Osteoarthritis Guidelines Putting into Practice

1
Osteoarthritis GuidelinesPutting into Practice

• Eric S Schned, MD
• Stephen Brunton, MD
• Laura Robbins, DSW
• Deborah Litman, MD

2
Osteoarthritis

• a painful, degenerative joint diseaseinvolving
  cartilage deterioration
• not an inflammatory process
• affects gt 16 million Americans

3
American College of Rheumatology Guideline

• The goals of osteoarthritis (OA) management are
  to control pain and other symptoms, minimize
  disability, and educate the patient about the
  disease and its therapy

4
Signs

• bony enlargement
• limitation of range of motion
• crepitus on motion
• tenderness on pressure
• pain on motion
• joint effusion
• malalignment and/or joint deformity

Arthritis Rheum 199538(11)1535-1546
5
Symptoms

• joint pain
• morning stiffness
• gel phenomenon
• buckling or instability
• loss of function

Arthritis Rheum 199538(11)1535-1546
6
Hip OsteoarthritisClassification Criteria

• Hip pain and at least 2 or of the following
• erythrocyte sedimentation rate lt20 mm/hr
• radiographic femoral or acetabular osteophytes
• radiographic joint space narrowing

Arthritis Rheum 199134(5)505-514 Arthritis
Rheum 199538(11)1535-1546
7
Knee OsteoarthritisClassification Criteria

• Knee pain and radiographic osteophytes and at
  least 1 of the following
• age gt50 yr
• morning stiffness ?30 min in duration
• crepitus on motion

Arthritis Rheum 198629(8)1039-1049 Arthritis
Rheum 199538(11)1535-1546
8
Nonpharmacologic Therapy

• Education
• Social support services
• Physical therapy
• Occupational therapy
• Aerobic exercise

9
Education

• Patients must realize that a cure and symptom
  free state may not be achievable goals
• Physician must understand the 3 Cs
• compliance
• communication
• control

10
Education

• Compliance
• 30 do not take meds as prescribed
• 27 noncompliant with exercise
• 65 noncompliant with assistive devices
• compliance tends to be lower with meds that are
  perceived as less potent and more common (as
  acetaminophen)

11
Education

• Communication
• patients are intimidated by physicians, afraid to
  ask questions
• most patient desire more information but
  understand less than doctors are aware
• physicians may not recognize the patients
  desire, may lack the time or skills to educate
  the patient

12
Education

• Control
• in chronic conditions, patients desire more
  participation in decision making
• patients perceive themselves at a disadvantage in
  their relationship to doctors
• the first step in empowering the patient is by
  listening supportively

13
Education

• Principles of Learning
• People remember
• 10 of what they read
• 20 of what they hear
• 50 of what they see and hear
• 70 of what they articulate
• 90 of what they articulate, do, or demonstrate

14
Education

• Self-management programs
• Arthritis Foundation
• Arthritis Self-Management Course
• videos, pamphlets, newsletters
• help patients understand the condition and steps
  they can take to alter the course of the disease

15
Social Support

• Health professional support via telephone contact
• involve family, friends, or caregivers
• opportunity to raise and answer questions
• reinforce info about medications and treatment
  compliance

16
Physical therapy

• weight loss (if over weight)
• assess mobility, flexibility, muscle strength,
  and ability to walk
• teach warm-up techniques (heat application,
  stretching, aerobic and strength exercises)
• provide assistive devices for ambulation (canes,
  crutches, walkers) to maximize mobility and
  minimize muscle strain and effort

17
Occupational Therapy

• Focusing on
• performing activities of daily living
• maintaining independence and self-reliance
• learning about joint protection and energy
  conservation techniques
• providing assistive devices

18
Aerobic Exercise

• ongoing plan for daily exercise
• aerobic walking
• aquatic activities
• sponsored programs
• Arthritis Foundation
• local youth (YMCA, YWCA) or senior centers

19
Pharmacologic Therapystep approach

• Acetaminophen - up to 1,000 mg qid
• first line therapy, effective, low cost
• NSAID (if acetaminophen fails)
• 3 fold risk of GI complications
• Opioid analgesics
• codeine, propoxyphene, oxycodone
• for short-term acute exacerbations
• Intra-articular corticosteroid injection

20
Individualizing thetreatment plan

• pain rating scale
• patient diary
• patient education
• presenting therapy as a physician-patient
  partnership

21
Patient-Physician Relationship

• A strong relationship is based on five concepts
• mutual trust
• mutual respect
• flexibility on the part of the physician
• concern of the patients well-being
• extend a hopeful and positive framework

22
References

• Guidelines for the medical management of
  osteoarthritis.Hochberg MC, Altman RD, Brandt
  KD. Arthritis Rheum 199538(11)1535-1546
• The American College of Rheumatology criteria for
  the classification and reporting of
  osteoarthritis of the hip.Altman R, Alarcon G,
  Appelrouth D. Arthritis Rheum 199134505-14
• Development of criteria for the classification
  and reporting of osteroarthritis classification
  of osteoarthritis of the knee.Altman R, Asch E,
  Block D, et al. Arthritis Rheum 1986291039-49
• OsteoarthritisCreamer P, Hochberg MC. Lancet
  1997350503-509