Osteoarthritis

Helping the Elderly Maintain Function and Mobility

Cathryn Caton, MD, MS

Objectives

Define OsteoarthritisDefine scope of problemReview potential causesDescribe associated symptomsReview diagnostic criteriaReview treatment optionsReview interventions/skills

DefinitionDegenerative 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

USAffects 50 – 80% of people >65Responsible for ½ of all

disabilitiesAssociated with

◦Pain◦Functional disability◦Being homebound

Potential CausesAgingWear and tear

◦ Bony spurs or formation of extra bone◦ Weakening and stiffening of ligaments and muscles

around the jointBeing overweightFractures or other joint injuriesJobsPlaying sportsBleeding disorders that cause bleeding into

jointsDisorders that block blood supply to the jointGout, pseudogout, or RA

SymptomsMost common are

◦Pain Worse with exercise and weight bearing

◦Stiffness

Over time rubbing grating crackling

Morning stiffness (~30mins)

Making the DiagnosisPhysical 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 DiagnosisRadiographs

◦ 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

TreatmentGoals 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 - DevicesCane 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 - MedicationsAcetaminophen

◦< 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 - MedicationsTopicals may help with symptomatic

reliefCapsaicin

◦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 - MedicationsSteroid 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 – MedicationsGlucosamine 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/dayLiver toxicity

NSAIDS Varying Varying GI and renal toxicitiesGI prophylaxis in patients:>75, hx of bleed, PUD, warfarin use, long-term steroid use

Tramadol 50-100 mg Q 4-6 hours SedationDose reduction required for CrCl <30 mL/min

Capsaicin 0.1% cream Apply QID Burning, erythemaShould not be applied to broken skin.Wash hands thoroughly after use.

Diclofenac topical 2 grams-Hand4 grams-Knee

Apply QID 6% systemic absorptionShould not be used with oral NSAID therapy.

Treatment – Surgical Intervention

After conservative therapyDurable pain reliefFunctional improvementImprove quality of lifeRisk 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. 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 Acad Orthop Surg. Sep 2009;17(9):591-600.