degenerative osteoarthritis treatment and rehabilitation assoc. prof. ece aydoĞ physical medicine...
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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)