HSE320 arthritis lecture 2023 All 3 combined 3 per page.pdf

18/08/2023 HSE320 Exercise, Health and Disease Arthrit...

18/08/2023 HSE320 Exercise, Health and Disease Arthritis Part A: Understanding Arthritis, How it is Diagnosed and the Key Risk Factors Dr Steve Fraser Some narrations re‐done by Andrew Betik due to poor audio quality of some slides. CRICOS Provider Code: 00113B 1 Learning Objectives On completion of this presentation, you should be able to: Arthritis: Lecture A Provide a definition and diagnostic criteria for the various forms of arthritis Discuss the prevalence and causes of arthritis Arthritis: Lecture B Describe the treatment for arthritis including the role of lifestyle intervention, medications and potential surgical options Arthritis: Lecture C Describe the role of exercise in the treatment of arthritis Describe the limitations and precautions when prescribing exercise for people with arthritis CRICOS Provider Code: 00113B 2 Arthritis: Definition And Pathology Literal meaning = Joint inflammation However, most joint disease is not inflammatory, and better termed as “arthrosis” or degenerative joint disease (DJD) There is no universal test or diagnostic criterion for arthritis – blood tests and X rays are widely used Joint pain with restricted movement and function is the best general definition CRICOS Provider Code: 00113B 3 1  18/08/2023 Arthritis: Definition and Pathology Arthritis is usually chronic and lifelong; early warning signs include pain, swelling, and limited movement that lasts for more than 2 weeks. Pain and loss of function / disability are the best indicators of severity Symptom tolerance varies ‐ what some regard as crippled with arthritis, others will call a bit of stiffness CRICOS Provider Code: 00113B 4 Arthritis Epidemiology  3.85 million Australians are affected by arthritis  Cost to society (medical and indirect) estimated at 23.9 billion  As population ages, there is an increased prevalence of arthritis, expected to affect 7 million Australians by 2050  Early intervention can delay the onset of disease Access Economics 2007 CRICOS Provider Code: 00113B 5 Types of Arthritis Osteoarthritis (DJD) is by far the most common – virtually all > 60 years have DJD of at least one joint Inflammatory arthritis – Rheumatoid arthritis – Gout – Psoriatic arthritis – Ankylosing spondylitis – Lupus (SLE) – Inflammatory bowel disease – Post viral eg Ross River, Dengue – More than 100 others CRICOS Provider Code: 00113B 6 2  18/08/2023 Osteoarthritis  A progressive joint disease characterized by an imbalance of articular cartilage biosynthesis and degradation attributed to both inflammatory and biomechanical factors  Moderate loading appears necessary for maintaining healthy cartilage, but abnormal loading may increase the risk of osteoarthritis.  The effects of obesity and physical activity may be mediated by systemic pro‐inflammatory agents and biomechanical factors. CRICOS Provider Code: 00113B 7 Key Features of Osteoarthritis The clinical presentation of osteoarthritis 1. There are multiple causes of osteoarthritis. 2. The most common clinical presentation can result from a wide variety of insults to the joint. Aetiopathogenesis 1. Osteoarthritis is initiated by a mechanical insult to the joint. 2. Osteoarthritis is a manifestation of attempts to heal the joint and ameliorate the abnormal biomechanics. 3. The osteoarthritis process may cause joint pain but often is successful, leading to a stable, painless joint. Radiology of osteoarthritis 1. Radiographic changes of osteoarthritis are extremely common in the population. 2. Many people who have severe radiographic changes of osteoarthritis are asymptomatic. 3. Radiographic progression of osteoarthritis usually is slow and may cease completely for many years Brandt et al, Rh Dis Clin Nth America 34:3 2008 CRICOS Provider Code: 00113B 8 Osteoarthritis Articular cartilage breaks down Joint loses shape, bone end thickens, and spurs develop. Not fatal, but is essentially incurable Symptoms of pain and stiffness can persist for long periods Feet, knees, hips and fingers most common Difficulty in walking, stair climbing, lifting etc CRICOS Provider Code: 00113B 9 3  18/08/2023 CRICOS Provider Code: 00113B 10 Knee Joint and Neck OA Good margins/joint space CRICOS Provider Code: 00113B 11 Hip Joint CRICOS Provider Code: 00113B 12 4  18/08/2023 Aetiology of Osteoarthritis – Normal ageing – Damage (trauma) – Overload (obesity) – Mechanical factors (high heels) – Genetic predisposition – Metabolic factors – Congenital deformity – Muscular weakness – Impaired proprioception CRICOS Provider Code: 00113B 13 Ch 43, ACSMs Resource Manual for Guidelines for Exercise Testing and Prescription, 7th Ed CRICOS Provider Code: 00113B 14 Risk Factors for Osteoarthritis Joint malalignment Repetitive impact to the joint Previous injury Obesity Increasing age Female sex / oestrogen deficiency Relative protective effect of maintaining strength Vigorous exercise and sports? do not increase the risk of osteoarthritis unless the involved joint has some sort of abnormality or previous major injury? CRICOS Provider Code: 00113B 15 5  18/08/2023 Occupational risk of OA CRICOS Provider Code: 00113B 16 Running and knee OA If runners do have healthy knees & hips regular running does not increase risk of OA Williams MSSE. 2013 Jul;45(7):1292‐7 CRICOS Provider Code: 00113B 17 Obesity Obesity may cause shifts in normal load bearing areas of joints through increased varus / valgus forces, especially at the knee. Obesity is associated with multiple metabolic disorders resulting in increased levels of adipokines – IL‐1, IL‐6, TNF‐α Exercise benefits appear to counteract biochemical factors even in the presence of obesity – fit and fat better than normal and sedentary? 4 x more likely to develop osteoarthritis if obese CRICOS Provider Code: 00113B compared to developing hypertension or T2D 18 6  18/08/2023 Rheumatoid Arthritis Autoimmune disease. Occurs 3‐5 times more in women than men. Usually appears between ages of 20 and 50 yrs. Small joints of the hands and the knee are most commonly affected, in a symmetrical pattern Inflammation begins in the synovial lining of the joint and can spread to the entire joint The inflamed joint lining leads to damage of the bone and cartilage. The joint space diminishes and the joint loses shape and alignment. CRICOS Provider Code: 00113B 19 CRICOS Provider Code: 00113B 20 Rheumatoid Arthritis Images CRICOS Provider Code: 00113B 21 7  18/08/2023 Rheumatoid Arthritis Symptoms Many of the same symptoms as OA with the exception of: Joint pain is generally equal on both sides of body Prolonged early morning stiffness Greater joint deformation and rheumatoid nodules RA is Systemic! Rheumatoid factor affects the whole body Numbness or tingling of the hands and feet Eye burning, chest pain, and/or dry‐mouth Damage to cardiorespiratory tissue Fever and fatigue CRICOS Provider Code: 00113B 22 Rheumatoid Arthritis side effects As RA is systemic it can affect many tissues Heart and blood vessels Lungs Skin Eyes Also ↑ likelihood of depression CRICOS Provider Code: 00113B 23 Gout Common painful condition affecting joints such as large toe Build up of uric acid crystals as individuals cannot excrete enough thru kidneys & urine Symptoms often come on quickly, joint becomes red, swollen and very painful. Other joints in wrists, hands, ankles, elbows, knees can be affected, often one joint at a time CRICOS Provider Code: 00113B 24 8  18/08/2023 Gout Risk factors: genetics predisposition, lifestyle factors such as obesity and alcohol intake – high cholesterol, high BP, insulin resistance/diabetes, kidney disease If poorly managed painful episode become more frequent, can become chronic Treatment includes NSAIDs, reduce alcohol intake, weight loss Anti gout medications such as uricosuric agents help the kidneys eliminate uric acid CRICOS Provider Code: 00113B 25 QUICK QUIZ? True or False? Arthritis is a disease of mainly the larger joints such as the hip and knee What are the symptoms of osteoarthritis? Summarise the main types of arthritis: osteoarthritis, Rheumatoid arthritis, gout. Identify 2‐3 key differences and key similarities True or False? Exercise such as running is likely to increase the likelihood of osteoarthritis in individuals with previously healthy joints How does obesity increase the risk and symptoms of OA? What are some common side effects of rheumatoid arthritis? CRICOS Provider Code: 00113B 26 9 [Add presentation title, presenter name here] 18/08/2023 HSE320 Exercise, Health and Disease Arthritis Part B: Treatments for Arthritis; Pharmacologic, Nutritional, Surgery Dr Steve Fraser CRICOS Provider Code: 00113B 1 Treatment For Arthritis Goals Ease pain Decrease painful inflammation Improve function Reduce joint damage Most treatments include a combination of:  Patient education, medication, exercise, rest, use of heat and cold, joint protection techniques and sometimes surgery CRICOS Provider Code: 00113B 2 The American College Of Rheumatology Guidelines Lifestyle changes: exercise to strengthen muscles, weight loss, assistive devices Pain management: physiotherapy, paracetamol, prescription of drugs or surgery Patient Education: informing, strategies for pain management, adjusting to their situation The magnitude of effect of most interventions is minimal W. Zhang et al, Osteoarthritis and Cartilage, 2010, pp. 476‐499 CRICOS Provider Code: 00113B 3 [Add Presenter contact details here] 1 [Add presentation title, presenter name here] 18/08/2023 Weight Loss Obesity is the most modifiable risk factor, and weight loss by far the single best intervention to prevent or to slow OA disease progression Messier SP et al Arthritis Rheum. 2004 May;50(5):1501‐10. Mean ± SEM unadjusted Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical function summary scores across the 18‐month intervention period. ∗ = P < 0.05, diet plus exercise group versus healthy lifestyle group. CRICOS Provider Code: 00113B 4 Joint Nutrition Evidence for dietary causes of arthritis eg. tomatoes, is dubious, except in gout Glucosamine sulfate has been shown to improve articular cartilage thickness slightly with long term use in mild DJD, and delays need for joint replacement. Need to use long term, but if no benefit after 6 months ‐ cease Many glucosamine preparations are available – most have not been tested. CRICOS Provider Code: 00113B 5 Joint Nutrition Vitamin D deficiency associated with increased incidence of OA, but no evidence yet to support supplementation for OA Chondroitin sulfate (shark cartilage) has little or no supporting evidence Omega‐3 fatty acids (fish oil) appear to be more useful in inflammatory arthritis CRICOS Provider Code: 00113B 6 [Add Presenter contact details here] 2 [Add presentation title, presenter name here] 18/08/2023 Drug Therapy Non steroidal anti‐inflammatory drugs (NSAID’s) – major effect in osteoarthritis is pain relieving, not disease modifying Pain relief may permit increased participation without fear of significant exacerbation The most potent anti‐inflammatories are corticosteroids – injections, tablets, etc Various disease‐modifying drugs are also prescribed to slow rheumatoid arthritis All are prone to causing significant side effects CRICOS Provider Code: 00113B 7 Invasive/ Surgical Treatments Of Arthritis CRICOS Provider Code: 00113B 8 Arthroscopy A procedure that involves a small incision near damaged joint and small camera can be a major problem Can clear small pieces of bone or trim/remove damaged cartilage Quick procedure, few complications CRICOS Provider Code: 00113B 9 [Add Presenter contact details here] 3 [Add presentation title, presenter name here] 18/08/2023 Arthroplasty: Joint Replacement Once reserved for those crippled and in severe pain Joint replacement and other restorative procedures now increasingly used in the active ageing with DJD Replacements of knee and hip most common Surgery considered when pain is extreme (eg wakes you from sleep, you avoid activity due to the severe bone on bone pain) Surgery results in joint pain relief,  ROM, joint realignment improving function CRICOS Provider Code: 00113B 10 https://www.youtube.com/watch?v=rb5axfV5UfU CRICOS Provider Code: 00113B 11 Knee Joint Replacement CRICOS Provider Code: 00113B 12 [Add Presenter contact details here] 4 [Add presentation title, presenter name here] 18/08/2023 Joint Replacement Challenges Bony fixation Bone stock, especially with revision Joint stability and function Component wear and loosening Toxic reactions to wear products Rehabilitation of muscles surrounding joint CRICOS Provider Code: 00113B 13 Autologous Chondrocyte Implantation CRICOS Provider Code: 00113B 14 QUICK QUIZ? True or False? NSAIDS slow the progression of OA and any further joint deformation How should arthritis sufferers be advised to take their medications if they want to engage in exercise? What role do chondroitin and glucosamine have on joint health? True or False? Exercise such as running is likely to increase the likelihood of osteoarthritis in individuals with previously healthy joints What impact does weight loss have on OA? Describe the following surgical procedures for OA: Arthroscopy, arthroplasty CRICOS Provider Code: 00113B 15 [Add Presenter contact details here] 5 [Add presentation title, presenter name here] 18/08/2023 HSE320 Exercise, Health and Disease Exercise and Arthritis Part C: Treatments for Arthritis: Exercise Dr Steve Fraser CRICOS Provider Code: 00113B 1 The Role of Exercise in Arthritis There are 3 objectives of exercise for patients with arthritis preserve or restore range of motion and flexibility around the affected joint increase muscle strength, proprioception and endurance to enhance joint stability – accumulating evidence that this will effectively control symptoms increase aerobic conditioning to improve psychological mood state and decrease risk of other lifestyle diseases Improved power / weight ratio underpins all exercise CRICOS Provider Code: 00113B 2 The Role of Exercise in Arthritis  Exercise generally does not affect the underlying disease state in people with established arthritis one way or the other, but it does improve many other areas of importance to life quality  Warm up to maximize range of movement, and cool down of special importance – heat enhances mobility, cold minimizes post exercise flare‐ups  Most exercise requires an effective level of control at the hip (lumbo‐pelvic) and shoulder girdles – proximal before distal CRICOS Provider Code: 00113B 3 [Add Presenter contact details here] 1 [Add presentation title, presenter name here] 18/08/2023 Exercise & Pain Reduction Exercise helps reduce the pain, but it is unclear whether it helps with stiffness Exercise moderately reduces pain in elderly patients with osteoarthritis and has an effect on reducing self‐reported disability Fear is often the biggest challenge – belief that exercise is harmful is widespread Disability model is entrenched and some are very resistant to exercise interventions CRICOS Provider Code: 00113B 4 Types of Exercise High impact exercise on affected joints is contraindicated Exercise to maintain and improve range of movement is important Resistance training beneficial Healthy weight should be maintained Beyond these factors, whatever the client finds comfortable and enjoyable is good, with the understanding that joint symptoms may impose an upper limit to intensity (stationary cycling, hydrotherapy and Tai Chi studies) CRICOS Provider Code: 00113B 5 Aquatic Exercise for Knee and Hip OA  Aquatic exercise appears to have some beneficial short‐term effects for patients with hip and/or knee OA while less evidence exist for long‐term effects  Based on this, one may consider using aquatic exercise as the first part of a longer term exercise program for osteoarthritis patients.  Water can reduce the weight through affected joints  Hydrotherapy is best conducted at 29‐36oC Cochrane Database of Systematic Reviews 2007 Oct 17;(4) CRICOS Provider Code: 00113B 6 [Add Presenter contact details here] 2 [Add presentation title, presenter name here] 18/08/2023 Physical Therapy Interventions in OA of the Knee There is high‐quality evidence that exercise and weight reduction reduce pain and improve physical function in patients with osteoarthritis of the knee. There is moderate‐quality evidence that acupuncture, transcutaneous electrical nerve stimulation, and low‐ level laser therapy reduce pain – Likewise, psycho‐educational interventions improve psychological outcomes For other interventions and outcomes, the quality of evidence is low or there is no evidence from some systematic reviews. Physical Therapy 2008 Jan;88(1):123‐36 CRICOS Provider Code: 00113B 7 Exercise Programming Morning stiffness can be profound and last for several hours, so later in the day may be better Fatigue may be an initial challenge No arthritis specific target levels apply Training benefits can certainly be achieved Flexibility training usefully incorporated in to cool down Short durations (10 mins) several times per day assist adherence initially 2 hour rule – any discomfort during or after exercise that lasts > 2 hours should lead to modification CRICOS Provider Code: 00113B 8 Exercise Programming Resistance training is important Standard program of 2‐3 x week, training multiple muscle groups Initial intensity may need to be as low as 10% of 1RM in severe arthritis, but typically 40‐60% of 1RM is safe Exercises may need to consider specific limitation of range of motion Flare ups (increased pain, swelling, stiffness) are common, especially in rheumatoid arthritis, and require modification of exercise CRICOS Provider Code: 00113B 9 [Add Presenter contact details here] 3 [Add presentation title, presenter name here] 18/08/2023 CRICOS Provider Code: 00113B 10 Summary: Exercise Prescription For Arthritis Refer the patient to a health care professional for appropriate Exercise prescription Supervised group or individual treatments are superior to independent home exercise for pain reduction.  Supplement home exercise with initial group exercise.  Exercise handouts or audiovisual material alone are ineffective.  Target quadriceps, hamstrings, and hip abductors for strengthening.  Minimize compressive joint forces.  Clinical outcome is not influenced by the type of strengthening exercise.  Use a combined program of strengthening, flexibility, and functional exercises.  Use strategies to maximize long‐term patient compliance with exercise Bennell et al, Rh Dis Clin Nth America 34:3 2008 CRICOS Provider Code: 00113B 11 QUICK QUIZ? True or False? Exercise should be avoided until pain is removed for OA sufferers How does exercise improve function and reduce pain in osteoarthritis? What are the benefits of aqua classes for those with arthritis? What are the exercise prescription guidelines for those with OA? True or False? High intensity impact loading is beneficial for arthritis sufferers. CRICOS Provider Code: 00113B 12 [Add Presenter contact details here] 4