Professional Documents
Culture Documents
Understanding Osteoarthritis
and its Management
(For Physiotherapists)
Cmone Mishra
Physiotherapist MPT (Musculoskeletal, Gold Medalist)
Sai Institute of Paramedical and Allied Sciences
Dehradun, Uttarakhand, India
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application of any of the contents of this work. If not specifically stated, all figures and
tables are courtesy of the author. Where appropriate, the readers should consult with
a specialist or contact the manufacturer of the drug or device.
Understanding Osteoarthritis and its Management
First Edition: 2012
ISBN 978-93-5025-558-2
Printed at
Dedicated to
My Mother
Who taught me that the joy of life lies more in giving than taking
My Father
For the support and encouragement that he gave me
My Best Friend
For being there when I needed him the most and for
being my inspiration to write
My Entire Family
For making my life worthwhile and joyful
and
All My Teachers
Who made me what I am today
Preface
It gives me immense pleasure to present my first edition of the book
entitled Understanding Osteoarthritis and its Management to all the
physiotherapy students. This book is also useful for professionals of
physiotherapy, teachers, doctors, rehabilitation professionals, other
paramedics and general public.
Physiotherapy, if properly understood and skillfully executed by
trained persons, gives excellent results in treating orthopedic disorders and in postoperative rehabilitation. For optimum results,
physiotherapy should be pursued systematically till its final logical
conclusion and should not be abandoned in the middle.
Osteoarthritis is a common condition presenting to most of the
physiotherapists in their clinical practice, but the modes of treatment applied are limited. The book gives you a vast idea about the
condition, its pathology, causes and the various prospects of treatment, which can be approached.
If fifty percent of improvement occurs during the treatment of
an orthopedic condition is through medication or surgery, then the
remaining fifty percent is definitely by physiotherapy.
The book has been written keeping in mind the undergraduate
students of physiotherapy and hence does not focus too much upon
the investigations or the differential diagnosis. The main aim behind
writing the book is to bring the entire concept in a simplified manner and to make the readers understand the protocol-wise treatment
and rehabilitation, which can be followed. The language used is very
viii
simple and the contents very concise that will enable maximum
information be produced by the students in the examination without having to put in too much effort.
The book covers the recent advances in the condition and the
range of exercises which can be followed. All the suggestions and
comments will be accepted with a warm welcome. I hope that the
readers enjoy the effort.
Cmone Mishra
Acknowledgments
First of all, I thank Lord Krishna, the savior, without whose divine
power I would not have been able to get the strength to complete
the book.
I would like to thank my mother, my father and all the members
of my family for giving me the constant morale throughout my life.
I would like to express my thanks and deep gratitude to my
teachers Dr Senthil Selvaseelan, Dr Vasanthan Kumar and lecturers, Oxford College of Physiotherapy, Bengaluru, Karnataka, India,
for their expert guidance, encouragement and support throughout
my course and from whom I have learnt various things in professional
sector. Their unconditional help and words of encouragement
worked as a driving force behind my study. Their constructive
criticism always stimulated me to strive for excellence and perfect
ion in my work.
I thank my friends, well-wishers, and colleagues Mr Brijesh,
Ms Monika, Mr Abhishek, Ms Payal, Ms Jhooma, Mr Rajeev who
had been instrumental in various ways that enabled me to complete
this book.
I thank all the patients who volunteered for this book.
Lastly, I would like to thank all the individuals who directly or
indirectly helped me in this effort of mine.
Contents
1. Osteoarthritis: An Overview..........................................1
Quick Facts2
Osteoarthritis2
Joints in Brief 5
xii
Environmental Barriers 24
Investigations25
4. Treatment in Osteoarthritis.........................................27
Treatment28
Lifestyle Modification28
Physiotherapy28
Joint Protection Techniques 51
Medication54
Surgery56
Alternative Treatments57
Other Supplements57
Contents
xiii
Chapter
Quick Facts
Osteoarthritis
Joints in Brief
Introduction
Osteoarthritis:
An Overview
QUICK FACTS
Osteoarthritis (OA)
Whether you have been diagnosed with osteoarthritis or have painful joints that you think may be arthritic, this summary will help you
to understand the causes and how the treatment and physiotherapy
can help you.
What is Osteoarthritis?
Osteoarthritis is a common condition that may cause joint stiffness,
swelling and painusually in the knees, hips, feet, hands and
spine (Fig. 1.1). Some people arthritis can be so severe that joint
replacements are the best solution, while others experience few
symptoms even though X-rays show that they have quite advanced
osteoarthritis.
Osteoarthritis: An Overview
Physical examination
Symptomatology
Radiology
Blood test
CT scan and MRI.
Osteoarthritis: An Overview
Joints in Brief
Joints are designed to provide flexibility, support, stability, and protection. These functions are essential for normal and painless movements,
and are primarily supplied by specific parts of the joint.
The Synovium and Cartilage
Synovium: Synovium is a membrane that surrounds the entire joint.
It is filled with synovial fluid, a lubricating liquid that supplies nutrient and oxygen to cartilage.
Cartilage: Cartilage is a slippery tissue that coats the ends of the bones.
Cartilage is one of the few tissues in the body that does not have its
own blood supply. It has a number of essential components: ChondrocytesThese are the basic cartilage cells, and are
critical for balance and function
WaterCartilage contains a high percentage of water, although it decreases with age. About 85% of cartilage is water
in young people, an about 70% is water in older individuals
ProteoglycansThese are large molecules, which help to make
up the cartilage. Their important value is their capacity to bind
with water, which ensures a high-fluid content in cartilage
CollagenThis is the critical protein in cartilage. It forms a
mesh to give support and flexibility to the joint. Collagen is the
main protein found in connective tissues of the body, including the muscles, ligaments and tendons.
The combination of the collagen meshwork and the high water content, tightly bound by proteoglycans, creates a resilient and slippery
pad in the joint, which resists the compression between bones during muscle movement. The synovial fluid lubricates and provides
oxygen and nutrients to the bloodless cartilage.
INTRODUCTION
Osteoarthritis: An Overview
The knee is the largest synovial joint in the body and is commonly affected by arthritis, as is the hip and the ankle, as well as the foot.
Arthritis is more common in weight bearing joints and so is more
frequently seen in the lower limb than the upper limb (Fig. 1.2).
A common misconception is that OA is solely due to wear and tear,
since OA typically is not present in younger people. However, while
age is correlated with OA incidence, this correlation merely illustrates
that OA is a process that takes time to develop. There is usually an
underlying cause for OA, in which case it is described as secondary OA.
If no underlying cause can be identified it is described as primary OA.
Degenerative arthritis is often used as a synonym for OA, but the
latter involves both degenerative and regenerative changes.
Arthritis of the knee is more common in people who expose
their joints to repetitive microtrauma, of which weight bearing is
a simple example. This will slowly overload the joint, especially
if the person is overweight. It is thought that people involved in
many years of sports, that include running, twisting and jumping
can also be predisposing themselves to an increased risk of arthritis
in future years.
Chapter
Osteoarthritis:
Types and Pathogenesis
Types
Primary
Secondary
Pathology
Pathogenesis
10
TYPES
Primary
In primary OA, there is no obvious cause. This type of OA is a
chronic degenerative disorder related to but not caused by aging,
as there are people well into their nineties who have no clinical or
functional signs of the disease. As a person ages, the water content
of the cartilage decreases due to a reduced proteoglycan content,
thus causing the cartilage to be less resilient. Without the protective
effects of the proteoglycans, the collagen fibers of the cartilage can
become susceptible to degradation and thus exacerbate the degeneration. Inflammation of the surrounding joint capsule can also
occur, though often mild (compared to that which occurs in rheumatoid arthritis). This can happen as breakdown products from
the cartilage are released into the synovial space, and the cells lining
the joint attempt to remove them. New bone outgrowths, called
spurs or osteophytes, can form on the margins of the joints,
possibly in an attempt to improve the congruence of the articular
cartilage surfaces (Fig. 2.1). These bone changes, together with the
inflammation, can be both painful and debilitating.
Secondary
This type of OA is caused by a number of predisposing factors but
the resulting pathology is the same as for primary OA:
Congenital disorders, such as:
11
12
PATHOLOGY
The first osteoarthritic change in articular cartilage, which has been
confirmed in humans, is an increase in water content. This increase
suggests that the proteoglycans have been allowed to swell with water
far beyond normal, although the mechanism by which this occurs
is unknown. Additionally, there are changes in the composition of
newly synthesized proteoglycan. In later stages of disease progression,
proteoglycans are lost, which diminishes the water content of cartilage. As proteoglycans are lost, articular cartilage loses its compressive
stiffness and elasticity, which in turn, results in the transmission of
compressive forces to underlying bone. Changes in cartilage proteoglycans will also negatively affect the ability of the cartilage to form a
squeeze film over its surface during joint loading. Collagen synthesis is
increased initially, although there is a shift from type 2 collagen fibers
to a larger proportion of type 1 collagen, the kind found in skin and
fibrous tissue. As the articular cartilage is destroyed, the joint space
narrows.
One of the first noticeable changes in cartilage is mild fraying or flaking of superficial collagen fibers. Deeper fraying or
13
PATHOGENESIS
Unlike the synovium in RA, the major pathological changes of OA
are found in the articular cartilage, particularly the concentration of
proteoglycan, which diminishes according to the severity of the disease. Furthermore, there are metabolic changes in the rate of enzyme
production that facilitate the destruction of cartilage. Even though
proteoglycan concentration decreases with OA, it is also true that
proteoglycan and collagen synthesis increases until the later stages of
the disease. This seeming paradox has given rise to several hypotheses
concerning the pathogenesis of OA, which have yet to be proven.
Given that proteoglycan synthesis increases with OA, it is possible
that the quality of this newly synthesized product may not be equal
to meet the biomechanical load, normally placed on an adult joint.
Chapter
Osteoarthritis:
Clinical Assessment
16
Not all people with arthritis have symptoms. Arthritis, as stated previously, is an age related phenomenon, and therefore the incidence
increases with age, but the mere presence of arthritic type changes
on X-ray does not equate with symptoms.
Not all joints are equally affected by OA. In the upper extremity,
the DIPs, PIPs, and CMC (Fig. 3.1) of the thumb are commonly
involved. The cervical and lumbar spine, hips, knees and first MTP
are also sites of for OA. Unlike RA, OA does not have a bilateral,
symmetrical presentation. A single joint or any combination of
joints on one individual, may be affected.
OA is not a systemic disease, and is therefore not associated
with systemic complaints such as morning stiffness, fever, and loss
of appetite. Individual with OA, may experience, some stiffness
in articular joints upon awakening that is similar to the stiffness
felt when mobilizing the same joints after inactivity during the
day; but this stiffness does not last as long as in individuals with
17
18
with fluid. Humid and cold weather increases the pain in many
patients.
As OA progresses, the affected joints appear larger, are stiff and
painful, and usually feel worse, the more they are used throughout the day, thus distinguishing it from rheumatoid arthritis. In
smaller joints, such as at the fingers, hard bony enlargements,
called Heberdens nodes (on the distal interphalangeal joints) and/
or Bouchards nodes (on the proximal interphalangeal joints), may
form, and though they are not necessarily painful, they do limit
the movement of the fingers significantly. OA at the toes leads to
the formation of bunions, rendering them red or swollen. Some
people notice these physical changes before they experience any
pain.
OA is the most common cause of joint effusion, sometimes
called water on the knee in lay terms, an accumulation of excess
fluid in or around the knee joint. OA of the hip commonly results
in decreased range of motion (ROM) with a tendency for the hip
19
Capsular Tightness
One of the most common causes of gross restriction of knee motion is capsular tightness. Fibrosis and subsequent loss of extensibility of the joint capsule, frequently accompanies the progression
of chronic joint diseases such as degenerative joint disease (DJD).
Capsular tightness at the knee results in a characteristic pattern of
restriction in which knee extension is limited by 20 to 30 degree,
and flexion is possible to only 80 to 100 degree. The functional
disability resulting from capsular restriction varies with the patients activity level, but ambulation is inevitably altered because
nearly full knee extension is necessary for normal gait. According to
Laubenthal and coworkers, the mean total flexion-extension necessary for the stance phase of gait is 21 degree for the swing phase
of gait 67 degree; for stair climbing 83 degree; and for sitting and
rising, 83 degree. Because capsular restriction at the knee typically
allows only 50 to 80 degree. Of flexion-extension, some functional
alteration is likely.
Of great significance during walking is the effect of reduced
knee extension on the stresses imposed on the articular surfaces of the joint. Normally, during the stance phase of gait, peak
weight-bearing forces are borne with the joint just short of full
knee extension, a position in which the tibiofemoral contact area
is greatest, and a position in which the joint capsule has not been
drawn completely tight. Since, stress equals force divided by unit
area, the compressive stress of weight-bearing is minimized by a
20
CLINICAL ASSESSMENT
The examination should begin by taking patients history that will
orient the therapist to the nature and extent of the current problem
and relate that problem to the past medical history. Following the
history, a review of the cardiopulmonary, integumentary, and neuromuscular systems should be undertaken before performing more
definitive examination of the musculoskeletal system.
A systemic approach is required in order to ensure that all the
relevant aspects are considered. Careful recording of the findings of
the assessment, treatment given and the patients response is necessary.
A great deal of information can be gained from the patients
notes and the PT assessment should concentrate on those aspects
of the patients condition which concern the PT, these include pain,
loss of function and joint stiffness mainly.
21
Pain Assessment
It is an indication of joint irritability and not the amount of joint
deterioration.
Site and Distribution of Pain
Quality: Burning, aching, throbbing, searing, referred pain.
Duration: Permanent, persistent, or intermittent.
Triggering factors: Weight bearing, jarring, sustained stress, specific
movement, rest, posture, weather, emotional state.
Relieving factors: Rest, particular movement, temporal/postural adjustments, PT procedures (traction, application of external heat/cold,
massage, manipulative procedures, resisted movements, analgesia).
Also evaluate the intra-articular factors causing pain. This may be
the result of:
22
Strength
A patient may be strong in the pain free portion of range, but weak
secondary to reflex inhibition in the very portion of the range that is
essential to a functional activity. Joint effusion also inhibits muscle contraction. Individual with deformed joints are inappropriate candidates
for traditional tests of strength. A functional test of strength is therefore
more indicative of rehabilitation needs and will identify the anticipated
goals of strengthening programs prior to initiating treatment.
Joint Stability
The ligamentous laxity of any affected joint should be fully investigated. Ligamentous instability of upper and lower extremity joints may
be a significant deterrent to ADL and ambulation. Improper loading
of an unstable joint may also further contribute to its deformation.
Assessment of Tenderness
The degree and the area of tenderness, effusion and crepitus are
carefully examined by palpation, volumetric measures or measuring
tape and relaxed passive ROM respectively.
23
Assessment of Deformity
24
A complete analysis, particularly noting the gait deviations. Substantial difference in knee ROM and gait velocity between patients
with OA and their peers without arthritis have been demonstrated.
Example
Osteoarthritis of the great toe results in lateral and posterior weight
shift, late heel rise and decreased single limb balance.
Pronation of the foot results in shuffled progression, decreased
step length, initial contact with the medial border of the foot and
decreased single limb support.
Sensory Integrity
Any indication of peripheral neuropathy or nerve involvement
should be investigated using standard examination procedures. Sensory changes that are concomitant with other conditions such as
diabetes or normal processes such as aging should be considered
when appropriate.
Environmental Barriers
The therapist should be aware of physical barriers in the home and
work environments that might require specific examination and
recommendations for change. A discussion about the home and
work environments may reveal conditions that impede regaining
complete independence and make the individual aware of the possibilities for altering these environments. The cost of such changes
may be a limiting factor for implementing these recommendations.
Example
The clinical assessment of a patient with knee arthritis, involves taking a detailed history which will include:
25
Loction of pain
Severity of pain
When the pain comes on activity related, rest pain or night
pain
Swelling of the knee
Walking distance
Activity restriction due to symptoms
The type of analgesia/anti-inflammatories used and their effect
on the symptoms
The effect of any previous treatment that has been givenfor
example, physiotherapy or injections
Any history either in the individual or the individuals family
of inflammatory arthritis or gout.
The next step is to examine the knee joint as well as assessing the hip
joint and the lumbosacral spine both of which can cause radiating
pain to the knee.
During the examination, the patients gait (walking pattern)
is assessed and any deformities of the knee in all the planes are
documented.
Investigations
Laboratory investigations are usually within normal limits. Radiological examination is the most important diagnosis. The following
are the radiological features seen in OA of the knee:
Loss of joint space (due to destruction of the articular cartilage)
Sclerosis (due to increased cellularity and bone deposition)
Subchondral cysts (due to synovial fluid intrusion into the
bone)
Osteophytes (due to revascularization of remaining cartilage
and capsular traction)
Bony collapse (due to compression of weakened bones)
Loose bodies (due to fragmentation of osteochondral surface)
26
Chapter
Treatment in
Osteoarthritis
Treatment
Lifestyle Modification
Physiotherapy
Joint Protection Techniques
Medication
Surgery
Alternative Treatments
Other Supplements
28
TREATMENT
Treatment of OA consists of exercise, manual therapy, lifestyle modification, medication and other interventions to alleviate pain.
Lifestyle Modification
No matter the severity or location of OA, conservative measures
such as weight control, appropriate rest, exercise, and the use of
mechanical support devices can be beneficial. In OA of the knees,
knee braces can be helpful. A cane, or a walker can reduce pressure
on involved leg joints which can be helpful for walking and support
(Fig. 4.1). Regular exercise such as walking or swimming, or other
low impact activities are encouraged. Applying local heat before,
and/or cold packs after exercise, can help relieve pain, as can relaxation techniques. Weight loss can relieve joint stress and may delay
progression, although research supporting this is equivocal.
Physiotherapy
Although there is no successful cure for osteoarthritis, the physical
therapy treatment is often directed towards relieving the symptoms
Treatment in Osteoarthritis
29
30
Treatment in Osteoarthritis
31
For pain impulse to pass, there should be unopposed passage of information but if impulses are also received from mechanical and
thermoreceptors (application of a hot or a cold pack over the joint
or the use of a modality), then this result in presynaptic inhibition
of C-fibers nociceptive information.
So, for the gate to be open to nociceptive traffic, the i/p has to
be of a smalldiameter nociceptive nature, i.e. through C- fibers.
If largediameter afferent information, i.e. through A- fibers is
superimposed then the gate is closed for pain.
Both the C-fibers and A fibers have a maximum frequency
at which they can conduct, i.e. C-15 pulses/sec. and for A-40
pulses/sec.
If a higher frequency of stimulation is applied, a physiological
block to conduction might occur. This effect can be produced via
TENS or interferential.
Pulsed electromagnetic energy or inductothermy
Pulsed electromagnetic energy or inductothermy is effective in some
patients especially in reducing a dull ache. The localized increase in
arterial blood flow may improve the nutrition to the joint cartilage.
Some patients report an increase in the aching and this is due to
venous congestion in the cysts in the subchondral bone, e.g. in the
head of the femur.
A group of patient with chronic knee arthritis shows improvement when receiving continuous short wave diathermy
with 27.12 MHz. frequency given for 20 minutes for 14 settings along with isometric quadriceps exercise (10 repetitions)
on each setting. Short wave diathermy treatment was given with
participants in sitting position using disk electrode, short wave
diathermy disks were placed at both the sides of the knee and
then the treatment was administered for 20 minutes. Participants
were asked to report any kind of discomfort or burning sensations
within the knee during treatment. Isometric quadriceps exercises
32
Treatment in Osteoarthritis
33
joint surfaces (Fig. 4.3). In case of a fat pad on the medial side of the
knee, ice therapy is not indicated.
Ultrasound
This is useful for treating chronic swelling as it softens fluid and loosens scar tissue so that subsequent exercises can be effective in reducing
the swelling and gain pain relief, especially deep aching (Fig. 4.4).
Free Active Exercises and Mobilizations
By restoring mobility and improving circulation can contribute to
pain relief.
Group Therapy
Can provide encouragement to lose weight, carry out home exercises, monitor muscle bulk and by providing moral support to enable
the patient to cope with the pain.
Exercises
Moderate exercise leads to improved functioning and decreased pain
in people with osteoarthritis. Although, exercise appears to be an
important intervention tool, the clinician and the patient should
34
Treatment in Osteoarthritis
35
36
B
Fig. 4.5: Strengthening exercises for abductors and quadriceps
Treatment in Osteoarthritis
37
38
Treatment in Osteoarthritis
39
ing straight ahead, then walk with toes pointing outwards and
then with the toes pointing inwards. After a short rest, the
procedure was repeated once again.
Heel walking: Walking for 20 meters on heels with toes pointing straight ahead, walking on heels with toes pointing out and
then with toes pointing in. After a short rest, the procedure was
completed once more (Fig. 4.7).
Cross body leg swings: Leaning slightly forward with hands on
a wall for support and weight on affected leg, other leg was
swung in front of the body, pointing toes upwards as foot
reaches its farthest point of movement. Then the same leg was
swung backwards as far as comfortably possible, again toes
up as the foot reaches its final point of movement. This was
40
repeated for 15 times and after a brief rest, 15 similar repetitions with the unaffected leg as weightbearing limb was
performed.
Balance exercises are important
to improve your ability to regulate shifts in your bodys center of gravity while maintaining
control. Usually, balance exercises should be performed for 5
minutes per day initially and progressed to 10 to 15 minutes
or longer provided they do not cause or increase symptoms.
Generally, you should select a range of exercises that challenge
your balancewithout causing an increase in symptoms. Always,set-upyour environment to ensure safety and prevent falls,
incase you lose your balance (e.g. practice at a bench or with a
spotter).
Basic Balance Exercises
Single leg balance
Standing on one leg, maintain your balance (Fig. 4.8). Try to
hold for 1 minute. Once this exercise is too easy, progress to eyes
closed.Afurther progression can involve performing, the exercisestanding on one or more pillows with eyes open and then eyes
closed.
Intermediate Balance Exercises
Ball around back
Standing on one leg, take a ball around your back whilst maintaining your balance (Figs 4.9A and B). Once this exercise is too easy,
progress to eyes closed.
Ball under leg
Standing on one leg, take a ball under your leg whilst maintaining
your balance (Fig. 4.10). Once this exercise is too easy, progress to
eyes closed.
Treatment in Osteoarthritis
41
42
Treatment in Osteoarthritis
43
44
Treatment in Osteoarthritis
45
Mobility of Joints
Realistically, when the joint surfaces are destroyed, mobility will be
restored only by joint surgery. Success with physiotherapy in restoring mobility depends on the limiting factors which may be:
Pain
Chronic thickened swelling
Muscle spasm
Fibrous contracture
Pain relief may be obtained by the methods already mentioned. This
includes free active exercises, which may release endogenous opiates
and thus relieve pain.
Chronic thickened swellings can be softened and at least partly
cleared by ultrasound. Whole hand and finger kneading together
with effleurage can also help (Fig. 4.15).
46
B
Figs 4.15A and B: Effleurage and finger kneading
Orthotic Supports
Treatment in Osteoarthritis
47
other. Hence, braces for arthritis pain can increase a patients mobility, and are a fantastic non-surgical treatment option.
Custom braces for arthritis pain are often used for the care of
rear foot arthritis and ankle arthritis to either hold a painful area in
place or restrict painful movement. In some cases, custom braces for
arthritis pain may also be used in realigning a joint to prevent stress
or overuse of a certain area of the joint.
Braces for arthritis pain can also be worn to support the spine or
the back and ease pain in this area. Spinal braces limits the backs
motion and relieve the stress on the vertebrae, thereby, effectively
controlling back pain.
For patients with knee arthritis, wearing braces for arthritis pain
will help alter their gait to relieve the painful areas from weight or
impact. Bow-legged patients wearing special braces for arthritis pain
will notice that most of their weight will be shifted on the outside of
their knee instead of the inside of their knee, which is what happens
in normal way of walking and which also causes the most pain.
There are also some braces for arthritis pain that insulate the affected joint, keeping it warm to reduce pain. An example of such a
brace is a neoprene sleeve. Where appropriate, the patient may wear an
elasticated support on, for example, the knee so that during walking
the oedematous fluid is compressed and should pass into the lymphatic
channels (Fig. 4.16). Interferential therapy is also effective.
Muscle spasm is best relieved by hold-relax, repeated contractions and possibly by pulsed electromagnetic energy or radiant heat.
If there is spasm in the lower limb muscle, it is worth considering
encouraging the patient to use a walking aid to reduce the weight
taken during the stance phase of walking, which in turn reduces the
pain and diminishes the development of muscle spasm. Ice may be
appropriate when there is acute pain and spasm.
Sling suspensions is helpful for regaining hip, knee and shoulder
movements in the presence of pain or spasm and also were there is
fibrous tightness limiting movements.
48
Fibrous contracture tends to occur in the muscles which produce deformity. This may be successfully treated by ultrasound, friction or finger kneading and passive stretching applied as a slow sustained stretch.
Mobilizations as either accessory or physiological movements are
invaluable at the earlier stages of the condition. Stretching the capsule and applying rhythmical movement facilitates synovial sweep
across the cartilage across the cartilage and may help to diminish
degeneration by improving nutrition. Compression and distraction
can be useful for the same reason. Mobilization may be applied in
the hydrotherapy pool, especially for the hip and the lumbar spine.
Grade 1 and 2 relieves pain. Grade 3 reduces resistance-fibrous
thickening and tightening.
Maintenance of Joint Range and Muscle Power
Every patient with OA should practice a program of exercises designed to move the joints and muscles through full range at least once
each day. Attendance at a group therapy session from time-to-time
Treatment in Osteoarthritis
49
50
Treatment in Osteoarthritis
51
52
Avoid any activity that causes pain and find a better way of accomplishing the task. Make compromises which will protect your
joints. If standing causes pain, attempt to do the activity while sitting. Avoid excessive pressure on the small joints of the hand. For
example, if opening a water bottle is painful, dont force your hand.
Get a bottle opener that works or have someone else open it for
you. Also, avoid heavy lifting. Ultimately, your common sense will
dictate what is an activity which you should avoid.
Check Out Assistive Devices Which are Available
There are myriad assistive devices which will help you accomplish tasks
that are otherwise difficult and painful. Jar openers, reachers, dressing sticks, long-handled cleaning tools, raised toilet seats, and shower
benches are just a few examples of assistive devices which are easy to
find. By using the assistive devices, you put less stress on your joints.
Use Largest and Strongest Joints and Muscles
You should use both arms when lifting or carrying an object. By using the largest and strongest joints, you will not stress single joints
or weaker areas of your body.
Use Good Posture and Body Mechanics
There are proper ways to stand, sit, bend, reach, and lift that will
allow you to put less stress on your joints. By moving properly, you
can preserve your joints.
Avoid Staying in One Position for Too Long
Staying in the same position for a long time can cause joints to
stiffen and become painful. You should change positions as often as
possible so you can protect your joints.
Treatment in Osteoarthritis
53
Its imperative to balance activity and rest. When your body signals
that it has had enough, schedule a period of rest. By balancing activity and rest, you will be able to do more, though it might take
longer, and you will be protecting your joints as well.
Avoid Prolonged Periods of Immobility
Prolonged inactivity and immobility will cause stiffness and increased pain. Gentle range-of-motion exercises should be performed
daily. Each joint should be put through its full range of motion by
bending, stretching and extending the joint.
Reduce Excess Body Weight
Extra weight adds stress to weight-bearing joints. By losing weight
and then staying at your ideal body weight, you will be protecting
your joints.
Simplify, Plan and Organize
Try to use your muscles and joints more efficiently. By planning and
organizing your work or any activity, the simplicity will translate
into energy conservation and less stress on your joints.
Weight-bearing Joints Carry the Burden
Being overweight, even just moderately, impacts weight-bearing
joints and can increase the pain of arthritis.
Research has shown that during walking the hips, knees and ankles bear three to five times a persons total body weight. For every
pound a person is overweight, three to five pounds of extra weight is
added to each knee during walking. In contrast, a ten pound weight
loss causes 30 to 50 pounds of extra stress to be relieved from the
joints.
54
For a person with arthritis, extra pounds burden the joints and
lead to increased inflammation and pain.
Medication
Drug therapy in OA has no effect on disease progression and is ancillary to the more general measures of pain control, which include patient related instruction, joint protection and exercise. The goal of drug
therapy in patients with OA is to relieve pain and decrease joint inflammation when it is present. Oral analgesics, NSAIDs and corticosteroid
injections are the primary medications used in OA management.
Paracetamol
Paracetamol (Tylenol/acetaminophen), an oral analgesic is commonly used to treat the pain from OA and is the drug of first choice.
It almost has no toxicity in recommended doses and do not causes
GI bleeding. However, there is no anti-inflammatory effect and
acetaminophen cannot be substituted for NSAIDs in this regard.
Acetaminophen may be taken episodically as needed for pain or
regularly when symptoms are more severe and long lasting. Liver
and kidney toxicity can occur with its use. Hepatoxicity most often
occurs after a drug overdose, but also may appear with therapeutic
use, especially in individuals who drink excessive amounts of alcohol. Kidney toxicity is less common. NSAIDs appear to be more
potent, but pose greater risk of side-effects.
Non-steroidal anti-inflammatory drugs
In more severe cases, non-steroidal anti-inflammatory drugs
(NSAID) may reduce both the pain and inflammation; they all act
by inhibiting the formation of prostaglandins, which play a central
role in inflammation and pain. However, it should be noted that
this class of drugs is not without risk for adverse events including increased gastrointestinal bleeding. Most prominent drugs in the class
include diclofenac, ibuprofen, naproxen and ketoprofen. High oral
Treatment in Osteoarthritis
55
drug doses are often required. However, diclofenac has been found
to cause damage to the articular cartilage. Even more importantly all
systemic NSAIDs are rather taxing on the gastrointestinal tract, and
may cause stomach upset, cramping, diarrhea and peptic ulcer. Such
systemic adverse side effects are normally not observed when using
NSAIDs topically, that is, on the skin around the target area. The
typically weak and/or short-lived therapeutic effect of such topical
treatments may be improved by using the drug in more modern
formulations, including or ketoprofen associated with the Transfersome carriers or diclofenac in DMSO solution.
Corticosteroids
Oral steroids are not recommended in the treatment of OA due to
their modest benefit and high rate of adverse effects. However intraarticular corticosteroid temporarily improve symptoms. Intra-articular corticosteroid injections are often used for acute episodes with an
expected modest response of 1 to 4 weeks duration. The knee is the
most common site; however, soft tissue injections for subacromial,
anserine and trochanteric bursitis also may be effective.
Narcotics
For moderate to severe pain a narcotic such as morphine may be
necessary.
Topical
There are several NSAIDs available for topical use (e.g. diclofenac,
ibuprofen, and ketoprofen) with little, if any, systemic side-effects
and at least some therapeutic effect. The more modern NSAID formulations for direct use, containing the drugs in an organic solution
or the Transfersome carrier based gel, reportedly, are as effective as
oral NSAIDs.
Creams and lotions, containing capsaicin, are effective in treating pain associated with OA if they are applied with sufficient fre-
56
Surgery
Surgery represents one of the greatest advances in the management
of arthritis in the last 35 years. Surgery is not appropriate, however,
for every individual with OA, and the careful selection of the patient
and the timing of the procedure is critical. The primary indication
of surgerypain, loss of function and progression of deformity, although the last two are not always correlated.
In general, there are three procedures that may be performed on
soft tissues: Synovectomy, soft tissue release, and tendon transfer.
Similarly, there are three general bone and joint procedures: Osteotomy, prosthetic arthroplasty, and arthrodesis. The choice of
specific postoperative physical therapy procedures will depend on
the articular surgical intervention, the extent of joint involvement
prior to surgery, individual characteristics of the patient and manifestations of the disease.
If the above management is ineffective, joint replacement surgery may be required. Individuals, with very painful OA joints may
require surgery such as fragment removal, repositioning bones, or
fusing bone to increase stability and reduce pain. Arthroscopic surgical intervention for osteoarthritis of the knee has been found to be
no better than placebo at relieving symptoms. Once the individual
has achieved an adequate level of function and release from surgical
Treatment in Osteoarthritis
57
Alternative Treatments
The majority of patients with arthritis have tried alternative treatments for their pain. Various studies have reported some benefit for
many of these approaches, including acupuncture and some herbal
supplements. However, the response rates tend to be low and there
is concern about bias in many studies.
Acupuncture
A meta-analysis of randomized controlled trials of acupuncture for
knee osteoarthritis concluded that it provided no clinical benefit.
Glucosamine/Chondroitin
There is controversy about glucosamines effectiveness for OA of
the knee. A 2005 review concluded that glucosamine may improve
symptoms of OA and delay its progression.
Chondroitin sulfate has also become a widely used dietary supplement for treatment of osteoarthritis, both in combination with
glucosamine and by itself.
Other Supplements
S-adenosylmethionine (SAMe) has been tested; a review of 10
studies found that it has an effect on pain relief similar to nonsteroidal anti-inflammatory drugs
Frankincense resin from Boswellia serrata treesIndian frankincense is a traditional treatment for arthritis in Ayurvedic medicine
Bromelain, protease enzymes extracted from the plant family
Bromeliaceae (pineapple), blocks some proinflammatory metabolites
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Chapter
Osteoarthritis:
Hip Joint
60
Arthritis of the hip can result from many causes such as slipped
capital epiphysis, childhood sepsis, and rheumatoid arthritis. About
30 percent of the patients with hip arthritis have a mild form of
acetabular dysplasia (a shallow socket), and 30 percent have a retroverted socket. Both of these conditions reduce the contact area of
the femoral head in the acetabulum, which increase the pressure and
makes wear more likely.
Arthritis of the hip is marked by progressive loss of articular
cartilage with joint space narrowing and pain. Stiffness encourages
development of osteophytes formation (bone spurs), which in turn
lead to further stiffness, making it difficult for the patient to put
on socks and shoes. This eventually leads to the general picture of
shortening, adduction deformity, and external rotation of the hip,
often with a fixed flexion contracture. Bone loss usually occurs slowly, but in AVN occasionally it occurs precipitously.
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Signs
Classification
According to radiographic appearance, OA can be classified as:
Concentric, in which there is uniform loss of the articular cartilage
Downward and medial migration of the femoral head
Upward and superolateral migration of the femoral head.
Diagnosis
The classic clinical test of hip arthritis is internal rotation of the hip
in flexion. With hip arthritis, this internal rotation is limited and
painful. Differential diagnosis include Hip dislocation, Hip fracture, Pelvic fracture or disruption, Entrapment of the lateral femoral
cutaneous nerve of the thigh, Tendonitis of piriformis or gluteus
62
maximus, or minimus tendons, Trochanteric bursitis, L3-L4 sciatica, Spine referred pain, Internal iliac artery stenosis, and Strain or
contusion of the quadriceps or hamstring muscle.
Radiographic examination includes an AP view of the pelvis and
AP and lateral views of the hip.
Treatment
Anti-inflammatory and analgesics are of some value.
Neutraceuticals, such as chondroitin sulphate and glucosamine
are popular but unproven.
A cane in the opposite hand helps to unload the hip significantly.
A proper fitted cane should reach the top of the patients greater
trochanter of the hip, while wearing shoes. Stretching and strengthening exercises or joining a yoga class can be of surprising value in
terms of regaining ROM because it may be stiffness rather than pain
that makes surgery necessary.
Exercises
Rules of Exercises in the Management of OA Hip
We use exercises that strengthen and stretch the muscles and capsule
of the arthritic hip, incorporating motion and strength needed by
the patient for daily functioning. These exercises are for the arthritic
hip, not after hip replacement.
Exercises Lying on the Back
Pelvic tiltTighten the thigh and buttock muscles pushing the
knee flat. Hold for a count of 5 and relax (Fig. 5.1).
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Pelvic liftBend both the knees up, push on the feet and lift.
Hold for a count of 5 and relax.
Leg stretchPush one leg along the floor as though you are trying to make it longer than the other. Hold for a count of 5 and
then repeat with the other leg.
Alternate leg raiseKeeping the knee straight, lift the alternate
leg, six inches from the ground.
Exercises Lying on your Side with the Painful Hip Up
Side leg raiseKeep the top leg straight and lift it up as high
(Fig. 5.2)
Knee and hip flexionBend the hip and knee of the top leg forwards, and hold for a count of 5. Then straighten the leg and
stretch backwards as far as it will go, hold for a count of 5, then
relax.
Exercises in Sitting Position
Knee together, feet apart
Feet together, knee apart.
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Exercises in Standing
65
66
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Stretches for hip flexors, adductors, iliotibial band, and gastrocnemius muscles and for hamstring tendon.
Strengthening (belt exercises,
leg lifts, closed kinetic chain,
standing on one foot, walking).
Operative Options
Osteotomies, such as pelvic and intertrochnateric osteotomies, were
popular in the past, with limited role now.
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Choice of Osteotomy
Pauwells varus osteotomyIt is done if OA is due to coxa valga.
Valgus osteotomyThis is more common and is done in adduction
deformity of the hip.
Displacement osteotomy (Mcmurrays)This is indicated in severe
OA of hip with large osteophytes. Osteotomy helps by changing the
line of weight bearing and bringing the normal surface into the line
of weight transmission.
The mainstay of surgical treatment is total hip replacement/
arthroplasty. It is a Latin word arth meaning joint and plasty
69
B
Figs 5.5A and B: The acetabular and stem components
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There is minimal bone resection and normal femoral loading. Maximum proprioceptive feedback.
Restores natural anatomy
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Abduction Pillow
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81
Home Instructions
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3. Gait faults
Occurs, if the patient takes a large step with the involved
leg and a short step with the uninvolved leg. The patient
does so to avoid extension of the involved leg, which causes
a stretching discomfort in the groin.
Occurs, when the patient breaks the knee in late stance
phase. Again, this is done to avoid extension of the hip.
It is associated with flexion of the knee early and excessive heel rise at stance phase. The patient should be
instructed to keep the heel on the ground in late stance
phase.
Occurs when the patient flexes forward at the waist in mid
and late stance. Once again, the patient is attempting to
avoid hip extension. To correct this, the patient is taught to
thrust the pelvis forward and the shoulders backward during
mid and late stance of gait.
Occurs simply as a habit which is difficult to break.
Additional Rehabilitation Points
Going up stairs: Step up first with the uninvolved leg, keeping crutches on the step below until both feet are on the step
above, then bring both crutches up on the step.
Going down the stairs: Place crutches on the step below, then
step down with the involved leg, and then with the uninvolved leg.
Cane use: Advocate the long term use of cane in the contra lateral
hand to minimize daily forces across the hip arthroplasty.
Deep Vein Thrombosis in Total Joint Replacement
Thromboembolic disease is the most common cause of serious complications, after total hip replacement. The risk appears to be higher
in the first 3 weeks of surgery. The most commonly used agents are
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low-dose warfarin, low dose heparin, dextran, and aspirin. Most authors recommend early ambulation, leg elevation, and use of graded
pressure stockings.
Other Complications
Chapter
Osteoarthritis:
Knee Joint
Exercise
Regimen
Training
Functional Training
Gait Training
Endurance
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Classification
Although, joint inflammation is implied by the itis in osteoarthritis, inflammation is typically found only after there has been substantial articular degeneration. The synovium of an osteoarthritic
joint, however, can demonstrate marked changes similar to those
seen in RA, in some joints. In epidemiological studies, OA is often graded on radiographs according to the criteria of Kellgren and
Lawrence, an ordinal scale of 5 levels:
1. Grade 0: Normal radiograph
2. Grade 1: Doubtful narrowing of the joint space and possible
osteophytes
3. Grade 2: Definite osteophytes and absent or questionable narrowing of the joint space
4. Grade 3: Moderate osteophytes and joint space narrowing,
some sclerosis, and possible deformity
5. Grade 4: Large osteophytes, marked narrowing of the joint
space, severe sclerosis and definite deformity.
Most studies have used grade 2 (the presence of definite osteophytes) as the criterion for defining disease, although a few others
have required evidence of joint space narrowing (grade 3), corresponding to clinically identified disease, to designate OA. Although,
radiographic evidence of joint space narrowing and osteophytes may
help confirm the diagnosis and classify the stage of OA, the clinical
criteria for hip and knee OA are described in terms of pain and limi-
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Hip osteoarthritis
Hip internal rotation >= 15 with pain, morning
stiffness <= 60 minutes, and age > 50 years, or
Hip internal rotation <15, and hip flexion <=155
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Biomechanics
Normal alignment of the lower limb results in weight-bearing forces
of the body going through the medial (inner) compartment of the
knee (Fig. 6.2). Therefore medial compartment arthritis is the usual
starting point for knee arthritis as this is the compartment that is
being continually loaded.
Any condition that changes the loading pattern and alters the
mechanical axis of the leg can result in arthritis distribution in other
compartments of the knee. This can
occur in fractures which heal with
malalignment or even with removal
of meniscus tissue which will result
in increased force being put through
the articular cartilage in the affected
compartment.
The increase force applied to the
articular cartilage over time causes
breakdown of the articular cartilage
and the development of arthritis.
Diagnosis
To examine the arthritic joint of the
knee, move the joint under load (e.g.,
to examine the medial compartment,
a varus strain is applied to the knee
and the knee is moved). Crepitus felt
under the hand applying varus strain
and pain will be produced. Similarly,
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a valgus strain and load are applied to the lateral joint. The knee is
examined for any laxity of the ligaments and the presence of any
fixed flexion deformity is noted. The patellar position (central or
subluxed) is important, as is the presence of a rotatory deformity of
the tibia. When the patient stands note the amount of genu varum
(bow-legged) and valgum (knock-knee).
Findings indicating the presence of knee osteoarthritis
Symptoms
Signs
Radiography
Pain with
activity
Joint line
or condylar
tenderness
Stiffness
Effusion
Subchondral
sclerosis
Intra-articular
osseous
debris (loose body).
Crepitation
Decreased ROM
Angular deformity
Joint narrowing
(unicompartmental)
Joint irregularity
Subchondral cysts
Osteophytosis
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tory deformities of the tibia that causes significant patellar maltracking or subluxation.
Risk factors for osteoarthritis of the knee
Established
Controversial
Obesity
Age
Osteoarthritis at other site
Previous knee trauma
Previous knee surgery
Sex (female)
Physical activity
Genetics
Smoking
Estrogen deficiency
Radiographic Evaluation
Evaluation should always include a standing (weight-bearing) AP
view of the knee. A lateral radiograph is required as is a skyline view
of the patella. If the problem is on the lateral side of the joint, a
standing postero-anterior view must be obtained with the knee in
30 degree of flexion. The reason for this is that the articular cartilage
loss in the medial compartment is in the distal femur and the central
tibia, but articular cartilage loss in the lateral compartment is in the
posterior femur and posterior tibia.
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Avoid stair climbing, kneeling, squatting, low chairs if patellofemoral arthritis exists.
NSAIDs- employ COX 2 inhibitors
There are though long term complications associated with
their use like peptic ulcer, renal effects, gastrointestinal
bleeding.
Cane in the opposite hand
Greatly decreases stress on the arthritic joint.
The most successful treatment is to protect the knee joint, especially
when we are weight-bearing. This is the Gold-Standard of medical
treatmentthe treatment most recognized by all of medicine to be
effective. Protecting the joint will ensure:
A reduction in joint pain
Significant slow down in the progress of the disease
A reduction in the chances of our injuring other joints when
we walk. If we have a painful knee, we sub-consciously force
ourselves to walk in an abnormal way, so as to try and minimize the pressure we exert on the knee joint. When we do this,
we apply abnormal and excessive pressure on other parts of
our body (such as the hip, back, etc.). This is called compensation. This compensation leads to overutilization of these areas,
and new sites of osteoarthritis.
The two most effective treatments used by doctors and therapists
to protect the arthritic knee joint are:
1. Knee braces (Figs 6.3 to 6.5) that provide pain relief by:
Stabilizing the knee
Exerting mild and soothing compression to reduce swelling of
the knee
Providing support for the knee ligaments and tendons that
have been affected by arthritis. When the knee joint wears
down unevenly, some of the ligaments and tendons around
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Exercise Regimen
Isometric Exercise
For quadriceps and hamstring done for 5 min, every hour is found
to be effective.
Types Speedy: Helps to reduce effusion in the joint
Slow and sustained: To reduce pain and improve strength.
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The patient sits at the edge of the high table and actively flexes and
extends the knee joint in a free swinging manner till there is no pain.
This helps in improving the ROM of the knee joint, facilitates joint
lubrication, and provides joint relaxation.
Isokinetic Exercises
In this group of exercises, resistance to the movement is either given
normally by the therapist or by the patient himself with the other
leg.
It is a self-controlled movement, is easy to do, and can be done
frequently, and helps in improving the muscle strength (Fig. 6.8).
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Calf stretch
With your hands against the wall, place your leg to be stretched
behind you as demonstrated (Fig. 6.13). Keep your heel down, knee
straight and feet pointing forwards. Gently lunge forwards until you
feel a stretch in the back of your calf/knee. Hold for 15 seconds and
repeat4 times at a mild to moderate stretch pain-free.
ITB stretch
Cross your leg to be stretched behind your other leg, taking it as far as
you comfortably can. Then push your hips to the side of your leg to
be stretched until you feel a stretch in your outer thigh/hip (Fig. 6.14).
Keep your back straight. Hold for 15 seconds and repeat4 times at a
mild to moderate stretch pain-free.
Adductor stretch
Standing tall, back straight, place your feet approximately twice
shoulder width apart. Gently lunge toone side, keeping yourother
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knee straight, until you feel a stretch in the groin of your straight
leg (Fig. 6.15). Hold for 15 seconds and repeat4 times at a mild to
moderate stretch pain-free.
Note: - Slogan for a OA knee patient, care for the joint to have a care
free joint in old age.
Strengthening Exercises
The following knee strengthening exercises are designed to improve
strength of the muscles of the knee. You should discuss the suitability of these exercises with your physiotherapist prior to begin
them. Generally, they should only be performed provided they do
not cause or increase pain.
Begin with the basicknee strengthening exercises. Once these are
too easy, they can be replaced with the intermediateknee strengthening exercises and eventually, the advanced knee strengthening
exercises.
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the front of your thigh (quadriceps). Hold for 5 seconds and repeat
10 times as hard as possible pain free.
Knee strengtheningintermediate exercises
The following intermediate knee strengthening exercises should
generally be performed 1 to 3 times per week, provided they do
not cause or increase pain. Ideally, they should not be performed on
consecutive days, to allow muscle recovery. As your knee strength
improves, the exercises can be progressed by gradually increasing the
repetitions, number of setsor resistance of the exercisesprovided
they do not cause or increase pain.
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105
Heel Raises
Begin this knee strengthening exercise standing at a bench or chair
for balance (Fig. 6.21). Keep your feet shoulder width apart and
facing forwards. Slowly, move up onto your toes, raising your heels
as far as possible and comfortable without pain. Perform 3 sets of
10 repetitions.
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107
B
Figs 6.22A and B: Single leg squat with swiss ball
with your middle toe. Your knee also should not move forward past
your toes. Perform 3 sets of 10 repetitions provided the exercise is
pain free.
Lunges with Weight
Begin this knee strengthening exercise standing holding light
weights, with your back straight in the position demonstrated (Figs
6.23A and B). Slowly, lower your body until your front knee is at a
right angle. Keep your knee in line with your middle toe and your
feet facing forward. Perform 3 sets of 10 repetitions.
Single Leg Heel Raises
Begin this knee strengthening exercise standing on one leg at a
bench or chair for balance (Fig. 6.24). Keeping your foot facing
forwards, slowly move up onto your toes, raising your heel as far
as possible and comfortable without pain. Perform 3 sets of 10
repetitions.
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Endurance Training
The cardiovascular fitness of individuals with OA may be compromised. A number of well-controlled trials have reported the ability to
improve this impairment through regular cardiovascular conditioning
without aggravating joints. Programs similar to those designed for deconditioned individuals can be instituted for individual with arthritis.
If weight-bearing is a barrier to exercise, a non-weight-bearing apparatus such as a cycle ergometry or aquatic program may be used.
For most people walking and stationary bicycles are safe and effective
means of aerobic exercise (Figs 6.25A and B). Furthermore, patients
who have engaged in such a program often report an increase in selfesteem and improved emotional status. Medical screening as appropriate for age and medical condition should occur prior to beginning an
exercise program that entails marked increase in physical activity levels.
Functional Training
Functional training for the individual with arthritis proceeds in the
same fashion as for other individuals with similar deficits. Therapists
may choose to reduce the functional demands of an activity either
temporarily, such as under conditions of acute inflammation, or permanently by incorporating a variety of aids into ADLs that substitute
for lost ROM and strength. Raising beds and chairs can reduce the
effort needed to stand up. Railings placed around the bed, bath and
along stairways also can help increase an individuals independence.
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Gait Training
111
Operative Options
Arthroscopy
With OA, degenerating articular cartilage and synovial tissue
release proinflammatory cytokines that include chondrocytes to
release lytic enzymes leading to the degradation of type 2 collagens and PG.
The lavaging effect of arthroscopy may dilute or wash out
these inflammatory mediators, although the effect is temporary.
Patients who benefit most from arthroscopy have mechanical symptoms (locking meniscus) of short duration (<6 mon.)
with mild arthritis on radiographs.
Patients with 3 to 6 month of unsuccessful supervised nonsurgical management with normal mechanical alignment and
mild to moderate arthritis on weight-bearing films are considered candidates for arthroscopic debridement.
Patients with tibial spine pain, osteophytes formation, and lack
of extension (flexion deformity) may benefit from arthroscopic
notch plasty and osteophytes removal.
Osteotomy
This is a mechanical load shifting procedure. The mechanical axis of
the knee is shifted from the worn compartment to the good compart-
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113
114
Cemented
Used for older, more sedentary
patients.
Porous ingrowths
Theoretically, porous ingrowths fixation should not
deteriorate with time (unlike
cemented fixation) and is thus
the ideal choice for younger or
more active candidates.
Hybrid technique
Noncemented
ingrowths
femoral and patellar compoFig. 6.28: Total knee
nent with a cemented tibial
arthroplasty
component
Frequently used because of
failure to achieve fixation with some of the original porous
coated tibial components reported in the literature.
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117
3 to 6 weeks
Improve ROM
Enhance muscular strength and endurance
Dynamic joint stability.
6 weeks
Begin weight-bearing as tolerated with ambulatory aid
Perform wall slides, progress to lunges
Perform quadriceps dips or step ups (Fig. 6.30)
Begin closed-chain knee exercises on total gym and progress
over 4 to 5 weeks
bilateral lower extremities
single leg exercises
incline
Progress to stationary bicycle
Perform lap stool exercises (hamstring strengthening) (Fig.
6.31)
Cone-walkingprogress from 4 to 6 to 8 inches cone.
Use McConnell taping of patella to unload patellofemoral
stress, if symptoms occur with exercise
Continue home physical therapy.
In later weeks, it is important to enhance the endurance, eccentricconcentric control of the limb, cardiovascular fitness, and to improve the functional activity performance.
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Major Complications
Joint deformities
Subluxation
Ankylosis
Intra-articular loose bodies.
Chapter
Types
Mobilization Techniques in
Arthritic Knee
of Mobilization Techniques
120
B
Figs 7.1A and B: Proximal tibiofibular joint. (A) Anterior glide;
(B) Posterior glide
121
B
Figs 7.2A and B: Superoinferior glide of the patellofemoral joint. (A) With
the knee in extension; (B) With knee in flexion
122
B
Figs 7.3A and B: Patellofemoral joint. (A) Medial glide in sidelying;
(B) Medial tilt
123
B
Figs 7.4A and B: Medial lateral glide of femorotibial joint. (A) Lateral glide
in side lying; (B) Medial glide in side lying
124
B
Figs 7.5A and B: Medial lateral glide of tibia. (A) Lateral glide;
(B) Medial glide
125
B
Figs 7.6A and B: Tilt of femorotibial joint. (A) Medial (varus) tilt of
femorotibial joint; (B) Lateral (valgus) tilt of femorotibial joint
Chapter
Osteoarthritis in
Various Joints
Joints
128
The Foot
Any degenerative changes resulting in wear and tear of the joint
or injury can cause osteoarthritis to develop even years after the
injury has occurred. Severe sprains or fractures can lead to osteoarthritis.
Abnormal foot structure and, consequently, abnormal foot mechanics can also cause osteoarthritis to develop. People with flat feet
or high arches are at greater risk for developing foot osteoarthritis.
Diagnosis of Foot Osteoarthritis
When diagnosing foot osteoarthritis, the therapist must differentiate osteoarthritis from other types of arthritis. The therapist will
consider your medical history and your description of symptoms.
The therapist will ask questions that will help to formulate your
diagnosis, such as:
When did the pain start?
Is the pain continuous or does it come and go?
Have you injured the foot? If yes, when and how was it
treated?
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130
131
The Shoulder
The Elbow
Osteoarthritis of the elbow is secondary and leads to a stiff joint. Arthroplasty (excisional or total joint replacement) may be indicated
in selected cases. Therapeutic modalities are employed to induce
relaxation and to reduce pain to the maximum. Functional use is
encouraged and guided within the limits of pain and discomfort.
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133
Fig. 8.2: Upper arrow shows Heberdens node at DIP joint; lower arrow
shows Bouchards node at proximal IP joint
134
Summary
OA is a condition commonly seen by physical therapists in their
clinical practice. The functional limitations seen in such cases
results from musculoskeletal impairments. Irregularities on the
bone surface, loss of joint mobility, muscle weakness, and atrophy
contribute directly to limitations in ADL and the ability to work.
Pain secondary to changes in normal joint structure and function often limits function as well. Musculoskeletal impairments
related to arthritis may also lead to impairments of other systems,
such as decreased cardiovascular endurance for functional activities. The physical therapist is well suited to evaluate and treat these
impairments, remediate the functional limitations, and educate the
patient in self-management skills to avoid unnecessary disability.
Rehabilitation of the individual with arthritis is most often directed
towards restoring or maintaining joint mobility and strength; and
emphasizes functional retraining and health promotion.
Appendix 1
The arthritis impact measurement scales (AIMS) is an American
questionnaire designed to measure the health status of patients with
arthritis.
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Appendix 1
143
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Appendix 2
Biomechanical Consideration
Related to Rehabilitation
Hip exercises (such as SLRs) are more stressful to hip than
walking
Functional activities including descending stairs, getting out
of a chair, and bending/lifting with bent knees, put the most
stress on hips and knees
During daily activities, loads of 3 to 4X body weight occur
5 to 10X in sports activities to 25X with weight lifting
Increased speed of walking or running, increased loads
But slower than normal walking speed also increases joint
forces
Exercise will decrease fall risk, increase bone density and thus
prosthesis fixation (amongst other benefits!).
Appendix 3
Getting Additional Rest
Rest is important because it reduces the pain and fatigue that accompany arthritis. It reduces the stress on the joints and protects
them from any further damage. Not only whole body rest, but the
local joint rest is very important.
The following points are essential:
1. Plenty nightly rest
2. Daily rest periodsyou can stretch out for several times in a
day, particularly supporting your joints
3. Five minute breathers are important
4. Local joint rest- when a joint hurts, stop and rest
5. Take out time for relaxing activities like listening to music,
reading, watching television.
Appendix 4
Core Strengthening Exercises
Core stabilization involves a co-contraction of lumbar multifidus
and transversus abdominis and seems to be an effective approach to
resolving osteoarthritic pain.
In 1992, a model proposed by Punjabi introduced a refinement in the definition of stabilization.
Instead of just looking at the joint in terms of bone and
ligament, Punjabi argued that muscle involvement and neurological control would play key roles in joint stability. The
ligaments main influence comes at the end range of the movement within the joint.
In the mid-range of the joint, what Punjabi calls the neutral
zone, the action of muscles would be necessary to maintain the
joints stability. [neutral zone] Panjabis model suggests that
the three aspectsosseoligamentous, muscular and neurologicalhave to work together.
The length of fibers of the stabilizers does not change very
much over the course of a movement. Instead, they remain
consistently short to hold the joint in its neutral zone (before
the end range where the ligaments get involved), to help it keep
its integrity while it is handling load or doing larger motion.
The muscle must be strong enough to do its job of stabilizing,
and also it must act at the proper time. In Panjabis model (see
above), knee problems or back pain were associated with too large
148
a neutral zone, in other words, the stabilizer muscles took too long
to begin to fire.
There are various exercises available for strengthening the muscle. Exercises done for the pelvic floor muscles accompany the
contraction of transversus abdominis. A sphygmomanometer or
a real time ultrasound biofeedback can be used to get a visual
feedback of the contraction.
Exercise is done with the patient in a supine lying position with
knees flexed bilaterally. Patient is asked to bring the stomach out
with every inhalation and take it in with exhalation. Repeat it two
times and then with the end exhalation try to touch the back to the
couch. The clinical measure used to ensure correct activation of the
transversus abdominis muscle was to observe a slight drawing-in
maneuver of the lower part of the anterior abdominal wall below
the umbilical level, consistent with the action of this muscle. In
addition, a bulging action of the multifidus muscle should have
been felt under the clinical physical therapists fingers when they
were placed on either side of the spinous processes of the L4 and L5
vertebral levels, directly over the belly of this muscle.
10 contraction repetitions for 10 second duration each 3 and
release done 3 to 4 times a day, helps in strengthening the core
muscles.
These exercises will be supplemented with exercises for the pelvic floor muscles, breathing control and control of spinal posture.
Patients are taught how to contract these muscles independently,
from the superficial trunk muscles. When this level of competence
has been achieved, patients will be considered ready to progress to
Stage 2.
Stage 2 of the approach involves increasing the complexity of
the exercise by progressing through a range of functional tasks and
exercises targeting coordination of trunk and limb movement and
maintenance of trunk stability.
Index
Page numbers followed by f refer to figure
A
Abduction pillow 79
Accelerated protocol 115
Active ROM exercises 97
Acupuncture57
Additional rehabilitation
points82
Adductor stretch 100, 102f
Advanced balance exercises 44
Alkaptonuria12
Alternate leg raise 63
Ankle
joint128
pumps76
Ankylosis118
Anterior capsular stretch 78f
Arthritic
changes in knee joint 86f
joints in body 7f
knee2f, 86
Arthritis 6, 11, 16
Arthrodesis 56, 113
Arthroplasty56
Arthroscopy111
Articular cartilage 17
Assessment of
deformity22
endurance, tone and
volume22
tenderness22
Assistive devices 79
B
Balance activity and rest 53
Ball
around back 40
balance exercise41f
circles around leg 42
leg balance exercise 43f
throws against wall 42
under leg 40
balance exercise42f
Basic balance exercises 40
Bathroom rehabilitation 79
Bend knee
back77
up while standing 77
Blind advanced one leg
balance38
150
Blood test 3
Bony
collapse26
enlargement88
tenderness88
Boswellia serrata 57
Bouchards node 18, 132, 133f
C
Calcaneocuboid joint 129
Calf stretch 100, 100f
Capsular tightness 19
Cartilage5
Cement less technique 76
Cemented
prosthesis76
total knee arthroplasty 115
Choice of osteotomy 68
Chondrocytes5
Chondroitin57
Chronic thickened swelling 45
Clasticated supports 48f
Cold effusion 61
Collagen5
Comfort elastic knee
stabilizer94f
Component malalignment 83
Congenital
disorders10
hip luxation 11
Corticosteroids55
Costochondritis11
Crepitus88
Cross body leg swings 39
E
Endurance training 109
Enhancing joint
proprioception37
Environmental barriers 24
Estrogen deficiency 92
Exercises 33, 62
in sitting position 63
in standing 64
lying on back 62
Extra-articular inflammatory
disease35
F
Fibrous contracture 45
First metatarsophalangeal
joint129
Fixation method for total knee
implants114
Flexion contracture of hip 81
Foam pillow balance
exercises44, 45f
G
Gait faults 82
General features of
osteoarthritis60
Glucosamine57
Gluteal sets 76
Gluteus maximus
strengthening80f
Gout11
Group therapy 33
H
Hamstring stretching 98, 99f
Heberdens nodes 18, 133f
Heel
raises105
walking39
Hemochromatosis12
High glide mobilization
technique120
Hip
abduction
adduction77
exercises77f
in standing80f
dysplasia11
internal rotation 88
joint59
osteoarthritis88
resurfacing 70, 71f
Index
151
Hormonal disorders 11
Hybrid technique 114
Hyperthyroidism11
I
Ice therapy 32
Indications for surgery 111
Inflammatory
arthritis6
diseases11
Infrared lamp 51f
Intermediate balance exercises 40
Intra-articular loose bodies 118
Isometric
exercises 76, 95, 97
hip abduction 76
J
Joint
deformities118
in brief 5
irregularity90
narrowing90
of thumb 134
protection
exercises35
techniques51
stability22
stiffness88
tightness61
K
Kienbocks disease 134
Knee
and hip flexion63
braces93
152
crossovers65f
extension in sitting vs resistance
band104
joint85
osteoarthritis 88, 90
pain88
strengthening 102, 103, 106
to chest lifts 66f
L
Lap stool of hamstring
strengthening118f
Leg
rotation64f
scissors against resistance 65f
stretch63
Location of pain 25
Loss of
joint space 25
movement61
Low glide mobilization
technique120
Lyme disease 11
M
Maintenance of joint range and
muscle power48
Malum coxae senilis 60
Marfan syndrome 12
Medial lateral glide of
femorotibial joint 123f
tibia124f
Metatarsocunieform joint 129
Mild inflammation 61
Minimizing deformity 49
Minimus tendons 62
Mobility of joints 45
Mobilization techniques in
arthritic knee119
Muscle
spasm45
strengthening35
N
Narcotics55
Neoroprene elastic knee
braces95f
Nerve palsy 83
Nodes in OA hand 18f
Non-steroidal anti-inflammatory
drugs54
O
Obesity 12, 88, 92
One leg balance 38
Orthotic supports 46
Osteoarthritic joint 35
Osteoarthritis 2, 6, 15, 24, 59,
85, 127, 131
of CMC joint of thumb 16f
of hip 60
of joint of big toe 130f
of knee 92
of small joints 133
Osteophytes 26, 89
Osteotomy 56, 89, 111
P
Pain
assessment21
gate theory 30
relief 30, 95
Paracetamol54
Passive
Index
Q
Quadriceps
sets76
strengthening97f
Quads over fulcrum 102, 103f
R
Range of motion 18, 20
Reduce excess body weight 53
Rehabilitation
after total hip replacement 71
protocol75
Resistance exercise with
band104f
Rheumatoid arthritis 6, 11, 18
153
ROM and stretching exercises 77
Rules of exercises in management
of OA hip 62
S
S-adenosylmethionine57
Sclerosis25
Selenium deficiency 58
Sensory integrity 24
Severity of pain 25
Side
kicks65f
leg lifting 63f
throw against wall 42
Single leg
balance 38f, 40, 41f
heel raises 107, 108f
squat with Swiss ball
106, 107f
Site and distribution of pain 21
Sports injuries 12
Squat with Swiss ball 105f
Standard ice pack 33f
Standing
leg swing 64
side leg swing 64
Static inner quadriceps
contraction102, 103f
Stationary cycle 68f
Stiffness90
Straight leg
lifts66f
raising 70, 98
Straighten knee 77
Straightening and bending
knee99f
154
T
Talonavicular joint 129
Tendon transfer 56
Thermoskin comfort arthritic knee
wrap94f
Thomas stretch 78f
Tibial osteotomy for genu
varum112f
Tibioltalar joint 129
Tilt of femorotibial joint 125f
Toe walking 39
Total
hip replacement 72, 74f
joint replacement 82
knee arthroplasty 113-115
Treatment
in osteoarthritis 27
of foot osteoarthritis 129
Trendelenburg gait 81
Trochanteric bursitis 62
Types of
arthritis6
mobilization techniques 120
U
Ultrasound 33, 34f
therapy96f
Unicompartmental knee
replacements113
V
Valgus osteotomy 68
Visual analog scale 21
Vitamin
B9 and B12 58
D deficiency 58
W
Walking on heel 39f
Wall balance exercise 43f, 44f
Water on knee 18
Wax
application for OA hand 32f
therapy32
Weak hip abductors 81
Weight-bearing
joints carry burden 53
status76
to tolerance 75
Wilsons disease 12
Wrist and hand 132