Osteoarthritis

Osteoarthritis is one of the most common degenerative conditions that comes with aging and almost every clinician comes across in day to day practice.The slideshow helps in understanding the approach to a patient with OA before planning a surgical intervention

1. Osteoarthritis Non Operative Management SHRIYANS JAIN

2. Osteoarthritis

3. Osteoarthritis Measurement Scales Western Ontario and McMaster Osteoarthritis Index (WOMAC) (**) Questionnaire with twenty four questions about pain, function, and stiffness Visual Analogue Scale 100 mm long line with descriptive words (no pain / worst pain ever felt) on either side Lequesne Index Questionnaire 11 questions that ask about the patient’s symptoms and functional ability (**) – More reliable than the other two scales

4. OA is a condition which progresses slowly over a period of many years and cannot be cured Treatment is directed at decreasing the symptoms of the condition, and slowing the progress of the condition Functional treatment goals: Limit pain Increase range of motion Increase muscle strength OA – Disease Management

5. Treatment overview

6. Patient education Self-management programs Weight loss (if overweight or obese) Aerobic exercise programs Physical therapy Muscle-strengthening exercises Assistive devices for ambulation Patellar taping Appropriate footwear Medial-wedged insoles (for genu valgum ) Bracing Occupational therapy Joint protection and energy conservation Assistive devices for activities of daily living Pharmacologic intervention Surgical intervention Therapeutic Advances in Musculoskeletal Diseases 1: 35-47

7. Lifestyle Modification Lifestyle modifications can include losing weight, switching from running or jumping exercises to swimming or cycling , and minimizing activities such as climbing stairs . Simple weight loss can reduce stress on weight bearing joints, such as the knee. Exercise Exercises can help increase range of motion and flexibility as well as help strengthen the muscles in the leg. Physical therapy and exercise are often effective in reducing pain and improving function. Supportive Devices Using supportive devices, such as a cane, wearing energy-absorbing shoes or inserts can be helpful. Knee braces may be especially helpful if the arthritis is centered on one side of the knee. There are two types of braces that are often used. An " unloader " brace shifts load away from the affected portion of the knee. A " support " brace helps support the entire knee load . Other Methods Other measures may include applications of heat or ice, water exercises, liniments or elastic bandages.

8. Pharmacotherapy The goals of pharmacotherapy in osteoarthritis are to reduce morbidity and to prevent complications Analgesics ( others ) Nonsteroidal anti-inflammatory drugs (NSAIDs), oral and topical Intra- articular corticosteroids Intra- articular sodium hyaluronate Opioids Duloxetine Muscle relaxants Nutriceuticals ( eg , glucosamine/ chondroitin sulfate)

9. Acetaminophen is the drug of choice for patients who have a documented hypersensitivity to aspirin or NSAIDs, who have a history of upper gastrointestinal (GI) tract disease, or who are on anticoagulants. NSAIDs ( Ibuprofen, Piroxicam , Diclofenac , Naproxem , Celecoxib ) have analgesic, anti-inflammatory, and antipyretic activities. They are used to relieve osteoarthritis pain when the clinical response to acetaminophen is unsatisfactory. The mechanism of action is nonselective inhibition of cyclooxygenase (COX)-1 and COX-2, resulting in reduced synthesis of prostaglandins and thromboxanes . In more inflammatory presentations of osteoarthritis, such as knee involvement with effusion , these agents may be used as first-line pharmacologic therapy . Use the lowest effective dose or intermittent therapy if symptoms are intermittent. All of these medications increase the risk for GI ulcers and have been associated with increased risk of cardiovascular disease . Patients at high risk for GI toxicity may consider adding misoprostol or a proton-pump inhibitor to the regimen or substituting a COX-2–specific inhibitor for the NSAID The selective serotonin- norepinephrine reuptake inhibitor (SNRI) Duloxetine may be effective for reducing osteoarthritis pain

10. Topical analgesics Used for osteoarthritis involving relatively superficial joints, such as the knee joint and the joints of the hands. They are much less effective for deeper joints , such as the hip joint.  Capsaicin is a topical analgesic of choice in osteoarthritis. Derived from plants of the Solanaceae family, it may render skin and joints insensitive to pain by depleting substance P in peripheral sensory neurons. Capsaicin must be used for at least 2 weeks for the full effects to be appreciated. Opioids They are a particularly reasonable choice in patients who do not want joint-replacement surgery, are too medically ill for joint replacement, are not candidates for joint replacement for other reasons, or are trying to buy time for subsequent joint-replacement surgery. Tramadol Tramadol inhibits ascending pain pathways, altering perception of and response to pain. Oxycodone Pure narcotic analgesics, such as oxycodone , might be the initial drug of choice. Eventually, this short-acting narcotic can be replaced with a long-acting transdermal preparation, such as fentanyl ( Duragesic patch).

11. Corticosteroids Intra- articular pharmacologic therapy includes corticosteroid injection and viscosupplementation . Steroid injections generally result in a clinically and statistically significant reduction in osteoarthritic knee pain as soon as 1 week after injection. The effect may last, on average, anywhere from 4 to 6 weeks per injection, but the benefit is unlikely to continue beyond that time frame . Methylprednisolone ( Depo-Medrol , Medrol , Solu-Medrol )   Betamethasone ( Celestone Soluspan )   Triamcinolone ( Aristospan Intra- Articular )   Intra- articular agents Injections of these agents are used to treat patients with osteoarthritic knee pain that is unresponsive to conservative nonpharmacologic therapy and simple analgesics ( eg , acetaminophen ). Sodium hyaluronate Sodium hyaluronate is a hyaluronic acid derivative that supports the lubricating and shock-absorbing properties of articular cartilage.

12. Glucosamine and Chondroitin Glucosamine and chondroitin sulfate are oral supplements may relieve the pain of osteoarthritis. These are two large molecules that are found in the cartilage of our joints. Supplements sold over-the-counter are usually made from synthetic or animal products . Other therapies TENS applied in conjunction with therapeutic exercise and daily activities increased quadriceps activation and function in patients with tibiofemoral osteoarthritis . Pulsed electromagnetic field stimulation is believed to act at the level of articular cartilage by maintaining the proteoglycan composition of chondrocytes through downregulation of its turnover .   The use of a highly optimized, capacitively coupled, pulsed electrical stimulus device yielded significant symptomatic and functional improvement Tai chi ( slow, rhythmic, meditative movements designed to help you find peace and calm )   is a potentially effective treatment for pain associated with osteoarthritis of the knee

13. Recommended Guidelines : Key Updates to 2013 OARSI Guidelines: Topical NSAIDs are recommended as appropriate for all patients with knee-only OA and in a scientific review, were found overall to be safer and better tolerated compared to oral NSAIDs. The prescription drug duloxetine was evaluated for the first time and found to be an appropriate treatment for knee-only OA patients without comorbidities and all multi-joint OA patients. Due to increased safety concerns about toxicity, acetaminophen/ paracetamol was given an “uncertain” recommendation for all patients with comorbidities .

14. Oral and transdermal opioid painkillers were given an “uncertain” recommendation for all patient groups due to concerns about increased risks for adverse and serious adverse events. Glucosamine and chondroitin were both found to be “not appropriate” for all patients when used for disease modification and “uncertain” for all patients when used for symptom relief. Balneotherapy , defined as using baths containing thermal mineral waters, was evaluated for the first time and found to be an appropriate therapy for patients with multi-joint OA and comorbidities , as this group has few other treatment options.

15. Knee OA Prevention

16. Prevention: The time is now Injury Lifetime risk of knee OA is 57% among persons with a history of prior knee injury, and specific injuries, such as anterior cruciate ligament (ACL) ruptures and ankle fractures, have been clearly linked to incident OA. Arthritis Rheum, 2008;59(9):1207-1213. Neuromuscular conditioning programs have demonstrated effectiveness in reducing the risk of ACL injury by 60%. Am J Sports med, 2006;34(3):490-8. Obesity Promote policies, initiatives and state and national partnerships to help all young people achieve and maintain a healthy weight, thereby potentially reducing their risk for developing OA. http://www.surgeongeneral.gov/topics/obesity/ The National Public Health Agenda for Osteoarthritis. Combined action of AF and CDC.

17. GAIT MODIFICATION APPROACHES TOE-OUT GAIT Walking with a toe-out gait—that is, with the foot externally rotated with respect to the direction of progression (Figure 3)—reduces the knee adduction moment in patients with medial knee OA. With respect to the long-term influence of toe-out gait, an increased baseline toe-out angle was associated with a reduced likelihood of disease progression in patients with medial knee OA over an 18-month follow-up period. LATERAL TRUNK LEAN In individuals who lean towards the side of the weight-bearing limb as they walk, the body's center of mass shifts laterally and moves closer to the center of pressure under the weight-bearing foot. As the ground reaction force tends to act through the center of mass, this approach changes the angle of the ground reaction force, shifting it towards the knee joint center. The outcome of this shift is a reduction in the moment arm of the ground reaction force that, in turn, reduces the knee adduction moment GAIT RETRAINING Gait modification approaches have been advocated to reduce the knee adduction moment and delay the progression of knee joint OA.[72-74] For example, the medial thrust gait pattern involves consciously pushing the knee joint in a medial direction during walking, which repositions the knee joint center closer to the ground reaction force, thus reducing the moment arm and lowering the knee adduction moment

18. GAIT RETRAINING Gait modification approaches have been advocated to reduce the knee adduction moment and delay the progression of knee joint OA. For example, the medial thrust gait pattern involves consciously pushing the knee joint in a medial direction during walking, which repositions the knee joint center closer to the ground reaction force, thus reducing the moment arm and lowering the knee adduction moment FOOTWEAR INTERVENTIONS I nterestingly, peak knee adduction moments while walking barefoot were similar to those measured in patients wearing flat walking shoes and 'flip-flops' . These two types of footwear have thinner and more flexible soles than the thick-soled, supportive, 'stability shoes' . Such footwear might enable increased foot flexibility in a manner similar to that of barefoot walking. Thin-soled, flexible shoes seem to be beneficial for reducing knee joint loads compared with shoes with thicker soles . Despite appearing counterintuitive, shoes with thick soles actually seem to increase joint loading at the medial tibiofemoral compartment, whereas shoes with thin soles are associated with reduced knee adduction loading. FLEXIBLE SHOES VERSUS STABILITY SHOES

19. LATERAL WEDGE INSOLES Lateral wedge insoles (that is, a wedge inclined along the outside of the foot) have been suggested as an intervention strategy to reduce the knee adduction moment during walking and attenuate the progression of medial knee OA. In patients with OA, the use of lateral wedge insoles of between 5° and 15° inclination reduced peak knee adduction moments by between 4% and 14% during walking compared with the corresponding values either without insoles or wearing even-thickness control insoles. The use of lateral wedge insoles also led to immediate reductions in pain during walking. VARIABLE-STIFFNESS SHOES 'Variable-stiffness' shoes with increased lateral stiffness have been tested as an alternative to lateral wedge insoles. Variable-stiffness shoes considerably reduced the peak knee adduction moment during walking (by up to 6%) in patients with OA compared with constant-stiffness control shoes.

20. VALGUS KNEE BRACES Knee braces can be adjusted to increase the extent of valgus alignment, which also increases the valgus moment applied at the knee joint. The peak net knee adduction moment progressively decreased with increasing valgus alignment of the knee brace. A neutrally aligned knee brace reduced the peak net knee adduction moment by 6% compared with the unbraced situation, whereas valgus brace alignments of 4° and 8° yielded reductions of 13% and 19%, respectively. The net knee adduction moment in a patient wearing a valgus brace is calculated as the external knee adduction moment minus the valgus moment exerted by the knee brace. Valgu s knee braces secured around the thigh and lower leg and worn throughout the day have been suggested as a conservative treatment strategy for patients with medial knee OA