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Knee Osteoarthritis: A Physiatrist’s Perspective

Cedric K. Akau, MS, MD, MPHAssociate Clinical Professor and Chief, Division of Physical

Medicine and Rehabilitation, JABSOM

Physiatrist, Hawai‘i Pacific Health Medical Group

What is a Physiatrist?

• Physical Medicine and Rehabilitation (PM&R) physicians, also knownas physiatrists, treat a wide variety of medical conditions affectingthe brain, spinal cord, nerves, bones, joints, ligaments, muscles, andtendons. ... Specifically, PM&R physicians: Treat patients of all ages.

• Sports Medicine, Pain Medicine, Spinal Cord Injury, PediatricRehabilitation, Neuromuscular Medicine, Brain Injury, CancerRehabilitation and Palliative Medicine

• Restore and improve FUNCTION, team-based care, holistic care

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Osteoarthritis (OA)

• Most common form of arthritis, also known as ”wearand tear” or ”degenerative” arthritis

• Leading cause of musculoskeletal disability in theworld and 11th highest contributor to global disability

• 70-90 % of Americans above age 75 have it

• ~ 12% or 27 million Americans affected

• OA most common in knees, hips and hands

• Knee OA is the leading cause of disability in theelderly, 19-28% of Americans over the age of 45 haveknee OA.

Osteoarthritis

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Osteoarthritis

Risk Factors

• Age

• Joint overload, stress, and trauma

• Obesity

• Race

• Genes

• Gender

• Weak muscles

• Quad muscles

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Symptoms and Signs

• Gradual onset of achy pain, slowly progressive

• Stiffness and loss of flexibility

• Swelling and tenderness

• Crackling, popping, grating noises, locking

• An increase in falls and subsequent fractures

• Associated back and neck pain

• Bone spurs seen on x-rays

• Heberden’s and Bouchard’s nodes and Bunions

• Weight gain and muscle loss

The Vicious Cycle

• Joint becomes painful

• Don’t move the joint

• Muscles become weak

• “Get out of shape”

• Gain weight

• Less protection to the joint

• Further decrease in range of motion

• Worsening of arthritis and pain

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Stop the Vicious Cycle and Start Rehabilitation

Protect the Joint: weight loss,bracing, assistive devices

Reduce Pain: (P.) R.I.C.E, oral,topical and injectable medications

Rehabilitation Program: Increase ROM, Strength, fitness

Protect the Joint

• Small amounts of weight loss benefits knee OA

• For knee OA, use cane in the arm opposite theaffected knee and for stair walking, “up with thegood and down with the bad”

• Off-loading (unloading) knee braces candecrease weight off the most affected part ofthe knee but if not coupled with a strengtheningprogram can lead to further muscle weaknessand progression of the OA

1 : 3 : 5

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Reduce Pain: P.R.I.C.E.

• P. Protect

• R. Rest, Rehab, Range of motion

• I. Ice

• C. Compression

• E. Elevation

Reduce Pain: Is ICE or HEAT Better?

• Ice is used after acute injuries or to decrease pain and inflammationsuch as when the joint feels warm and/or is swollen.

• Heat is used for more chronically stiff and non-inflamed joints,typically to relax muscles around joints such as in the morning orbefore exercising.

• Do not use either for more than 15-20 minutes at a time, do notapply the packs directly to the skin and avoid areas that are infectedor directly over nerves.

• Avoid ice over areas of poor circulation.

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Oral Medications

• Acetaminophen (Tylenol), no more than 3gm/day, recommended bythe American College of Rheumatology as the first line drug of choicefor osteoarthritis, watch for liver toxicity.

• Non-Steroidal Anti-Inflammatory Drugs (NSAIDs). Greater risks ofadverse affects in the elderly (heart attack, stroke, GI bleeding, Kidneyand Liver damage). Use with caution and have close physician followup.

• Narcotic medications, Tramadol and other stronger Opiates. At riskfor developing tolerance and dependence.

OTC Topical Medications

• Methyl salicylates (“Ben Gay”)

• Capsaicin Cream

• Topical Lidocaine 4% patches

• Topical Diclofenac (Voltaren Cream)

This Photo by Unknown Author is licensed under CC BY-SA

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Injections

• Steroid injections offer short term relief

• Rest joint after injection

• Skin changes at site of injection

• Infections, bleeding, glucose elevation

• Flushing of skin, insomnia, agitation

• Does not prevent joint damage

• Typically, limited to 3-4 times per year

• Activity modification after injection

• Need to wait 3 months before Total KneeReplacement

Injections

• Viscosupplementation

• Injection of concentrated hyaluronic acid gel

• Similar to healthy joint (synovial) fluid

• FDA approved only for the knee

• Not a cure

• May offer longer relief than intra-articularsteroids

• May improve joint flexibility and reduce OApain at its source

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Injections• Biologic therapies

• Platelet Rich Plasma (PRP)

• Stem Cell, bone marrow and adipose

This Photo by Unknown Author is licensed under CC BY-SA

This Photo by Unknown Author is licensed under CC BY-SA

Injections • Radiofrequency ablation of the genicular nerve for chronic knee

pain

W Choi et al. Radiofrequency treatment relieves chronic knee osteoarthritis pain: a double-blind randomized controlled trial.Pain. 2011 Mar;152(3):481-7. doi: 10.1016/j.pain.2010.09.029.

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Rehabilitation Program, Improve FUNCTION

Increase Range of Motion of the joint

Increase Strength of the Muscles surrounding the joint

Activity modification

WebMD.com, “Knee Osteoarthritis Exercises”

PREVENTION through a Fitness program

• Prevent disability related to knee OA thru improving yourfitness by maintaining proper weight, muscle tone, range ofmotion and flexibility. Motion and movement are good!

• Non or minimally weight bearing cardiovascular exercises

• Balancing exercises

• Strengthening exercises

• Weight control and ”joint healthy” diet

See Dr Akau’s “Fun and Fitness” handout, tips on starting a fitness program

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Aquatic Exercises

This Photo by Unknown Author is licensed under CC BY-NC

This Photo by Unknown Author is licensed under CC BY-SA

Tai chi• Slow, graceful, controlled body movements while the body remains

straight and upright.

• Improves balance, which can prevent falls and fractures.

• A 2007 study found that OA symptoms improved with aquatherapyor tai-chi at 12 and 24 weeks.

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Yoga• Improves endurance, spine flexibility, weight loss, more efficient

breathing, controls blood pressure, and relieves stress.

• Low impact on joints.

• Studies show pain relieving benefits in OA of hips and knees.

This Photo by Unknown Author is licensed under CC BY-SA This Photo by Unknown Author is licensed under CC BY

Alternative and Complementary Therapies

• 12%-25% of Americans use herbals and other supplements

• Glucosamine

• Chondroitin

• Omega-3 fatty Acids

• Turmeric

• Astaxanthin

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Glucosamine

• Major component of joint cartilage• Derived from shellfish• May help pain & stiffness• Not conclusively shown to prevent or reverse cartilage loss• Benefits are controversial• Dosage: 1500 – 2000 mg a day

• WARNINGS:• May cause mild stomach upset, nausea, heartburn, diarrhea and

constipation• May increase blood sugar, blood pressure, cholesterol, triglycerides and

worsen glaucoma

Chondroitin• Component of cartilage and bone• Derived from cow or shark cartilage• Not conclusively shown to prevent or reverse cartilage

loss• Symptom benefit is controversial• Dosage: 1200 – 1600 mg a day

• WARNINGS:• Blood-thinning properties - may increase risk of

bleeding or bruising.• Other side effects include diarrhea, constipation and

abdominal pain.

This Photo by Unknown Author is licensed under CC BY-ND

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Omega-3 Fatty Acids• Anti-inflammatory

• Two 3-ounce servings of fish a week arerecommended

• Natural blood thinner

• Fish oil (EPA, DHA)– Dose of EPA or DHA of 500-1000 mg daily– Salmon, shrimp, sardines, herring, butterfish,

mackerel• Plant sources (ALA)

– Flax & chia seeds, walnuts, soybeans

• WARNINGS:– Blood-thinning properties - may increase

bruising and risk of bleeding.

This Photo by Unknown Author is licensed under CC BY-NC-ND

Turmeric• A yellow-colored powder ground from the root of the

turmeric plant

• Curcumin is the active ingredient in turmeric• Popular in Chinese and Ayurvedic medicine

• Plant is related to ginger

• Anti-inflammatory• A 2010 clinical trial showed long-term improvement in

pain and function in patients with knee OA

• Dosage: Capsules, typically 400 mg to 600 mg, threetimes per day

• Warnings:– High doses of turmeric can be a blood thinner and

cause stomach upset.

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Astaxanthin

• Anti-oxidant (flavonoids) and anti-inflammatory

• In microalgae (↑↑↑), shellfish (↑↑), salmon(↑)

• Causes pink color in flamingos, salmon andcooked shrimp

• Anti-inflammatory and anti-oxidant benefits

• Reduces cardiovascular inflammation and C-reactive protein (CRP) levels

• Generally recognized as safe by FDA

• “Bio Astin,” “Zanthosyn”

Supplements: Caution!

• Lack of manufacturing Standards. Not FDAregulated.

• Potential Drug interactions! Some mayinteract with blood thinners!

• May cause lab abnormalities! Inform yourdoctor if you are taking supplements

This Photo by Unknown Author is licensed under CC BY-SA

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Sample Menu

• Fish (&/or shellfish) curry, withginger, and red chili peppers

• A side of soy beans

• Avocado and pineapple salad

• And a green tea beverage

Summary: A Physiatrist’s Approach to OA

• Physical Medicine and Rehabilitation, PMR specialist, Physiatrist,Restore and Improve FUNCTION

• Knee Osteoarthritis

• Vicious Cycle

• Protect the Joint, Reduce Pain, Rehabilitation Program

• Non-surgical treatments

• Prevention through a Fitness program

• Alternative and complimentary therapies

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Words of Wisdom

• “If we could give every individual the right amount of nourishmentand exercise, not too little and not too much, we would have foundthe safest way to health.” “Eating alone will not keep a man well, hemust also take exercise.” -Hippocrates

• “The doctor of the future will give no medicine but will educate hispatients in the care of the human frame, in diet and in the cause andprevention of disease.” -Thomas Edison

• ”Exercise is Medicine”, a global educational campaign launched in2007 by the American College of Sports Medicine

• Whatever you do, have FUN and do it with others!

Thank You

for participating in the 2021 John A. Burns School of Medicine

Mini-Medical School