Osteoarthritis lecture to gps
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a 2 hour presentation on non-operative management of osteoarthrits, looking at current concepts in exercise and physical therapy

a 2 hour presentation on non-operative management of osteoarthrits, looking at current concepts in exercise and physical therapy

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Osteoarthritis lecture to gps Osteoarthritis lecture to gps Presentation Transcript

  • Physiotherapy Management of Osteoarthritis Cameron Bulluss Advanced Physiotherapy and Injury Prevention 335 Hillsborough Rd Warners Bay
  • Physio Facts 12000 registered Physios in Australia 1200 of these have a formally recognised specialty  Musculoskeletal  Sports  Neurology
  • Advanced Physiotherapy Warners Bay 8 full-time Physios 220 new patients per month, half of these from g.p.s and specialists Patients range over 10, with average of 46 Most common reason to seek a visit with us is for an OA knee 20 % of our patients present with symptomatic OA Physio provider for Newcastle Jets Soccer
  • Osteoarthritis The most common musculoskeletal disorder The leading cause of pain an disability in the community
  • Age and Gender
  • Joint Replacement Trend
  • Common Sites 19% 30% 41%
  • Definition- Clinical definitions- Radiological definitions- Anatomical definitions- All vary and none appear to encompass all aspect of the disease- These even vary between body parts
  • Definition “The synovial joint is an organ, and OA represents failure of that organ and can be initiated by abnormalities arising in any of its constituent tissues. “ (Brandt 2008)
  • These abnormalities are in  Articular Cartilage  Bone  Synovium  Periarticular Soft Tissues  Muscles  Nerves
  • Articular Cartliage  Exposes sub-chondral bone  Irritation of synovium via debris  Alteration of joint alignment  No pain directly possible as it is aneural
  • The Bony Changes We See Are Increased density of subchondral plate Bone necrosis Bone cysts Bone oedema Sclerosis Osteophytes
  • Subchondral Bone Much of the pain comes from the subchondral bone (Hunter 2009 Rad Clin North America 2009 (539 -531)
  • Diagnosis Clinical Examination is crucial Imaging can be used to confirm the diagnosis and exclude other pathology X-Rays provide further information but are notoriously insensitive MRI provides greater insight  subchondral bone marrow lesions,  synovitis  subarticular bone attrition  Articular cartilage damage
  • Knee x-ray useful additional view A clear x-ray does not exclude osteoarthritis Knee X-rays should include Rosenberg view if looking for OA Erect PA view at 45 degrees flexion
  • Keys toManagement Activity modification and strengthening Weight Pharmaceutical Reduction Psychological
  • Keys toManagement Activity modification and exercise Weight Pharmaceutical Reduction Psychological
  • Keys to ManagementWeight Reduction• For every 2 units of BMI increase there is a 36% increase in the risk of developing knee OA
  • Keys to ManagementWeight Reduction• For every 2 units of BMI increase there is a 36% increase in the risk of developing knee OA• BMI>30 there is a 20 fold increased risk of knee OA
  • Keys to ManagementWeight Reduction• For every 2 units of BMI increase there is a 36% increase in the risk of developing knee OA• BMI>30 there is a 20 fold increased risk of knee OA• Body fat % perhaps more important than BMI  Inflammatory proteins such as cytokinenes may contribute to sensitisation of nerve endings, tendon and muscle degeneration
  • Keys to ManagementWeight Reduction For every 5 kg decrease in body weight during the preceeding 10 years the risk of OA of the knee declines by more than 50%. (MJA 2004)
  • Consider the load in the situation where someone 30kg overweight walks down 10 steps• Impact loading will increase with increased body weight  30 kg overweight will result in over 10 steps  30 x 4 x 10 = 1200 kg extra accumulated load through Patellofemoral joint
  • Keys toManagement Activity modification and exercise Weight Pharmaceutical Reduction Psychological
  • Keys toManagement Activity Modification and Exercise Weight Pharmaceutical Reduction Psychological
  • Optimise Loading in Commence Low Intensity Current Activities Cyclical Exercise Activity Modification and ExerciseCommence Low Impact Commence Range of Strengthening Motion Exercises
  • Optimise Loading in Current Activities Activity Modification and Exercise
  • Optimise Loading with CurrentActivities Reduce Loading if excessive  Reduce pressure on subchondral bone  Less stress on articular cartilage Increase Loading if inadequate  Improved nutrition of articular cartilage
  • Change Loading – How? Optimise Activity Selection (exercise and recreational)  An understanding is required of the forces involved  PFJ 4 -10x body weight in running  PFJ 1.5x body weight in walking  3-4x body weight ascending and descending stairs  6x body weight in squatting  4x body weight sit-stand
  • Loading Changes – examples Replace running with walking Replace walking with low intensity bike Commence weekly hydrotherapy Reduce BMI Reduce hills Improve shoes Walk on grass rather than concrete Provide Supportive Device
  • Reduce Loading with Bracing
  • Reducing Load Through the first MTP
  • Reducing Load with shoesBrooks Addictions
  • Reducing Load with a Lateral HeelWedge
  •  Are foot orthotics efficacious for treating painful medial compartment knee osteoarthritis? A review of the literature R. Marks L. Penton Article first published online: 11 FEB 2004 “These data indicate a strong scientific basis for applying wedged insoles in attempts to reduce osteoarthritic pain of biomechanical origin. Further research to substantiate their efficacy in well-designed clinical trials seems warranted”
  • American Podiatric MedicineAssociation Journal
  • Commence Low ImpactStrengthening Activity Modification and Exercise
  • Commence Low Impact Strengthening –Why?  Load Sharing Occurs Between Joints and Muscles  Muscle weakness is likely to be present in knees with symptomatic Osteoarthrits.  It is also likely to be a risk factor for the development and progression of knee osteoarthritis. (Ann Intern Med. 1997  Muscle weakness is probably more important in the pathogenesis of OA than wear and tear (Br J Sports Med 2004)
  • Low Impact Strengthening – example openchain exerciseOpen chain means that the distal part isfree to move
  • Quadriceps Strength Pre-operative quadriceps strength is a good predictor of functional outcomes 1 year post total knee replacement
  • Commence LowIntensity Cyclical Exercise Activity Modification and Exercise
  • Commence Low Intensity CyclicalExercise - Why Improved nutrition of subchondral bone and articular cartilage Assist with weight loss Assist with range of motion
  • Commence Low Intensity CyclicalExercise - Examples Exercise bike Hydrotherapy Low Impact walkingBike Set-up is crucial
  • CommenceRange of Motion Exercises Activity Modification and Exercise
  • Commence Range of Motion Exercises– Why? Increasing flexibility of peri-articular soft tissues is likely to improve functional range of motion  60 degrees knee flexion to walk  80 degrees knee flexion to climb a step  10 degrees ankle dorsiflexion to walk  105 degrees knee flexion to ride a bike
  • American Academy of OrthopaedicSurgeons – Clinical Guidelines
  • Clinical GuidelinesRecommendation 1 We suggest patients with symptomatic OA of the knee be encouraged to participate in self-management educational programs such as those conducted by the Arthritis Foundation, and incorporate activity modifications (e.g. walking instead of running; alternative activities) into their lifestyle.
  • Recommendation 3 We recommend patients with symptomatic OA of the knee, who are overweight (as defined by a BMI>25), should be encouraged to lose weight (a minimum of five percent (5%) of body weight) and maintain their weight at a lower level with an appropriate program of dietary modification and exercise
  • Recommendation 4 We recommend patients with symptomatic OA of the knee be encouraged to participate in low-impact aerobic fitness exercises.
  • Recommendation 5 Range of motion/flexibility exercises are an option for patients with symptomatic OA of the knee.
  • Recommendation 6 We suggest quadriceps strengthening for patients with symptomatic OA of the knee.
  •  Recommendation 9 We are unable to recommend for or against the use of a brace with a valgus directing force for patients with medial uni- compartmental OA of the knee. Grade of Recommendation: Inconclusive Recommendation 10 We are unable to recommend for or against the use of a brace with a varus directing force for patients with lateral uni- compartmental OA of the knee. Grade of Recommendation: Inconclusive
  • Clinical Trials Effects of tai chi exercise on pain, balance, muscle strength, and perceived difficulties in physical functioning in older women with osteoarthritis: a randomized clinical trial.The Journal of Rheumatology CONCLUSION: Older women with OA were able to safely perform the 12 forms of Sun-style tai chi exercise for 12 weeks, and this was effective in improving their arthritic symptoms, balance, and physical functioning Effect of therapeutic exercise for hip osteoarthritis pain: results of a meta-analysis Source: Arthritis and Rheumatism 2008 Method: systematic review CONCLUSION: Therapeutic exercise, especially with an element of strengthening, is an efficacious treatment for hip OA
  • Exercise variables - Loading Generally low
  • Exercise Variable – Repetitions or Time- Generally high- 15 mins on an exercise bike at 60 RPM=900 knee flexion – extensions between 5 and 105 degrees
  • Exercise Variable - Frequency Minimum 3 times per week
  • Exercise Variable – Trial period 8 weeks is usually required
  • Resources Useful Websites  www.aaos.org  www.arthritisaustralia.com.au
  • Questions Acknowledgements – Jess Fidler
  • OA Changes to the Synovium Hyperplasia Fibrosis Thickening Lymphocytic infiltration Inflammation
  • OA Changes to Nerves Changes leading to reduced proprioception  Loss of mechanoreceptors Structural changes leading increased pain  Disorganisation  Truncation
  • Biological Pain Generators in OA Synovium Periarticular soft tissues Bone
  • Risk Factors for Development of OA Non-Modifiable  Modifiable  Age  Muscle strength  Dysplasia  Activity type and level  Joint alignment  Obesity  Traumatic injury  Traumatic injury
  • Risk Factors for the Development andProgression of Osteoarthritis Age Joint dysplasia e.g. FAI of hip
  • Risk Factors for the Development andProgression of Osteoarthritis – malalignment
  • Risk Factors for the Development andProgression of Osteoarthritis Joint Instability or Injury Leading to  Mechanical, Biochemical Damage to chondral surface  ACL (50 – 60% greater risk of osteoarthritis)  1st CMC – UCL rupture  Scapholunate
  •  Visual Analog Scores before and after Knee BracingPain (mm) 7.9 vs 4.4Activity level (%) 36 vs 61
  • References
  • Pathophysiology of Osteoarthritis OA represents abnormalities of any of the constituent tissues of the synovial joint Breakdown of the dynamic equilibrium between breakdown and repair Not a degenerative disease in that the cells are normal
  • The Normal Anatomy of Synovial Joints
  • The Normal Anatomy Synovial Joints –Synovium
  • The Normal Anatomy of Synovial Joints– Articular Cartilage
  • Changes to the Articular Cartilage Loss of chondrocytes Matrix degeneration
  • What Causes the Pain Psychological Biological Social Pain
  • Physiotherapy and OA Prevention andManagement Modifiable Risk Factors  Non-modifiable Risk  Impact Loading Factors  Obesity  Previous Injury  Muscle strength  Joint Dysplasia  Future injury  Gender  Attitudes  Age
  • Modifiable Risk Factors – Injury Risk ACL incidence reduced by 85 – 90% in several studies by use of a special preventative program
  • Treatment
  • OA Prevention and Management Some of the symptoms come from changes to the synovium, bone and nerves  Medical treatment Much of the pathology comes from degeneration in the articular cartilage  Irreversible but can be slowed Much of the pain comes from the subchondral bone  Partly reversible Much of the loss of range comes from either the pain or from the periarticular soft tissues  This can be improved with an exercise program