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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
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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
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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)
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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
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KNEE PAIN • ACUTE
CONTUSION LIGAMENTOUS /CAPSULAR MENISCAL CHONDRAL INFLAMMATORY (eg Gout) FRACTURE MIXED
• CHRONIC
DEGEN (CHONDRAL) - stages MENISCAL RHEUMATOID INFLAMMATORY PATELLO – FEMORAL MIXED
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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
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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
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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
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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**
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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)
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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.
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AUSTRALIA FIGURES (AIHW)
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US,JAPAN,ITALY,GERMANY,FRANCE,SPAIN,UK
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AGE PROGRESSION FOR OA
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HOW LONG ARE WE LIVING?
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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.
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$$ SPEND BY DISEASE GROUP 2009 (ABS, AIHW)
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DO WE KNOW WHAT CAUSES ARTHRITIS ?
maybe…….what do we think we know ?
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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
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KNEE ALIGNMENT
STRESS LOADING TO JOINT SURFACE
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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
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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
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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
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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 ?
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CLINICIAN DILEMMA
Do we provide treatment which allows symptom management but will inevitably
progress the disease process ?
Ethical? Moral? Informed consent?
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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 ? )
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WHAT ARE COMMON PRESENTING KNEE COMPLAINTS ?
• PAIN • SWELL • STIFFNESS – ROM LOSS • ACHING • WEAKNESS • INSTABILITY • “NOISES” (CREPITATIONS) • MECHANICAL
– CLICK – CATCH – LOCKING LOSS OF FUNCTION / MOBILITY **
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CLINICAL PRESENTATION - OA
Recent change in symptoms * - insidious ?
Swelling - incident ?
Aching Stiffness Catching Grinding or clicking Locking Sharper pains Progressive deformity (angulation)
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CLINICAL MANAGEMENT PATHWAY
• Clinical Presentation (History)
} “eyes & ears”
• Physical Findings
• Investigations
• Management
• Prognosis
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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..
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COLLATERAL LIGAMENTS:
• Valgus / varus force • Assess at 0º/30º for grading /
severity • Other pathology ??
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LACHMAN TEST FOR ACL:
Firm, Soft or Absent End Point
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SPECIAL CLINICAL TESTS
• PATELLA APPREHENSION • COLLATERALS • ANTERIOR DRAWER (ACL / PCL)
• LACHMAN (ACL /PCL)
• PIVOT SHIFT (ACL)
• McMURRAY’S (MENISCI) • APLEY
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What are the treatment
options ??
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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
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OA MANAGEMENT - STAGES
• SECOND LINE MEASURES • “Pain Modifiers”
• MEDICATIONS
• PARACETAMOL, non narcotic • NSAID – anti -inflammatories • OTHER – TENS, ETM
ADJUNCT THERAPIES – ACUPUNCTURE,BOWEN …..
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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
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OA MANAGEMENT - STAGES
• SURGICAL OPTIONS “Structure Modifiers”
• ARTHROSCOPY • DEBRIDEMENT • REALIGNMENT OSTEOTOMY • RESURFACING , ACI, GRAFTING • HEMI ARTHROPLASTY • TOTAL ARTHROPLASTY
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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…
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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)
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MORE IS MISSED BY NOT LOOKING THAN NOT KNOWING
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THANK YOU !