Osteoarthritis and Exercise

1
Osteoarthritis and Exercise

• Rochelle M. Nolte, MD
• CDR USPHS/USCG

2
Objectives

• 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

3
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

4
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

5
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
  together
• Prevents the concentration of forces when bones
  are loaded

6
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

7
Symptoms 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)

8
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)

9
Laboratory 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

10
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

11
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

12
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

13
Epidemiology 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

14
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

15
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

16
Epidemiology 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

17
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

18
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

19
Risk factors for OA

• Systemic
• Age
• Gender
• Ethnicity
• Genetics
• Hormonal status
• Bone density
• Metabolic/nutritional status

20
Risk factors for OA

• Local
• Obesity
• Major trauma
• Joint deformity
• Physical disability
• Muscle weakness
• Occupational/sports stress

21
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

22
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

23
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

24
Management/Treatment of OA

• Goals
• Educate patient about disease and management
• Improve function
• Control pain
• Alter disease process and its consequences

25
Management/Treatment of OA

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

26
Management/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

27
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

28
Management/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

29
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

30
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

31
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

32
Treatment/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)

33
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)

34
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
  evaluation
• Reumalex (willow bark preparation) inconclusive
• Tipi tea inconclusive

35
Management/Treatment of OA

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

36
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

37
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
  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)

38
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

39
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

40
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)

41
Management/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

42
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

43
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
  questionable
• Study only lasted 6 months. lt500 patients

44
Management/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

45
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

46
Management/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

47
Management/Treatment of OA

• Ultrasound was of no benefit for
• Pain
• Range of motion
• Functional status

48
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
  B)
• Electrical stimulation
• Showed improvement in measurements, but
• Clinical significance from the patients
  perspective is questionable

49
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

50
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

51
Summary

• 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

52
Thank you for coming

• Questions?