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1. CASE PRESENTATION Divya Irkar Sukruti Pillai Shivangi Gupta Prajakta Kadam

2. Demographic data : Name : Mrs. Madhumati Malati Age/Gender : 62 years/Female Address: Khanda Colony,Panvel (row house with 8 stairs and indian washroom.) Education : 9th std Occupation: Housewife Dominance : Right. DOE :2/1/19. Chief complaints: Pain on outer side of both the knees (right>left) and difficulty while descending stairs, sit to stand and performing Activites of daily life .

3. History of present illness : Patient was apparently alright 2 years back when she started experiencing pain in both her knees(right>left) while descending 3 flights of stairs which gradually progressed in intensity ,for which she took hot water fomentation and homeopathic treatment but the pain did not subside. Two months back, her pain aggravated while descending stairs, sit to stand, squatting position and it increased gradually with warmth and swelling for

4. which she visited MGM hospital orthopedic department where investigation of radiograph were carried on 26/12/18 which revealed grade 3 osteoarthritis knee for which she was referred for physiotherapy treatment and is undergoing the same. Current functional status : The Patient is functionally independent with no use of an assistive device but performs all the activities of daily life with pain and difficulty.

5. Pain History: Side : Bilateral knee joints Site : Lateral and medial aspect of both knees Type : Dull aching Frequency : Intermittent Onset : Gradual Duration : Acute on chronic Numerical rating scale: On Rest:0/10 On activity:Right:6/10 ; left:3/10 Diurnal variation : Absent Aggrevating factors : Descending stairs, sit to stand, squatting, prolonged walking for than 10mins Relieving factors :Rest,supine and high sitting

6. Systemic Review: Other musculoskeletal symptoms: None Neurological symptoms :None . Cardiorespiratory symptoms :None Special senses : vision- Presbiopia,uses spectacles since 7-8 years , depth perception : present ; vision problem at night : none . Hearing :none Vestibulocochlear system :no episode of dizziness, vertigo, blackouts. Bowel/ bladder :none

7. FALL HISTORY : WHEN : 3-4 years back Mechanism : In the bus, due to sudden jerk lost balance and fell on the knee Past medical/surgical history: Appendicitis and underwent surgery for the same 6years back Personal history:- Diet : Nutritous ,Non-vegetarian Bowel/ bladder: normal Addictions:Denied Sleep : normal Appetite :Normal

8. Family History: :Mother-Diabetes Socio-economic members: number of members:2 Earning members:none Status:Fair Investigation :- X-ray (AP view) dated 26/12/18 revealed joint space reduction in left knee on medial aspect and definite narrowing of joint space and moderate osteophyte formation .

9. Drug history :None Psychological history: Memory -Intact Cognition -Intact Depression - moderate The patient is well oriented to time,place and person Environmental history : Exterior : House-Ground floor, 8 stairs to enter the house, has to climb 3 flights of stairs with no railings. Interior :Washroom- Indian=inside the house,no bars to get up from the toilet. Lighting : adequate lighting.

10. Hypothesis formation: Sources of symptoms :Bone,articular cartilage. Structures involved : Articular cartilage, subchondral bone. Contributing factors : Stair-climbing and descending, indian washroom , daily activities (squats down the floor to perform household chores), sleeps on the floor.

11. Assessment: On Observation: General condition: Patient is well oriented to time , place and person Built : Endomorphic Nurtition : well nourished Skin/Nail condition : normal Pallor, icterus , clubbing,lymphadenopathy : Absent Swelling : present over the lateral aspect of the Rt knee along the joint line. Muscle wasting : seen over quads and hams of the Rt leg. Patella position : shift present – patella alta Presence of any soft tissue enlargement : Functional position : Rt knee In flexion (about 10-15 deg) Deformity: knee flexion deformity (10-15deg)

12. Posture (localized ): In standing: Anterior view- Increased weight bearing on lt foot. Lateral view- Rt knee slightly flexed , Posterior view- increased weight bearing on lt side. Generalised : in standing : Lateral view - decreased lumbar lordosis , rounded shoulders

13. On palpation: Tenderness : Grade 2 over lateral and medial patellofemoral and lateral tibiofemoral joint line Warmth : present on Rt side (lateral aspect of the knee ) Swelling :Present over the right knee (lateral aspect) Crepitation : present Rt >Lt during knee flexion /extension.

14. On examination 1-Musculoskeletal system examination Range of motion

15. Joint reactivity : low reactivity Joint irritability : low irritability Joint play : patellar lateral mobility reduced Rt >Lt

16. Manual muscle testing :

17. Q angle measurement : Rt - 13 deg ; Lt – 15 deg Tibial torsion : medial torsion present on rt side. Tightness : not present Special test : Clarke’s test positive b/l All systems i.e. Neurological , cardiovascular , pulmonary are intact. Myopia present which is corrected by glasses. Psyco -social assessment: 1. MMSE- 30/30 2. GDS- 6/15 suggestive of mild depression

18. Functional assesment : Tug : 16 Bbs : 52/56 Gds : 6/15 Womac : 45/96

19. ICF HEALTH STATUS:- Mrs Madhumati M 62 years old female comes with a complaint of pain since 2 years in the lateral aspect of the knee right> left is diagnosed with tibiofemoral osteoarthritis of right knee(Grade 3) and patellofemoral arthropathy of left knee CO MORBID FACTORS:- None

20. BODY STRUCTURE DOMAIN INTACT IMPAIRED Supportive findings CLINICAL REASONING QUALIFIER Structure related to movements B/L hip and ankle joint Knee joint- ligament, bursa 1.Right tibiofemoral joint – a. Articular cartilage Radiograph X-ray (AP view) dated 26/12/18 revealed joint space reduction in left knee on medial aspect and definite narrowing of joint space and moderate osteophyte formation Due to aging ,repetitive wear and tear and improper weight bearing there is defibrillation of the cartilage there is increase in water content, loss of proteoglycans and focal loss of chondrocytes moderate

21. -disturbance of dissipation of stresses makes he cartilage subject to excessive stress and strain and leads to decreased nourishment and eventually necrosis of the cartilage. Progression of process results in loosening and flaking of the articular cartilage results in inflammation as the cartilage fragments that break off and irritate the  synovium . Inflammation stimulates macrophages , results in the release of cytokines and interleukin 1 , Futher stimulates the synovial fluid to produce plasminogen activators. that are proteases causing cartilage destruction.

22. Also degneration causes chondrocytes to produce more type 1 and type 2 collagen and loss of proteoglycans – loss of extracellular matrix- Decrease in elaticity and wearing out.

23. DOMAIN INTACT IMPAIRED CLINICAL REASONING QUALIFIER b.Bone The cartilage gets abraded by the grinding mechanism between the apposing surfces . Eventually the cartilage develops fissures and erodes resulting in exposure of thr subchondral bone with further rubbing the the subchondral bone becomes hard and glossy  remodeling of bone occurs flattening of articular end . moderate

24. Osteophyte formation X-ray There is inflammatory synovitis because of which the joint margin hypertrophies – cytokines stimulates osteocyte to change osteoblast to osteophyte formation-,there is new bone and cartilage outgrowths at the margins of the articular cartilage, they form projecting spurs are called osteophytes . moderate Subchondral sclerosis X-ray As the cartilage gets eroded, microfractures of the trabaculae develop in the subchondral bone – reabsorption of these microfractures result in subchondral cyst formation – the cytokines trigger osteocytes activity causing dispropotion between the formation of new bone cells in response to degeneration . moderate

25. Narrowing of medial joint space X – ray Due to age and over use of joint , damage to the articular cartilage there is excessive weight bearing on the articular surfaces resulting in reduction of joint space. moderate 3 .Lateral shift of patella Improper weight bearing- Constant pull of the lateral musculature of the knee joint- overfiring of tfl – lateral shift of patella moderate

26. intact Impaired Supportive findings CLINICAL REASONING QUALIFIER 4.Flexion deformity On observation Loose flakes of cartilage incite synovial inflammation , thickening of the capsule occurs, also adaptive flexion posture to accommodate excess swelling results in flexion deformity Severe 2.Left patellofemoral joint due to age related degenerative changes and altered kinematics of the rt the knee also undergoes osteoarthritic changes. mild

27. INTACT IMPAIRED SUPPORTIVE FINDING CLINICAL REASONING MUSCLES OF BILATERAL UPPER LIMB LOWER LIMB – B/L HAMS, TA, GLUETS, PLANTARFLEXORS AND DORSIFLEXORS LT - quads and hams , it band RT- quads and hams ON OBSERVATION chronic pain  Inhibition of the muscles  DUE TO REFLEX inhibition of muscles-- weaknesss of muscle disuse atrophy severe Rt - it band friction syndrome On palpation Tightness of the band as it overfires to compensate for the improper weight bearing over time leads to increase in friction and irriation when the band crosses back and forth at the lateral femoral condyle moderate

28. DOMAIN (BODY FUNCTION INTACT IMPAIRED Supportive finding CLINICAL REASONING QUALIFIER Related to sensory function and pain Sensory function Pain Pain history Repetitive wear and tear damage to articular cartilage and subchondral boneactivation of inflammatory responserelease moderate Of inflammatory mediators like cytokines and prostaglandins stimulation of free nerve endings leading to pain

29. Related to neuromusculokskeletal and movement related function Neurological system 1. Crepitus on both knee rt > lt On palpation while performing flexion and extention Defribillated /fragmented segments of cartilage results in loose body formation whoch come in between the bony surfaces while performing the movement moderate 2.Rom –re Duced A - flexion On examination Soft tissue approximation increases the compressive forces acting on the joint resulting pain and reducced r.o.m mild B- extension Due to pain, swelling, the patient avoids movement which leads joint stiffness which reuslts in decreased r.om mild

30. 3.Strength – weakness of quadriceps and gluteus maximus On manual muscle testing Reflex inhibition of the musculature due to pain and altered mechanics of joint results in reduced strength moderate 4-swelling On observation Joint effusion caused by inflammation of the synovial tissues. 5tenderness over lateral and medial patellofemoral and lateral tibiofemoral joint line the On palpation Osteophyte formation and swelling results in release of cytokines like IL-1B , TNF etc that produce tenderness

31. DOMAIN INTACT IMPAIRED CLINICAL REASONING QUALIFIER 6joint stiffness On history and examination Due to synovial joint effusion and capsular thickening results in morning stifess moderate 7.Gait ( antalgic gait) On gait examination To avoid compensation forces avoiding weight bearing on right knee mild

32. DOMAIN ACTIVITY AND PARTICIPATION LIMITATION CAPACITY PERFORMANCE D2 – general task and demand Able to do activities of upper limb Difficulty doing household tasks Should be able to perform all activities without pain Difficulty in performing activity pain free and requires assisstance D4 - mobility standing Should be able to perform pain free Difficulty in standing for prolonged period of time walking Should be able to perform Uses compensatory mechanism to avoid pain

33. DOMAIN ACTIVITY AND PARTICIPATION LIMITATION CAPACITY PERFORMANCE Stair climbing Should be able to perform without assisstance Uses support of bars for stair climbing Cross sitting Should be able to sit in cross sitting comfortably Avoids sitting down due to pain and stiffness D5- self care Combing, brushing, bathing,grooming Toileting activity Should be able to sit in full squat position Sits in half squat position due to pain and stiffness in knee

34. CONTEXTUAL FACTORS FACILITATOR BARRIER ENVIRONMENTAL FACTORS Product and technology Support and relationship attitudes Stairs(8 steps) Indian washroom Slippery floor of house PERSONAL FACTORS Coping styles Individual character style Age Gender Lifestyle Education Profession (housewife)

35. Management Problem list : 1-difficulty in performing sit to stand activities 2- pain in climbing stairs 3- difficulty in performing household tasks of daily living.

36. Acute Care Management 1- Patient Education : The patient is educated about the course of the disease , causative factors and prognosis. The patient is given advice for joint protection and enegry conservation :- Monitor activities and stop when discomfort Use short episodes of exercise Alternate activities to avoid faitgue

37. d)Maintain a functional level of joint rom and muscle strength and endurance. e) Balance and rest to avoid muscular and total body faitgue f) Avoid deforming positions g) Maintaing a good posture h) Work in pain free range i )Use of splinths to promote blood flow, amd safe functional activities that reduce stress on the knee.

38. 2 Pain management : Depending on symptoms, Use of thermal agents along with I.F.T or TENS for pain treatment and symptomatic treatment respectively Thermal agents : Hot packs : on the I.T band, quadriceps Dosage : 8-10mins Rationale : Increased circulation to your injured body part helps to bring in nutrients, oxygen, and cells that help to promote healing. This increased circulation can also wash away metabolic waste materials that may gathered around your injured body site.

39. b) Cold packs : in the supra and infra patellar region of the knee joint , where swelling is present Dosage : helps in reduction of edema (Lewis Hunting reaction ) and decrease release of pain inducing irritants by blocking the “fast “ pain signals carried by Adelta fibres . Has little effect on the conduction of Cfibres by reducing the rate of firing of nociceptors that is the rate at which pain signals are produced

40. TENS for pain relief : HIGH TENS/ CONVENTIONAL : frequency :50-100Hz Pulse width : 20-60 microsecond Intensity : 0-30mA Duration :30-60 twice daily Principle : presynaptic inhibition by pain gate mechanism by stimulating A delta and C fibres USE : in acute conditions

41. ULTRASOUND : Mode : Pulsed (in acute stage) Output frequency : 3MHz Duration : 8-10mins Rationale : increases blood flow , supply of fresh nutrients and wash out of irritants , therefore decreases swelling as well as promotes tissue healing and decrease in inflammation . Also increases the connective tissue extensibilty just decreasing joint stifness . Swelling :

42. TO MAINTAIN SOFT TISSUE AND JOINT MOBILITY: Mobilizations : Grade 1 maitland oscillations along with the thermal agents and tens for pain relief as well as maintain joint mobility . Active Assisted exercises : Perform all the activities in the pain free range For eg : the patient may be able to perform active R.O.M in gravity eliminated , side lying or self assisted R.o.M

43. Maintaining joint mobility and integrity : To Maintain joint movement : A )Isometric exercise : of quads, hams , gluteus and gastro bilaterally dosage : 10 times/ session b) Multiple angle isomterics : quads, hams muscle setting exs with the knee in various pain free positions. Eg : Setting exs for co- contaction Alternating isometrics with rhythimc stabilisation

44. FUNCTIONAL ADAPTATIONS : INSTRUCT THE PATIENT TO MINIMIZE STAIR CLIMBING, USE ELEVATED SEATS OF COMMODES AND AVOID DEEP SEATED OR LOW CHAIRS TO MINIMIZE THE STRESS IN THE KNEE . IF NECESARRY DURING THE ACUTE FLARE OF OA, USE OF ASSISTIVE DEVICES CAN BE ADVISED.

45. FUNCTIONAL RESTORATION PHASE : TO IMPROVE SIT TO STAND ACTIVITIES : Continue thermotherpay so that it reduces the stiffness and muscle spasm . Goal 1 – increase strength : Isometric training of gluets , hams, quads, and gastro muscle with 10sec hold , 5-10 repetitions Hip muscles : Knee to chest , hip flexion in high sitting side lying hip abduction adduction Clamp shelss Lunges- sidewards - forward

46. Knee muscle : a)leg extension b) Leg raises with knee extension c) VMO strengthening d) Knee flexion in prone Ankle muscle: Heel raises Toe raises Leg raises with dorsiflexion and plantarflexion Begin with multiple angle angle isomterics to both knee flexion and extension in open and closed chain exs . PNF mthods can also be used

47. Dose : 10timeas, 2-3 reps/ Day Rationale : reuired to increase tolerance to adl , joint stability , preparatory phase for ambulation. GOAL 2 : it band trigger release and stretches Trigger point release using myofascial release for 5-10mins as reuired . It band rehab : Ice pack for 10-15mins It band release using foam roller

48. It band stretches :

49. Dosage : 5-7 times ,2reps/day rationale : prevents overfiring of the band, prevsnts lateral shift of patella that alters biomechanics at the knee thus reduces stress on the medial compartment .

50. GOAL 3 : TO IMPROVE MOBILITY : A)GRADE 3 or 4 sustained or oscillatory techniues to the tibiofemoral and patellofemoral articulations. B)To improve flexion : position tibia in medial rotattion and apply posterior glide against anterior aspect of the medial tibial plateau C)To improve extension : tibia in lateral rotation and apply anterior glide against the posterior aspecy of the lateral tibial plateau. D) MET :contract relax method can be used askingthe patient to use 20 percent of his strength against resistance folllowed by relaxation and passively moved to the new range by the therapist

51. GOAL4 : GLUETS STRENGHTENING a)Bridging b)One leg bridging c) Hip extension in prone with therabands , weight cuffs tied d) Alternate legs and hand extension in all fours position Dose : 8-10 times, 2-3 times a day Rationale : helps to build a strong proximal musculature neede for stair climbing

52. GOAL 5 : functional training : a ) Wall slides and minisuats to 90 if tolerated b)Partial lunges c)Balance activities d)Ambulation on various terrains e)Sit to stand activities from various depths

53. GOAL 5 : ENDURANCE TRAINING AND STRATEGY Once strength is achived then strategize : Use of hand bars to grasp while sitting down or getting up from the commode Use safe biomechanics while picking up objects from the floor Use of therabands to provide self resistance while performing minisquats . use of railings while climbing stairs Orthotic support if necessary . RATIONALE : FOR THE ACHIVED STRENGTH AND MOBILITY TO BE MAINTAINED

54. Preventive management Risk Factor : Age Management : Health Promotion Includes : a) Environmental modifications : identifying the potential risk factors in the environment and their modification. For eg : well lighted house, non-slip floors, railings for stair climbing, hand bars in the washroom.

55. b) Dietary advice : advise the patient to take a proper and well balanced diet in terms of proteins, carbs , fats. c) Stress Management :show the patient relaxation techniques like Jacobsons ..and coping strategies. d) Lifestyle Modification : regular exercises, advise for periodic health check ups.

56. Risk Factor: Gender (prone to osteoporosis post menopause) Management: Weight bearing exercises for the trunk and upper and lower limb. Risk Factor : Balance Management : Single leg stance Turning 360degrees Tandem standing ( with eyes open and eyes close)

57. Risk Factor : Cognition Management : solving jigsaw puzzles, hobbies like drawing, playing chess, card games, scrabble etc Risk factor : Aerobic Capacity Management : Low impact exercises Frequency :3-5 times/week Intensity : 60-80 % of Hrmax Time : warm up-10mins, 30-40 mis exercise , 10mins cool down Type : walking, jogging, cycling