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

1. Physiotherapy Management of
Osteoarthritis
Cameron Bulluss
Advanced Physiotherapy and Injury
Prevention
335 Hillsborough Rd Warners Bay

2. Physio Facts
 12000 registered Physios in Australia
 1200 of these have a formally recognised specialty
 Musculoskeletal
 Sports
 Neurology

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. Osteoarthritis
 The most common musculoskeletal disorder
 The leading cause of pain an disability in the community

5. Age and Gender

6. Joint Replacement Trend

8. Common Sites
19%
30%
41%

9. 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

10. 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)

11. These abnormalities are in
 Articular Cartilage
 Bone
 Synovium
 Periarticular Soft Tissues
 Muscles
 Nerves

12. Articular Cartliage
 Exposes sub-chondral bone
 Irritation of synovium via
debris
 Alteration of joint
alignment
 No pain directly possible as
it is aneural

13. The Bony Changes We See Are
 Increased density of subchondral plate
 Bone necrosis
 Bone cysts
 Bone oedema
 Sclerosis
 Osteophytes

15. Subchondral Bone
 Much of the pain comes from the subchondral bone (Hunter 2009
Rad Clin North America 2009 (539 -531)

16. 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

17. 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

18. Keys to
Management
Activity modification and
strengthening
Weight
Pharmaceutical Reduction
Psychological

19. Keys to
Management
Activity
modification
and exercise
Weight
Pharmaceutical
Reduction
Psychological

20. Keys to Management
Weight Reduction
• For every 2 units of BMI increase there is a 36% increase in the
risk of developing knee OA

21. Keys to Management
Weight 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

22. Keys to Management
Weight 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

23. Keys to Management
Weight 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)

24. 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

25. Keys to
Management
Activity modification and
exercise
Weight
Pharmaceutical Reduction
Psychological

26. Keys to
Management
Activity
Modification and
Exercise
Weight
Pharmaceutical Reduction
Psychological

27. Optimise Loading in Commence Low Intensity
Current Activities Cyclical Exercise
Activity
Modification
and Exercise
Commence Low Impact Commence Range of
Strengthening Motion Exercises

28. Optimise Loading
in Current
Activities
Activity
Modification
and Exercise

29. Optimise Loading with Current
Activities
 Reduce Loading if excessive
 Reduce pressure on subchondral bone
 Less stress on articular cartilage
 Increase Loading if inadequate
 Improved nutrition of articular cartilage

30. 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

31. 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

32. Reduce Loading with Bracing

33. Reducing Load Through the first MTP

34. Reducing Load with shoes
Brooks Addictions

35. Reducing Load with a Lateral Heel
Wedge

36.  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”

37. American Podiatric Medicine
Association Journal

38. Commence Low
Impact
Strengthening
Activity
Modification
and Exercise

39. 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)

40. Low Impact Strengthening – example open
chain exercise
Open chain means that the distal part is
free to move

41. Quadriceps Strength
 Pre-operative quadriceps
strength is a good predictor
of functional outcomes 1
year post total knee
replacement

42. Commence Low
Intensity Cyclical
Exercise
Activity
Modification
and Exercise

43. Commence Low Intensity Cyclical
Exercise - Why
 Improved nutrition of subchondral bone and articular
cartilage
 Assist with weight loss
 Assist with range of motion

44. Commence Low Intensity Cyclical
Exercise - Examples
 Exercise bike
 Hydrotherapy
 Low Impact walking
Bike Set-up is crucial

45. Commence
Range of Motion
Exercises
Activity
Modification
and Exercise

46. 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

47. American Academy of Orthopaedic
Surgeons – Clinical Guidelines

48. Clinical Guidelines
Recommendation 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.

49. 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

50. Recommendation 4
We recommend patients with symptomatic OA of the knee
be encouraged to participate in low-impact aerobic fitness
exercises.

51. Recommendation 5
Range of motion/flexibility exercises are an option for
patients with symptomatic OA of the knee.

52. Recommendation 6
We suggest quadriceps strengthening for patients with
symptomatic OA of the knee.

53.  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

54. 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

55. Exercise variables - Loading
 Generally low

56. 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

57. Exercise Variable - Frequency
 Minimum 3 times per week

58. Exercise Variable – Trial period
 8 weeks is usually required

59. Resources
 Useful Websites
 www.aaos.org
 www.arthritisaustralia.com.au

60. Questions
 Acknowledgements – Jess Fidler


61. OA Changes to the Synovium
 Hyperplasia
 Fibrosis
 Thickening
 Lymphocytic infiltration
 Inflammation

62. OA Changes to Nerves
 Changes leading to reduced proprioception
 Loss of mechanoreceptors
 Structural changes leading increased pain
 Disorganisation
 Truncation

63. Biological Pain Generators in OA
Synovium
Periarticular
soft tissues
Bone

64. Risk Factors for Development of OA
 Non-Modifiable  Modifiable
 Age  Muscle strength
 Dysplasia  Activity type and level
 Joint alignment  Obesity
 Traumatic injury  Traumatic injury

65. Risk Factors for the Development and
Progression of Osteoarthritis
 Age
 Joint dysplasia e.g.
FAI of hip

66. Risk Factors for the Development and
Progression of Osteoarthritis – malalignment

67. Risk Factors for the Development and
Progression 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

69.  Visual Analog Scores before and after Knee Bracing
Pain (mm) 7.9 vs 4.4
Activity level (%) 36 vs 61

70. References

71. 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

72. The Normal Anatomy of Synovial Joints

73. The Normal Anatomy Synovial Joints –
Synovium

74. The Normal Anatomy of Synovial Joints
– Articular Cartilage

75. Changes to the Articular Cartilage
 Loss of chondrocytes
 Matrix degeneration

76. What Causes the Pain
Psychological Biological
Social
Pain

77. Physiotherapy and OA Prevention and
Management
 Modifiable Risk Factors  Non-modifiable Risk
 Impact Loading Factors
 Obesity  Previous Injury
 Muscle strength  Joint Dysplasia
 Future injury  Gender
 Attitudes  Age

78. Modifiable Risk Factors – Injury Risk
 ACL incidence reduced by 85 – 90% in several studies by use
of a special preventative program

79. Treatment

80. 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