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

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

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

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

About CAM Comprehensive Arthritis Management, Inc. is a private orthopaedic practice based in Toronto, Canada, specializing in advice and treatment options to manage pain and functional disability caused by osteoarthritis. We develop personalized treatment plans for each patient, focusing on the incremental application of safer and less invasive therapeutic options, leaving surgical interventions as a last resort. Our research supports the further development and validation of the non-invasive treatment programmes, through a community-wide clinical registry and study of patient outcomes over time for different treatment paths. K. Wayne Marshall, MD, PhD, FRCSC CAM Vision ​ Apply a programmatic approach to arthritis care, emphasizing the use of non-surgical therapies as safe and effective alternatives, leaving invasive surgical options as the last resort. Osteoarthritis Overview About OA Osteoarthritis is a joint condition in which the articular cartilage that normally provides a smooth, stable surface, begins to break down. This compromises the normal smooth, painless functioning of joint surfaces. Common causes of OA are aging, genetic predisposition, gender, joint injury, obesity and overuse. Symptoms As joint cartilage begins to fail, small molecules are released which cause an inflammatory reaction. This leads to aching pain, swelling, weakness and stiffness. Mechanical symptoms such as crunching, grinding or locking may also occur, caused by unstable fragments of cartilage or soft tissue problems such as meniscus tears. Treatment The treatment of osteoarthritis focuses on managing inflammation as a first step. If the inflammatory reaction of the joint can be effectively treated, patients can function well with little or no symptoms despite having significant underlying OA damage. For certain joints with advanced OA, surgical options may be required. Triage When assessing a patient for OA, the key is to determine whether there are significant mechanical symptoms that necessitate surgical intervention. Fortunately, most patients do not require surgery, and less invasive therapy options directed at reducing inflammation can be considered. Learn more about therapies >

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 >

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. ​ ​

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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. ​

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