Professional Documents
Culture Documents
ARTH
(Joint)
IT IS =
(Inflammation)
Osteoarthritis
Rheumatoid Arthritis
Ankylosing Spondylitis
Fibromyalgia
Lupus
Gout
Bursitis
Juvenile Rheumatoid Arthritis
Osteogenesis Imperfecta
Myositis
Scleroderma
Lyme Disease
Carpel Tunnel
Psioriatic Arthritis
Osteoarthritis
Rheumatoid Arthritis
OSTEOARTHRITIS
Definisi
Osteoarthritis
Osteoarthritis
Normal Joint
Joint with
Osteoarthritis
Risk Factors
Genetics
Trauma
Overuse syndromes
Post-infectious
Obesity
Etiology of Osteoarthritis
Etiology of Osteoarthritis
Proteoglycans
Collagen
Etiology of osteoarthritis
Etiology of Osteoarthritis
Conceptual Model of OA
Biochemical changes/ cells and tissue
Structural changes
Classification of OA
Primary (idiopathic)
unidentified causes
Secondary
precipitating factors
16
Joints affected by OA
Knees (41%)
Hands (30%)
Hips (19%)
Spine (cervical and
lumbar regions)
Toes (first metatarsophalangeal joint)
17
Clinical signs of OA
Crepitus
Restricted joint
movement
Joint instability
Bony swelling
Soft tissue swelling
Joint deformity
Joint tenderness
Increased joint warmth
Muscle atrophy or
weakness
Limp while walking
18
Subchondral bone
Nerve endings in periosteum
Stretching of ligaments
Distention of joint capsule
Inflammation of synovium
Periarticular muscle spasm
19
Pain drawings
Mark the area on your body
where you feel the described
sensations
Use the appropriate symbol
Mark the areas of radiation
Include all affected areas
Numbness
====
Pins and needles
Burning
xxxxxxxx
Stabbing
///////
Rating scales
Visual analogue scale
Worst
possible
pain
No
pain
Pain intensity
0
1
2
3
4
5
No pain
Mild
Discomforting
Distressing
Horrible
Excruciating
McMurray Maneuver
(menisci)
Duck Waddle
(stability)
Diagnosis of OA
Symptoms
Pain
Decreased function
Diagnosis of OA
Signs
On physical exam
Asymmetry of findings usually of large joints
Heberdens/Bouchards nodes (may be
symmetrical)
Typical OA Hand:
Know It When You See It
Hard boney
enlargements
Heberdens nodes at
the DIP joints
Bouchards nodes at
the PIP joints
Often have squared
first CMC joint due to
osteophytes at that
joint
Diagnosis of Knee OA
Classic Clinical Criteria
> 50 yo
Morning stiffness < 30 min
Crepitus
Bony tenderness
Bony enlargement
No palpable warmth 5
Diagnosis of Knee OA
Classification Tree
Clinical symptoms
Synovial fluid
1.
2.
3.
WBC<2000/mm3
Clear color
High Viscosity
No OA
X-rays
1.
2.
3.
4.
Osteophytes
Loss of joint space
Subchondral sclerosis
Subchondral cysts
Confirmed by arthroscopy
(gold standard) 6
Sensitivity 94 %;
Specificity 88 %
Diagnosis of Knee OA
Diagnosis of OA
By imaging
X-ray
OA Hip:
Osteoarthritis:
Narrow joint space
Lipping osteophyte
Dislocation
Osteoporosis.
Joint space
narrowing
Marginal
osteophytes
Subchondral cysts
Boney sclerosis
Malalignment
Joint space
narrowing
Osteoarthritis: Ankylosis
Osteoarthritis:
Osteoarthritis:
Subchondral cysts
(solid arrowhead)
OA Fingers:
Diagnosis of OA
Imaging
MRI
Newer technique
Able to provide a 3 D image of the joint as an
organ
Laboratory findings in OA
Synovial fluid
Mild leukocytosis (<2000 WBC/microliter)
Can be used to exclude gout, CPPD, or septic arthritis if
diagnosis is in doubt
Management: Algorithm
Lifestyle Modifications
NSAIDs PRN
Steroid Injections
Acetaminophen PRN
Celecoxib
Opioids PRN
Hyaluronan Injections
Surgical Referral
Management: Lifestyle
Weight loss
Exercise Program
PT referral
Quadriceps strengthening
ROM exercises
Low impact activities e.g. swimming, biking 7
Nutrition referral
Cane
Walker
Insoles
Unloader knee braces
Weight reduction
44
Thermal modalities
Heat
Relaxes muscles
Stimulates blood flow
Cold
Eases muscle spasms
Blocks pain signals
45
Management: Lifestyle
Varus (bowlegged) vs Valgus (knock-kneed)
G2 Unloader Brace
Exercise
Range of motion
Muscle strengthening
Aerobics
49
Patient education
1-800-283-7800
Education can
improve arthritis
symptoms 15% to
30%
Can last up to 2 years
following intervention
http://www.arthritis.org
50
Management: Medical
Glucosamine/Chondroitin
Acetaminophen
NSAIDs
Cox-2 inhibitors
Opioids
Intraarticular injections
Glucocorticoids
Hyaluronans
Management: Medical
Glucosamine/Chondroitin
Patient satisfaction
proteoglycans
HA
EFFECT:
-anti-inflammatory
activity
-Membrane
stabilising action
INHIBITS:
cartilage degradative enzymes
(collagenase,elastase,
proteoglycanase, fosfolipase A2,
N-acetylglucosaminidase, etc.)
cartilage damaging
substances (free radicals)
apoptosis
NO
Stromelysin (MMP-3)
NF-kB
(3) Ronca F et.al. Osteoarthritis Cart (1998) 6, (Supplement A), 14-21. (4) Blanco FJ. et. al. Rev. Esp.
Reumatol 2001; 28, 1: 12-17.
Management: Medical
Acetaminophen
NSAIDs
Management: Medical
Cox-2 inhibitors
APC Trial: 700 pts each assigned to placebo, 200 BID, 400 BID
Increased risk at higher doses 11
CLASS Trial: 8,000 pts compared Celecoxib vs Ibuprofen
Similar risk to Ibuprofen 12
Cyclooxygenase (COX)
Two isoenzymes
Cyclooxygenase-1 (COX 1): constitutive
- physiologic production of PG in gastric mucosa,
Good Prostaglandins
GI cytoprotection
Platelet activity
Renal function
COX-2
Inducible
Bad Prostaglandins
Inflammation
Pain
Fever
Prostaglandins
COX-2
Inducible
Prostaglandins
Pathological
GI cytoprotection
Platelet activity
Renal function
Inflammation
Pain
Fever
Physiological
Renal function
Vascular
Tissue repair
Management: Medical
Opioid Analgesics
Indication:
Moderate-severe pain
Acute exacerbations
NSAIDs/Cox-2 inhibitors failed or contraindicated
Oxycodone synergistic w/ NSAIDs 13
Tramadol/acetaminophen vs codeine/acetaminophen
Similar pain relief 14
Avoid long-term use
Caution in elderly
Confusion, sedation, constipation
Opioids
63
64
Management: Medical
Intraarticular Injections
Technique
Patient supine
Leg straight
Manipulate patella
Angle needle slightly posteriorly
Inject after drop in resistance or fluid aspirated
Management: Surgical
When to Refer
Types of Procedures
Arthroscopic Irrigation
Arthroscopic Debridement
High Tibial Osteotomy
Partial Knee Arthroplasty
Total Knee Arthroplasty
Management: Surgical
High Tibial Osteotomy
Indication:
Unicompartmental arthritis
Genu varus or valgus
Management: Surgical
Partial Knee Arthroplasty
Indication:
Unicompartmental arthritis
Ligaments spared
Increased ROM
Faster recovery
Arthroplasty
Management: Surgical
Total Knee Arthroplasty
Indication:
Diffuse arthritis
Severe pain
Functional impairment
glucosamine
chondroitin
hyaluronic acid
Management option 10
Surgery
Thank you
LA
ALA
d6d
d6d
GLA
Meat
SDA
el
Mother's milk
DGLA
el
d5d
AA
EPA
cyc
cyc
lip
cyc
PGE1
PGE2
LEUK
PGE3
Fish
Arachidonic Acid
Cyclooxygenase
COX -1 - constitutively
expressed
COX -2 - inducible
Prostaglandin H2
Thromboxane A2
TXA2
synthase
isomerase
PGI2
synthase
Prostacyclin (PGI2)
reductase
Prostaglandin D2
Prostaglandin F2
Prostaglandin E2
Metabolic Pathways of
Arachadonic Acid
Membrane Phospholipids
Non-Enzymatic
Lipid Peroxidation
Catalyzed by Free
Radicals
ARACHIDONIC ACID
12-Lipoxygenase
COX
12-HETE, 12-HPETE
- promotes inflammation and
allergic signs/symptoms
Isoprostanes
- Amplifies platelet response
to other agonists.
- Vasoconstrictor
- Plasma levels 1-2 orders
of magnitude > COX
-derived metabolites.
Prostaglandin H2
Thromboxane A2
Prostacyclin
- Platelet Aggregation
- Vasoconstriction
- Platelet Aggregation
- Vasodilation
Platelet
TXA2
Vasoconstriction
Platelet Aggregation
COX -2
Endothelial PGI2
(Prostacyclin)
Vasodilation
Anti-Platelet Aggregation
Aspirin
COX-1
COX-2 inhibitors
Prostacyclin Thromboxane
Thromboxane
Decreased
CV events
COX-2
Prostacyclin
Increased
CV events
BIOLOGIC MARKERS
HRQOL / UTILITY
INFLAMMATION
PAIN
PHYSICAL
FUNCTION
PATIENT GLOBAL
IMAGING (1YR)
90%
STIFFNESS
36%
MD GLOBAL
OTHER Eg, Performance based
Flares
Time to Surgery
Analgesic Count
8%
Anti-Inflammatories