1. Management of Knee Osteoarthritis By: Dr Maryam Sahebari Assistant Prof. of Rheumatology Gaem Hospital

2. What is the problem? Pain Limitation of motions (cardiovascular risk,…) If inflammation adds: night pain Deformities (genuovarus, valgus, recurvatum) Falling risk Depression ….

3. Prevention is superior to treatment Life style modification (sitting, walking, sleeping, shoe wearing, exercise, nutrition,…) Weight control Deformity corrections

4. Treatment The management plan should be individualized, accounting for factors such as: sources of pain and extent of accompanying inflammatory factors

5. Treatment (source of pain) Most of the time some periarticular soft tissue swellings remains neglected as an important sources of knee pain: Anserine bursitis Radiated trocantheric bursitis Lumber radiculopathy Mood disorders and depression

9. Knee OA Treatment

10. Importance of weight reduction It is very very important for knee OA Loss of fat is more important than loss of total body weight Special program for weight loss in elderly people is mandatory Some of my experience in my weblog: http://Drshahebari.mihanblog.com

11. Body mass index and knee osteoarthritis risk: A dose- response meta-analysis Obesity, 2014 Evidence Based Medicine A non–linear dose–response association between BMI and risk of knee OA was significant (P=0.001).

12. treatment Treatment strategies according to PE results: If there is no deformity, only mechanical pain by severe physical activities,

13. Exercises Range of motion and strengthening exercises Exercises with low load effects: Swimming Bicycling Walking Tai Chi Which one is preferred?(isometric or isotonic) A systematic review showed both of them had moderate effects.

14. Treatment Physical activities:

15. Treatment (Temperature Modalities) Cold or warm? It depends on patient Warm applications for chronic pain: no more than 45 (0C), and 30 min Contraindicated in: poor vascular supply, neuropathy, cancer Benefits of Warm applications: decreased pain and stiffness, relief of muscle pain and spasm and contractures

16. Treatment (Orthotic and bracing) Lateral wedge: (medial compartment knee OA and genuovarous) Cane and walkers, rolling walkers

17. Immediate efficacy of laterally-wedged insoles with arch support on walking in persons with bilateral medial knee osteoarthritis Archives of Physical Medicine and Rehabilitation, 07/11/2014 However, ankle invertor moments were increased (p<0.05) when wearing LWAS. Brouwer R et al. Braces and orthoses for treating osteoarthritis of the knee. Cochrane Database Syst Rev Jan 25 (1), CD004020. (2005) They discussed the efficacy of braces and orthoses for treating OA of the knee. They concluded that laterally wedged insoles have small beneficial effect in knee OA.

18. physiotherapy Ultrasound therapy appears to have no proven benefit and not recommended as a therapeutic option.(UTD) TENS : several RCTs supported its small efficacy in pain reduction. Patellar taping: may be effective in pain reduction

19. physiotherapy The clinical effectiveness of magnets for people with osteoarthritis: A systematic review and meta-analysis Current Rheumatology Reviews, 02/17/2014 The findings indicated that magnets did not significantly reduce pain or medicine requirement nor enhanced function, joint proprioception or muscle strength compared to placebo (p>0.05).

20. Diet & nutrition Vit D, Vit C, VitE in observational cohort studies showed may be effective in the pain reduction and stopping progression but not in the development of OA, however …

21. Pharmacologic Therapy (Pain Reduction) Acetaminophen: Up to 3gr/d (a larg meta- analysis 2006: Acetaminophen is superior to placebo but less effective than NSAIDs in hip & knee OA) Opioids: Codeines for a short period of pain suppression, Tramadol: added to acetaminophen or alone: effective, especially in whom NSAIDs are not tolerated or contraindicated (EULAR & ACR)

22. Pharmacologic Therapy (Pain Reduction) NSAIDs: EULAR Rec: after enough acetaminophen therapy, ACR Rec: in some acetaminophen native patients with severe pain. What is important in choosing an NSAID: If there is CAD concern: Naproxen is the safest one If there is GI concern: Cox2 inhibitors are the best Ibuprofen has the most blocking effect on aspirin in ischemic heart disease

23. Pharmacologic Therapy (Pain Reduction) Topical NSAIDs: Diclofenac, Brofen(rabufen), salicylates Effective in knee or hand OA (enough dose, continuing therapy) short term effect in pain relief is approved by strong studies. Capsaicin: it is not a well tolerated drug, should be used 4 times a day at least for 2-3 weeks to start pain relief.

24. Pharmacologic Therapy (disease modifying therapy) Omega 3: The antiinflammatory and anti- cartilage degradation effect of omega-3 have been proven completely (in elderly people it has a lot of cardioprotective effects too) Glucosamine and Chondroitin sulfate Soy bean extracts( piascledine)

25. Display Settings: Abstract Send to: See comment in PubMed Commons below Semin Arthritis Rheum. Semin Arthritis Rheum. 2014 May 14. pii: S0049-0172(14)00108-5. doi: 10.1016/j.semarthrit.2014.05.014. [Epub ahead of print] An algorithm recommendation for the management of knee osteoarthritis in Europe and internationally: A report from a task force of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO). Bruyère O Bruyère O 1, Cooper C 2, Pelletier JP 3, Branco J 4, Luisa Brandi M 5, Guillemin F 6, Hochberg MC 7, Kanis JA 8, Kvien TK 9, Martel-Pelletier J 3, Rizzoli R 10, Silverman S 11, Reginster JY 12. Cooper C Pelletier JP Branco J Luisa Brandi M Guillemin F Hochberg MC Kanis JA Kvien TK Martel-Pelletier J Rizzoli R Silverman S Reginster JY

26. Chondroitin and glucosamine in the management of osteoarthritis: An update Current Rheumatology Reports, 08/19/2013 Clinical Article Henrotin Y et al. – The objective of osteoarthritis (OA) treatment is not only control of symptoms (i.e. reducing pain and improving function) but also to preserve joint structure and maintain quality of life. This review will discuss all these subjects and emphasize the importance of the quality of tested compounds for achieving high quality clinical trials. OA management remains challenging. Glucosamine and chondroitin are two compounds available for treatment of OA patients. Taken alone or in combination, they have a good safety profile and a variety of effects. In–vitro and in–vivo experiments have revealed that both compounds induced key intermediates in the OA pathophysiological process. Clinical trials, although providing conflicting and questionable results, report symptomatic and structure–modifying effects for both pharmaceutical–grade compounds.

27. . Chondroitin and glucosamine in the management of osteoarthritis: an update. Henrotin Y Henrotin Y 1, Lambert C. Curr Rheumatol Rep. 2013 Oct;15(10):361. doi: 10.1007/s11926-013-0361-zLambert C Curr Rheumatol Rep. EULAR & OARSI recommended it but ACR did not it is not FDA approval as an medication Immunomedulatory effect and cartilage repair

28. Randomised, controlled trial of avocado-soybean unsaponifiable (Piascledine) effect on structure modification in hip osteoarthritis: the ERADIAS study Annals of Rheumatic Diseases, 01/06/2014 CONCLUSIONS: 3 year treatment with ASU-E reduces the percentage of JSW (joint space widths progress) progressors, indicating a potential structure modifying effect in hip OA to be confirmed, and the clinical relevance requires further assessment.

29. Pharmacologic Therapy (Pain Reduction) Intra -articular injections: Corticosteroids: in effusive OA of hip and knee, triamcinolone or methyl prednisolone No more than 4 injections per year. Hyaluronic Acid Derivatives: Anti-inflammatory effect Short term lubricant effect Analgesic effect Stimulating of normal hyaluronic acid secretion

30. Display Settings: Abstract Send to: See comment in PubMed Commons below Curr Rheumatol Rep. Curr Rheumatol Rep. 2013 Oct;15(10):361. doi: 10.1007/s11926-013-0361-z. Chondroitin and glucosamine in the management of osteoarthritis: an update. NASHA hyaluronic acid vs methylprednisolone for knee osteoarthritis: A prospective, multi-centre, randomized, non-inferiority trial Osteoarthritis and Cartilage, 12/17/2013 Clinical Article Leighton R, et al. In total, 442 participants were enrolled. In response to NASHA treatment at 26 weeks, sustained improvements were seen in WOMAC outcomes irrespective of initial treatment. No serious device–related adverse events (AEs) were reported.

31. PRP?? PRP injection may be an alternative therapy in selective patients resistant to current nonsurgical treatments of knee osteoarthritis.

33. Surgical therapy non responsive to pharmacological therapy Sustained pain (related exactly to knee OA) Limitation of daily activities Severe deformities Cooperative patients for rehabilitation Very late decision for surgery: muscle atrophy and poor compliance (two types : osteotomy and replacement surgury)

34. Treatment strategies Non-pharmacological therapy and pain reduction strategies Chondroitin and glucosamine sulfate, Piascledine,? if appropriate Intra articular injection (if effusive Gcs), Hyaluronic Acid, PRP? Surgical management if possible