DEGENERATIVE OSTEOARTHRITIS Treatment and Rehabilitation Assoc. 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 ‘

Individual risk factors for development 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 Originates in joint /periarticular soft tissue 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 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 Heat Cold Water Pressure Sound Electrical 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 -

General Indications Purported Uses Modulate pain Reduce or eliminate inflammation Increase rate of healing Modify muscle tone Increase connective tissue extensibility

Ice Contraindications Precautions 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 Heat Hot 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 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, growth factor 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 Ultrasound Pain 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)