replacement – Total knee replacement • Pre-op education only reduced hospital stay in patients with complex needs Treatment/Management of OA • Current studies – Non-pharmacologic • Aquatic exercise for the treatment of knee/hip OA • Acupuncture for osteoarthritis – Pharmacologic • Chloroquines, HRT, chondroitin, homeopathy • Opioids Summary • Non-pharmacologic therapy is important in the prevention and treatment of OA • The best studied and most effective non- pharmacologic therapy is EXERCISE • Exercise helps control weight, increase strength, improve and maintain function and decrease pain Thank you for coming Questions?
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