© copyright annals of internal medicine, 2014 ann int med. 161 (1): itc1-1. * for best viewing:...

© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (1): ITC1-1.

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in the clinic

Osteoarthritis


What are the major risk factors for OA?

Older age

Genetic inheritance

Race and ethnicity

Similar rates hand, knee OA in Europeans and Americans

Lower rates hip OA in African blacks, Asian Indians, and Chinese persons from Beijing and Hong Kong

Higher rates knee OA among older Chinese women in Beijing than white women in the Framingham study

Being female

Local mechanical factors

Malalignment, muscle weakness, internal derangements

Excessive joint loading


Obesity: most important modifiable risk factor

Counsel overweight and obese patients to lose weight

Should diet and physical activity be modified to prevent knee OA?

Encourage physical activity

Conditioning programs, graduated training schedules

Muscle strengthening for quadriceps

But avoid intense loading of previously injured joints

Contact sports increase risk of knee injuries

Meniscal tears and cruiciate ligament injuries predispose patients to OA regardless of surgical repair


CLINICAL BOTTOM LINE: Prevention…

Obesity is most important modifiable risk factor for knee OA

Encourage exercise to maintain quadriceps strength

If participating in sports, advise proper training and conditioning to avoid injury


Pain

Activity-related or mechanical

Exacerbated by use and alleviated by rest

Usually insidious in onset; nocturnal in advanced disease

What are the characteristic symptoms of OA?

Morning stiffness of brief duration

Reduced range of motion and crepitus

Absence of systemic features (e.g., fever)


Crepitus

Audible, palpable grating quality when the knee is flexed and extended

What are the characteristic physical examination features?

Bony prominence

Particularly finger joints: Heberden and Bouchard nodes

Squaring of joint contour: 1st carpometacarpal articulation

Malalignment

Use goniometer to visually bisect thigh and lower leg

Remember: back and hip disorders can refer pain to knee

Evaluate both anatomical sites to isolate the origin of pain


Diagnose OA on the basis of history and physical exam

Radiographs are insensitive to early pathologic features

Radiograph findings correlate poorly with symptoms

When should imaging studies be ordered?

Plain-film radiography can confirm clinical suspicion

Joint space narrowing

Osteophyte (or spur) formation at the joint margin

Cortical bone thickening (or eburnation)

Formation of subchondral cysts

MRI useful to evaluate for internal derangement of knee or early osteonecrosis


For diagnosis, lab testing is not helpful

OA is relatively noninflammatory

CBC & acute-phase reactants should be normal

Should other diagnostic studies be pursued in suspected cases?

Before NSAIDs: test creatinine level + liver function tests

Especially in elderly and in those with comorbid conditions

Establishes a baseline if iatrogenic features develop


Knee OA

Use criteria from American College of Rheumatology

Based on clinical, radiologic, & synovial fluid analysis data

Hip OA and hand OA

American College of Rheumatology Criteria also valuable for classifying OA of the hip and hand joints

What are the diagnostic criteria?


Generalized OA

Affects multiple joints in appendicular and axial skeleton

Are there distinct subsets?

Secondary OA

Result of well-defined cause (e.g., injury, endocrinopathy)

Previous damage from infection or an underlying inflammatory arthropathy

Erosive OA

Involves hand joints and predominantly affects women

Flares cause erythema, swelling, severe pain

arosion of affected joints and osteophytes and ankylosis


Primary OA

Hemochromatosis

Ochronosis

Multiple epiphyseal and spondyloepiphyseal dysplasia

Calcium pyrophosphate deposition disease

Acromegaly

Rheumatoid arthritis

Psoriatic arthritis

Trochanteric bursitis

What is the differential diagnosis?

Anserine bursitis

De Quervain tenosynovitis

Meniscal tear

Osteonecrosis

Gout

Neuropathic (Charcot) joint

Nodal generalized OA

Inflammatory (erosive) OA

OA due to trauma or mechanical factors

OA of 1st carpometacarpal joint


If the pattern of joint involvement is atypical

If symptoms suggest inflammatory arthropathy

If manifestations are severe

If features suggest a periarticular source of pain

Such as pes anserine bursitis or trochanteric bursitis

If joint is red, hot, and swollen

Aspiration is needed right away

When should clinicians consult a rheumatologist or an orthopedist?


CLINICAL BOTTOM LINE: Diagnosis…

Diagnose OA on the basis of history and physical exam

Use plain-film radiographs for diagnostic confirmation

In atypical cases, perform diagnostic joint aspiration

Confirm suspicion of OA

Exclude other diagnoses (gout, pseudogout, septic arthritis)

Reserve MRI to evaluate for internal derangement

Joint locking or giving way


Tailor management to the individual patient

What is the overall therapeutic approach to OA?

Diminish joint pain, enhance functional capacity

Don’t define treatment rigidly by radiographic findings

Modify treatment according to responses to therapy

Begin with nonpharmacologic, nonsurgical strategies

Including PT, OT, nutritionist

Offer pharmacologic agents if conservative efforts don’t improve function

Use surgery as a a last resort


Encourage participation in self-management programs

Information about the natural history of disease

Resources for social support

Instructions on coping skills

Support undertaking a new diet or exercise program

Patient education interventions show therapeutic benefit

How does education fit into the patient-physician discussion?


Absolutely!

Encourage weight loss through diet and exercise

Can help alleviate OA symptoms if overweight or obese

Is weight loss part of the treatment plan for knee OA?


What is the role of exercise in the management of OA of the knee or hip?

Increases aerobic capacity, muscle strength, endurance

Facilitates weight loss

Individualize exercise programs

To improve adherence, seek an exercise the patient enjoys

Encourage low-impact aerobic exercise (walking, biking)

Discourage high velocity / high impact exercise (running)


PT can improve joint biomechanics with knee or hip OA

Active and passive ROM exercise

Muscle strengthening

Improve alignment

Joint-protection principles

When should clinicians prescribe physical and occupational therapy?

OT is a key resource in management of OA of the hand

ROM exercises

Joint protection instruction

Splinting of the first carpometacarpal joint


For knee or hip OA

Cane or walker can improve gait & mobility, diminish pain

Cane transfers body weight away from the structurally compromised osteoarthritic limb

Instruction in proper use of a cane is warranted

Is there a role for assistive devices?

For hand OA

Large-grip utensils, writing instruments, key holders

Reduce force across arthritic fingers and base of thumb

Enhance the gripping motion and reduce pain


Knee OA with predominant unilateral involvement

Consider an unloading brace and lateral shoe wedges

Transfers load from the narrowed to the more open knee compartment

Alleviates knee pain

But evidence for these measures is conflicting

What is the role of lateral-wedge insoles?


Which analgesic agents should clinicians prescribe first?

Acetaminophen in doses up to 4 g/day

Comparable efficacy to NSAIDs but with safer GI profile

Add NSAIDs or substitute with them if response is inadequate

NSAIDs

Common 1st-line Rx, but routine use has disadvantages

Significant potential toxicity, particularly in the elderly

Toxicity contributes to hospitalizations and deaths

Prescribe COX-2-selective and nonselective NSAIDs with caution in light of concern regarding CV risk


When are topical analgesics useful?

Topical NSAIDs

Maximizes local delivery and minimizes systemic toxicity

Good first-line agent to avoid systemic therapy

Minimal side effects (local rash, itching, burning)

Topical capsaicin

Active ingredient of chili peppers

Modulates nociceptive fibers


When are intra-articular glucocorticoids or hyaluronic acid indicated?

Knee OA

Improve pain and function in the context of knee OA

Benefit is short-term (about 1 wk)

Intra-articular steroids

Don’t use more than once every 4 months

Repeated use can cause cartilage and joint damage

Hyaluronic acid injection

High-molecular-weight polysaccharide in the extracellular matrix of connective tissue

Symptomatic benefit equivalent to arthrocentesis


What is the role of glucosamine-chondroitin and acupuncture?

Glucosamine and chondroitin

Symptom-modifying effect is similar to placebo

Potential structure-modifying benefits are uncertain

Acupuncture

May relieve pain and improve function

But data are equivocal


When should clinicians consider joint lavage, debridement, or joint replacement?

When symptoms are refractory to medical therapy

Debilitating pain

Major functional limitations (walking, working, sleeping)

Joint lavage or arthroscopic debridement

No role in OA

Joint replacement

No clear standards for who gets joint replacement

Consider for patients with moderate to severe symptoms after adequate trial of conservative therapy


CLINICAL BOTTOM LINE: Treatment…

Goal: alleviate pain and improve functional capacity

Nonpharmacologic treatments Weight loss and exercise Physical therapy, occupational therapy

Pharmaceutical options If conservative efforts dont improve function First-line: acetaminophen for mild pain NSAIDs: use caution due to potential side effects

Surgery Reserve for advanced disease When symptoms don’t respond to medical therapy

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