1 Knee Osteoarthritis: A Physiatrist’s Perspective Cedric K. Akau, MS, MD, MPH Associate Clinical Professor and Chief, Division of Physical Medicine and Rehabilitation, JABSOM Physiatrist, Hawai‘i Pacific Health Medical Group What is a Physiatrist? • Physical Medicine and Rehabilitation (PM&R) physicians, also known as physiatrists, treat a wide variety of medical conditions affecting the brain, spinal cord, nerves, bones, joints, ligaments, muscles, and tendons. ... Specifically, PM&R physicians: Treat patients of all ages. • Sports Medicine, Pain Medicine, Spinal Cord Injury, Pediatric Rehabilitation, Neuromuscular Medicine, Brain Injury, Cancer Rehabilitation and Palliative Medicine • Restore and improve FUNCTION, team-based care, holistic care
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Knee Osteoarthritis: A Physiatrist’s Perspective
Cedric K. Akau, MS, MD, MPHAssociate Clinical Professor and Chief, Division of Physical
Medicine and Rehabilitation, JABSOM
Physiatrist, Hawai‘i Pacific Health Medical Group
What is a Physiatrist?
• Physical Medicine and Rehabilitation (PM&R) physicians, also knownas physiatrists, treat a wide variety of medical conditions affectingthe brain, spinal cord, nerves, bones, joints, ligaments, muscles, andtendons. ... Specifically, PM&R physicians: Treat patients of all ages.
• Sports Medicine, Pain Medicine, Spinal Cord Injury, PediatricRehabilitation, Neuromuscular Medicine, Brain Injury, CancerRehabilitation and Palliative Medicine
• Restore and improve FUNCTION, team-based care, holistic care
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Osteoarthritis (OA)
• Most common form of arthritis, also known as ”wearand tear” or ”degenerative” arthritis
• Leading cause of musculoskeletal disability in theworld and 11th highest contributor to global disability
• 70-90 % of Americans above age 75 have it
• ~ 12% or 27 million Americans affected
• OA most common in knees, hips and hands
• Knee OA is the leading cause of disability in theelderly, 19-28% of Americans over the age of 45 haveknee OA.
Osteoarthritis
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Osteoarthritis
Risk Factors
• Age
• Joint overload, stress, and trauma
• Obesity
• Race
• Genes
• Gender
• Weak muscles
• Quad muscles
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Symptoms and Signs
• Gradual onset of achy pain, slowly progressive
• Stiffness and loss of flexibility
• Swelling and tenderness
• Crackling, popping, grating noises, locking
• An increase in falls and subsequent fractures
• Associated back and neck pain
• Bone spurs seen on x-rays
• Heberden’s and Bouchard’s nodes and Bunions
• Weight gain and muscle loss
The Vicious Cycle
• Joint becomes painful
• Don’t move the joint
• Muscles become weak
• “Get out of shape”
• Gain weight
• Less protection to the joint
• Further decrease in range of motion
• Worsening of arthritis and pain
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Stop the Vicious Cycle and Start Rehabilitation
Protect the Joint: weight loss,bracing, assistive devices
Reduce Pain: (P.) R.I.C.E, oral,topical and injectable medications
• For knee OA, use cane in the arm opposite theaffected knee and for stair walking, “up with thegood and down with the bad”
• Off-loading (unloading) knee braces candecrease weight off the most affected part ofthe knee but if not coupled with a strengtheningprogram can lead to further muscle weaknessand progression of the OA
1 : 3 : 5
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Reduce Pain: P.R.I.C.E.
• P. Protect
• R. Rest, Rehab, Range of motion
• I. Ice
• C. Compression
• E. Elevation
Reduce Pain: Is ICE or HEAT Better?
• Ice is used after acute injuries or to decrease pain and inflammationsuch as when the joint feels warm and/or is swollen.
• Heat is used for more chronically stiff and non-inflamed joints,typically to relax muscles around joints such as in the morning orbefore exercising.
• Do not use either for more than 15-20 minutes at a time, do notapply the packs directly to the skin and avoid areas that are infectedor directly over nerves.
• Avoid ice over areas of poor circulation.
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Oral Medications
• Acetaminophen (Tylenol), no more than 3gm/day, recommended bythe American College of Rheumatology as the first line drug of choicefor osteoarthritis, watch for liver toxicity.
• Non-Steroidal Anti-Inflammatory Drugs (NSAIDs). Greater risks ofadverse affects in the elderly (heart attack, stroke, GI bleeding, Kidneyand Liver damage). Use with caution and have close physician followup.
• Narcotic medications, Tramadol and other stronger Opiates. At riskfor developing tolerance and dependence.
OTC Topical Medications
• Methyl salicylates (“Ben Gay”)
• Capsaicin Cream
• Topical Lidocaine 4% patches
• Topical Diclofenac (Voltaren Cream)
This Photo by Unknown Author is licensed under CC BY-SA
Increase Strength of the Muscles surrounding the joint
Activity modification
WebMD.com, “Knee Osteoarthritis Exercises”
PREVENTION through a Fitness program
• Prevent disability related to knee OA thru improving yourfitness by maintaining proper weight, muscle tone, range ofmotion and flexibility. Motion and movement are good!
• Non or minimally weight bearing cardiovascular exercises
• Balancing exercises
• Strengthening exercises
• Weight control and ”joint healthy” diet
See Dr Akau’s “Fun and Fitness” handout, tips on starting a fitness program
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Aquatic Exercises
This Photo by Unknown Author is licensed under CC BY-NC
This Photo by Unknown Author is licensed under CC BY-SA
Tai chi• Slow, graceful, controlled body movements while the body remains
straight and upright.
• Improves balance, which can prevent falls and fractures.
• A 2007 study found that OA symptoms improved with aquatherapyor tai-chi at 12 and 24 weeks.
• Major component of joint cartilage• Derived from shellfish• May help pain & stiffness• Not conclusively shown to prevent or reverse cartilage loss• Benefits are controversial• Dosage: 1500 – 2000 mg a day
• WARNINGS:• May cause mild stomach upset, nausea, heartburn, diarrhea and
constipation• May increase blood sugar, blood pressure, cholesterol, triglycerides and
worsen glaucoma
Chondroitin• Component of cartilage and bone• Derived from cow or shark cartilage• Not conclusively shown to prevent or reverse cartilage
loss• Symptom benefit is controversial• Dosage: 1200 – 1600 mg a day
• WARNINGS:• Blood-thinning properties - may increase risk of
bleeding or bruising.• Other side effects include diarrhea, constipation and
abdominal pain.
This Photo by Unknown Author is licensed under CC BY-ND
• Fish (&/or shellfish) curry, withginger, and red chili peppers
• A side of soy beans
• Avocado and pineapple salad
• And a green tea beverage
Summary: A Physiatrist’s Approach to OA
• Physical Medicine and Rehabilitation, PMR specialist, Physiatrist,Restore and Improve FUNCTION
• Knee Osteoarthritis
• Vicious Cycle
• Protect the Joint, Reduce Pain, Rehabilitation Program
• Non-surgical treatments
• Prevention through a Fitness program
• Alternative and complimentary therapies
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Words of Wisdom
• “If we could give every individual the right amount of nourishmentand exercise, not too little and not too much, we would have foundthe safest way to health.” “Eating alone will not keep a man well, hemust also take exercise.” -Hippocrates
• “The doctor of the future will give no medicine but will educate hispatients in the care of the human frame, in diet and in the cause andprevention of disease.” -Thomas Edison
• ”Exercise is Medicine”, a global educational campaign launched in2007 by the American College of Sports Medicine
• Whatever you do, have FUN and do it with others!
Thank You
for participating in the 2021 John A. Burns School of Medicine