physiotherapy assessment & management in arthritis.pptx

Introduction
Osteoarthritis is characterized by the progressive destruction of cartilage and the formation of bone near cartilage, affecting one or more synovial joints and soft tissues. It leads to impairment, activity limitations, and participation restrictions, making it a significant public health issue.

Epidemiology
The incidence of OA increases after the age of 40.
Men are more commonly affected before the age of 40, while women are more commonly affected after 40.
Etiology
Factors include aging, genetic predisposition, trauma, occupational microtrauma, malalignment (e.g., varus deformity at the knee), obesity, and femoroacetabular impingement.
Pathophysiology
Normal cartilage consists of chondrocytes, type-2 collagen, and proteoglycans.
Cartilage has no nerve supply, blood, or lymphatic vessels; it receives nutrition and eliminates waste through synovial fluid.
Extreme loading on cartilage is detrimental, while moderate loading promotes proteoglycan synthesis and concentration.
Disease Onset & Course
OA onset is gradual and may go undetected initially.
Pain is triggered by specific activities and later becomes chronic and severe.
It is a slow progressive condition with variable prognosis, contributing to increased disability, especially with aging and other comorbid conditions.
Classification & Diagnostic Criteria
OA can be classified as primary or secondary, localized or generalized.
Radiographic classification is a 5-point system ranging from normal (Grade 0) to severe (Grade 4) joint damage.
Clinical criteria for diagnosing OA in the knee, hip, and hand include persistent pain, morning stiffness, reduced function, crepitus, and limited range of motion.
Radiography
X-rays and high-resolution MRI are used to detect structural changes and pathology.
Real-time ultrasound can detect effusion, synovitis, early osteophyte formation, and Baker's cyst in the popliteal region.
Clinical Presentation
Symptoms include pain, swelling, reduced range of motion (ROM), and bone deformity.
Commonly affected joints include DIP, PIP, CMC, cervical and lumbar spine, hip, knee, and MTP of the greater toe.
Morning stiffness lasts less than 30 minutes, and crepitus can range from painless to extremely painful.
Severe fatigue is common due to pain, decreased physical activity, and depression.
Progression
The disease involves increased water content and proteoglycan disruption in the cartilage matrix.
Subchondral bone changes include sclerosis, cyst formation, and osteophytes.
Inflammatory reactions and increased cytokines contribute to low-grade synovitis.
Medical Management
Drug therapy focuses on pain relief rather than disease progression.
Treatment includes oral analgesics (e.g., acetaminophen), NSAIDs, intra-articular corticosteroid injections, and visco-supplementation (hyaluronic acid injections).
Topical treatments include analgesics and anti-inflammatory agents.
Rehabilitative Management
Patient education and self-management are crucial.

1. Arthritis B y Avani Akbari (FY MPT)

2. Contents Introduction Epidemiology Etiology Pathophysiology Disease onset & course Classification & diagnostic criteria Radiography Clinical presentation Progression Medical management Rehabilitative management

3. Introduction ≥1 synovial joint & soft tissue affected two pathological feature - Progressive destruction of cartilage & Formation of bone near cartilage Impairment, activity limitation & participation restriction Important public health issue

4. Epidemiology Incidence ↑es >40 Before 40 - men > women After 40 - women > men

5. Etiology Aging Genetic factor Trauma in adulthood Microtrauma (occupation require heavy lifting - hip OA), (occupation require kneeling & heavy lifting – knee OA) Malalignment (Varus deformity at knee) & LLD – knee OA Femoroacetabular impingement – hip OA Obesity – knee OA, women > men

6. Pathophysiology Normal cartilage: Contents: chondrocytes, matrix (60-80% water), type-2 collagen (10%), glycoprotein, non collagenous protein Matrix – protect chondrocyte during joint use Chondrocyte- secrete matrix, present only 1% in body, dispersed all over the matrix, concentrated in deep layer In superficial layer- collagen fibers & water - tensile force & shear force Proteoglycans – have protein core, GAGs, hyaluronic acid & chondroitin sulphate

7. Pathophysiology proteoglycan - concentrated in middle & deep layer Articular cartilage – have no nerve supply, blood & lymphatic vessels Get nutrition & eliminate waste by synovial fluid Role of articular cartilage - ↓es friction between articular joint surface, distribute force & shock absorption Force acting on joint cartilage – body weight, muscle contraction, GRF, rate & duration of loading Extreme loading - detrimental Moderate loading - proteoglycan synthesis & concentration

8. Joint pathology ↑es water content, Proteoglycan - swollen, disruption of matrix component Matrix stiffness ↓es, ↑es mechanical damage Later, proteoglycan- lost, water content ↓es, stiffness & elasticity ↓es, force transmit to bone Collagen synthesis type-2 to type-1 Articular cartilage damage - Chondrocyte attempt- synthesizing new matrix by proliferation Later, catabolic activity- digest matrix, damage- cartilage Age related oxidative stress- ↓es proliferation of cell & ↑es production of inflammatory cytokines 1 st noticeable change- flaking of superficial collagen fiber Fibrillation of 1/3 of cartilage (where stress is more) Full thickness fissure

9. Joint pathology Change in subchondral bone- sclerosis, cyst cavity, marginal osteophytes Exposure of subchondral bone - necrosis Subchondral bone – stiffer, ↓es shock absorption osteophytes- fibrous, cartilaginous or bony composition, tender to palpate & can seen in superficial joint Osteophyte formation- ↑es vascularity of damaged articular cartilage, venous congestion form subchondral cyst, thick subchondral trabeculae & damage to articular cartilage Bony growth- pain & ↓es ROM Inflammatory reactions- ↑es cytokines & low grade synovitis Cyst contain- myxoid, fibrous & cartilaginous tissue with bone marrow lesion seen in MRI

10. Diseases onset & course O nset- gradual May go undetected in some Pain triggered by specific activity Later, chronic dull aching pain & severe pain (episodic) Pain – individual seek medical help Slow progressive condition – everyone do not require surgical intervention Prognosis- variable OA contribute to ↑es disability with other co morbid condition with aging

11. Classification

12. Diagnostic criteria Radiograph - joint damage & disease severity Radiographic classification – 5 point system Grade 0 : normal radiograph Grade 1: doubtful narrowing of joint space, possible osteophytes Grade 2: questionable joint space narrowing & definite osteophytes Grade 3: joint space narrowing, sclerosis, possible deformity & moderate osteophytes Grade 4: marked narrowing of joint space, severe sclerosis & definite deformity Radiograph can not strongly related to clinical feature Muscle strength & pain more reliable for function loss

13. Clinical criteria for hip, knee & hand 1. Knee OA- Persistent knee pain Morning stiffness ≤ 30 mins ↓es function Crepitus ↓es movement 2. Hip OA- >50 years Pain while ≥ 15° IR IR range < 15°, hip flexion <115° Morning stiffness ≤ 60 mins 3. Hand OA- Age > 40 years Present Heberden’s node Family history of node Joint space narrowing in finger joints

14. Radiograph/ imaging X-Ray High resolution MRI- Structural change & pathology Real time ultrasound for bony & soft tissue- detect effusion, synovitis & early osteophyte backer’s cyst in popliteal by ultrasound image Ultra sound imaging > MRI backer’s cyst in popliteal by ultrasound image

15. Clinical presentation Sign & symptom (impairment): Pain, swelling & ROM ↓es Bone deformity All joint not equally affected UE- DIP, PIP, CMC, cervical, lumbar, hip, knee, MTP of greater toe Not compulsory bilateral symmetrical presentation (exception - generalised OA) Single or combination of joint affected Morning stiffness < 30 mins, Not generalised to whole body Crepitus – painless to extreme painful

16. Clinical presentation Severe fatigue (hip & knee OA) – due to pain, ↓es physical activity & depression Articular cartilage have no nerve – pain due to abnormal surface, osteophyte, vasocongestion, trabecular micro fracture, distension of joint capsule, ligament & muscle spasm Synovitis & effusion- specially in OA knee Amplified pain - central sensitization at spinal/ cortical level Pain with motion, later, pain - at rest & at activity

17. Joints Hand & FINGER: DIP & PIP involved ↓es ROM, ↓es Grip strength & fine motor skills ↓es Collateral ligament stretch Joint angulation PIP- bouchard’s node DIP- Heberden’s node Tender in early stage CMC- abduction, extension & opponence ↓es Pain, ↓es pinch strength, squaring of thumb, due to subluxation of MCP, weakness & contracture of thenar muscle, grip strength ↓es & hand function ↓es Hand affected in generalised OA, symmetrical manner Painful inflammation, synovitis, erosion, cystic swelling & osteophyte Ankylosing of DIP & PIP

18. Joints HIP: Gradual onset Hip ROM- painful & ↓es, mainly IR pain in groin, buttock or trochanter Hip- tendency to be in flexion, abduction & EX rotation Lateral hip pain- suggest tendinopathy - gluteus Medius & minimums Stride length ↓es, walking speed ↓es, balance issue, ↑es energy expenditure Early hip OA, 52% ↑es risk of fall

19. Joints KNEE: Pain in weight bearing activity (stair climbing & squatting) Later, pain & stiffness after prolong sitting Joint locking & buckling Damage to menisci & ligament Muscle weakness at hip (mainly gluteal) Soft tissue shortening- rectus femoris Genu Varus - medial knee joint, MCL & LCL, very common Genu valgus - lateral compartment, less common Flexion deformity - painful knee, functional LLD, ↓es step length ↑es fatigue & strain over quadriceps patellofemoral OA- anterior knee pain, due to patellar malalignment, abnormal patellar tracking & loading ↑es risk of fall

20. Joints FEET & TOES: 1. 1 st MTP joint- Hallux valgus, hyperextension Hindfoot eversion (pronation feet) 2. Polyarticular foot OA Other MTP, toes, medial arch affected, shorting of long extensors Hammer toe Painful- limited push off in stance phase of gait Slow walking speed & balance issue

21. Joints SPINE: Lower cervical & middle to lower lumbar affected Facet (synovial) joint affected – due to Degeneration of intervertebral disc ↑es compressive load Facet joint - osteophyte Lateral & central canal stenosis, nerve root impingement Pain in facet joint & nerve (radicular pain) in lumbar region, ↑es with spinal extension, rotation, prolong standing & sitting

22. Consequences of OA ↑es chance of – CVD Because - functional & walking disability & use of walking aid ↑es CVD even if controlling obesity, diabetes & hypertension

23. Activity limitation & participation restriction Functional limitation Heart disease, CHF, COPD Severe disease- they will not move joint due to pain So they will avoid function of daily living – importance to check activity limitation WOMAC – use ICF – check functions affected shorter brief ICF core set used – for clinical purpose OA create – work related disability, ↓es productivity & absenteeism

24. Prognosis Slow progression Self limiting Progression- joint & soft tissue damage to complete failure of joint Surgery – arthrodesis & arthroplasty (hip & knee) Rapid progression- uncommon Age ↑es , disability ↑es Co morbidity & inactivity

25. Medical management PHARMACOLOGICAL THERAPY IN OA KNEE: Drug therapy have no effect on progression Role of drug therapy- ↓es pain & swelling Oral analgesic, oral/tropical NSAIDS & Corticospinal injections 1. Oral analgesics: Acetaminophen First choice – no toxicity or minimal GI side effects No any anti-inflammatory effect More use can lead to kidney & liver toxicity specially in alcoholics Hospitalization due to GI perforation, peptic ulceration & bleeding

26. Medical management 2. NSIADS: Used in combination with acetaminophen Keep low dose to avoid GI toxicity 3. Intra-articular cortico-steroid injection: For acute episode of pain - moderate pain relief 4. Visco-supplementation – intra-articular injection: Hyaluronic acid injection- weekly injections In OA natural HA ↓es & ↓es ability to absorb shock ↓es pain & stiffness Effect last for months Risk of adverse effect – low allergic reaction & joint swelling

27. Medical management 5. Glucosamine sulphate (GS) & glucosamine hydrochloride (GH): moderate pain relief 6. Topical: Analgesics & anti inflammatory rubefacients – content methyl salicylate/ capsaicin (derived from red chili pepper) ↓es pain 33% when applied 4 times/day effect- burning & stinging Topical – NSAIDS- gel, liquid, or patch – absorbed through skin

28. Rehabilitative management POC - includes patient education & self management OA – affect health, function, participation & Quality of life Patient should be able to self manage – physiotherapist help to ↓es disability & gain confidence

29. Physical therapy examination Multisystem examination & history is important Careful examination at first visit - patient’s gait, ability to transfer into chair, etc… Joint stiffness- morning/static posture Previous activity level Degree of fatigue Co-morbidities Previous medication Previous therapy Complementary approaches, etc…. HISTORY: Medical & social history Patient’s understanding about the disease Red flag – if present seek medical help immediately Pain assessment- location, duration, pattern, quality, intensity Joint inflammation- joint temperature, swelling & erythema

30. Observation, sensitivity & tenderness Observation - posture, gait & functional transfers Skin temperature Joint swelling & muscle wasting Deformity Presence of nodules Note tenderness reported by patient Check joint involvement (bilateral/unilateral) Peripheral pulse Sensory changes due to co-morbidities

31. Range of motion PROM- goniometer assessment hip & knee involved – check bilateral If PROM not possible due to pain, check functional ROM by performing activity Check symmetry & smoothness- while doing gait, stair climbing, raise from chair, etc.. Ascending stairs - is best for analysis, because knee flex in that activity to maximum Note tenderness, crepitus, pain - while checking ROM ↓es ROM- ↑es fall risk functional range to prevent fall – hip flexion-50° & knee flexion-90°

32. strength Pain free range - muscle generate force Pain & effusion - muscle contraction ↓es (painful range) Measure functional strength patient having LAG or LACK phenomenon – ROM ↓es If therapist does modification in standard method (oxford grading) – do note all changes – ex, using break test, resistance throughout ROM, etc… Mention day, time of test & medication taken by patient Check proximal joint muscle strength - to know abnormal biomechanics Note severity of pain & obesity – because it influence in assessment

33. Joint stability Essential for normal biomechanics & function Pseudo laxity - seen in Uni-compartmental OA knee Check – ACL, PCL & collateral ligament, in bilateral knee joint

34. Cardio vascular disease Patient with OA report fatigue Impact of fatigue on functioning Check – HR, RR, BP, RPE RPE ↑es - indicate impairment of pulmonary/cardiac function Check cardiovascular fitness because if it is there – there will be ↑es chance of CAD because of chronic disease, inactivity & walking disability

35. Functional examination Provide patient centred approach to assessment Include- patient reported outcome measure (PROs) Selection of functional measure according to age, gender, level of depth information required measure sensitivity & responsiveness of treatment ARTHRITIS IMPACT MEASURMENT SCALE (AIMS2): Check- physical function, performance in psychological & social domain, patients satisfaction with current level of function – complicated to used & expensive

36. Functional examination WESTERN ONTARIO MCMASTER UNIVERSITY OSTEOARTHRITIS INDEX (WOMAC): 24 Item - 3 category - pain, stiffness & function KNEE INJURY & OSTEOARHRIRTIS OUTCOME (KOOS): Include sports, recreation & quality of life related questions Based on WOMAC scale Easy to score reliable & valid Modified KOOS for hip called – HOOS LOWER EXTREMITY FUNCTIONAL SCALE (LEFS): 20 item Easy for clinical use Comparison of different LE condition

37. Functional examination 5 performance test For >40 years It checks functional mobility & aerobic capacity 1. 30 second chair stand test - sit to stand ability 2. 4 by 10 meter fast paced walk test - test walking activity, speed over short distance with changing direction

38. Functional examination 4. timed stair climbing test - check stair negotiation 5. 6-min walk test - information about aerobic capacity & walk shorter distance 3. timed up & go test (TUG) - check functional mobility & gait speed

39. Mobility, gait & balance Detailed gait examination Knee OA - Antalgic gait ↓es ROM- ↓es speed of walking ↓es stride length, cadence & plantarflexion During ambulation patient with knee OA with medial joint affected- EX rotate knee ↓es extensor moment Ligament instability Alter biomechanics on stairs & on floor

40. Mobility, gait & balance Hip OA - ↓es hip ROM, pain & lateral muscle weakness (↓es hip extension) ↑es cadence & ankle power generation, anterior pelvic tilt, ↓es step width Dropped pelvis – Trendelenburg gait

41. Psychological status Anxiety ad depression They change pain experience, function & response to treatment intervention Chronic pain, fatigue, loss of function , ↓es activity level - lead to emotional distress If patient have signs, refer for screening – to improve coping skill

42. Environmental factor Therapist must aware about home, work & leisure environment – to know facilitator/ barrier Ergonomic & environmental modification can be done at home & workplace Cost is limiting factor Work environment affect employment & disability Use of assistive device for ADL- mobility & transportation

43. Physical therapy intervention Outcome - according to type of arthritis, activity level, clinical presentation & patient centred care Mutual goal setting - ↑es participation of patient in management Goal should be measurable, attainable, documented & completed in specific time General goal & outcome: ↓es pain , ↑es ROM, ↑es muscle activation, strength & joint stability , ↓es biomechanical stress on joint & prevent deformity ↑es endurance Independent ADL like dressing, transfer & self care improve gait pattern, ↓es fall risk & ↑es balance Maintain musculoskeletal, cardiac & general health ↑es self management & joint protection, patient & family education

44. Modalities for pain relief Can be given before passive/dynamic stretching & other exercise Most common – thermotherapy HEAT: Superficial heat- penetrate to few millimetre , produce local analgesia Ex , MHP, dry heat pad, lamps, paraffin wax, hydrotherapy, etc.. Paraffin – used on irregular joint surface Hydrotherapy- aquatic therapy, exercise while heating of tissue, expensive Deep heating- ultrasound, affect viscoelastic properties & ↑es plastic stretch of ligament – ↓es pain & ↑es function

45. Modalities for pain relief COLD: Produce local analgesia Initially, vasoconstriction, ↑es circulation , ↓es intraarticular temperature Used at inflamed or swollen joint where heat can not be used Wet/dry cold application Contrast bath - hand & feet - alternate kept in hot & cold water for specific ratio of time – ↓es swelling, stiffness & pain ELECTOTHERAPY MODALITIES: TENS – for 4 weeks effective High frequency TENS IFC – more pain relief than TENS

46. Orthosis, splints & braces Use of splint in OA of 1 st CMC – give short & long term pain relief foot orthosis- ↓es pain by giving biomechanical support & correction (hallux valgus) Lateral wedge insole- to ↓es medial compartmental stress- to ↓es pain Patellofemoral taping & unloader knee brace

47. Rest Complete bed rest- rarely advised Adequate sleep at night (8-10 hour) & short rest during day time (30 min) Inactivity - lead to deconditioning, depression, ↑es pain threshold, ↓es bone & soft tissue health Goal – maintain adequate level of physical activity & avoid consequences of inactivity

48. Range of motion & flexibility exercise In patient hip & knee OA Manual therapy (exercise) Passive movement & muscle stretching Soft tissue mobilization To ↓es pain & ↑es function

49. Strengthening exercise Initially- isometric exercise – can be done to activate muscle In this >50% MVC so – restrict blood flow & ↑es BP Patient with cardiopulmonary disease should take care of breathing to prevent Valsalva maneuver Do not hold contraction for >6sec Inhale - relaxation & exhale – contraction Dynamic exercise by body weight or free weight Exercise in pain free range Progression by increasing repetition, resistance & frequency if pain & swelling present ↓es frequency & intensity

50. Cardiovascular training By this ↑es aerobic capacity & activity level without aggravating condition Walking can be done If weight bearing is barrier, low/non weight bearing- stationary cycling & pool based aerobics can be done ↑es self esteem Screening should be done before starting aerobic exercise

51. Physical activity Patient with OA – less physically active than normal individual Spend 2/3 time in sedentary behaviour (ex, watching tv, using computer, etc..) ↑es morbidity & mortality Physiotherapist counsel for “move more & sit less” Technology can help patient to motivate to be physically active & track progress Example, 1. arthritis power- enter exercise, data of fatigue, sleep, medication, disease symptoms, etc… 2. health log- patient can record & track exercise, weight, sleep, mood, etc.. 3. walk with ease- track steps

52. Functional training ↑es muscle strength, function & ↓es pain Exercise can be done: Sit to stand in a chair Standing star exercise walking up & down a ramp Ascending & descending stairs walking indoors

53. Balance training Static & dynamic balance ↓es Balance training – progression static posture to dynamic posture Weight shift from one foot to other & then in different direction Double to single limb support Stable to unstable surface Adding perturbation Dynamic balance activity- by maintaining postural alignment walking on different surfaces – ↑es vestibular & proprioceptive system

54. Gait training In patient with OA – ↓es proprioception, ↓es neuromuscular reflexes, altered biomechanics of joint Pain & muscle weakness Patient with OA will have – gait asymmetry, ↓es velocity, cadence, ↓es stride length, ↑es double support time, Inadequate initial contact & push off Use of assistive device. ex, standard cane Using cane in contralateral hand, ↓es loading on joint ↓es pain in patient with hip & knee OA Gait of patient with OA should be safe, functional & cosmetically acceptable ↑es walking speed should be goal

55. Education & self management Education about the condition (taking medicine & do exercise) Joint protection: Shock absorbing insoles & subtalar taping Avoidance of high heels & sandals May prevent LE joint pain later in life self management - to carry out vocational & social role To deal with emotion like depression, fear & frustration By this ↑es self efficiency to do the task

56. Reference PHYSICAL REHABILITATION by Susan B. O’Sullivan, Thomas J. Schmitz, George D. Fulk – 7 th edition

57. Thank you