Cours - Cofemer

27/06/2016
AGENDA
Actualités de l’arthrose en 2016
Pr Francois Rannou
Epidémiologie
Physiopathologie
Nouvelles recommandations
OARSI
Rehabilitation Unit, Rheumatology Department
Hopital Cochin, AP-HP
INSERM UMR-S 1124
Université Paris Descartes
Self reported disability in French population
Palazzo et al, PLoS ONE, 2012
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27/06/2016
OA is a whole joint disease
and probably more!
EPIDEMIOLOGIE
1) Notion d’espérance de vie sans handicap
donc sans arthrose!
2) Nouveau paradigme pour nos
autorités (politiques, sanitaires, agences) :
l’arthrose une maladie non mortelle mais
handicapante donc couteuse
OA : a dialogue between joint tissues
OA is an inflammatory disease
Normal
Synovial tissue
(TGF)
Fibrosis
Mild
Inflammation
Severe
Inflammation
(Goldring M, Best Pract Res Clin Rheumatol)
Control
CTS 5% 1Hz 24h
150
Marq.
OA is a mechanical disease:
link with inflammation!
Prostaglandines E2 (nηg/ml)
IL-1β 10ng/ml, 24h
COX-2
250
296 bp
V
C
20
15
10
5
0
CTS IL-1β
COX-2
72 kDa
C
CTS
IL-1β
Mechanical stress induces PGE2
production in chondrocytes
Rannou et al, personnal data
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IL-1
Transcriptional factors
OA is an IL-1 dependant disease
IL-1RI
Kinase cascade
TAK1
Inflammation
IkB kinases
MAP kinases
AP-1
IkB
NFkB
Degradation
P
AP-1
C/EBP
AP-1
NFkB
NFkB
IL1-Target genes
Degradation
Mechanical stress modulates inflammation!
Agarwal et al,, FASEB J
Deschner et al, Curr Opin Clin Nutr Metab Care
From Corvol MT
OA is a bone disease!
Targets for specific
treatments
TARGET !
PHYSIOPATHOLOGIE
1) Role clé de l’os sous-chondral via TGF béta
2) Maladie de toute l’articulation
adipokines
3) Maladie inflammatoire
TARGET !
TARGET !
4) Rôle clé du stress mécanique
5) Rôle de NGF : concept de biothérapie
symptomatique
Sellam & Berenbaum. Nature Reviews Rheum (2011)
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Vitamin D
Strontium ranelate
Efficacy and safety of strontium ranelate in the
treatment of knee osteoarthritis: results of a
double-blind, randomised placebo-controlled trial
Possible structural effect
but not on the symptomatic compartment!
Clinical effect at 2g but not 1g
No clinical and no structural effect!
McAlindon, JAMA 2013
Bisphosphonate
Reginster, ARD 2013
Structural treatment:
the surgical distraction!
Intema et al, ARD 2011
Laslett, ARD 2013
Tanezumab in knee OA
OA and treatment strategies
WOMAC Pain
- Mechanical stress
- Inflammation
- Obesity
- Aging
- Genetic
Tanezumab in Osteoarthritis of the Knee NE Lane, TJ Schnitzer et al. N Engl J Med 2010;363:1521-31
Arthrose – V2 – Mai 2012
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Pain management : a key point in OA
treatment
Pain management : acetaminophen the first
line treatment
Pain management : acetaminophen the first
line treatment
Pain management and high quality trials!
OARSI guidelines
The key messages of 2010
OARSI guidelines
1) ES of acetaminophen is very low
2) The ES of the pharmacological treatments
decrease when the quality of the studies increase
3) Treatment must combinate non pharmacological
and pharmacological modalities
4) NSAIDs need to be use at the lower dose and for
the shorter duration
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OARSI guidelines in knee OA
OARSI guidelines in knee OA
OARSI guidelines in knee OA
OARSI guidelines in knee OA
The key messages of 2014
OARSI guidelines
The keys of OA management
1) Acute phase treatment
1) ES is important but SE (Side Effects) are very
important to consider!
2) Chronic phase treatment
2) It is important to distinguish mono from poly joint
OA
4) Mono or poly joint OA
3) Comorbidities have to be detected, treated before
any OA pharmacological prescription
3) Joint specific treatment
5) Comorbidities
Non pharmacological and
pharmacological treatments!!
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Multidisciplinary approach
1) GPs, Rheumatologists, PMR, surgeons
2) Physiotherapists, occupationnal
podologists, nurses
therapists,
Bracing in knee OA
Chronic phase treatment
whatever the joint affected
1)
Pain killer (acetaminophen : 3 grammes a day)
2)
SYSADOA (symptomatic slow acting drugs for OA),
hyaluronic acid injection
3)
NSAIDs: discontinued cures + topics
4)
Non pharmacological treatment in order
decrease the load on the symptomatic joint
5)
Weight reduction, a part of non-pharmacological
treatment
to
The non-pharmacological
treatment in knee OA?
Chronic phase treatment
and non pharmacological
treatment
• Sticks, insole, knee bracing,
and weight reduction
+ Physical therapy
• Involving :physical therapist,
occupationnal therapist,
podologist, orthesist, and
dietician
The rational of the non pharmacological treatment is
to modulate mechanical stress at the joint level !
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Splint for base of thumb OA
Decreases pain and improves
disability
Splint for base of thumb OA
Decreases pain and improves
disability
Rannou et al, Ann Int Med 2009
Rannou et al, Ann Int Med 2009
Chronic phase treatment
and non pharmacological
treatment
Chronic phase treatment
and non pharmacological
treatment
Exercises
Weight reduction
The non-pharmacological
treatment in knee OA?
Acute phase treatment
and non pharmacological
treatment
• Sticks, insole, knee bracing,
and weight reduction
+ Exercise
• Involving :physical therapist,
occupationnal therapist,
podologist, orthesist, and
dietician
The rational of the non pharmacological treatment is
to modulate mechanical stress at the joint level !
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Acute phase treatment
and pharmacological
treatment:
Corticosteroid injections,
NSAIDs: discontinued cures
+ topics
CONCLUSION
Osteoarthritis is a whole joint inflammatory
disease
To date treatments are only symptomatic
Comorbidities need to be evaluated in order
to adapt the pharmacological treatment
Courtesy of X Ayral, Cochin Hospital, Paris
Ordonnance type : gonarthrose FTI
• Membres inférieurs
• Renforcement chaîne externe (BF, TFL)
• Renforcement des muscles stabilisateurs du
genou (IJ, QU)
• Travail aérobie
• Gain d’amplitude articulaire, lutte contre le
flessum, posture et autoposture
• Travail proprioceptif
• Autoprogramme
• Pas d’US, pas de massages
Ordonnance type : gonarthrose FTI
du patient jeune
• 1 paire de semelles amortissantes
• 1 genouillère
• 1 paire d’orthèse plantaire avec coin
postéro-externe
• 1 orthèse dynamique
The treatment of the acute phase is different
from the chronic phase treatment
Ordonnance type : gonarthrose FTI
• 1 paire de semelles amortissantes
• 1 genouillère
• 1 paire d’orthèse plantaire avec coin
postéro-externe
Ordonnance type : gonarthrose
FTE
• Membres inférieurs
• Renforcement chaîne interne (Patte d’oie))
• Renforcement des muscles stabilisateurs du
genou (IJ, QU)
• Travail aérobie
• Gain d’amplitude articulaire, lutte contre le
flessum, posture et autoposture
• Travail proprioceptif
• Autoprogramme
• Pas d’US, pas de massages
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Ordonnance type : gonarthrose
FTE
Ordonnance type : gonarthrose
FTE du patient jeune
• 1 paire de semelles amortissantes
• 1 genouillère
• 1 paire d’orthèse plantaire avec coin
postéro-interne
• 1 paire de semelles amortissantes
• 1 genouillère
• 1 paire d’orthèse plantaire avec coin
postéro-interne
• 1 orthèse dynamique
Ordonnance type : rhizarthrose
Ordonnance type : coxarthrose
• Renforcement des muscles intrinsèques et
extrinsèques de la main, de la pince pouce
index
• Membres inférieurs
• Renforcement pelvitrochantériens
• Renforcement des muscles stabilisateurs de la
hanche (Eventail fessier)
• Travail aérobie
• Gain d’amplitude articulaire, lutte contre la perte
d’extension et le flessum, posture et autoposture
• Autoprogramme
• Travail aérobie
• Pas d’US, pas de massages
• Membres supérieurs
• Gain d’amplitude, posture et autoposture de la
1ère commissure
• Autoprogramme
Ordonnance type : coxarthrose
• 1 paire de semelles amortissantes
• Conseils de chaussage
• canne
Ordonnance type : rhizarthrose
• Orthèse de repos pouce-index
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