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Osteoarthritis and Exercise

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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?