Physiotherapy Guidelines

on the Management of Osteonecrosis

in Post-SARS Patients

Physiotherapy Working Group on SARS

Coordinating Committee in Physiotehrapy

Hospital Authority

December 2003
Introduction

Some patients who have been recovering from the Severe Acute Respiratory Syndrome
(SARS) have developed osteonecrosis. In a recent press release (Hospital Authority, 2003),
it was reported that among the 418 patients being screened with MRI, 49 showed
osteonecrosis. The incidence is about 11.7%. Among those with osteonecrosis, 29 (59.2%)
had involvement of the hip joint.

Currently, there is a paucity of information about the causes of osteonecrosis in post-SARS

patients, although steroid treatment may be considered as one of the risk factors in this group
of patients (HKCOS & HKOA, 2003). However, the prevalence and the natural history of
steroid-induced osteonecrosis are still not certain (Assouline-Dayan et al, 2002). The
presence or absence of pain symptoms in post-SARS patients is not a reliable indicator for
detecting osteonecrosis, especially in the early stages. At present, the MRI is considered as
the first choice of diagnostic method to detect early osteonecrosis (Pavelka, 2000). The
successful management of osteonecrosis would depend on the early detection with treatment
in influencing the natural history of the disease (Lavernia et al, 1999). The orthopaedic
surgeons of the Hospital Authority have come to a consensus of management protocols on
osteonecrosis of knee and hip based on the staging systems (HKCOS & HKOA, 2003).

Table 1: Classification and Staging of Osteonecrosis of Knee based on Mont et al (1997)

Stage Criteria Recommended Treatment by

HKCOS & HKOA (2003)
I Normal x-ray but abnormal MRI Observation
II Sclerotic or cystic changes, or both, on plain Observation or core
x-ray; normal contour of articular surface and decompression or osteotomy
no subchondral fracture
III Subchondral collapse or crescent sign Observation or osteotomy
IV Narrowing of joint space with secondary Observation or knee joint
changes of articular surface replacement

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Table 2: Classification and Staging of Osteonecrosis of Hip based on the University of
Pennsylvania System

Stage Criteria Recommended Treatment by

HKCOS & HKOA (2003)
Stage 0 Normal MRI Observation
Stage I Normal radiograph; abnormal MRI
A Mild (<15% of head affected) Observation if asymptomatic
B Moderate (15% to 30% of head affected) Observation or core
C Severe (>30% head affected) decompression if asymptomatic
Stage II Lucent and sclerotic changes in femoral head
A Mild (<15% of head affected) Observation or core
B Moderate (15% to 30% of head affected) decompression or vascularized
C Severe (>30% head affected) bone graft
Stage III Subchondral collapse
A Mild (<15% of head affected) Observation or vascularized
B Moderate (15% to 30% of head affected) bone graft
C Severe (>30% head affected)
Stage IV Flattening of femoral Head
A Mild (<15% of head affected & <2mm Observation or vascularized
depression) bone graft or
B Moderate (15% to 30% of head affected or 2 hip joint replacement
to 4-mm depression)
C Severe (>30% head affected or > 4mm
depression)
Stage V Joint narrowing and/or acetabular change
A Mild
B Moderate
C Severe
Stage VI Advanced degenerative changes

This document is developed by the Physiotherapy Working Group on SARS of the

Coordinating Committee in Physiotherapy, Hospital Authority for the management of
osteonecrosis in post-SARS patients. It serves as the guidelines for physiotherapists
working in the Hospital Authority to offer appropriate advice and interventions for
post-SARS patients with suspected or confirmed diagnosis of osteonecrosis.

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 Physiotherapy Treatment Goals

The treatment goals of physiotherapy for post-SARS patients with osteonecrosis are to:
1. Maintain the muscle strength and joint range of motion;
2. Prevent or retard the deterioration of osteonecrosis from early to late stages;
3. Maintain the physical functions to cope with daily activities; and
4. Manage symptoms.

Physiotherapy Treatments - Recommendations

The physiotherapy treatments for SARS patients with suspected osteonecrosis will depend on
the presence of symptoms and MRI status:

Screening for Osteonecrosis by MRI

MRI +ve MRI -ve Pending MRI

Operative Conservative If asymptomatic If asymptomatic If symptomatic

Treatment Treatment - Activity & - Activity & - Symptoms
- Follow - Crutch/stick ergonomic ergonomic management
post-op walking if advice advice - ROM Ex.
protocol indicated - Suspend
- Protected - ROM ex. If symptomatic high joint
weight - Activity & - Symptoms loading
bearing for ergonomic management exercises or
6-12/weeks advice - ROM Ex. activities
- ROM ex. - Symptoms - Consider - Crutch/stick
- Symptoms management modify mode walking if
management - Avoid high of training in symptoms
joint loading avoiding high can be
exercises or joint loading improved
activities exercises or
activities

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Considerations of Joint Loading During Therapeutic Exercises and Activities

In order to minimize the deleterious effect of inactivity and immobilization while to minimize
the hazard of aggravating the process of osteonecrosis, the limit of acceptable joint loading
for post-SARS patients with knee or hip osteonecrosis of stage I or less is set to the level
comparable to walking with slow speed (i.e. < 2 km/h) (Fagerson, 1997; Kuster 2002). With a
slow walking speed, the joint loading of the knee or hip is about double of the body weight
(Fagerson, 1997). Activities or exercises which create loading at knee or hip below 2 body
weight (BW) are classified as low impact while those generate loading ranged from 2 to 5
BW are classified as medium impact. Activities or exercises which create loading above 5
BW are classified as high impact. The knee and hip joint impacts in various exercises and
activities are shown as follows:

Table 3: Knee Joint Impact in Various Exercises and Activities (Fagerson, 1997; Kuster
2002)
Knee Joint Force
Activities/Exercises Low Impact Medium Impact High Impact
(< 2 BW) (2 to 5 BW) (> 5 BW)
A. Exercises • Isokinetic knee
extension
B. Walking • Slow or free • Walking at >2 – 5
speed walking km/hr
(speed: 1-2
km/hr)
C. Cycling • Low to high
resistance
D. Hydrotherapy# • Free exercises in • Exercises against buoyancy or resistance
water at low at moderate to high speed
speed
E. Other Activities • Stair climbing • Jogging/Running
• Ramp

#
Hydrotherapy can be an effective means of limited weight-bearing in patients with
orthopaedic conditions. The percentages of weight bearing during immersed walking at
different level of immersion are estimated as follows (Harrison et al, 1992):

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Level of Immersion Static Slow walking Fast walking
C7 0% - 25% 0% - 25% 0% - 25%
Xiphisternum 25% - 50% 25% - 50% 50% -75%
ASIS 50% - 75% 50% - 75% 75% - 100%

Table 4: Hip Joint Impact in Various Exercises and Activities (Fagerson, 1997; Kuster
2002)

Hip Joint Force

Activities/Exercises Low Impact Medium Impact High Impact
(< 2 BW) (2 to 5 BW) (> 5 BW)
A. Exercises • Gravity free • Bridging • Isometric resisted
ROM exercises hip exercises at
100% MVC
• Supine SLR
• Prone hip
extension
B. Walking • Protected
weight-bearing
walking with
crutches or sticks
• Slow or free • Walking at > 2 – • Walking at > 5
speed walking 5 km/hr km/hr
(speed: 1-2
km/hr)
C. Cycling • Low to high
resistance
D. Hydrotherapy • Free exercises in • Exercises against buoyancy or resistance
water at low at moderate to high speed
speed
E. Other Activities • Jogging/Running
• Stair climbing
• Bath/Car entry

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General Considerations in Physiotherapy Interventions

The treatments for each post-SARS patient would be individualized and based on his/her
clinical signs and symptoms, and the status of osteonecrosis detected with MRI. The
followings are general principles and considerations for selected types of treatments for
post-SARS patients:

Muscle Strengthening Exercises

In strengthening the muscles of patients with rheumatoid arthritis, it is recommended that the
goal for the load level of strengthening exercises should be moderate to hard (i.e. 50% to 80%
of a maximal voluntary contraction) with a frequency of 2 to 3 times per week (Stenström &
Minor 2003). Physiotherapists can base on this general guideline to recommend the load
level of strengthening exercises to post-SARS patients, taking into considerations of any
contraindications or precautions. Because there is a paucity of information on the loading
duration (either continuous or accumulative) that may cause adverse effects on osteonecrotic
joints. The duration and repetitions of exercise will be individualized and guided by
subjective complaint and / or signs of muscle fatigue.

The joints in upper limbs are essentially non-weight bearing joints and the exercise
prescription of muscles of upper limbs will follow the same principles as in lower limbs.

Cardiopulmonary Fitness Training

Cycle ergometer would be the choice of modality for cardiopulmonary fitness training
because of its known low impact on lower limb joints (Ercison, 1986; Westby, 2001; ACSM
1998). The recommended training intensity would be 50% or 60% to 85% of maximum
heart rate for 30 minutes and three times a week (Stenström & Minor 2003). Aquaerobics
(pool aerobic exercise) at target heart rate of 70% of maximal heart rate is also shown to be
effective in improving exercise tolerance (Smith et al, 1998).

Activity Modification, Ergonomic Advice & Risk Management

Post-SARS patients with osteonecrosis should:

• avoid extreme flexion positions like squatting or kneeling
• avoid shoulder abduction and external rotation (for patients with AVN of humeral head)
• avoid carrying loads in contralateral hand to their bad hip because of higher loading
induced (Neumann, 1996)

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• sit-to-stand transfer from a high chair (62 cm) because of less contact pressure is created
at hip joint (Fagerson, 1995)
• avoid prolonged exposure of weight bearing
• minimize additional vertical loading such as heavy lifting
• avoid risk factors of fall
• avoid high impact activities or movements and follow the recreational sports guidelines
for patients having total knee replacement and total hip replacement:

(1) High impact sports are not recommended such as baseball, basketball, climbing,
football, downhill skiing, parachuting, racquetball, jogging, running, weight lifting,
soccer, sprinting, volleyball, high impact aerobics, gymnastics, handball and hockey.
(2) Allowable sports activities include: archery, bicycling, billiards, pool exercises,
swimming, bowling, croquet, shuffleboard, fishing, golf, hunting, low-impact aerobics,
most shooting sports, scuba diving & walking.

Potential Beneficial Physiotherapeutic Modality - Application of Pulsed

Electromagnetic Field (PEMF)

The beneficial effect of pulsed electromagnetic fields (PEMFs) in treating non-union has
been shown in the literature (Bassett, 1993). Several models of Electrical Bone Growth
Stimulator using non-invasive PEMF were approved by the U.S. Food and Drug
Administration (FDA) in the treatment of non-unions, congenital pseudoarthroses and
promotion of spinal fusion (Polk, 2000). However, no optimal frequency and intensity can
be identified for bone healing due to diversified parameters used in those studies with
positive results (Polk, 2000). With the potential effect on stimulating osteogenesis, PEMFs
could be considered as one of the modalities in treating osteonecrosis. Details of the clinical
application of PEMFs is described in the Appendix.

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Specific Recommended Treatments for Post-SARS Patients with Suspected or Confirmed Osteonecrosis of Hip (Stage 0 to
Stage 1)

Table 5: Recommended Treatments for Post-SARS Patients with Suspected or Confirmed Osteonecrosis of Hip

Patient Exercises Walking Cycling Hydrotherapy Advice

Subgroups
Pending MRI
Asymptomatic Low to medium impact Comfortable speed* Low to high resistance Free exercises at low Normal activities as usual
(4.5-5 km/h) speed
Symptomatic Low impact Slow speed ± Pain-free Low to Medium Free exercises at low Avoid prolonged weight
crutches/stick (<2 km/h) resistance speed, pain-free bearing, e.g. standing >
15-20 min
MRI received
Stage 0
Asymptomatic Low to medium impact Comfortable speed (4.5-5 Low to high resistance Free active & resisted Normal activities as usual
km/h) exercises below medium
speed
Symptomatic Low impact Slow speed ± Low to Medium Free exercises at low Avoid prolonged weight
crutches/stick (<2 km/h) resistance, pain-free speed, pain-free bearing, e.g. standing >
15-20 min
Stage 1 A & B
Asymptomatic Low impact Comfortable speed (4.5-5 Low to Medium resistance Free exercises at low Avoid prolonged weight
km/h) speed, pain-free bearing, e.g. standing >
Symptomatic Crutch Walking Low resistance 15-20 min
Stage 1 C
Asymptomatic Low impact Comfortable speed (4.5-5 Low resistance Pain-free, free exercises Avoid prolonged weight
km/h) at low speed bearing, e.g. standing >
Symptomatic Crutch Walking 15-20 min
* based on Bohannon (1997)

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Appendix: Clinical Application of Pulsed Electromagnetic Field (PEMF)
The duration of application of PEMF ranged from 3 hours to 24 hours as described in various
studies.

Contra-indications

• Patents having implanted pacemaker or defibrillator

• Haemorrhage
• Pregnancy
• Tumors

There are 6 factors to be considered in the application of PEMFs (Magnetopluse™):

1. Frequency around 4 to 6 Hz should be used to combat inflammatory conditions (acute or

chronic);
2. Frequency above 10 Hz cause vasodilatation;
3. Acute conditions generally respond best to lower frequencies;
4. Chronic conditions generally require higher frequency;
5. Traumatic conditions usually require longer treatment time (30 minutes);
6. This therapy is safe to use with stainless steel or plastic implants, as there is no immediate
thermal effect.

Recommended treatment with PEMFs (Magnetopluse™)

• Treatment in 2 phases
• The first phase is the first week post fracture (operation). Lower frequency range (4-6 Hz)
is used to treat tissue damage.
• The second phase starts from second week onwards. Higher frequency range (>10 Hz) is
used to cause promotion of osteogenesis.

Phase I

• 30 minutes 60 Gauss 5 Hz
• 30 minutes 80 Gauss 8 Hz
• 30 minutes 99 Gauss 12 Hz

Phase II

• 30 minutes 99 Gauss 12 Hz
• 30 minutes 99 Gauss 25 Hz
• 30 minutes 99 Gauss 50 Hz

Two to three sessions per week is recommended. Daily treatment more than 14 days is not
recommended by the manufacturer of Magnetopulse™.

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