Evidence Based Medicine: Treatment of Osteoarthritis. Kenneth D. Kleist, M.D. Joint Replacement and Knee Arthroscopy HealthPartners Medical Group St. Paul, MN In this third talk I hope to give you some tools to take back to your own practices

Basic Tenets of OA Care Treatment should be tailored to the patient The relationship between the healthcare team and the patient should be a two-way process Patient education has a significant impact on pain management and patient satisfaction Treatment should be a combination of non-pharmacological and pharmacological measures It is likely that each individual patient will have to try a number of management options before finding the combination which works best for them

Evidence Based, Patient Centered Care Patient Education and Lifestyle Modification Rehabilitation/Physical Therapy Complementary Care and Alternative Therapies Pain Relievers Intra-articular injections SOURCES AAOS – 2008 ARHQ –2006 - 2007 EULAR - 2005 ACR – 2000 Cochrane Library

Levels of Evidence Guideline Language Grade Level of Evidence We Recommend A I We Suggest B II or III Option C IV or V Inconclusive None or conflicting

Patient Education and Lifestyle Modification Participation in self-management programs (II,B) Education Programs such as the arthritis foundation Studies suggest that education is around 20% as effective as NSAIDs, and can have a synergistic effect with other treatments Promote healthy activities and management Walking instead of running Regular visits related to the osteoarthritis (IV,C) Weight Management (I,A) BMI > 25 should be encouraged to lose 5% body weight and maintain the new weight I would add assistive devices here

Does Weight Loss Really Matter? For a woman of normal height, weight loss of only 5kg reduces the risk of OA by more than 50%. Changing BMI Category e.g. obese to overweight, or overweight to normal weight, could prevent 33% of OA in women and 20% in men. Felson et al: Annals of Internal Medicine 1992 Data from the Framingham Study

Rehabilitation Participation in low impact aerobic fitness (I,A) ROM/Flexibility Exercise Program (V,C) Quadriceps Strengthening Program (II,B) Patellar Taping (II,B) +/- Unloader Bracing (V/II,inconclusive) DO NOT use lateral heel wedges (II,B)

Exercise Prescriptions Kenneth D. Kleist, M.D. Name: Baby Boomer Hip/Knee ROM Lower Extremity Strength-focus on Quadriceps and Pelvifemoral Strength Proprioception/balance training

Complementary Care and Alternative Therapies DO NOT prescribe Glucosamine and/or Chondroitin sulfate (I,A) No scientific evidence +/- Acupuncture (I,inconclusive) I would add in aromatherapy, music therapy, massage, tai chi, Reiki, etc into this category No Evidence Based Data on supplements

Pain Relievers Unless contraindications one of below (II,B) Acetaminophen NSAIDs Increased GI risk: Age > 65, PUD, concurrent corticosteroids, anticoagulant usage Topical NSAIDs Non-selective NSAID + GI protective Cox-2 inhibitor Narcotics Poor choice due to chronicity of disease

Intra-articular Injections Corticosteroids for short-term relief (II,B) Cannot Recommend for or against Hyaluronic Acids(I/II, Inconclusive)

Footnotes on Surgery Arthroscopy is NOT recommended for debridement and lavage (I/II, A/B) Arthroscopy may be an option for those with OA and primary signs and symptoms of a loose body or meniscus tear(V,C)

So what do we do now? Do a good History and Physical Examination. Individualize treatment to the Patient. Encourage Patient Involvement Non-pharmacologic therapy is the hallmark of treatment for Osteoarthritis. Exercise is always good…it’s the type that needs to be carefully determined. Medication therapy is adjunctive. Set appropriate expectations throughout Surgery when quality of life continues to deteriorate despite appropriate care

Website Resources Available American Academy of Orthopaedic Surgeons P.O. Box 1998 Des Plaines, IL 60017 847–823–7186 or 800–824–BONE (2663) (free of charge) Fax: 847–823–8125 www.aaos.org American Association of Hip and Knee Surgeons 6300 N. River Road, Suite 615 Rosemont, IL 60018-4237 Telephone: (847)698-1200 Fax: (847)698-0704 Email helpdesk@aahks.org www.aahks.org United States Bone and Joint Decade, NFP (USBJD)   6300 North River Road   Rosemont, IL 60018   Phone: 847.384.4010   Fax: 847.823.0536   Email: usbjd@usbjd.org www.usbjd.org National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) National Institutes of Health 1 AMS Circle Bethesda, MD 20892–3675 Phone: 301–495–4484 or 877–22–NIAMS (226–4267) (free of charge) TTY: 301–565–2966 Fax: 301–718–6366 E-mail: NIAMSInfo@mail.nih.gov www.niams.nih.gov NIH Osteoporosis and Related Bone Diseases ~National Resource Center 2 AMS Circle Bethesda, MD 20892-3676 Phone: 202–223–0344 or 800–624–BONE TTY: 202–466–4315 Fax: 202–293–2356 www.niams.nih.gov/bone American College of Rheumatology 1800 Century Place, Suite 250 Atlanta, GA 30345 Phone: 404–633–3777 Fax: 404–633–1870 www.rheumatology.org American Physical Therapy Association 1111 North Fairfax Street Alexandria, VA 22314–1488 Phone: 703–684–2782 or 800–999–APTA (2782) (free of charge) Fax: 703–684–7343 www.apta.org Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality Office of Communications and Knowledge Transfer 540 Gaither Road, Suite 2000 Rockville, MD 20850. (301) 427-1364. www.ahrq.gov Arthritis Foundation P.O. Box 7669 Atlanta, GA 30357-0669 www.arthritis.org

Save Your Knees Online Portal Media Launch saveyourknees.org The new Save Your Knees Web Portal, saveyourknees.org, is the most comprehensive interactive site about knees on the Web. It is full of multimedia information focused on knees: keeping knees healthy, exercise, common knee problems, injury prevention, treatments, including non-surgical and surgical options and more. On the site you will find: Question of the Week, Healthy Knees at Any Age, Fun Knee Facts, Kids Korner, eMotion Pictures, Patient Stories, Public Service Announcements, and Press Releases and Press Kits. Information about the “Save your Knees” portal appeared on a strategically placed electronic billboard located on the Las Vegas strip across from the Wynn and Venetian hotels during the 2009 Annual Meeting. The 4,000 square foot outdoor billboard broadcast our video, print PSA and Web address almost 50 times.

Get Up! Get Out! Get Moving! Let’s Exercise Now! Facebook Application www.aaos.org/facebook There are currently millions of active users on Facebook worldwide. To reach this new, social audience, the Academy created an exercise application called, “Get Up! Get Out! Get Moving! Let’s Exercise!” The application has several features including setting your own fitness goals (promoting weight-bearing exercises), tracking those goals, joining teams, challenging friends on Facebook to meet and/or beat your personal or team goals, and competing to earn points with people around the globe to get healthy, strengthen your bones and get into the game of life! If you, your family, friends, peers, colleagues or patients have a Facebook account, go to www.aaos.org/facebook to get started.

Top 10 Patient FAQs… and their Answers Is there anything that can regrow cartilage or reverse arthritis? No there is no known cure and very limited situations where cartilage procedures are a viable option and that is in very young patient with focal traumatic injuries

Top 10 Patient FAQs… and their Answers Is there anything that can regrow cartilage or reverse arthritis? Can’t you just clean up the knee with arthroscopy? Several studies have shown that arthroscopic debridement and lavage is not effective for treatment of OA.

Top 10 Patient FAQs… and their Answers Is there anything that can regrow cartilage or reverse arthritis? Can’t you just clean up the knee with arthroscopy? How Many Cortisone shots can I get and how often? There is no maximum lifetime dosage, but injection should be spaced apart about 3 to 4 months because too many injections close together can soften the remaining cartilage.

Top 10 Patient FAQs… and their Answers Is there anything that can regrow cartilage or reverse arthritis? Can’t you just clean up the knee with arthroscopy? How Many Cortisone shots can I get and how often? How will I know when I am ready for joint replacement? Most people reach a point where their quality of life is diminished enough that they know it is time. Other indicators can include loss of sleep, constant pain, inability to do typical activities of daily living, or failure of pain relief options that had been previously working.

Top 10 Patient FAQs… and their Answers Is there anything that can regrow cartilage or reverse arthritis? Can’t you just clean up the knee with arthroscopy? How Many Cortisone shots can I get and how often? How will I know when I am ready for joint replacement? How long is the recovery for joint replacement? Recovery from joint replacement is highly variable among individuals. A lot depends on age, health, preoperative function. On average most people will be 85% recovered by 3 months after surgery. Most people will return to a sitting job by 4-6 weeks maximum and a standing, walking, active job by 2 months, but again this is highly variable.

Top 10 Patient FAQs… and their Answers Is there anything that can regrow cartilage or reverse arthritis? Can’t you just clean up the knee with arthroscopy? How Many Cortisone shots can I get and how often? How will I know when I am ready for joint replacement? How long is the recovery for joint replacement? What is the likelihood I will improve with joint replacement? On average 85% of people say they would have knee or hip replacement again.

Top 10 Patient FAQs… and their Answers Is there anything that can regrow cartilage or reverse arthritis? Can’t you just clean up the knee with arthroscopy? How Many Cortisone shots can I get and how often? How will I know when I am ready for joint replacement? How long is the recovery for joint replacement? What is the likelihood I will improve with joint replacement? How long do joint replacements last? Knee 15-20 years, Hip 10-15 years conservatively. Factors such as weight, age, and activity level play a large role.

Top 10 Patient FAQs… and their Answers Is there anything that can regrow cartilage or reverse arthritis? Can’t you just clean up the knee with arthroscopy? How Many Cortisone shots can I get and how often? How will I know when I am ready for joint replacement? How long is the recovery for joint replacement? What is the likelihood I will improve with joint replacement? How long do joint replacements last? What types of activity can I do after joint replacement? There is no evidence based research to show what you can safely do. I recommend low impact exercise. Avoidance of high impact activities. In general golf, swimming, biking, walking, hiking, skating, and cross country skiing appear to be safe activities.

Top 10 Patient FAQs… and their Answers Is there anything that can regrow cartilage or reverse arthritis? Can’t you just clean up the knee with arthroscopy? How Many Cortisone shots can I get and how often? How will I know when I am ready for joint replacement? How long is the recovery for joint replacement? What is the likelihood I will improve with joint replacement? How long do joint replacements last? What types of activity can I do after joint replacement? Am I a candidate for minimally invasive surgery? Minimally invasive surgery is an option for everyone, but what that is can vary from person to person. No study has confirmed any long term benefit of minimally invasive surgery functionally. The most important thing to you as a patient is to get the pieces placed in the appropriate position so you can a have good long term function of your joint replacement.

Top 10 Patient FAQs… and their Answers Is there anything that can regrow cartilage or reverse arthritis? Can’t you just clean up the knee with arthroscopy? How Many Cortisone shots can I get and how often? How will I know when I am ready for joint replacement? How long is the recovery for joint replacement? What is the likelihood I will improve with joint replacement? How long do joint replacements last? What types of activity can I do after joint replacement? Am I a candidate for minimally invasive surgery? Why did I get arthritis? Arthritis is due to multifactorial influences. Factors that are known to contribute are weight, trauma, genetics, activity level, and diet.

Thank You!