12/12/2015 Disclosures � No financial disclosures UCSF 10 th Annual Primary Care Sports Medicine Conference Total joints and sports medicine? 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 Brian Ben Ma Anthony Me Feeley Luke � Knee 2-3x > Hip 1
12/12/2015 Impact Evidence Based Guidelines � AAOS Clinical Practice Guidelines � Total annual costs of OA per patient: $5700 � 22 recommendations � Job related costs: $3.4 – 13.2 billion � Published in 2008, revised in 2013 � Systematic review of available studies on knee OA � About 40% of all OA patients rated their � Highlights effective and efficient nonarthroplasty treatment health “poor” or “fair” of knee OA � In 1999 adults w/ knee OA reported more � OARSI Guidelines than 13 days of missed work lost due to � OA Research Society International health problems � 25 guidelines � OA is associated with excess mortality from � Systematic review (1945-2006) � Adopted in 2008 all causes, cardiovascular and dementia � International multidisciplinary team (primary care, related deaths rheumatology, orthopedics) Treatment Effectiveness vs Risk Interventions Summary Low Risk Intermediate Risk High Risk � Goal is to reduce pain and maintain Patient Self Education Acupuncture Arthroscopic function Debridement Regular Contact to Acetaminophen/NSAIDs Osteotomies Promote Self Care � Interventions range from lifestyle Weight Loss Corticosteroid Injections Interpositional Devices modification, rehabilitation, mechanical Low Impact Aerobic Hyaluronate Injections Exercises aids to pharmacologic therapy and surgery ROM Exercises Needle Lavage QuadStrengthening � More invasive treatments carry greater risk, Patellar Taping require mutual discussion of options Heel Wedges between patient and physician Unloader Brace Glucosamine- Chondroitin Walking aid 2
12/12/2015 Primer on AAOS Grading & OARSI Grading & Strength of Recommendations Recommendations (SOR) � A: Good evidence � A: Recommended (consistent level I studies) � B: Fair evidence � B: Suggested (consistent level II and III studies) � C: Poor quality evidence (level IV or � C: Option V) � Inconclusive: when there is insufficient � Inconclusive: Neither OR conflicting recommended, nor evidence not recommended Low Risk Treatment Low Risk Recommendations Recommendations � Grade A � Grade C � Weight loss � Regular contact to promote self-care � Low impact aerobic fitness exercises � Range of motion/flexibility exercises � Do NOT recommend glucosamine/chondroitin sulfate � Inconclusive � Grade B � Patient self education � Unloader braces � Quadriceps strengthening exercises � Patellar taping for short term pain relief � Do NOT suggest heel wedges 3
12/12/2015 Weight loss Weight loss � Knee joint forces range: � Patients with OA who are overweight (BMI > 25) should be encouraged to lose weight � 1/3 to ½ body weight during (min 5% of body weight) and maintain walking weight at lower level with diet modification � 3x BW during stair climbing and exercise � LOE: 1, Grade A; SOR 96% � 7x BW during squatting � Weight reduction can have � Knee: a multiplicative effect on � 2 RCTs and a meta-analysis with mild to forces across body joints moderate effect sizes for pain relief, stiffness and functional improvement � Most effective � Decrease in WOMAC scores of >50% interventions combine diet, � Hip: physical exercise and � no RCTs behavior modifications � Based on expert opinion (LoE IV) Aerobic Exercises Aerobic Exercises � Patients with OA should � Although benefits towards undertake regular low-impact OA symptoms may be aerobic exercise modest, use is supported by � LOE: I, Grade A, SOR 96% low cost and additional � Knee: overall health benefits � Supported by 13 RCTs, pain relief (ES = 0.52), disability (ES = 0.46) � Hip: � Aquatic Exercises: � Largely based on clinical expertise (LoE IV) � Minimize joint stress and ground � 2 RCTs show mild benefit of reaction forces water therapy in pain relief (ES = � Beneficial to cardiopulmonary system 0.25) and stiffness (ES = 0.17) by reducing abrupt ↑ in HR and ↑ O2 consumption compared to land 4
12/12/2015 Glucosamine Glucosamine � ORSI: � Level I, Grade A, SOR 63% � Treatment with glucosamine may provide � AAOS: � CANNOT RECOMMEND it be prescribed symptomatic benefit. � Based on AHRQ (Agency for Healthcare � However if no benefit noted within 6 Research & Quality) report on 1 RCT and 6 systematic reviews months, it should be discontinued. � Glucosamine/Chondroitin Arthritis Intervention Trial (GAIT) � Large (n=1583), high quality, NIH funded � In US, glucosamine not regulated by multicenter RCT � Showed no significant differences FDA for medical use compared to placebo at 24 weeks � Highest level of available evidence � As a dietary supplement, formulation and � 5 of 6 meta-analyses concluded that safety are solely responsibility of glucosamine or chondroitin superior to placebo manufacturer � However, these results do not outweigh GAIT due to lower quality of primary studies and small differences reported Patient Self Education Quadriceps strengthening � LOE: II, Grade B � Supported by AAOS and OARSI: � OARSI – muscle � LOE: II, Grade B, SOR 97% strengthening had 0.32 � Lifestyle changes, exercise, weight pooled ES for pain and loss, activity modification disability based on 13 � Statistically sig improvement in pain RCTs � Supported by two meta-analyses, � AAOS – one level II overall ES small (0.06) systematic review of 9 RCTs showing statistically � Low cost, no associated harms significant, and possibly � Not possible to refine which aspects clinically significant effect of self-management programs most � Low risk/harm intervention effective 5
12/12/2015 Patellar taping Patient contact/Telephone � LOE: II, Grade B � Monthly telephone contact by lay � Goal of reducing lateral facet personnel aimed at promoting self contact forces on patella care for knee OA patients can � Review of one level I RCT and improve joint pain and physical two level II RCTs showing function statistically significant and � LOE: IV, Grade C, SOR 66% possibly clinically significant � RCT of 439 OA patients (posthoc effect after taping (measured by analysis) VAS) � Pain relief (ES = 0.65) even in small � Only when taping is compared group of patients whose medical w/ no taping, not when treatment and PT remained stable compared to sham Range of Motion Exercises Unloader Brace � LOE: II, Grade inconclusive � LoE V, Grade C � AAOS: 1 systematic review of 2 RCTs � AAOS: Qualitative, not quantitative data � Pts improved more than neoprene sleeve or � No published studies � control � Based on expert opinion alone that range of � Cochrane Review (LoE I) and single RCT compared 3 groups: motion exercises address impairment in OA use of valgus brace + medical treatment and are low harm, low cost � neoprene sleeve + medical treatment � � OARSI: medical treatment alone � Assessment at 6 months showed greater � � ROM lumped with aerobic fitness and improvement in WOMAC scores w/ valgus brace than neoprene sleeve muscle strengthening, no separate analysis 6
12/12/2015 Physical Therapy Walking aids � Grade- inconclusive, SOR 89% � No RCTs, but expert consensus � OARSI: (LoE IV) to support use � patients with hip and knee OA may benefit from referral to PT for evaluation and instruction in exercises � Evidence showing 40% of patients � Evaluation may result in provision of assistive devices such as canes and walkers, as appropriate w/ hip or knee OA own cane or � Mainly supported by expert panel consensus (LoE stick IV) � Three RCTs showed improvements in knee pain, � Kinematic studies showing function, health related quality of life diminished joint reactive forces up � Two other RCTs showed no persistent benefit compared to standard treatment without PT or to 50% using cane placebo PT Moderate Risk Treatment Lateral Heel Wedges Recommendations � LOE: II, Grade B, SOR 76% � Grade A � AAOS: � We CANNOT recommend using � Cannot suggest lateral heel wedges intraarticular hyaluronate injections � 1 level II systematic review, 3 level II � Grade B RCT � Acetaminophen/NSAIDs � OARSI: � Intraarticular corticosteroids for short term � Every patient with hip or knee OA pain relief should receive advice on appropriate footwear � We CANNOT suggest Needle lavage � Based on expert opinion alone (LoE IV) � Inconclusive � Lateral wedged insoles for varus knee � Acupuncture OA supported by three observational studies but not by three RCTs 7
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