Assistant Professor

Physiotherapy Department

Rama Institute Of Paramedical Sciences

 Kanpur, Uttar Pradesh, India 

Osteoarthritis

Definition: - Osteoarthritis is a degenerative , non-inflammatory joint disease. It is a common type of joint disease which is more common in weight bearing joint like hip and knee, but also seen in spine and hand.

Osteoarthritis is characterised by joint pain , loss of function and degenerative changes occur in articular cartilage.  It can be classified into two categories:

1. Primary osteoarthritis

2. Secondary osteoarthritis. 

Primary osteoarthritis: - It is a common types of arthritis having no previous pathology in elderly peoples. Primary osteoarthritis is caused by the breakdown of cartilage, that causes the friction in the joints. It can happen in any joint but usually affects the fingers, thumbs, spine, hips, knees, or big toes.

Due to destruction of inter articular cartilage joints over and over damages the cartilage, leading to pain and swelling. Proteins break down start in the cartilage and it bone surface become fragile. It may start to flake or get tiny tears. In severe cases, lose all the cartilage between the bones of a joint so that they rub together, making it harder and more painful to use the joint. Cartilage damage can also trigger the new bone growths (spurs) around your joints.

Secondary osteoarthritis: - Secondary osteoarthritis is occurred by another disease which is responsible to damage the cartilage of the joint. Causes of Secondary osteoarthritis are obesity, surgery of the joint, rheumatoid arthritis, gout, diabetes and menopause etc.

 

Pathophysiology :-  Hyaline cartilage covers the bone in articulating surface of the joint space . it act as a cap of the bone. Hyaline cartilage provides a smooth, gliding surface for joint motion and acts as a shock absorber like as a cushion between the bones.  The nature of hyaline cartilage is proteoglycan, that is why it provide resilient property.

In the osteoarthritis, Cartilage is the first structure which is get to be affected ,and breaks down which causes the joint pain. Osteoarthritis is a degenerative condition primarily affected the articular cartilage then the affected structure are:-bone, synovial membrane ,capsule ligament and muscles.

The activity of osteoclast is increased and causing the erosion often centrally and frequently weight bearing joint. This increased activity of the osteoclast causes the softening , splitting and fragmentation of the cartilage which disturbed the alignment of collagen fibres and there is disorganisation of the proteoglycan collagen.

These break off cartilage erodes the bone and formed the bonny flakes which act as osteophytes. Theses osteophytes erode the bony surface and disturbed the shape of bone . surface of the bone become flat and look like a mushroom.

After that synovial membrane undergo hypertrophy and get to oedematous, result is that synovial fluid secretion is decreased. As a result, loss of nutrition and lubrication of cartilage is decreased during movement is the joint.

It causes pain , swelling  around the joint and have difficulty in movement.

 

Clinical features:-

More common joints are:-

1Hip

2. Knee

3. Feet

4. Spine

5. Hand (Interphalangeal joint)

Uncommon Joints are:-

1. Shoulder

2.  Wrist

3. Elbow

4. Metacarpophalangeal joint

5. TMJ

6. SI

7.  Ankle

Clinical features depends upon the joint affected and symptoms vary from individual to individual but still some features are common, these are:-

1. Pain & Tenderness

2. Restricted movement

3. Stiffness

4. Crepitus

5. Muscle spasm

6. Muscle weakness

7. Deformity

8. Joint effusion

1. Pain: Pain is induced by mobilisation, which is increased by long standing work, sternous work and also, increases with fatigue muscles but it may be decreased with rest. Pain occurs in the morning or after a period of inactivity. Mostly, there's no overnight pain. The intensity of pain is vary . Sometimes it's dull and tolerable, and some time it is intolerable. Weather is also affected the joint like during winter season pain increases and any and fatigue can act as a stimulator for pain.

2. Restricted movement (loss of ROM): Movement of the joint is decreased because of swelling and joint stiffness. The space of the joint is decreased which causes morning stiffness . The severity of joint stiffness increased by time and is accompanied with the joint deformity .

3. Crepitus : the movement of the joint produces sound , is called crepitus sound. This sound produced by flake cartilage and  eburnated bone ends.

4. Deformity : Knock knee deformity is more common. Heberdon’s nodes are present at the OA of DIP joint.

5. Difficult and painful mobilization: It's important to differentiate between total blocking and limited mobility. Total blocking is caused by the presence of meniscus, unusual structures, etc.and will need further investigation.

6. Mild swelling around a joint.

Radiological Examination:

Osteoarthritis is one of the most prevalent weight bearing joint disease  .

Primary osteoarthritis include nonuniform joint space loss, osteophyte formation, cyst formation and subchondral sclerosis. The initial radiographs may not show all of the findings. At first, only minimal, nonuniform joint space narrowing may be present.

Joint spaces have an asymmetric distribution. 

As the disease progresses, subluxations may occur and osteophytes may form.

Subchondral cystic changes can occur at joint space and these cyst may or may not communicate with the joint space . these sclerotic changes occur before cartilage loss and have a part affected with sclerosis and formed the sclerotic border around the joint.

[*sclerotioc changes-A hardening or induration of bone tissues]

As cartilage loss increases, Subchondral sclerosis or subchondral bone formation occurs in the joint space and look like  as an area of increased density on the radiograph.

In the advanced stage of the disease, a collapse of the joint may occur; however, ankylosis does not usually occur in patients with primary osteoarthritis.

 

The severity of osteoarthritis is  evaluated by radiograph which is explained by Kellgren. According to him, we can discriminate four degrees of severity in osteoarthritis:-

Degree I: normal joint with a minimal osteophyte.

Degree II: Osteophytes on two points with minimal subchondral sclerosis, proper joint space and no deformity.
Degree III: Moderate osteophytes, early deformity of the bone endings and a joint space which narrows.
Degree IV: Large osteophytes, deformity of bone endings, narrowing joint space, sclerosis and cysts.

 

MRI Presentation:- MRI provides better soft tissue contrast than CT and x-ray. It can differentiate better between fat, water, muscle, and other soft tissue than CT (CT is usually better at imaging bones). These images provide information to physicians and can be useful in diagnosing a wide variety of diseases and conditions.

MRI shows the characteristic of OA which include:-

·       focal loss of articular (hyaline) cartilage,

·       osteophytes,

·       subchondral marrow lesions,

·       joint effusion.

Frequently seen with OA and at Advance stage It represents the smeniscal tears, especially meniscal extrusion, and periligamentous edema at the MCL

Principles of Treatment :

a)     To delay the occurrence of the disease, if the disease has not begun yet.

b)     To stall progress of the disease and relieve symptoms, if the disease is in early stage.

c)     To rehabilitate the patient, with or without surgery, if his disabilities can be partially or completely alleviated.

Conservative Management

§     Reduction of weight.

§     Avoidance of stress and strain to affected joint in day to day activities.

§     Local heat provide relief of pain and stiffness.

§     Exercise for building up the muscles controlling the joint help in providing the stability to the joint.

§     Local application of the counter-irritants provide dramatic relief.

§     Walking and light aerobic excercises.

Medical Management :

·       DRUGS : Analgesics are used mainly to suppress pain like Acetaminomorphine.

·       NSAIDs (Non-selective NSAIDs,COX-2 selective ) and muscles relaxants .

·       Newer drugs such as Glucosamine, Chondroitin sulfates are known to  help in regeneration of articular cartilage. They are called DMARDs (Disease Modifying  antirheumatic Drugs ).

Injections : Intra-articular injections of steroids and synovial fluid preparation.

Viscosuplementation : Sodium Hylarunon has been introduced. It is injected. It is injected in the joint 3-5 times at weekly interval. It is suppose to improve cartilage functions and  is claimed to be chondroprotective.

Surgical Management :In selected case, surgery can provide significant relief, some procedure performed in OA.

§  Osteotomy: Osteotomy near a joint has been known to bring about relief in symptoms,a high tibial osteotomy for OA of the knee with genu varum and inter-trochentric osteotomy for OA of the hip have been shown a useful for pain relief.

§  Excision Of Loose Bodies, meniscectomy: Synovectomy and reconstruction or joint debridement are best done by Arthroscopy.

§  Total Knee Replacement: This indicated when both compartment of are destroyed or if valgus or varus deformity is more than 15 degree. It is also indicated in failed conservative treatment.

§  Arthrodesis: Indicated less commonly than arthroplasty.  If  the patient is young and involve in heavy occupation, arthrodesis is indicated to give a stable and strong knee. 

Physiotherapy Management

Aims of Physiotherapy :

§     To educate the patient.

§     To reduce pain, inflammation and stiffness.

§     To restore muscle balance.

§     To maintain improvement of ROM.

§     TO maintain or improvement in functional independence, including participation in a vocational activites.

Measures to Relieve Pain and Muscle Spasm

1)     DURING ACUTE PHASE :During this phase pain can be satisfactorily controlled by Transecuteneous Electrical Nerve Stimulation (TENS), Ultrasound (UST), Shortwave Diathermy (SWD), Hydrotherapy, Cryotherapy, etc.

2)     DURING THE CHRONIC PHASE :Deep heating by UST or SWD may help.

Thermotherapy :

·       Heat applied through various heat packs , relieves pain .

·       Heat close the PAIN GATE, Improve local circulation, increacse collagen extencibility, Reduce muscle spasm, Improve ROM.

·       It appear to be a simple, cost effective, means of assisting pain control and therefore it is an appropriate tool in patient self-management regimes.

NOTE :In osteoarthrirtis, it is an effective method for pain relief and improvement of function and quality of life in short term.

Cryotherapy :

·       It applied through ice packs or bath may relive pain via the ‘PAIN                            GATE’ mechanism.

·       Reduce peripheral nerve excitibility .

·       Reduce joint effusion and oedema.

NOTE : In osteoarthrirtis, cryotherapy help in pain management,decrease knee stiffness, improve range of motion of joint ,and physical function of joint.

Ultrasound Therapy (UST) :

·       Probebly most common used electrotherapy modality specially for hip, knee, and spinal OA.

·       It is claimed to alters cell function, vascularity, and collagen extencibilty, resulting relief in inflammatory condition.

NOTE :In osteoarthritis, UST is a safe and effective modality which give relief in pain by increasing the cell fuctional activity and decreasing the inflammation.

Tens :

·       It is used in acute and in chronic condition.

·       It’s electrical stimulation in large diameter neural fibers ‘closing the pain gate’ which give relief in pain.

·       It can be effective when used in high frequancy and strong burst mode (not in all condition).

Note : In osteoarthrirtis, TENS help in reduction of pain by closeing the ‘Pain Gate’ at the spinal cord level and maintain or improve physical function.

SWD :

·       It results in tissue heating and subsequent increase circulation of treated area.

·       Cell membrane potential may also been affected.

Note : In osteoarthritis, SWD decrease pain by increseing the blood circulation.

     Exercise Regimen (For The Knee OA)

Various forms of exercise are recommended for osteoarthritis knees are :

·       ISOMETRIC EXCERCISES : Strong isometric exercise of the quadriceps and hamstring muscle done ,quadriceps known as the powerhouse of the knee,a possible role for quadriceps strengthening in slowing disease progression.

·       Isometric of quadricep by pushing against the soft pillow beneath the knee,contacting knee cap offering resistance by pushing down with the help of hand .

·       STRENGHTNING of hip abductors : Abductor muscle controll pelvic position in frontal plane may reduce knee load, weekness of hip abductor cause drop in level of pelvis .

 

·       Streching Excercises : Streching for hip flexors, hamstring and calf muscle help in improve ROM, pain and flexibility of joint.

·       In the hamstring strching exercise, the patient attempts to touch the toes, while the knee extended in the sitting posture.

 

·       Active Rom Exercise :   Patieny sits at the edge of the bed or chair and actively flex the knee joint in free swinging movement within limits of pain.It is east to perform and improbe ROM of the knee, facilitates joint lubrication.

·       Isokinetic Exercise :In this group of excercises, resistance is either given by the therapist or by patient themself with other leg.

·       It is self controlled, easy to do and improve the muscle strngth.

·       Straight Leg Raising Excercises :Bilateral straight leg raising with isometric to the quadricep and dorsifexionof the ankle is very effective.

Orthoses Used In OA of Knee :Patellofemoral knee brace,Unloaderknee brace,Offloading type beace which shift the load away from the invilved khnee compartment.

Footwear and Insoles :Lateral Wedges ,Shock-Absorbing Insoles.

TAPING : Work offload the joint similar to bracing, this is effective for short term in primary knee osteoarthritis , act as alternative conservative treatment.

Management For Osteoarthritis Of Hip

To Relive Pain : Cryotherapy,Thermotherapy,TENS,IFT etc,. may help.

·       Sustained low traction help to relive pain, spasm and prevent deformities

To Mobilize The Joint:Active ROM excercises to the hip, knee and ankle.

·       Free active assisted movements by using pedo-cycle,stationary cycle.

·       Hydrotherapy improve mobility and muscle strngth.

·       Proprioceptive Neuromuscular Facilitation (PNF) Technique and Maitland Technique of low grade mobilization .

To Improve Muscle Strengthening :Isometric excercises to the gluteus muscle,quadriceps,hamstring,and hip abductor muscles.

·       Active ROM excercises

·       Progressive resistive excercises in later stages.

Activities to avoid in oa condition

Unsupported climbing,getting up, etc,.fit railings next stairs or toilet and bath side .

§  Squatting on the ground.

§  Using Indian toilets.

§  Unnecessary bending, standing, walking.

§  Kneeling.

§  Carrying heavy weight.

References

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23. John Ebenezer (text book of orthopaedic)

24. Maheshwari

25. Jayant Joshi, Prakash P Kotwal 

26. Campbell’s operative orthopaedics

27. Orthopedic Physical Assessment" by David J. Magee,; "Clinical Orthopaedic Rehabilitation"

28.Maitland; Neural tissue mobilization – Butler.

Acknowledgement 

Author would like to acknowledge Muskan Agrahari for her crucial support and contribution towords this book chapter.