OSTEOARTHRITIS

 OSTEOARTHRITIS

Introduction:

Arthritis is inflammation of one or more joints. Pain, swelling, and stiffness are the primary symptoms of arthritis. Any joint in the body may be affected by the disease, but it is particularly common in the knee.

Knee arthritis can make it hard to do many everyday activities, such as walking or climbing stairs. It is a major cause of lost work time and a serious disability for many people.

The most common types of arthritis are osteoarthritis and rheumatoid arthritis, but there are more than 100 different forms. While arthritis is mainly an adult disease, some forms affect children.

Although there is no cure for arthritis, there are many treatment options available to help manage pain and keep people staying active.

Anatomy of knee joint :

                                               

The knee is the largest and strongest joint in your body. It is made up of the lower end of the femur (thighbone), the upper end of the tibia (shinbone), and the patella (kneecap). The ends of the three bones where they touch are covered with articular cartilage, a smooth, slippery substance that protects and cushions the bones may bend and straighten knee.

Two wedge-shaped pieces of cartilage called meniscus act as “shock absorbers” between thighbone and shinbone. They are tough and rubbery to help cushion the joint and keep it stable.

The knee joint is surrounded by a thin lining called the synovial membrane. This membrane releases a fluid that lubricates the cartilage and reduces friction.

DEFINITION:

• Osteoarthritis is a chronic, degenerative disorder of multi-factorial etiology, characterized by loss of articular cartilage and periarticular bone remodelling, particularly large weight-bearing joints.
• Common in older patients but can occur in younger patients ( genetic mechanism , previous joint trauma ).
• The most common form of arthritis.

PATHOLOGY:

• It is caused by the breakdown of cartilage.
• Cartilage is the tough elastic material that covers and protects the ends of bones. Bits of cartilage may break off and cause pain and swelling in the joint between bones.
• This pain and swelling is called inflammation.
• Degenerative alterations primarily begin in the articular cartilage
• External forces accelerate the catabolic effects of the chondrocytes and disrupt the cartilaginous matrix.
• Enzymatic destruction increases cartilage degradation   ? proteoglycans and collagen synthesis.
• Decreased strength of the cartilage is compounded by adverse alterations of the collagen.
• Reduced contact area of the cartilage.
• Loss of cartilage results in the loss of the joint space.
• Progressive erosion of the damaged cartilage occurs until the underlying bone is exposed.
• Subchondral bone responds with vascular invasion and increased cellularity, at areas of pressure.
• The traumatized subchondral bone may undergo cystic degeneration.
• At nonpressure areas along the articular margin ? irregular outgrowth of new bone (osteophytes).
• Surface layer of cartilage break down and wears away,causes the bones under the cartilage to rub together.
• Pain, swelling, and loss of motion result.
• Formation of bone spurs.

CAUSES of Osteoarthritis :

Primary Osteoarthritis causes:

• Idiopathic
• Defective gene

Secondary Osteoarthritis :

• Obesity
• Repetitive use (ie, jobs requiring heavy labor and bending)
• Previous trauma (ie, posttraumatic OA)
• Infection
• Crystal deposition
• Acromegaly
• Previous rheumatoid arthritis (ie, burnt-out rheumatoid arthritis)
• Heritable metabolic causes (eg, alkaptonuria, hemochromatosis, Wilson disease)
• Hemoglobinopathies (eg, sickle cell disease, thalassemia)
• Underlying orthopedic disorders (eg, congenital hip dislocation, slipped femoral capital epiphysis)
• Disorders of bone (eg, Paget disease, avascular necrosis)
• Joint injury:
• Sport injury (Wear and tear in join)
• Occupation (Squat position over many years).
• Other disease RA
• High heel shoes.

SIGNS AND SYMPTOMS in Osteoarthritis :

• Pain.
• Swelling.
• Stiffness.
• Instability.
• Tenderness.
• Effusion.
• Crepitus.
• Limitation of movement and muscle wasting.

In early stage,

• Joints may appear normal.
• Gait may be antalgic if weaight-bearing joints are involved.

In late stage,

• Visible osteophytes may be noted.
• Joints may be warm to palpation.
• Palpable osteophytes frequently are noted.
• Joint effusion frequently is evidenced in superficial joints.
• Range of motion limitations, because of bony restrictions and/or soft tissue contractures are characteristic.
• Crepitus with range of motion is not uncommon.

DIAGNOSIS:

Imaging:

                                                X-ray of OA knee

• Joint aspiration:The doctor will numb the affected area and insert a needle into the joint to withdraw fluid. The fluid will be examined for evidence of crystals or joint deterioration. This test can help rule out other medical conditions or other forms of arthritis.
• X-ray: X-rays can show damage and other changes related to osteoarthritis to confirm the diagnosis.
• MRI: Magnetic resonance imaging (MRI) does not use radiation. It is more expensive than X-rays, but will provide a view that offers better images of cartilage and other structures to detect early abnormalities typical of osteoarthritis.

Lab tests

Analyzing your blood or joint fluid can help confirm the diagnosis.

• Blood tests: Although there is no blood test for osteoarthritis, certain tests may help rule out other causes of joint pain, such as rheumatoid arthritis.
• Joint fluid analysis: Your doctor may use a needle to draw fluid out of the affected joint. Examining and testing the fluid from your joint can determine if there’s inflammation and if your pain is caused by gout or an infection.

TREATMENTS:

• Symptomatic treatment.
• Structure modifying treatment.
• Surgical treatment.

PHYSIOTHERAPY TREATMENTS:

• Physiotherapy and exercise improve flexibility and strengthen the muscles surrounding the joints.
• People who exercise regularly their arthritis will typically have less pain and better function than those who are inactive.

Physiotherapy treatment program:

• Reduce pain.
• Improve movement and posture.
• Strengthen muscles.
• Improve independent function.
• Assess and treat bio-mechanical problems that may exacerbate the pain and loss of function.

Exercise can help:

• prevent the disability that result from inactivity.
• It promotes the health and normal function of muscles and bones.
• Exercise keeps the muscles toned and increases bone mineral density, which reduces the risk of osteoporosis and fractures. It also promotes cardiovascular health, which decreases the risk of heart disease.
• In addition, there are also psycho social benefits to exercise, including an improved sense of well-being and the relief of depression

RANGE OF MOTION EXERCISES:

• Range-of-motion exercises are gentle stretching exercises which move each joint as far as possible in all directions.
• These exercises need to be done daily to help keep joints fully mobile and prevent stiffness and deformities.
• ROM (range-of-motion) exercises are especially important for arthritis patients, who because of intense inflammatory pain tend not to want to move painful joints.

STRENGTHENING EXERCISE:

• Strengthening exercises help increase muscle strength. Strong muscles help to support the joints, making the joints more stable, and helping a person move more easily and with less pain.
• The two types of strengthening exercises are isometric and isotonic:
• Isometric exercises involve tightening the muscles, without moving the joints. These exercises are especially useful when joint motion is impaired.
• Isotonic exercises involve strengthening the muscles by moving the joints.

STRETCHING EXERCISE:

• Stretching the muscles that support the knee is  important in preventing injury. Flexible muscles are not as easily injured as tight muscles. Tightness of muscles connected to the knee can also pull the knee out of alignment.
• When doing stretching knee exercises, be careful to go slowly and not to overstretch.

AEROBIC EXERCISE:

• Aerobic exercise benefits those with knee problems by toning the muscles of the leg that support the knee joint  to absorb shock before it reaches the knee joint.
• Aerobic exercises also help in weight reduction. Losing weight reduces stress on the knee joint – the impact placed upon on the knees is three times the body weight while walking.
• Aerobics also stimulate your the body to release endorphins – natural painkillers produced by one’s own body.
• Aerobic exercise is important for the health of the heart, lungs, and overall function of the body.
• Warm up before aerobic exercise to slowly increase your heart rate and breathing rate. Five minutes of slow paced walking, and a few minutes of stretching are sufficient. Cooling down in the same manner is also important be sure to stretch your quadriceps and hamstrings.

WALKING:

• Start with about 5 minutes of slower paced walking to warm up.
• Walk at a medium pace for about another 10 minutes per day and gradually build up to 30 – 60 minutes by adding a few minutes each time you walk.
• End your walk with 5 minutes of slower paced walking.
• After you get into better shape you can start walking at a faster pace to increase the intensity of your walks.

SWIMMING AND WATER EXERCISES:

• swimming is an excellent no-impact exercise. Regular ‘land’ exercises can also be done underwater.
• The buoyancy of the water supports most of the body’s weight while the resistance of the water make your muscles work harder to perform movements.
• You can use dumbbells and weights strapped to the ankles to intensify the workout without stressing the knees and other weight-bearing joints.

STATIONARY BIKE:

• Make sure your seat is high enough so that your knees are not bent beyond a 90-degree angle. Your knee should be slightly bent when your pedal is furthest away. An upright stationary bike (looks like a regular bike) gives you a higher intensity work out than a recumbent bike.

HEAT AND COLD THERAPIES:

• Applying heat and cold to arthritic joints can help to control symptoms such as pain and stiffness.
• Heat therapy : Heat relieves pain and stiffness in arthritic joints. Heat can be applied to the joints with hot packs, hot water bottles, heating pads, or electrically heated mittens. Heating pads should be set on a timer and used for no more than 20 minutes at a time. The heating pad can be reapplied after 20 minutes of no use.
• Cold therapy : Cold relieves pain in arthritic joints and reduces muscle spasms. Cold can be applied for short periods using ice packs or topical coolant sprays. People with certain medical conditions, such as the Raynaud phenomenon, should not use cold therapy.

ORTHOSIS AND ASSISTIVE DEVICES:

ORTHOSIS For Osteoarthritis :

• Orthosis are devices that promote normal alignment and function of the joints. There are many different types of orthosis that can reduce symptoms and help maintain function in people with osteoarthritis.
• Well-cushioned shoes and shoe inserts may reduce stress on the joints of the spine and leg.
• Splints that immobilise the joints can reduce pain and inflammation, and many splints can be worn throughout the day and night. Braces can help stabilise unstable joints.

ASSISTIVE DEVICES:

• Canes, walkers, electric powered seat lifts, raised toilet seats, and tub and shower bars can reduce the stress on joints and make it easier to perform daily tasks.

TENS/IFT  THERAPY:

• A TENS/IFT  unit delivers a mild electrical current to the skin, stimulating nerve fibers in the skin that may interfere with the transmission of pain signals from the arthritic joint.
• The use of TENS for people with osteoarthritis is controversial. Some studies have found that those who use TENS for arthritis of the knee have reduced knee pain, a greater ability to bend the knee, and a reduced duration of morning stiffness.
• However, one study found that the benefits occurred primarily during active use of the TENS unit, and another study found that TENS was no more effective for relieving pain than the drug naproxen.

ACTIVITY LIMITATIONS:

• The following positions and activities place excessive pressure on the knee joint and must be limited until knee pain and swelling resolve: Squatting ,Kneeling ,Twisting and pivoting, repetitive bending and Bicycling.
• The preferred exercise equipment for the knee should provide smooth motion of the knee, maximal toning of the front and back thigh muscles (quadriceps and hamstring muscles).

PRIMARY PREVENTION OF OA:

• Regular exercises.
• Weight control.
• Prevention of trauma.

AIMS OF TREATMENT:

• Pain relief.
• Preservation and restoration of joint function.
• Education.

NON PHARMACOLOGICAL TREATMENT OF OA:

• Patient education.
• Weight loss (if overweight).
• Aerobic exercise programs.
• Physical therapy .
• Range-of-motion exercises Muscle-strengthening exercises.
• Assistive devices for ambulationPatellar tapingAppropriate footwear Lateral-wedged insoles (for genu varum).
• Bracing.
• Occupational therapy.
• Joint protection and energy conservation.

PHARMACOLOGIC TREATMENT OF OA:

• Oral Systemic Medical Agents
  – Analgesics (acetaminophen)
  – NSAIDs
  – Opioid analgesics
• Intraarticular agents:
  – Hyaluronan
  – Glucocorticoids (effusion)
• Topical agents

INVASIVE METHODS:

• Joint lavage
• Arthroscopy
• Cartilage grefting- genetic engineering
• Surgery
  – Osteotomy
  – Joint replacement

THOSE ABOVE ARE COLLECTED FROM SOME BOOKS AND WEBSITES..

THANK YOU,

 SRIKUMARAN PHYSIOTHERAPY CLINIC & FITNESS CENTER