Knee osteoarthritis & its physiotherapeutic approaches

This presentation is about knee OA and related Physiotherapeutic Approaches

1. Knee Osteoarthritis & its
Physiotherapeutic
Approaches
By
Dr. Shazia Abdul Hamid Khalfe, PT

2. Arthritis
•Rheumatoid
Arthritis
–Autoimmune
–Symmetrical
–Joint pain,
swelling, stiffness,
fatigue
–Better once joint
is used
•Osteoarthritis
–Asymmetrical
–Joint pain,
stiffness
–Pain is worse with
use
–Boney
enlargement
–Weight bearing
joints
–Joint space
narrowing

3. Osteoarthritis
•Most common joint disorder worldwide
•Diagnosed on clinical presentation and
supported by radiography.
•Risk Factors
–Older age, female sex, obesity, trauma,
quadriceps weakness, and nutritional
deficiencies

4. Knee Joint

5. KNEE OA
•Knee osteoarthritis (OA), also known as
degenerative joint disease, is typically the
result of wear and tear and progressive loss
of articular cartilage. It is most common in
elderly people.

7. Clinical Symptoms
•Knee pain that is gradual in onset and
worse with activity,
•Knee stiffness and swelling,
•Pain after prolonged sitting or resting.

8. Epidemiology
•OA is the most common disease of the
joints worldwide, with the knee being the
most commonly affected joint in the body.
•OA affects nearly 6% of all adults
•Women more commonly affected than men
•Prevalence will continue to increase as life
expectancy and obesity rises.

9. Etiology
•Primary knee OA is the result of articular
cartilage degeneration without any known
reason. This is typically thought of as
degeneration due to age as well as wear
and tear.
•Secondary knee OA is the result of articular
cartilage degeneration due to a known
reason.

10. Characteristics/Clinical Presentation
•Signs of knee OA are:
•Pain on movement
•Stiffness, particularly early morning stiffness
•Loss of range of movement
•Pain after prolonged sitting or lying
•Pain on joint line palpation
•Joint enlargement.

11. Diagnosis
The severity of osteoarthritis can be evaluated
by radiography, according the Kellgren we can
discriminate four degrees of severity in
osteoarthritis:
Grade I: normal joint with a minimal osteophyte.

12. •Grade II: Osteophytose on two points with
minimal subchondral sclerosis, proper joint
space and no deformity.

Diagnosis

13. •Grade III: Moderate osteophytose, early
deformity of the bone endings and a joint
space which narrows.


Diagnosis

14. •Grade IV: Large osteophytes, deformity of
bone endings, narrowing joint space,
sclerosis and cysts.


Diagnosis

15. Radiographic Findings of OA
•Joint space narrowing
•Osteophyte formation
•Subchondral sclerosis
•Subchondral cysts
•Early stages of OA shows a minimal
unequal joint space narrowing.
•In severe OA the joint line may disappear
completely

16. Examination
•Take a proper history of pain including when the
pain started if it was gradual or sudden, if there was
any previous injury to the same knee.

17. Subjective Assessment
The common subjective symptoms of knee OA are:
•Early morning stiffness
•Dull achy pain
•Pain after sitting
•Pain after increased activity
•Reduced mobility
•Difficulty weight bearing on the affected leg
•Decrease in the abilities of daily functioning
•Sleep may be affected

18. Objective Assessment
•After a thorough subjective assessment it may be
clear the diagnosis of the patient already,
however, it is always necessary to perform an
objective assessment to rule out differential
diagnoses and provide objective outcome
measures such as range of movement (ROM).
•Observation of the knee: it may be enlarged,
swollen or red if the OA is very reactive or irritated.
•Observation in general: movement patterns at
rest and when performing simulations of daily
activities such as getting up from and down on a
chair.

19. Objective Assessment
•Gait assessment: use of walking aids may
be required due to pain, is there any
stiffness during gait, is there significant
reduced weight bearing of the affected
knee.
•Palpation: swelling, temperature changes,
joint line tenderness may all be present in
an acutely aggravated OA knee
•ROM: flexion and extension may be limited
due to stiffness or formation of osteophytes
in the joint

20. Objective Assessment
•Strength: reduced strength is normal in an
OA knee due to pain and deconditioning
•Normal functional activities: such as
climbing stairs may be affected
•Balance: may be affected due to pain, this
needs to be assessed to rule out falls risk.

21. Outcome Measures for Osteoarthritis
(Pain Component)
•Knee Injury and Osteoarthritis Outcome Score
•Western Ontario and McMaster Universities
Osteoarthritis Index, also known as WOMAC
Osteoarthritis Index
•Algofunctional index (AFI)
•Intermittent and constant osteoarthritis pain index
(ICOAP)
•West-Haven-Yale Multidimensional Pain Inventory
–Assesses chronic pain in individuals and
recommended for use in conjunction with
behavioural and psycho-physiological
strategies.

22. •Oxford Knee Score
–Developed as an outcome measure to be used
with patients having a total knee replacement.
•McGill Pain Questionnaire Short-Form
–Created to assess both the intensity and quality
of pain.
•Knee Injury and Osteoarthritis Outcome
Score

Outcome Measures for Osteoarthritis
(Pain Component)

23. •Canadian Occupational Performance Measure
•Medical Outcomes Study Short Form 36
•WHO Quality of Life-BREF (WHOQOL-BREF)
•Community Integration Questionnaire II
•Quebec User Evaluation of Satisfaction with
Assistive Tech.
•Physical Activity Scale for the Elderly
•Lower Extremity Functional Scale
•Keele Assessment of Participation
•Knee Injury and Osteoarthritis Outcome Score

Outcome Measures for Osteoarthritis
(ADL Component)

24. Physiotherapy Management
•Physiotherapy should be started with all patients with a
diagnosis of OA.
•Pain is a common symptom that occurs at different
intensities depending on the individual, it is not necessarily
related to severity of OA progression.
•Exercise has been proven to be effective as pain
management and also improves physical functioning in the
short term. Exercises have to take place under the
supervision of a physiotherapist initially and when properly
instructed these exercises can be performed at home,
though research has shown that group exercise combined
with home exercise is more effective.

25. Education
•Understanding what OA is
•Explaining pain
•Explain long term management of OA
•Educate regarding activity modification
•Role of weight loss
•Promote active, healthy lifestyle
Role of Physiotherapy

26. Exercise
•Reduce knee pain and inflammation.
•Normalise knee joint range of motion.
•Strengthen lower kinetic chain
•Cardio-vascular exercise
•Improve proprioception, agility and balance.
•Improve function
•Use of walking aids as needed

Role of Physiotherapy

27. Exercise has also been found to be beneficial
for other co-morbidities and overall health.
Walking, resistance training,
cycling, yoga and Tai Chi are examples of
such exercises. An individualised exercise
program should be set by a physiotherapist
initially, taking into account the patient's goals
and hobbies to ensure long term exercise
compliance.
Role of Physiotherapy

28. Other Interventions
•Hydrotherapy - this may be particularly helpful if pain is very
high and analgesia is not tolerated. It can be useful to build
up strength and reduce stiffness around the knee joint in a
non-weight bearing position.
•Taping - works to offload the joint similar to bracing, this is
useful in the short term.
•Manual therapy - effective to improve ROM
•Massage - may be useful to control pain in some subjects,
but this has low evidence to show its effectiveness
•Bracing
•Electrotherapy - such as TENS and muscle stimulation may
be used to improve quadriceps strength and has some
evidence to show it can help with pain reduction

29. •Exercise
•Education/ self Management
•Manual Therapy
•TENS
•Acupuncture
•Therapeutic Ultrasound
•Thermotherapy
•Weight Control
•Electro-therapeutic modalities

Evidence Based Physical Therapy

30. References
•https://www.physio-pedia.com/Knee_Osteoarthritis assessed on 4th Jan, 2021
•https://www.physio-pedia.com/Osteoarthritis assessed on 4th Jan, 2021
• Nicola E Walsh

, Michael V Hurley Evidence based guidelines and current
practice for physiotherapy management of knee osteoarthritis,
Musculoskeletal Care. 2009 Mar;7(1):45-56
•Carolyn J Page, Rana S Hinman, Kim L Bennell, Physiotherapy management
of knee osteoarthritis, Int J Rheum Dis. 2011 May;14(2):145-51.
•Joseph J. Ruane, DO, Physical Therapy for Knee Osteoarthritis Strengthening
Exercises and Other Osteoarthritis Treatments. Available at
https://www.practicalpainmanagement.com/patient/conditions/osteoarthritis/knee/
physical-therapy-knee-osteoarthritis, Assessed on 4
th
Jan 2021.
•Olusola Ayanniyi, Roseline F. Egwu, Ade F. Adeniyi, Physiotherapy management
of knee osteoarthritis in Nigeria-A survey of self-reported treatment preferences,
Hong Kong Physiotherapy Journal Volume 36, June 2017, Pages 1-9
•