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Management

Once the diagnosis of OA is established


the therapeutic programm is then designed on
the basis of different
symptoms,
signs and
functional limitations.
When different joints are affected different
therapeutic options are used.

The correlation of pain severity, functional


limitation, impaired health-related quality of life
with the extent of structural changes as measured
by the radiograph is only modest.
Hence management decision should not be made
solely on the presence and severity of
radiographic changes.

Treatment Options
1.

NonPharmacological

2.

Pharmacological

3.

Surgical

Non-pharmacological treatment modalities


should include:
1.

Patient Education

2.

Weight Reduction

3.

Physiotherapy/Exercise

4.

Appliances

Patient Education
Education is most important intervention for
all people with OA.
Education of the patient with OA can
increase the
practice of healthy behavior,
improve health status and
decrease health care utilization.

Weight Loss
Over weight is the single most important
potentially modifiable risk factor for the
development of lower limb OA.
Felson et al revealed that a weight loss of 11.2
pounds over a 10-year period decreased the
likelihood of developing knee OA by 50%.

A decrease in body
mass is associated
with a significant
reduction
in
compressive and
resultant knee
forces.

A 9.8N (equivalent to a 1 kg) reduction in body


weight, is associated with a 40.6N reduction in
compressive force and a 38.7N reduction in
resultant force.
Thus, each unit of weight loss is associated with
4-unit reduction in knee forces

The

accumulated

reduction in knee load for


a 1-pound loss in weight
would be more than 4,800
pounds per 1 mile walked
(assuming1,200strides/
mile)

Arthritis, Diet and Activity Promotion Trial a


single blinded, randomized controlled trial
designed to compare the effect of exercise,
dietary weight loss and the combination of both
to the usual care in sedentary patient with
symptomatic knee OA with BMI over 25kg/meter
square;
concluded that the combination of weight loss
programme plus moderate exercise provide
better improvement in both symptoms and
function.

Physical Therapy
American College of Rheumatology recommend
that patients with symptomatic lower limb OA
m u s t b e e n r o l l e d i n a Ph y s i o t h e r a p y
Programme.

Recommendation for Exercise


1.Exercise therapy should be individualized and
patient
Centered .
age,
comorbidity and
over all mobility.
2.To be effective exercise programme should
include
advice and education to promote a positive life
style
change with an increase in physical activity.

3.Group exercise and home exercise are


equally
effective and patient preference should be
considered.
4.Adherence is the principle predictor of long
term
outcome from exercise.
5.Strategies to improve and maintain
adherence
Should be adopted.

Although an exact physical therapy formula for


OA patient has not been developed.
A general principle is that a Physiotherapy
programme should consist of at least following.

1.

Specific Modalities

2.

ROM Exercise

3.

Stretching Exercise

4.

Muscle Strengthening Exercises

5.

Mobility Training

6.

Aerobic Conditioning

7.

Home Exercise Programme.

Specific Modalities
(Thermotherapy/Cryotherapy/Electrical
Stimulation)
Cold:
is more likely than heat to benefit in acute
arthritic flares characterized by pain and
swelling.
Principle:
cold induced vasoconstriction which helps to
limit tissue edema and has anti-inflammatory
effect by lowering joint temperature,
collagenase activity and WBC count with in

A Cochrane Systematic Review , examining effect


of cold, heat and placebo on patient with
radiological confirmation of OA concluded that
ice has a statistically significant beneficial effect
on
range of motion,
function and
knee strength as compared to
control.

Heat:
is used in OA patients in order to enhance
stretching exercises by increasing tissue elasticity
and in order to provide analgesia.
Principle:
Heat induced analgesia occurs as a result of direct
suppression of free nerve endings via vasodilation.
It also suppress
skeletal muscle hyperactivity
through activation of descending pain inhibitory
system.

Therapeutic ultrasound
Therapeutic ultrasound is the most commonly
used deep heating modality.
In this the high frequency sound wave produce
heat at deep tissue

TENS
TENS has been found superior to placebo and
useful as an effective adjunct to therapeutic
exercise or NSAIDs with respect to pain relief by
many studies.

TENS Techniques
TENS is a technique to stimulate different
categories of nerve fibers.

1.

Conventional TENS:

Low-intensity pulsed currents are administered


at high- frequencies (between 10-200 pulses per
second, pps) at the site of pain.

The user experiences a strong, non- painful


sensation often described as tingling or pleasant
electrical paraesthesiae.
Physiologically, conventional TENS activates large
diameter non-noxious afferents which has been
shown to close the pain gate at spinal segments
related to the pain .

2.

Acupuncture-like TENS (AL-TENS)

High-intensity and low-frequency (less than


10pps, usually 2pps) administered over muscles,
acupuncture and trigger points.
The purpose of AL-TENS is to activate small
diameter afferents which has been shown to
close the pain gate using extra- segmental
mechanisms.

3.

Intense TENS

TENS can also be used as a counter-irritant,


termed intense TENS, using high-intensity and
high-frequency currents.

Pulse Electrical Stimulation


Pulse Electrical Stimulation act at the level
of hyaline cartilage by maintaining
proteoglycan composition of articular
cartilage via the down regulation of its
turnover

ROM Exercise
ROM exercise are generally given to prevent
motion loss with in the osteoarthritic joint.
Physiotherapy programme should be tailored
according to a patients ability to independently
perform range of motion.

Stretching Exercise
To prevent abnormal force generation to
develop across a joint
because of muscle
tightness.
Stretching is most
effective if performed
on a daily basis
particularly after tissue
has been heated as
heating enables collagen
to be maximally
stretched.

Muscle Strengthening Exercises


A meta-analysis by Roddy at.al found that
strengthening exercise plays an important role in
the management of hip and knee OA.
There are evidence that open chain kinematic
exercise may pathologically increase forces with
in the knee like tibiofemoral compressive forces,
patellofemoral compressive forces and
tibiofemoral shear forces.

Mobility Training
(Ambulation, elevation,stairs, assistive devices)
Assistive devices are capable of partially
unloading painful weight bearing joints.( 15% of
body weight)
Use of assistive cane on contralateral side is
most effective.
Unfortunately compliance with assistive devices
for ambulation is less

Aerobic Conditioning
Aerobic conditioning programme counteracts the
decreased aerobic capacity that may have an
adverse impact on overall morbidity and
mortality.
It also provides analgesic effect by releasing
endogenous opioids.
It also counteracts depression and anxiety.

Home Exercise Programme.


Long term compliance with a home exercise
programme is a major goal as good exercise
compliance has been found to be associated with
improved physical function in overweight and
obese.

Orthotic Management
Orthotic intervention is recommended for some
patients with knee and hip OA.
Lateral wedge foot orthoses have been shown in
some biomechanical and clinical studies to reduce
load on the medial compartment of the knee.

Pharmacological Management

1.

Opioids may be considered when other oral

treatment is unsuccessful.
Codine one to two 30mg tablets every 4 to 6 hrly
to a maximum of 240mg (60mg codine =6mg
morphine)
2.

Intra-articular injections may be useful in


severe

pain.
Intra-articular injections with corticosteroids can
be given when patient have moderate to severe
pain and when there are local signs of
inflammation and joint effusion.

Surgical Management
Surgery is deployed both early in the course of
disease as well as later, when joint destruction
occurs.
Surgery may also have a preventive role prior to
the onset of OA.

Arthroscopic procedures for OA


the most common indication for arthroscopic
surgery in patients with OA of the knee is,
concomitant meniscal tear.
Procedures to alter mechanical environment
Malalignment is a well-recognized risk factor for
OA: incidence and progression .
Osteotomy is performed to realign joints with the
goals of relieving pain in symptomatic patients
and delaying OA onset or progression.

Methods of evaluating the alignment of the


whole lower extremity.
Two lines are drawn from the center of the
femoral head to the center of the distal femur
and from the center of the distal femur to the
center of the ankle mortise.
The mechanical axis (degrees varus) is measured
at the intersection of these lines.

The load bearing axis deviation of the lower


limb is the perpendicular distance from the
weight-bearing line (hip-to-ankle line) and the
center of the knee.

The weight-bearing ratio is calculated by


measuring the distance from the medial edge of
the proximal tibia to the point where the weightbearing line intersects the proximal tibia (B), and
dividing the measurement by the entire width of
the tibia (A).
A percentage is calculated by multiplying this
ratio by 100%

TJR for advanced OA


Total ankle, elbow, and wrist replacements are
per- formed less frequently for several reasons.
Principally, OA occurs less commonly at these sites
than at the hip or knee.
Second, arthrodeses of the ankle and wrist joints
are reliable, reproducible, and effective
alternatives to TJR and restore a reasonable level
of function with good relief of pain.

A fused elbow, on the other hand, is quite


functionally limiting, and as a result, elbow
arthrodesis has a limited role.
Innovative joint arthroplasty technologies.
1.

Hip resurfacing.

This procedure does not require complete


resection of the femoral head.
The femoral component of a hip resurfacing
implant has a cap that covers the femoral head,
replacing the cartilage surface, and a much
shorter stem that anchors the implant in the
femoral neck.

2.

Minimally invasive TJR is another area of


innovation. Minimally invasive implies
a smaller incision with less soft tissue
disruption than occurs in the usual TJR
procedure.

3.

Reverse total shoulder


A major limitation of total shoulder
replacement is that the implant requires an
intact rotator cuff for shoulder abduction.
This presents a problem for patients who
have advanced rotator cuff degeneration,
which is a major cause of OA in the shoulder.

Reverse total shoulder replacement changes


the biomechanics such that the humeral
component serves as the new socket and the
glenoid component serves as the ball. This
reversal permits the deltoid to be used as the
shoulder abductor, restoring active elevation
of the shoulder

Surgical and biologic procedures


Autologous chondrocyte implantation (ACI).
This procedure attempts to repair a symptomatic
cartilage defect through implantation of
chondrocytes grown ex vivo from a small
cartilage biopsy sample obtained from the
patient in a through arthroscopy.

Appropriate patients for this procedure are


younger individuals, typically age 50 years, with
isolated cartilage defects typically greater than
3 cm2 in size.
Rehabilitation following ACI is demanding;
patients cannot be fully weight bearing for two
months, and return to athletic activities is
delayed for 1218 months until the cartilage has
fully matured.

Meniscal transplantation is performed in an open


or arthroscopic-assisted procedures. The
transplanted meniscal tissue is ordered
specifically for the individual patient and is side
and size matched in order to fit the anatomy of
the recipient knee.

The grafts are harvested from organ donors with


intact knee joints and processed sterilely to
reduce the risk of contamination, then frozen
for storage until matching recipients can be
found.

Osteoarthritis Guidelines Development


Group(OAGDG)
Thirteen experts from relevant medical
disciplines (primary care, rheumatology,
orthopedics, physical therapy, physical medicine
and rehabilitation, and evidence-based
medicine),
three continents and
ten countries (USA, UK, France, Netherlands,
Belgium, Sweden, Denmark, Australia, Japan, and
Canada) and a patient representative comprised
the Osteoarthritis Guidelines Development
Group(OAGDG)

Osteoarthritis Research Society


International (OARSI)
OARSI has developed guidelines for the non-surgical
treatment of osteoarthritis of the knee that are
stratified to each of four patient groups:
patients with knee-only OA and no comorbidities,
patients with knee-only OA with comorbidities,
patients with multi-joint OA and no
comorbidities, and
patients with multi-joint OA with comorbidities.

Comorbities included
diabetes,
hypertension,
cardiovascular disease,
renal failure,
GI bleeding,
depression, or
a physical impairment limiting activity,
including obesity.