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Therapeutic management of knee osteoarthritis; physiotherap case study


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a case study presentation on physiotherapy management of knee osteoarthritis

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Therapeutic management of knee osteoarthritis; physiotherap case study

  2. 2. OUTLINE  Introduction  Epidemiology & economic importance  Relevant anatomy  Pathophysiology  Classification  Aetiology & Risk factors  Clinical presentation  Differentials  Assessment  Therapeutic exercises  Management  Case study 1  Case study 2  Conclusion  Recommendation  References
  3. 3. Introduction • The name osteoarthritis(OA) is a Greek word, osteo, arthro and itis. It is characterized by age related degenerative changes of cartilage and its underlying bone within a joint as well as bony overgrowth. • Osteoarthritis(OA) is a condition that is associated with pain and inflammation of the joint capsule (Naredo et al,2005), impaired muscular/ligament stabilization (Brandt et al, 2000), reduced range of motion (Steultjens et al,2000) and disability over time.
  4. 4. Cont… • Knee osteoarthritis (OA) is the most common type of OA.( Andrianakos et al,2003) and its prevalence is rising in parallel with the increasing age of the population. (Felson et al,2005) • Knee OA is one of the most chronic and degenerative joint diseases and a major cause of pain and joint stiffness in the elderly (Doherty, 2002)
  5. 5. Cont.. • It is also one of the most common musculoskeletal conditions resulting in disability (Mody & Woolf, 2003). • The specific causes of OA are unknown, but are believed to be as a result of both mechanical and molecular events in the affected joint. The disease onset is gradual and usually begins after the age of 40 years (Centers for Disease Control and Prevention, 2009).
  6. 6. Cont… • Knee OA results in persistent pain and limited function (Guccione et al., 1994) and substantially reduces life expectancy by 12% when occurring as a co morbidity with obesity (Warner, 2011). • The management of knee OA is focused on optimizing the patient’s quality of life by decreasing pain and improving function (Hunter & Felson, 2006).
  7. 7. Cont…. • Treatment of knee OA is also focused on preventing/reducing joint stiffness, and improving muscular/ligament stabilization and joint mobility (Zhang et al,2008).
  8. 8. Epidemiology and Economic Importance. • Osteoarthritis is the most prevalent form of arthritis and occurs especially in the knee joint. • It affects nearly 6% of all adults • The burden of knee OA alone is particularly high and is on the rise. (Cram et al., 2010) • According to data from 2003 to 2005, at least 27 million Americans have OA. ( Lawrence et al.,2008).
  9. 9. • Health impact, and economic consequences of OA, are largely due to the aging of the US population and the obesity epidemic ( CDC,2010) • At least two hospital-based studies have shown that OA is common in Nigeria (Akinpelu et al., 2007; Ogunlade, Alonge, Omololu & Adekolujo, 2005).
  10. 10. • About 10% of people with the age of 55yrs or above (and 50% of 65+) are having knee OA, of whom a quarter are severely disabled. • Although OA occurs all over the world, there are ethnic differences in its prevalence (Mody & Woolf, 2003).
  11. 11. • Approximately 10% of men and 18% of women suffer symptomatic OA (Woolf & Pfleger, 2003) with radiological evidence in more than 50% of people over 65 years of age (Royal Australian College of General Practitioners, 2009).
  12. 12. • Akinpelu et al.,(2007) documented that osteoarthritis is more common in females than males (3.5:1) and that the knee joint is most frequently affected. • Reported to substantially reduce life expectancy by 12% when occurring as a co morbidity with obesity (Warner, 2011).
  13. 13. According to American Academy of Orthopedic Surgeons (2008) • Approximately 60 000 primary total knee arthroplasty (TKA) procedures, a common procedure in patients with severe knee OA, are performed annually in the United States.
  14. 14. • TKA volume increased to 161.5% in the US Medicare population between 1991 and 2010. • Furthermore, in 2006, 496 000 hospital admission, and $19 billion in hospital charges were due to knee OA.
  15. 15. INCIDENCE OF OA KNEE IN NOH-DALA (JULY, 2018- JUNE, 2019) MONTH AFFECTED SIDE TOTAL LEFT RIGHT BILATERAL M F M F M F M F JULY 2 2 2 1 - 3 4 6 AUGUST 2 - 1 - 1 1 4 1 SEPTEMBER - - 1 1 1 1 2 2 OCTOBER 1 1 - 1 1 2 2 4 NOVEMBER - 1 1 1 1 2 2 4 DECEMBER - 2 1 1 1 2 2 5 JANUARY - 1 2 2 1 - 3 2 FEBRUARY 2 1 - 2 2 2 4 5 MARCH 1 2 1 1 3 3 5 6 APRIL 1 1 1 - 1 3 3 4 MAY - 1 1 2 1 1 2 4 JUNE 1 - 1 2 2 2 4 4 TOTAL 10 12 12 14 15 22 37 48
  16. 16. ECONOMIC IMPORTANCE OF OA KNEE IN NOH-DALA (JULY,18-NOV, 2018) • From above statistic, a total of 85 knee OA patients comprising of 37 males and 48 females presented for treatment in ten month.
  17. 17. • Each attending twice/week, 8 times/month • An individual patient would have incurred the sum of #5000 for five physiotherapy sessions.
  18. 18. RELEVANT ANATOMY OF THE KNEE • The knee is composed of two joints, the tibiofemoral and the patellofemoral. • It is an articulation between the distal condyle of femur and the proximal surface of tibia and the articulation between the femur as well as the patella.
  19. 19. OSTEOLOGY The bones that form the joint are; • Femur • Tibia • Patella
  20. 20. MUSCULATURE ANTERIOR MUSCLE GROUP • Muscles acting on the patellofemoral joint are the quadriceps muscles: • Rectus femoris, • Vastus medialis, • Vastus lateralis, • Vastus intermedius. (Kenhub, 2014).
  21. 21. POSTERIOR MUSCLE GROUP • Hamstrings muscles • Calf muscles
  22. 22. LATERAL MUSCLE GROUP • Hamstring tendon • Iliotibial band
  23. 23. OTHER SOFT TISSUES • Ligaments & • Cartilages
  24. 24. INNERVATION • Innervation: branches of the femoral, obturator, tibial and common peroneal nerves (Hamilton, 1987).
  25. 25. VASCULAR SUPPLY • Blood supplies: popliteal arteries through a bout of anastomosis from superior and inferior, medial and lateral and descending genicular arteries and the anterior tibia recurrent artery (Hamilton, 1987).
  26. 26. PATHOPHYSIOLOGY • The pathogenesis of knee OA have been linked to biomechanical and biochemical changes in the articular cartilage of the knee joint. • The key functional feature of OA is that the articular cartilage can no longer act as a shock absorber because its extracellular matrix has been destroyed by the repetitive wear and tear from the frictional forces and/or other predisposing factors.
  27. 27. • Degradation of matrix components corresponds to failure of the articular cartilage to withstand cyclic loading, which, in turn, accelerates its further degradation especially in the load-bearing regions. • Molecular events simultaneously taking place, will further help in the destruction of the articular surfaces.
  28. 28. • Early stages of the condition are characterized by changes in cartilage thickness, which in turn are associated with an imbalance between cartilage breakdown and repair. • The cartilage eventually becomes softened and roughened.
  29. 29. • Over time the cartilage wears away, and the subchondral bone, deprived of its protective cover, attempts to regenerate the destroyed tissue, resulting in increased bone density (sclerosis) at the site of damage and an uneven remodeling of the surface of the joint.
  30. 30. • This is followed by the destruction of other joint tissues, such as the subchondral bone, the synovial capsule. • Destroyed/exposed subchondral bone subsequently develop cracks and some small fluid filled bone lesions called the bone cyst
  31. 31. • Thick bony outgrowths (osteophytes) subsequently develop, from the deposits calcium of the degraded articular surface and thickened synovium. • Joint space narrowing becomes significant. • Articulation of the joint becomes difficult.
  33. 33. CLASSIFICATION • OA is classified into two groups according to its etiology: primary (idiopathic or non-traumatic) and secondary (usually due to trauma or mechanical misalignment). • The severity of the disease can also be graded according to the radiographical findings by the Kellgren–Lawrence (KL) system described in 1957.
  34. 34. The Kellgren and Lawrence system is a method of classifying the severity of knee osteoarthritis (OA) using five grades: • Grade 0: no radiographic and symptomatic features of OA are present, healthy joint. • Grade 1: doubtful joint space narrowing (JSN) and possible osteophytic lipping, with no pain or loss of function.
  35. 35. • Grade 2: definite osteophytes and possible JSN on anteroposterior weight-bearing radiograph, symptoms begin to appear. • Grade 3: multiple osteophytes, definite JSN, sclerosis, possible bony deformity, obvious cartilage damage and more frequent symptoms. • Grade 4: large osteophytes, marked JSN, severe sclerosis, complete severe cartilage loss, mal alignment and definite bony deformity with persisting symptoms.
  36. 36. RISK FACTORS • Age • Gender • Obesity • Previous knee injury • Occupation • Smoking • Joint hypermobility or instability • Peripheral neuropathy • History of prolong immobilisation • Family history (Coleman et al., 2012)
  37. 37. CLINICAL PRESENTATION • Pains/inflammation • Loss of function • Decrease in joint ROM • Crepitation
  38. 38. • Joint stiffness • Muscle atrophy • Joint deformity (varus/valgus) • Bony hypertrophy • Elevated sensitivity (esp. COLD)
  39. 39. DIFFERENTIALS • Meniscal pathology • Ligamentum and/or soft tissue pathology • Bursitis • Chondromalacia patellae • Other arthritic conditions Etc
  40. 40. ASSESSMENT • Subjective Evaluation: - Relevant clinical history - Mechanism of injury (when, where/ how) - Aggravating factors/relieving factors -Previous history of trauma/infection 11/8/2019 45
  41. 41. • O/E Observation; gait, erythyema, temperature, swelling, atrophy, deformity, bony contour Body physique/body build
  42. 42. • Palpation; pain/ tenderness, tonicity, soft or bony enlargement • Joint rom/integrity- PROM/AROM- goniometry • Crepitus associated with movement 11/8/2019 47
  43. 43. • Muscle power grading • Ligament status assessment • Functional ability/limitations • Radiological/laboratory investigations
  44. 44. Aims of management • To relieve pain • To improve/maintain ROM • To strengthen mms • To improve functional abilities • To improve the quality of life
  45. 45. MANAGEMENT • The management of knee OA is multi-disciplinary, involve; – Pharmacological therapy – Physiotherapy – Surgery 11/8/2019 51
  46. 46. Physiotherapy Treatment It may comprise: • Cryotherapy • Thermotherapy • Therapeutic Exercise – Strengthening exercise – Open chain /Closed chain kinetic Exs – Free resistance exercise
  47. 47. Bicycle Ergometer And Electrical Muscle Stimulator
  48. 48. Physiotherapy mgt contd • Soft tissue manipulation • The use of walking aids • Joint mobilization • Activity modification • Biomechanical correction (e.g. the prescription of orthotics)
  49. 49. Therapeutic Exercise • Physical therapy and Exercises are important components in the management of knee OA and can help patient achieve and maintain optimal mobility. • Exercise helps to: • Increase flexibility • Maintain range of motion
  50. 50. • Strengthen surrounding muscles • Decrease associated inflammation • Improve overall fitness
  51. 51. • Exercise is recommended as a first-line conservative intervention approach for knee (OA). • Exercise included aerobic or endurance activities (eg, walking and cycling), strength training with and without weights, and balance training.
  52. 52. • Evidence supports both aerobic exercise (land-based or water-based) and progressive strengthening exercises reducing pain and improving physical function in patients with mild to moderate knee OA.
  53. 53. • Therapeutic exercises have been found to have effects on the followings; • Pain • Stiffness • Range of movement • Muscle strength • Position sense
  54. 54. Hamstring stretch and calf stretch
  55. 55. Straight leg raise and quad set
  56. 56. seated Hip march and pillow squeze
  57. 57. Heel raise and side leg raise
  58. 58. Sit to stand and one leg balance
  59. 59. Steps up and walking
  60. 60. Low impact activities and water aerobics • Other exercises that are easy on the knees include biking, swimming, and water aerobics. Water exercise takes weight off painful joints.
  61. 61. Exercise Prescription - Frequency - Intensity - Mode - Duration - Progression - All these have to be considered based on the assessment and findings of the patients conditions.
  62. 62. OUTCOME MEASURES • IKHOAM • Numeric pain rating scale • Goniometer • WOMAC
  63. 63. REVIEW OF STUDIES ON THERAPEUTIC EXERCISES • An overview of systematic reviews of physiotherapy interventions for patients with OA of the knee demonstrates that exercise can reduce pain and improve function in patients with knee OA (Jamtvedt et al., 2008).
  64. 64. • According to OA Research Society International (OARSI) , patients with symptomatic knee OA may benefit from appropriate exercises to reduce pain and improve functional capacity.
  65. 65. • In OARSI guideline ( Zhang et al, 2007), patients with knee OA should be encouraged to undertake and continue regular aerobic, muscle strengthening, and range-of motion exercises.
  66. 66. • In a research done by Egwu, et al, (2015)on the comparative efficacy of self management education (sme) and quadriceps strengthening exercises (qse) on 79 knee OA patients . • Result established significant reduction in pain intensity in quadriceps strengthening group.
  67. 67. Case study: 1 • Name: A.B • ADDRESS: kano • AGE: 48 • SEX: male • P/C: left knee pain x 5/12 • H/X : patient developed insidious onset of intermittent left knee pain 5/12 ago, pain was more at night and relieved on sitting but worsened early in the morning and subsides later in the day. He found it difficult to walk fast as a result of the pain, he has been on pain reliever with mild relief later decided to visit NOHD after a relative advised him to do so. Was referred from SOPD 2/12 ago prior to presentation to commence physiotherapy management. • PMHX: HTNO, DMO, TraumaO, SCDO .
  68. 68. Cont… • DHX: currently on pain reliever • FSHX: married with three children, a police officer, physically active who enjoys playing football, AlcoholO, kola nutO, smokingO • O/E: an apparently healthy looking man, who walked into physiotherapy outpatient treatment unit on a normal gait. Not in obvious pain distress, afebrile to touch, anicteric, and acynosed. • CNS: well oriented in TPP, conscious and alert. • Vital Sign: B/P: 110/80 mmHg • PR: 78bpm • RR: 20cpm. • BMI: 20kg/m2 (weight 65kg, height 1.77m)
  69. 69. Functional Assessment • Lower Limb Assessment • Right Lower Limb Apparently Normal • Left Lower Limb (knee) • ROM: full and painful in both active and passive range of motion • GMP: 4 • Deformity: mild valgus deformity present • Tenderness: 1 • Atrophy: nil • Swelling: mild swelling observed at the lateral aspect of the knee.
  70. 70. Special Test • Goniometric measurement • flexion 0-135o Extension 0o • Valgus Stress Test: +ve Varus Stress Test: -ve • Anterior and posterior drawer’s test: -ve • Patella apprehension test: -ve • Patella mobility test: mobile • Patella grinding test: +ve • Crepitus: present • Apley’s Test : -ve • Pain assessment • Numerical Pain Rating Scale (NPRS)= 6/10 • Nature of pain: dull and intermittent • Site of pain: lateral aspect of the knee
  71. 71. X-RAY
  72. 72. • Functional Abilities And Limitations • Pain on long distance walk • Unable to carry load • Independent on activities of daily living (ADL) • Impression: Reduced musculoskeletal function of the left knee 2o to osteoarthritis (grade 2)
  73. 73. Management • Aim of management • To relieve pain • To improve function • To prevent complication • To improve the Quality of life • Plan of management • Cryotherapy/Thermotherapy • Manual therapy • Strengthening and flexibility exercise • Open chain kinetic exercise • Knee support • Home program
  74. 74. Review • Findings after 6 sessions • GMP 5 • Swelling subsided • NPRS reduced to 2/10
  75. 75. case study 2 • Name: U F • Gender: Female • Address: Kano • Age: 61Years • P/C: bilateral knee pain x 2years • Hx: patient developed right knee pain 2years ago, 2/12 later the pain transferred to the left knee, patient reported early morning stiffness of which pain subsided during the day. Pt found it difficult to stand after a prolonged sitting however, resorted to self medication with mild relief and the swelling was controlled. Upon visit back to kano, she decided to come to NOHD and thus was referred to physiotherapy through the SOPD to commence management.
  76. 76. • PMHX: HTNO, DMO, TraumaO, SCDO. • DHX: currently on pain reliever • FSHX: A widow, blessed with 7 children, a trader who lives in a bungalow, AlcoholO, kola nutO, smokingO • O/E: An apparently elderly woman, walked into physiotherapy outpatient unit on an antalgic gait. Afebrile to touch, anicteric and acyanosed. On obvious pain distress.
  77. 77. • CNS: conscious and well oriented in TPP. • Vital sign: BP: 140/90 mmHg PR: 80 bpm RR: 21cpm BMI: 22kg/m2 (weight 60kg, height 1.65m) • Pain Assessment • Numeric Pain Rating Scale (NPRS): right 7/10 and left 5/10 • Nature Of Pain: dull and intermittent • Site Of Pain: lateral aspect of both knee
  78. 78. Both Knee Functional Assessment Right Muscle Strength Grading Flexors 4 Extensors 3 Range Of Movement Active : limited and painful Passive: limited and painful Swelling: mild Stiffness: present Tenderness: 2 Deformity: Mild valgus deformity Warmth: Nil Left 4 4 Limited and painful Full and painful Nil Absent 2 Nil Nil
  79. 79. Special Test • Right • Goniometry Assessment: Flexion: 0-100 o Extension: 0 o • Crepitus: present • Anterior Drawers Test: +ve • Posterior Drawers Test: -ve • Valgus Stress Test: +ve • Varus Stress Test: -ve • Apley’s Test: -ve • Patella Apprehension Test: +ve • Patella Grinding Test: +ve • Patella Mobility Test: Not mobile • left • 0-90 o and 0o • Present • +ve • -ve • -ve • -ve • -ve • +ve • +ve • Not mobile
  80. 80. Cont….
  81. 81. X-ray
  82. 82. • Functional Activities And Limitations • Difficulty sitting for a long time (5 mins) • Lying relieves pain • Walking elicited mild pain. • Impression: limited functional ability of the both knee 2o to osteoarthritis (grade 3) • Aims Of Management • To relieve pain on both knee • To improve and maintain function • Prevent complication • Improve the quality of life
  83. 83. • Plan Of Management • Cryotherapy/Thermotherapy • Manual therapy • Strengthening and flexibility exercise • Open kinetic chain exercises • Knee support • Home program
  84. 84. Review • Findings After 8 Sessions • Swelling subsided • GMP: improved to 4/5 bilaterally • Range of motion improved 110o respectively • NPRS reduced to 4/10 for right and 2/10 respectively • Valgus test: –ve bilaterally
  85. 85. CONCLUSION • OA is a common disease of the ageing population, showing its inevitability and of economic importance. • Pain and associated disability of the knee are common symptoms of OA. Exercises and physical activity have been proven to provide relief in patient with knee OA.
  86. 86. Recommendation • Exercises due to its effectiveness, and its availability is recommended in the management of Knee OA.
  87. 87. References • 1) Andrianakos A, Trontzas P, Christoyannis F, Dantis P, Voudouris C, Georgountzos A, Kaziolas G, Vafiadou E, Pantelidou K, Karamitsos D, Kontelis L, Krachtis P, Nikolia Z, Kaskani E, Tavaniotou E, Antoniades C, Karanikolas G, Kontoyanni A.: Prevalence of rheumatic diseases in Greece: a crosssectional population based epidemiological study. The ESORDIG Study. J Rheumatol. 2003, 30: 1589-1601. [PubMed] • 2) Felson DT, Lawrence RC, Hochberg MC, McAlindon T, Dieppe PA, Minor MA, Blair SN, Berman BM, Fries JF, Weinberger M, Lorig KR, Jacobs JJ, Goldberg V.: Osteoarthritis: new insights. Part 2: treatment approaches. Ann Intern Med. 2000, 133: 726-737. [PubMed] • 3) Naredo E, Cabero F, Palop MJ, Collado P, Cruz A, Crespo M.: Ultrasonographic findings in knee osteoarthritis: a comparative study with clinical and radiographic assessment. Osteoarthritis Cartilage. 2005, 13: 568-574. [PubMed] • 4) Brandt KD, Heilman DK, Slemenda C, Katz BP, Mazzuca S, Braunstein EM, Byrd D.: A comparison of lower extremity muscle strength, obesity, and depression scores in elderly subjects with knee pain with and without radiographic evidence of knee osteoarthritis. J Rheumatol. 2000, 27: 1937- 1946. [PubMed] • 5) Steultjens MP, Dekker J, van Baar ME, Oostendorp RA, Bijlsma JW.: Range of joint motion and disability in patients with osteoarthritis of the knee or hip. Rheumatology (Oxford). 2000, 39: 955- 961. [PubMed] • 6) Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N, Bierma-Zeinstra S, Brandt KD, Croft P, Doherty M, Dougados M, Hochberg M, Hunter DJ, Kwoh K, Lohmander LS, Tugwell P.: OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidencebased, expert consensus guidelines. Osteoarthritis Cartilage. 2008, 16: 137-162. [PubMed]
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