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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

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

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. ​ ​

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. ​

COVID-19 Notice Comprehensive Arthritis Management, Inc. is in compliance with orders pertaining to medical practices in Ontario. The health and safety of our patients is our top priority. We have implemented specific protocols and procedures to keep patients and staff as safe as possible while attending to those with medical needs, including the following: ​ • Wait-rooms and other areas have been modified to provide physical distancing • Hand sanitizer is available at front reception and throughout the clinic • All patients arriving without a mask are provided one • Touch surfaces throughout the clinics are regularly sanitized, and any extraneous items have been removed ​ Standards and requirements are subject to change based on updates provided from government and health agencies. ​ For further information on COVID-19, please visit https://www.publichealthontario.ca/en/diseases-and-conditions/infectious-diseases/respiratory-diseases/novel-coronavirus Return to Site

Hyaluronic Acid Hyaluronic acid (HA) gels have been available for twenty-five years. They are a very safe therapy that 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. Specifically, they are typically effective in approximately 50-60% of patients, provide symptom relief of approximately 40% and typically last around 6-12 months. Hyaluronic acid gel therapies are moderately expensive but are now covered on many third-party insurance plans. While there are a large number of HA product options available, Comprehensive Arthritis Management utilizes a HA gel product called Synvisc given its good track record of quality and efficacy. Additional information on the hyaluronic acid product used by CAM are available by clicking here .

Platelet Rich Plasma (PRP) This therapy represents the first biologic therapy available for the management of OA. Biologic therapies generally manipulate normal human biology in order to treat disease, rather than using drugs. 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 platelet 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 patient's knee and the injected platelets release a large number of anti-inflammatory and growth factor molecules into the joint environment. PRP is effective in diminishing inflammation and OA symptoms, shown in clinical study to decrease symptom severity by 78%. The benefit lasts in excess of one year, with many patients achieving multiple years of improvement before the effectiveness fades. Key clinical study results are reported here: https://pubmed.ncbi.nlm.nih.gov/26831629/ There are some forms of PRP injections that include white cells in part of the injectable cells, but 'leukocyte poor' PRP, in which the white cells are removed, is considered to be more effective than the leukocyte rich form of PRP. CAM uses a specific type of leukocyte poor PRP injection called autologous conditioned plasma (ACP) for its treatments. For more information on the PRP product used by CAM, click here .

Alternative Medicine There are a variety of alternative medicine options available that may help manage OA symptoms. The success of these options is very specific to the individual and often difficult to predict, but when they work for a patient it can be very positive especially if more invasive treatments are avoided. Given their generally low risk, individuals with chronic OA should certainly consider the alternative medicine options they are comfortable with, in consultation with their doctor. General categories of these treatments include the following: ​ Acupuncture . This is an eastern medicine practice involving the placement of fine needles at specific points on the body. Clinical studies on their efficacy are generally mixed, but there is some evidence of help for managing pain from OA. [1 ] ​ Supplements . A number of popular supplements, such as glucosamine chondroitin, and omega-3, are used to manage the effects of OA. While clinical studies on their efficacy of OA are also mixed, some benefits can be achieved. Be sure to speak to your physician before starting supplements, as they may interact with medications or affect other unrelated conditions. Cannabinoids . The medicinal use of marijuana has been expanding in recent years. The active ingredients CBD and THC, used individually or in combination, do provide OA pain and symptom relief for some patients. There is a limited but growing body of information on the proper dosing and efficacy of cannabis products.

Corticosteroid Corticosteroid injections have been available for around fifty years. Used appropriately, they are effective at treating joint inflammation. They also have the advantage of being relatively inexpensive compared to other treatment options. However, their effect is generally short-lived, which limits their utility as a therapy for chronic aging-related OA. ​ Corticosteroids are most useful in managing acute inflammatory flares and post-surgical inflammation. They must be applied judiciously since they have the potential for causing cartilage damage if used inappropriately or excessively. But when used appropriately, they play an important role in OA management.

Partial Joint Replacement A partial knee replacement is a surgical procedure where either the inside or outside compartments of the knee or other joint are removed and replaced with a prosthesis. This differs from a total joint replacement where all compartments are removed and replaced. Knee replacement surgery, the most common form of joint replacement, has benefits that typically last about 20 years, so younger patients should be aware that additional future surgery may be required. Partial knee replacement is similar to total knee replacement in terms of the benefits, risks, and potential outcomes (see total joint replacement description for more details). There is increasing concern that partial joint replacements do not hold up as well as total joint replacement, and revision surgery, if required, is more complex. Together, these options require careful consideration by an experienced surgeon, and alternative options should be explored before selecting surgery.

Total Joint Replacement Total knee replacement is a surgical procedure in which the osteoarthritic cartilage and adjacent underlying bone are 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 very invasive, expensive, and comes with a risk of significant complications. The results can be very positive, but for some patients, they can be poor. Multiple studies have documented that 12-20% of patients are dissatisfied with their outcome [1 ,2 ]. Given the potential for an unfavorable outcome, it is important to ensure that alternatives to surgery have been explored with your doctor. Another important risk to be aware of is the potential for post-operative opioid addiction. U.S. study data indicates that total knee replacements have the second-highest rate of opioid use among all surgery types performed and a 15.2% chronic opioid addiction rate after total knee replacement. [3 ] Although joint replacement has been life-changing for many patients, it should be considered as a last resort given its invasiveness and risk.