Dr. Aly Abdulla, MD, CCFP, FCFP, DipSportMed CASEM, CTH, CCPE, McPL,¹
Neelam Charania, BSc, MSc (OT),²

CLINICAL TOOLS

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Abstract: Osteoarthritis is most common form of arthritis. It is also very disabling. Fortunately, there is a long list of medical therapies including education, OTC meds, strengthening, braces, prescribed medications, standard and non-standard intra-articular therapies and some new experimental therapies. This article focuses on well known and well proven therapies like cortisone and hyaluronic acid injections into large joints like knees and hips. Large meta-analysis shows improvement in pain, physical function and stiffness in a simple well tolerated procedure with minimal side effects.

Key Words: osteoarthritis, arthritis, knee, hip, joint injections, steroid, hyaluronic acid.

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OA symptoms include joint pain, morning stiffness <30min, reduced ROM, and possibly swelling.

The most common joints are knees, hips, fingers, thumbs, big toes and lumbar spine.

The key pathophysiology in OA is destruction of cartilage and bone formation, which reduces function and causes pain.

Simple x-rays are diagnostic. There is no need for advanced imaging like CT or MRI for OA.

A combination of therapy is key to successfully managing this condition.

If morning stiffness >30 minutes, stiffness and pain increases with rest, joint warmth or erythema, or three or more joints, you should think of inflammatory, septic, or crystal arthritis RATHER than osteoarthritis.

Don't forget about weight loss, bracing, topical agents, or non conventional medications like duloxetine or tramadol in osteoarthritis.

There is no maximum amount of cortisone injections in a joint but it is mainly used for stiffness, swelling and pain.

Hyaluronic acid intra articular injections manage symptoms of pain, stiffness, range of motion, and physical function. The best formulations are high MW and cross-linked because they last longer.

New experimental therapies like PRP, MSC, and ACI have limited evidence and are costly.

To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is $80 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.

I am writing this editorial after finishing our falls prevention clinic at the Toronto Western Hospital. Falls are the prototype of the classic geriatric syndrome, in which one cause is rarely the issue but rather a substantial number of possible contributing factors are found. However, it is a rare older patient who does not have some musculoskeletal disorder as one of the predisposing conditions for falls. One of my patients today had severe osteoarthritis of her knees as well as painful feet with bunions and corns that contributed to her falls. As I have mentioned before on these pages, mobility is an essential quality of life issue for older adults, and so I am always excited when our issue focuses on musculoskeletal disorders.

We have several superb articles on our theme in this issue. The common topic of “Crystal-induced Arthritis” is tackled by Dr. Ian Tsang and Dr. Simon Huang, while Dr. R. Martinez-Galliano, L. Burke, and Dr. Bob McCormack delineate “An Active Approach to the Treatment of Frozen Shoulder.” We seldom appreciate how much we rely on our shoulder’s range of motion until we lose it! Our continuing education article this month is on the most common of the inflammatory arthritides. The article “Rheumatoid Arthritis among Older Adults” is by the distinguished rheumatologist, Dr. Arthur Bookman. For a variety of reasons, some people get much better care for their arthritis than others, something which theoretically should not happen in a country with universal health care. The reasons for this disturbing occurrence are discussed in the article “How to Make Sure Your Patient with Osteoarthritis Gets the Best Care” by Dr. Cornelia Borkhoff and Dr. Gillian Hawker.

As usual, we have a range of articles on other geriatric topics. The article “An Update on Prostate Cancer among Older Men” is by Dr. Michel Carmel, a researcher with our partner association, the Canadian Society for the Study of the Aging Male. Our cardiovascular column is on “Treatment of Hypertension in Older Adults” by Dr. W.S. Aronow, a prolific contributor both to our journal and the peer reviewed medical literature. Our psychology of aging column this month is called “Personality Traits: Stability and Change with Age” and is written by Drs. Antonio Terraciano, Robert McCrae, and Paul Costa, Jr. Our dementia column is on a topic that has become an important topic both for stroke neurologists and dementia experts, namely “Post-stroke Dementia among Older Adults.” It is written by Dr. Aleksandra Klimkowicz-Mrowiec.

Enjoy this issue,
Barry Goldlist

There is nothing like waking up in the morning with a stiff back and difficulty moving to remind oneself that arthritic disorders are an important factor in the quality of our everyday lives. Over the years I have frequently reminded our readers that among older adults living in the community, musculoskeletal problems are a more important determinant of quality of life than are cardiac diseases such as angina. The high prevalence of arthritic complaints among older adults makes arthritis the single most important medical factor in determining the quality of life for older adults. Fortunately, the once nihilistic approach to arthritis in older people is changing with newer therapeutic modalities and surgical options. Hopefully, the days of older patients simply being told, “You’re 90 years old: what do you expect?” are being phased out and replaced by, “You’re 90 years old: we will have to see what can help with your problems.”

Our CME article this month concerns probably the most common arthritic condition among older people, “Osteoarthritis of the Knee.” This learning module has been created by Drs. Kevin D. Gross and David J. Hunter. Dr. Peter G. Passias and Dr. James V. Bono review one of the most successful modern surgical procedures in their article “Total Hip Arthroplasty in the Older Population.” Although we usually think that inflammatory arthritis is a syndrome of younger adults, it can be an important cause of morbidity in older adults as well. Tara Snelgrove and Dr. Proton Rahman review this important topic in their article “Inflammatory Polyarthritis in the Older Adult.”

We also have our usual collection of diverse articles. The interesting area of gender difference in medicine is explored in this issue’s Cardiovascular column and addresses “Gender and Congestive Heart Failure” by Dr. Silja Majahalme. An internationally renowned group from the Centre for Research in Neurodegenerative Diseases at the University of Toronto, Drs. Yosuke Wakutani, Peter St. George-Hyslop, and Ekaterina Rogaeva discuss “The Genetic Profile of Dementia.”

Our cancer column addresses “Cancer Chemotherapy in the Older Cancer Patient” and is contributed by Dr. Lodovico Balducci. Finally, the cancer theme is continued in the article “Epidemiology of Colorectal Cancer and Aging” by Dr. Maida J. Sewitch and Caroline Fournier.

Enjoy this issue,
Barry Goldlist

Ian K. Tsang, MB, FRCPC, Clinical Professor, Division of Rheumatology, Faculty of Medicine, University of British Columbia, Vancouver, BC.

Gout is more prevalent in older adults than middle-age adults, and it affects women almost as commonly as men. An important clinical consideration regarding gout is that while hyperuricemia is commonly associated with gouty arthritis, a diagnosis of asymptomatic hyperuricemia does not generally require treatment. In addition, the clinical presentation and course of gout in older patients differ from the typical cases of middle-aged patients. Moreover, older gout patients present a challenge for physicians who manage them because of the high incidence of comorbid conditions and the likely occurrence of reduced renal function among this age group. This article reviews the diagnosis and management of asymptomatic hyperuricemia and gout in the older adult.
Key words: gout, hyperuricemia, NSAID, allopurinol, arthritis.

In the July/August issue of Geriatrics & Aging, I wrote an editorial on falls in the elderly. Falls, of course, are part of the broader issue of mobility in the elderly, and nothing lowers the quality of life for older people as much as impaired mobility. In fact, more severe mobility restrictions (e.g., being housebound) are also correlated with decreased survival. The reasons for the association between aging and mobility impairment are very complex. In our last issue, the importance of fitness in maintaining mobility was stressed. Age- and disease-related changes in the neurological system also are important factors in decreased mobility, and neurological disease increases dramatically with advancing age. However, there is no doubt that arthritis is probably the most common reason for impaired mobility in the elderly. As I have noted in previous issues, arthritis is much more likely to impair quality of life than is angina. Often, older persons are less frightened by the issues of mortality than they are by the prospect of pain and disability.

This issue addresses problems seen in several of the common types of arthritis. Dr. Herbert von Schroeder outlines the surgical management of osteoarthritis of the hand and the wrist, Dr. Benjamin R. Davis reviews the management of temporomandibular disorders in older people, and Dr. Geoffrey F. Dervin discusses management of the arthritic knee. Oksana Davidovich gives an overview of the painful geriatric foot, a condition in which arthritis is an important, but not exclusive, factor. Our Drugs & Aging column focuses on the very expensive biologic treatments for inflammatory arthritis, and their possible role in older persons. Dr. Charles D. Ray writes about the diagnosis and treatment of lumbar spinal stenosis. I sometimes feel that this is an area in which our ability to image the problem is far advanced compared to our understanding of its clinical diagnosis and management.

We have a variety of other articles on offer as well. Dr. Alan K. Berger reviews the literature on reperfusion therapy for acute myocardial infarction while Jonathan Ship outlines the diagnosis and management of a common and often ignored issue in older people, xerostomia. Drs. Christina M. Canil and Jennifer J. Knox discuss the topic of renal cell cancer, and the relationship between statin use and dementia is reviewed by Dr. Milita Crisby.

Enjoy this issue.

The year 2000 was a memorable one for me, but not necessarily in a positive manner. I woke up on the morning of February 29 (I will never look favourably on leap years again), with pain in the lateral side of my right knee. Being an astute clinician, and one who has considerable expertise in mobility disorders, I did the obvious thing: I ignored the pain, and continued to do everything as I always did (admit it, you would have done the same). By the end of the week, the pain was so severe that I could no longer exercise. Walking from the office to the hospital ward became a daily torture. I consulted an excellent rheumatologist who was puzzled by the lack of physical findings (except tenderness) and unimpressive x-ray results. An MRI, however, revealed severe bone marrow edema and bone loss in the medial femoral condyle. The picture was absolutely typical for a rare disorder called 'transient regional osteoporosis.' In typical physician manner, I had selected an unusual disease that was rarely seen (fortuitously my rheumatologist had written a paper on the topic a decade earlier, the last time he had seen the disease). I was embarrassed to find out that I, an internist, had developed an internal medicine disorder of which I had never even heard! After my films were reviewed by every orthopod and rheumatologist in the hospital, the consensus was that the bone was in great danger of breaking, and I would have to be completely non-weight bearing!

The pain started to ease as soon as I kept off my leg completely, but I was then in the position of so many of my patients: my life was tremendously constrained because of my lack of mobility. Survey after survey has revealed that the single greatest factor impairing quality of life in the elderly is arthritis, usually osteoarthritis. However, as physicians we often ignore these complaints and frequently do not even properly examine the joints. We are more concerned about the life-threatening disorders such as cancer and heart disease, or disabling neurological disorders such as stroke or dementia. These are of course crucial issues, but painful joints also require careful attention. As I struggled up stairs, learned how to use a shower stool, and continuously complained about my restrictions, I began to understand a little more clearly the problems experienced by so many of my patients. I was also surprised that my usual cheerful disposition (okay, there is some dispute about that) evaporated. I was depressed, and even though my ability to do paper work was theoretically unimpaired, my concentration and initiative were clearly decreased. The side effects of drugs I experienced could fill an entire article on their own.

I am, therefore, quite pleased that this edition of Geriatrics & Aging is focussing on arthritic disorders. Several years ago, David Naylor (currently Dean of Medicine at the University of Toronto), in his Gold Medal address to the Royal College of Physicians and Surgeons of Canada, commented on the under utilization of joint replacement in Canada. I suspect that this is still the case. Dr. Mahomed and Dr. Hawker will update us on this valuable surgical approach for the elderly. Most elderly persons will not have surgery for their osteoarthritis, and Dr. Tenenbaum discusses the medical management of these patients. There are articles on new treatments for arthritis (de los Reyes et al.), non-pharmacological therapy (Lineker), innovative programs (Malik) and the treatment of rheumatoid arthritis (Juby and Davis) and polymyalgia rheumatica (Little). In addition, there are articles on psychotropic medication use in the elderly (Conn), herb drug interactions (Dergal and Rochon), pharmacokinetics (Turnheim), and atrial fibrillation (Burstein). Also included in this issue is an article on the global aging phenomenon (Keller and Kalache), and the use of the Internet by seniors (Ryan).

Back to my personal problems, you might ask what was the most important lesson I learned from my travails last year. I would sum it up this way: have a wonderful spouse and family to care for you, and tremendous colleagues to shoulder your burden of work. Also, I learned to be very thankful for the word 'transient' in my diagnosis of transient regional osteoporosis.

Enjoy this issue.

Sydney C. Lineker, MSc, BScPT
Affiliated Scientist,
Toronto Western Research Institute;
Research Coordinator,
The Arthritis Society, Consultation and Rehabilitation Service, Toronto;
President, Arthritis Health Professions Association,
Toronto, ON.

Linda C. Li, BSc(PT), MSc
Arthritis & Autoimmunity Research Centre,
University Health Network;
The Arthritis Society,
Consultation and Rehabilitation Service, Toronto; Board Member,
Arthritis Health Professions Association,
Toronto, ON.

Introduction
Arthritis, in its many forms, is the most common cause of long-term disability in the elderly,^1-4 often resulting in functional problems, the loss of leisure, social and vocational activities, isolation and depression. Osteoarthritis (OA) is the most common type of arthritis in this population.¹

Pain, disability and psychosocial and educational needs are often underestimated by health care providers.^5,6 Pain is the most frequently reported symptom6 and is a complex phenomenon requiring a multidimensional approach. Pain may be under-reported by the elderly.^6,7 Signs of inflammation--redness, pain and swelling--may be less marked8 and it may be difficult to attribute pain to a specific cause.² Comorbidity, polypharmacy and complications of pharmacological interventions unique to the elderly add to the mix.

A new study by the Institute of Health Economics has estimated that the indirect economic impact of bone and joint problems, including arthritis, totaled $17.9 billion dollars in 1997. Apparently, the main reason for this figure is the lost productivity of people who are unable to work and conduct business. The study reveals that osteoarthritis is two and a half times more prevalent in Canada than is heart disease, and over six times more prevalent than cancer. It is estimated that with Canada's aging population, the number of people with bone and joint-related health problems in Canada will increase by 124% over the next 30 years.

Despite this increased demand, a shortage of orthopaedic surgeons is making it difficult for people to get the care they need. On average, patients are forced to wait more than six months for joint replacement surgery in Canada, and many have to wait longer than a year.

The findings of this study were supported by a parallel phone survey conducted by Decima Research, which found that 42% of Canadians have been affected by bone and joint problems--either personally or through the severe physical pain of a family member or friend.

The Canadian Orthopaedic Association and The Arthritis Society have now developed a comprehensive plan to address the issues that are critical to orthopaedic care in Canada. Entitled Canada in Motion: Mobilizing Access to Orthopaedic Care the plan calls for Canada's federal and provincial ministers of health to work with the medical community to develop a national orthopaedic care strategy.

Please see next month's issue of Geriatrics & Aging for articles on the various options available for the treatment of arthritis in the elderly.

If the thought of packing into a crowded banquet hall this summer to get those CME credits does not excite you, then you may want to consider "studying" at The Arthritis University. Produced by McNeil Consumer Healthcare, in consultation with Canadian Rheumatologists, GPs and The Arthritis Society, the newly launched CD-ROM is designed to support doctors in refining their diagnosis and treatment of musculoskeletal conditions. MAINPRO-M2 accreditation is available.

"With the prevalence of arthritis growing at such a rapid pace, and newer treatments for the disease being developed all the time, we saw a need to provide some context on the critical issues of diagnosis and management," said Dr. J Carter Thorne, Rheumatologist, Medical Coordinator of The Arthritis Program (TAP) at York County Hospital, and chairman of the Teaching Faculty of The Arthritis University. "And when we considered the time constraints that physicians face, we decided to take advantage of the available technology."

The virtual campus has three larger buildings: a lecture hall, where expert faculty provide key insights into arthritis and discuss epidemiology, diagnosis, treatment and patient issues; a library which is filled with practice management tools such as treatment matrices and algorithms, as well as web links and an arthritis prevalence calculator; and a clinic/laboratory where users can access six patient case studies with accompanying video and commentary.

The CD-ROM also in-cludes a campus building for The Arthritis Society outlining its programs and services as well as downloadable patient information, and the McNeil building , which offers physicians an osteoarthritis CME toolkit complete with downloadable slides. "Clearly, one of the benefits of learning via CD-ROM is that it allows physicians to learn at their own pace, and to revisit areas of particular interest," said Dr. Thorne.

According to Dr. Thorne, one of the primary focuses of the CD-ROM is diagnosis, which emphasizes the need for a thorough case history. "Correctly diagnosing patients leads to more appropriate treatment plans. The pain experienced in mild to moderate osteoarthritis, for example, is primarily related to the mechanical nature of the disease as opposed to the presence of inflammation. In these situations, it may be more appropriate to prescribe a simple analgesic."

According to Denis Morrice, President of the Arthritis Society, The Arthritis University is a valuable tool for sorting through the huge volume of information on the disease. "Ongoing research has enabled us to gain a vast amount of knowledge about arthritis. The key now is to ensure that all of this information filters down to the people who need it most…"

To obtain a free copy of The Arthritis University, please call McNeil Consumer Healthcare at 1 800 265-7323.

Anna Liachenko, BSc, MSc

Despite potentially serious side effects, non-steroidal anti-inflammatory drugs (NSAIDs) are currently one of the very few options available for alleviating chronic pain and inflammation. Over the past 30 years, scientists searched for safer NSAIDs and managed to create the 20 different drugs and 40 dosing options currently available in Canada. While some of the newer drugs turned out to be safer than others, their design was based largely on trial-and-error. A recent major breakthrough in the understanding of the molecular mechanisms of NSAID action allowed researchers to methodically design a new class of NSAIDs. These new drugs, the Cox-2 Inhibitors or C-2SIs, are not only comparable to the older NSAIDs in efficacy but are also (at least in theory) devoid of some of the most serious side effects. One of these drugs, celecoxib (Celebrex) has just become available in the US and Canada. Another, rofecoxib (Vioxx) is under review by the Food and Drug Administration (FDA) in the US and the Health Protection Branch (HPB) in Canada. Moreover, increased safety of some of the previously approved NSAIDs is now thought to be attributed to the same molecular mechanism. Newly arriving NSAIDs as well as the best NSAID options currently available in Canada are discussed below.