DEGENERATIVE OSTEOARTHRITISTreatment and RehabilitationAssoc. Prof. Ece AYDOĞ

Physical Medicine and Rehabilitation

Cartilage is a protein substance that serves as a "cushion" between the bones of the joints.

Osteoarthritis is a type of arthritis

that is caused by the breakdown and eventual loss of the cartilage of one or more joints.

Constituents of hyaline cartilage

Cellular material: Chondrocytes:5%

Extracellular material: Matrix:95%

( Water comprises approximately 70%)

– Collagen fibres – Proteoglycan molecules

Proteoglycan Aggregate

• Large hygroscopic molecules

• Long central chain of hyaluronic acid

• Numerous side chains alongs its length, each with;

– Central cores of protein– Chondroitin sulphate and keratan

sulphate side chains

• Pg’s attract water and put collagen under tension

Normal Articular Cartilage Softening and swelling of cartilage

Loss of cartilage

• Softening and swelling

• Fibrillation

• Full thickness cracks

• Eburnation

• Subchondral cysts

• Subchondral sclerosis

• Osteophyte formation

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Individual risk factors fordevelopment of OA

•Obesity: knee > Hip

• Family history (genetic): polyarticular esp hands

• Trauma

• Hypermobility

• Dysplasia: Hip and knee

• Occupation and sport: excessive and repeated loading of a joint

Clinical features

Pain and tenderness Originates in joint /periarticular soft tissue

Diffuse/ sharp and stabbing local pain

Initially, symptomatic patients incur pain during activity, which can be relieved by rest and may respond to simple analgesics

Joints may become unstable as the OA progresses; therefore, the pain may become more prominent (even during rest) and may not respond to medications

Movement abnormalities

Gelling stiffness after periods of inactivity passes over within minutes of using joint again

Coarse crepitus palpate/hear

Reduced ROM capsular thickening and bony changes in joint

Deformities

Mild synovitis

Osteophytes

Joint laxity

Asymmetrical joint destruction leading to angulation

Treatment Principles•Education

• Physiotherapy

– Exercise program

– Pain relief modalities

• Aids and appliances

• Medical Treatment

• Surgical Treatment

•Prevent overloading of joint; Obesity!!•Appropriate use of treatment modalities•Importance of exercise program

Exercises Flexibility exercises — daily stretching and range-of-movement

exercises.

Strengthening exercises — (a) Isometric exercises (static muscle contraction that does not move a joint or alter muscle length) up to twice daily during acute inflammatory periods; and (b) Isotonic exercises (resistance training exercises, often with weights), maximum two days per week.

Endurance/fitness exercises — such as walking, swimming, dancing, aquarobics, cycling, 3–4 times per week.

The intensity, duration, and frequency of exercise should be specified and graded to allow for progression.

Physical Agents

HeatColdWaterPressureSoundElectrical Current

Physical Agents Cryotherapy: Ice packs, commercial cold packs, iced towels, ice massage, cold baths

(immersion), vapocoalant spray, contrast baths. Radiant heat: Infrared Conductive heat -Hot packs -Paraffin bath Superficial heat Hydrotherapy -Whirlpool -Hubbard tank Shortwave diathermy Deep heat Ultrasound

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General Indications

Purported UsesModulate painReduce or eliminate inflammation Increase rate of healingModify muscle tone Increase connective tissue extensibility

Ice

Contraindications Cold hypersensitivity

Raynaud’s disease

Regenerating peripheral nerves

Precautions Over superficial main

branches of nerve Peroneal nerve

Open wounds

Poor sensation

Application

10 minutes is sufficient

Re-applied regularly, every 2-3 hours

Following approximately the first 3-5 days of an acute injury

Red/Infra-Red Phototherapy

Conductive HeatHot Packs Moist heat Canvas filled wityh silica gel Immersed in water of about 77 C

Paraffin Bath

Tank containing a mixture of paraffin and mineral oil

52-53 C Areas that are diffucult to heat Helps to soften the skin

Contraindications (heat)

Pregnancy Acute inflammotory conditions Active Cancer Active bleeding Patients with cardiac insufficiency Extremly old adults and children less than 4 years

old Patients with peripheral vascular disease Tissues that are devitalized by x-ray theraphy Already existing fever

Precautions Already existing edeme Patients with sensory loss Patients who are confused

Low Level Laser Therapy Cold Laser Therapy

Primary Effects– Similar to effects of Infrared therapy

Secondary Effects– Cell proliferation, protein synthesis, growthfactor secretion, neurotransmitter modification

Tertiary Effects– System effects; Increase immune response, stimulate bone healing

Ultrasound

Therapeutic Ultrasound sends high frequency sound waves through tissue and has a thermal effect.

Therapeutic ultrasound frequency used is 0.7 to 3.3.MHz

Maximum energy absorption in soft tissue is 2 to 5 cm.

Intensity decreases as the waves penetrate deeper.

They are absorbed primarily by connective tissue: ligaments, tendons, and fascia (and also by scar tissue)

Ultrasound

Typical applications of UltrasoundPain control (Munting 1978)

Increase tissue extensibility (Knight 2001)

Accelerate healing wounds (Dyson 1978), bone fractures (Duarte 1983)

et al Pharm Res 1992)

Ultrasound

Two types of benefit: Thermal effects Non thermal effects Indications: Soft tissue shortening (Joint contractures,

scarring) Subacute and chronic inflammation

Electrical Stimulation

Common uses:Pain control (TENS, interferential) Iontophoresis (Direct Current)Muscle stimulation (NMES)Tissue healing (wound care)

TENS (Transcutaneous Electrical Nerve Stimulation)

Pain control

2 theories of how TENS may control pain

Gate control theory – high frequency TENS Opiate-mediated control – low frequency TENS

(Acupuncture- like TENS)

TENS

Contraindications Patients with cardiac pacemakers

Pregnancy

Sites over the carotid sinus, laryngeal or pharyngeal muscles, sensitive eye areas, or mucosal membranes

Do not use while operating hazardous machinery

Aids and appliances

Braces / splints

Special shoes/insoles

Mobility aids

Aids: dressing, reaching, tap openers, kitchen aids

Taping of patella in patello femoral OA

Tapping

Medical Treatment

Simple analgesics: paracetamol Topical treatment; NSAI, capsaicin creams Glucoseamine; oral, topical NSAID’s Tramadol or opioidis Intra-articular corticosteroids Intra-articular viscosupplementation PRP

Joint replacement surgery

• Indications: pain affecting work, sleep,

walking and leisure activities

• Complications

– sepsis

– loosening

– lifespan of materials (mechanical failure)