Presentation on theme: "A Fresh Outlook on Osteoarthritis and Physical Capabilities"— Presentation transcript:
1A Fresh Outlook on Osteoarthritis and Physical Capabilities Randy Raugh, PT, DPT
2Osteoarthritis (OA) 37.4% > age 60 with knee OA % of AmericansLeading cause of immobility/disability > 60Symptoms: 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?
3CDCOA knee: 1 of 5 leading causes of disability among non-institutionalized adults.~ 80% of patients - some degree of movement limitation25% cannot perform major activities of daily living11% knee OA need help with personal care14% 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
4Excessive stress to entire joint Articular (hyaline) cartilageSynovial liningBone beneath cartilageLigamentsDiagnosed by X-Rays and symptomsJoint space narrowingSclerosis (increased bone density)Spurs, lipping
5X-Rays of OA jointsNormal kneeOsteoarthritic knee
6X-Rays don’t correlate well to pain Decreased space: meniscus or articular cartilageCartilage: no nerves = no painX-Rays activityFear/anxiety = activityUntreated OA lesions fared no worseWiduckowski et al (2009) 2-4 cm lesions w/out tx no worse in 13 – 17 year follow-upSurgical debridement of OA no better than physical therapy/medicationRisberg et al; Kirkley et al; Moseley et al
7Risks for OA Excess weight Trauma, surgery, etc. NO movement For OA riskNot for progression unless misalignmentsTrauma, surgery, etc.NO movementImmobilizationSedentary lifestyleRepetitive, excessive twistingRapid impact activitiesExcessive Joint flexibilityMisalignments/movement impairments
8Articular cartilageHyaline cartilage – bluish, opalescent, glassy, homogenousThinner with ageNo blood vessels / no nervesHeals very slowlyNo pain80% water-filled matrixMust have dynamic (cyclic) loading to move nutrients in/damaged cells/waste products out.
9Functions of articular cartilage Absorb and distribute compressive forcesLike a gel bicycle seatLying down (~0 compressive force) - kneeJumping (~24 x body weight) – kneeFlow of fluid through porous matrix, away from force.Stiffer to higher loadsShock absorption (deformation of cancellous bone most, then subchondral bone and slightly cartilage (1-3%)Slippery500 to 2000 x slipperier than ice on ice.Synovial fluid – consistency like egg whiteHelps cartilage resist sliding forces
10Tensile stress-strain curve of articular cartilage TENSILE FORCESTensile stress-strain curve of articular cartilage
11Compressive forcesThe non-linear response of articular cartilage to compressive force on fluid flow through the matrix
12Types of physical stresses encountered by articular cartilage Stretching (tensile) forcesCompressive forcesSliding (shear) forces
13Compressive loads Short term Long term changes 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 changesInadequate load/immobilizationJortikka 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%.
14Compression 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 womenSlemenda et al (1997)- each 10-lb/ft increase knee extensor strength = 20% knee OAMikesky et al (2006) – 221 older adults, strength vs ROMStrength group showed slower rate of JSN at 30 months.Excess weight increases load and riskFelson et al in Framingham Study (1992), wt loss risk of knee OASharma et al (2000) BMI correlated more with risk than progression except in bowed legs
15Shear (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 shearTwisting and bending knees sidewaysLess pain with movement impairment corrections
16Causes of compression problems Inadequate (rhythmic) compression“I better not wear it out faster”Sedentary lifestyleStatic posturesProlonged standingExcess compressionExcess body weightHigh impact or rapid loading activitiesWeak muscles (or muscles untrained for faster loads)
17Causes of excessive shear Activities which twist joints with compressionSkiingTennisDancingRunning with flexible kneesPoor movement patternsSit stand with knees in/outUp/Down steps with hip/knees in/outPoor body mechanics with activities
19General advice about joint care Avoid static postures – especially bad ones – move!No pain, no gain = no brain.Avoid joint noise if possibleMaintain adequate strengthStretch muscles, not jointsHealthy weightAll joints need regular movement to feel their best.If you can’t find comfort, seek helpStart with conservative care (physical therapy)If no improvement in 6 – 8 visits, change therapistsTreat it as a mechanical problem
20Feet are the foundation Do not tolerate uncomfortable shoes – ever!Maintain healthy weightAlternate sport shoes each dayShock absorption is slow to recover after compressionChoose activities that don’t hurt.Walking is better than standingFoot exercises?
21Knees to last a lifetime Healthy weightAvoid unnecessary twistingBiking?Avoid breaststroke, scissor or frog kicks in swimmingFocus on alignmentMaintain strong legs and HIPSWear proper shoes
22Hip, hip hooray! IF flexible, avoid extreme stretches for hip Avoid performing “splits,” race-walking, extreme yoga asanas that take hips back beyond neutral with pelvicMaintain strong buttock and hip musclesAvoid becoming “hamstring dominant”Jogging worse than runningIF you have very stiff hips with OA, stretch the hips and strengthen them too
23Spine pain Seek help if: Bowel/bladder problemsDecreased strength in lower extremity or upper extremityTingling/numbness in genital regionSensory changes in both sides of UE or LEStart with conservative care – proceed slowly on that route.“But my MRI showed that…”