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

2. 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

3. 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

4. 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

5. 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

6. 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)

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. Thank you.
Questions?