Osteoarthritis

Osteoarthritis is a non inflammatory degenerative disorder of the joint. A type of arthritis that occurs when flexible tissue at the ends of bones wear down. OA is the most common chronic condition of the joint. OA can affect any joint, but it occurs most often in knees, hips, lower back and neck, small joints of the fingers and bases of the thumb and big toe. It's characterized by progressive deterioration of the articular cartilage and formation of new bone at the joint surface.                        

The disease processes not only affect the articular cartilage, but involve the entire joint, including the subchondral bone, ligaments, capsule, synovial membrane, and periarticular muscles. Ultimately, the articular cartilage degenerates with fibrillation, fissures, ulceration, and full thickness loss of the joint surface.

Epidemiology

OA affects about 3.3% to3.6% of the population globally. It is the 11th most debilitating disease around the world, causing moderate to severe disability in 43 million people. 80% of population over 65 years old has radiographic evidence of OA, with 60% of this subset having symptoms. It is most adults aged 80 years and older, with just over one-third(35%) of people in this age group reporting the condition. OA is also more common in females than males.

Etiology

Risk factors for developing OA include age, female gender, obesity anatomical factors, muscle weakness, and joint injury.

We define two types of OA, primary and secondary. Both involve the breakdown of cartilage in joints, which causes bones to rub together.

Primary osteoarthritis

Wear and tear on joints as people age cause primary OA. Therefore it starts showing up in people between the ages of 55 and 60. Theoretically, everyone experiences cartilage breakdown as they get older, but some cases are more severe than others.

Secondary Osteoarthritis

Secondary OA involves a specific trigger that exacerbates cartilage breakdown. Common triggers for OA include-

• Injury- Bone fractures increase a person's chance of  developing OA and can bring about disease earlier.
  
• Obesity- According to the arthritis foundation, every pound of extra body weight places three pounds of pressure on the knees and six pounds on hips.
• Inactivity
• Genetics- Researchers have noticed that OA runs in families, so certain genes could also put you at risk.
• Inflammatory disease- Perthe's disease, Lyme disease and all chronic forms of arthritis.

• History of certain conditions example, Diabetes, Marfan syndrome, Wilson's disease, joint infection.

Pathology

       

This will be considered in relation to each joint structure as following-

1. Articular cartilage
2. Bone
3. Synovial membrane
4. Capsule
5. Ligaments
6. Muscle

1. Articular cartilage- Erosion occurs, often central and frequency in the weight-bearing areas.Cartilage is usually the first structure to be affected. Fibrillation which causes softening, splitting and fragmentation of the cartilage occurs in body weight-bearing and non-weight-bearing areas.

Collagen fibers split and there is disorganization water is attracted into catilage when causes further softening and flaking. Flakes of cartilage break off and may be impacted between the joint surfaces causing locking and inflammation.

Ploriferation occurs at the periphery at the cartilage.

2. Bone- 

Eburnation- The bone surfaces become hard and polished as there is loss of protection from the cartilage.

Cystic cavities form in the subchondral bone because ebumated bone brittle that occur allowing the passage of synovial fluid into the bone tissue. There can also be venous congestion in subchondral bone. Osteophytes form at the articular surfaces where they may project into the capsule and ligaments. Bone of the weight-bearing joints alters in shape- the femoral head becomes flat and mushroom shaped. The tibial condyles become flattened.

3. Synovial member-

This undergoes hypertrophy and becomes oedematous. Later there is fibrous degeneration. Reduction of synovial fluid secretion results in loss of nutrition and lubrication of the articular cartilage.

4. Capsule-

The undergoes fibrous degeneration and there as low-grade chronic inflammatory changes.

5. Ligament-

 These undergo the same changes as the capsule and according to the aspect of the joint become contracted or elongated.

6.Muscle-

These undergo atrophy which may be related to disuse because pain limits movements and function. Without adequate exercise the muscles may undergo fibrous atrophy.

Characteristics and clinical presentation 

Clinical signs depend mainly to the affected joint but usually, they show some common characteristics.

They're mainly local. Symptoms are:

• Pain- This is a mechanical type of pain which is generated by mobilization, which is generated by mobilization, increases with fatigue and decreases with rest. Pain occurs in the morning or after a period of overnight pain. The intensity of pain is variable. Sometimes it's dull and tolerable, other times it's very heavy with short peaks.
• Loss of ROM- Limitation in movements is insidious, progressive and will be noticed after several years. This limitation is mainly related to the blocking of voluntary muscle functioning and reflex contracture. It's also the result of chanes in the articular spaces, with incongruent joint surfaces.
  
• Sounds- The sounds like cracking, scraping and sounds from crepitation. They're generated by mobilization of the joint.
• Difficult and painful mobilization: It's important to differetiate between total blocking and limited mobility. Total blocking is caused by the presence of meniscus, unusual structures, etc. and will need further investigation.
• Mild swelling around a joint.
  

Differential diagnosis

Diagnosing OA is usually fairly straight forward. In cases were it is not consider:

• Periarticular structure derrangement: Perarticular pain that is not reproduced by passive motion or palpation of the joint should suggest an alternate etiology such as bursitis, tendonitis or periostitis.
• Inflammatory arthritis: If  the distribution of painful joints includes MCP, wrist, elbow, ankle shoulder, OA is unlikely, unless there are specific risk factors (such occupational, sports-related, history of injury). Prolonged stiffness points more to an inflammatory arthritis eg rheumatoid arthritis.
• Other inflammatory/systemic condition: Weight loss, fatigue, fever and loss of appetite suggestive of a systemic illness eg polymyalgia rheumatica, lupus or sepsis or malignancy. 

Diagnostic Procedures

The severity of osteoarthritis can be evaluated by radiography, according the Kellgren. By this way, we can discriminate four degrees of severity in osteoarthritis:

Degree 1: normal joint with a minimal osteophyte.

Degree 2: Osteophytes on two points with minimal subchondral sclerosis, proper joint space and no deformity.

Degree 3: Moderate osteophytes, early deformity of the bone endings and a joint space which narrows.

Degree 4: Large osteophytes, deformity of bone endings, narrowing joint space, sclerosis and cysts.

Management

Symptomatic treatment

• NSAIDs: Low doses and duration due to side effects. To be used for patients not responding well to paracetamol. Patients with high risk of developing gastrointestinal side effects: Non-selective NSAID together with a gastroprotective agent or selective COX-r inhibitor.
• Duloxetine: works on central nervous system to inhibit pain.
• Opioids: Tradmadol (non-narcotic opioid). Can be used in combination with paracetamol. Alternative if NSAIDs and COX-2 inhibitors are not effective or contraindicated.
• Itnra-articular injections:
  
• Corticosteroids- Consider when patients are having flare-ups and is responding to paracetamol and NSAIDs 
• Platelet-rich plasma
  
• Hyaluronic acid- Evidence still lacking for effectiveness in the management osteoarthritis.

Surgery

Joint surgery can repair or replace severely damaged joints, especially hips or knees. A doctor will refer an eligible patient to an orthopaedic surgeon to perform the procedure.

Physiotherapy Management

    Goals of PT management-

• Reduce pain
• Reduce tenderness
  
• Increase range of motion
• Improve flexibility
  
• Improve strength
  
• Improve functional activity
• Perform ADLs independently
• Balance and co-ordination
• Improve posture
  

Treatment-

Reduce pain and tenderness patient is suffering for pain and tenderness around the joint line and it is relief by electro therapy and exercise therapy.

• Electro therapy-
  

TENS - Burst mode for pain relief

Ultrasound- Tenderness, swelling 0.5Iw for 6 minutes

Hot fermentation- To relief pain for 10minutes

• Exercise therapy-
  

Joint mobility- Grade 1 & 2 to relief pain.

PNF pattern is used to relief pain rhymical initial and stabilization.

Improve range of motion.

Goals to the activity improve ROM.

Mobilization: Grade3 and 4 both increase joint ROM.

Reduce stiffness- By hold and relax method of antagonist muscle.

Hot fermentation and paraffin wax for 10minutes.

Improve muscle flexibility by stretching which improve ROM.

Movements

• Active movements (10 repetitions)
• Passive movements with repetitions 

Improve flexibility

• Stretching- Active & Passive
  
• Muscles- Hamstring (short & long)  calf muscles (soleous- Gastronemious) quadriceps            Repeat- 5 repetitions 30 sec hold and 30 sec relax                                                                              Hold and relax- Antagonist,  Agonist 
• MET muscle energy technique- MET of muscle 3-5 repetitions 7 seconds hold.
  
• Myofacial relax of muscle will improve activity of golgi tendon origin and muscle spindle.

Improve strength-

• Active movements of hips and knee joint.
• SLR straight leg raise- Flex muscle of hip, abductor of hip 10 sec hold, 3-5 rest b/w repetition.

PRE Progressive resisted exercise-

• Strength- Increased weight, Reduce repetition.
  
• Endurance- Increased repetition, decreased weight.
  
• Technique- DAPRE (Daily adjustable progressive resistive exercise)
  
• Medicine ball.
• Increased strength, weight 1-2 kg used.
• Spring and pully used.
  
• Manual and mechanical resistance given.
• The leverage will increased strength.
• Therabands used: It is used according to the band color.
  

Functional and ADL improve.

• Functional activity improve- PNF pattern with resistance by improving strength, flexibility, ROM.

Functional ability by walking, speed walk, brisk walk, toe walking, jogging and running.

Guiding force behind,

Dr Rajesh Gautam (PT)

                                                                            

References-

Tidy's Physiotherapy by Stuart Porter

https://www.physio-pedia.com/Osteoporosis#share

Orthopaedic by Jayant Joshi