All about Osteoarthritis (in 20 minutes

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• All about Osteoarthritis (in 20 minutes)

Howard Amital, MD, MHA Daniela Amital, MD,
MHA Department of Medicine D Meir Medical
Center, Kfar-Saba
Wear and tear of the joints
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Definition

• Also known as degenerative joint disease or
  wear and tear arthritis.
• Progressive loss of cartilage with remodeling of
  subchondral bone and progressive deformity of the
  joint (s).
• Cartilage destruction may be a result of a
  variety of etiologies

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• Prevalence and epidemiology
• Over 20 million affected in U.S.
• About 60-90 of people over age 65
• Under 45 yrs it is equally common in men and
  women
• Over 55 yrs its more common in women
• Nodal OA involving DIP and PIP joints is more
  common in women and their first degree female
  relatives

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Age-Related Prevalence of OA Changes on X-Ray
Men
Women
DIP
DIP
Knee
Prevalence of OA ()
Prevalence of OA ()
Knee
Hip
Hip
Age (years)
Age (years)
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• Premature OA associated with gene mutations that
  encode collagen types 2, 9, 10
• OA of knee is more common in African American
  women
• Commonest cause of long-term disability
• Large economic impact as a result of medical
  costs
• OA cost the U.S. economy nearly 125 billion per
  year in direct expenses and lost wages and
  production.

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• Risk factors
• Metabolic (hemachromatosis)
• Inflammatory (RA, infection)
• age
• gender

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• Risk factors
• genetic factors
• trauma
• weight

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Classification

• Primary
• Idopathic
• Localized or generalized
• Local knee, hip, spine, hands
• Generalized large joints and spine
• Small peripheral joints and spine
• Mixed and spine

• Secondary
• Post-traumataic
• Congenital or developmental
• Localized or generalized
• Calcium deposition disease
• Other
• Inflammatory
• Avascular necrosis

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The process at a cellular level

• Cartilage matrix has increased water content and
  decreased proteoglycan
• This is different from the changes that occur
  with aging ? cartilage dries up.
• Increased activity of proteinases compared to
  inhibitors of proteinases.
• Breakdown products of cartilage cause
  inflammatory reaction of synovium
• Cytokines cause matrix degeneration. Where do
  they come from?
• ? chondrocytes
• Cycle of destruction starts
• Compensatory bone overgrowth occurs - subchondral
  bone increases in density

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Overview of the process

• Articular cartilage gets disrupted
• Damage progresses deeper to subchondral bone

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• Fragments of cartilage released into joint
• Matrix degenerates
• Eventually there is complete loss of cartilage
• Bone is exposed

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What to look for in an x-ray

• Radiographic changes visible relatively late in
  the disease
• Subchondral sclerosis
• Joint space narrowing esp where there is stress
• Subchondral cysts
• Osteophytes
• Bone mineralization should be normal

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• Left View of normal elbow cartilage through an
  arthroscope - white, glistening, smooth
• Right severe elbow osteoarthritis - cartilage is
  lost and the bone underneath is exposed

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• left Normal x-ray
• Right worn away cartilage reflected by decreased
  joint space

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• Joint space narrowing where there is more stress
• Subchondral bone has thickened
• bony overgrowth

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• significant joint space narrowing as well as
  proliferative bone formation around the femoral
  neck (arrows)

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• painful bone on bone contact at the CMC joint and
  the large bone spurs -- osteophytes.

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• Are crystals found in osteoarthritic joints?
• Yes
• Calcium pyrophosphate dihydrate and apatite.
• Are of unknown significance and asymptomatic

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Clinical features and diagnosis

• Pain
• Sources
• Joint effusion and stretching of the joint
  capsule
• Torn menisci
• Inflammation of periarticular bursae
• Periarticular muscle spasm
• Psychological factors
• Deep, aching localized to the joint
• Slow in onset
• Worsened with activity in initial stages
• Occurs at rest with advanced disease

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Involved joints

• DIP, PIP
• 1st carpometacarpal
• cervical/lumbar facet joints
• 1st metatarsophalangeal
• Hips
• Knees
• Uncommon
• Wrist, elbows, shoulders, ankles

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• 1st metatarso-phalangeal most commonly affected
  in OA of the foot.

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Typical findings

• Heberdens nodes
• Bouchards nodes

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• Rt varus deformity of the knee

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Treatment

• Non-pharmacokinetic
• No proven medication-based disease modifying
  intervention exists.
• Analgesics (acetominophen)
• NSAIDS
• Help pain symptoms but controversial for long
  term use in non-inflammatory OA because of risks
  vs benefits
• Narcotics
• Intra-articular steroids
• Chondroprotective agents
• Anti-depressants
• Physical activity

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Intra-articular corticosteroids

• May be used if NSAIDS are contraindicated,
  persistent pain despite use of other medications.
• (not gt 4 injections per year per joint)
• 2004 meta-analysis of controlled trials (w/
  placebo) showed short term improvement in knee
  pain, but efficacy in other joints is uncertain.
• saline vs steroid injection?
• A study comparing the two in knee OA showed no
  effect on joint space narrowing or significant
  difference in pain at the end of the study, but
  over a 2 yr period saline injections has less
  pain relief.

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Intra-articular hyaluronans

• Evidence shows they have a small advantage in
  terms of pain control, compared to
  intra-articular placebos or NSAIDS.
• No evidence for improvement in function
• Two studies comparing intra-articular steroids to
  hyaluronans have come to opposite
  conclusions-more trials are needed.

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Surgical arthroscopy

• arthroscopy is not recommended for nonspecific
  "cleaning of the knee.
• Used to fix specific structural damage on imaging
  (repairing meniscal tears, removing fragments of
  torn menisci that are producing symptoms).

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• Joint replacement
• If all other rx ineffective, and pain is severe
• Loss of joint function
• Joints last 8-15 years without complications

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• Fibromyalgia
• Are new horizons seen ?
• OR Fibromyalgia for the psychiatrist

Howard Amital, MD, MHA Daniela Amital, MD,
MHA Department of Medicine D Meir Medical
Center, Kfar-Saba
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• "The Three Graces" by Peter Paul Rubens
  (1577-1640), Prado, Madrid, Spain.

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• Fibromyalgia - criteria

• Widespread musculoskeletal pain
• Excess tenderness in at least 11 of 18
  predefined anatomic

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Frida Kahlo (1907-1954)
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Frida used to describe her own paintings as "the
most frank expression of myself"
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The Broken Column
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Chronic Pain Defined by Mechanisms

• Peripheral (nociceptive)
• Primarily due to inflammation or damage in
  periphery
• NSAID, opioid responsive
• Behavioral factors minor
• Examples
• OA
• Acute pain models (e.g. third molar,
  post-surgery)
• RA
• Cancer pain

• Central (non-nociceptive)
• Primarily due to a central disturbance in pain
  processing
• Tricyclic responsive
• Behavioral factors more prominent
• Examples
• Fibromyalgia
• Irritable bowel syndrome
• Tension and migraine headache
• Interstitial cystitis / vulvodynia, non-cardiac
  chest pain / etc.

• Mixed
• Neuropathic

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• Fibromyalgia - some facts

• 10 times more common in females Studies of
  humans and of animals have noted that females
  have a lower pain threshold and tolerance and a
  higher sensitivity to various noxious stimuli.
  Pillemer et al. Arthritis Rheum.
  1997401928-1939
• Prevalence in the community increases with age
  from
  2 at age 20 to 8 at age 70
• Most patients present between the ages of 30 and
  55
• Approximately 50 of cases appear after a
  specific event, most often (physical or
  emotional trauma)
• Wolfe F et al. Arthritis Rheum 1995, 3819-28.

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• The tender point count functions as a
  sedimentation rate' for distress

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WHAT IS THE ASSOCIATION BETWEEN FM AND
PSYCHIATRIC ILLNESS? - Depression

• A lifetime history of depression has been
  reported in 50 to 70
• Current major depression, however, was found in
  only 18 to 36

Goldenberg DL et al, Arthritis Rheum.
1996391852-1859 Goldenberg DL et al, Arch
Intern Med, 1999159777-785
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WHAT IS THE ASSOCIATION BETWEEN FM AND
PSYCHIATRIC ILLNESS? - Depression

• Similar symptoms fatigue, sleep disturbances,
  and cognitive disturbances.
• Similar comorbid conditions migraines, muscular
  headaches, CFS, IBS, and premenstrual syndrome.
• Often improve with antidepressant medications

Triadafilopoulos G et al, Dig Dis Sci.
19913659-64.
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WHAT IS THE ASSOCIATION BETWEEN FM AND
PSYCHIATRIC ILLNESS? - other psychiatric
disturbances

• Dysthymia - 10 Current prevalence (CP)
• Panic disorder - lifetime prevalence (LP) -16,
  CP- 7
• Phobia LP - 16, CP -12.

Epstein SA et al. Psychosomatics 19994057-63.
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The overlapping ill defined disorders
FIBROMYALGIA 2 - 4 of population defined by
widespread pain and tenderness
MULTIPLE CHEMICAL SENSITIVITY - symptoms in
multiple organ systems in response to multiple
substances
CHRONIC FATIGUE SYNDROME 1 of population
fatigue and 4/8 minor criteria
SOMATOFORM DISORDERS 4 of population multiple
unexplained symptoms - no organic findings
EXPOSURE SYNDROMES e.g. Gulf War Illnesses,
silicone breast implants, sick building syndrome
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Rate of fibromyalgia
plt0.001 ?240 (d.f 2)
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Distribution of severity of FM
No. of patients
plt0.0001 ?260.5 (d.f 8)
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Results average tender point count
plt0.001, Anova

• Controls (n49) 0.18 0.4
• PTSD (n55) 8.9 5.4
• Depression - (n20) 2.85 3

Clinical Global Impression (CGI) PTSD
5.67 DEPRESSION 5.65
p0.62, Anova
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A Six-month, Double-blind, Placebo-controlled,
Durability of Effect Study of Pregabalin for Pain
Associated With Fibromyalgia Crofford et al ACR
2006

• By the end of the study nearly twice as many
  placebo patients (61) had lost therapeutic
  response compared with pregabalin-treated
  patients (32).
• The most common AEs considered treatment related
  during OL were dizziness (36) and somnolence
  (22).

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Thank you for your attention