Transcript Osteoarthritis

Osteoarthritis
Helping the Elderly Maintain Function and Mobility
Cathryn Caton, MD, MS
Objectives
Define Osteoarthritis
 Define scope of problem
 Review potential causes
 Describe associated symptoms
 Review diagnostic criteria
 Review treatment options
 Review interventions/skills

Definition

Degenerative arthritis or degenerative
joint disease

Mechanical abnormalities
◦ Degradation of the joints
 Articular cartilage
 Subchondral bone
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
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
Symptoms

Most common are
◦ Pain
 Worse with exercise and weight bearing
◦ Stiffness

Over time rubbing grating crackling

Morning stiffness (~30mins)
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
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
Treatment

Goals of treatment are
◦ Pain relief
◦ Improvement or maintenance of functional
status
Treatment – Lifestyle Changes

Weight loss –
◦ through exercise and a calorie-restricted diet
◦ 24% improvement in physical function
◦ 30% decrease in knee pain
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
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

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
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
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
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
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
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
Drug
Dose
Frequency
ADE/Monitoring
acetaminophen
325-500 mg
Q4-6 hours
(Most effective when
dosed around the clock)
Max of 3g/day
Liver toxicity
NSAIDS
Varying
Varying
GI and renal toxicities
GI prophylaxis in patients:
>75, hx of bleed, PUD, warfarin
use, long-term steroid use
Tramadol
50-100 mg
Q 4-6 hours
Sedation
Dose reduction required for
CrCl <30 mL/min
Capsaicin
0.1% cream
Apply QID
Burning, erythema
Should not be applied to broken
skin.
Wash hands thoroughly after
use.
Diclofenac topical
2 grams-Hand
4 grams-Knee
Apply QID
6% systemic absorption
Should not be used with oral
NSAID therapy.
Treatment – Surgical Intervention
After conservative therapy
 Durable pain relief
 Functional improvement
 Improve quality of life
 Risk of complications

◦ Increases with age
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
ACOVE Interventions

As part of this ACOVE you will learn how
to quickly do a functional assessment
ACOVE Interventions
ACOVE Interventions
ACOVE Interventions
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.

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 Acad Orthop Surg. Sep 2009;17(9):591-600.
Hunter DJ. In the clinic Osteoarthritis. Ann Intern Med. Aug 2007;147(3):ITC8-1-ITC8-16.