Privacy Policy – Comprehensive Arthritis Management, Inc. Last updated: 9/28/2020 Comprehensive Arthritis Management, Inc. ("us", "we", or "our") operates http://www.managearthritis.com (the "Site"). This page informs you of our policies regarding the collection, use and disclosure of Personal Information we receive from users of the Site. We use your Personal Information only for providing and improving the Site. By using the Site, you agree to the collection and use of information in accordance with this policy. Information Collection And Use While using our Site, we may ask you to provide us with certain personally identifiable information that can be used to contact or identify you. Personally identifiable information may include, but is not limited to your name ("Personal Information"). Log Data Like many site operators, we collect information that your browser sends whenever you visit our Site ("Log Data"). This Log Data may include information such as your computer's Internet Protocol ("IP") address, browser type, browser version, the pages of our Site that you visit, the time and date of your visit, the time spent on those pages and other statistics. In addition, we may use third party services such as Google Analytics that collect, monitor and analyze this for purposes of improving the services we provide to you. Communications We may use your Personal Information to contact you on subjects related to the services we provide, along with, on rare occasion, newsletters, marketing or promotional materials. Cookies Cookies are files with small amount of data, which may include an anonymous unique identifier. Cookies are sent to your browser from a web site and stored on your computer's hard drive. Like many sites, we use cookies to collect information. You can instruct your browser to refuse all cookies or to indicate when a cookie is being sent. However, if you do not accept cookies, you may not be able to use some portions of our Site. Security & Privacy The security and privacy of your Personal Information is important to us, but remember that no method of transmission over the Internet, or method of electronic storage, is 100% secure. We use commercially acceptable means to protect your Personal Information, consistent with the laws and regulations in Ontario, Canada. However, we cannot guarantee the absolute security of information that you share with us. Changes To This Privacy Policy This Privacy Policy is effective as of 9/28/2020 and will remain in effect except with respect to any changes in its provisions in the future, which will be in effect immediately after being posted on this page. We reserve the right to update or change our Privacy Policy at any time and you should check this Privacy Policy periodically. Your continued use of the Service after we post any modifications to the Privacy Policy on this page will constitute your acknowledgment of the modifications and your consent to abide and be bound by the modified Privacy Policy. If we make any material changes to this Privacy Policy, we will notify you either through the email address you have provided us, or by placing a prominent notice on our website. Contact Us If you have any questions about this Privacy Policy, please contact us. Terms of Use – Comprehensive Arthritis Management, Inc. Last updated: 9/28/2020 Please read these Terms of Use ("Terms", "Terms of Use") carefully before using the https://www.managearthritis.com website operated by Comprehensive Arthritis Management, Inc. ("us", "we", or "our"). Your access to and use of the Service is conditioned on your acceptance of and compliance with these Terms. These Terms apply to all visitors, users and others who access or use the Service. By accessing or using the Service you agree to be bound by these Terms. If you disagree with any part of the terms then you may not access the Service. Sharing and Accessing Private Healthcare Information and Related Content Visiting this site may involve the sharing, viewing or modifying of your private, protected healthcare information. If you wish to access this Site, you may be asked to supply certain information. Our Service allows you to upload, store, share and otherwise make available certain information, text, graphics, videos, or other material ("Content"). Comprehensive Arthritis Management, Inc. agrees to comply with the laws and regulations of its local jurisdiction, Ontario, Canada, as it relates to the handling and processing of this information and content. ​ Termination We may terminate or suspend access to our Service immediately, without prior notice or liability, for any reason whatsoever, including without limitation if you breach the Terms. All provisions of the Terms which by their nature should survive termination shall survive termination, including, without limitation, ownership provisions, warranty disclaimers, indemnity and limitations of liability. Links To Other Web Sites Our Service may contain links to third-party web sites or services that are not owned or controlled by Comprehensive Arthritis Management, Inc. Comprehensive Arthritis Management, Inc. has no control over, and assumes no responsibility for, the content, privacy policies, or practices of any third party web sites or services. You further acknowledge and agree that Comprehensive Arthritis Management, Inc. shall not be responsible or liable, directly or indirectly, for any damage or loss caused or alleged to be caused by or in connection with use of or reliance on any such content, goods or services available on or through any such web sites or services. ​ Changes ​ We reserve the right, at our sole discretion, to modify or replace these Terms at any time. If a revision is material we will try to provide at least 7 days' notice prior to any new terms taking effect. What constitutes a material change will be determined at our sole discretion. Contact Us If you have any questions about these Terms, please contact us.

CAM Clinic PHONE: (647) 624-5171 ​ FAX: (855) 607-3858 ​ HOURS: Mon-Fri 8am to 5pm ET ​ EMAIL: info@managearthritis.com ​ ADDRESS: (Within the Emkiro Clinic) 70 University Avenue, Suite 120 Toronto, ON M5J 2M4 (at corner of University & Wellington) Map Link ​ 70 University Ave Street Level Access Parking available under 70 University Avenue Impark 372 Lot -- accessed at 19 Emily Street ​ TTC Access via St. Andrew or Union Stations

Surgical Options for Osteoarthritis Surgical Options Arthroscopy The least invasive surgical procedure that may be effective in osteoarthritis is arthroscopy. Its greatest strength is in treating mechanical symptoms such as unstable flaps of articular cartilage, loose fragments or very unstable meniscus tears. It also has the potential to treat inflammatory symptoms as the pro-inflammatory molecules released from failing cartilage are washed out of the joint at the time of arthroscopy. However, the surgical trauma created by the arthroscopic procedure creates an acute post-surgical inflammation. In effect, acute inflammation is being created by the procedure that is attempting to alleviate chronic inflammation by removing pro-inflammatory cartilage debris from the joint. Thus, it is very important to aggressively treat post-surgical inflammation in order to maximize the potential benefits from arthroscopy. The use of arthroscopy in the management of osteoarthritis, particularly knee osteoarthritis has been controversial with studies both supporting and other studies questioning the effectiveness of arthroscopy. ​ Total knee replacement Total knee replacement is a surgical procedure in which the osteoarthritic cartilage and adjacent underlying bone is removed and metal and plastic prostheses are cemented into place. This is a thirty year old technology that revolutionized the management of arthritis. However it is extremely invasive, hugely expensive and can have significant complications. Multiple studies have documented that 20-30% of patients are dissatisfied with their outcome. Importantly, recent data has indicates that total knee replacements have a higher rate of opioid use than any other surgery performed. Disturbing data coming from the U.S. indicates a 15% chronic opioid addiction rate after total knee replacement. Thus, although joint replacement has been life changing for many patients, it is the most expensive, invasive and riskiest treatment for managing osteoarthritis and is best used as a last resort. ​

Frequently Asked Questions What is bone on bone? Bone on bone means that there has been full thickness loss of cartilage resulting in exposed bone between two joint surfaces.This does not mean that there is no cartilage left.There is a broad spectrum of bone on bone, just a small area of exposed bone or there may be a very broad area across which cartilage has been lost. Does bone on bone mean I need a joint replacement? Only a small number of patients with bone on bone changes will require joint replacement. In fact, many patients with bone on bone changes experience little or no osteoarthritic symptoms. In many patients with bone on bone changes that experience symptoms, their symptoms can be managed effectively with non-surgical anti-inflammatory therapy options. How important are the results from x-rays or MRI in determining what treatment I should have? Imaging modalities can be helpful. However, there is often a big disconnect between symptom severity and the changes on imaging modalities such as plain x-rays and MRI. Two patients can have exactly the same imaging findings wherein one patient is totally disabled with pain and loss of function and the other patient has no symptoms. The most important information for creating an effective treatment plan for managing osteoarthritis is embedded in the individual patients story. Do I need an MRI? There are certain situations in which information provided by an MRI may be helpful. However, the vast majority of patients with osteoarthritis do not require an MRI in order to determine an effective treatment plan. Is there currently a cure for osteoarthritis? There is no cure for osteoarthritis. Current therapies are focused on managing the symptoms of osteoarthritis but will not provide a cure. Is there any current treatment that regenerates or regrows cartilage? No, while there are some anecdotal instances of cartilage repair or regeneration, there is no strongly conclusive study that this is possible. What is the difference between unexpanded stem cells and expanded stem cell therapies? Stem cells can be obtained from many sources but most typically from bone marrow or fat. Aspirates or biopsies from the areas can be processed through a centrifuge and immediately injected into an osteoarthritic joint. In this case, there are a small number of stem cells along with other biologically active cells that are being injected. These cells can be effective in treating inflammation which in turn will help to improve patient symptoms. Unfortunately, there is no evidence that these treatment approaches will regenerate cartilage. Although there are a small number of stem cells that are injected with these treatments, it is not appropriate to consider these true stem cell therapies. True stem cell therapies are when a source of stem cells such as from bone marrow, fat, umbilical cord blood or other sources has a small number of stem cells which are identified and extracted and subsequently grown over a number of weeks in a laboratory environment to create millions of stem cells. What is the regulatory status of stem cells? Unexpanded stem cell therapies are currently not approved in the U.S. or Canada. There are some approved for use in Europe. There are no expanded stem cell therapies which are currently approved for use in Canada, the U.S. or Europe. Expanded stem cell therapy is currently available in South Korea. Expanded stem cell therapies have greater potential than unexpanded stem cells for regenerating cartilage. Given our current state of knowledge, it is expected that the first generation of expanded stem cell therapies will be more effective than current biologic therapies in managing inflammation resulting in improvement in pain and function but will be unlikely to regenerate cartilage. However, they may be effective in slowing down the natural rate of osteoarthritic progression. It is likely that the ability to regenerate cartilage will only happen with second or third generation expanded stem cell therapies. Certainly, the holy grail of regenerating cartilage is still many years away from clinical reality.

Osteoarthritis Treatment Options Click to learn more Exercise & Weight Loss Non-clinical Corticosteroids Injections Arthroscopy Surgeries Physiotherapy & Braces Hyaluronic Acid Partial Joint Replacement Alternative Medicine Platelet Rich Plasma Total Joint Replacement Pain Medication nSTRIDE Osteotomy Increasing invasiveness and risk For more information, see our FAQ page and brochures for PRP , Synvisc , and nSTRIDE with post-treatment information Therapy Selection Strategy Therapies are progressively selected based on these clinical priorities: 1. Control Inflammation ​ 2. Strengthen Joint 3. Enhance Physical Activity Periodic follow-up and use of quantitative clinical performance scoring are keys to facilitating favourable progression Following an initial consultation and exam, a personalized treatment programme is developed for each patient, including: • Step-wise treatment plans, built on the patient’s history and unique needs • Schedule of periodic follow-ups • Home care guidelines • Detailed descriptions and references

Information for Healthcare Practitioners The CAM Clinic is a Toronto-based private practice providing orthopaedic patient care. The services offered include treatment types that are available in Canada, either on or off-label, but are not readily available to patients within the public system and/or potentially not covered under the Ontario Health Insurance Plan (OHIP). As a result, CAM's services are generally provided to patients on a cash-pay basis and we rely on close collaboration with referring physicians and practices within the public system. ​ As part of this collaboration, we encourage our referral partners to participate in the follow-up assessment of patients and capture the valuable outcomes data in our clinical registry. As patients are referred to us, we will provide instructions back on how to participate in the registry, and for access to the research findings. See the Research page on this website for additional information on our study goals and approach. ​ If you would like to learn more about our practices, its policies & procedures, and registry, or if you would like to initiate a referral to us, please contact our office at (647) 624-5171. ​ ​

Non-clinical treatment options Weight Loss Many patients experiencing osteoarthritis symptoms are overweight. Excess weight does increase strain on all the damaged cartilage tissue which can contribute to a worsening of osteoarthritis symptoms and acceleration of the underlying disease process. Thus, losing weight has the potential to decrease the severity of osteoarthritis symptoms and slow down the progression of the disease. Unfortunately, by the time most patients seek treatment; their symptoms are sufficiently severe that it is difficult for them to effectively exercise in order to lose weight. Thus, it is often necessary to first initiate therapies that can decrease the severity of the osteoarthritis symptoms so that the patient can then subsequently increase their exercise program in order to lose weight. Physiotherapy Physiotherapy is a very important modality for effectively managing osteoarthritis. The central focus of physiotherapy is on maintaining range of motion and strength of the joint, both of which can be compromised by osteoarthritis. Although physio is critically important in enhancing range of motion and regaining and maintaining strength, the timing of the physiotherapy is also important. If aggressive physiotherapy is pursued in an actively inflamed joint, the therapy may exacerbate the inflammatory process making symptoms worse. It is first necessary to bring the inflammatory symptoms under control and then subsequently introduce the range of motion and strengthening program that does not exacerbate inflammation. Pain Medication Acetaminophen (Tylenol) is a non-narcotic analgesic that can be effective in treating mild to moderate symptoms of osteoarthritis. Acetaminophen does not have any anti-inflammatory activity and is purely an analgesic. As such it avoids many of the complications that are associated with oral anti-inflammatory medications. With regard to narcotic analgesics, there is no place for them in the chronic management of osteoarthritic pain. They may play a limited role in the short term management of severe osteoarthritic pain associated with an acute inflammatory flare up. ​ Nonsteroidal anti-inflammatory drugs (NSAIDs) can be very effective in treating the symptoms of osteoarthritis as they are focused on treating inflammation. They may work extremely well in some patients while they may not work at all in others. The significant problem with these medications is that they are oral systemic medications which can lead to complications such as hypertension, GI bleeding, kidney and cardiac problems. These risks increase with age. Since symptomatic osteoarthritis typically occurs in a single or small number of joints, it is preferable to treat most patients with local therapies rather than with a systemic drug that has significant risk for body-wide toxicity. Click here to find out about injectible therapies offered by Comprehensive Arthritis Management

Advancing personalized treatments to improve patient experience in arthritis care Learn more about treatment options > A specialty orthopaedic practice applying personalized treatment programmes which prioritize safer, less invasive therapies, leaving surgical options as a last resort 1 in 5 of Canadians suffer from arthritis, with 40% of those reporting pain that limits activity 1, 2 20% of total knee replacement recipients reported being dissatisfied with the outcome 3, 4 CAM Clinic - Toronto A co-located partner clinic of The CAM Clinic offers several injectable therapies, and personalized consultation and planning, with the aim to avoid surgery if possible. ​ Available therapies and support: • Corticosteroid injections • Hyaluronic acid gels • Platelet Rich Plasma (PRP) therapy • nSTRIDE Autologous Protein Solution therapy • Consultation on surgery, biologics, clinical trials, and emerging experimental cell therapy options ​ For information , call 647-624-5171 To schedule an appointment, fax the referral and MRI or x-ray report taken within the past year to 855-607-3858 (fax) Visiting Us >

What is Osteoarthritis Overview of osteoarthritis Osteoarthritis is a condition in which the articular cartilage that normally provides a smooth, stable surface, begins to fail leading to breakdown. This compromises the normal smooth, painless functioning of the joint surfaces. The most common cause of osteoarthritis is aging. However, a number of other factors can lead to osteoarthritis including genetic predisposition, gender, joint injury, obesity and overuse. As the cartilage tissue begins to fail, small inflammatory molecules are released into the joint environment which results in inflammatory reaction in joint tissues, most notably the synovium. This inflammatory reaction leads to aching pain, swelling, weakness and stiffness. This inflammation accounts for most of the symptoms experienced by patients with osteoarthritis. Some patients may also experience mechanical symptoms such as crunching, grinding or locking that are caused by unstable fragments of cartilage, loose bodies or unstable soft tissue problems such as meniscus tears. There are a wide range of treatment options that can be effective for osteoarthritis including weight loss, exercise, physiotherapy, pain medication, anti-inflammatory medication, injectable therapies and surgical options. Central role of inflammation It has become apparent that most human disease processes are driven by inflammation. Osteoarthritis is no exception. The broken-down molecules that are released into the joint as cartilage begins to fail, leads to inflammatory changes in the synovium, which is the tissue that lines the joint. This inflammatory reaction drives symptoms such as: Pain; Aching; Swelling; Weakness; Stiffness. Increasingly, the treatment of osteoarthritis has focused on managing inflammation. If the inflammatory reaction of the synovium can be effectively treated, patients can function well with little or no symptoms despite having significant underlying osteoarthritis damage. Mechanical Symptoms Although inflammatory symptoms are more common, some patients have mechanical symptoms which can range from relatively mild clicking to much more significant symptoms such as crunching, grinding or in extreme situations locking or mechanical seizing up of the joint. Patients who have marked mechanical symptoms such as crunching, grinding and locking may require surgical intervention. Initial Triage On initially assessing a patient with osteoarthritis, it is important to determine whether or not there are significant mechanical symptoms which require surgical intervention. Fortunately, most patients do not have marked mechanical symptoms. Thus, surgery does not need to be the initial form of treatment for the vast majority of patients. Most patients presenting with osteoarthritis symptoms can be managed with safer, less invasive therapies that are directed at reducing inflammation. Click here to find more information on non-clinical treatment options

Research Focus Areas : ​ • Community-wide clinical registry supporting long-term observational studies ​ • Retrospective and prospective analysis of clinical outcomes to evaluate the effectiveness of non-surgical treatments ​ ​ • Building partnerships for advancing the science and real-world study of emerging cell-based therapies CAM is strongly committed to collecting real-world evidence with the goal of driving positive change in the management of arthritis Our emphasis is on the evaluation of biologic and injectable treatments as alternatives to traditional surgical options Research Programmes

Injectible Therapy Options Injectible therapies Injectable therapies have the advantage of being a local treatment for what is typically a local problem. The most common application of injectable therapies is for knee osteoarthritis followed by shoulder and hip as these are the joints with the greatest prevalence of osteoarthritis. Injectable therapies can also be used in other joints such as the elbow, wrist, ankle and occasionally in certain small joints of the foot and hand as well as in the spine. ​ Corticosteroid injections ​ ​ Corticosteroid injections have been available for approximately fifty years. Used appropriately, they can effectively treat joint inflammation. They have the advantage of being relatively inexpensive. However their effectiveness is usually short lived, which limits their effectiveness for treating osteoarthritis as it is a chronic condition of aging. Corticosteroids are most effective in managing acute inflammatory flares. They are also often used to manage post-surgical inflammation. However, corticosteroid injections must be used judiciously as they have potential for causing cartilage damage if used inappropriately or excessively. ​ ​ Hyaluronic acid gels Hyaluronic acid gels have been available for twenty-five years. They are a very safe therapy which works by decreasing joint inflammation and lubricating the joint surface. Although there is a wide degree of variability in their effectiveness in any individual patient, there are typically effective in approximately 50-60% of patients, provide symptom relief of approximately 40% and will last around 6-12 months before eventually wearing off and losing their effectiveness. Hyaluronic acid gel therapies are moderately expensive but have been around for such a long period of time that they are now covered on many third-party insurance plans. At Comprehensive Arthritis Management, we believe that the most effective Hyaluronic acid gel product is Synvisc although it should be noted that there are a large number of options currently available. ​ Platelet Rich Plasma (PRP) ​ This therapy represents the first biologic therapy that has become available for the management of osteoarthritis. A biologic therapy is manipulating normal human biology in order to treat osteoarthritis. In the case of PRP, a blood sample is taken from the patient’s arm and placed into a centrifuge which allows the blood to be separated into two layers. The top, lighter layer contains platelets cells that are suspended in the plasma. The lower portion of the sample contains red cells and white cells which cause inflammation and are discarded. The plasma with the suspended platelets is injected into the patients knee and the injected platelets release a large number of anti-inflammatory and growth factor molecules into the joint environment. This is effective in diminishing inflammation and osteoarthritis symptoms in 70-80% of patients, typically decreasing symptom severity by 70-80% and typically lasting in excess of one year with most patients getting multiple years of improvement before the effectiveness wears off. There are some forms of PRP injections which include white cells in part of the injectable cells, but we feel that leukocyte poor PRP in which the white cells are removed is more effective than leukocyte rich PRP. We use a form of PRP injection called autologous conditioned plasma (ACP). ​ nStride ​ ​ nStride is relatively new biologic therapy that is also based on a blood sample but is very different in its mechanism of action than platelet therapy. Click here to see surgical options for osteoarthritis