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OSTEOARTHRITIS
conservative therapy:
a practical approach
Alexander R. Shikhman MD, PhD, FACR
ifsmed.com
PRESENTATION MATERIALS
• Slides available on slideshare.com/ifsmed
• Video available on youtube.com/ifsmed
OSTEOARTHRITIS
A degenerative joint disease characterized by:
• cartilage loss
• changes in the subchondral bone (bone underlying the
cartilage)
• adaptive changes in tendons and ligaments
• mechanical misalignment
• eventual loss of the joint function
OSTEOARTHRITIS
SYMPTOMS AND SIGNS
• pain after physical activity
• joint swelling
• joint stiffness
• loss of joint flexibility/function
• changes in the joint appearance/joint deformities
OSTEOARTHRITIS
PRINCIPLES OF THERAPY
Control of pain and
inflammation
• NSAIDs
• Acetaminophen
• Opioid analgesics
• Viscosupplementation
therapy
• Food supplements
• Physical therapy
(modalities)
• Bionicare device
Prevention of cartilage
degeneration
• Viscosupplementation
therapy
• Food supplements
Restoring joint function
• Food supplements
• Viscosupplementation
therapy
• Physical therapy
• Orthotics
VISCOSUPPLEMENTATION
THERAPY
INDICATIONS
• Joint pain
• Osteoarthritis
CONTRAINDICATIONS
• Ongoing joint inflammation (active synovitis)
• Crystal-induced arthropathy (gout/pseudogout)
• Infection
VISCOSUPPLEMENTATION
THERAPY
PREDICTORS OF GOOD OUTCOME
• Mild to moderate joint deformities
• Absence of large synovial effusions
• Well-preserved periarticular muscle mass
• Minimal joint instability
VISCOSUPPLEMENTATION
THERAPY
High Success
Rate
Knees 1st CMCs TMJs
Moderate
Success Rate
Hips Ankles
Low Success
Rate
Shoulders
VISCOSUPPLEMENTATION
THERAPY
OUTCOME OPTIMIZATION
• Pre-viscosupplementation intraarticular steroid injection
• Injection in a ‘dry joint’
• Selection of the right viscosupplementation agent
• Ultrasound guidance of joint injections
• Post-injection joint immobilization
• Physical therapy
• Food supplements
• Post-viscosupplementation platelet-rich plasma (PRP)
therapy
ULTRASOUND GUIDANCE OF
JOINT INJECTIONS
• Better assessment of joint anatomy
• Avoidance of unexpected findings
• Crystals (calcium pyrophosphate, urate,etc.)
• Active synovitis or active tendinitis
• Hidden effusions
• Guaranteed drug delivery to the joint space
• Biofeedback effect
MUSCULOSKELETAL ULTRASOUND
UNEXPECTED SOURCE OF KNEE PAIN
ULTRASOUND GUIDED KNEE
ARTHROCENTHESIS
ULTRASOUND GUIDED
HIP INJECTION WITH EUFLEXXA
FOOD SUPPLEMENTS FOR OA
CARTILAGE MATRIX OPTIMIZERS VISCOELASTICITY
Chondroitin Sulfate Celadrin
MSM Oral Hyaluronic Acid
N-Acetylglucosamine
Oral Hyaluronic Acid
Oral Collagen Type 2
INHIBITORS OF INFLAMMATION INHIBITORS OF NEOANGIOGENESIS
Boswellia/Curcumin Sea Cucumber Extract
Devil’s Claw
Yucca Schidigera Extract
Omega-3 polyunsaturated fatty acids
- fish oil
- krill oil
- green lipped muscle extract – lyprinol
PLATELET-RICH PLASMA THERAPY
(PRP)
• Platelet attachment to collagen fibers results in
their activation and massive release of growth
factors
• Released growth factors stimulate cartilage
matrix synthesis and suppress inflammatory
responses
• Published data indicate that PRP therapy benefits
patients with knee and hip OA
PHYSICAL THERAPY
TREATMENT METHODS
• Iontophoresis with acetic acid
• Class IV laser therapy
• Manual therapy
• Pilates based rehab exercises
IONTOPHORESIS WITH
ACETIC ACID
• Reduce calcific deposits and bone spurs
• Insoluble calcium in the form of calcium
pyrophosphate reacts with acetic acid to form
calcium acetate, which is more soluble and
therefore, more easily dissolved by our body
fluids (synovial fluid, blood)
CLASS IV LASER THERAPY
• Reduce pain, inflammation, and enhance
tissue healing of muscle, ligaments and bones
• Increase circulation and oxygenation of tissues
>RBC’s to area and increasing venous and
lymphatic return
• Non-invasive use of laser energy to generate a
photochemical response (helping cells
produce ATP/energy) in damaged or
dysfunctional tissue
LASER THERAPY
MANUAL THERAPY
• Reduce pain, increase joint range of motion,
increase joint proprioception and increase
muscle length
• Passive physiological and accessory
movements, manual muscle stretching and
soft tissue mobilization
PILATES BASED REHAB
Benefits:
o increases range of
motion
o increases flexibility
o increases strength
o increases spine
stabilization
o improves balance
o improves posture
o enhances body
awareness
o decreases joint stress
o enhances breathing
Joseph Pilates: exercise format embodying
“complete coordination of body, mind and
spirit”
PILATES
PRESENTATION MATERIALS
• Slides available on slideshare.com/ifsmed
• Video available on youtube.com/ifsmed
THANK YOU FOR COMING!

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Osteoarthritis Treatment Alternatives

  • 1. OSTEOARTHRITIS conservative therapy: a practical approach Alexander R. Shikhman MD, PhD, FACR ifsmed.com
  • 2. PRESENTATION MATERIALS • Slides available on slideshare.com/ifsmed • Video available on youtube.com/ifsmed
  • 3. OSTEOARTHRITIS A degenerative joint disease characterized by: • cartilage loss • changes in the subchondral bone (bone underlying the cartilage) • adaptive changes in tendons and ligaments • mechanical misalignment • eventual loss of the joint function
  • 4. OSTEOARTHRITIS SYMPTOMS AND SIGNS • pain after physical activity • joint swelling • joint stiffness • loss of joint flexibility/function • changes in the joint appearance/joint deformities
  • 5. OSTEOARTHRITIS PRINCIPLES OF THERAPY Control of pain and inflammation • NSAIDs • Acetaminophen • Opioid analgesics • Viscosupplementation therapy • Food supplements • Physical therapy (modalities) • Bionicare device Prevention of cartilage degeneration • Viscosupplementation therapy • Food supplements Restoring joint function • Food supplements • Viscosupplementation therapy • Physical therapy • Orthotics
  • 6. VISCOSUPPLEMENTATION THERAPY INDICATIONS • Joint pain • Osteoarthritis CONTRAINDICATIONS • Ongoing joint inflammation (active synovitis) • Crystal-induced arthropathy (gout/pseudogout) • Infection
  • 7. VISCOSUPPLEMENTATION THERAPY PREDICTORS OF GOOD OUTCOME • Mild to moderate joint deformities • Absence of large synovial effusions • Well-preserved periarticular muscle mass • Minimal joint instability
  • 8. VISCOSUPPLEMENTATION THERAPY High Success Rate Knees 1st CMCs TMJs Moderate Success Rate Hips Ankles Low Success Rate Shoulders
  • 9. VISCOSUPPLEMENTATION THERAPY OUTCOME OPTIMIZATION • Pre-viscosupplementation intraarticular steroid injection • Injection in a ‘dry joint’ • Selection of the right viscosupplementation agent • Ultrasound guidance of joint injections • Post-injection joint immobilization • Physical therapy • Food supplements • Post-viscosupplementation platelet-rich plasma (PRP) therapy
  • 10. ULTRASOUND GUIDANCE OF JOINT INJECTIONS • Better assessment of joint anatomy • Avoidance of unexpected findings • Crystals (calcium pyrophosphate, urate,etc.) • Active synovitis or active tendinitis • Hidden effusions • Guaranteed drug delivery to the joint space • Biofeedback effect
  • 14. FOOD SUPPLEMENTS FOR OA CARTILAGE MATRIX OPTIMIZERS VISCOELASTICITY Chondroitin Sulfate Celadrin MSM Oral Hyaluronic Acid N-Acetylglucosamine Oral Hyaluronic Acid Oral Collagen Type 2 INHIBITORS OF INFLAMMATION INHIBITORS OF NEOANGIOGENESIS Boswellia/Curcumin Sea Cucumber Extract Devil’s Claw Yucca Schidigera Extract Omega-3 polyunsaturated fatty acids - fish oil - krill oil - green lipped muscle extract – lyprinol
  • 15. PLATELET-RICH PLASMA THERAPY (PRP) • Platelet attachment to collagen fibers results in their activation and massive release of growth factors • Released growth factors stimulate cartilage matrix synthesis and suppress inflammatory responses • Published data indicate that PRP therapy benefits patients with knee and hip OA
  • 16. PHYSICAL THERAPY TREATMENT METHODS • Iontophoresis with acetic acid • Class IV laser therapy • Manual therapy • Pilates based rehab exercises
  • 17. IONTOPHORESIS WITH ACETIC ACID • Reduce calcific deposits and bone spurs • Insoluble calcium in the form of calcium pyrophosphate reacts with acetic acid to form calcium acetate, which is more soluble and therefore, more easily dissolved by our body fluids (synovial fluid, blood)
  • 18. CLASS IV LASER THERAPY • Reduce pain, inflammation, and enhance tissue healing of muscle, ligaments and bones • Increase circulation and oxygenation of tissues >RBC’s to area and increasing venous and lymphatic return • Non-invasive use of laser energy to generate a photochemical response (helping cells produce ATP/energy) in damaged or dysfunctional tissue
  • 20. MANUAL THERAPY • Reduce pain, increase joint range of motion, increase joint proprioception and increase muscle length • Passive physiological and accessory movements, manual muscle stretching and soft tissue mobilization
  • 21. PILATES BASED REHAB Benefits: o increases range of motion o increases flexibility o increases strength o increases spine stabilization o improves balance o improves posture o enhances body awareness o decreases joint stress o enhances breathing Joseph Pilates: exercise format embodying “complete coordination of body, mind and spirit”
  • 23. PRESENTATION MATERIALS • Slides available on slideshare.com/ifsmed • Video available on youtube.com/ifsmed THANK YOU FOR COMING!