Disclosures No financial disclosures UCSF 10 th Annual Primary Care - - PowerPoint PPT Presentation

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UCSF 10th Annual Primary Care Sports Medicine Conference

Disclosures

No financial disclosures

Total joints and sports medicine?

Anthony Luke Ben Ma Brian Feeley Me

Epidemiology

In the US, OA affects

13.9% of adults over 25 years old and 33.6% of those 65+

An estimated 26.9

million US adults in 2005

Knee 2-3x > Hip

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Impact

Total annual costs of OA per patient: $5700 Job related costs: $3.4 – 13.2 billion About 40% of all OA patients rated their

health “poor” or “fair”

In 1999 adults w/ knee OA reported more

than 13 days of missed work lost due to health problems

OA is associated with excess mortality from

all causes, cardiovascular and dementia related deaths

Evidence Based Guidelines

AAOS Clinical Practice Guidelines 22 recommendations Published in 2008, revised in 2013 Systematic review of available studies on knee OA Highlights effective and efficient nonarthroplasty treatment

• f knee OA

OARSI Guidelines OA Research Society International 25 guidelines Systematic review (1945-2006) Adopted in 2008 International multidisciplinary team (primary care,

rheumatology, orthopedics)

Treatment Effectiveness vs Risk

Goal is to reduce pain and maintain

function

Interventions range from lifestyle

modification, rehabilitation, mechanical aids to pharmacologic therapy and surgery

More invasive treatments carry greater risk,

require mutual discussion of options between patient and physician

Interventions Summary

Low Risk Intermediate Risk High Risk Patient Self Education Acupuncture Arthroscopic Debridement Regular Contact to Promote Self Care Acetaminophen/NSAIDs Osteotomies Weight Loss Corticosteroid Injections Interpositional Devices Low Impact Aerobic Exercises Hyaluronate Injections ROM Exercises Needle Lavage QuadStrengthening Patellar Taping Heel Wedges Unloader Brace Glucosamine- Chondroitin Walking aid

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Primer on AAOS Grading & Recommendations

A: Good evidence

(consistent level I studies)

B: Fair evidence

(consistent level II and III studies)

C: Poor quality

evidence (level IV or V)

Inconclusive: when

there is insufficient OR conflicting evidence

A: Recommended B: Suggested C: Option Inconclusive: Neither

recommended, nor not recommended

OARSI Grading & Strength of Recommendations (SOR) Low Risk Treatment Recommendations

Grade A Weight loss Low impact aerobic fitness exercises Do NOT recommend glucosamine/chondroitin

sulfate

Grade B Patient self education Quadriceps strengthening exercises Patellar taping for short term pain relief Do NOT suggest heel wedges

Low Risk Recommendations

Grade C Regular contact to promote self-care Range of motion/flexibility exercises Inconclusive Unloader braces

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Weight loss

Patients with OA who are overweight (BMI

> 25) should be encouraged to lose weight (min 5% of body weight) and maintain weight at lower level with diet modification and exercise

LOE: 1, Grade A; SOR 96% Knee: 2 RCTs and a meta-analysis with mild to

moderate effect sizes for pain relief, stiffness and functional improvement

Decrease in WOMAC scores of >50% Hip: no RCTs Based on expert opinion (LoE IV)

Weight loss

Knee joint forces range: 1/3 to ½ body weight during

walking

3x BW during stair climbing 7x BW during squatting Weight reduction can have

a multiplicative effect on forces across body joints

Most effective

interventions combine diet, physical exercise and behavior modifications

Aerobic Exercises

Patients with OA should

undertake regular low-impact aerobic exercise

LOE: I, Grade A, SOR 96% Knee: Supported by 13 RCTs, pain

relief (ES = 0.52), disability (ES = 0.46)

Hip: Largely based on clinical

expertise (LoE IV)

2 RCTs show mild benefit of

water therapy in pain relief (ES = 0.25) and stiffness (ES = 0.17)

Aerobic Exercises

Although benefits towards

OA symptoms may be modest, use is supported by low cost and additional

• verall health benefits

Aquatic Exercises:

Minimize joint stress and ground

reaction forces

Beneficial to cardiopulmonary system

by reducing abrupt ↑in HR and ↑O2 consumption compared to land

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Glucosamine

Level I, Grade A, SOR 63% AAOS: CANNOT RECOMMEND it be prescribed Based on AHRQ (Agency for Healthcare Research & Quality) report on 1 RCT and 6 systematic reviews Glucosamine/Chondroitin Arthritis

Intervention Trial (GAIT)

Large (n=1583), high quality, NIH funded

multicenter RCT

Showed no significant differences

compared to placebo at 24 weeks

Highest level of available evidence 5 of 6 meta-analyses concluded that

glucosamine or chondroitin superior to placebo

However, these results do not outweigh

GAIT due to lower quality of primary studies and small differences reported

Glucosamine

ORSI: Treatment with glucosamine may provide symptomatic benefit. However if no benefit noted within 6 months, it should be discontinued. In US, glucosamine not regulated by

FDA for medical use

As a dietary supplement, formulation and

safety are solely responsibility of manufacturer

Patient Self Education

Supported by AAOS and OARSI: LOE: II, Grade B, SOR 97% Lifestyle changes, exercise, weight

loss, activity modification

Statistically sig improvement in pain Supported by two meta-analyses,

• verall ES small (0.06)

Low cost, no associated harms Not possible to refine which aspects

• f self-management programs most

effective

Quadriceps strengthening

LOE: II, Grade B OARSI – muscle

strengthening had 0.32 pooled ES for pain and disability based on 13 RCTs

AAOS – one level II

systematic review of 9 RCTs showing statistically significant, and possibly clinically significant effect

Low risk/harm intervention

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Patellar taping

LOE: II, Grade B Goal of reducing lateral facet

contact forces on patella

Review of one level I RCT and

two level II RCTs showing statistically significant and possibly clinically significant effect after taping (measured by VAS)

Only when taping is compared

w/ no taping, not when compared to sham

Patient contact/Telephone

Monthly telephone contact by lay

personnel aimed at promoting self care for knee OA patients can improve joint pain and physical function

LOE: IV, Grade C, SOR 66% RCT of 439 OA patients (posthoc

analysis)

Pain relief (ES = 0.65) even in small

group of patients whose medical treatment and PT remained stable

Range of Motion Exercises

LoE V, Grade C

AAOS: No published studies Based on expert opinion alone that range of

motion exercises address impairment in OA and are low harm, low cost

OARSI: ROM lumped with aerobic fitness and

muscle strengthening, no separate analysis

Unloader Brace

LOE: II, Grade inconclusive AAOS: 1 systematic review of 2 RCTs

• Qualitative, not quantitative data
• Pts improved more than neoprene sleeve or

control Cochrane Review (LoE I) and single

RCT compared 3 groups:

• use of valgus brace + medical treatment
• neoprene sleeve + medical treatment
• medical treatment alone
• Assessment at 6 months showed greater

improvement in WOMAC scores w/ valgus brace than neoprene sleeve

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Physical Therapy

Grade- inconclusive, SOR 89% OARSI: patients with hip and knee OA may benefit from referral to

PT for evaluation and instruction in exercises

Evaluation may result in provision of assistive devices

such as canes and walkers, as appropriate

Mainly supported by expert panel consensus (LoE

IV)

Three RCTs showed improvements in knee pain,

function, health related quality of life

Two other RCTs showed no persistent benefit

compared to standard treatment without PT or placebo PT

Walking aids

No RCTs, but expert consensus

(LoE IV) to support use

Evidence showing 40% of patients

w/ hip or knee OA own cane or stick

Kinematic studies showing

diminished joint reactive forces up to 50% using cane

Lateral Heel Wedges

LOE: II, Grade B, SOR 76% AAOS: Cannot suggest lateral heel wedges 1 level II systematic review, 3 level II RCT OARSI: Every patient with hip or knee OA should receive advice on appropriate footwear Based on expert opinion alone (LoE IV) Lateral wedged insoles for varus knee OA supported by three observational studies but not by three RCTs

Moderate Risk Treatment Recommendations

Grade A We CANNOT recommend using

intraarticular hyaluronate injections

Grade B Acetaminophen/NSAIDs Intraarticular corticosteroids for short term

pain relief

We CANNOT suggest Needle lavage Inconclusive Acupuncture

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Viscosupplementation

LOE: I, Grade A, SOR 64% AAOS

We CANNOT RECOMMEND use of HA

injections for OA

Based on AHRQ findings (42 RCTs, 6 meta-

analyses)

In summary, generally positive effects on pain

and function compared to placebo.

However, variable trial quality, potential

publication bias, unclear clinical significance:

○ Smaller poor-quality trials with pooled effect

size twice as big as larger high-quality trials

○ Lack of minimally clinically important

improvement

Pharmacotherapy

LOE: II, Grade B, SOR 92% Acetaminophen First line analgesic and

preferred analgesic for long term use

≤ 4g / day Cochrane review based on

5986 in 15 RCTs

○ Found to be superior to placebo

in terms of pain relief, but very small reduction (ES = 0.13) of questionable clinical benefit

○ NNT ranging from 2 to 4-16 ○ Toxicity not significantly different

from placebo

Pharmacotherapy

NSAIDs OARSI recommends using NSAIDs at lowest effective dose, but avoiding long term use if possible Evidence that NSAIDs more effective than Acetaminophen from 2004 metaanalysis of RCTs However, NSAIDs adverse effects >> Acetaminophen In patients w/ GI issues, use COX-2 selective med or PPI Exercise caution in patients with CV morbidity

Pharmacotherapy

For patients with increased GI risk

(age > 60, comorbid medical conditions, history of PUD, GIB, concurrent use of corticosteroids/anticoagulants):

Acetaminophen Topical NSAIDs Gastroprotective medication Or COX-2 Topical NSAIDs may provide pain

relief (ES = 0.4) and improvement in function/stiffness vs placebo

Less systemic toxicity than oral, but local

reactions such as itching, burning, rashes

Possibility of publication bias and

• verestimated effect

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Opioids

Weak opioid use can be

considered for treatment of refractory pain.

SOR 82% OARSI:

All systematic reviews highlight lack of long term trials of opiate use (concerns about addiction, dependence)

Moderate (ES = 0.78) effect in pain

relief short term

Significantly limited by side effects:

nausea (30%), constipation (23%), dizziness (20%), somnolence (18%), vomiting (13%)

25% of patients treated with opioids

withdrew from placebo controlled RCTs

Intraarticular Corticosteroids

LOE: II, Grade B, SOR 78% AAOS Suggest it be used for short term pain relief 3 systematic reviews of 12 lesser quality RCTs Demonstrate short term pain relief (1 wk and 16-24 wks; 1- 3wks, within 1-2wks) OARSI: 2006 Cochrane review w/ 13 RCTs Two RCTs support IA steroid injections in OA hips

Needle Lavage

LOE: I/ II, Grade B AAOS recommendation AGAINST needle lavage One level I RCT and three level II RCTs studying needle lavage in knee OA patients Lack of caregiver and

patient blinding in level II studies

Overall lack of

demonstrated effectiveness

Acupuncture

LOE: I, Grade Inconclusive,

SOR 59%

AAOS conducted own meta-analysis

with conflicting results:

Largest effect on pain and

function in studies that did not employ blinding

Small effect in studies with

verified blinding, suggesting apparent effects are result of placebo effect

OARSI May be of symptomatic benefit conflicting evidence from two

RCTs and one systematic review regarding symptomatic benefit

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High Risk Treatment Recommendations

Grade A Arthroscopic debridement or lavage should NOT

be used for primary diagnosis of OA

Grade B Recommend AGAINST free floating

interpositional devices for unicompartmental OA

Grade C Realignment osteotomy is an option in young

patients with unicompartmental OA and malalignment LOE: I/II, Grade A 178 patients: 92 scope, 86 ‘sham’ Primary outcome: WOMAC at 24 months f/u No difference in WOMAC or SF-36 at any

interval

Interpositional Device

LOE: IV, Grade B AAOS Recommend AGAINST using for unicompartmental OA 1 case series High secondary surgeries and revision to TKA

○ 32% @ 2yrs, 62% @3yrs

Realignment Osteotomy

LOE: IV,V: Grade C,

SOR 75%

AAOS: Is an option in active patients w/ sx unicompartmental OA 5 case series No comparison to control/placebo Benefits lasted up to 2 years

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Summary

Optimal management of OA requires

combination of pharmacologic and non- pharmacologic treatment

Weigh treatment efficacy against

risks/cost

Patients who are not obtaining adequate

relief from a combination of pharmacologic and non-pharmacologic measures should be considered for TJA referral

References

• http://www.cdc.gov/arthritis/basics/osteoarthritis.htm
• Samson DJ, Grant MD, Ratko TA, Bonnell CJ, Ziegler KM, Aronson N: Treatment of

Primary and Secondary Osteoarthritis of the Knee. Rockville, MD, Agency for Healthcare Research and Quality, 2007 Sep 1, Report No. 157.

• Zhang W, Moskowitz RW, Nuki G, et al: OARSI recommendations for the management
• f hip and knee osteoarthritis: Part I. Critical appraisal of existing treatment guidelines

and systematic review of current research evidence. Osteoarthritis Cartilage 2007;15:981-1000.

• Zhang W, Moskowitz RW, Nuki G, et al: OARSI recommendations for the management
• f hip and knee osteoarthritis: Part II. OARSI evidencebased, expert consensus
• guidelines. Osteoarthritis Cartilage 2008;16:137-162.
• Brown GA. AAOS clinical practice guideline: treatment of osteoarthritis of the knee:

evidence-based guideline, 2nd edition. J Am Acad Orthop Surg. 2013 Sep;21(9):577-9. doi: 10.5435/JAAOS-21-09-577.

• Hunter DJ. Viscosupplementation for Osteoarthritis of the Knee. N Engl J Med. 2015

Jun 25;372(26):2570. doi: 10.1056/NEJMc1505801.

• Skou ST, Roos EM, Laursen MB, Rathleff MS, Arendt-Nielsen L, Simonsen O,

Rasmussen S. A Randomized, Controlled Trial of Total Knee Replacement. N Engl J

• Med. 2015 Oct 22;373(17):1597-606. doi: 10.1056/NEJMoa1505467.
• Kirkley A, Birmingham TB, Litchfield RB, Giffin JR, Willits KR, Wong CJ, Feagan BG,

Donner A, Griffin SH, D'Ascanio LM, Pope JE, Fowler PJ. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2008 Sep 11;359(11):1097-107. doi: 10.1056/NEJMoa0708333.

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