Dr. Howard C. H. Chen Athlete s Care Sports Medicine Centres DFCM University of Toronto

Transcription

1 Dr. Howard C. H. Chen Athlete s Care Sports Medicine Centres DFCM University of Toronto

2 Faculty: Dr. Howard C. H. Chen Program: 51 st Annual Scientific Assembly Relationships with commercial interests: Grants/Research Support: None Speakers Bureau/Honoraria: None Consulting Fees: None Other: None

3 This program has received no financial support This program has received no in-kind support Potential for conflict(s) of interest: Dr. Howard C. H. Chen has received no payment/funding, etc. from any organization supporting this program AND/OR organization whose product(s) are being discussed in this program.

4 Not applicable

5 Learning Objectives Discuss the latest evidence and guidelines for the clinical diagnosis and management of OA Explore changing paradigms to a patientcentered treatment model with exercise, weight- loss and education, as the keys Learn about exercise prescriptions Demonstrate OA strengthening exercises for the knee Review OA web-based resources

6 Canadian Statistics Arthritis is most common cause of disability OA 1 in 8 (13%), 4.4 million Canadians 600, 000 limitations to ADLs 300,000 mod severe pain (1 in 100 > 19 years) 2040 prevalence > 10 million, 1 in 4 Knee OA one of most common forms Arthritis Alliance of Canada 2012 Impact Report

7 Obesity Statistics Obesity rate 17.7%, to 29.3% by 2040 risk of OA with weight Strongest association with OA onset Weight reduction prevents OA development and improves Sxs Obesity is a modifiable primary risk factor Arthritis Alliance of Canada 2012 Impact Report

8 Osteoarthritis Heterogeneous group of conditions joint pain, functional limitation ROM and reduced quality of life Knees, hips, small joints of hands most affected Structural changes often occur without Sxs Aging is #1 risk factor, but not cause Does not necessarily deteriorate with age

9 Osteoarthritis Metabolically active repair process in joint tissues - slow but efficient local cartilage loss and bone remodeling results in a structurally altered but symptom-free joint trauma or repair loss of compensation and symptomatic disease Extreme variability in presentation and outcome, even within the same person in different joints ~ 30% improvement over 7 years - tended BMI, co-morbidity

10 The Pathophysiology of OA

11 Stages of Change - Precontemplation

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13 ACR 1986 OA Classification Criteria Useful for classification of Knee OA Developed using hospital-referred patients and control group with other arthritis ( >50% RA) More useful to differentiate OA from other forms of arthritis Not as useful for Dx OA in clinical setting

14 EULAR Evidence Based Recommendations for Dx Knee OA X-rays often gold-standard, but not only marker for OA Assuming background prevalence of 12.5% Adults aged 45 Probability of having OA with number of positive sx/signs 99% probability of OA with all 6 Dx OA can be made without X-rays, or if normal X-rays

15 EULAR Criteria Persistent Knee pain (1 month, most days) LR 1.67 ( ) Limited Morning Stiffness (< 30 min.) LR 1.84 ( ) Impaired Function LR 1.50 ( ) Crepitus LR 2.23 ( ) ROM LR 4.4 Bony enlargement LR11.81 ( )

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17 Stages of Change - Contemplation

18 Osteoarthritis Treatment Pyramid

19 NICE Guidelines 2008 (National Institute of Clinical Evaluation, UK) Patient-centred, holistic, informed decision, good communication Key priorities Exercise is core Tx Exercise is Medicine Regardless of age, comorbidity, pain or disability Arthroscopy only for mechanical sx/signs, not pain Acetominophen and topical NSAIDs prior to oral NSAIDs, COX-2 and opioids NSAIDS/COX-2 with PPI Total Joint Replacement when Sxs substantial impact on QoL and refractory to non-surgical Tx Referral made before prolonged and established limitation and severe pain

20 NICE Guidelines OA Tx (National Institute of Clinical Evaluation, NHS UK)

21 Effective Tx with toolbox of evidence-based interventions Core Treatments Relatively Safe Pharmaceutical options Adjunctive Treatments less efficacy, Sx relief and risk Pharmaceutical Self-management Surgery Other non-pharmaceutical

22 Core Safe Adjunct

23 Zhang et al. OsteoArthritis Research Society International OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis and Cartilage (2008) 16, doi: /j.joca OARSI recommendations for the management of hip and knee osteoarthritis Part III: changes in evidence following systematic cumulative update of research published through January Osteoarthritis and Cartilage 18 (2010) doi: /j.joca

24 Oarsi 2013 Knee OA Guidelines OARSI Guidelines for the Non-Surgical Management of Knee Osteoarthritis Draft for public comment Commissioned by the Osteoarthritis Research Society International 9/3/ guidelines%20report% %20for%20public%2 0comment.pdf

25 Stages of Change - Preparation

26 Osteoarthritis K N O W YO U R O P T I O N S

27 The Arthritis Society s LIFESTYLE SERIES Physical Activity &Arthritis Nutrition & Arthritis

28 ARTHRITIS MEDICATIONS A CONSUMER S GUIDE Endorsed by the Canadian Rheumatology Association

29 An Introduction to Complementary and Alternative Therapies

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31 Stages of Change - Action

32 Metabolic OA 2 nd most common OA Phenotype Part of systemic metabolic disorder Age years Characterized by major causative features Adipokines Hyperglycemia Hormonal imbalance Zhuo et al, Metabolic Syndrome meets Osteoarthritis NRR doi: /nrrrheum

33 Metabolic OA Metabolic Syndrome (MetS) 59% OA patients, 23% MetS without OA Odds of OA with each additional component of MetS OA patients have prevalence CVD, especially CAD Possible 5 th component of MetS Zhuo et al, Metabolic Syndrome meets Osteoarthritis NRR doi: /nrrrheum

34 OA and Metabolic Syndrome (MetS)

35 Metabolic OA Inflammation Low grade inflammatory condition IL-1, IL-6, IL-10, TNF, Leptin Oxidative stress MetS pro-oxidative state Imbalance between Reactive Oxygen Species (ROS) Accelerated aging, senescence and apoptosis in cartilage Fibrosis in synovium Decreased remodelling in bone

36 Metabolic OA Metabolites Vitamin D 2x risk of hip OA and progression of knee OA TGF-β affects chondrocyte maturation and matrix production Insulin resistance related to visceral adiposity - CV/OA risk factor in men Leptin levels related to sub Q fat - CV/OA risk factor in women estradial associated with development of knee OA Endothelial dysfunction Independent association between knee/hand OA and atherosclerosis in women Visceral adiposity and insulin resistance create multiple signaling pathways affecting nitric oxide production

37 The Pathophysiology of OA

38 Exercise Prescription

39 Exercise prescription for knee OA Dose not delineated No specific recommendations frequency, intensity, time, type Supervised greater benefit than home exercise Dynamic strengthening exercises provides small to moderate benefit for pain and function Exercise well tolerated

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41 Canadian Exercise Guidelines (CSEP) ml?hash=fuiad0ai&wmode=window&bgc olor=eeeeee&t=

42 Exercise Prescription

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47 Exercise Aerobic exercise and quadriceps strengthening core recommendation in 21/21 guidelines 8 SR and MA LoE 1a ES pain Aerobic Exercise 0.52 (0.34,0.70) Strength 0.32 (0.23,0.42) ES function Aerobic Exercise 0.46 (0.25,0.67) Strength 0.32 (0.23,0.41) Water-based activity not as effective Effects comparable to analgesics and NSAIDs

48 Acetominophen ACR, NICE, AAOS, OARSI guidelines up to 4 g/day Small ES pain, no effect function and stiffness ES pain 0.14 (0.05,0.23) NNT 3 (2,52),? 7 (4,23) FDA max adult <4g/day, single dose max 650mg evidence for adverse effects dose > 3 g/day GI risk hospitalization, GI perforation, ulcer, bleeding HR 1.20 (1.03,1.40) Renal GFR > 30 ml/min OR 2.04 (1.28,3.24) BP F > 500 mg/day, M with daily intake RR 1.34 (1.00,1.79)

49 Topical NSAIDs ES Pain 0.44 (0.27,0.62) Heterogeneity between products? Publication bias with over estimation of efficacy Probably as effective as Oral NSAIDs, possibly safer Cost/Effect - by 2 nd year oral more effective, but also more costly QID dosing

50 Joint Loading Forces as expressed in multiples of Body weight (BW) Activity Knee Walking 5 km/hr Jogging 9 km/hr Running at 16 km/h Cycling Stair ascent Stair descent Isokinetic knee extension Squat descent x BW 8-9 x BW Up to 14 x BW 1.2 x BW x BW x BW Up to 9 x BW 5.6 x BW

51 Stages Of Change - Maintenance

52 Water Exercise Deep Water Running/Walking Water Aerobics Swimming

53 Walking Non-impact Exercise Skiing Cycling Hockey/skating

54 Knee Braces

55 Quadricep Strengthening Isometric Straight leg raise

56 Short Arc Extensions 30

57 Gluteal Strengthening Clam Shell

58 Side leg lift

59 Quadricep/Gluteal Strengthening Wall Sit/Slides

60 Single leg ¼ squat

61 Dr. Mike Evans 23 ½ hours: What is the Single Best Thing We Can Do for Our Health? mbedded&v=auains6higo

62 Online Exercise program

63 Be careful out there. Thank You!