Arthritis

Question 1

what is primary OA

Answer 1

idiopathic

Question 2

what is secondary OA

Answer 2

post - traumatic
underlying cause or event or congenital malformation

Question 3

prevalance of OA

Answer 3

302 mil world wide
1 in 4 people in US

leading cause of disability in older adults

spands decades of life

Question 4

most commonly affects joints

Answer 4

hips
knees
hands

Question 5

clinical features of OA

Answer 5

loss of articular cartilage

synovitis

boney changes

ligamentous changes

meniscal changes

Question 6

patient impct of OA

Answer 6

Pain- -secondary affects contribute to the pain such as synovitis not necessarily loss of cartilage

Swelling – occur w synovitis

Stiffness – walking/moving on it less

Loss of Function

Question 7

OA pathophysiology

Answer 7

degenerative process of the whole joint with different phenotypes emerging

Question 8

risk factors for primary OA

Answer 8

age
obesity/metabolic disease
sex (60% female(

Question 9

major components of normal cartilage

Answer 9

water
extracellular matrix (ECM) and proteoglycans
chondrocytes (responsible for both catabolism and anabolism)

Question 10

function of cartilage

Answer 10

Withstand highly repetitive compressive and shear loads, maintain a near frictionless joint surface environment, allow force transmission between articulating bones

Question 11

physiology and biomechanics of normal cartilage

Answer 11

Uses hydrodynamics- water flows out in response to compression

Proteoglycans are hydrophilic, attract water to flow back into cartilage following water loss

Combination of hydrodynamics and ECM structure allow compressive forces to be converted to shear at the calcified cartilage/bone interface

Question 12

cartilage regeneration of normal cartilage

Answer 12

Chondrocytes repair ECM (very slow process) (Otero 2012, Eyre 2006) -> poor healing potential (Buckwalter 1998)

Chondrocytes are mechanosensitive, regenerative process is stimulated in response to loading (Gilbert 2018)

Question 13

impairment of cartilage regeneration of OA

Answer 13

Regeneration is too slow to keep up with damage repair AND/OR regeneration pathway is altered
- Presence of inflammation impacts chondrocyte function
–Produce more pro-inflammatory markers and matrix degrading enzymes
–Early chondrocyte senescence (Liu-Bryan 2015) = death

Proteoglycan loss occurs first, followed by eventual ECM breakdown
-Loses ability to handle loads via hydrodynamics (less water), placing more stress on ECM

Articular Cartilage Breakdown
–This process is going on for YEARS/DECADES before we can see cartilage breakdown
–Translation: By the time we start to see cartilage breakdown its far too late

Question 14

secondary OA due to an associated event could be

Answer 14

joint injury: PTOA
- knee injury 6x risk increases

abnormal alignment or geometry
- malalignment of the knee is on independent risk of OA progression

The normal joint structure and biomechanics are impacted resulting in both inflammatory environment and changes to loading environment
Slow cartilage metabolism does not adapt quickly enough to joint changes

Question 15

PTOA

Answer 15

The major issue:
250k ACLR yearly (mostly impacting people under 25)
~50% will have radiographic OA within 10-20 yrs

Translation:
- Huge cohort of young individuals with old knees
–Lots of years left in the medical system
—Downstream healthcare impacts of physical inactivity and/or disability
–Joint arthroplasty only lasts~ 20 yrs
—These people may need multiple arthroplasties in their lifetime = $$$$$

Question 16

summary of OA?

Answer 16

Much more complex than originally thought (not just wear and tear)
Cartilage regeneration is unable to keep up with microdamage
Impacted by biomechanics and/or inflammatory environment
Impacts the whole joint (not just articular cartilage)
We don’t fully understand what causes symptoms
Worse radiographic OA more likely to have symptoms
Primary OA: Intersection between aging, genetics, metabolic syndrome/obesity, lifestyle choices
Secondary OA: Intersection between joint biomechanics and inflammation

Question 16

common imaging features

Answer 16

Loss of joint space width
Osteophyte formation
Sclerosis of subchondral bone

Question 17

imaging modalities

Answer 17

radiographs (gold standard)
MRI
CT

Question 18

grade 1 OA

Answer 18

possible osteophites
doubtful JSN
doubtful OA

Question 19

grade 2

Answer 19

definite osteophites
possible JSN
mild OA

Question 20

grade 3 OA

Answer 20

moderate osteophites
definite JSN
moderate OA

Question 21

grade 4 OA

Answer 21

large osteophites
great JSN
severe OA

Question 22

grade 0 OA

Answer 22

no OA
no osteophites
no jsn

Question 23

OA imaging

Answer 23

Advanced Imaging Techniques

New promising imaging sequences that allow us to assess cartilage physiology before cartilage damage is evident

MRI T1rho: Associated proteoglycan content/concentration

MRI T2*: Associated with ECM orientation and free vs bound water

Question 24

OA treatment

Answer 24

We currently have zero treatments that have been proven effective at reversing OA or stopping its progression The treatments we do have: Treat the symptoms (reduce pain) Promote function Prevent OA from happening in the first place Injury prevention (Secondary OA) Lifestyle (Primary OA) Moderate Activity Weight Management

Question 25

OA medical management treatment for NSAIDS

Answer 25

Effective at reducing pain and targeting synovitis Cheap Cons: Some with comorbidities unable to use Some have topical versions available Con: Treats symptoms, no impact on disease

Question 26

common NSAIDS OA treatment

Answer 26

Ibuprofen Naproxen Diclofenac

Question 27

pharm interventions for OA

Answer 27

NSAIDs Corticosteroids Hyaluronic Acid Biologics

Question 28

surgery interventions for OA

Answer 28

Debridement Cartilage Repair Joint Replacement

Question 29

corticosteroids treatment

Answer 29

common: cortisone injections (kenalog) tx: Effective at reducing short-term pain and inflammation Intended to be an adjunct More localized treatment Cons: Some with comorbidities unable to use Con: Treats symptoms, no impact on disease Con: Limited dosage schedule, infection risk

Question 30

hyaluronic acid for OA

Answer 30

common: Viscosupplementation) Synvisc Hyalgen Euflexxa treatment: Can improve symptoms and function in mild/moderate OA (high bias evidence) “lubricates” the joint Cons: Expensive (limited insurance coverage) Con: Treats symptoms, no impact on disease Con: Limited dosage schedule

Question 31

biologics for OA tx

Answer 31

Common: Stem Cell Therapy Platelet Rich Plasma (PRP) Treatment: Promising basic science results Some mixed results but mostly poor findings of effectiveness in vivo No Standardization Cons: Expensive (not covered by insurance) Cons: Travel to special clinic

Question 32

summary of medical management for OA

Answer 32

DMOADs do not exist yet Corticosteroids have short-term symptomatic benefits and should be adjuncts Placebo effect from injections (Bannuru 2015, Ayhan 2014) Viscosupplementation studies that show benefit have high risk of bias Recommendation: try it if the patient had little to no effect from steroid or can’t have steroid Surgery: Joint replacement is highly effective but still considered a salvage procedure Reduces pain, reduces disability, improves QOL

Question 33

rehab interventions: weight management

Answer 33

9-76% reduction in pain following gastric bypass (McGoey 1990) Pain scores reduced, functional scores improve (Abu-Abeid 2005) Improved joint space associated with weight loss (Abu-Abeid 2005) Con: Poor adherence to interventions Dose response exists (More weight loss more symptomatic improvement) Messier 2018

Question 34

rehab interventions: exercise

Answer 34

Maintain and/or improve functional capacity Supplement diet for weight loss `No specific recommendations: Moderate activity (ACSM) No evidence to support a hierarchy of types of exercise Whatever the patient likes to do will improve adherence

Question 35

rehab program for exercise OA management

Answer 35

Decrease pain, improve function, improve QOL Quad strength/power = Function PT had better outcomes through 1 year follow up vs corticosteroid injection

Question 36

bracing for management

Answer 36

Unloader braces have some symptomatic benefit Other braces: Likely placebo/tactile Braces are generally bulky, uncomfortable, and/or not aesthetically pleasing

Question 37

the debate

Answer 37

dont unnecessarily load vs dont change activity pendulum

Question 38

current opinoin

Answer 38

Not all OA is the same: Primary vs secondary with phenotypes of each It is unlikely there will be one blanket recommendation, each subset will need its own specific recommendations that is also adjusted to the individual patient The most basic principle of treatment is the risk reward benefit to the patient Primary OA: Should we promote physical activity (including that with high joint loading) despite the risk of promoting articular cartilage degeneration Secondary OA: Does the risk reward benefit change given the different pathophysiology?

Question 39

treattment principples summary

Answer 39

Promote physical activity for weight management, joint health maintenance, pain/mental health Weigh the risk reward for whether higher loading activity is appropriate Use irritability as a guide Quad strength and power to maintain function Combination of open and closed chain depending on joint irritability and compensations Assistive device use for significant gait deviations Self-management focus Booster visits currently being explored, watch for evidence

Question 39

the future

Answer 39

Harness mechanosensitivity of chondrocytes to promote regeneration Can we identify specific loading inputs to optimize cartilage health after injury and surgery Likely in combination with pharm Use of biologics to regenerate damaged cartilage Our current post-injury and post-op treatments are focused on short term goals of return to sport and function and have little focus on long-term joint health

Question 40

inflammatory arthritis history

Answer 40

UNEXPLAINED joint pain with associated swelling (No MOI but inflammation). Joint(s) can look acutely injured or infected (warm, red, swollen, painful) Frequently have relapsing remitting presentation Joints can become damaged over time leading to changes similar to OA (chronic joint degradation) Make sure you do a high quality systems review as many of these conditions have systemic effects impacting things other than MSK

Question 41

rheumatoid arthritis

Answer 41

Fairly common: 0.3 – 1% in US (Alamanos 2006) Chronic Systemic autoimmune disease that attacks the joints Hands, wrists, shoulders, elbows, knees, ankles feet General fatigue How many joints and any structural deformity Increased cardiovascular risk Promote physical activity

Question 42

psoriatic arthritis

Answer 42

Autoimmune disease in people with psoriasis that can impact joints Nail and skin changes 1/3 of people with psoriasis DIPs, wrists, ankles, knees Can also impact enthesis (usually heel)

Question 43

lupus

Answer 43

Arthritis/arthralgia is present in 95% of patients with SLE -Mimics RA in 5-15%

Question 44

lymes disease

Answer 44

Tends to occur in late stage infection After systemic symptoms have resolved Can have intermittent or persistent joint attacks Lyme bacteria enters joint and can remain Common in knee Can have swelling without pain

Question 45

gout

Answer 45

Inflamed joints due to urate crystal formation in synovial fluid. 3.9% in US

Question 46

boutonniere

Answer 46

PIP flexed and DIP ext

Question 47

swan neck

Answer 47

PIP extended, DIP flexed, MCP flexed

Question 48

hitchhikers thumb

Answer 48

MCP flexion, IP extension

Question 49

claw toe

Answer 49

MTP ext, PIP/DIP flexion

Question 50

IA medical management - disease modifying antirheumatic drugs (DMARDS)

Answer 50

Many different DMARD protocols, used in virtually all inflammatory arthritis conditions Typically have a maintenance dose that is then increased during flares Trial and error to get maintenance and flare doses right (as little as gets the job done) Can be combined with corticosteroids to minimize inflammation during flares Common Pharm Methotrexate Leflunomide Hydroxycholoroquine Sulfasalazine Because they inhibit immune response, increased risk of infection

Question 51

IA PT Management

Answer 51

Identify when joints are “Hot”: Red, swollen, painful/irritable During Flare: Reduce pain and inflammation, promote ROM and maintain strength Avoid high impact activity During Remission: Promote physical activity to limit systemic impacts Promote moderate intensity exercise and maintenance of strength and ROM to avoid deformity and/or dysfunction Always use your irritability principles to guide your treatment Splinting for deformity (covered in Rehab Tech)