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

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

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

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.

Not applicable

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

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

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

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

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

The Pathophysiology of OA

Stages of Change - Precontemplation

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

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

EULAR Criteria Persistent Knee pain (1 month, most days) LR 1.67 (1.44-1.94) Limited Morning Stiffness (< 30 min.) LR 1.84 (1.49-2.27) Impaired Function LR 1.50 (1.23-1.84) Crepitus LR 2.23 (1.90-2.63) ROM LR 4.4 Bony enlargement LR11.81 (4.94-28.22)

Stages of Change - Contemplation

Osteoarthritis Treatment Pyramid

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

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

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

Core Safe Adjunct

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) 16,137-162 doi:10.1016/j.joca.2007.12.013 OARSI recommendations for the management of hip and knee osteoarthritis Part III: changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis and Cartilage 18 (2010) 476 499 doi:10.1016/j.joca.2010.01.013

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 9/3/2013 http://www.oarsi.org/pdfs/oarsi%20knee%20oa%2 0guidelines%20report%209.4.13%20for%20public%2 0comment.pdf

Stages of Change - Preparation

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

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

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

An Introduction to Complementary and Alternative Therapies

Stages of Change - Action

Metabolic OA 2 nd most common OA Phenotype Part of systemic metabolic disorder Age 45-65 years Characterized by major causative features Adipokines Hyperglycemia Hormonal imbalance Zhuo et al, Metabolic Syndrome meets Osteoarthritis NRR doi:10.1038/nrrrheum.2012.135

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:10.1038/nrrrheum.2012.135

OA and Metabolic Syndrome (MetS)

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

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

The Pathophysiology of OA

Exercise Prescription

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

Canadian Exercise Guidelines (CSEP) http://files.flipsnack.com/iframe/embed.ht ml?hash=fuiad0ai&wmode=window&bgc olor=eeeeee&t=1351794674

Exercise Prescription

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

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)

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

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 3.4-4 x BW 8-9 x BW Up to 14 x BW 1.2 x BW 4.3-5 x BW 3.8-6 x BW Up to 9 x BW 5.6 x BW

Stages Of Change - Maintenance

Water Exercise Deep Water Running/Walking Water Aerobics Swimming

Walking Non-impact Exercise Skiing Cycling Hockey/skating

Knee Braces

Quadricep Strengthening Isometric Straight leg raise

Short Arc Extensions 30

Gluteal Strengthening Clam Shell

Side leg lift

Quadricep/Gluteal Strengthening Wall Sit/Slides

Single leg ¼ squat

Dr. Mike Evans 23 ½ hours: What is the Single Best Thing We Can Do for Our Health? http://www.youtube.com/watch?feature=player_e mbedded&v=auains6higo

Online Exercise program http://www.webmd.com/osteoarthritis/jointinjections-9/slideshow-knee-exercises

Be careful out there. Thank You!