MANAGEMENT OF JOINT OA PAIN PROMOTING JOINT HEALTH

NON OPERATIVE VS OPERATIVE MANAGEMENT

EPWORTH MSK INSTITUTE SYMPOSIUM 24 JUNE 2016

Dr Peter A Larkins

Sports & Exercise Physician

MBBS, B.MED.SC (HONS), FASMF, FACSP, FFSEM (UK)

Epworth Sports & Exercise Medicine Group

TODAY…….. • Overview of Knee pain

• (OSTEOARTHRITIS)

• Diagnosis , investigation & intervention

• Multi-disciplinary approach to outcomes

• Management principles for OA inc non surgical options & • rehab goals

• New modalities

• Lots of questions

All knee injuries should be taken

seriously and treated and rehabilitated

effectively to prevent the early onset of

degenerative joint disease.

(J.G.P. Williams)

Most Common Knee Injuries (Acute)

1. Simple bruise or strain (“jarred”) 2. Patello-femoral pain 3. Medial ligament 4. Meniscus tear (cartilage) 5. Bone surface injury (chondral) 6. Anterior Cruciate ligt.(ACL) 7. Patella dislocation 8. Posterior Cruciate ligt (PCL) 9. Patella Tendonopathy 10. Capsular

KNEE PAIN • ACUTE

CONTUSION LIGAMENTOUS /CAPSULAR MENISCAL CHONDRAL INFLAMMATORY (eg Gout) FRACTURE MIXED

• CHRONIC

DEGEN (CHONDRAL) - stages MENISCAL RHEUMATOID INFLAMMATORY PATELLO – FEMORAL MIXED

TAKE HOME MESSAGES Knee problems ~ 30% MSK trauma 90% + managed conservatively History & Signs cornerstone of Dx Initial physical exam can be difficult (acute) Multi modal Rx works best Imaging is adjunct to clinical Ax Incomplete Dx = Incomplete Mx = Risk of poor outcome

OSTEOARTHRITIS

a progressive deterioration in the protective articular (cushioning) cartilage covering joint

bone surfaces caused by a failure of cartilage cells to regenerate / resynthesise themselves

after some form of insult

GRADES OF ARTICULAR (CHONDRAL) DAMAGE

• GRADE 1 - softening, swelling, blistering

• GRADE 2 - fibrillation, egg shell cracking, early erosions

• GRADE 3 - loss of surface layers, deeper fissuring. chondral flaps, craters

• GRADE 4 - full thickness loss, ragged margins exposed subchondral bone, joint debris

OSTEOARTHRITIC KNEE PAIN IS A COMPLEX MIX OF

INFLAMMATORY,

MECHANICAL, SYNOVIAL,

NEUROGENIC, BIOCHEMICAL

& BONE SUBCHONDRAL

PATHOLOGY WHICH CAN FLUCTUATE WIDELY IN INTENSITY… & FREQUENTLY BEARS NO OBVIOUS RELATIONSHIP TO PATIENT ACTIVITY LEVELS.

MULTI MODAL TREATMENT APPROACH NEEDED**

THE BURDEN OF ARTHRITIS

16 % populn ( 3.8 million F>M ) 2050… 7million MSK / arthritis OA 56% , RA 15% , other 37% ** $23.9 billion p.a. (direct $6.6b) Pharmaceutical exp $680 million (14%) $6200 per patient p.a. OA 63% hospital inpatient expenditure 9.2% total health system expenditure 4th highest disease category (#1 CVD) Arthritis research 1.2% total health costs (natl ave. all

disease 2.4%) (Access Economics, Arthritis Aust 2009)

There were 332,857 total hip replacements and 719,652 total knee replacements, primarily for arthritis, in the US in 2010, the most recent year for which figures from the CDC are available.

AUSTRALIA FIGURES (AIHW)

US,JAPAN,ITALY,GERMANY,FRANCE,SPAIN,UK

AGE PROGRESSION FOR OA

HOW LONG ARE WE LIVING?

9.18 HEALTH EXPENDITURE ON NATIONAL HEALTH PRIORITY AREAS(a) - 2000-01

Hospital Aged care homes(b)

Out-of-hospital medical services

Other professional services(c) Pharmaceuticals Research Total

Disease group $m $m $m $m $m $m $m

Cardiovascular diseases 2,533 526 782 73 1,411 153 5,479

Arthritis and other musculoskeletal conditions 1,828 482 879 710 680 55 4,634

Injuries 2,831 105 622 265 184 6 4,013

Mental disorders 1,196 366 499 134 616 109 3,741

Cancer 1,988 37 343 22 183 215 2,918

Diabetes mellitus 289 38 183 33 234 35 812

Asthma 170 16 110 21 370 6 692

All NHPAs 10,835 1,570 3,418 1,258 3,678 580 22,289

(a) Allocated recurrent expenditure (which totalled $50.1b in 2000-01). (b) Includes expenditure on residents that require and receive a level of care that falls within one of the four highest levels in residential aged care services. (c) Includes services delivered outside of hospitals by paramedical professionals such as physiotherapists, chiropractors, occupational therapists, audiologists, speech therapists, hydropaths, podiatrists, therapeutic and clinical massage therapists, clinical psychologists, dietitians and osteopaths.

Source: AIHW 2005b.

$$ SPEND BY DISEASE GROUP 2009 (ABS, AIHW)

DO WE KNOW WHAT CAUSES ARTHRITIS ?

maybe…….what do we think we know ?

PREDICTORS FOR OSTEOARTHRITIS…

• OVERWEIGHT • MALALIGNMENT • PAST TRAUMA • PREVIOUS SURGERY • INFLAMMATORY * • PHYSICAL INACTIVITY • GENETICS • IDIOPATHIC

…N or XS load on abnormal joints….YES … ? Role of abnormal loads on normal joints ??...UNCLEAR

KNEE ALIGNMENT

STRESS LOADING TO JOINT SURFACE

Consequences of injury

www.zimmer.com

Loss of joint structure and function

Cartilage loss

Bone damage

Inflammation

instability

Pain

Reduced function Activity

restriction

Quality of life

KNEE PAIN IN EVERYDAY CLINICAL PRACTICE

APPROACH TO ASSESSMENT

• EPWORTH MSK INSTITUTE SYMPOSIUM 24 JUNE 2016

Dr Peter A Larkins

Sports & Exercise Physician

MBBS, B.MED.SC (HONS), FASMF, FACSP, FFSEM (UK)

Epworth Sports & Exercise Medicine Group

CASE PRESENTATION - OA

• 42 yo male • Active sports age 12 – 30 • Football, basketball, cricket, running, gym • Arthroscopy age 23…”bit of cartilage scrape/clean

up” • Recent years inactive….run after kids • GOW 12 kg • 12 mos stiffness, occas swell, vague ache.. • Wants to increase fitness

CLINICIAN DILEMMA

What advice should we give to this patient with established early to moderate

degenerative knee disease who wants to continue with high impact weight bearing

activities ?

CLINICIAN DILEMMA

Do we provide treatment which allows symptom management but will inevitably

progress the disease process ?

Ethical? Moral? Informed consent?

APPROACH TO CLINICAL ASSESSMENT

• WHAT IS PATIENT CONCERN ? • WHAT IS PATIENT EXPECTATION ? • WHAT PRE-CONCEIVED IDEAS DO THEY BRING ?

(Dr Google) • “CAREFUL LISTENING” • THOROUGH REVIEW OF Rx TO DATE….. (” tried

everything”…..but have they really ? )

WHAT ARE COMMON PRESENTING KNEE COMPLAINTS ?

• PAIN • SWELL • STIFFNESS – ROM LOSS • ACHING • WEAKNESS • INSTABILITY • “NOISES” (CREPITATIONS) • MECHANICAL

– CLICK – CATCH – LOCKING LOSS OF FUNCTION / MOBILITY **

CLINICAL PRESENTATION - OA

Recent change in symptoms * - insidious ?

Swelling - incident ?

Aching Stiffness Catching Grinding or clicking Locking Sharper pains Progressive deformity (angulation)

CLINICAL MANAGEMENT PATHWAY

• Clinical Presentation (History)

} “eyes & ears”

• Physical Findings

• Investigations

• Management

• Prognosis

PHYSICAL EXAM - HAVE STRUCTURED SYSTEMATIC APPROACH -

• OBSERVATION ** • Shape, thickening, quads, alignment… • EFFUSION • ROM • PATELLA • COLLATERALS • CRUCIATES • JOINT LINES • CORE, HIP, THIGH, CALF STRENGTH..

• OTHER PALPATION…creps, bakers cyst..

COLLATERAL LIGAMENTS:

• Valgus / varus force • Assess at 0º/30º for grading /

severity • Other pathology ??

LACHMAN TEST FOR ACL:

Firm, Soft or Absent End Point

SPECIAL CLINICAL TESTS

• PATELLA APPREHENSION • COLLATERALS • ANTERIOR DRAWER (ACL / PCL)

• LACHMAN (ACL /PCL)

• PIVOT SHIFT (ACL)

• McMURRAY’S (MENISCI) • APLEY

What are the treatment

options ??

OA MANAGEMENT - STAGES

• FIRST LINE MEASURES “Stress modifiers” • EDUCATION / COUNSELLING • WEIGHT LOSS • GRADED EXERCISE • CORRECT BIOMECHANICS – footwear, brace , orthotic

• ACTIVITY MODIFICATION

• NUTRACEUTICALS - GLUCOSAMINE, FISH OILS…? Holy water

OA MANAGEMENT - STAGES

• SECOND LINE MEASURES • “Pain Modifiers”

• MEDICATIONS

• PARACETAMOL, non narcotic • NSAID – anti -inflammatories • OTHER – TENS, ETM

ADJUNCT THERAPIES – ACUPUNCTURE,BOWEN …..

OA MANAGEMENT - STAGES

• INJECTABLES • ‘Biochemical modifiers”

• INTRA ARTICULAR STEROID • PRP – growth factors ( TGF. IGF, VEGF..?), nutrient

• ORTHOKINE / INTERLEUKIN MODULATORS • STEM CELLS – MULTIPLE SOURCES (FAT, BONE MARROW, BLOOD)

• SYNVISC , DUROLANE... (HA) • HOLY WATER

• ? OTHER

OA MANAGEMENT - STAGES

• SURGICAL OPTIONS “Structure Modifiers”

• ARTHROSCOPY • DEBRIDEMENT • REALIGNMENT OSTEOTOMY • RESURFACING , ACI, GRAFTING • HEMI ARTHROPLASTY • TOTAL ARTHROPLASTY

WHY IS EARLY INTERVENTION BEST?

• Relieve early symptoms • Improve mobility & function • Identify / alter modifiable risk factors • Educate patient on self care • Improve QOL • Slow progression of disease • Reduce health costs ($200m pa less TKR )

cf. CVD - BP, chol, diabetes, obesity…

TREATMENT PRINCIPLES

• Pain management • Inflammatory component ( ?nsaid use) • Medication role – paracetamol / opioid • Address swelling, stiffness, weakness (local)

• Thigh-hip-glute strength (kinetic chain) • Alignment / bracing • Activity modification (impact, ROM)

• Patient education • Realistic expectations! (surgeon vs reality)

MORE IS MISSED BY NOT LOOKING THAN NOT KNOWING

THANK YOU !