Transcript Slide 1
* For Best Viewing:
Open in Slide Show Mode
Click on
icon
or
From the View menu, select the
Slide Show option
* To help you as you prepare a talk, we have included the
relevant text from ITC in the notes pages of each slide
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
Terms of Use
The In the Clinic® slide sets are owned and copyrighted by the
American College of Physicians (ACP). All text, graphics,
trademarks, and other intellectual property incorporated into the
slide sets remain the sole and exclusive property of ACP. The slide
sets may be used only by the person who downloads or purchases
them and only for the purpose of presenting them during not-forprofit educational activities. Users may incorporate the entire slide
set or selected individual slides into their own teaching
presentations but may not alter the content of the slides in any way
or remove the ACP copyright notice. Users may make print copies
for use as hand-outs for the audience the user is personally
addressing but may not otherwise reproduce or distribute the slides
by any means or media, including but not limited to sending them as
e-mail attachments, posting them on Internet or Intranet sites,
publishing them in meeting proceedings, or making them available
for sale or distribution in any unauthorized form, without the
express written permission of the ACP. Unauthorized use of the In
the Clinic slide sets constitutes copyright infringement.
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
in the clinic
Osteoarthritis
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
What are the major risk factors for OA?
Older age
Genetic inheritance
Race and ethnicity
Similar rates hand, knee OA in Europeans and Americans
Lower rates hip OA in African blacks, Asian Indians, and
Chinese persons from Beijing and Hong Kong
Higher rates knee OA among older Chinese women in
Beijing than white women in the Framingham study
Being female
Local mechanical factors
Malalignment, muscle weakness, internal derangements
Excessive joint loading
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
Should diet and physical activity be
modified to prevent knee OA?
Obesity: most important modifiable risk factor
Counsel overweight and obese patients to lose weight
Encourage physical activity
Conditioning programs, graduated training schedules
Muscle strengthening for quadriceps
But avoid intense loading of previously injured joints
Contact sports increase risk of knee injuries
Meniscal tears and cruiciate ligament injuries predispose
patients to OA regardless of surgical repair
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
CLINICAL BOTTOM LINE: Prevention…
Obesity is most important modifiable risk factor for knee OA
Encourage exercise to maintain quadriceps strength
If participating in sports, advise proper training and
conditioning to avoid injury
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
What are the characteristic symptoms of OA?
Pain
Activity-related or mechanical
Exacerbated by use and alleviated by rest
Usually insidious in onset; nocturnal in advanced disease
Morning stiffness of brief duration
Reduced range of motion and crepitus
Absence of systemic features (e.g., fever)
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
What are the characteristic physical
examination features?
Crepitus
Audible, palpable grating quality when the knee is flexed
and extended
Bony prominence
Particularly finger joints: Heberden and Bouchard nodes
Squaring of joint contour: 1st carpometacarpal articulation
Malalignment
Use goniometer to visually bisect thigh and lower leg
Remember: back and hip disorders can refer pain to knee
Evaluate both anatomical sites to isolate the origin of pain
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
When should imaging studies be ordered?
Diagnose OA on the basis of history and physical exam
Radiographs are insensitive to early pathologic features
Radiograph findings correlate poorly with symptoms
Plain-film radiography can confirm clinical suspicion
Joint space narrowing
Osteophyte (or spur) formation at the joint margin
Cortical bone thickening (or eburnation)
Formation of subchondral cysts
MRI useful to evaluate for internal derangement of knee
or early osteonecrosis
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
Should other diagnostic studies be
pursued in suspected cases?
For diagnosis, lab testing is not helpful
OA is relatively noninflammatory
CBC & acute-phase reactants should be normal
Before NSAIDs: test creatinine level + liver function tests
Especially in elderly and in those with comorbid conditions
Establishes a baseline if iatrogenic features develop
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
What are the diagnostic criteria?
Knee OA
Use criteria from American College of Rheumatology
Based on clinical, radiologic, & synovial fluid analysis data
Hip OA and hand OA
American College of Rheumatology Criteria also valuable
for classifying OA of the hip and hand joints
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
Are there distinct subsets?
Generalized OA
Affects multiple joints in appendicular and axial skeleton
Secondary OA
Result of well-defined cause (e.g., injury, endocrinopathy)
Previous damage from infection or an underlying
inflammatory arthropathy
Erosive OA
Involves hand joints and predominantly affects women
Flares cause erythema, swelling, severe pain
arosion of affected joints and osteophytes and ankylosis
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
What is the differential diagnosis?
Primary OA
Anserine bursitis
Hemochromatosis
De Quervain tenosynovitis
Ochronosis
Meniscal tear
Multiple epiphyseal and
spondyloepiphyseal
dysplasia
Osteonecrosis
Calcium pyrophosphate
deposition disease
Neuropathic (Charcot) joint
Acromegaly
Inflammatory (erosive) OA
Rheumatoid arthritis
OA due to trauma or
mechanical factors
Psoriatic arthritis
Trochanteric bursitis
Gout
Nodal generalized OA
OA of 1st carpometacarpal
joint
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
When should clinicians consult a
rheumatologist or an orthopedist?
If the pattern of joint involvement is atypical
If symptoms suggest inflammatory arthropathy
If manifestations are severe
If features suggest a periarticular source of pain
Such as pes anserine bursitis or trochanteric bursitis
If joint is red, hot, and swollen
Aspiration is needed right away
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
CLINICAL BOTTOM LINE: Diagnosis…
Diagnose OA on the basis of history and physical exam
Use plain-film radiographs for diagnostic confirmation
In atypical cases, perform diagnostic joint aspiration
Confirm suspicion of OA
Exclude other diagnoses (gout, pseudogout, septic arthritis)
Reserve MRI to evaluate for internal derangement
Joint locking or giving way
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
What is the overall therapeutic approach
to OA?
Tailor management to the individual patient
Diminish joint pain, enhance functional capacity
Don’t define treatment rigidly by radiographic findings
Modify treatment according to responses to therapy
Begin with nonpharmacologic, nonsurgical strategies
Including PT, OT, nutritionist
Offer pharmacologic agents if conservative efforts don’t
improve function
Use surgery as a a last resort
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
How does education fit into the patientphysician discussion?
Encourage participation in self-management programs
Information about the natural history of disease
Resources for social support
Instructions on coping skills
Support undertaking a new diet or exercise program
Patient education interventions show therapeutic benefit
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
Is weight loss part of the treatment plan
for knee OA?
Absolutely!
Encourage weight loss through diet and exercise
Can help alleviate OA symptoms if overweight or obese
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
What is the role of exercise in the
management of OA of the knee or hip?
Increases aerobic capacity, muscle strength, endurance
Facilitates weight loss
Individualize exercise programs
To improve adherence, seek an exercise the patient enjoys
Encourage low-impact aerobic exercise (walking, biking)
Discourage high velocity / high impact exercise (running)
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
When should clinicians prescribe physical
and occupational therapy?
PT can improve joint biomechanics with knee or hip OA
Active and passive ROM exercise
Muscle strengthening
Improve alignment
Joint-protection principles
OT is a key resource in management of OA of the hand
ROM exercises
Joint protection instruction
Splinting of the first carpometacarpal joint
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
Is there a role for assistive devices?
For knee or hip OA
Cane or walker can improve gait & mobility, diminish pain
Cane transfers body weight away from the structurally
compromised osteoarthritic limb
Instruction in proper use of a cane is warranted
For hand OA
Large-grip utensils, writing instruments, key holders
Reduce force across arthritic fingers and base of thumb
Enhance the gripping motion and reduce pain
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
What is the role of lateral-wedge insoles?
Knee OA with predominant unilateral involvement
Consider an unloading brace and lateral shoe wedges
Transfers load from the narrowed to the more open knee
compartment
Alleviates knee pain
But evidence for these measures is conflicting
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
Which analgesic agents should clinicians
prescribe first?
Acetaminophen in doses up to 4 g/day
Comparable efficacy to NSAIDs but with safer GI profile
Add NSAIDs or substitute with them if response is
inadequate
NSAIDs
Common 1st-line Rx, but routine use has disadvantages
Significant potential toxicity, particularly in the elderly
Toxicity contributes to hospitalizations and deaths
Prescribe COX-2-selective and nonselective NSAIDs with
caution in light of concern regarding CV risk
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
When are topical analgesics useful?
Topical NSAIDs
Maximizes local delivery and minimizes systemic toxicity
Good first-line agent to avoid systemic therapy
Minimal side effects (local rash, itching, burning)
Topical capsaicin
Active ingredient of chili peppers
Modulates nociceptive fibers
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
When are intra-articular glucocorticoids or
hyaluronic acid indicated?
Knee OA
Improve pain and function in the context of knee OA
Benefit is short-term (about 1 wk)
Intra-articular steroids
Don’t use more than once every 4 months
Repeated use can cause cartilage and joint damage
Hyaluronic acid injection
High-molecular-weight polysaccharide in the
extracellular matrix of connective tissue
Symptomatic benefit equivalent to arthrocentesis
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
What is the role of glucosamine-chondroitin
and acupuncture?
Glucosamine and chondroitin
Symptom-modifying effect is similar to placebo
Potential structure-modifying benefits are uncertain
Acupuncture
May relieve pain and improve function
But data are equivocal
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
When should clinicians consider joint
lavage, debridement, or joint replacement?
When symptoms are refractory to medical therapy
Debilitating pain
Major functional limitations (walking, working, sleeping)
Joint lavage or arthroscopic debridement
No role in OA
Joint replacement
No clear standards for who gets joint replacement
Consider for patients with moderate to severe symptoms
after adequate trial of conservative therapy
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
CLINICAL BOTTOM LINE: Treatment…
Goal: alleviate pain and improve functional capacity
Nonpharmacologic treatments
Weight loss and exercise
Physical therapy, occupational therapy
Pharmaceutical options
If conservative efforts dont improve function
First-line: acetaminophen for mild pain
NSAIDs: use caution due to potential side effects
Surgery
Reserve for advanced disease
When symptoms don’t respond to medical therapy
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.