Osteoarthritis and Exercise

1. Osteoarthritis and Exercise Rochelle M. Nolte, MD CDR USPHS/USCG

2. Objectives Understand factors involved in the etiology and epidemiology of osteoarthritis Understand how exercise helps prevent osteoarthritis Understand how exercise is used in the treatment of osteoarthritis

3. Etiology of Osteoarthritis Disease of the synovial joints Primary changes of OA begin in the cartilage Most pronounced in load bearing areas of articular cartilage Fibrocartilaginous repair is inferior to original hyaline cartilage Other tissues affected include: subchondral bone, synovium, meniscus, ligaments, muscle

4. Etiology of Osteoarthritis Articular cartilage is composed of: Proteoglycans Provide compressive stiffness and ability to withstand load Collagen Provides tensile strength and resistance to shear

5. Etiology of osteoarthritis Articular cartilage (1-2 mm thick) Provides a smooth bearing surface With synovial fluid as a lubricant, the coefficient of friction for cartilage on cartilage is 15X lower than rubbing 2 ice cubes together Prevents the concentration of forces when bones are loaded

6. Etiology of Osteoarthritis Growth of cartilage and bone at the joint margins leads to osteophytes which can restrict movement Chronic synovitis and thickening of the joint capsule further restrict movement Periarticular muscle wasting is common and plays a major role in sx and disability

7. Symptoms of osteoarthritis PAIN (Articular cartilage is aneural) OA pain is not from the cartilage Stretching of nerve ending in periosteum covering osteophytes Microfractures in subchondral bone Stretching of joint capsule Synovitis Ligament stretching or muscle pain STIFFNESS (esp. after inactivity)

8. Physical exam findings of OA Bony or soft tissue swelling Bony crepitus Synovial effusions (usually small) Mild warmth Periarticular muscle atrophy Bony hypertrophy (advanced OA) Joint subluxation (advanced OA)

9. Laboratory findings in OA THERE ARE NO DIAGNOSTIC LAB TESTS FOR OSTEOARTHRITIS OA is not a systemic disease, therefore: ESR, Chem 7, CBC, and UA all WNL Synovial fluid Mild leukocytosis (<2000 WBC/microliter) Can be used to exclude gout, CPPD, or septic arthritis if diagnosis is in doubt

10. Radiology findings in OA Often great disparity between the severity of radiographic findings and severity of symptoms and functional ability 90% of people >40 have x-ray changes 30% are symptomatic During early OA radiographs may be normal

11. Radiology findings in OA Joint space narrowing may be earliest sign Secondary to loss of articular cartilage Subchondral sclerosis Subchondral cysts Osteophytes Change in joint contour secondary to bony remodeling and joint subluxation

12. Epidemiology of OA OA of the knee is the leading cause of chronic disability in the elderly in developed countries In patients over the age of 55: Hip OA is more common in men IP and 1st MCP OA is more common in women Knee OA (with sx) is more common in women

13. Epidemiology of OA In patients under the age of 55: Joint distribution of OA is equal between men and women Due to genetics or joint usage????? Mother and sister of a woman with DIP OA are 2 & 3 X more likely to have the same Racial differences in prevalence and pattern of joint involvement also point to genetic basis

14. Epidemiology of OA Age is the most powerful risk factor for OA Women < 45 years of age: 2% with OA Women 45-64: 30% with OA Women >65: 68% with OA

15. Epidemiology of OA There is no convincing data to support an association between nonspecific nonprofessional athletic activities and osteoarthritis (excluding major trauma) Neither long-distance running nor jogging has been shown to cause osteoarthritis

16. Epidemiology of OA Obesity is a risk factor for knee (and hand) osteoarthritis In the highest quintile of BMI Relative risk of developing OA in the next 36 years was 1.5 for men and 2.1 for women For SEVERE OA, the RR rose to 1.9 for men and 3.2 for women Weight loss of 5kg was associated with a 50% reduction in the odds of developing OA

17. Epidemiology of OA Disability in subjects with knee OA More strongly associated with QUADRICEPS WEAKNESS than with joint pain or radiographic severity Demographics associated with increased likelihood of being symptomatic: women, unemployed, divorced, poor social support

18. Risk factors for OA Age Sex Race Genetic factors Congenital defects Prior inflammatory joint disease Metabolic disorders Major joint trauma Repetitive stress Vocational Recreational Obesity

19. Risk factors for OA Systemic Age Gender Ethnicity Genetics Hormonal status Bone density Metabolic/nutritional status

20. Risk factors for OA Local Obesity Major trauma Joint deformity Physical disability Muscle weakness Occupational/sports stress

21. Prevention of OA Physiological effects of physical activity are most marked in those parts of the body that are used most during exercise Physical activity is the best way to ensure the maintenance of functional capacity Endurance-type activity using rhythmic movements of large muscle groups are the best studied

22. Prevention of OA Exercise reduces the pain and functional disturbance in OA of the knee (SOR A) Data insufficient for conclusions about the type of exercise that should be preferred Sudden overloading, incorrect joint loading, and various injuries predispose people to OA Preventing excessive wt gain helps

23. Prevention of OA Current studies Isokinetic exercise for improving knee flexor and extensor muscles in healthy adults to assess safety and effectiveness Will also assess in adults with neurological, orthopedic, and rheumatologic conditions

24. Management/Treatment of OA Goals Educate patient about disease and management Improve function Control pain Alter disease process and its consequences

25. Management/Treatment of OA No known cure for OA HOWEVER Impaired muscle function Reduced fitness Affect pain and dysfunction Are amenable to therapeutic exercise

26. Management/Treatment of OA Pharmacologic Acetaminophen NSAIDS Cox-2 specific inhibitors With PPI or misoprostol Nonacetylated salicylate Tramadol Opioids Topical Capsaicin Methylsalicylate NSAIDS Intra-articular Corticosteroids Hyaluronic acid

27. Treatment/Management of OA Pharmacologic Acetaminophen Grade A/Level I for short-term pain relief Pain decreased 4 points (100 point scale) compared to placebo Relatively inexpensive compared to NSAIDS Relatively safe compared to NSAIDS Usually studied in doses of 2-4 g/d Liver toxicity is major concern

28. Management/Treatment of OA Pharmacologic NSAIDS Grade A/Level I for short-term pain relief Shown to provide better pain control than acetaminophen, especially with more severe pain No difference in functional improvement Greater GI toxicity than acetaminophen No difference in efficacy among NSAIDS

29. Management/Treatment of OA Pharmacologic Tramadol Pain decreased 8.5 points compared to placebo 39 had minor side effects (18 with placebo) 21 had major side effects (8 with placebo) Opioids Grade B/ Level I for pain control in OA Must balance side effect profile for risk/benefit

30. Management/Treatment of OA Pharmacologic Topical Capsaicin Inconclusive evidence Topical NSAIDs + short-term pain relief in very limited short-term studies only compared to placebo. No studies comparing to PO medications

31. Management/Treatment of OA Pharmacologic Intra-articular steroids Grade A/Level I for short-term pain relief Intra-articular hyaluronic acid Grade A/Level I for short-term treatment

32. Treatment/Management of OA Pharmacologic Intraarticular corticosteroids Superior to placebo for pain control for 2-3 weeks At 4-24 weeks, no evidence of improvement in pain No evidence of improvement in function Hyaluronic acid More effective than corticosteroids 5-13 weeks post-injection (pain, ROM, function)

33. Treatment/Management of OA Pharmacologic Hyaluronic acid (HA) Better than placebo Comparable effectiveness to NSAIDs Fewer systemic adverse events More local reactions Longer-acting than IA steroids No major safety issues SOR B (76 heterogeneous trials)

34. Treatment/Management of OA Pharmacologic Herbal therapy Avocado soybean unsaponifiables (ASU�s) with promising results in 2 studies on: Functional index, pain, NSAID use, and global evaluation Reumalex (willow bark preparation) inconclusive Tipi tea inconclusive

35. Management/Treatment of OA Possible structure/disease modifying stuff Glucosamine Diacerein Cytokine inhibitors Cartilage repair Bisphosphonates Degradative enzyme inhibitors Tetracyclines, metalloproteinase inhibitors

36. Treatment/Management of OA Pharmacologic Glucosamine 20 studies with >2500 patients If only high quality studies evaluated: No benefit over placebo on pain If all studies included: Pain may improve by as much as 13 points 2 RCT�s using Rotta preparation: Demonstrated slowing of radiological progression of OA over a 3 year period

37. Treatment/Management of OA Pharmacologic Diacerein Pain improved 5 points compared to placebo Over 3 years, Slowed progress of OA in the hip compared to placebo Did not slow progress of OA in the knee Diarrhea is most common side effect 42 out of 100 had diarrhea in the first 2 weeks 18 discontinued because of side effects (13 in placebo)

38. Management/Treatment of OA Non-pharmacologic Patient education Self-management programs Weight loss PT/OT ROM exercises Muscle strengthening Non-pharmacologic Assistive devices Patellar taping Appropriate footwear Lateral-wedged insoles Bracing Joint protection and energy conservation

39. Management/Treatment of OA Non-pharmacologic (Exercise) Walking program v. control. Level I/Grade A (RCT n=1089) for improvement in: Pain Functional status Stride length Aerobic capacity Energy level Medication use Disability transferring from bed and bathing

40. Management/Treatment of OA Non-pharmacologic (Exercise) Whole-body functional exercise v. control. Level I/Grade A (RCT n=864) for: Pain Functional status Mobility Walking Work Disability in Activities of Daily Living (ADL�s)

41. Management/Treatment of OA Non-pharmacologic (Exercise) Home strengthening program for knee v. control. Level I/Grade A (controlled clinical trial n=81) for: Pain Functional status Energy level Range of motion (ROM) in flexion Other studies: group exercise program as effective as one-on-one

42. Management/Treatment of OA No differences between high and low intensity aerobic exercise in people with OA for: Functional status Pain Gait Aerobic capacity Therapeutic range (btwn suitable and excessive exercise) may be narrow in some patients

43. Management/Treatment of OA Non-pharmacologic (brace) study (SOR B) Valgus knee brace better than: Neoprene sleeve better than: Control group according to pain scale While score changes were statistically significant, clinical significance is questionable Study only lasted 6 months. <500 patients

44. Management/Treatment of OA Non-pharmacologic (insole) study (SOR B) Laterally wedged insoles may decrease knee OA pain Laterally wedged insoles decrease the amount of pain medication taken Pain decreased by one point (100 point scale) in laterally wedged insoles. Decreased by 5 points in neutrally wedged insoles. However, pain medication use decreased more in laterally wedged insole patients and patients wore the laterally wedged insoles for a longer period of time

45. Management/Treatment of OA Non-pharmacologic (exercise programs) Exercise programs improve health and function (SOR A) People tend to stick with a home exercise program more than exercising at a center (SOR B) The specific type of exercise that is best needs more research

46. Management/Treatment of OA Thermotherapy Heat had no benefit on swelling over cold or placebo Cold did not significantly improve pain Cold did slightly improve swelling Ice 20 min/d 5d/wk for 2 weeks did show improved muscle strength, ROM, and a decrease in time to walk 50 feet

47. Management/Treatment of OA Ultrasound was of no benefit for: Pain Range of motion Functional status

48. Treatment/Management of OA Transcutaneous electrical nerve stimulation (TENS) for knee OA Active and �acupuncture like� TENS for at least four weeks reduced pain and knee stiffness (SOR B) Electrical stimulation Showed improvement in measurements, but Clinical significance from the patient�s perspective is questionable

49. Treatment/Management of OA Surgery Valgus high tibial osteotomy (HTO) for treatment of medial compartment OA No study comparing HTO to conservative txment Partial knee replacement Total knee replacement Pre-op education only reduced hospital stay in patients with complex needs

50. Treatment/Management of OA Current studies Non-pharmacologic Aquatic exercise for the treatment of knee/hip OA Acupuncture for osteoarthritis Pharmacologic Chloroquines, HRT, chondroitin, homeopathy Opioids

51. Summary Non-pharmacologic therapy is important in the prevention and treatment of OA The best studied and most effective non-pharmacologic therapy is EXERCISE Exercise helps control weight, increase strength, improve and maintain function and decrease pain

52. Thank you for coming Questions?