1. DEGENERATIVE OSTEOARTHRITIS Treatment and Rehabilitation
Assoc. Prof. Ece AYDOĞ
Physical Medicine and Rehabilitation

2. 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.

3. Constituents of hyaline cartilage
Cellular material: Chondrocytes:5%
Extracellular material: Matrix:95%
( Water comprises approximately 70%)
– Collagen fibres
– Proteoglycan molecules

4. 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

5. Normal Articular Cartilage
Softening and swelling of cartilage

6. Loss of cartilage • Softening and swelling • Fibrillation
• Full thickness cracks
• Eburnation
• Subchondral cysts
• Subchondral sclerosis
• Osteophyte formation ‘

9. 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

10. 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

11. 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

12. Deformities Mild synovitis Osteophytes Joint laxity
Asymmetrical joint destruction leading to angulation

14. Treatment Principles •Education • Physiotherapy – Exercise program
– Pain relief modalities
• Aids and appliances
• Medical Treatment
• Surgical Treatment

15. Prevent overloading of joint; Obesity
Prevent overloading of joint; Obesity!! •Appropriate use of treatment modalities •Importance of exercise program

17. 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.

19. Physical Agents
Heat
Cold
Water
Pressure
Sound
Electrical Current

20. 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 -

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

22. Ice Contraindications Precautions Cold hypersensitivity
Raynaud’s disease
Regenerating peripheral nerves
Precautions
Over superficial main branches of nerve
Peroneal nerve
Open wounds
Poor sensation

23. Application 10 minutes is sufficient
Re-applied regularly, every 2-3 hours
Following approximately the first 3-5 days of an acute injury

24. Red/Infra-Red Phototherapy

25. Conductive Heat Hot Packs
Moist heat
Canvas filled wityh silica gel
Immersed in water of about 77 C

26. Paraffin Bath Tank containing a mixture of paraffin and mineral oil
Areas that are diffucult to heat
Helps to soften the skin

27. 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

28. Precautions Already existing edeme Patients with sensory loss
Patients who are confused

29. 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

30. 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)

31. 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)

32. Ultrasound Two types of benefit: Thermal effects Non thermal effects
Indications:
Soft tissue shortening (Joint contractures, scarring)
Subacute and chronic inflammation

33. Electrical Stimulation
Common uses:
Pain control (TENS, interferential)
Iontophoresis (Direct Current)
Muscle stimulation (NMES)
Tissue healing (wound care)

34. 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)

35. 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

36. Aids and appliances Braces / splints Special shoes/insoles
Mobility aids
Aids: dressing, reaching, tap openers, kitchen aids
Taping of patella in patello femoral OA

38. Tapping

39. 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

41. Joint replacement surgery
• Indications: pain affecting work, sleep,
walking and leisure activities
• Complications
– sepsis
– loosening
– lifespan of materials (mechanical failure)