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.Euflexxa.com www.drjohnbradway.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 moderatequality 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 lowintensity 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
www.youtube.com
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 Northiowatoday.com
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.
Viewpoints.com
Healthtap.com
Lookpainsolutions.com
For pain, all outperformed oral placebo with effect sizes from 0.18 to 0.63.
Drugsdetails.com
Rxstars.net
IA Corticosteroids
www.rheumatologynetwork.com
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.”
IA Hyaluronic Acid
AMSSM News Release
BJSM, January 2016
Meta-analysis 11 papers, using OMERACTOARSI 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 Osteoarthritisblog.com function and improved quality of life.
Breg Fusion
• 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. Thebracingexperts.com
Surgical Management
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
Bionicreporter.staradvertiserblogs.com
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;35:181188. 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/bjsports2015-095424. 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
