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

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Osteoarthritis lecture to gps

  1. 1. Physiotherapy Management of Osteoarthritis Cameron Bulluss Advanced Physiotherapy and Injury Prevention 335 Hillsborough Rd Warners Bay
  2. 2. Physio Facts 12000 registered Physios in Australia 1200 of these have a formally recognised specialty  Musculoskeletal  Sports  Neurology
  3. 3. 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
  4. 4. Osteoarthritis The most common musculoskeletal disorder The leading cause of pain an disability in the community
  5. 5. Age and Gender
  6. 6. Joint Replacement Trend
  7. 7. Common Sites 19% 30% 41%
  8. 8. 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
  9. 9. 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)
  10. 10. These abnormalities are in  Articular Cartilage  Bone  Synovium  Periarticular Soft Tissues  Muscles  Nerves
  11. 11. Articular Cartliage  Exposes sub-chondral bone  Irritation of synovium via debris  Alteration of joint alignment  No pain directly possible as it is aneural
  12. 12. The Bony Changes We See Are Increased density of subchondral plate Bone necrosis Bone cysts Bone oedema Sclerosis Osteophytes
  13. 13. Subchondral Bone Much of the pain comes from the subchondral bone (Hunter 2009 Rad Clin North America 2009 (539 -531)
  14. 14. 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
  15. 15. 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
  16. 16. Keys toManagement Activity modification and strengthening Weight Pharmaceutical Reduction Psychological
  17. 17. Keys toManagement Activity modification and exercise Weight Pharmaceutical Reduction Psychological
  18. 18. Keys to ManagementWeight Reduction• For every 2 units of BMI increase there is a 36% increase in the risk of developing knee OA
  19. 19. 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
  20. 20. 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
  21. 21. 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)
  22. 22. 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
  23. 23. Keys toManagement Activity modification and exercise Weight Pharmaceutical Reduction Psychological
  24. 24. Keys toManagement Activity Modification and Exercise Weight Pharmaceutical Reduction Psychological
  25. 25. Optimise Loading in Commence Low Intensity Current Activities Cyclical Exercise Activity Modification and ExerciseCommence Low Impact Commence Range of Strengthening Motion Exercises
  26. 26. Optimise Loading in Current Activities Activity Modification and Exercise
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. Reduce Loading with Bracing
  31. 31. Reducing Load Through the first MTP
  32. 32. Reducing Load with shoesBrooks Addictions
  33. 33. Reducing Load with a Lateral HeelWedge
  34. 34.  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”
  35. 35. American Podiatric MedicineAssociation Journal
  36. 36. Commence Low ImpactStrengthening Activity Modification and Exercise
  37. 37. 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)
  38. 38. Low Impact Strengthening – example openchain exerciseOpen chain means that the distal part isfree to move
  39. 39. Quadriceps Strength Pre-operative quadriceps strength is a good predictor of functional outcomes 1 year post total knee replacement
  40. 40. Commence LowIntensity Cyclical Exercise Activity Modification and Exercise
  41. 41. Commence Low Intensity CyclicalExercise - Why Improved nutrition of subchondral bone and articular cartilage Assist with weight loss Assist with range of motion
  42. 42. Commence Low Intensity CyclicalExercise - Examples Exercise bike Hydrotherapy Low Impact walkingBike Set-up is crucial
  43. 43. CommenceRange of Motion Exercises Activity Modification and Exercise
  44. 44. 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
  45. 45. American Academy of OrthopaedicSurgeons – Clinical Guidelines
  46. 46. 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.
  47. 47. 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
  48. 48. Recommendation 4 We recommend patients with symptomatic OA of the knee be encouraged to participate in low-impact aerobic fitness exercises.
  49. 49. Recommendation 5 Range of motion/flexibility exercises are an option for patients with symptomatic OA of the knee.
  50. 50. Recommendation 6 We suggest quadriceps strengthening for patients with symptomatic OA of the knee.
  51. 51.  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
  52. 52. 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
  53. 53. Exercise variables - Loading Generally low
  54. 54. 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
  55. 55. Exercise Variable - Frequency Minimum 3 times per week
  56. 56. Exercise Variable – Trial period 8 weeks is usually required
  57. 57. Resources Useful Websites  www.aaos.org  www.arthritisaustralia.com.au
  58. 58. Questions Acknowledgements – Jess Fidler
  59. 59. OA Changes to the Synovium Hyperplasia Fibrosis Thickening Lymphocytic infiltration Inflammation
  60. 60. OA Changes to Nerves Changes leading to reduced proprioception  Loss of mechanoreceptors Structural changes leading increased pain  Disorganisation  Truncation
  61. 61. Biological Pain Generators in OA Synovium Periarticular soft tissues Bone
  62. 62. Risk Factors for Development of OA Non-Modifiable  Modifiable  Age  Muscle strength  Dysplasia  Activity type and level  Joint alignment  Obesity  Traumatic injury  Traumatic injury
  63. 63. Risk Factors for the Development andProgression of Osteoarthritis Age Joint dysplasia e.g. FAI of hip
  64. 64. Risk Factors for the Development andProgression of Osteoarthritis – malalignment
  65. 65. 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
  66. 66.  Visual Analog Scores before and after Knee BracingPain (mm) 7.9 vs 4.4Activity level (%) 36 vs 61
  67. 67. References
  68. 68. 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
  69. 69. The Normal Anatomy of Synovial Joints
  70. 70. The Normal Anatomy Synovial Joints –Synovium
  71. 71. The Normal Anatomy of Synovial Joints– Articular Cartilage
  72. 72. Changes to the Articular Cartilage Loss of chondrocytes Matrix degeneration
  73. 73. What Causes the Pain Psychological Biological Social Pain
  74. 74. 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
  75. 75. Modifiable Risk Factors – Injury Risk ACL incidence reduced by 85 – 90% in several studies by use of a special preventative program
  76. 76. Treatment
  77. 77. 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

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