Non-Surgical Management - PowerPoint Presentation

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Non-Surgical Management of Osteoarthritis

Marc Wahlquist, M.D.

TriHealth Orthopedic and Sports Institute

Goals of this lecture

Help you understand what is osteoarthritisDiscuss different ways that arthritis can be treated without surgeryGive you ideas as to what you can do on your own to treat arthritisAnswer any questions you may have

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What is osteoarthritis

Osteoarthritis is the “wear and tear” type arthritis The articular cartilage at the ends of our bones develops fissures or cracks over time and eventually thins and wears awayOsteoarthritis is the loss of articular cartilageIt is different than rheumatoid arthritis or psoriatic arthritis or septic arthritis or arthritis as a result of dysplasia or growth abnormalities

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X-ray findings for arthritis

Joint space narrowing, as the cartilage thins the bones get closer togetherPeriarticular osteophytes (the dreaded bone spurs). As the bone underneath the cartilage sees more stress then it stimulates abnormal bone growth in the form of bone spursSubchondral sclerosis. The bone exposed by the loss of cartilage becomes more dense and hardened. It then shows up brighter on the X-ray Subchondral cyst formation. As arthritis progresses the joint produces more fluid. This fluid can leak into the bone itself and form cysts under the bone

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Clinical symptoms of arthritis

Pain localized to the affected jointFor hip arthritis pain is typically localized to the groinFor knee arthritis is depends on which side of the joint is affected, medial or lateralPain that is worse with weight bearing and improved with rest Joint swellingGrinding or crunching in jointStart up stiffnessOccasionally patients will have night time aches and pains

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Clinical signs of arthritis

Tenderness localized to the affected jointIt should not radiate to other parts of the bodyJoint swellingJoint stiffness or contractureJoint deformity (bowlegged or knock-kneed)

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Treatment options

Physical therapy Goals are to increase and maintain current function and prevent further worsening of the condition Range of motion exercises; gentle stretching can help prevent contractures, and active ROM helps provide nutrition to the cartilageStrengthening exercises (use it or lose it)A muscle at complete rest will lose strength at 3% a daySeveral controlled trials have shown improvement in function, pain and strength with strength training compared to controlsIsometric exercises are less likely to produce inflammation and pain

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Treatment options

Weight lossThe knee experiences 4x the body weight with every stepIt makes sense that weight reduction would result in improved knee symptoms, although that hasn’t been proven conclusivelyDiet in combination with exercise has been shown to improve knee pain and function compared to diet alone and exercise aloneWeight loss has been shown to decrease operative risks when it comes to joint replacement

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Treatment options

BracingA simple elastic knee brace can provide support to the knee and improve symptomsCheap with little side effectsMore complicated hinged braces specific for arthritis are “unloader” braces. These try to shift the load from the arthritic part of the knee to the part of the knee with intact cartilageThese have been shown to be helpful in reducing pain and increasing functionBut they are only effective when actually worn on the knee

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Education

Having an understanding of the disease process and its natural history or clinical course can help patients make effective lifestyle changes and allows them to have some control of their conditionSeveral studies have shown that patient education can decrease arthritic pain

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Acetaminophen

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Tylenol

Non-narcotic pain medication

Works on central nervous system but, exactly how it helps reduce pain is poorly understood

Generally safe at doses below 4 grams/day

Higher doses combined with alcohol can lead to permanent liver and kidney damage

Non-steroidal anti-inflammatory drugs

Blocks the COX enzyme that is present in normal tissuesCOX-1 plays a role in GI mucosal defense, renal perfusion and platelet aggregationCOX-2 appears in areas of inflammation and injuryMost NSAIDs on market are non-selective, meaning the work on both enzymesThese are drugs like Ibuprofen, Naprosyn, Diclofenac, etc.COX-2 specific drugs like Celebrex are supposed to avoid the GI side effects of the nonspecific COX inhibitors but, they may have unwanted increased risk of cardiac or kidney problems

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Steroid injections

Has been around since the 1950’sVery common treatment for arthritic in the clinicDespite its frequent use, clinical trails have not been overwhelming in its favorCan be beneficial in the short term – typically 4-12 weeksThe risks are infection (vary rare), steroid flare (also rare and resolves in 1-3 days), temporary elevation of blood sugar in diabetics, facial flushing and hot flashesShould not be given too close together. In my clinical practice I don’t give them any closer together than three months in the same jointYou should rest for a day or two after the injection

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Hyaluronic acid (HA)

Plays a role in the viscosity of joint fluidArthritic joints have fluid which is very thinInjections of HA are thought to help better lubricate the joint. The exact mechanism of action is still not clearSeveral different brands are available with differing preparations and molecular weightsSome are one injection, other brands are 3-5 injections given weekly

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Hyaluronic acid (HA)

These are only FDA approved for knee arthritis No clear evidence supports one brand over anotherIn fact, no clear evidence really supports the use of any of themBut recent studies seem to suggest that those preparations with higher molecular weights like Synvisc, GelOne, and potentially Euflexxa may be more beneficial.I tell patients that about 60% of patients will notice an improvement in their symptomsThere are expensive – about $700 to $1000

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Glucosamine

Natural building block of cartilageMost preparations are derived from crustacean shells, but there are some that are derived from bovine cartilageSeems to increase joint production of hyaluronic acidHas been used in animals for many yearsFew side effects

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Chondroitin

Another building block of cartilage As we age the concentration of chondroitin in the cartilage decreasesMay be chondroprotectiveIn one study comparing chondroitin to an NSAID – the patients noticed more rapid improvement with NSAID but, had slower more significant response to chondroitinWell tolerated with few side effects

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Glucosamine/Chondroitin Combo

Seem to work synergisticallyIn one study with an animal model, there was more improvement with the combination than either one aloneWhile they have been extensively studied and used in Europe, they have not been shown to be effective here in the USThe reason may be, in Europe it is a regulated drug; whereas in the US it is considered a nutraceutical and so it isn’t regulated very wellThe AAOS which governs orthopedics in the US has come out with a “strong” recommendation against using GC

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Methylsulfonylmethane

MSMThis is a newer nutritional supplementAgain, in Europe the studies are very much in favor of using MSM in combination with GS/CIn the US recent studies have not shown such a dramatic effectNo studies show any significant side effects

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Thank you.

Questions?

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