Evidence Based Medicine: Treatment of Osteoarthritis.

1. Evidence Based Medicine:Treatment of Osteoarthritis. Kenneth D. Kleist, M.D. Joint Replacement and Knee Arthroscopy HealthPartners Medical Group St. Paul, MN

2. Basic Tenets of OA Care • Treatment should be tailored to the patient • The relationship between the healthcare team and the patient should be a two-way process • Patient education has a significant impact on pain management and patient satisfaction • Treatment should be a combination of non-pharmacological and pharmacological measures • It is likely that each individual patient will have to try a number of management options before finding the combination which works best for them

3. Patient Education and Lifestyle Modification Rehabilitation/Physical Therapy Complementary Care and Alternative Therapies Pain Relievers Intra-articular injections SOURCES AAOS – 2008 ARHQ –2006 - 2007 EULAR - 2005 ACR – 2000 Cochrane Library Evidence Based, Patient Centered Care

4. Levels of Evidence

5. Patient Education and Lifestyle Modification • Participation in self-management programs (II,B) • Education Programs such as the arthritis foundation • Studies suggest that education is around 20% as effective as NSAIDs, and can have a synergistic effect with other treatments • Promote healthy activities and management • Walking instead of running • Regular visits related to the osteoarthritis (IV,C) • Weight Management (I,A) • BMI > 25 should be encouraged to lose 5% body weight and maintain the new weight • I would add assistive devices here

6. Does Weight Loss Really Matter? • For a woman of normal height, weight loss of only 5kg reduces the risk of OA by more than 50%. • Changing BMI Category • e.g. obese to overweight, or overweight to normal weight, could prevent 33% of OA in women and 20% in men. Felson et al: Annals of Internal Medicine 1992 Data from the Framingham Study

7. Rehabilitation • Participation in low impact aerobic fitness (I,A) • ROM/Flexibility Exercise Program (V,C) • Quadriceps Strengthening Program (II,B) • Patellar Taping (II,B) • +/- Unloader Bracing (V/II,inconclusive) • DO NOT use lateral heel wedges (II,B)

8. Exercise Prescriptions • Kenneth D. Kleist, M.D. • Name: Baby Boomer • Hip/Knee ROM • Lower Extremity Strength-focus on Quadriceps and Pelvifemoral Strength • Proprioception/balance training

9. Complementary Care and Alternative Therapies • DO NOT prescribe Glucosamine and/or Chondroitin sulfate (I,A) • No scientific evidence • +/- Acupuncture (I,inconclusive) • I would add in aromatherapy, music therapy, massage, tai chi, Reiki, etc into this category • No Evidence Based Data on supplements

10. Pain Relievers • Unless contraindications one of below (II,B) • Acetaminophen • NSAIDs • Increased GI risk: Age > 65, PUD, concurrent corticosteroids, anticoagulant usage • Acetaminophen • Topical NSAIDs • Non-selective NSAID + GI protective • Cox-2 inhibitor • Narcotics • Poor choice due to chronicity of disease

11. Intra-articular Injections • Corticosteroids for short-term relief (II,B) • Cannot Recommend for or against Hyaluronic Acids(I/II, Inconclusive)

12. Footnotes on Surgery • Arthroscopy is NOT recommended for debridement and lavage (I/II, A/B) • Arthroscopy may be an option for those with OA and primary signs and symptoms of a loose body or meniscus tear(V,C)

13. So what do we do now? • Do a good History and Physical Examination. • Individualize treatment to the Patient. • Encourage Patient Involvement • Non-pharmacologic therapy is the hallmark of treatment for Osteoarthritis. • Exercise is always good…it’s the type that needs to be carefully determined. • Medication therapy is adjunctive. • Set appropriate expectations throughout • Surgery when quality of life continues to deteriorate despite appropriate care

14. American Academy of Orthopaedic SurgeonsP.O. Box 1998Des Plaines, IL 60017847–823–7186 or800–824–BONE (2663) (free of charge)Fax: 847–823–8125www.aaos.org American Association of Hip and Knee Surgeons 6300 N. River Road, Suite 615Rosemont, IL 60018-4237Telephone: (847)698-1200Fax: (847)698-0704Email helpdesk@aahks.org www.aahks.org United States Bone and Joint Decade, NFP (USBJD)  6300 North River Road  Rosemont, IL 60018  Phone: 847.384.4010  Fax: 847.823.0536  Email: usbjd@usbjd.org www.usbjd.org National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)National Institutes of Health1 AMS CircleBethesda, MD 20892–3675Phone: 301–495–4484 or877–22–NIAMS (226–4267) (free of charge)TTY: 301–565–2966Fax: 301–718–6366E-mail: NIAMSInfo@mail.nih.govwww.niams.nih.gov NIH Osteoporosis and Related Bone Diseases ~National Resource Center 2 AMS CircleBethesda, MD 20892-3676Phone: 202–223–0344 or 800–624–BONETTY: 202–466–4315Fax: 202–293–2356www.niams.nih.gov/bone American College of Rheumatology1800 Century Place, Suite 250Atlanta, GA 30345Phone: 404–633–3777Fax: 404–633–1870www.rheumatology.org American Physical Therapy Association1111 North Fairfax StreetAlexandria, VA 22314–1488Phone: 703–684–2782 or800–999–APTA (2782) (free of charge)Fax: 703–684–7343www.apta.org Agency for Healthcare Research and Quality Agency for Healthcare Research and QualityOffice of Communications and Knowledge Transfer540 Gaither Road, Suite 2000Rockville, MD 20850. (301) 427-1364. www.ahrq.gov Arthritis Foundation P.O. Box 7669Atlanta, GA 30357-0669 www.arthritis.org Website Resources Available

15. Save Your KneesOnline Portal Media Launch saveyourknees.org

16. www.aaos.org/facebook Get Up! Get Out! Get Moving!Let’s Exercise Now! Facebook Application

17. Top 10 Patient FAQs…and their Answers • Is there anything that can regrow cartilage or reverse arthritis? • Can’t you just clean up the knee with arthroscopy? Several studies have shown that arthroscopic debridement and lavage is not effective for treatment of OA.

18. Top 10 Patient FAQs…and their Answers • Is there anything that can regrow cartilage or reverse arthritis? • Can’t you just clean up the knee with arthroscopy? • How Many Cortisone shots can I get and how often? There is no maximum lifetime dosage, but injection should be spaced apart about 3 to 4 months because too many injections close together can soften the remaining cartilage.

19. Top 10 Patient FAQs…and their Answers • Is there anything that can regrow cartilage or reverse arthritis? • Can’t you just clean up the knee with arthroscopy? • How Many Cortisone shots can I get and how often? • How will I know when I am ready for joint replacement? Most people reach a point where their quality of life is diminished enough that they know it is time. Other indicators can include loss of sleep, constant pain, inability to do typical activities of daily living, or failure of pain relief options that had been previously working.

20. Top 10 Patient FAQs…and their Answers • Is there anything that can regrow cartilage or reverse arthritis? • Can’t you just clean up the knee with arthroscopy? • How Many Cortisone shots can I get and how often? • How will I know when I am ready for joint replacement? • How long is the recovery for joint replacement? Recovery from joint replacement is highly variable among individuals. A lot depends on age, health, preoperative function. On average most people will be 85% recovered by 3 months after surgery. Most people will return to a sitting job by 4-6 weeks maximum and a standing, walking, active job by 2 months, but again this is highly variable.

21. Top 10 Patient FAQs…and their Answers • Is there anything that can regrow cartilage or reverse arthritis? • Can’t you just clean up the knee with arthroscopy? • How Many Cortisone shots can I get and how often? • How will I know when I am ready for joint replacement? • How long is the recovery for joint replacement? • What is the likelihood I will improve with joint replacement? On average 85% of people say they would have knee or hip replacement again.

22. Top 10 Patient FAQs…and their Answers • Is there anything that can regrow cartilage or reverse arthritis? • Can’t you just clean up the knee with arthroscopy? • How Many Cortisone shots can I get and how often? • How will I know when I am ready for joint replacement? • How long is the recovery for joint replacement? • What is the likelihood I will improve with joint replacement? • How long do joint replacements last? Knee 15-20 years, Hip 10-15 years conservatively. Factors such as weight, age, and activity level play a large role.

23. Top 10 Patient FAQs…and their Answers • Is there anything that can regrow cartilage or reverse arthritis? • Can’t you just clean up the knee with arthroscopy? • How Many Cortisone shots can I get and how often? • How will I know when I am ready for joint replacement? • How long is the recovery for joint replacement? • What is the likelihood I will improve with joint replacement? • How long do joint replacements last? • What types of activity can I do after joint replacement? There is no evidence based research to show what you can safely do. I recommend low impact exercise. Avoidance of high impact activities. In general golf, swimming, biking, walking, hiking, skating, and cross country skiing appear to be safe activities.

24. Top 10 Patient FAQs…and their Answers • Is there anything that can regrow cartilage or reverse arthritis? • Can’t you just clean up the knee with arthroscopy? • How Many Cortisone shots can I get and how often? • How will I know when I am ready for joint replacement? • How long is the recovery for joint replacement? • What is the likelihood I will improve with joint replacement? • How long do joint replacements last? • What types of activity can I do after joint replacement? • Am I a candidate for minimally invasive surgery? Minimally invasive surgery is an option for everyone, but what that is can vary from person to person. No study has confirmed any long term benefit of minimally invasive surgery functionally. The most important thing to you as a patient is to get the pieces placed in the appropriate position so you can a have good long term function of your joint replacement.

25. Top 10 Patient FAQs…and their Answers • Is there anything that can regrow cartilage or reverse arthritis? • Can’t you just clean up the knee with arthroscopy? • How Many Cortisone shots can I get and how often? • How will I know when I am ready for joint replacement? • How long is the recovery for joint replacement? • What is the likelihood I will improve with joint replacement? • How long do joint replacements last? • What types of activity can I do after joint replacement? • Am I a candidate for minimally invasive surgery? • Why did I get arthritis? Arthritis is due to multifactorial influences. Factors that are known to contribute are weight, trauma, genetics, activity level, and diet.

26. Thank You!