Pain Management of Knee Osteoarthritis
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1 Pain Management of Knee Osteoarthritis Zachary McCormick, M.D. Assistant Professor Physical Medicine and Rehabilitation Department of Orthopaedic Surgery University of California, San Francisco Objectives Review: What is knee osteoarthritis (OA)? What causes pain in knee OA? Scope of the problem Spectrum of care; treatment options What is Knee OA? Degenerative condition: Synovial inflammation Loss of articular cartilage Subchondral sclerosis and cysts Joint hypertrophy/osteophytes
2 What causes pain in knee OA? Inflammation Synovitis Mechanical Changes friction shock-absorption Ligament + capsule stretch Joint Instability Pain Sensitization Peripheral Central
3 Scope of the Problem Chronic Pain due to knee OA is common: >25 million (US alone) 1 13% of adults >65 years of age %: chronic pain after knee replacement 3 Spectrum of Care Weight Loss Bracing Cane/assistive device Weight loss Bracing Cane/assistive device Ice/cryotherapy, Heat Continued Pain and Disability Despite Treatment Formal Physical Therapy - Strength, mobility -Gait - Ergonomics -Pacing - Graded home exercise program - Phenol/alcohol Surgery -Total Knee Replacement - Partial Knee Replacement Ice/cryotherapy, Heat Oral Anti-inflam meds Targeted Exercise - Quad, hip girdle - Bike/swimming Oral Anti-inflam meds Targeted Exercise - Quad, hip girdle - Bike/swimming
4 Formal Physical Therapy - Strength, mobility -Gait - Ergonomics -Pacing - Graded home exercise program Individualized to unique anatomy and biomechanics Active > Passive Quadriceps, hip girdle, core strength - Address imbalances Gait, movement, lifting mechanics Techniques for pain exacerbations, pacing Graded independent exercise program Steroid Anti-inflammatory Nerve membrane stabilizing 3 per year Hyaluronic Acid Reduces loading/sheering forces on joint Supplement + stimulate production 1-5 injections/ 6 months Regenerative Treatments Platelet Rich Plasma Stem Cells Adipose Bone marrow Placental Chondrogenesis Early evidence
5 Indications Continued pain and functional disability despite conservative management Desire to avoid surgery Inability to undergo surgery Thermocoagulation of sensory nerves Radiofrequency Energy Vibration of H 2 O molecules -> heating Predictable + Controlled lesion size 4 Genicular nerves Sensory No motor fibers Defined anatomic locations Diagnostic nerve injections Small volume of local anesthetic >80% pain relief = positive response
6 Surgery - Knee Replacement Radiofrequency Denervation of the Genicular Nerves Light sedation Well tolerated Safe Spectrum of Care Summary Weight loss Bracing Cane/assistive device Ice/cryotherapy, Heat Continued Pain and Disability Despite Treatment Formal Physical Therapy - Strength, mobility -Gait - Ergonomics -Pacing - Graded home exercise program - Phenol/alcohol Surgery -Total Knee Replacement - Partial Knee Replacement Knee OA is a common degenerative condition Major cause of pain and disability Treatments range from conservative to surgical Regenerative and joint denervation techniques provide a novel approach to treatment Oral Anti-inflam meds Targeted Exercise - Quad, hip girdle - Bike/swimming
7 References Thank You 1. Garstang, S, Stitik, T. Osteoarthritis: epidemiology, risk factors, and pathophysiology. Am J Phys Med Rehabil S Bedson J, Jordan K, Croft P.The prevalence and history of knee osteoarthritis in general practice: a case control study. Fam Pract Feb;22(1): Lewis GN, Rice DA, McNair PJ, Kluger M. Predictors of persistent pain after total knee arthroplasty: a systematic review and meta analysis. Br J Anaesth 2014: 114(4): Cosman ER, Dolensky JR, Hoffman RA. Factors that affect radiofrequency heat lesion size. Pain Med. 2014;15(12): Questions?
Prevention Diagnosis Assessment Prescription and /or application of wide range of interventions and PRM program management
OA PATHOLOGY Characterized by progressive deterioration and ultimate loss of articular cartilage Reactive changes of joint margins and joint thickening of the capsule When OA symptomatic leads to: Pain
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