Non-Surgical Management of Osteoarthritis Marc Wahlquist, M.D. TriHealth Orthopedic and Sports Institute

Goals of this lecture Help you understand what is osteoarthritis Discuss different ways that arthritis can be treated without surgery Give you ideas as to what you can do on your own to treat arthritis Answer any questions you may have

What is osteoarthritis Osteoarthritis is the “wear and tear” type arthritis The articular cartilage at the ends of our bones develops fissures or cracks over time and eventually thins and wears away Osteoarthritis is the loss of articular cartilage It is different than rheumatoid arthritis or psoriatic arthritis or septic arthritis or arthritis as a result of dysplasia or growth abnormalities

X-ray findings for arthritis Joint space narrowing, as the cartilage thins the bones get closer together Periarticular osteophytes (the dreaded bone spurs). As the bone underneath the cartilage sees more stress then it stimulates abnormal bone growth in the form of bone spurs Subchondral sclerosis. The bone exposed by the loss of cartilage becomes more dense and hardened. It then shows up brighter on the X-ray Subchondral cyst formation. As arthritis progresses the joint produces more fluid. This fluid can leak into the bone itself and form cysts under the bone

Clinical symptoms of arthritis Pain localized to the affected joint For hip arthritis pain is typically localized to the groin For knee arthritis is depends on which side of the joint is affected, medial or lateral Pain that is worse with weight bearing and improved with rest Joint swelling Grinding or crunching in joint Start up stiffness Occasionally patients will have night time aches and pains

Clinical signs of arthritis Tenderness localized to the affected joint It should not radiate to other parts of the body Joint swelling Joint stiffness or contracture Joint deformity (bowlegged or knock-kneed)

Treatment options Physical therapy Goals are to increase and maintain current function and prevent further worsening of the condition Range of motion exercises; gentle stretching can help prevent contractures, and active ROM helps provide nutrition to the cartilage Strengthening exercises (use it or lose it) A muscle at complete rest will lose strength at 3% a day Several controlled trials have shown improvement in function, pain and strength with strength training compared to controls Isometric exercises are less likely to produce inflammation and pain

Treatment options Weight loss The knee experiences 4x the body weight with every step It makes sense that weight reduction would result in improved knee symptoms, although that hasn’t been proven conclusively Diet in combination with exercise has been shown to improve knee pain and function compared to diet alone and exercise alone Weight loss has been shown to decrease operative risks when it comes to joint replacement

Treatment options Bracing A simple elastic knee brace can provide support to the knee and improve symptoms Cheap with little side effects More complicated hinged braces specific for arthritis are “unloader” braces. These try to shift the load from the arthritic part of the knee to the part of the knee with intact cartilage These have been shown to be helpful in reducing pain and increasing function But they are only effective when actually worn on the knee

Education Having an understanding of the disease process and its natural history or clinical course can help patients make effective lifestyle changes and allows them to have some control of their condition Several studies have shown that patient education can decrease arthritic pain

Acetaminophen Tylenol Non-narcotic pain medication Works on central nervous system but, exactly how it helps reduce pain is poorly understood Generally safe at doses below 4 grams/day Higher doses combined with alcohol can lead to permanent liver and kidney damage

Non-steroidal anti-inflammatory drugs Blocks the COX enzyme that is present in normal tissues COX-1 plays a role in GI mucosal defense, renal perfusion and platelet aggregation COX-2 appears in areas of inflammation and injury Most NSAIDs on market are non-selective, meaning the work on both enzymes These are drugs like Ibuprofen, Naprosyn, Diclofenac, etc. COX-2 specific drugs like Celebrex are supposed to avoid the GI side effects of the nonspecific COX inhibitors but, they may have unwanted increased risk of cardiac or kidney problems

Steroid injections Has been around since the 1950’s Very common treatment for arthritic in the clinic Despite its frequent use, clinical trails have not been overwhelming in its favor Can be beneficial in the short term – typically 4-12 weeks The risks are infection (vary rare), steroid flare (also rare and resolves in 1-3 days), temporary elevation of blood sugar in diabetics, facial flushing and hot flashes Should not be given too close together. In my clinical practice I don’t give them any closer together than three months in the same joint You should rest for a day or two after the injection

Hyaluronic acid (HA) Plays a role in the viscosity of joint fluid Arthritic joints have fluid which is very thin Injections of HA are thought to help better lubricate the joint. The exact mechanism of action is still not clear Several different brands are available with differing preparations and molecular weights Some are one injection, other brands are 3-5 injections given weekly

Hyaluronic acid (HA) These are only FDA approved for knee arthritis No clear evidence supports one brand over another In fact, no clear evidence really supports the use of any of them But recent studies seem to suggest that those preparations with higher molecular weights like Synvisc, GelOne, and potentially Euflexxa may be more beneficial. I tell patients that about 60% of patients will notice an improvement in their symptoms There are expensive – about $700 to $1000

Glucosamine Natural building block of cartilage Most preparations are derived from crustacean shells, but there are some that are derived from bovine cartilage Seems to increase joint production of hyaluronic acid Has been used in animals for many years Few side effects

Chondroitin Another building block of cartilage As we age the concentration of chondroitin in the cartilage decreases May be chondroprotective In one study comparing chondroitin to an NSAID – the patients noticed more rapid improvement with NSAID but, had slower more significant response to chondroitin Well tolerated with few side effects

Glucosamine/Chondroitin Combo Seem to work synergistically In one study with an animal model, there was more improvement with the combination than either one alone While they have been extensively studied and used in Europe, they have not been shown to be effective here in the US The reason may be, in Europe it is a regulated drug; whereas in the US it is considered a nutraceutical and so it isn’t regulated very well The AAOS which governs orthopedics in the US has come out with a “strong” recommendation against using GC

Methylsulfonylmethane MSM This is a newer nutritional supplement Again, in Europe the studies are very much in favor of using MSM in combination with GS/C In the US recent studies have not shown such a dramatic effect No studies show any significant side effects

Thank you. Questions?