Knee Osteoarthritis for the Primary Care...

Knee Osteoarthritis for the Primary Care Physician SCOTT ANNETT, MD PRIMARY CARE SPORTS MEDICINE APRIL 22ND, 2016

Objectives

1. Describe the clinical course of knee osteoarthritis.

2. Formulate a patient-centered and evidence-based treatment plan.

3. Focus on issues of particular importance to the primary care physician, such as prevention, therapeutic lifestyle changes, and health maintenance.

“The weakest and oldest among us can become some kind of athlete, but only the strongest can survive as spectators. Only the hardiest can survive the perils of inertia, inactivity and immobility.”

What is OA?

Usually a progressive disease of synovial joints that represents failed repair of joint damage from stress

This results in breakdown of cartilage and bone, leading to symptoms of pain, stiffness, and functional disability.

This may occur as result of biomechanical, biochemical, and/or genetic factors.

This may be localized to a single joint, a few joints, or generalized.

Initiating factors likely vary amongst different joints

This complexity and variability of OA suggests the need for patient-specific, etiology-based treatments.

The Burden of Knee Osteoarthritis

27 million Americans affected

Leading cause of disability in the US for those over 65 years old (7 million)

Prevalence Knee OA 9.5% of those aged 55 and over

By 2030: Estimated 20% population, 6 fold increase in TKR’s; obesity, baby-boomers

Indirect and direct costs of knee OA in the US equal $100 billion annually

www.medicographia.com

Risk Factors

Age >50 years old

Female Gender

First-degree Family member with Osteoarthritis

History of Major Injury to the Joint

Previous Surgery to the Joint

Overweight/Obesity

Job requiring bending or carrying

www.bumrungrad.com

Signs and Symptoms

• Pain • Stiffness • Swelling • Reduced range of motion • Weakness • Deformity

www.webMD.com

Diagnostic Workup

History, Physical Exam

Labs? ESR/CRP, RF studies, joint fluid analysis

Plain films- preferably weight bearing

MRI- usually not needed

www.aafp.org

XR Staging of Knee Osteoarthritis

www.drjohnbradway.com

www.Euflexxa.com

Natural History of Knee OA

Arthritis Rheum. 1995 Oct;38(10):1500-5.

The incidence and natural history of knee osteoarthritis in the elderly. The Framingham Osteoarthritis Study.

Felson DT1, Zhang Y, Hannan MT, Naimark A, Weissman BN, Aliabadi P, Levy D.

Mean 8.1 year follow up of >1000 surviving subjects, mean age 71 2% per year radiographic disease

1% per year symptomatic disease

4% per year progressive knee osteoarthritis

Management of Knee OA

“We do not treat groups, we treat individuals.”

Conservative Management Options

Exercise

Nutrition and Supplements

Pharmacologic Options (NSAIDs and Tylenol)

Intra-articular corticosteroids

Intra-articular hyaluronic acid

Bracing and orthotics

Exercise and Knee OA

“The major challenge many physicians face is how to get their patients with OA moving. There’s currently very little empirical evidence defining what type of exercise is best or most effective for relieving OA symptoms.”

Pennstatehersheyorthoreport.com

What we know

Activity Decreases bone loss, promotes healthy cartilage

Increases physical function

Decreases pain and joint fatigue

Psychological benefits, improving depression

Prevention and delay of arthritis onset and symptoms

Top10md.com

Exercise Recommendations

50 minutes of moderate-intensity aerobic exercise per week

OR

75 minutes of vigorous-intensity aerobic exercise per week

OR

an equivalent combination of moderate and vigorous exercise

The MOVE Consensus: Evidence-based Guidelines (2005)

Strengthening and aerobic exercises can both reduce pain and improve function (1B)

A program that has a general aerobic fitness component and more local strength training is ideal (4)

This should be patient centered and individualized (4)

Advice and education to promote a positive lifestyle change (1B) Lifestyle Medicine Initiative; motivational interviewing

Medscape.org

The MOVE Consensus: Contraindications (4)

Hypertrophic Cardiomyopathy

Severe aortic stenosis

Acute Febrile Illness

Acute viral illnesses, myocarditis

Exercise-induced cardiac arrhythmias

Unstable cardiac symptoms

Slideshare.net

The MOVE Consensus

Group and home exercise programs have been shown to be equally effective patient preference (1A)

Adherence to regimen is important predictor of long term results (1B)

Strategies to improve and maintain adherence should be adopted, e.g. long-term monitoring/review and inclusion of spouse/family in exercise (1B- exercise)

Effectiveness of exercise is independent on severity of radiographs (4)

Improvements in strength and proprioception may halt progression (4)

Where have we come in the last 10 years?

Impact of Exercise Type and Dose on Pain and Disability in Knee Osteoarthritis: A Systematic Review and Meta-Regression Analysis of Randomized Controlled Trials

Arthritis and Rheumatology 2014 Meta-analysis of 48 randomized control trials, >4000 patients

Optimal exercise programs for knee OA should have one aim and focus

on improving aerobic capacity, quadriceps muscle strength, or lower extremity performance.

In patients with poor aerobic capacity and muscle strength, aerobic exercise and strength training should be performed on different days in order to achieve the best effect.

For best results, the program should be supervised, carried out 3 times weekly, and comprise at least 12 sessions.

Such programs have similar effects regardless of patient characteristics, including radiographic severity of OA.

Exercise for osteoarthritis of the knee: a Cochrane systematic review. British Journal Sports Medicine 2015

54 RCT’s, >5000 patients High-quality evidence suggests that land-based therapeutic exercise provides

benefit in terms of reduced knee pain and improved quality of life and moderate-quality evidence of improved physical function among people with knee osteoarthritis.

It can be assured that any type of exercise program that is performed regularly and is closely monitored can improve pain, physical function and quality of life related to knee OA in the short term.

The magnitude of immediate treatment effects of exercise on pain and physical function increases with the number of face-to-face contact occasions with the healthcare professional.

High-intensity versus low-intensity physical activity or exercise in people with hip or knee osteoarthritis.

Cochrane Database 2015 6 RCT’s, >650 patients

We found very low-quality to low-quality evidence for no important

clinical benefit of high-intensity compared to low-intensity exercise programs in improving pain and physical function in the short term.

There was insufficient evidence to determine the effect of different types of intensity of exercise programs.

Land-based versus aquatic therapy

Small study, data presented at AMSSM 2013 Patients were randomly assigned to exercise using an underwater

treadmill, a regular treadmill, or an upright stationary cycle for thirty minutes, three times per week for eight weeks.

Patients were allowed to continue their regular oral or topical analgesic treatments for OA.

About 80 percent of the water treadmill patients experienced clinically significant OA symptom improvement versus about 60 percent of patients in the other exercise groups.

More water treadmill patients stuck with the regimen and completed the study

Aquatic exercise for the treatment of knee and hip osteoarthritis. Cochrane Systematic Review 2016

13 RCT’s, nearly 1200 patients

Moderate quality evidence that aquatic exercise may have small, short-term, and clinically relevant effects on patient-reported pain, disability, and quality of life in people with knee and hip OA.

Exercise.lovetoknow.com

General Exercise Recommendations

Start with range of motion exercises and isometric strengthening Anwer and Alghadir. “Effect of Isometric Quadriceps Exercise on Muscle Strength, Pain,

and Function in Patients with Knee Osteoarthritis: A Randomized Controlled Study.” J Phys Ther Sci. 2014 May; 26(5): 745–748.

If active inflammation, advanced knee OA, profound functional impairment, this may be your mainstay

Low impact exercises (recumbent bike), aquatic therapy may be better for those with severe knee OA or deconditioning

Avoid excessive stair climbing. Running ok for some

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General Exercise Recommendations

Both aerobic and strength exercises can reduce pain and improve function; any type of exercise program will help

Fight obesity, lose weight; Lifestyle medicine

Get to know your patients; advice and education, give them best chance of success; HEP, YMCA, physical therapy adherence

See them back; long term follow up and accountability

Treat the patient, not the Xray.

Supervised PT probably offers the most contact with health care professional.

Unknown if low or high intensity programs offer best results

Medschool-motivation.tumblr.com

What if I don’t want to exercise?

Theodysseyonline.com

Supplements- Glucosamine and Chondroitin

Multicenter, double-blind, placebo- and celecoxib-controlled Glucosamine/chondroitin Arthritis Intervention Trial (GAIT)

New England Journal of Medicine 2006. the combination of glucosamine and chondroitin sulfate may be

effective in the subgroup of patients with moderate-to-severe knee pain.

People with osteoarthritis who take glucosamine: may reduce their pain

may improve their physical function

will probably not have side effects

Walmart.com

Pharma for Knee OA

Comparative Effectiveness of Pharmacologic Interventions for Knee Osteoarthritis: A Systematic Review and Network Meta-analysis

Annals of Internal Medicine 2015 137 randomized trials of adults with knee OA

comparing 2 or more of the following: acetaminophen, diclofenac, ibuprofen, naproxen, celecoxib, intra-articular (IA) corticosteroids, IA hyaluronic acid, oral placebo, and IA placebo.

For pain, all outperformed oral placebo with effect sizes from 0.18 to 0.63.

Viewpoints.com

Northiowatoday.com

Healthtap.com

Drugsdetails.com

Lookpainsolutions.com

Rxstars.net

IA Corticosteroids

Intra-articular corticosteroid for knee osteoarthritis Cochrane Database Systematic Review, 2015 27 trials, >1700 participants

“Whether there are clinically important benefits after

one to six weeks remains unclear.”

www.rheumatologynetwork.com

IA Hyaluronic Acid

AMSSM News Release BJSM, January 2016 Meta-analysis 11 papers, using OMERACT-

OARSI criteria 15% more likely to respond versus IA-steroids,

and 11% more likely than IA-placebo For Grades 2 and 3 Kellgren and Lawrence

knee osteoarthritis, high quality data supporting use of hyaluronic acid in those age >60 years old

Moderate quality data in those < 60 years old

Bracing and orthotics

“Braces and Orthoses for treating osteoarthritis of the knee.”

Cochrane Database 2015

• Low‐quality evidence suggests that people with OA who use a knee brace may have little or no reduction in pain, improved knee function and improved quality of life.

• Moderate‐quality evidence suggests that people with OA of the knee who wear laterally wedged insoles or neutral insoles probably have little or no improvement in pain, function and stiffness.

Breg Fusion

Thebracingexperts.com

Osteoarthritisblog.com

Surgical Management

Bionicreporter.staradvertiserblogs.com

Arthroscopy, with or without debridement, typically not recommended.

Total Knee Arthroplasty recommended when patient has failed conservative measures and their osteoarthritis has impacted their quality of life.

1% per year failure rate = 90-95% chance will last 10 years, 80-85% chance will last 20 years

Nonsurgical Candidates

Pain management Opiod-based pain options

Radiofrequency Treatment

Questions?

Dogonews.com

References

Lohmander, S. “Knee replacement for osteoarthritis: facts, hopes, and fears.” Medicographia. 2013;35:181-188. http://www.medicographia.com/2013/10/knee-replacement-for-osteoarthritis-facts-hopes-and-fears/

Felson DT1, Zhang Y, Hannan MT, Naimark A, Weissman BN, Aliabadi P, Levy D. “The incidence and natural history of knee osteoarthritis in the elderly. The Framingham Osteoarthritis Study. Arthritis Rheum.” 1995 Oct;38(10):1500-5

Duivenvoorden T, Brouwer RW, van Raaij TM, Verhagen AP, Verhaar JAN, Bierma‐Zeinstra SMA. “Braces and orthoses for treating osteoarthritis of the knee.” Cochrane Database of Systematic Reviews 2015, Issue 3. Art. No.: CD004020. DOI: 10.1002/14651858.CD004020.pub3

Trojian TH, Concoff AL, Joy SM, Hatzenbuehler JR, Saulsberry WJ, Coleman CI. “AMSSM scientific statement concerning viscosupplementation injections for knee osteoarthritis: importance for individual patient outcomes.” Br J Sports Med. 2016 Jan;50(2):84-92. doi: 10.1136/bjsports-2015-095683

Jüni P, Hari R, Rutjes AW, Fischer R, Silletta MG, Reichenbach S, da Costa BR. “Intra-articular corticosteroid for knee osteoarthritis.” Cochrane Database Syst Rev. 2015 Oct 22;10:CD005328. doi: 10.1002/14651858.CD005328.pub3

Raveendhara R. Bannuru, MD; Christopher H. Schmid, PhD; David M. Kent, MD; Elizaveta E. Vaysbrot, MD; John B. Wong, MD; and Timothy E. McAlindon, MD. “Comparative Effectiveness of Pharmacologic Interventions for Knee Osteoarthritis: A Systematic Review and Network Meta-analysis.” Ann Intern Med. 2015;162(1):46-54. doi:10.7326/M14-1231

References Clegg et al. “Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis.” N

Engl J Med. 2006 Feb 23;354(8):795-808

Silvis M, Sylvester J, Hacken B, et al. “Comparison of the Underwater Treadmill, Land Based Treadmill, and Exercise Cycle on Patient Reported Symptoms of Knee Osteoarthritis.” Presented at the Annual meeting of the American Medical Society for Sports Medicine, April 17-21, 2013, San Diego, CA

Roddy et al. “Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or knee—the MOVE consensus.” Rheumatology (2005), 44(1):67-73

Juhl, C., Christensen, R., Roos, E. M., Zhang, W. and Lund, H. “Impact of Exercise Type and Dose on Pain and Disability in Knee Osteoarthritis: A Systematic Review and Meta-Regression Analysis of Randomized Controlled Trials.” Arthritis & Rheumatology (2014), 66: 622–636. doi: 10.1002/art.38290

Bartels EM1, Juhl CB, Christensen R, Hagen KB, Danneskiold-Samsøe B, Dagfinrud H, Lund H. “Aquatic exercise for the treatment of knee and hip osteoarthritis.” Cochrane Database Syst Rev. 2016 Mar 23;3:CD005523. doi: 10.1002/14651858.CD005523.pub3

References

Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M1, Bennell KL. “Exercise for osteoarthritis of the knee: a Cochrane systematic review.” Br J Sports Med. 2015 Dec;49(24):1554-7. doi: 10.1136/bjsports-2015-095424. Epub 2015 Sep 24

Regnaux JP1, Lefevre-Colau MM, Trinquart L, Nguyen C, Boutron I, Brosseau L, Ravaud P. “High-intensity versus low-intensity physical activity or exercise in people with hip or knee osteoarthritis.” Cochrane Database Syst Rev. 2015 Oct 29;10:CD010203. doi: 10.1002/14651858.CD010203.pub2