Osteoarthritis and exercise Sirintorn Chansirikarnjana MD.Msc.(Geriatric Med) Chief, Division of Geriatric Medicine Department of Medicine Ramathibodi Hospital Sucheera

Sucheera

Osteoarthritis Age > 50 years Hereditary for hand osteoarthritis Insidious onset of joint pain, progress slowly over months to years Mono/oligo arthralgia (knee, hip) > polyarthalgia (fingers) No or only mild inflammation Develops symptom when standing or prolong using Improves with rest, may have gelling phenomenon Can be associated with crystal-induce synovitis Sucheera

Symptoms and signs Joint involvement : common - DIP, PIP, first CMC, hip, knee, lumbar and cervical spine rare - MCP, MTP, wrist, elbow Systemic symptom : rare Localized symptoms : tenderness, crepitus and cracking Sign : mild joint enlargement with firm consistency Joint effusion : little or none Sucheera

JOINT LOCATION Weight-bearing joints femoral head and knee joints decreased progressively with age, but not in the talus knee joint chondrocytes exhibit more interleukin (IL)-1 receptors than ankle joint chondrocytes knee chondrocytes express mRNA for matrix metalloproteinase (MMP)-8 Sucheera

Laboratory ESR: usually normal CBC : normal RF, ANA : negative Synovial fluid analysis : good viscosity with normal mucin clot; modest increase in leukocyte number, presence of fibrils an debris(wear particles) R/o septic joint or crystal Sucheera

Radiographic findings Narrowing of joint space Subchondral bony sclerosis(eburnation) Marginal osteophyte formation Bone cysts and bony collapse Gross deformity with subluxation and loose bodies Articular cartilage ulceration New bone formation Proliferation of cartilage and bone Subchondral microfractures Ligamentous laxity as a result of mechanical forces Sucheera

Sucheera

Knee Osteoarthritis Non uniform loss of joint space No erosion No demineralization Subchondral sclerosis Osteophyte formation Sucheera

Hand Osteoarthritis Bouchard’s node Heberden’s node Sucheera

Erosive osteoarthritis Hereditary, postmenopausal woman Clinical resemble RA PIP, DIP, CMC jt. Painful inflammatory episode Joint deformity, ankylosis Film: joint space narrowing, spur formation , subchondral bone sclerosis, prominent bony erosion Lab: RF, ANA - neg Sucheera

Current Treatment of Osteoarthritis Pharmacologic Therapy Nonopioid analgesics (e.g., acetaminophen) Topical analgesics (e.g., capsaicin) Nonsteroidal anti- inflammatory drugs Intra-articular steroid Intra-articular hyaluronate Opioid analgesics Non-Pharmacologic Therapy Patient education Programmed exercises Weight loss Joint protection Thermal modalities Surgical Approaches Arthroscopic debridement Osteotomy Total joint arthroplasty Sucheera

NSAID gastropathy NSAID-related GI toxicity is most common serious drug-induced toxicity1 Dyspepsia occurs in about 15% of patients2 Prevalence of upper GI ulcers is 15–311 Higher risk of developing gastric than duodenal ulcers3,4 Risk of complications increases 4-fold4 Relative risk of bleeding 3.091 Relative risk of perforation 5.931 Relative risk of death 7.621 1. Sung et al., J Gastroenterol Hepatol 2000; 15: G58–68. 2. Larkai et al., J Clin Gastroenterol 1989; 11: 158–62. 3. Graham et al., Ann Intern Med 1993; 119: 257–62. 4. Hawkey, Gastroenterol 2000; 119: 521–35. Sucheera

Risk Factors for Ulcer Complications Definite Advanced age (substantial risk after age 65) Prior ulcer disease or ulcer complications High-dose, multiple NSAIDs (including low-dose aspirin) Concomitant use of anticoagulants Concomitant use of corticosteroid therapy Serious systemic disorder Possible Cigarette smoking Alcohol consumption Infection with Helicobacter pylori Singh et al., J Rheumatol 1999; 26(Suppl 56): 18-24. Larkai et al., J Clin Gastroenterol 1989; 11: 158–62. Graham et al., Ann Intern Med 1993; 119: 257–62. Hawkey, Gastroenterol 2000; 119: 521–35. Sucheera

Risk factors for serious GI complications Age and history of ulcer are strong predictors of ulcer complications Risk of hospitalisation or death1: 3/1000 patient-years for patients under 63 years 19/1000 patient-years for patients aged 63–75 years 42/1000 patient-years for patients over 75 years Relative risk of ulcer complications1: 2.9 for a history of dyspepsia 6.1 for a history of uncomplicated ulcers 13.5 for a history of bleeding ulcers Men have a 2-fold higher risk of developing complications than women2 The risk of NSAID-related ulcer complications is increased in the elderly, in patients with a history of PUD and in men. It is important to be aware of the risk factors for serious GI complications because many patients taking NSAIDs do not experience any warning signs. 1. Sung et al., J Gastroenterol Hepatol 2000; 15: G58–68. 2. Hernández-Díaz & García Rodríguez, Arch Intern Med 2000; 160: 2093–99. Sucheera

Complications associated with NSAID dose and duration The risk of ulcer complications increases with NSAID daily dose1: Low dose: relative risk 3.0 (95% CI, 2.6–3.4) Medium dose: relative risk 4.1 (95% CI, 3.6–4.5) High dose: relative risk 6.9 (95% CI, 5.8–8.1) NSAIDs increase the risk of ulcer complications in new and long-term users alike: 1–30 days’ NSAIDs: relative risk 5.7 (95% CI, 4.9–6.6) 181–365 days’ NSAIDs: relative risk 5.1 (95% CI, 3.9–6.5) Relative risk drops when NSAIDs are stopped and returns to baseline within about 2 months The risk of NSAID-induced ulcer complications is dose-dependent, is present from the first dose and is maintained throughout therapy. In this meta-analysis, doses of NSAIDs were defined as follows, depending on the individual studies and NSAID used: – low dose: 0.5 x standard dose OR <2.0 x standard dose OR below specific cut-off value – medium dose: 1.0-1.5 x standard dose OR within specific cut-off value – high dose: 3.0 x standard dose OR 14.0 x standard dose OR above specific cut-off value As early as the first dose, NSAID use is associated with an increased rate of GI complications. At risk patients should be protected with a fast-acting agent. Hernández-Díaz & García Rodríguez, Arch Intern Med 2000; 160: 2093–99. Sucheera

Rx of NSAID-induced PU disease Discontinue use of NSAIDs or substitute with less toxic agents Low-toxicity NSAIDs or COX-2 inhibitors Suppress acid secretion Normal-dose PPI therapy High-dose H2RA therapy Use mucosal protectants Misoprostol (side-effects can be problematic) NSAID-induced peptic ulcers are, ideally, managed by removal of the causative factor (the NSAID) and suppression of acid secretion, to allow healing. NSAIDs can be replaced with less toxic agents such as COX-2 inhibitors. The use of mucosal protective agents (e.g. the prostaglandin E1 analogue, misoprostol) does prevent gastric injury by NSAIDs, but causes GI side effects at the doses needed to protect against NSAID-induced ulcers. Acid suppression with normal-dose PPIs or high-dose H2RAs is effective. Seager & Hawkey, BMJ 2001; 323: 1236–9. Silverstein et al., Ann Intern Med 1995; 123: 241–9. Graham et al., Ann Intern Med 1993; 119: 257–62. Yeomans et al., N Engl J Med 1998; 338: 719–26. Sucheera

Acid suppression in NSAID-induced PU Antacids Limited efficacy, especially in preventing gastric ulcer H2RAs Effective in preventing gastric ulcer; some drug interactions, well tolerated PPIs More effective than H2RAs for healing NSAID-induced ulcers, well tolerated A number of agents can be used to suppress acid production for NSAID-induced peptic ulcer management, although some have limited efficacy. Seager & Hawkey, BMJ 2001; 323: 1236–9. Goldstein et al., Gut 1999; 25(Suppl V): A101. Yeomans et al., N Engl J Med 1998; 338: 719–26. Sucheera

NSAIDs and Cardiovascular All NSAIDs : Salt and water retention Increase BP May cause CHF in patient with cardiac problem Interfere with antihypertensive drugs ACEI Beta blocker Calcium antagonist Sucheera

Effects and CV Risk COX-2 COX-1 PGI2 TxA2 Thrombotic Risk Low-Dose ASA Conventional NSAIDs Prob Naproxen (high-dose) COX-2 Inhibitors +ASA ?? Sucheera

COX-2 selective inhibitors VS NSAID: balancing GI and CV risk Conclusion: Calculating annualized event rates for GI and CV harm shows that while complicated GI events occur more frequently with NSAIDs than coxibs, serious CV events occur at approximately equal rates. For each coxib, the reduction in complicated upper GI events was numerically greater than any increase in APTC events. R A Moore, et.al : BMC Musculoskeletal Disorders 2007, 8:73 Event rate difference (coxib-NSAID) per 1000 per year Sucheera

Shared Toxicities of NSAIDs Renal Sodium retention Weight gain and edema Hypertension Type IV renal tubular acidosis and hyperkalemia Acute renal failure Papillary necrosis Acute interstitial nephritis Accelerated chronic renal failure Sucheera

Indication for COX-2 Inhibitors Age > 70 yr. with no cardiovascular, renal or hepatic diseases History of aspirin induced asthma History of major peptic ulcer complication (bleeding, obstruction, perforation) Continue GI complication even after adding gastroprotective agents to conventional NSAIDs Pre and post operative pain (short course) Sucheera

Exercise Prescription for Special Populations Advanced age Resistance training is recommended by most health promotion organizations for its effects on maintenance of strength, muscle mass, bone mineral density, functional capacity, and prevention and/or rehabilitation of musculoskeletal problems (eg,low back pain) Emedicine.medscape Jun 24, 2009 Amer Suleman, MD; Kyle D Heffner, MS, CPFT, CCT Sucheera

Exercise Prescription for Special Populations Advanced age In elderly individuals, resistance training is both safe and beneficial in improving flexibility and quality of life Emedicine.medscape Jun 24, 2009 Amer Suleman, MD; Kyle D Heffner, MS, CPFT, CCT Sucheera

Contraindications Absolute contraindications to exercise include Suspected acute coronary syndrome 3rd-degree heart block Uncontrolled hypertension Acute heart failure Uncontrolled diabetes mellitus Merch Manaul April 2009 by Brian D. Johnston; Paul L. Liebert, MD Sucheera

Contraindications Relative contraindications include Cardiomyopathy Valvular heart disease Complex ventricular ectopy Merch Manaul April 2009 by Brian D. Johnston; Paul L. Liebert, MD Sucheera

Screening 1 Detecting cardiac disorders and Physical limitations to exercise For sedentary patients who plan to begin intense exercise, stress testing is indicated if they have any of the following: Merch Manaul April 2009 by Brian D. Johnston; Paul L. Liebert, MD Sucheera

Screening 2 Known coronary artery disease Symptoms of coronary artery disease > 2 cardiac risk factors (hypercholesterolemia, hypertension, obesity, sedentary lifestyle, smoking, family history of early coronary artery disease) Suspected lung disease Suspected diabetes Merch Manaul April 2009 by Brian D. Johnston; Paul L. Liebert, MD Sucheera

Exercise program Exercise should ideally include Aerobic activity Strength training Flexibility and balance Merch Manaul April 2009 by Brian D. Johnston; Paul L. Liebert, MD Sucheera

Physical Activity and Public Health in Older Adults: Recommendation from the American College of Sports Medicine and the American Heart Association Sucheera

30 minutes a day of aerobic activity five days a week Resistance training exercise to reduce stress on joints, bones and soft tissues; Add flexibility and balance to the mix Sucheera

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กล้ามเนื้อข้อเข่า Sucheera

การบริหารกล้ามเนื้อข้อเข่า ห้อยเท้า ผูกน้ำหนักที่ข้อเท้า ½ - 1 กิโล ทั้ง 2 ข้าง (ทำวันละ 1-3 ครั้ง ครั้งละ 5-15 นาที) Sucheera

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กล้ามเนื้อข้อสะโพก Sucheera

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