Title: Osteoarthritis and Exercise
1Osteoarthritis and Exercise
- Rochelle M. Nolte, MD
- CDR USPHS/USCG
2Objectives
- Understand factors involved in the etiology and
epidemiology of osteoarthritis - Understand how exercise helps prevent
osteoarthritis - Understand how exercise is used in the treatment
of osteoarthritis
3Etiology 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
4Etiology of Osteoarthritis
- Articular cartilage is composed of
- Proteoglycans
- Provide compressive stiffness and ability to
withstand load - Collagen
- Provides tensile strength and resistance to shear
5Etiology 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
together - Prevents the concentration of forces when bones
are loaded
6Etiology 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
7Symptoms of osteoarthritis
- PAIN (Articular cartilage is aneural)
- OA pain is not from the cartilage
- Stretching of nerve ending in periosteum covering
osteophytes - Microfractures in subchondral bone
- Stretching of joint capsule
- Synovitis
- Ligament stretching or muscle pain
- STIFFNESS (esp. after inactivity)
8Physical 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)
9Laboratory findings in OA
- THERE ARE NO DIAGNOSTIC LAB TESTS FOR
OSTEOARTHRITIS - 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
10Radiology 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
11Radiology 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
12Epidemiology 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
13Epidemiology of OA
- In patients under the age of 55
- Joint distribution of OA is equal between men and
women - 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
14Epidemiology 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
15Epidemiology 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
16Epidemiology of OA
- Obesity is a risk factor for knee (and hand)
osteoarthritis - 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
17Epidemiology 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
18Risk factors for OA
- Age
- Sex
- Race
- Genetic factors
- Congenital defects
- Prior inflammatory joint disease
- Metabolic disorders
- Major joint trauma
- Repetitive stress
- Vocational
- Recreational
- Obesity
19Risk factors for OA
- Systemic
- Age
- Gender
- Ethnicity
- Genetics
- Hormonal status
- Bone density
- Metabolic/nutritional status
20Risk factors for OA
- Local
- Obesity
- Major trauma
- Joint deformity
- Physical disability
- Muscle weakness
- Occupational/sports stress
21Prevention 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
22Prevention 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
23Prevention 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
24Management/Treatment of OA
- Goals
- Educate patient about disease and management
- Improve function
- Control pain
- Alter disease process and its consequences
25Management/Treatment of OA
- No known cure for OA
- HOWEVER
- Impaired muscle function
- Reduced fitness
- Affect pain and dysfunction
- Are amenable to therapeutic exercise
26Management/Treatment of OA
- Pharmacologic
- Acetaminophen
- NSAIDS
- Cox-2 specific inhibitors
- With PPI or misoprostol
- Nonacetylated salicylate
- Tramadol
- Opioids
- Topical
- Capsaicin
- Methylsalicylate
- NSAIDS
- Intra-articular
- Corticosteroids
- Hyaluronic acid
27Treatment/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
28Management/Treatment of OA
- Pharmacologic
- NSAIDS
- 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
29Management/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
30Management/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
31Management/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
32Treatment/Management of OA
- Pharmacologic
- Intraarticular corticosteroids
- Superior to placebo for pain control for 2-3
weeks - 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)
33Treatment/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)
34Treatment/Management of OA
- Pharmacologic
- Herbal therapy
- Avocado soybean unsaponifiables (ASUs) with
promising results in 2 studies on - Functional index, pain, NSAID use, and global
evaluation - Reumalex (willow bark preparation) inconclusive
- Tipi tea inconclusive
35Management/Treatment of OA
- Possible structure/disease modifying stuff
- Glucosamine
- Diacerein
- Cytokine inhibitors
- Cartilage repair
- Bisphosphonates
- Degradative enzyme inhibitors
- Tetracyclines, metalloproteinase inhibitors
36Treatment/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
37Treatment/Management of OA
- Pharmacologic
- Diacerein
- Pain improved 5 points compared to placebo
- Over 3 years,
- Slowed progress of OA in the hip compared to
placebo - 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
placebo)
38Management/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
39Management/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
40Management/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)
41Management/Treatment of OA
- Non-pharmacologic (Exercise)
- Home strengthening program for knee v. control.
Level I/Grade A (controlled clinical trial n81)
for - Pain
- Functional status
- Energy level
- Range of motion (ROM) in flexion
- Other studies group exercise program as
effective as one-on-one
42Management/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
43Management/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
questionable - Study only lasted 6 months. lt500 patients
44Management/Treatment of OA
- Non-pharmacologic (insole) study (SOR B)
- Laterally wedged insoles may decrease knee OA
pain - 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
45Management/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
46Management/Treatment of OA
- Thermotherapy
- Heat had no benefit on swelling over cold or
placebo - 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
47Management/Treatment of OA
- Ultrasound was of no benefit for
- Pain
- Range of motion
- Functional status
48Treatment/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
B) - Electrical stimulation
- Showed improvement in measurements, but
- Clinical significance from the patients
perspective is questionable
49Treatment/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
50Treatment/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
51Summary
- 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
52Thank you for coming