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Your link to osteoarthritis research in Canada "State of the Art" Treatment of Osteoarthritis
By John M. Esdaile, MD, MPH, FRCPC, Co-Principal Investigator
Research by scientists in the Tooling Up for
Exercise
by New Emerging Team scientists, is looking Early Osteoarthritis: Measuring What Matters
Exercise is increasingly used to treat OA of the for "markers" of potential targets to prevent or research program has shown that early on most
knee, but it is still an under prescribed treatment improve the cartilage and bone damage that is the osteoarthritis (OA) of the knee is not seen on X-rays option. Aerobic exercise as well as strength hal mark of OA, no medication has definitely been - even OA that is detectable on X-ray may not training around the knee joint can reduce pain shown to prevent OA or to repair the damage.
have been diagnosed. The same is likely true for and disability resulting from it. Aerobic exercise A step-wise approach
OA of the hip. While the topic of this article is not can include water exercise or swimming. Strength Acetaminophen (like Tylenol®) either on a fixed diagnosis, two quick points should be made: training can be as simple as quadriceps exercises dose (up to 1.0 gm three times a day) or on an • Appropriate physical examination of a joint is or more formal programs. Post-exercise stretching "as needed" basis remains the starting point essential to early diagnosis and applying ice on joints with OA may reduce for medication treatment. While non-steroidal • X-ray diagnosis of hip or knee OA must be taken subsequent pain and stiffness. A graded exercise anti-inflammatory drugs or "NSAIDs" are more in a weight-bearing position – non-weight program is advised. The Arthritis Society of Canada effective than acetaminophen at control ing pain bearing X-rays are a waste of time and money.
offers Joint Works and Water Works in some and inflammation, they can have more side- communities. These are tailored to people with effects. If acetaminophen is ineffective, an NSAID arthritis and are led by exercise leaders trained in can be used with or without the acetaminophen. Surprisingly, most patients referred to a specialist the disease. The key to success for an OA exercise If medications improve the pain, then non- for OA have received little or no information on program is to maintain its frequency intensity, and medication treatments – such as exercise and non-medication therapies. Surprising because OA to check in with the prescribing physician so that weight loss – become easier to do and may diagnosis should be the domain of the primary they can assess its effectiveness. even end up reducing the long term need for care physician (family doctor) and non-drug medications. For mild OA, NSAIDs can be used on treatments are often what patients seek as a an as needed basis, or to prevent pain e.g. before first treatment approach. Research by the New "Exercise is increasingly used to treat doing something that always causes pain such as Emerging Team is studying the effect of exercise OA of the knee, but it is still an under going shopping, working in the garden, or playing and gait on causing and treating OA.
a round of golf.
prescribed treatment option." Orthoses
Safety issues
For OA of the toes, insoles are more effective and The withdrawal of the COX-2 selective medications safer than any drug treatment. A good relationship (also cal ed "coxibs") rofecoxib (Vioxx®) and with a professional orthotics fitter ("orthoticist") Ideal Body Weight
valdecoxib (Bextra®) because of cardiovascular or an occupational therapist is needed. If the Just as weight gain is associated with the side-effects has caused no end of heartache for orthotics are not helping, ask the orthoticist to try development of knee OA, weight loss can improve physicians, pharmacists and patients, alike. Results to modify them. Wedged insoles can also assist pain. Weight loss as small as 10 to 15 lbs (4 to 7 kg) from all of the previous research on rofecoxib and in knee OA. Bracing helps OA in one specific area can cause improvement - it does not matter how valdecoxib, and huge randomized trials of new or "compartment" (mainly medial) in the knee, the weight is lost, but it must be lost and no one is coxibs have now clarified the issue. There are two but good braces are expensive. Again, knowing better positioned to oversee this than the primary key points to be aware of: who is good brace fitter (physiotherapists do care physician.
All NSAIDs and all coxibs currently available this) in your community is important. Taping can carry an increased risk of cardiovascular events. help pain in the patel o-femoral (knee cap) joint. There is some suggestion that naproxen may A well made splint helps with thumb OA (the first Much is known about medication treatments have a slightly lower risk, therefore making it a in OA. While intensive research, including that Continued on page 4

Today's research into
Impact of osteoarthritis
on daily living
osteoarthritis — the view
For people with osteoarthritis, the disease brings a radical change in the way they live their lives. They from people living with it
have to make tough decisions about what they have the strength and energy to do, prioritizing certain aspects of their lives and having to forgo For the mil ions of Canadians living with osteoarthritis (OA), research others, yet to date, not a lot of research has gone into disease prevention and management is critical. Arthritis research into this area. One study coming out of the looks for answers to Canada's largest burden on the health care system Tooling Up For Early Osteoarthritis research program is addressing this gap. and serves to guide good treatment and care by enabling our doctors The research project, Measuring What Matters: Participation in – and ourselves – to better understand our disease and the impact Everyday Life, is examining the impact of osteoarthritis on important of it across the spectrum of our lives. For that reason, we wanted to activities and roles such as paid work, the home, social life, hobbies, highlight projects underway in Dr. Gil ian Hawker's Pain and Fatigue
leisure activities and personal relationships and how this changes in Osteoarthritis and Drs. John Esdaile and Monique Gignac's Tooling
over the course of the disease. Led by research investigators Monique Up For Early Osteoarthritis: Measuring What Matters research
Gignac, Catherine Backman, Elizabeth Badley, Aileen Davis, Diane Lacail e and person with osteoarthritis and rheumatoid arthritis, programs. Funding support for these two research programs comes Pamela Montie, this research will provide a unique perspective on from the Canadian Institutes of Health Research and the Canadian how osteoarthritis effects the quantity and quality of time spent Arthritis Network.
doing things that are valuable to people with osteoarthritis. This research will help to ensure that programs to address and manage OA are better suited to the needs and experiences of those living with the disease.
Older peoples' attitudes towards
taking pain medication: Are you Martha or Henry?
Martha and Henry grew up in the 1930's and 1940's so they're in their sleep. Pain from their OA has affected their social life and makes it difficult 70's now. People like Martha and Henry have been the subject of many for them to exercise. As a result, they are unable to ful y benefit from the studies by the researchers of the Pain and Fatigue in OA - New Emerging physical, psychological and social benefits that are often realized if pain is Team at Dr Gil ian Hawker's Canadian Osteoarthritis Research Program. control ed properly.
Martha and Henry have lived through the depression years, those years Further research on younger and more cultural y diverse groups when one does not buy things they don't need, when one saves new is necessary, but to benefit the current Martha and Henry subjects, clothes for "Sunday Best", when one eats all that is on their plates and researchers conclude that it is necessary to rethink how pain medication wishes for more, when one looks out for others who may be suffering, for OA is prescribed. The "take as needed" instruction may be one of the and when one spends an hour to pick up a dropped penny through a reasons that Martha and Henry don't take pain prescriptions or over- crack in the wooden sidewalk. In the depression years, Martha and Henry the-counter pain medicine efficiently. Researchers think that people saved and saved, they were self reliant and they "made-do"! These habits with OA should be more closely observed for disabling pain by their served them well through the years, but now that Martha and Henry clinicians. Perhaps the most important conclusion to be observed by have OA, some of those habits may not always serve them so wel .
Martha and Henry is that failure to fol ow treatment recommendations Recent research at the Canadian Osteoarthritis Research Program shows for pain medication means that they are achieving less than satisfactory that Martha and Henry may suffer needlessly from OA pain because they pain relief. This results in significant loss in quality of life to themselves, either do not take pain medication regularly, take less than the amount their families and costs to the Canadian health care system. In order to prescribed, or sometimes don't take it at al ! People like Martha and provide an appropriate level of pain relief, people living with OA, like Henry often belittle their pain saying it comes with age, or they state Martha and Henry, and the clinicians that treat them, need to address the they have a high pain tolerance. Often, they make fun of their pain. They reasons why pain medications are not taken in the ways recommended personify it and fight it. They avoid social outings and exercise because to provide the most benefit. of it and fear they may become addicted to pain medication. They say they are not as badly off as they could be while they don't think their friends should have to suffer any pain. They feel that their pain is not life-threatening so it becomes part of their life. They feel proud if they have not given in to it. They say there is nothing they can do about it even though they have not experienced the possible pain relief that might be forthcoming by taking their pain medication (prescription or over-the-counter) as prescribed.
Because of the pain, Martha and Henry can't tie their shoelaces, can't comb their hair, can't walk more than a few steps and can't get enough The role of fatigue and sleep
People with pain and fatigue from osteoarthritis (OA) are too often told • People with OA report fatigue that is similar to the levels of fatigue that they are "just getting older". This leads to confusion and frustration reported by people living with cancer. among people with OA, and their health care practitioners, around • Some people with OA experience considerable daytime sleepiness how best to deal with these complaints. Researchers are trying to yet are not aware of the problem. dispel this myth. • OA pain can make it difficult to get a decent night's sleep, and that a Fatigue is recognized as an important symptom in some diseases poor night's sleep can make it more difficult to deal with OA pain the such as cancer or rheumatoid arthritis but it has not routinely been evaluated in OA. Like arthritis, sleep problems are fairly common • OA pain isn't always the reason for a poor night's sleep. among the elderly. Some of the risk factors that are related to OA (such Improvements in sleep quality have been seen in people who as obesity, being female and increasing age) are the same things that thought that OA pain was preventing a good night's sleep when, in increase one's risk of having a sleep disorder. As such, we would expect fact, an easily treated sleep disorder was to blame. sleep disorders to be more common among people with OA than they • There are limited tools to assess fatigue and sleep problems in OA, are in the general population. and the tools that are available, have not been widely used.
Research from the Pain and Fatigue in Osteoarthritis research Above al , it's become clear that it is important to continue program suggests a link between fatigue, pain and underlying investigating fatigue and sleep in OA. There is an enormous potential sleep disorders. Since late 2003, people with OA have shared their for improvement in the lives of people living with OA through greater experiences of living with pain and fatigue with Dr. Gil ian Hawker's understanding of how fatigue and sleep play a role in OA. It is hoped research team. What they have found is that among people living with that greater understanding of the relationships between pain, fatigue, OA, fatigue and sleep problems can have a significant impact on one's sleep and mood will push the development of new treatment strategies, targeted to individuals in the context of their families and What has been learned about fatigue and sleep in OA from this the community as a whole.
research? So far, this research shows that:• Living with OA pain can "wear you out" and leave you feeling tired Understanding the
A tool to better
changing role of pharmacists
understand
Many people living with osteoarthritis have found that in addition to a great general practitioner and a great Another important initiative that has come out of the Tooling Up For rheumatologist, their pharmacist is a key person on the health Early Osteoarthritis: Measuring What Matters research program, and care provider team. Not only do people with the disease get which is led by team members who live with arthritis (Jean Légaré, their medications dispensed from pharmacists, pharmacists Jay Fiddler, Anne Fouil ard, Pamela Montie and Cheryl Koehn) is the also provide important information about the medications Glossary for Consumers Involved in Health Research. This glossary
people are taking or thinking about taking. Pharmacist- will be a vital y important tool for making sure that everyone interested Initiated Intervention Trial in OsteoArthritis (PHIT-OA), led by in arthritis research development and results can all understand and Principal Investigator, Carlo Marra, is studying the changing benefit from them. role of pharmacists in the provision of health care for chronic Written in easy-to-understand language, the Glossary for Consumers diseases such as OA. The purpose of this study is to find out Involved in Health Research will help people living with osteoarthritis to if a screening program conducted by pharmacists to identify understand the scientific language used in the development of research people with previously undiagnosed knee osteoarthritis is questions and methods of doing research, and reports and articles accurate and feasible. This research could have important about research that appear in newspapers and on radio and television. benefits to those of us living with osteoarthritis, serving But the glossary is not just for those living with the disease. The glossary to reduce the debilitating impact of this disease on our is also a valuable tool for the research investigators who want to lives. The findings of this research may contribute to earlier communicate more clearly and easily with their own research col eagues diagnosis and a timely referral to doctors and other required in other scientific fields, as well as with consumer col aborators, research health care professionals. In addition, as osteoarthritis is a subjects, funders and the public media. growing public health issue in Canada, the outcomes of this If you would like your own free copy of the Glossary for Consumers
research may also benefit the health care system in general Involved in Health Research, please visit the OsteoArthritis &
by diagnosing osteoarthritis before it becomes too advanced You web site at http://net.arthritisresearch.ca/oapublic/news/
and requires more serious medical procedures such as total knee replacements or realignment surgeries.
"State of the Art" Continued
as gastric ulcer by 50%. In those at high risk of ulcer or bleeding who real y need the benefits of The researchers and consumers involved in the "Tooling reasonable first choice for an NSAID. The increase Up for Early Osteoarthritis" grant grateful y acknowledge an anti-inflammatory, a coxib makes sense. The the funding received from the Canadian Institutes of in cardiovascular events was not well recognized alternative choice is an NSAID with a proton pump Health Research and the Canadian Arthritis Network.
in the past because those taking these drugs inhibitor or an NSAID with misoprostol, but for the may be at high risk anyway. Thus, detecting elderly, often on many drugs already, a multi-dose a small increase in the rates of heart attack or NSAID and a PPI or misoprostol is not as easy as stroke requires randomized trials involving tens of a once a day coxib. For those at very high risk of thousands of patients (and costing more than $100 bleeding a coxib and a PPI may be needed. Risk million each). The two new coxibs – lumiracoxib factors for peptic ulcers – including a bleeding The editors of OsteoArthritis & You thank Novartis (Prexige®) and etoricoxib (Arcoxia®) - have been ulcer – are being over the age of 60 (the risk climbs Pharmaceuticals Canada Inc. for their unrestricted studied in trials of 18,000 and 28,000, respectively. educational grant to support the printing of this issue. The every decade after the age of 60), a past history These are the two largest clinical trials ever content of this issue is free from influence from any public of peptic ulcer or bleeding ulcer, a concomitant or private funding.
conducted for arthritis medications and as a result inflammatory arthritis and use of anticoagulants Special thanks to The Arthritis Research more is known about their safety than any other (general y considered a contraindication for NSAID Centre of Canada for administrative and on the market today. hosting assistance.
or coxib use). Low dose ASA may reduce the Why the increased risk of heart attack, benefit of a coxib. In this case, a PPI may be used. congestive heart failure and stroke occurs is Helen Prlic, Research Coordinator Currently, two coxibs are available in Canada – uncertain, but that NSAIDs and coxibs increase Arthritis Research Centre of Canada celebrex (Celecoxib®) and lumiracoxib (Prexige®).
blood pressure in some people – especial y 895 West 10th Avenue, Vancouver, BC V5Z 1L7Website: www.arthritisresearch.ca those with high blood pressure to start with – is Other treatment options
unquestioned. Blood pressure monitoring is Intra-articular corticosteroids provide short-term essential when taking any type of NSAID or coxib. relief, especial y in the presence of inflammatory Using the lowest dose of anti-inflammatory symptoms or signs. Intra-articular hyaluronate This newsletter is provided for general information only. It medication (or any medication) needed to control should not be relied on to suggest a course of treatment injections also provide relief but require multiple OA symptoms makes the best sense.
for or as a substitute for consultation with qualified health joint aspirations and injections. They are professionals who are familiar with your individual medical The coxib advantage
needs. Should you have any health care related questions, probably best in OA limited to the knees where if you should contact your physician. You should never Coxibs have one advantage over NSAIDs. They improvement occurs, other drug treatment can be disregard medical advice or delay in seeking it because of reduce the risk of serious GI side-effects such something you have read in this newsletter.
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Source: http://net.arthritisresearch.ca/oapublic/news/documents/OAANDY3_Eng_000.pdf