osteoarthritis

Question 1

Define osteoarthritis

Answer 1

Commonest form of arthritis – present in most people over 60 to some extent.
‘Wear + Tear’ or ‘Degenerative Joint Disease’

Question 2

Pathology of osteoarthritis

Answer 2

Loss of cartilage, narrowing of the joint space, low grade synovial inflammation, thickening of subchondral bone and development of bony outgrowths - osteophytes

Question 3

Features of OA

Answer 3

abnormal loading of normal tissues/normal loading of abnormal issues gives progressive OA

ability of tissues to adapt and respond to injury and insult/ repair potential gives stabilisation or repair

Question 4

Risk factors for OA

Answer 4

age - time to develop and respond to injuries - old cartilage repairs less well , reduced muscle strength and bulk and reduced joint propioception w age
systemic factors (genetic/environment) - twins show 65% concordance of OA ; multiplicity of genes involved-complex
local biochemical factors
obesity 30-35 BMI x4 increased risk of knee OA
sex- women have more knee(mechanical) and hand(Endocrine) OA
trauma/injury
joint shape
repetitive use
muscle weakness
joint laxity
occupational factors

determine site and severity of OA

Question 5

Symptoms/Signs of OA

Answer 5

Pain and stiffness
Gel phenomenon, stiffness after immobility
Worse with prolonged use
Poor correlation with radiographs
Multiple factors influence pain including cognitive, emotional, stress, sleep etc.

signs; heberdens, bouchards nodes, genu varus

Question 6

Patterns of OA

Answer 6

Hands and Feet (Heberden’s , Bouchard’s nodes, Generalised OA)
Spine
Large weight bearing joints
Generalised or just a few joints
Typical patterns but most joint can be affected

Question 7

Pathophysiology of osteoarthritis

Answer 7

-wear and tear of cartilage

• chondrocytes in early OA- metabolically active + help repair but as OA progresses, chondrocytes get distressed and Cytokines TNF-a, IL-1, IL-6, collagenases, metalloprotineases, aggrecanases – are released from inflam cells & important in degradation
  causes chondrocyte apoptosis, loss of proteoglycans and collagen fibril damage and bone sclerosis

IL4, TGFb, IGF1, TIMP - protective cytokines

Question 8

How do you view cartilage?

Answer 8

via arthroscope

Question 9

Diagnosis of OA

Answer 9

CLINICAL Often History and exam is enough- typical patterns of symptoms and joints involved
Blood tests normal (unlike RA)- mostly to R/O other types arthritis
Xrays late on show joint space narrowing, osteophytes, sclerosis

Question 10

What are the goals of OA

Answer 10

Relieve pain
Maintain or restore function with rehabilitation and exercise
Delay progression if possible

Question 11

Pharm tx for pain

Answer 11

Paracetamol should be tried first - many will respond
NSAIDs & Coxibs should be tried next – many (but not all) patients will respond better- ibruprofen, diclofenac,naproxen - inhibits prostaglandin production
Mild opiates – co-proxamol, codeine, Tramadol
Start with the simplest and use as needed for symptom management only

Question 12

Side effects of NSAIDS

Answer 12

gastritis, GI bleeds
can aggrevate renal impairment and hypertension
increase CV risk w pts with ischaemic heart disease
coxibs are GI safe

Question 13

Physical management of pain

Answer 13

Use of Heat & Cold - hot packs, hot water, cold pack provide symptomatic relief
Evidence for other physiotherapy Tx is weak but it may provide some relief
Acupuncture – few good trials

Question 14

Other pharm tx?

Answer 14

IA hyaluronic acid derivatives may have a trophic effect on cartilage – given in a course of 3-4 IA injections
Intra-articular depot corticosteroids - give effective but short term relief

Question 15

Other aspects of OA to be treated?

Answer 15

depression - tx needed; promotion of self efficacy
diet
exercise

Question 16

Explain more on diet and exercise related to OA

Answer 16

weight loss improves OA knee outcome significantly Physiotherapy based exercise programs both for fitness and quadriceps strengthening have been shown to work
Educational programs emphasising exercise and self management delivered in groups are effective

Question 17

What are types of exercises performed in OA pt

Answer 17

aerobic- swimming, walking etc improves functional status

strength exercise - correction of muscle weakness by intensive quads program -> reduces pain and improves function
compliance is important

Question 18

Explain importance of foot wear in OA pts

Answer 18

Wide fitting deep shoes with rounded toe boxes and cushioned soles to maximise shock absorption
Orthotics to realign foot to decrease forces acting on medial compartment in early OA

Question 19

Function of occupational therapy?

Answer 19

Can improve function by a targeted approach involving education and specific measures including…
Joint Protection & Energy Conservation
Adaptive equipment & Splinting
Education

Question 20

What is the last resort treatment that can be done?

Answer 20

joint replacement surgery
knee and hip replacement
>90% satisfied
pain relief

Question 21

List the secondary causes of OA

Answer 21

METABOLICOchronosis, haemachromatosis, acromegaly, CPPD affect cartilage repair

ANATOMICSlipped epiphyses, AVN, CDHAny condition congenital or acquired that alters joint mechanics

TRAUMAmajor joint trauma or FractureMenisectomy,Occupational or repetitive injury or stress

Prior septic or inflammatory arthritis – e.g. RA