Download - 2021-10-05 M2 TC4 PHYSIO BIONIQUE ET OA
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OSTEOARTHRITIS
Yves-Marie PERS, MD, PhD
MCU-PH
Département de rhumatologie, CHU Montpellier
INSERM U1183, IRMB
The bionic revolution in the management of osteoarthritis: challenges and
perspectives
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Epidemiology OA
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• 17% whole population
• Incidence Ø Knee OA: 240/100.000 PAØ Hand OA: 100/100.000 PAØ Hip OA: 88/100.000 PA
• Overweight +++Ø RR 1.9 (hand OA + weight-bearing
joints)Ø High risk joint replacement (X 5)
Epidemiology OA
Bijlsma JWJ et al. Lancet 2011The GBD 2015 collaboration. N Engl J Med 2017;377:13-27
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Epidemiology OA
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Epidemiology OA
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Epidemiology OA
• Major public health problem in young people (< 50 years old)Ø Risk factors: overweight/obesity/traumaØ 7-13% knee (<45 YO)Ø Peak at 50 for the kneeØ Disability increases in 20 years (X2)Ø Parallel to obesityØ Increasing TKR and THR
Ø + 76%Ø + 30-60%
Pereira D. O&Cart 2011Ackerman J. Orthop Sports Phys Therapy 2017
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OA Comorbidities
• OA and comorbiditiesØ Meta-analysis Observational
studiesØ RR X 1.2 versus non-OAØ Most frequent:
Ø StrokeØ Gastric UlcerØ Metabolic syndrome
Swain et al. ACR 2020
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OA Comorbidities
• OA and comorbiditiesØ Meta-analysisØ Association between comorbidities and pain/decrease physical performance
Calders et al. Sem A Rheum 2018
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• OA and mortality• Meta-analysis
• All causes and CV mortality with 3 OA sites (hand, knee, hip)
• No increased risk of any cause mortality in OA patients (global)
• Significant association between OA and mortality (after removing hand OA)
• Higher CVD mortality HR 1.21 (CI: 1.10-1.34)
Veronese N. Seminar in Arthritis and Rheumatism 2016
Epidemiology OA
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• Symptoms• Mechanical pain, often insidious and highly variable • Short morning stiffness • Limitation of function/motion• Others: depression, sleep disturbance, decrease QoL • No correlation exists between the joint symptoms and the structural
alterations on X-ray +++
Diagnosis OA
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Diagnosis OA
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• X-ray• Exclude other diagnosis (Paget, neuroalgodystrophy…)• Not mandatory for diagnosis OA• Assess OA severity (KL grading)• Normal with early OA• No correlation with joint symptoms +++
Imaging OA
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• Hip OA
Clinical subsets of OA
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• Knee OA
Clinical subsets of OA
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• Hand OA
Clinical subsets of OA
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Pathophysiology in OA
• All the components of the joint are involved in the process: Ø Cartilage ≈ chondrocytes + ECMØ Subchondral bone ≈ OC/OBØ Synovial ≈ inflammationØ Muscles, ligaments
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Treatment objectives
§ Reduce pain§ Improve function§ Maintain physical activity§ Education§ Slow down cartilage degradation
§ NB: DMOAD (disease modifying OA drug): structural modulation
No drugs meet this definition
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Main principles of OA treatment
§ Multidisciplinary approach§ Personalized approach§ Considering:
Ø General risk factors: age, comorbidity, drugs interactionsØ Local risk factors: obesity, mechanical loading, physical activity, dysplasia, axial
disordersØ LocalizationØ X-ray abnormalitiesØ Pain and disability intensity
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Therapeutic resources for OA
§ RCT, open studies§ EBM, experts advices§ International Recommendations (OARSI, EULAR, ACR, AAOS)
Non-pharmacological therapies
Pharmacological therapies
Surgery
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Therapeutic resources for OA
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Pharmacological treatment in OA
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Non-pharmacological interventions§ PHYSICAL ACTIVITY§ Insufficient physical activity WHO (Male adults)
WHO 2016: less than 150 minutes of moderate intensity physical activity per week, or less than 75 minutes of vigorous intensity physical intensity per week, or equivalent
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Non-pharmacological interventions§ PHYSICAL ACTIVITY§ Insufficient physical activity WHO (Female adults)
WHO 2016: less than 150 minutes of moderate intensity physical activity per week, or less than 75 minutes of vigorous intensity physical intensity per week, or equivalent
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Non-pharmacological interventions§ PHYSICAL ACTIVITY§ Insufficient physical activity WHO (by world bank income group)
WHO 2016: less than 150 minutes of moderate intensity physical activity per week, or less than 75 minutes of vigorous intensity physical intensity per week, or equivalent
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Non-pharmacological interventions§ PHYSICAL ACTIVITY§ Measures of metabolic equivalents of task (MET) for PA§ Four major PA domains (occupation, home production, travel, and
active leisure) and sedentary time among adults§ 5 countries: United States (1965–2009), the United Kingdom (1961–
2005), Brazil (2002–2007), China (1991–2009), and India (2000–2005)§ Perspectives to 2020 and 2030 for each of these countries
Ng SW et al. Obes Rev 2012
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Non-pharmacological interventions§ PHYSICAL ACTIVITY
UK BRAZIL
Major threat to global health…
Ng SW et al. Obes Rev 2012
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Therapeutic resources for OA
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Epidemiology OA
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Surgical interventions
§ Total hip arthroplasty (THA) and total knee arthroplasty (TKA) § Patients with persistent pain, stiffness and reduced function AND refractory to
non-surgical treatments AND impact on their quality of life§ Evidence based on numerous uncontrolled observational studies§ Appropriate rehabilitation and domestic support in the first weeks§ Recovery from TKA is slower§ THA is more effective than TKA in restoring function to normal§ Over 95% of joint replacements continue to function well into the second decade
after surgery, and most provide lifelong pain-free function.§ Approximately 20% patients are not satisfied
Martel-Pelletier J. Nat Rev Disease Primers 2016
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Bionic in OA : Questions raised ?
§ Exoskeleton§ Help rehabilitation or restore mobility with less pain
§ Bio prothesis (TKR, THR)§ Promote better bone integration§ Avoid infections§ Longer-life
§ The bionic leg…
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Exoskeleton§ Military context
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Exoskeleton§ Honda Walking Assist (HWA) is a hip-wearable exoskeleton robot for
gait training that assists in hip flexion and extension movements
Koseki K et al. Geriatric Orthopaedic Surgery 2021
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Exoskeleton§ To evaluate the effects of walking exercises with HWA in patients who
underwent total knee arthroplasty (TKA)
Koseki K et al. Geriatric Orthopaedic Surgery 2021
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Exoskeleton§ A significant difference between preoperative and week 2
§ Self-selected walking speed (SWS)§ Maximum walking speed (MWS)
Koseki K et al. Geriatric Orthopaedic Surgery 2021
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Exoskeleton
§ PA and exercise is central to conservative management of knee OA§ Difficult for patients with KOA to regularly maintain
§ To quantify how a lower-extremity robotic exoskeleton (dermoskeleton) modifies the external knee moments during over-ground walking
§ Pilot study with healthy adults
McGibbon et al. Knee 2017
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Exoskeleton
McGibbon et al. Knee 2017
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Exoskeleton
McGibbon et al. Knee 2017
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Exoskeleton§ Users took shorter and wider steps when walking with the dermoskeleton§ Ground reaction forces increased due to the added mass
McGibbon et al. Knee 2017
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Exoskeleton
§ Knee adduction moment significantly reduced in late stance phase of gait
McGibbon et al. Knee 2017
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• Occitanie funding: innovative regional platform• Coordination: Pr C. Jorgensen• Organization:
CARTIGEN platform
Mobility
• Analysis and modelling movement for better management
• I. Laffont
Tissue Engineering
• Development of new therapies based on tissular Engineering and 3D bioprinting
• D. Noel
Robotic
• Bionic, exoskeleton• A. Khedar
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CARTIGEN MOBILITY platform
• Isokinetic
• MRI (ESAOTE)
• Grail (virtual reality)
• XSENS-Awinda
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SALLE HEBERGEE AU CREPS DE MONTPELLIER
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CARTIGEN MOBILITY platform
• Isokinetic
• MRI (ESAOTE)
• Grail (virtual reality)
• XSENS-Awinda
MRI (ESAOTE)
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APPLICATION EXPLORATOIRE RACHISLombalgies chez Short Trackers
EVALUATION ISOCINETIQUE
• Ratio Fléchisseurs/Extenseurs
EVALUATION IRM EN CHARGE
• Lordose en charge ?• Protrusion discale en charge ?
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RACHISINFLUENCE DE LA POSITION DEBOUT SUR L’ÉQUILIBRE
SAGITTAL DU RACHIS
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RACHISMOBILITE PELVIENNE LORS DE L’ANTE/RETROVERSION
DU BASSIN EN CHARGE
ANTEVERSION : PS = 70°
RETROVERSION : PS = 20°
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•Point fort IRM ouverte : possibilité flexion jusqu’à 120° (en décharge)
APPLICATION EXPLORATOIRE GENOUHyper mobilité méniscale
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GENOUMOBILITE MENISCALE LORS DE LA FLEXION DU GENOU MENISQUE EXT
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GENOUMOBILITE MENISCALE LORS DE LA FLEXION DU GENOU MENISQUE INT
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CARTIGEN MOBILITY platform
• Equipment:• Isokinetic• MRI• Grail (virtual reality)• XSENS-Awinda
• 17 inertial sensors allowing to estimatethe orientation, speed and accelerationof the different members of the body
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àAnalyzing the movement would provide an objective measure of motor behavior compared to subjective questionnaires
à Facilitating clinical assessment and may be an important therapeutic goal for follow-up
Spine OA study: low back pain
Objectives
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7 MovementsSimple movements : flexion / extension More complexmovements : right-left rotation / picking up an object / standing-sitting / walking
Spine OA study: low back pain
Methodology
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Exploratory study
Recruitment: 15 patients with LBP and 15 healthy subjects
Inclusion criteria: Common LBP evolving for at least 3 months between 18
and 65 years old with a BMI between 18 and 30
Exclusion criteria: history of lumbar fracture or pelvic surgery, severe
scoliosis, neurological or inflammatory pathology.
Matched with sex, age (+/- 5 years) and BMI ( +/-1)
Spine OA study: low back pain
Methodology
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1. ROM lumbar flexion
Spine OA study: low back pain
Results
ROM < 10° LBP
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2. Maximal speed
Spine OA study: low back pain
Results
Vmax Thorax-Flexion
Vmax Bassin-Flexion
Vmax Thorax-Extension
Vmax Bassin-Extension
Speed : Healthy > 1.5 x LBP
FLEXION Extension
Bassin
Thorax
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3. Fluidity analysis
Spine OA study: low back pain
Results
57
LBP
Healthy Flexion
Pelvis Pelvis
T8 T8
Speed profiles Amount of saccade (acceleration/deceleration)
3-4 X more fluid after Rehabilitation57
Extension
Pelvis
Flexion
Post Pré
T8
Post Pré
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à Confirm some parameters described in the literature
à Identify new indicators such as fluidity
à Correlate the kinematic results with the results of the questionnaires
Spine OA study: low back pain
Conclusions
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GLOBAL KINETIC Sport medicine Volley ball
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Acknowledgements
60
• CARTIGEN Engineer : Gilles DUSFOUR• CARTIGEN steering committee: I Laffont, D Mottet, S Perrey, M Julia,
C Jorgensen, AL Bonnefont, S Kremer
• Team “Rachis”: A Glintzbeck, I Tavares, A Dupeyron• Sport medicine : M Julia• Other ongoing projects• Knee OA : A. Rakotozafiarison• Ankle OA: M Hechiche, P Aboukrat
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Bionic in OA : Questions raised ?
§ Exoskeleton§ Help rehabilitation or restore mobility with less pain
§ Bio prothesis (TKR, THR)§ Promote better bone integration§ Avoid infections§ Longer-life
§ The bionic leg…
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Bio prothesis§ Bio prothesis (TKR, THR)
§ Promote better bone integration§ Avoid infections§ Longer-life
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Bio prothesis§ Titanium-based scaffolds are widely used implant materials for bone
defect treatment§ Insufficient bone integration
§ Unmatched biomechanics§ Poor bioactivities of conventional titanium based implants
§ Critical to develop novel titanium-based scaffolds
Ma et al. Bioactive Materials 2021
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Bio prothesis
Ma et al. Bioactive Materials 2021
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Bio prothesis
Ma et al. Bioactive Materials 2021
§ Ti–6Al–4V alloy (TC4)/gelatin methacrylate (GelMA) hybrid scaffold with dual bionic features (GMPT) for bone defect repair
§ Goal: mimics microstructure, mechanical properties and environment
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Bio prothesis
Ma et al. Bioactive Materials 2021
§ GMPT demonstrates better osteogenic and angiogenic capabilities than PT
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Bio prothesis
Ma et al. Bioactive Materials 2021
§ GMPT in vitro and rabbit radius bone defect experimental results§ RNA-Seq analysis via the Pi3K/Akt/mTOR pathway
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Bio prothesis – Avoid infections
Zhu et al. Mat Advances 2021
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Bio prothesis - Promote better bone integration
Zhu et al. Mat Advances 2021
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Bionic in OA : Questions raised ?
§ Exoskeleton§ Help rehabilitation or restore mobility with less pain
§ Bio prothesis (TKR, THR)§ Promote better bone integration§ Avoid infections§ Longer-life
§ The bionic leg…
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The bionic leg
No electronics or sensors or magnets, just a simply-shaped
spring that stores energy and uses it
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The bionic leghttps://www.youtube.com/watch?v=kaFiwC1xh2Y
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Challenges in OA
§ Epidemiology in expansion: young people +++
§ Prevention for post-traumatic OA +++
§ Find new biomarkers (mobility) less subjective than pain
§ Personalized medicine
§ Non-pharmacological approaches: bionic to strongly reinforce
rehabilitation and exercise/physical activity
§ Joint surgery more accurate, more “biologic”, less complications
§ Find futures therapies with a structural benefit
QUESTIONS ????