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

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 >

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

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 >

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

nSTRIDE nSTRIDE is a relatively new biologic therapy that is also based on manipulating human biology but is very different in its mechanism of action. In simple terms, the patient's blood is collected and processed. The anti-inflammatory proteins, referred to as IL-1 antagonists, are isolated and then injected back into the affected joint. One key difference between nSTRIDE and PRP is the number of injections. nSTRIDE treatment is delivered with a single injection vs. three for PRP. Clinical study results have shown that the single nSTRIDE injection can provide relief for up to 24 months, which is longer than other available treatments. Relief of pain typically comes within 1 to 2 weeks of the injection. Product details are available in this brochure and post-treatment details are available here . nSTRIDE is approved for use in Canada for knee osteoarthritis. Recently published clinical study results, showing favourable progress of study participants across a three year monitoring period, can be found at this link: https://pubmed.ncbi.nlm.nih.gov/32870042/ .

Physiotherapy & Braces Physiotherapy is a very important and effective tool for managing OA. The central focus of physiotherapy is on maintaining range of motion and strength of the joint, both of which can be compromised. The timing of the physiotherapy is very important. If aggressive PT is pursued in an actively inflamed joint, the therapy may exacerbate the inflammatory process, making symptoms worse. The preferred approach is to bring the inflammatory symptoms under control, then subsequently introduce the range of motion and strengthening PT programme. ​ Braces provide stability for the affected joint and increase confidence in its use. When used correctly and consistently, braces have been shown to reduce OA symptoms and improve joint function.

Exercise & Weight Loss Regular exercise and maintaining a healthy weight can together help to prevent the onset of osteoarthritis (OA) and help to manage existing symptoms. When suffering from OA, excess weight increases the strain on damaged cartilage tissue, which in turn contributes to a worsening of symptoms and acceleration of the underlying disease process. Conversely, losing weight has the potential to decrease the severity of OA symptoms and slow down the progression of the disease. ​ Low impact exercises, performed regularly, are helpful for managing OA. Example exercises include yoga, tai chi, biking, walking, and pool aerobics. Building muscular strength through exercise can help support the joints and slow further disease onset. Patients should talk to their doctor before starting any new exercise routine. ​ Unfortunately, by the time many patients seek treatment for OA, their symptoms are sufficiently severe that it is more difficult to exercise in order to lose weight. In these cases, it is necessary to first initiate therapies that decrease the severity of the OA symptoms so that the patient can then subsequently increase their exercise programme in order to lose weight and further reduce disease progression. The importance of healthy weight, diet, and exercise as part of OA management cannot be overstated.

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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

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.