Osteoarthritis is one of the most common degenerative conditions that comes with aging and almost every clinician comes across in day to day practice.The slideshow helps in understanding the approach to a patient with OA before planning a surgical intervention

1. Osteoarthritis
Non Operative Management
SHRIYANS JAIN

2. Osteoarthritis

3. Osteoarthritis Measurement Scales
• Western Ontario and McMaster Osteoarthritis Index
(WOMAC) (**)
Questionnaire with twenty four questions about pain, function,
and stiffness
• Visual Analogue Scale
100 mm long line with descriptive words (no pain / worst
pain ever felt) on either side
• Lequesne Index
Questionnaire 11 questions that ask about the patient’s
symptoms and functional ability
(**) – More reliable than the other two scales

4. •OA is a condition which progresses slowly over a
period of many years and cannot be cured
•Treatment is directed at decreasing the symptoms of
the condition, and slowing the progress of the
condition
Functional treatment goals:
•Limit pain
•Increase range of motion
•Increase muscle strength
OA – Disease Management

5. Treatment overview

6. Patient education
Self-management programs
Weight loss (if overweight or obese)
Aerobic exercise programs
Physical therapy
Muscle-strengthening exercises
Assistive devices for ambulation
Patellar taping
Appropriate footwear
Medial-wedged insoles (for genu valgum)
Bracing
Occupational therapy
Joint protection and energy conservation
Assistive devices for activities of daily living
Pharmacologic intervention
Surgical
intervention
Therapeutic Advances in Musculoskeletal Diseases 1: 35-47

7. Lifestyle Modification
Lifestyle modifications can include losing weight, switching from
running or jumping exercises to swimming or cycling, and minimizing
activities such as climbing stairs. Simple weight loss can reduce stress
on weight bearing joints, such as the knee.
Exercise
Exercises can help increase range of motion and flexibility as well as
help strengthen the muscles in the leg. Physical therapy and exercise
are often effective in reducing pain and improving function.
Supportive Devices
Using supportive devices, such as a cane, wearing energy-absorbing
shoes or inserts can be helpful. Knee braces may be especially helpful if
the arthritis is centered on one side of the knee. There are two types of
braces that are often used. An "unloader" brace shifts load away from
the affected portion of the knee. A "support" brace helps support the
entire knee load.
Other Methods
Other measures may include applications of heat or ice, water exercises, liniments
or elastic bandages.

8. GAIT MODIFICATION APPROACHES
TOE-OUT GAIT
Walking with a toe-out gait—that is, with the foot
externally rotated with respect to the direction of
progression (Figure 3)—reduces the knee adduction
moment in patients with medial knee OA.With respect to
the long-term influence of toe-out gait, an increased
baseline toe-out angle was associated with a reduced
likelihood of disease progression in patients with medial
knee OA over an 18-month follow-up period.
LATERAL TRUNK LEAN
In individuals who lean towards the side of the weight-bearing limb as they walk, the body's
center of mass shifts laterally and moves closer to the center of pressure under the weight-
bearing foot. As the ground reaction force tends to act through the center of mass, this
approach changes the angle of the ground reaction force, shifting it towards the knee joint
center. The outcome of this shift is a reduction in the moment arm of the ground reaction
force that, in turn, reduces the knee adduction moment

9. GAIT RETRAINING
Gait modification approaches have been advocated to reduce the knee adduction moment
and delay the progression of knee joint OA.For example, the medial thrust gait pattern
involves consciously pushing the knee joint in a medial direction during walking, which
repositions the knee joint center closer to the ground reaction force, thus reducing the
moment arm and lowering the knee adduction moment
FOOTWEAR INTERVENTIONS
Interestingly, peak knee adduction moments while walking barefoot were similar to those
measured in patients wearing flat walking shoes and 'flip-flops' . These two types of
footwear have thinner and more flexible soles than the thick-soled, supportive, 'stability
shoes'.Such footwear might enable increased foot flexibility in a manner similar to that of
barefoot walking.
Thin-soled, flexible shoes seem to be beneficial for reducing knee joint loads compared
with shoes with thicker soles. Despite appearing counterintuitive, shoes with thick soles
actually seem to increase joint loading at the medial tibiofemoral compartment, whereas
shoes with thin soles are associated with reduced knee adduction loading.
FLEXIBLE SHOES VERSUS STABILITY SHOES

10. LATERAL WEDGE INSOLES
Lateral wedge insoles (that is, a wedge inclined along the outside of the foot) have been
suggested as an intervention strategy to reduce the knee adduction moment during
walking and attenuate the progression of medial knee OA. In patients with OA, the use
of lateral wedge insoles of between 5° and 15° inclination reduced peak knee adduction
moments by between 4% and 14% during walking compared with the corresponding
values either without insoles or wearing even-thickness control insoles. The use of
lateral wedge insoles also led to immediate reductions in pain during walking.
VARIABLE-STIFFNESS SHOES
'Variable-stiffness' shoes with increased lateral stiffness have been tested as an
alternative to lateral wedge insoles. Variable-stiffness shoes considerably reduced the
peak knee adduction moment during walking (by up to 6%) in patients with OA
compared with constant-stiffness control shoes.

11. VALGUS KNEE BRACES
Knee braces can be adjusted to increase the
extent of valgus alignment, which also increases
the valgus moment applied at the knee joint.
The peak net knee adduction moment
progressively decreased with increasing valgus
alignment of the knee brace. A neutrally aligned
knee brace reduced the peak net knee
adduction moment by 6% compared with the
unbraced situation, whereas valgus brace
alignments of 4° and 8° yielded reductions of
13% and 19%, respectively.
The net knee adduction moment in a patient
wearing a valgus brace is calculated as the
external knee adduction moment minus the
valgus moment exerted by the knee brace.
Valgus knee braces secured around the thigh
and lower leg and worn throughout the day have
been suggested as a conservative treatment
strategy for patients with medial knee OA

12. Pharmacotherapy
The goals of pharmacotherapy in osteoarthritis
are to reduce morbidity and to prevent
complications
• Analgesics ( others )
• Nonsteroidal anti-inflammatory drugs (NSAIDs), oral and topical
• Intra-articular corticosteroids
• Intra-articular sodium hyaluronate
• Opioids
• Duloxetine
• Muscle relaxants
• Nutriceuticals (eg, glucosamine/chondroitin sulfate)

13. Acetaminophen is the drug of choice for patients who have a documented
hypersensitivity to aspirin or NSAIDs, who have a history of upper
gastrointestinal (GI) tract disease, or who are on anticoagulants.
NSAIDs ( Ibuprofen, Piroxicam, Diclofenac , Naproxem , Celecoxib )
have analgesic, anti-inflammatory, and antipyretic activities. They are used to relieve
osteoarthritis pain when the clinical response to acetaminophen is unsatisfactory. The
mechanism of action is nonselective inhibition of cyclooxygenase (COX)-1 and COX-2,
resulting in reduced synthesis of prostaglandins and thromboxanes.
In more inflammatory presentations of osteoarthritis, such as knee involvement with
effusion, these agents may be used as first-line pharmacologic therapy. Use the
lowest effective dose or intermittent therapy if symptoms are intermittent. All of
these medications increase the risk for GI ulcers and have been associated with
increased risk of cardiovascular disease. Patients at high risk for GI toxicity may
consider adding misoprostol or a proton-pump inhibitor to the regimen or
substituting a COX-2–specific inhibitor for the NSAID
The selective serotonin-norepinephrine reuptake inhibitor (SNRI) Duloxetine
may be effective for reducing osteoarthritis pain

14. Topical analgesics
Used for osteoarthritis involving relatively superficial joints, such as the knee joint and
the joints of the hands. They are much less effective for deeper joints, such as the hip
joint.
Capsaicin is a topical analgesic of choice in osteoarthritis. Derived from plants of the
Solanaceae family, it may render skin and joints insensitive to pain by depleting
substance P in peripheral sensory neurons. Capsaicin must be used for at least 2 weeks
for the full effects to be appreciated.
Opioids
They are a particularly reasonable choice in patients who do not want joint-replacement
surgery, are too medically ill for joint replacement, are not candidates for joint
replacement for other reasons, or are trying to buy time for subsequent joint-
replacement surgery.
Tramadol
Tramadol inhibits ascending pain pathways, altering perception of and response to pain.
Oxycodone
Pure narcotic analgesics, such as oxycodone, might be the initial drug of choice.
Eventually, this short-acting narcotic can be replaced with a long-acting transdermal
preparation, such as fentanyl (Duragesic patch).

15. Corticosteroids
Intra-articular pharmacologic therapy includes corticosteroid injection and
viscosupplementation. Steroid injections generally result in a clinically and statistically
significant reduction in osteoarthritic knee pain as soon as 1 week after injection. The
effect may last, on average, anywhere from 4 to 6 weeks per injection, but the benefit
is unlikely to continue beyond that time frame.
Methylprednisolone (Depo-Medrol, Medrol, Solu-Medrol)
Betamethasone (Celestone Soluspan)
Triamcinolone (Aristospan Intra-Articular)
Intra-articular agents Injections of these agents are used to treat patients with
osteoarthritic knee pain that is unresponsive to conservative nonpharmacologic
therapy and simple analgesics (eg, acetaminophen).
Sodium hyaluronate
Sodium hyaluronate is a hyaluronic acid derivative that supports the lubricating and
shock-absorbing properties of articular cartilage.

16. Glucosamine and Chondroitin
Glucosamine and chondroitin sulfate are oral supplements may relieve the pain of
osteoarthritis. These are two large molecules that are found in the cartilage of our joints.
Supplements sold over-the-counter are usually made from synthetic or animal products.
Other therapies
• TENS applied in conjunction with therapeutic exercise and daily activities increased
quadriceps activation and function in patients with tibiofemoral osteoarthritis.
• Pulsed electromagnetic field stimulation is believed to act at the level of articular
cartilage by maintaining the proteoglycan composition of chondrocytes through
downregulation of its turnover.
The use of a highly optimized, capacitively coupled, pulsed electrical stimulus device
yielded significant symptomatic and functional improvement
• Tai chi (slow, rhythmic, meditative movements designed to help you find peace and
calm ) is a potentially effective treatment for pain associated with osteoarthritis of the
knee

19. Recommended Guidelines :
Key Updates to 2013 OARSI Guidelines:
• Topical NSAIDs are recommended as appropriate for all patients with
knee-only OA and in a scientific review, were found overall to be safer and
better tolerated compared to oral NSAIDs.
• The prescription drug duloxetine was evaluated for the first time and
found to be an appropriate treatment for knee-only OA patients without
comorbidities and all multi-joint OA patients.
• Due to increased safety concerns about toxicity, acetaminophen/
paracetamol was given an “uncertain” recommendation for all patients with
comorbidities.

20. • Oral and transdermal opioid painkillers were given an “uncertain”
recommendation for all patient groups due to concerns about increased
risks for adverse and serious adverse events.
• Glucosamine and chondroitin were both found to be “not appropriate” for all
patients when used for disease modification and “uncertain” for all patients
when used for symptom relief.
• Balneotherapy, defined as using baths containing thermal mineral waters, was
evaluated for the first time and found to be an appropriate therapy for patients
with multi-joint OA and comorbidities, as this group has few other treatment
options.

21. Knee OA Prevention
PAR
Obesity
Knee injury
Occupational
risk
Other

22. Prevention: The time is now
Injury
Lifetime risk of knee OA is 57% among persons with a history of prior knee injury, and specific
injuries, such as anterior cruciate ligament (ACL) ruptures and ankle fractures, have been
clearly linked to incident OA.
Arthritis Rheum, 2008;59(9):1207-1213.
Neuromuscular conditioning programs have demonstrated effectiveness in reducing the risk of
ACL injury by 60%.
Am J Sports med, 2006;34(3):490-8.
Obesity
Promote policies, initiatives and state and national partnerships to help all young people achieve
and maintain a healthy weight, thereby potentially reducing their risk for developing OA.
http://www.surgeongeneral.gov/topics/obesity/
The National Public Health Agenda for Osteoarthritis. Combined action of AF and CDC.