Osteoarthritis

1. Osteoarthritis Helping the Elderly Maintain Function and Mobility Cathryn Caton, MD, MS

2. Objectives • Define Osteoarthritis • Define scope of problem • Review potential causes • Describe associated symptoms • Review diagnostic criteria • Review treatment options • Review interventions/skills

3. Definition • Degenerative arthritis or degenerative joint disease • Mechanical abnormalities • Degradation of the joints • Articular cartilage • Subchondral bone

4. Why do we care? • Most prevalent form of arthritis in US • Affects 50 – 80% of people >65 • Responsible for ½ of all disabilities • Associated with • Pain • Functional disability • Being homebound

5. Potential Causes • Aging • Wear and tear • Bony spurs or formation of extra bone • Weakening and stiffening of ligaments and muscles around the joint • Being overweight • Fractures or other joint injuries • Jobs • Playing sports • Bleeding disorders that cause bleeding into joints • Disorders that block blood supply to the joint • Gout, pseudogout, or RA

6. Symptoms • Most common are • Pain • Worse with exercise and weight bearing • Stiffness • Over time rubbing grating crackling • Morning stiffness (~30mins)

7. Making the Diagnosis • Physical Exam • Crepitation • Joint swelling – bones around joints may feel larger than normal • Limited Range of Motion • Tenderness to palpation • Normal movement often results in pain

8. Making the Diagnosis • Radiographs • Insensitive to early pathologic features • Absence of findings does not r/o symptomatic disease • Presence of findings does not guarantee that OA is the cause of patient’s current pain – • peri-articular sources including pes anserine bursitis or trochanteric bursitis • Loss of joint space • Wearing down of the ends of bone and bone spur formation in advanced cases • No available blood tests to aid diagnosis

9. Treatment • Goals of treatment are • Pain relief • Improvement or maintenance of functional status

10. Treatment – Lifestyle Changes • Weight loss – • through exercise and a calorie-restricted diet • 24% improvement in physical function • 30% decrease in knee pain

11. Treatment – Lifestyle Changes • Exercise • Encourage patients to do something they enjoy • Low-impact aerobic exercise program • Walking, biking or swimming • Quadriceps strengthening exercises • Avoid high-velocity impact • Running and step aerobics

12. Treatment – Physical Therapy • Refer if patients do not seem to be obtaining maximum benefit from their own exercise program • Improve muscle strength and motion of stiff joints and balance • If no benefit after 6-8 weeks then likely to not work • Range of motion, joint protection instruction and splinting

13. Treatment - Devices • Cane useful in patients with persistent ambulatory pain from hip or knee OA • Self-reported higher functional ability • Increased ablility to perform more functional tasks • Splints or braces support weakened joints • If used incorrectly, may result in worsening of symptoms

14. Treatment - Medications • Acetaminophen • < 3 g/day • AGS, ACR and others recommend as first line analgesic • Less effective overall on pain than NSAIDs • Similar efficacy to NSAIDs on improvements in functional status

15. Treatment - Medications • NSAIDs • More effective than acetaminophen • More GI and Renal Toxicities • 2.2 to 5.4 greater risk of various adverse GI events • Risk estimates for Renal events 1.6 to 4.1 and 2.1 to 8.8 in CKD patients • If at high risk for bleeding then use PPI • Age >75 • Peptic Ulcer Disease • h/o GI bleeding • Warfarin use • Chronic steroid use Tramadol is an option for patients with a contraindication for NSAIDs

16. Treatment - Medications • Topicals may help with symptomatic relief • Capsaicin • 0.1% cream, applied QID • May cause burning, erythema • Diclofenac topical • 2 grams – Hand • 4 grams – Knees • Applied QID; 6% systemic absorption; should not be used with oral NSAID therapy

17. Treatment - Medications • Steroid Injections • Reduces swelling and pain • Useful for short-term relief • 1 -2 weeks • Improves pain and function • Do not use more frequently than Q 4 months • Repeated use can cause cartilage and joint damage • Results in disease progression

18. Treatment – Medications • Glucosamine and Chondroitin • Meta-analyses show that symptom modifying effect similar to placebo • Structure modifying benefits are not clear • AAOS clinical practice guideline recommend against prescribing

20. Treatment – Surgical Intervention • After conservative therapy • Durable pain relief • Functional improvement • Improve quality of life • Risk of complications • Increases with age

21. Treatment – Surgical Intervention • Total Knee Replacement • Average age 65 years • After 4 years, nearly 90% had good to excellent outcome • After 5 years • 75% had no pain • 20% had mild pain • 3.7% had moderate pain • 1.3% had severe pain

22. ACOVE Interventions • As part of this ACOVE you will learn how to quickly do a functional assessment

23. ACOVE Interventions

24. ACOVE Interventions

25. ACOVE Interventions

26. References • 1. A.D.A.M. Medical Encyclopedia. Osteoarthritis. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001460/. Accessed May 30, 2012. • 2. Diseases NIoAaMaS. What is Osteoarthritis? [Web Site]. 2010; http://www.niams.nih.gov/Health_Info/Osteoarthritis/osteoarthritis_ff.pdf. Accessed May 30, 2012. • 3. Hunter DJ. In the clinic Osteoarthritis. Ann Intern Med. Aug 2007;147(3):ITC8-1-ITC8-16. • 4. MacLean CH, Pencharz JN, Saag KG. Quality indicators for the care of osteoarthritis in vulnerable elders. J Am Geriatr Soc. Oct 2007;55 Suppl 2:S383-391. • 5. Quality AfHRa. Managing Osteoarthritis: Helping the Elderly Maintain Function and Mobility. In: Research CfOaE, ed. Rockville, MD: AHRQ; 2002. • 6. Richmond J, Hunter D, Irrgang J, et al. Treatment of Osteoarthritis of the knee (nonarthroplasty). J Am AcadOrthop Surg. Sep 2009;17(9):591-600.