Osteoarthritis

1. Osteoarthritis or O = O ld age, A = A rthritis By: Dr . P. Ratan Khuman (PT) M.P.T., (Ortho & Sports ) Sr. Lecturer C.U. Shah Physiotherapy College

2. Introduction OA is one of the most common condition treated by the Physiotherapist. Osteoarthritis is the most common form of arthritis worldwide.. It can occur in any synovial joint; the commonest sites being the knees, hips & small hand joints. Consequences of OA include pain, reduced function, & restriction in daily activities. Management is made complex because structural changes can occur without the patient displaying any symptoms. 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 2

3. Introduction cont… 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 3 The word "arthritis," meaning "inflammation of a joint," is a misnomer.

4. Definition 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 4 Carol David, 1999 Definition of OA vary, but considered to be a chronic degenerative & progressive condition affecting synovial joint. John Ebnezar , 2003 It is a degenerative, non-inflammatory joint disease characterized by destruction of articular cartilage & formation of new bone at the joint surface & margins. Royal College of Physician, 2008 OA refers to a clinical syndrome of joint pain accompanied by varying degrees of functional limitation & reduced quality of life.

5. classification According to number of joint involved – Mono articular Oligo or Poly articular According to type of OA described – Inflammatory Erosive OA Generalized OA (GOA) Other classifications – Primary idiopathic OA Secondary OA Endemic OA Cooper, 1994 19-Jun-12 5 P.R.Khuman MPT, Ortho & Sports

6. Primary (idiopathic) oa Localized - hands and feet, knee, hip, spine or other joint Generalized - three or more joint areas It occurs in old age, mainly in weight bearing joints (Hip, knee) It is more common than secondary OA. M. Sofue , N. Endo, 2007 19-Jun-12 6 P.R.Khuman MPT, Ortho & Sports

7. Secondary oa 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 7 There is an underlying primary disease of the joint which leads to degeneration of the joint. It can occur at any age after adolescence. The predisposing factors are – Congenital mal development of joint Irregularity of joint surface from previous trauma Previous disease producing a damage to articular cartilage Internal derangement of the knee Obesity & excessive weight

8. Examples of secondary oa Developmental Congenital hip dislocation Legg-Calves-Perthes disease Congenital hip dislocation Epiphyseal dysplasias Mechanical Hypermobility syndromes Leg length discrepancy Mal-alignment Trauma (acute or chronic) Accidental Sports injury Occupational Iatrogenic (post-surgical) Metabolic Hemachromatosis Mucopolysaccharidoses Gout Pseudogout Calcium crystal depo sition 19-Jun-12 8 P.R.Khuman MPT, Ortho & Sports

9. Endocrine Acromegaly Hyperparathyroidism Hypothyroidism Inflammatory Any systemic rheumatic disease Septic arthritis Miscellaneous Hemophilias Paget’s disease Osteonecrosis Neuropathic arthropathy 19-Jun-12 9 P.R.Khuman MPT, Ortho & Sports

10. Endemic oa 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 10 Only found in a certain population or in a certain region (M. Sofue , N. Endo, 2007)

11. Pathology of oa 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 11 OA is a multi-factorial, metabolically active process usually begins in middle age. It was thought to be only degenerative, but it have reparative features. The activity & behavior of chondrocytes provides the key to progressive nature of joint degeneration.

12. Patho -mechanics 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 12 Increased in water content in articular cartilage Changes in quality of collagen fibers, which increased in diameter & disrupt collagen bundle. At molecular level – loss of proteoglycans in cartilage & severity of lesions appear to be proportional. ( Lotts et al., 1987) Repeated weight bearing on such cartilage leads to fibrillation. Cartilage gets abraded by the grinding mechanism

13. Patho -mechanics cont… 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 13 Further rubbing – subchondral bone become hard & glossy (eburnated) The bone at the margins of the joints hypertrophies to form a rim of projecting spurs known as osteophytes . The loose flakes of cartilage incite synovial inflammation & thickening of capsule. These leads to stiffness & deformities of the joint.

14. Incidence 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 14 Affected 44% - 70% of population of age 55years. Symptomatic OA increased with age & weight Weight bearing joints are more affected. Relationship between osteoporosis & OA is largely increasing. Athletes involves in running does not reduce the incidence of OA. Age, genetic & presence of other local articular pathology affect the biomechanical structure of joint.

15. How common is arthritis ? 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 15 1 in 8 people have osteoporosis. 1 in 10 people have osteoarthritis. 1 in 33 people have fibromyalgia. 1 in 100 people have rheumatoid arthritis. 1 in 1,000 children have juvenile chronic arthritis . 1 in 1,000 people have ankylosing spondylitis. 1 in 2,000 people have systemic lupus erythematosus . 1 in 10,000 people have scleroderma.

16. 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 16 Tissue involved in OA Cartilage Focal softening and loss Bone Osteophyte, sclerosis, but subchondral osteopenia Capsule Thickening Synovium Thickening and modest inflammation Muscle Atrophy and weakness Ligaments Degeneration Bursae Secondary bursitis Vessels Angiogenesis (formation of new blood vessels), avascular necrosis, venous hypertension

17. Clinical features 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 17 Pain Muscle spasm Stiffness Inflammation Loss of ROM Capsular pattern Muscular inhibition & atrophy Joint instability Crepitus Deformities Reduce function

18. pain 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 18 It is often most immediate importance to the patient Worsen at night – due to raised pressure in subchondral bone ( Pinals , 1996) Often raised with movement & relive with rest. Many structure may give rise to pain in OA Periarticular soft tissue – capsular/ligament strain Periosteal elevation secondary to raised intraosseous pressure Muscular pain & weakness Inflamed & overstretched synovium Refer pain from spine Inability to cope

19. Muscle spasm 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 19 It is a protective mechanism Movement cause pain so the body attempts to stop movement But prolong spasm cause pain due to metabolic accumulation & fatigue. Adaptive shortening may also occur in muscles.

20. stiffness 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 20 Probably deprivation of normal movement Subchondral micro-fractures heal & callus forms, this cause loss of joint mobility & stiffness

21. Inflammation & effusion 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 21 It is not always present unless the joint is underwent over activity Sign & symptoms includes are – Heat Erythema Tenderness Effusion Discomfort & Pain.

22. Loss of Range of motion 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 22 Combination of joint pain, stiffness & possible effusion will often cause limitation of end ROM Certain joint may develop capsular pattern with restriction in certain ROM

23. 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 23 CAPSULAR PATTENS Hip Adduction contracture – due to increase force in lateral margin of acetabulum Knee Flexion contracture. 75% medial compartment, 25% lateral, 48% PF Ankle Increase valgus force – limited inversion & supination Great toe Hallux valgus – restricted abduction Shoulder Adhesive capsulitis may develop – restricted abduction, lateral & medial rotation Hands The small joints of fingers are often involved. DIP Typically Heberden’s nodes – in 70% of OA hand PIP Bouchard’s nodes – in 35% of patients MCP In 10% of patients CMC In 60% of patients

24. Muscle inhibition & atrophy 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 24 Effusion will inhibit surrounding muscle of joint. This may be a safety mechanism as the intra articular pressure becomes relatively positive. E.g. quadriceps contraction may lead to rupture of knee joint capsule (Bland, 1994). Chronic muscle inhibition is often linked to chronic pain & will lead to atrophy & ensuring weakness.

25. crepitus 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 25 The flaked cartilage & eburnated bone end grate against each other characterized sound. Mild creaking – indicate synovitis Loud cracking – indicate advance disease

26. Joint instability 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 26 Surrounding muscle weaken & imbalance Pain episodes are unpredictable causing joint to give away. These process together with chronic stretch of soft tissue will alter joint alignment. These will lead to instability & possibly subluxation

27. deformities 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 27 Osteophyte development reduce joint instability by increasing the peripheral articular surface area. Such deformities are more profound in established OA but may not developed equally on medial & lateral. This may contribute to varus & valgus deformities Together with the soft tissue laxity, it will alter normal joint biomechanics.

28. Radiographic finding 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 28 X-ray changes – Loss of joint space Sclerosis Altered bone end shape Osteophytes

29. 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 29 Kellgren & Lawrence grading system for osteoarthritis Grade 0 Normal Grade 1 Doubtful narrowing of joint space, possible osteophyte Grade 2 Definite osteophyte, possible narrowing Grade 3 Moderate multiple osteophytes, definite narrowing, some sclerosis, possible deformity of bone ends Grade 4 Large osteophytes, marked narrowing, severe sclerosis, definite deformity of bone ends

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31. Reduce function 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 31 All the clinical features described above can result in functional difficulty. Often described problems are – walking a distance, climbing stairs, getting out of chair, writing, opening jars etc. But most patients compensate by alternative ways of achieving the task.

32. 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 32 Inflammation Pain Loss of ROM Muscle atrophy Effusion Muscle Inhibition Instability Reduce Function Inter-relationship of symptoms & sign in OA

33. ROLE OF KNEE LOADING IN Oa 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 33 Knee loading plays a major role in OA knee development and progression . During the stance phase of gait, high loads are applied to knee in both sagittal and frontal planes . T he most relevant load is the external knee adduction moment (AM) in the frontal plane generated because the ground reaction force vector (GRFv) passes medial to the joint center . This moment forces the knee laterally into varus & is resisted by an internal abduction moment, resulting in compression of the medial joint compartment & stretching of the lateral structures .

34. ROLE OF KNEE LOADING IN Oa 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 34 The AM influences the load distribution between the medial & lateral plateaus. The higher the AM the greater the load on the medial plateau relative to the lateral plateau. Importantly, the AM during gait is a factors known to predict OA progression in humans . A 20 to 30% increase in the AM is associated with a 2.8 to 6.5 time increase in the risk of progression.

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36. LOCAL MECHANICAL FACTORS Influencing KNEE LOADING & PHYSICAL THERAPY OUTCOMES 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 36 The effectiveness of physical therapy interventions in knee OA is likely to differ depending on local mechanical factors . The main local mechanical factors are – Mal-alignment Laxity .

37. Mal-alignment 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 37 The mechanical alignment of LL influences distribution of loads across the medial and lateral knee joint compartments. Pre-existing mal-alignment - contribute development of OA Or mal-alignment may arise - consequence of OA process due to cartilage loss, bony attrition, and meniscal damage. Mal-alignment has been shown to be mediator for the effects of other factors (such as obesity) on disease progression .

38. 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 38 GRFv – In Neutrally Aligned Knee – passes slightly medial to knee joint In Varus Knee – displaced more medially to knee In Valgus Knee – passes more laterally to knee

39. Laxity 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 39 Passive knee laxity refers to abnormal motion of tibia with respect to femur in unloaded state . It is determined by ligaments, joint capsule, other soft tissues, and the joint surfaces . Varus-valgus laxity has been found to be greater in people with knee OA . Dynamic stability relies on integrity of passive structures with the coordinated activity of muscles around the knee joint.

40. 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 40 Declines in joint stability can lead to a change in load distribution. The cartilage may then be less able to withstand applied loads and this may lead to degeneration .

41. Diagnostic Approach to Joint Pain & OA 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 41 Diagnosis of OA is made clinically based on – History Physical examination Laboratory and radiologic investigations To exclude inflammatory arthritis , secondary osteoarthritis , and non-articular causes of joint pain .

42. 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 42 A practical diagnostic approach to a patient presenting with joint pain, which is suspected to be due to osteoarthritis is to ask 3 questions: Is the source of pain articular or non-articular? If articular, is the pathology osteoarthritis? If osteoarthritis, is the pathogenesis idiopathic (primary) or secondary ?

43. Is it articular or non-articular pain? Peri-articular soft tissue pain: Ligament (tear/strain) Tendon (tendonitis, enthesitis) Muscle (myositis, myofascial pain, disuse atrophy, tight hamstrings) Fascia (fasciitis, iliotibial band syndrome) Bursa (bursitis) Plica Fat pad (Hoffa’s syndrome) Blood vessel (aneurysm, varicose veins) Bone (avascular necrosis, tumour) Nerve (neuroma ). Referred pain: , e.g. knee pain due to: Hip pathology Myofascial piriformis pain Prolapsed lumbar disc with sciatica . Central pain: Fibromyalgia Restless Leg Syndrome Complex regional pain syndrome (Sudeck’s dystrophy). 19-Jun-12 43 P.R.Khuman MPT, Ortho & Sports Palpation is key in evaluation. Non-articular sources of joint pain include :

44. Is it osteoarthritis ? 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 44 As osteoarthritis has no specific clinical characteristic or diagnostic laboratory test, and radiographic findings may not correlate with clinical severity, the diagnosis is made clinically based on history and physical examination, with laboratory and radiologic tests selectively undertaken to exclude inflammatory arthritis, secondary osteoarthritis, and non-articular causes of joint pain.

45. “red-flags ” to alert diagnosis of oa 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 45

46. Is it primary or secondary oa? 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 46 Primary/idiopathic OA has a symmetrical predilection for joints of fingers, hips, knees & spine. Involvement of other joints should prompt an evaluation for secondary causes of osteoarthritis : Trauma, Charcot’s (neuropathic) joint, Avascular necrosis Inflammatory arthritis Crystal arthropathy Rheumatoid arthritis Septic arthritis Congenital/developmental

47. pattern of joint involvement 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 47 Primary OA can be further subdivided into localized or generalized (involving 3 or more sets of joints ) The more common joints involved in OA are shown shaded in the figure:

48. Pharmacological Conservative Surgical Management of Oa 19-Jun-12 48 P.R.Khuman MPT, Ortho & Sports

49. Pharmacologic Rx of OA 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 49 Acetaminophen NSAIDs Non-selective NSAID COX-2 selective Tramadol, opioids Joint injection Supplements Glucosamine Chondroitin sulfate etc.

50. “Those who think they have not time for bodily exercise will sooner or later have to find time for illness” —Edward Stanley, British Prime Minister (1799-1869) PHYSICAL THERAPY INTERVENTIONS FOR KNEE OA 19-Jun-12 50 P.R.Khuman MPT, Ortho & Sports

51. Aims of physical therapy 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 51 To educate the patient To reduce pain, inflammation & stiffness To eliminate aggravating factors To maintain or improvement of ROM To maintain or improvement, of muscle strength To restore muscle balance To reduce stress on the involved joints To retrain gait To maintain or improvement in functional independence, including participation in a vocational activities

52. Patient Education 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 52 A major objective of education is to improve patient knowledge in order to integrate him or her into the decision-making team. Content should include information concerning OA pathophysiology , clinical presentations, how the disease is assessed, its natural course & the indications and expected results of various Rx modalities. T he route of administration include discussions with health professionals, group discussion or self-reviewed materials (e.g., booklets, web sites ).

53. Exercise 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 53 Goal of exercise – To prevent or delay disability. An exercise program should incorporate – To lessen pain during activity To increase or maintain joint ROM, To strength muscle , To stabilize joint & To improve aerobic capacity or level of conditioning. Exercise in OA should be adapted according to the presence and severity of pain .

54. Exercise cont… 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 54 In painful episodes – Isometric exercise Non weight-bearing exercise (OCK) e.g ., biking, rowing with adapted tools or Partial weight-bearing exercises (CKC) e.g ., aquatic exercises should be recommended. In painless (or less painful) periods – The exercise program may include progressive muscle performance exercises.

55. Strengthening Specific Muscles 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 55 Quadriceps Muscle Strengthening – A possible role for quadriceps-strengthening ex in slowing disease progression was first explored in 1999. Muscle weakness ( particularly quadriceps ) is a well-recognized impairment in people with knee OA. It has been associated with increased pain & a greater deterioration in function over time . Quadriceps strengthening has formed the cornerstone of traditional OA exercise therapy.

56. Strengthening Specific Muscles cont… 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 56 Quadriceps Muscle Strengthening – cont… Quadriceps strengthening ex have consistently found significant reductions in pain & improvements in physical function . Stronger quadriceps muscles reduced the risk of developing radiographic knee OA. Quadriceps muscles play a large role in resisting the abduction moment (AM). Women with a moderate to high isokinetic quadriceps strength had respectively a 55% - 64 % reduced risk of developing hip or knee OA .

57. Strengthening Specific Muscles cont… 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 57 Hamstring Muscle Strengthening – Weakness of the hamstring muscles has been found in patients with knee OA. Control of varus-valgus laxity is largely produced by co-contraction of the quadriceps & hamstring muscles. An increase in hamstring strength was associated with less deterioration in function in people with knee OA .

58. Strengthening Specific Muscles cont… 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 58 Hip Abductor Strengthening ( Frontal plane mover )– Strengthening the hip abd muscles controlling pelvic position in frontal plane may reduce knee loads and slow disease progression. Weakness of hip abductor – Drop in the level of the pelvis , Shifting the center of mass (COM) and Increasing the knee AM . Strengthening abductor muscles could reduce knee load by increasing toe-out during gait

59. Strengthening Specific Muscles cont… 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 59 Hip adductor muscles ( Frontal plane mover ) – Assist in resisting the knee AM – particularly in a varus mal-aligned knee . Eccentrically restrain the tendency of the femur to move into further varus Knee OA had stronger hip adductors compared with age-matched controls group. Hip strengthening could be a novel intervention for rehabilitation of knee OA patients .

60. 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 60 F ig: Hip adductor muscles reduce knee varus by their distal attachment to the proximal femur.

61. Strengthening Specific Muscles cont… 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 61 Strengthening of hip extensor ( Sagittal plane mover ) – Hip extensor muscle play an important role in dynamically stabilizing hip & pelvic in sagittal plane. The gluteus maximus act as a restraint for forward progression during gait. It also helps to minimize deformity in sagittal plane. E.g. hip & knee flexion deformity S trengthening should consider both short & long lever

62. Exercise – stretching 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 62 Stretching ex for hip flexor, hamstring & calf musculature helps improving ROM, pain & flexibility of knee OA. It should be made as a routine part of Rx.

63. Recommendations for musculoskeletal flexibility 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 63 Mode: Gentle static stretching Frequency: Minimum 2–3 days/week Intensity: Stretch to a position of mild tension/discomfort Duration: Hold position for 10–30 seconds Repetitions: 3–4 repetitions for each stretch

64. Muscles imbalance in bow-leg Hip – Flexors Knee – Medial hamstring Q,ceps Ankle – Gastrocnemius (medial head) Hip – Abductors Extensors Knee – Lateral hamstring Q,ceps (VMO) Ankle – Gastrocnemius (lateral head) 19-Jun-12 64 P.R.Khuman MPT, Ortho & Sports Tight or Short Muscles Weak or Elongated Muscles

65. Muscles imbalance in knock -knee Hip – Flexors Adductors Knee – Lateral hamstring Q,ceps Ankle – Gastrocnemius (lateral head) Hip – Abductors Extensors Knee – Medial hamstring Q,ceps (VMO) Ankle – Gastrocnemius (medial head ) 19-Jun-12 65 P.R.Khuman MPT, Ortho & Sports Tight or Short Muscles Weak or Elongated Muscles

66. Gait Retraining 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 66 Gait patterns can influence loading at the knee joint, and thus changing them through gait retraining could slow disease progression . Parameters altering include – toe-out angle, walking speed & location of loading under foot during stance. Although patients may be able to alter their gait pattern when instructed in clinic, use of biofeedback devices, leg/foot taping, or other strategies may be necessary to allow the pattern to become habitual.

67. Gait Retraining cont… 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 67 Degree of toe-out It represents the angle of foot placement (FP) It is the measure of angle formed by each foot’s line of progression & a line intersecting the center of the heel and the 2 nd toe. Normal angle for male 7 The degree of toe-out decreases as the speed of walking increases in normal men. Toe-out angle – There was 10% reduction in odds of structural disease progression per additional 1 of toe-out angle. Thus, small alterations in toe-out angle may have clinically relevant effects .

68. Gait Retraining cont … 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 68 Walking speed – It is another factor associated with knee load , with faster walking speeds increasing all knee loads (including the knee AM). Indeed , people with knee OA often walk more slowly than the average, which is thought to be an adaptive mechanism in reducing knee loads.

69. Aerobic Exercise 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 69 Aerobic exercise – including cycling, swimming, and walking has been found to be effective for relieving symptoms in knee OA. Such exercise could also have benefits for longer-term joint health by assisting with weight reduction . the combination of dietary weight loss and exercise ( including both aerobic and resistance components) was more effective in improving function and pain in people with knee OA

70. Orthoses/ knee bracing 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 70 Supports , braces & corrective devices may assist in relieving pain & improving function of affected joints. They are used – To reduce vertical forces applied to skeleton at heel strike Realign unstable or structurally deficient joints with restoration of normal force distribution Improve proprioception; and improve stability and patient perception of instability.

71. 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 71 Patellofemoral joint brace Unloader knee brace

72. FOOTWEAR AND INSOLES 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 72 Lateral Wedges (LW) – Wedged insoles were first proposed as a treatment for knee OA in the 1980s by Japanese researchers. Wedged insoles exert a mechanical effect on the lower limb by altering the magnitude, temporal pattern, and plantar location of GRFv acting on the foot during gait . LW increase the subtalar joint valgus moment thereby reducing the moment arm of the knee AM arm in the frontal plane.

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74. Shock-absorbing Insoles 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 74 Viscoelastic materials used in footwear or in insoles augment body tissues (particularly the heel pad) in reducing the magnitude of the heel-strike transient . With age, heel pad structure alters and results in a loss of shock absorbing capacity. Viscoelastic insoles can attenuate transient forces incurred during walking, running, stair climbing, and jumping activities.

75. Electrotherapy for pain 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 75 Electrotherapeutic modalities are widely used in PT departments to decrease pain associated with OA. Popular Rx include - US, IFT, SWD, LASER & TENS. The proposed physiological effects of these modalities include deep heating, increased blood flow, reduced muscle-spasm , promotion of inflammatory response, and pain relief .

76. 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 76 There are many laboratory-based studies that demonstrate the physiological effects of electrotherapy modalities that should theoretically produce therapeutic effects. Until clinical trials replicate laboratory findings, electrotherapy cannot be considered an efficacious , cost-effective, evidence-based intervention for OA. However, it should be noted that patients generally like electrotherapy Rx & considerable placebo effects could be used to enhance other aspects of a Rx package.

77. Thermotherapy 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 77 Heat applied through various heated packs, relieves pain Heat ‘close the pain gate’, improved local circulation, increased collagen extensibility, reduced muscle spasm, and improved ROM. Similarly , cold therapy applied through ice packs or baths may relieve pain via the ‘pain-gate’ mechanism, reduced peripheral nerve excitability , and reduction in joint effusions and oedema. Thermotherapy appears to be a simple, cost-effective, means of assisting pain control & therefore is an appropriate tool in patient self-management regimes.

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79. Ultrasound ( US) 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 79 Ultrasound (US) is probably the most commonly used electrotherapy modality , especially for hip, knee, and vertebral OA. It is claimed to alters cell function, vascularity, and collagen extensibility, resulting in a proinflammatory effect. A meta-analysis of US in musculoskeletal conditions concluded that it has no role in the relief of pain.

80. Transcutaneous electrical nerve stimulation (TENS ) 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 80 TENS receives widespread use in many acute & chronic pain conditions. The main theoretical rationale for pain relief is that electrical stimulation of large diameter neural fibres ‘closes the pain gate’. Alternatively , counter-irritant stimulation may facilitate release of endogenous opioid substances. TENS can effect pain relief when used at high frequency or strong burst mode for more than four weeks.

81. Interferential therapy (IFT ) 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 81 Physiological effects of this modality differ according to level of stimulation & type of nerves fibres stimulated. Stimulation of motor nerves – Leads to muscle contraction, as a result increases circulation in the area. This is of limited use in OA where active exercise is of proven benefit Sensory nerve stimulation – Facilitating opioid production and ‘closing the pain-gate ’. However, there is no evidence for its benefit in stimulating healing & only limited evidence supporting analgesic effects .

82. SWD 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 82 SWD have been used in a variety of orthopaedic and musculoskeletal conditions with varied success. Pulsed or continuous delivery results in tissue heating and subsequent increased circulation of treated area. Cell membrane potentials may also be effected although this theory remains contentious. Study suggested that pulsed Rx relieved pain in subjects with knee OA.

83. Low-level laser therapy (LLLT) 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 83 LLLT has evolved as a therapeutic intervention for OA over the last decade. Therapeutic doses are too low to induce thermal effects within the tissues and the physiological benefits are thought to derive from photochemical reactions at cellular level, which produce an anti-inflammatory effect. A recent review failed to conclude whether LLLT was beneficial in Rx of OA.

84. Balneotherapy (hydrotherapy or spa therapy ) 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 84 Balneotherapy is one of the oldest recorded treatments for rheumatic conditions. It utilizes buoyancy—the assistant and resistant properties offered by water- in combination with the ‘healing ’ effects of warm, mineral rich waters. The aim is to relieve muscle spasm, increase joint ROM and muscle strength, with subsequent improvement in function.

85. Spa Therapy 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 85 Spa Therapy is normally delivered on a 2–3 week residential basis at spa resorts. It consists of daily thermal bathing , exercise sessions, mudpacks, and jet massage.

86. Hydrotherapy 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 86 Hydrotherapy consisting of heated pool is popular with patients , and effective in relieving pain, improving joint ROM & patient function & quality of life. Due to demand and limited resources, Rx are normally of short duration with little possibility of follow-up Rx. Patients with a variety of rheumatic conditions benefit from balneotherapy, with reductions in pain and muscle spasm, and accompanying improvements in functional activities. At present it is an expensive intervention based on scientific evidence .

87. Walking aids 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 87 Sticks & crutches are supplied to reduce the stress applied to weight bearing joints and to improve patient stability during ambulation. Unfortunately, walking aids are not always popular with patients, who perceive them as being for the elderly and infirm. They can also be impractical when performing other functional activities.

88. Walking aids cont… 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 88 Historically, patients have been encouraged to use walking aids on the contralateral side to the problematic joint, thus encouraging improved weight distribution , and an energy efficient gait pattern. For knee patients walking aids function as a vertical load-sharing implement and cannot effect forces in the frontal plane .

89. Manual therapy 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 89 Physiotherapists, osteopaths and chiropractors use manual techniques , to reduce joint pain and stiffness , and increase ROM. Manual therapy applied to knee together with an ex programme may be used to improve knee function & pain relief for patients with OA of the knee. Manipulation often gain short-term benefit. Studies suggest minimal efficacy in relieving pain, improving ROM and function .

90. Joint Mobilization cont… 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 90 Despite, it is still commonly used in outpatient departments in conjunction with other modalities such as electrotherapy and exercise. Further work is necessary to determine the efficacy of these interventions especially at different stages of disease progression, as there is a possibility that benefits will differ accordingly.

91. Massage 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 91 Patients frequently report that rubbing or massaging a joint temporarily relieves pain, probably because the mechanical stimulus excites large diameter nerve fibres closing the pain gate. The additional application of topical agents may enhance the benefits of massage. However , one back pain study reported that massage was no better than manipulation, but was inferior to TENS, in relieving pain. Massage is likely to be used by patients and encouraged by practitioners .

92. Patellar taping 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 92 Aim is to control patellar tracking and minimize contact stress Most common method is medially directed taping to offload lateral compartment of PFJ Significant improvements in pain and physical function Direct effect on pain not attributable to placebo or cutaneous stimulation No research on long-term effects of taping or role in disease pathogenesis

93. Physical activity recommendations for health 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 93 Activity: Daily activity (walking, yard work, etc.) Frequency: Most days of the week Intensity: Moderate; 55–70% of age-predicted maximal heart rate; RPE 2–4 Duration: Accumulate at least 30 minutes of activity (e.g ., three 10-minute bouts )

94. Recommendations for physical fitness (cv fitness) 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 94 Mode: Rhythmic, aerobic exercise (walking, jogging, cycling, swimming , etc.) Frequency: 3–5 days/week Intensity: 70–85% age-predicted maximal heart rate; RPE 4–5 Duration: 20–30 minutes continuous

95. Recommendations for physical fitness (muscular fitness) 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 95 Mode: Dynamic, resistance exercise for major muscle groups Frequency: 2–3 days/week on alternate days Volume: 8–10 exercises; resistance adequate to induce moderate, volitional fatigue after 8–12 repetitions. If the subject is more than 50–60 years of age or frail, or the primary goal is to improve endurance, choose a level of resistance that will produce moderate fatigue after 10–15 repetitions .

96. references 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 96 M. Sofue , N. Endo, Treatment of Osteoarthritic Change in the Hip Joint Preservation or Joint Replacement?, 2007 J. Maheshwari , Essential Orthopaedics , 3 rd edition, 2008 John Ebnezar , Essential of Orthopaedics for Physiotherapists, 1 st edition, 2003 Carol David, Jtll Lloyd, Rheumatological Physiotherapy , 1999

97. 19-Jun-12 P.R.Khuman MPT, Ortho & Sports 97 Dr Marwan Bukhari , The NICE guideline on osteoarthritis: treatment and management in primary care , 2008 ROYAL COLLEGE OF PHYSICIANS, OSTEOARTHRITIS National Clinical Guideline For Care & Management In Adults, 2008