gross management of osteoarthritis fileosteoarthritis pathology • osteoarthritis is driven by

Management of Osteoarthritis: From the Periphery to the Spine

Andrew J Gross, MD

Associate Professor of Medicine

UCSF Rheumatology Clinic Director

Director of UCSF Rheumatology Clinical Programs

Disclosures

• None

Osteoarthritis Pathology• Osteoarthritis is driven by

interactions between cartilage, synovial tissue and subchondral bone.

• Biomechanical changes to the joint lead to cartilage damage

• Ineffective cartilage repair processes lead to production of tissue‐destructive proteinases that results in death of chondrocytes and breakdown of extracellular matrix

• This leads to changes in the subchondral bone with edema (seen on MRI) osteophyte formation, bone remodeling, and subchondral sclerosis

Bijlsma JW, et al. Lancet 2011, PMID 21684382

Sites Most Commonly Involved in Osteoarthritis

Risk factors for Osteoarthritis

• Age

• Female sex (but only after age 50 – post‐menopausal)

• Obesity (for knee and hip OA)

• Genetics (family clustering)

• Repetitive Joint Use (prolonged standing for hip OA) but not low‐moderate distance running

Johnson VL & Hunter DJ. Best Pract Res Clin Rheumatol 2014, PMID 24792942Spector TD & MacGregor AJ. Osteoarthritis and Cartilage 2004

Estimated heritability of osteoarthritis at different sites

A conceptual model of OA

Roos, E. M. & Arden, N. K. Nat. Rev. Rheumatol. 2015 doi:10.1038/nrrheum.2015.135

Diagnosis of Knee Osteoarthritis

In order to diagnose knee osteoarthritis one must obtain x‐rays and/or laboratory testing

True

False

Diagnosis of Knee Osteoarthritis

The classic criteria for the diagnosis of osteoarthritis of the knee are based upon the presence of knee pain AND at least 3 of the following six clinical characteristics:

• Greater than 50 years of age

• Morning stiffness for less than 30 minutes

• Crepitus

• Bony tenderness

• Bony enlargement

• No palpable warmth

96% sensitive and 69% specific for osteoarthritis

X‐rays not always needed to make diagnosis of OA

• Insensitive in mild to moderate disease

Altman R. Arthritis Rheum 1986, PMID 3741515

Altman R. Arthritis Rheum 1986, PMID 3741515

Knee Osteoarthritis: Radiologic features

• Osteophytes

• Joint Space Narrowing

• Subchondral sclerosis

• Subchondral cysts

• Joint deformity

TIP: Weight bearing films can better assess the degree of cartilage loss

Kellgren, Annals of Rheum Dis., 1957

MRI for evaluation of Knee Osteoarthritis

A 69 year old man returns to see you for worsening pain in hip right knee. You have previously diagnosed him with osteoarthritis based on symptoms as well as x‐rays showing moderate medial compartment joint space narrowing and presence of osteophytes. The patient requests you order an MRI. Which of the following symptoms predict a condition that would MRI would be helpful to diagnose:

A. Worsening knee pain

B. Acute knee swelling

C. Frequent episodes where the knee gives way (buckles)

D. Frequent episodes where the knee gets stuck (locked) in a flexed position

Utility of MRI for evaluation of Knee Osteoarthritis

A 69 year old man returns to see you for worsening pain in hip right knee. You have previously diagnosed him with osteoarthritis based on symptoms as well as x‐rays showing moderate medial compartment joint space narrowing and presence of osteophytes. The patient requests you order an MRI. Which of the following symptoms predict a condition that would MRI would be helpful to diagnose:

A. Worsening knee pain

B. Acute knee swelling

C. Frequent episodes where the knee gives way (buckles)

D. Frequent episodes where the knee gets stuck (locked) in a flexed position


• Presence of bone marrow lesions associated with fluctuation in knee pain (Zhang et al, A&R, 2011; 63)

• MRI is not helpful to predict optimal timing for arthroplasty

• Many MRI abnormalities may be nonspecific

>50% of normal adults without radiographic OA with OA‐type abnormalities on MRI (Guermazi et

al., BMJ; 2012)


• Patients with symptomatic osteoarthritis of the knee frequently also have meniscal tears; but tears not associated with worse symptoms or dysfunction. (Bhattacharyya T, J Bone Joint Surg Am. 2003, PMID 12533565)

• Arthroscopic Debridement is ineffective for reducing pain in patients with osteoarthritis and meniscal tears (Moseley JB, et al. NEJM 2002, PMID 12110735)

• No clear benefit for meniscal tear repair v. PT (Katz J, et al. NEJM 2013)

• Arthroscopic Surgery can be effective for managing locking symptoms from loose bodies

Non‐pharmacologic treatmentof knee (and hip) osteoarthritis

American College of Rheumatology 2012

Guidelines

Hochberg MC, et al. Arthritis Care Res 2012,

PMID 22563589 www.rheumatology.org

American College of Rheumatology 2012 Guidelines

Hochberg MC, et al. Arthritis Care Res 2012

PMID 22563589 www.rheumatology.org Roos, E. M. & Arden, N. K. Nat. Rev. Rheumatol. 2015 doi:10.1038/nrrheum.2015.135

Exercise for knee osteoarthritis

• Aerobic exercise - improve cardiovascular fitness• Strength training - increase muscle strength & muscle mass• Neuromuscular exercise - improve sensorimotor control

and joint stabilization

Assistive Devices for Knee Osteoarthritis

A 73‐year‐old man with osteoarthritis of left knee comes to see you. He has tried a number of analgesics with limited benefit. He does not want arthroplasty. You appropriately advise him to reduce weight‐bearing on the knee by using a cane. What is the appropriate length of the cane and how should the patient use it?

A) Hold cane in the right hand, with top of the cane at the distal wrist crease, with the elbow straight when cane is planted; move the cane forward at the same time as the right leg.

B) Hold cane in the right hand, with top of the cane at the distal wrist crease, with the elbow at 30 degrees flexion, move the cane forward at the same time as the left leg.

C) Hold cane in the left hand, with top of the cane at the greater trochanter, with the elbow straight when the cane is planted, move the cane forward at the same time as the left leg.

Assistive Devices for Knee Osteoarthritis

A 73‐year‐old man with osteoarthritis of left knee comes to see you. He has tried a number of analgesics with limited benefit. He does not want arthroplasty. You appropriately advise him to reduce weight‐bearing on the knee by using a cane. What is the appropriate length of the cane and how should the patient use it?

A) Hold cane in the right hand, with top of the cane at the distal wrist crease, with the elbow straight when cane is planted; move the cane forward at the same time as the right leg.

B) Hold cane in the right hand, with top of the cane at the distal wrist crease, with the elbow at 30 degrees flexion, move the cane forward at the same time as the left leg.

C) Hold cane in the left hand, with top of the cane at the greater trochanter, with the elbow straight when the cane is planted, move the cane forward at the same time as the left leg.

Cane use: medial knee unloading

• Cane held in the contralateral hand to the affected knee (or hip)

• Cane height to distal wrist crease

• Elbow flexed to 30 degrees

• Move cane forward with the contralateral knee to unload

Pharmacologic Management of Knee Osteoarthritis




Recommendations are similar for

hip osteoarthritis except no role for topical agents

Acetaminophen for OsteoarthritisCochrane review of 15 RCTs involving 5986 participants

• 7 RCTs compared acetaminophen to placebo– acetaminophen was superior to placebo in five of the seven RCTs

– Acetaminophen led to significant reduction in pain, but only by 4 points on a 0‐100 scale (questionable clinical significance)

– Acetaminophen had a similar safety profile to placebo

– The NNT to achieve an improvement in pain ranged from 4 to 16

• 10 RCTs compared acetaminophen to NSAIDs

– NSAIDs were probably more effective than acetaminophen to reduce pain and improve function

– 19% of patients in the traditional NSAID group versus 13% in the acetaminophen group experienced an adverse GI event.

Conclusion: In OA subjects with moderate‐to‐severe levels of pain, NSAIDs appear to be more effective than acetaminophen

Towheed TE, et al. Cochrane Database Syst Rev 2006, PMID 16437479

Naproxen is more effective for knee osteoarthritis than acetaminophen

• 2 year double blind study of acetaminophen vs. naproxen

• Patients treated with naproxen were less likely to withdraw from the study due to lack of efficacy.

• No difference in reduction of pain

• Naproxen lead to slightly better function

• More side effects from naproxen ‐almost 3x more withdrawing from GI distress in the naproxen group

•Naproxen 375 mg twice daily

oAcetaminophen 650 mg 4x/day

Williams HJ, et al. Arthritis Rheum 1993

NSAID management of Osteoarthritis

Which of the following is a risk factor for complications from treatment with NSAIDs:

A. Age >65

B. History of MI

C. History of GI bleeding

D. High Dose NSAID therapy

E. Concurrent use of anticoagulation or corticosteroids or low dose aspirin

F. All of the above

NSAID management of Osteoarthritis

Which of the following is a risk factor for complications from treatment with NSAIDs:

A. Age >65

B. History of MI

C. History of GI bleeding

D. High Dose NSAID therapy

E. Concurrent use of anticoagulation or corticosteroids or low dose aspirin

F. All of the above

Lanza FL, et al. Guidelines for prevention of NSAID‐related ulcer complications. Am J Gastroenterol 2009, PMID 19240698

NSAIDs: Preventing GI Side Effects

• Proton Pump Inhibitors & Misoprostol are effective at reducing NSAID induced peptic ulcers• Misoprostol 200 mcg 4x/day often causes

cramping and diarrhea. Lower doses (400–600mcg/day) are still protective and have less side effects

• Omeprazole 20 mg/d may be slightly more effective than misoprostol

(Lanza F, et al, Am J Gastroenterol 2009)

• COX‐2 specific inhibitor (celecoxib) may have less risk of causing lower GI bleeding then non‐selective NSAID + proton pump inhibitor (Chan et al, Lancet, 2010)

• All patients with history of peptic ulcer disease should be tested for H. pylori prior to starting NSAIDs. (Lanza F, et al, Am J Gastroenterol 2009)

Opioids for the management of Osteoarthritis

Two Meta‐analyses:

• Patients with osteoarthritis had improvement in pain and physical function from treatment with opioids although the effect size was relatively small (0.7 cm on a 10‐cm visual pain scale, 0.6 units on a disability 0‐10 scale – da Costa BR 2014).

• Adverse events often cause participants to stop taking the medication and limit opioid usefulness.

• The long‐term efficacy and safety of these drugs is undetermined

Avouac J, et al. Osteoarthritis Cartilage 2007, PMID 17398122da Costa BR, et al. Cochrane Database Syst Rev 2014, PMID 2522935

Papaver somniferum

Corticosteroid Injections for Knee Osteoarthritis

Cochrane Meta‐analysis

• Unclear if there are clinically important benefits after 1‐6 weeks

• An effect seems to decrease over time with no effect remaining after six months

• Adverse effects do not seem to be a problem

Self reported pain assessed by Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire (score range, 0‐100). 50 patients in each group, all participated in an exercise program

Henricken M, et al. JAMA Intern Med 2015, PMID 25822572

Peter J, et al. Cochrane Database Syst Rev 2015. PMID 26490760

Glucosamine/Chondroitin

Results of Glucosamine & Chrondroitin Sulfate studies are slightly conflicting and controversial

Most studies indicate no significant benefit in:

• Pain

• Function

• Joint Structure

Very few adverse effects GAIT Study: No significant reduction in pain or function (Clegg DO et al., NEJM, 2006)

Kwoh CK, et al. Arthritis Rheumatol 2014, PMID 24616448

Herbal Supplements for Osteoarthritis

• Boswellia serrata slightly improves pain and function

• Avocado‐soybean unsaponifiables (ASU) probably improves pain

• Data from other studies of other nutritional supplements is of to low quality to draw any conclusions.

• Herbal therapies may cause side effects. Risk is unclear

Oral herbal therapies for treating osteoarthritis, Cameron M, et al. 2014, DOI: 10.1002/14651858.CD002947.pub2

Arthroplasty for Knee Osteoarthritis

• Randomized, controlled trial of 100 patients with knee osteoarthritis

• Total knee replacement followed by nonsurgical treatment is more efficacious than nonsurgical treatment alone in providing pain relief and improving function and quality of life after 12 weeks

• However, clinically relevant improvements were noted in both groups, and patients who underwent total knee replacement had a higher number of serious adverse events.

Soren T, et al. New Engl J Med 2015, PMID 26488691

Knee Injury and Osteoarthritis Outcome Score subscales, covering pain, symptoms, activities of daily living, and quality of life (KOOS4)

What is the Optimal Timing to Refer for Arthroplasty?

Many studies have investigated who is most likely to benefit from arthroplasty, but no clear answers

Some key points:

• Worse pain & function prior to surgery predicts greater improvement following surgery

• More affected joints & comorbidities predicts less improvement from surgery (but these patients may have more to gain for quality of life)

• Preoperative exercise does not seem to improve outcomes following surgery (but does improve function while waiting for surgery)

Hawker GA, et al. Arthritis Rheum 2013, PMID 23459843Fortin PR, al al. Arthritis Rheum 2002, PMID 12483739Rooks DS, et al. Arthritis Rheum 2006, PMID 17013852

There is no simple test to determine who should undergo joint replacement

What is the Optimal Timing to Refer for Arthroplasty?

Finding the “sweet spot”

The ideal time for patients to undergo arthroplasty ‐“the optimal level of preoperative pain and functional limitation, is intimately intertwined with the definition of outcome. If we define success in terms of improvement, patients who wait longer until they are more limited and symptomatic will have a greater probability of a successful outcome. In contrast, if success is defined in terms of achieving an acceptable symptom state, patients with less pain and fewer limitations preoperatively will be more likely to have successful outcomes”

Losina E & Katz JN, Arthritis Rheum 2013, PMID 23460000

What is the Optimal Timing to Refer for Arthroplasty?Dialog between physician and patient may be the key

Mandl LA, Nat Rev Rheumatol 2013, PMID 23478495

Vicious Cycle of Acceptance in Osteoarthritis

Note: women are 2x less likely than men to be referred for arthroplasty by PCPs but are just as likely to benefit (Borkhoff CM, et al. CMAJ 2008)

Osteoarthritis of the Hands

Hand Osteoarthritis

DIP (Heberdon’s nodes)&

PIP (Bouchard’s nodes)

Base of Thumb OACarpal‐Metacarpal (CMC)(Trapeziometacarpal joint)

Myths about hand osteoarthritis

A 64 year old woman comes to your office with a number of questions about her arthritis. Which one of her understandings is CORRECT:

A. I avoid exercising because it can make my osteoarthritis worse

B. I sometimes crack my knuckles, but I do not think it makes my osteoarthritis worse.

C. Night‐shade vegetables can exacerbate my arthritis

D. Turmeric supplements can help my arthritis

E. There is nothing I can do for osteoarthritis

Myths about hand osteoarthritis

A 64 year old woman comes to your office with a number of questions about her arthritis. Which one of her understandings is CORRECT:

A. I avoid exercising because it can make my osteoarthritis worse

B. I sometimes crack my knuckles, but I do not think it makes my osteoarthritis worse.

C. Night‐shade vegetables can exacerbate my arthritis

D. Turmeric supplements can help my arthritis

E. There is nothing I can do for osteoarthritis

Knuckle cracking is not associated with hand OA

During an attempt to crack a knuckle, the joint is manipulated by axial distraction, hyperflexion, hyperextension, or lateral deviation. This lengthens part or all of the joint space and greatly decreases intra‐articular pressure, causing gases that have dissolved in the synovial fluid to form microscopic bubbles, which coalesce. When the joint space reaches its maximum distraction (up to 3 times its resting joint space distance), joint fluid rushes into the areas of negative pressure. The larger bubbles suddenly collapse into numerous microscopic bubbles, leading to the characteristic cracking sound. The maneuver leaves the joint space wider than it had been and synovial fluid more widely distributed. The stretching of joint ligaments required to produce the widened joint space also leaves the joint with greater range of motion.

Debeber K, et al. J Am Board Fam Med 2011, PMID 21383216Castellanos J, Axelrod D. Ann Rheum Dis 1990

Swezey RL, Swezey SE. West J Med 1975

Hand Osteoarthritis Management

Optimal management of hand OA requires a combination of non‐pharmacological & pharmacological treatment modalities

individualized to the patient’s requirements

Pharmacologic Management of Hand OA

You are seeing a 75 year old woman with moderate hand pain from osteoarthritis, particularly at the base of her right thumb, despite taking acetaminophen 1000 mg three times a day. She has a history of hypertension, a‐fib and stroke treated with warfarin. She sustained a hip fracture last year following a fall.

What is your first choice for management of hand OA

A. Capsaicin gel

B. Naproxen 500 mg twice a day

C. Intra‐articular corticosteroid injection

D. Tylenol with codeine four times a day

E. Prednisone taper

Pharmacologic Management of Hand OA

You are seeing a 75 year old woman with moderate hand pain from osteoarthritis, particularly at the base of her right thumb, despite taking acetaminophen 1000 mg three times a day. She has a history of hypertension, a‐fib and stroke treated with warfarin. She sustained a hip fracture last year following a fall.

What is your first choice for management of hand OA

A. Capsaicin gel

B. Naproxen 500 mg twice a day

C. Intra‐articular corticosteroid injection

D. Tylenol with codeine four times a day

E. Prednisone taper




Hand OA: Pharmacologic

– Topical capsaicin– Topical NSAIDs–Oral NSAIDs– Tramadol

–Opioid Analgesics– Intra‐articular injections

• Local treatments are preferred over systemic treatments, especially for mild to moderate pain and when only a few joints are affected. Topical NSAIDs and capsaicin are effective and safe treatments for hand OA

Less Optimal treatments

• SYSADOA (for example, glucosamine, chondroitin sulfate, avocado soybean unsaponifiables, diacerhein, intra‐articular hyaluronan) may give symptomatic benefit with low toxicity, but effect sizes are small, suitable patients are not defined and clinically relevant structure modification, and pharmacoeconomic benefits have not been established

• Intra‐articular injection of long‐acting corticosteroid might be effective for painful flares of OA, especially trapeziometacarpal joint OA.

• Surgery (for example, interposition arthroplasty, osteotomy or arthrodesis) is an effective treatment for severe thumb base OA and should be considered in patients with marked pain and/or disability when conservative treatments have failed

Hochberg MC, et al. Arthritis Care Res 2012, PMID 22563589 www.rheumatology.org

Anti‐Inflammatory Medicationsare Ineffective for Hand Osteoarthritis

Kloppenburg M. Nat Rev Rheumatol 2014, PMID 24468932

Non‐pharmacologic treatmentof hand osteoarthritis

Hand Therapy

All of the following are effective treatments for osteoarthritis that can be provided by hand therapists, EXCEPT:

A. Thumb splints to help osteoarthritis of the CMC joint

B. Exercises

C. Local application of heat (paraffin bath)

D. Education concerning joint protection (how to avoid adverse mechanical factors)

Hand Therapy

All of the following are effective treatments for osteoarthritis that can be provided by hand therapists, EXCEPT:

A. Thumb splints to help osteoarthritis of the CMC joint

B. Exercises

C. Local application of heat (paraffin bath)

D. Education concerning joint protection (how to avoid adverse mechanical factors)

Trick question: all are probably effective, but no data to indicate the use of heat application is effective

Hochberg MC, et al. Arthritis Care Res 2012, PMID 22563589. www.rheumatology.org

American College of Rheumatology 2012 GuidelinesBase of Thumb Osteoarthritis

Base of Thumb OATrapeziometacarpal joint

orCarpal‐Metacarpal (CMC)

Base of Thumb Splints

• Splints are used to support, stabilize, protect or immobilize a painful osteoarthritic.

• RCT study by Rannou et al demonstrated the use of the splint at night significantly decreased pain and hand disability compared with usual care at 1 year. There was no effect at 1 month and the splint had no effect on the radiographic progression of osteoarthritis.

• Avoid 24 hr use of splints due to muscle atrophy, and weakness.

Rannou F, et al. Ann Intern Med 2009, PMID 19451573

Exercises for Hand Osteoarthritis

1. Making a fist

2. Making a small fist (flexing the PIP and DIP joints only)

3. Flexing the MCP joints while keeping the PIP and DIP joints stretched

4. Touching the tip of each finger with the tip of the thumb while keeping each finger flexed

5. Spreading the fingers as far as possible with the hand lying flat on a table

6. Pushing each finger in the direction of the thumb with the hand lying flat on a table

7. Touching the MCP V joint with the tip of the thumb.

Exercises should be done 10 times daily with both hands.

Stamm TA, et al. Arthritis Rheum 2002, PMID 11932877

Exercises + Education for hand osteoarthritis

Clinical Trial: 30 minutes of education + 3 months of daily exercises at home lead to:

• 25% increase in grip strength

• Increase in patient global hand function compared with control participants

NNT = 2 (number needed to treat ‐ the average number of patients that need to be treated for one to benefit compared with a control)


JPE = joint protection & exercise

Principles of Hand Osteoarthritis Education

• Need for balance between movement and resting a joint

• Dividing stress between as many joints as possible

• Using larger and stronger joints

• Using each joint in its most stable plane to reduce pressure on the joint

• avoiding staying in one position

• Training to protect the joints using assistive devices if necessary to perform Activities of Daily Living (ADL).

Examples of activities that can be done in a protective way

• wringing a cloth

• using enlarged grips for writing

• opening jars, cans, or boxes with grips

• using a rocker or angled knife for cutting food.


Assistive Devices

• Assistive devices can help patients perform tasks and activities. These devices increase function and protect the joint from mechanical overloading. – rubber grips

– kitchen tools

– key turners

– zipper pulls

– Button hooks

• Assistive devices are best provided in association with education

www.arthritissupplies.com www.aidsforarthritis.com www.amazon.com

Lumbar Spine

Common Degenerative Changes to the Lumbar Spine

1. Degenerative Disc Disease

2. Facet joint hypertrophy3. Spondylolithesis4. (scoliosis – not shown)

Deyo RA, NEJM 2007, 17538083

Common Degenerative Changes to the Lumbar Spine

Deyo RA, NEJM 2007, 17538083

Conventional Diskectomy

Deyo RA, NEJM 2007, 17538083

Lumbar Spinal Fusion

Deyo RA, NEJM 2007, 17538083

Key points for lumbar spine osteoarthritis

• Corticosteroid injections are generally ineffective for back or neck pain

• Surgery is probably no more effective for treating back or neck pain than conservative therapy

• Surgery might be effective for radiculopathy although many patients will improve with conservative therapy

• Spinal stenosis can be effectively treated with surgery

References

• American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip and knee. Hochberg, et al. Arthritis Care Res 2012. PMID 22563589. www.rheumatology.org/Practice‐Quality/Clinical‐Support/Clinical‐Practice‐Guidelines

gross management of osteoarthritis fileosteoarthritis pathology • osteoarthritis is driven by

Documents