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.

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.

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.