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Randy Raugh, PT, DPT 1. Osteoarthritis (OA) 37.4% > age 60 with knee OA 2030 - 25% of Americans Leading cause of immobility/disability > 60 Symptoms:

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Presentation on theme: "Randy Raugh, PT, DPT 1. Osteoarthritis (OA) 37.4% > age 60 with knee OA 2030 - 25% of Americans Leading cause of immobility/disability > 60 Symptoms:"— Presentation transcript:

1 Randy Raugh, PT, DPT 1

2 Osteoarthritis (OA) 37.4% > age 60 with knee OA % of Americans Leading cause of immobility/disability > 60 Symptoms: pain, stiffness, noisy and local swelling Wear and tear? CDC: Incurable, progressive and degenerative??? …focal and progressive loss of the hyaline cartilage of joints, underlying bony changes. A disease or a Mechanical problem? A cartilage problem? 2

3 CDC OA knee: 1 of 5 leading causes of disability among non- institutionalized adults. ~ 80% of patients - some degree of movement limitation 25% cannot perform major activities of daily living 11% knee OA need help with personal care 14% require help with routine needs. ~ 40% of adults with knee OA reported their health poor or fair. 1999, knee OA - more than 13 days of lost work due to health problems 3

4 Excessive stress to entire joint Articular (hyaline) cartilage Synovial lining Bone beneath cartilage Ligaments Diagnosed by X-Rays and symptoms Joint space narrowing Sclerosis (increased bone density) Spurs, lipping 4

5 Normal kneeOsteoarthritic knee X-Rays of OA joints 5

6 X-Rays dont correlate well to pain Decreased space: meniscus or articular cartilage Cartilage: no nerves = no pain X-Rays activity Fear/anxiety = activity Untreated OA lesions fared no worse Widuckowski et al (2009) 2-4 cm lesions w/out tx no worse in 13 – 17 year follow-up Surgical debridement of OA no better than physical therapy/medication Risberg et al; Kirkley et al; Moseley et al 6

7 Risks for OA Excess weight For OA risk Not for progression unless misalignments Trauma, surgery, etc. NO movement Immobilization Sedentary lifestyle Repetitive, excessive twisting Rapid impact activities Excessive Joint flexibility Misalignments/movement impairments 7

8 Articular cartilage Hyaline cartilage – bluish, opalescent, glassy, homogenous Thinner with age No blood vessels / no nerves Heals very slowly No pain 80% water-filled matrix Must have dynamic (cyclic) loading to move nutrients in/damaged cells/waste products out. 8

9 Functions of articular cartilage Absorb and distribute compressive forces Like a gel bicycle seat Lying down (~0 compressive force) - knee Jumping (~24 x body weight) – knee Flow of fluid through porous matrix, away from force. Stiffer to higher loads Shock absorption (deformation of cancellous bone most, then subchondral bone and slightly cartilage (1-3%) Slippery 500 to 2000 x slipperier than ice on ice. Synovial fluid – consistency like egg white Helps cartilage resist sliding forces 9

10 Tensile stress-strain curve of articular cartilage 10 TENSILE FORCES

11 The non-linear response of articular cartilage to compressive force on fluid flow through the matrix 11 Compressive forces

12 Stretching (tensile) forces Compressive forces Sliding (shear) forces Types of physical stresses encountered by articular cartilage 12

13 Compressive loads Short term Eckstein et al Eckstein et al (2005) – MRI before/after deep knee bends, squatting, walking, cycling – decreased thickness 5.0 to 8.8% After 100 knee bends, return to original thickness took 90 minutes. Long term changes Inadequate load/immobilization Jortikka et al (1997) – 11 weeks of immobilization PG in beagle knees – did not fully recover after 50 weeks or remobilization. Hinterwimmer et al (2004) – 20 patients mean knee cartilage thickness after partial LE immobilization for ankle fx x 7 weeks. Vanwanseele et al (2002) – after 2 years post-injury, spinal cord patients cartilage thickness patella 23%, medial tibia 25%, lateral tibia 19%. 13

14 Compression Excess load = cartilage Low compression synthesis; high decreased it. Weak quadriceps (Youssef et al, 2009) saline or botox injected into quads. Segal et al (2010) – weak quads correlated to JSN in women Slemenda et al (1997)- each 10-lb/ft increase knee extensor strength = 20% knee OA Mikesky et al (2006) – 221 older adults, strength vs ROM Strength group showed slower rate of JSN at 30 months. Excess weight increases load and risk Felson et al in Framingham Study (1992), wt loss risk of knee OA Sharma et al (2000) BMI correlated more with risk than progression except in bowed legs 14

15 Shear (sliding force) Wong et al (2008) – cadaveric osteochondral cores subjected in vitro to shear with 15% compression. More irregular surface had 5 x > shear than normal cartilage. More irregular surface = > friction = more degradation with shear) Shear more inflammation, production of degrading enzymes, etc. Shear more common than excess compression with people over 60? Clinically – patients often report more pain with movements that increase shear Twisting and bending knees sideways Less pain with movement impairment corrections 15

16 Causes of compression problems Inadequate (rhythmic) compression I better not wear it out faster Sedentary lifestyle Static postures Prolonged standing Excess compression Excess body weight High impact or rapid loading activities Weak muscles (or muscles untrained for faster loads) 16

17 Causes of excessive shear Activities which twist joints with compression Skiing Tennis Dancing Running with flexible knees Poor movement patterns Sit stand with knees in/out Up/Down steps with hip/knees in/out Poor body mechanics with activities 17

18 TISSUE RESPONSE TO PHYSICAL STRESS More physical stress Healthier Optimum Health Cell death 18

19 General advice about joint care Avoid static postures – especially bad ones – move! No pain, no gain = no brain. Avoid joint noise if possible Maintain adequate strength Stretch muscles, not joints Healthy weight All joints need regular movement to feel their best. If you cant find comfort, seek help Start with conservative care (physical therapy) If no improvement in 6 – 8 visits, change therapists Treat it as a mechanical problem 19

20 Feet are the foundation Do not tolerate uncomfortable shoes – ever! Maintain healthy weight Alternate sport shoes each day Shock absorption is slow to recover after compression Choose activities that dont hurt. Walking is better than standing Foot exercises? 20

21 Knees to last a lifetime Healthy weight Avoid unnecessary twisting Biking? Avoid breaststroke, scissor or frog kicks in swimming Focus on alignment Maintain strong legs and HIPS Wear proper shoes 21

22 Hip, hip hooray! IF flexible, avoid extreme stretches for hip Avoid performing splits, race-walking, extreme yoga asanas that take hips back beyond neutral with pelvic Maintain strong buttock and hip muscles Avoid becoming hamstring dominant Jogging worse than running IF you have very stiff hips with OA, stretch the hips and strengthen them too 22

23 Spine pain Seek help if: Bowel/bladder problems Decreased strength in lower extremity or upper extremity Tingling/numbness in genital region Sensory changes in both sides of UE or LE Start with conservative care – proceed slowly on that route. But my MRI showed that… 23

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27 Spine: Spine pain is a mechanical problem too Posture Exercise Avoid heavy lifting Never bend and lift or worse, bend, twist and lift For heavy objects – the Raugh Method 27

28 Shoulders Allow your shoulders to rise when you reach. Lift in line with the shoulder blades Dont keep them down (for your neck too). 28

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