Osteoarthritis and Exercise - PowerPoint PPT Presentation


PPT – Osteoarthritis and Exercise PowerPoint presentation | free to view - id: acf94-ZjY1M


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation

Osteoarthritis and Exercise


Occupational/sports stress. Prevention of OA ... Aquatic exercise for the treatment of knee/hip OA. Acupuncture for osteoarthritis. Pharmacologic ... – PowerPoint PPT presentation

Number of Views:430
Avg rating:3.0/5.0
Slides: 53
Provided by: Roch150


Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Osteoarthritis and Exercise

Osteoarthritis and Exercise
  • Rochelle M. Nolte, MD

  • Understand factors involved in the etiology and
    epidemiology of osteoarthritis
  • Understand how exercise helps prevent
  • Understand how exercise is used in the treatment
    of osteoarthritis

Etiology of Osteoarthritis
  • Disease of the synovial joints
  • Primary changes of OA begin in the cartilage
  • Most pronounced in load bearing areas of
    articular cartilage
  • Fibrocartilaginous repair is inferior to original
    hyaline cartilage
  • Other tissues affected include subchondral bone,
    synovium, meniscus, ligaments, muscle

Etiology of Osteoarthritis
  • Articular cartilage is composed of
  • Proteoglycans
  • Provide compressive stiffness and ability to
    withstand load
  • Collagen
  • Provides tensile strength and resistance to shear

Etiology of osteoarthritis
  • Articular cartilage (1-2 mm thick)
  • Provides a smooth bearing surface
  • With synovial fluid as a lubricant, the
    coefficient of friction for cartilage on
    cartilage is 15X lower than rubbing 2 ice cubes
  • Prevents the concentration of forces when bones
    are loaded

Etiology of Osteoarthritis
  • Growth of cartilage and bone at the joint margins
    leads to osteophytes which can restrict movement
  • Chronic synovitis and thickening of the joint
    capsule further restrict movement
  • Periarticular muscle wasting is common and plays
    a major role in sx and disability

Symptoms of osteoarthritis
  • PAIN (Articular cartilage is aneural)
  • OA pain is not from the cartilage
  • Stretching of nerve ending in periosteum covering
  • Microfractures in subchondral bone
  • Stretching of joint capsule
  • Synovitis
  • Ligament stretching or muscle pain
  • STIFFNESS (esp. after inactivity)

Physical exam findings of OA
  • Bony or soft tissue swelling
  • Bony crepitus
  • Synovial effusions (usually small)
  • Mild warmth
  • Periarticular muscle atrophy
  • Bony hypertrophy (advanced OA)
  • Joint subluxation (advanced OA)

Laboratory findings in OA
  • OA is not a systemic disease, therefore
  • ESR, Chem 7, CBC, and UA all WNL
  • Synovial fluid
  • Mild leukocytosis (lt2000 WBC/microliter)
  • Can be used to exclude gout, CPPD, or septic
    arthritis if diagnosis is in doubt

Radiology findings in OA
  • Often great disparity between the severity of
    radiographic findings and severity of symptoms
    and functional ability
  • 90 of people gt40 have x-ray changes
  • 30 are symptomatic
  • During early OA radiographs may be normal

Radiology findings in OA
  • Joint space narrowing may be earliest sign
  • Secondary to loss of articular cartilage
  • Subchondral sclerosis
  • Subchondral cysts
  • Osteophytes
  • Change in joint contour secondary to bony
    remodeling and joint subluxation

Epidemiology of OA
  • OA of the knee is the leading cause of chronic
    disability in the elderly in developed countries
  • In patients over the age of 55
  • Hip OA is more common in men
  • IP and 1st MCP OA is more common in women
  • Knee OA (with sx) is more common in women

Epidemiology of OA
  • In patients under the age of 55
  • Joint distribution of OA is equal between men and
  • Due to genetics or joint usage?????
  • Mother and sister of a woman with DIP OA are 2
    3 X more likely to have the same
  • Racial differences in prevalence and pattern of
    joint involvement also point to genetic basis

Epidemiology of OA
  • Age is the most powerful risk factor for OA
  • Women lt 45 years of age 2 with OA
  • Women 45-64 30 with OA
  • Women gt65 68 with OA

Epidemiology of OA
  • There is no convincing data to support an
    association between nonspecific nonprofessional
    athletic activities and osteoarthritis
  • (excluding major trauma)
  • Neither long-distance running nor jogging has
    been shown to cause osteoarthritis

Epidemiology of OA
  • Obesity is a risk factor for knee (and hand)
  • In the highest quintile of BMI
  • Relative risk of developing OA in the next 36
    years was 1.5 for men and 2.1 for women
  • For SEVERE OA, the RR rose to 1.9 for men and 3.2
    for women
  • Weight loss of 5kg was associated with a 50
    reduction in the odds of developing OA

Epidemiology of OA
  • Disability in subjects with knee OA
  • More strongly associated with QUADRICEPS WEAKNESS
  • than with joint pain or radiographic severity
  • Demographics associated with increased likelihood
    of being symptomatic women, unemployed,
    divorced, poor social support

Risk factors for OA
  • Age
  • Sex
  • Race
  • Genetic factors
  • Congenital defects
  • Prior inflammatory joint disease
  • Metabolic disorders
  • Major joint trauma
  • Repetitive stress
  • Vocational
  • Recreational
  • Obesity

Risk factors for OA
  • Systemic
  • Age
  • Gender
  • Ethnicity
  • Genetics
  • Hormonal status
  • Bone density
  • Metabolic/nutritional status

Risk factors for OA
  • Local
  • Obesity
  • Major trauma
  • Joint deformity
  • Physical disability
  • Muscle weakness
  • Occupational/sports stress

Prevention of OA
  • Physiological effects of physical activity are
    most marked in those parts of the body that are
    used most during exercise
  • Physical activity is the best way to ensure the
    maintenance of functional capacity
  • Endurance-type activity using rhythmic movements
    of large muscle groups are the best studied

Prevention of OA
  • Exercise reduces the pain and functional
    disturbance in OA of the knee (SOR A)
  • Data insufficient for conclusions about the type
    of exercise that should be preferred
  • Sudden overloading, incorrect joint loading, and
    various injuries predispose people to OA
  • Preventing excessive wt gain helps

Prevention of OA
  • Current studies
  • Isokinetic exercise for improving knee flexor and
    extensor muscles in healthy adults to assess
    safety and effectiveness
  • Will also assess in adults with neurological,
    orthopedic, and rheumatologic conditions

Management/Treatment of OA
  • Goals
  • Educate patient about disease and management
  • Improve function
  • Control pain
  • Alter disease process and its consequences

Management/Treatment of OA
  • No known cure for OA
  • Impaired muscle function
  • Reduced fitness
  • Affect pain and dysfunction
  • Are amenable to therapeutic exercise

Management/Treatment of OA
  • Pharmacologic
  • Acetaminophen
  • Cox-2 specific inhibitors
  • With PPI or misoprostol
  • Nonacetylated salicylate
  • Tramadol
  • Opioids
  • Topical
  • Capsaicin
  • Methylsalicylate
  • Intra-articular
  • Corticosteroids
  • Hyaluronic acid

Treatment/Management of OA
  • Pharmacologic
  • Acetaminophen
  • Grade A/Level I for short-term pain relief
  • Pain decreased 4 points (100 point scale)
    compared to placebo
  • Relatively inexpensive compared to NSAIDS
  • Relatively safe compared to NSAIDS
  • Usually studied in doses of 2-4 g/d
  • Liver toxicity is major concern

Management/Treatment of OA
  • Pharmacologic
  • Grade A/Level I for short-term pain relief
  • Shown to provide better pain control than
    acetaminophen, especially with more severe pain
  • No difference in functional improvement
  • Greater GI toxicity than acetaminophen
  • No difference in efficacy among NSAIDS

Management/Treatment of OA
  • Pharmacologic
  • Tramadol
  • Pain decreased 8.5 points compared to placebo
  • 39 had minor side effects (18 with placebo)
  • 21 had major side effects (8 with placebo)
  • Opioids
  • Grade B/ Level I for pain control in OA
  • Must balance side effect profile for risk/benefit

Management/Treatment of OA
  • Pharmacologic
  • Topical Capsaicin
  • Inconclusive evidence
  • Topical NSAIDs
  • short-term pain relief in very limited
    short-term studies only compared to placebo.
  • No studies comparing to PO medications

Management/Treatment of OA
  • Pharmacologic
  • Intra-articular steroids
  • Grade A/Level I for short-term pain relief
  • Intra-articular hyaluronic acid
  • Grade A/Level I for short-term treatment

Treatment/Management of OA
  • Pharmacologic
  • Intraarticular corticosteroids
  • Superior to placebo for pain control for 2-3
  • At 4-24 weeks, no evidence of improvement in pain
  • No evidence of improvement in function
  • Hyaluronic acid
  • More effective than corticosteroids 5-13 weeks
    post-injection (pain, ROM, function)

Treatment/Management of OA
  • Pharmacologic
  • Hyaluronic acid (HA)
  • Better than placebo
  • Comparable effectiveness to NSAIDs
  • Fewer systemic adverse events
  • More local reactions
  • Longer-acting than IA steroids
  • No major safety issues
  • SOR B (76 heterogeneous trials)

Treatment/Management of OA
  • Pharmacologic
  • Herbal therapy
  • Avocado soybean unsaponifiables (ASUs) with
    promising results in 2 studies on
  • Functional index, pain, NSAID use, and global
  • Reumalex (willow bark preparation) inconclusive
  • Tipi tea inconclusive

Management/Treatment of OA
  • Possible structure/disease modifying stuff
  • Glucosamine
  • Diacerein
  • Cytokine inhibitors
  • Cartilage repair
  • Bisphosphonates
  • Degradative enzyme inhibitors
  • Tetracyclines, metalloproteinase inhibitors

Treatment/Management of OA
  • Pharmacologic
  • Glucosamine 20 studies with gt2500 patients
  • If only high quality studies evaluated
  • No benefit over placebo on pain
  • If all studies included
  • Pain may improve by as much as 13 points
  • 2 RCTs using Rotta preparation
  • Demonstrated slowing of radiological progression
    of OA over a 3 year period

Treatment/Management of OA
  • Pharmacologic
  • Diacerein
  • Pain improved 5 points compared to placebo
  • Over 3 years,
  • Slowed progress of OA in the hip compared to
  • Did not slow progress of OA in the knee
  • Diarrhea is most common side effect
  • 42 out of 100 had diarrhea in the first 2 weeks
  • 18 discontinued because of side effects (13 in

Management/Treatment of OA
  • Non-pharmacologic
  • Patient education
  • Self-management programs
  • Weight loss
  • PT/OT
  • ROM exercises
  • Muscle strengthening
  • Non-pharmacologic
  • Assistive devices
  • Patellar taping
  • Appropriate footwear
  • Lateral-wedged insoles
  • Bracing
  • Joint protection and energy conservation

Management/Treatment of OA
  • Non-pharmacologic (Exercise)
  • Walking program v. control. Level I/Grade A (RCT
    n1089) for improvement in
  • Pain
  • Functional status
  • Stride length
  • Aerobic capacity
  • Energy level
  • Medication use
  • Disability transferring from bed and bathing

Management/Treatment of OA
  • Non-pharmacologic (Exercise)
  • Whole-body functional exercise v. control. Level
    I/Grade A (RCT n864) for
  • Pain
  • Functional status
  • Mobility
  • Walking
  • Work
  • Disability in Activities of Daily Living (ADLs)

Management/Treatment of OA
  • Non-pharmacologic (Exercise)
  • Home strengthening program for knee v. control.
    Level I/Grade A (controlled clinical trial n81)
  • Pain
  • Functional status
  • Energy level
  • Range of motion (ROM) in flexion
  • Other studies group exercise program as
    effective as one-on-one

Management/Treatment of OA
  • No differences between high and low intensity
    aerobic exercise in people with OA for
  • Functional status
  • Pain
  • Gait
  • Aerobic capacity
  • Therapeutic range (btwn suitable and excessive
    exercise) may be narrow in some patients

Management/Treatment of OA
  • Non-pharmacologic (brace) study (SOR B)
  • Valgus knee brace better than
  • Neoprene sleeve better than
  • Control group according to pain scale
  • While score changes were statistically
    significant, clinical significance is
  • Study only lasted 6 months. lt500 patients

Management/Treatment of OA
  • Non-pharmacologic (insole) study (SOR B)
  • Laterally wedged insoles may decrease knee OA
  • Laterally wedged insoles decrease the amount of
    pain medication taken
  • Pain decreased by one point (100 point scale) in
    laterally wedged insoles. Decreased by 5 points
    in neutrally wedged insoles. However, pain
    medication use decreased more in laterally wedged
    insole patients and patients wore the laterally
    wedged insoles for a longer period of time

Management/Treatment of OA
  • Non-pharmacologic (exercise programs)
  • Exercise programs improve health and function
    (SOR A)
  • People tend to stick with a home exercise program
    more than exercising at a center (SOR B)
  • The specific type of exercise that is best needs
    more research

Management/Treatment of OA
  • Thermotherapy
  • Heat had no benefit on swelling over cold or
  • Cold did not significantly improve pain
  • Cold did slightly improve swelling
  • Ice 20 min/d 5d/wk for 2 weeks did show improved
    muscle strength, ROM, and a decrease in time to
    walk 50 feet

Management/Treatment of OA
  • Ultrasound was of no benefit for
  • Pain
  • Range of motion
  • Functional status

Treatment/Management of OA
  • Transcutaneous electrical nerve stimulation
    (TENS) for knee OA
  • Active and acupuncture like TENS for at least
    four weeks reduced pain and knee stiffness (SOR
  • Electrical stimulation
  • Showed improvement in measurements, but
  • Clinical significance from the patients
    perspective is questionable

Treatment/Management of OA
  • Surgery
  • Valgus high tibial osteotomy (HTO) for treatment
    of medial compartment OA
  • No study comparing HTO to conservative txment
  • Partial knee replacement
  • Total knee replacement
  • Pre-op education only reduced hospital stay in
    patients with complex needs

Treatment/Management of OA
  • Current studies
  • Non-pharmacologic
  • Aquatic exercise for the treatment of knee/hip OA
  • Acupuncture for osteoarthritis
  • Pharmacologic
  • Chloroquines, HRT, chondroitin, homeopathy
  • Opioids

  • Non-pharmacologic therapy is important in the
    prevention and treatment of OA
  • The best studied and most effective
    non-pharmacologic therapy is EXERCISE
  • Exercise helps control weight, increase strength,
    improve and maintain function and decrease pain

Thank you for coming
  • Questions?
About PowerShow.com