Medical And Surgical Treatment

Of Arthritis

Gerald J. Broock M.D.

CWA
gbroock@cox.net

Feb 7, 2004
Alternative
Alternative Medicine
Medicine

Complementary Approaches May

Ease symptoms
Improve outlook and attitude
Nutritional research is still in its infancy
as far as understanding how plant
chemicals and antioxidants work --- to
prevent and treat diseases such as
arthritis.
Arthritis Foundation
 Non-Proven remedies
Vitamins/Herbal therapy
Acupuncture
Magnets
Electric stimulation
Copper bracelets
Chiropractic (Cranial/sacral manipulation)
Naturopathic, Aromatic, Homeopathic
Reflexology, Herbalist, Ayurveda ----
 Alternative Medicine
Therapy Symptom
Pain Stiffness Fatigue Inflammation Anxiety/
Depression
Biofeedback

Visualization

Hypnosis

Relaxation

Yoga Pilates

Tai Chi
Acupuncture

Magnets

Vegetarian
Diet
Herbs &
Supplements
Alternative
Alternative Medicine
Medicine

Complementary Approaches Will

Not
Cure osteoarthritic changes
Replace proven medical treatments for
Osteoarthritis
Side effects of herbs
Bromelain May increase effects of blood-
thinning drugs and tetracycline
antibiotics.
Echinacea Might counteract immune-
suppressant drugs such as
glucocorticoids taken for lupus and
rheumatoid arthritis. Might increase
side effects of methotrexate.
Evening Primrose oil Can counteract the effects of anti-
convulsant drugs.
Fish oil May increase effects of blood-
thinning drugs and herbs.
Folic acid Interferes with methotrexate; ask
your doctor how to take it.
G.L.A. May increase effects of blood-
thinning drugs and herbs.
Garlic Can increase effects of blood-
thinning drugs and herbs.
Ginger Can increase NSAID side effects
and effects of blood-thinning drugs
and herbs.
Ginkgo May increase effects of blood-
thinning drugs and herbs.
Ginseng May increase effects of blood-
thinning drugs, estrogens and
glucocorticoids; shouldnt be used
by those with diabetes; may interact
with MAO inhibitors.
Kava Kava Can increase effects of alcohol,
sedatives and tranquilizers.
Magnesium May interact with blood pressure
medications.
St. Johns Wort May enhance effects of narcotics,
alcohol, and antidepressants;
increase risk of sunburn; interfere
with iron absorption.
Valerian Can increase the effects of
sedatives and tranquilizers.
Zinc Can interfere with glucocorticoids
and other immunosuppressing
drugs
Other over the counter RX.

Topical NSAIDs ? No strong studies yet

Topical Glucosamine and chondroitin S ?
No strong studies yet
Vitamin C, D, or E ? No validated studies
SAM-e ?? Not validated nor do I
personally recommend this until
further information
Medical
Medical Treatment
Treatment of
of
Osteoarthritis
Osteoarthritis
 Diagnosis
Diagnosis

Before Your Appointment

Prepare to describe your symptoms

Gather medical history

Make list of medications

Write down concerns & questions and

bring them
Diagnosis
Diagnosis
Physical History and Exam
X-Rays (MRI-CT)
Blood Tests- to rule out
other diseases
Diagnosis
Diagnosis

Healthy knee Osteoarthritic knee

data do not support the routine use of
magnetic resonance imaging for the
evaluation and management of meniscal
tears in patients with osteoarthritis of the
knee. JBJS 1/2003
Diagnosis
Diagnosis
During Your Appointment
What should I expect from my treatment?
What effect will my treatment have on my
daily activities?
What can I do to prevent further disability?
Comments on medication refer to clinical studies with statistical
outcomes. So these are general statements. There are
commonly varying individual responses to a medication. For
example- Vioxx may be much more satisfactory than Celebrex
even though they are essentially the same drug. You may
have little or no relief with one class of drugs and a good
result with another. For example you may do much better
with Tylenol than Celebrex. A newer, higher cost, more
heavily advertised drug does not necessarily mean its best for
you. No drug has yet been proven to restore joint cartilage or
prevent deterioration. Hopefully, this will occur in our lifetime.
 Medical Treatment of Osteoarthritis

NSAIDs are nonsteroidal anti-inflammatory

drugs
Aspirin
Ibuprofen
Motrin-Rx 400-800mg.
Naproxen
Naprosyn-Rx 250-500mg.
Indocin
Butazolidin
 Than NSAIDS
or Tylenol for
pain relief

BECTRA
Medication

Cox-2 inhibitors offer the

benefits of other NSAIDs
with a decreased incidence
of gastrointestinal side
effects.
Indications for Cox-2 inhibitors
Celebrex Vioxx - Bectra

History of Gastrointestinal problems

such as ulcer or bleeding
Intolerance of NSAIDs or Tylenol
 Problems with Cox-2 drugs

Cost
Caution use with high blood pressure
congestive heart failure or renal
insufficiency
Do not use if allergic to aspirin or NSAIDS
May increase risk of cardiac problems
 Medication
Medication
Oral Narcotics Opioids (Injection
rarely!)
Darvon, Darvocet
OxyContin, Percodan, Percoset
Vicodin, Lortab, Tylenol and
Codeine, Talwin
Dilaudid, MSContin
These are appropriate for only a brief
time
 Medication
Medication
Other pain Rx
Toradol limited to 5 days
Ultram or Tramadol
 Cortisone Injection
Aristospan-Solucortef-DepoMedrol
Kenalog-Dalalone-Celestone

Cortisone orally Medrol pack

Infrequently
MEDICATION
MEDICATION

Muscle relaxants Flexaril, Valium

Sedatives Ambien, Ativan, Seconal
Phenergan, Valium
Viscosupplimentation
Viscosupplimentation
WD-40
WD-40 Joint
Joint Injections
Injections

Synovisc Hyalgan
Intra-articular hyaluronic acid has a small effect
when compared with an intra-articular placebo.

JAMA Dec.2003
 Unilateral Compartment
Osteoarthritis of the Knee
Commonly the inside (medial) compartment of the
knee involved much more than outside (lateral)

Medial

Lateral
compart
ment
Rx- Bracing (usually covered
DME)
Durable Medical Equipment covered by Insurance
Lateral thick on
outside of heel
Unilateral
Unilateral compartment
compartment
OA
OA of
of the
the knee
knee
 Physical
Physical Therapy
Therapy
Goals
Goals of
of Treatment
Treatment

To relieve pain
Increase motion
Improve strength
 Physical therapy
Rules
for Arthritis
The Patient must be active not passive
If there is pain theres No Gain!
The patient is a better judge of progress than the therapist
The therapist should mainly be an instructor and monitor
The primary goal provide patient with an independent
HEP
Home Exercise Program

Empowering the patient !

 Unproven PT Techniques
for Osteoarthritis
Diathermy
Ultrasound
LASER treatment
Muscle stimulator
TENS unit (transcutaneous electrical
nerve stimulator)
 THEREFORE
THE VICIOUS CYCLE OF PAIN IS
NEVER BROKEN

THE VICIOUS CYCLE OF PAIN

OVERSTRESS PAIN INHIBITION (REST)

INSTABILITY WEAKNESS P.T.
 Physical
Physical therapy
therapy
Rules
Rules
for
for Arthritis
Arthritis
The Patient must be active not passive
If theres pain theres No Gain!
The patient is a better judge of progress than the therapist
The therapist should mainly be an instructor and monitor
The primary goal provide patient with an independent
HEP
Home Exercise Program

Empowering the patient !

Exercise for osteoarthritis of the hip or knee

Cochrane Review 2003

Therapeutic exercise was shown to reduce
pain and improve physical function for OA of
the knee
Supervised exercise classes ---beneficial as
---one to one basis
 WHY IS P.T./ HEP SO IMPORTANT?
APPROPRIATE P.T./ HEP CAN PREVENT UNNECESSARY SURGERY
INAPPROPRIATE P.T./ HEP PROVOKES UNNECESSARY SURGERY

IF P.T./ HEP FAILS - EVALUATE PROGRAM AND CONSIDER

CHANGING THERAPIST or FACILITY
 USUAL PROBLEMS WITH FAILED PT PROGRAM

PATIENT MANAGED PASSIVELY -MODALITIES EMPHASIZED

CONSTRAINTS PLACE ON STRENGTHENING - USE RED
THERABAND UNTIL I TELL YOU TO USE BLUE
NO WEIGHT SYSTEM PROVIDED THAT ALLOWS
RESTORATION OF FULL STRENGTH
PATIENT CONTINUES STRESS PROVOCATIVE ACTIVITY
WITHOUT COUNSEL.
HEP POORLY INSTRUCTED WITHOUT ADEQUATE
FREQUENCY OR MONITORING
PATIENT TOLD TO EXPECT SLOW PROGRESS- THIS WILL
TAKE 24 SESSIONS
THERAPIST/DOCTOR DO NOT BUY IN TO HEP CONCEPT
OR
UNDERSTAND THE VICIOUS CYCLE.
POST-OP REHABILITATION OF THE PATIENT FAILING
PRIMARY REHABILITATION WHO COMES TO
SURGERY

IF THE P.T./HEP PROGRAM REMAINS ESSENTIALLY

UNCHANGED-
THERE IS AN INCREASED CHANCE FOR FAILED
SURGERY.

IF CONSERVATIVE THERAPY(P.T./HEP) FAILS AT

FIRST - POSTOP P.T./HEP CAN FAIL AGAIN !

FOR BACK-SHOULDER-KNEE SURGERIES

THE VICIOUS CYCLE IS ENHANCED AND
UNFORTUNATELY
MAY LEAD TO REPEAT SURGERY !
Osteoarthritis in other Joints

-virtually any joint can be affected-

Osteoarthritis of the Shoulder

Trauma
Trauma -- Developmental
Developmental --Primary
Primary
Osteoarthritis
Osteoarthritis of
of the
the Shoulder
Shoulder

Physical Therapy Independent home

exercise
Steroid injection occasionally
Manipulation -rarely
 Osteoarthritis of the Elbow
TRAUMA

Support
Injection-
occasionally
Osteoarthritis of the
Basilar Thumb Joint
(Metacarpal-
Trapezial Joint)
Most common joint
clinically involved
in females

Etiology- Lax
ligaments
 Basilar
Basilar Thumb
Thumb Joint
Joint
Arthritis
Arthritis
Splinting - limited
Steroid injections limited
Exercise slow/gentle/non-painful
Exercise putty/PlayDough/SillyPutty/Clay
Ball
Shift to side-pinch from thumb-tip
pinch
Other areas of osteoarthritis of hand and wrist
Heberdens Nodes Bouchards Nodes
Gouty Arthritis

Tophus
Mucous cyst or ganglion
 Wrist
Wrist Ganglion
Ganglion

Usually from arthritic joint

 Non- arthritic hand conditions

Dupuytrens disease
contracture

Trigger finger
Non-surgical
Non-surgical care
care of
of hand
hand
and
and wrist
wrist arthritis
arthritis
Activity modification
Handshaking, Hand gripping, squeezing,
wringing, pulling
Splinting more applicable to wrist (bowling
splint with single or double metal inserts)
Accomodative devices
Golf club, tennis racquet, tools- larger(thicker)
grips
Thicker pen, pencil
Tools for unscrewing jar tops
Easy-open pill containers
Ergonomic tools rake, clippers, contoured
tool grips
Osteoarthritis of the Hip
Osteoarthritis
Osteoarthritis of
of the
the Hip
Hip
Etiology
Developmental failure of full
containment of femoral hip within
acetabulum
Trauma
Primary
Osteoarthritis
Osteoarthritis of
of the
the Hip
Hip
Non-Surgical
Non-Surgical Treatment
Treatment
Exercise
Support temporary
Cane opposite hand
walker/crutches ( steps- up with the
good ! ; down with the bad !)
Injection rarely
Physical therapy water exercise
Join a Spa
Osteoarthritis
Osteoarthritis of
of the
the Foot
Foot

Usually from trauma

Usually from trauma

Osteoartitis
Osteoartitis of
of the
the Ankle
Ankle
Shoe modification-heel support/heel
height/cushioned heel (SACH heel)
Boot
Pronation correction/heel wedges
Inserted heel cushion(+/- wedge)/arch
support with flat foot
Brace (SACH heel)
Injection- infrequent
Osteoarthritis
Osteoarthritis of
of the
the Foot
Foot

Shoe design heel height, toe box

Firm and supportive shoe arch support,
thicker shock absorbing heel and sole
Inserted foot support
Silicone heel cushion wedged
Arch support for flat or high arch
Metatarsal pad
Full length steel shank in split sole
 Calluses
Calluses

Calluses
Callusesarise
arisefrom
fromskin
skinreaction
reactionto
toabnormal
abnormalpressure
pressure
As
Aslong
long as
as abnormal
abnormalpressure
pressurepersists
persiststhe
thecallus
calluswill
willrecur
recur
 Care
Care of
of Callus
Callus (( Corn)
Corn)
Remove
Remove abnormal
abnormal pressure
pressure
Shoe
Shoe design
design
Lowest
Lowestheel
heeland
andlargest
largesttoe
toebox
box
Arch
Arch support/metatarsal
support/metatarsal pad
pad
Protective
Protective cushions-
cushions- silicone
silicone toe
toe sleeve
sleeve
Corn
Corn care
care sanding
sanding (pumice
(pumice stone),
stone), corn
corn
file,
file, removers,
removers, Podiatry
Podiatry
Beware
Beware of of ulcers/sores
ulcers/sores (especially
(especially ifif
diabetic)
diabetic)
Surgery
Surgery last
last resort!
resort!
 Bunion
Bunion
with
with Osteoarthritis
Osteoarthritis
 Bunion
Bunion
non-surgical
non-surgical treatment
treatment
Accomodative shoes with minimal heel
The shoe will be much wider than you
will like
(If the shoe fits- it will be ugly!)
Foot /big toe supports
Night splint
MEDICAL CARE PROBLEMS WITH
THE TREATMENT OF
OSTEOARTHRITIS
PATIENT PRESENTS WITH PAIN - DO SOMETHING !
MAKE A DIAGNOSIS ! TREAT THE PAIN !
TEST - TEST - TEST !
TESTS COMMONLY SHOW ABNORMALITIES --
NORMAL POPULATION SURVEYS DEMONSTRATE HIGH INCIDENCE
OF ABNORMALITY -
CADAVER, MRI, PLAIN XRAY
SPINAL DISC CHANGES IN TWENTIES
TORN ROTATOR CUFF BY FIFTY
MENISCAL TEARS AND DJD BY FORTY
PROFESSIONAL CONSERVATIVE CARE - OFTEN INAPPROPRIATE AND
INADEQUATE
PATIENT NOT PROTECTED FROM INCITING STRESSES UNTIL
RECONDITIONED.
PATIENT RECEIVES PASSIVE P.T. AND NOT RECONDITIONED BEFORE
RETURN TO SPORT OR WORK.
NO SUSTAINED HOME EXERCISE PROGRAM IS PROVIDED.