Physiotherapy Guidelines on the Management of Osteonecrosis in Post-SARS Patients

Physiotherapy Working Group on SARS Coordinating Committee in Physiotehrapy Hospital Authority December 2003

Introduction
Some patients who have been recovering from the Severe Acute Respiratory Syndrome (SARS) have developed osteonecrosis. In a recent press release (Hospital Authority, 2003), it was reported that among the 418 patients being screened with MRI, 49 showed osteonecrosis. The incidence is about 11.7%. Among those with osteonecrosis, 29 (59.2%) had involvement of the hip joint. Currently, there is a paucity of information about the causes of osteonecrosis in post-SARS patients, although steroid treatment may be considered as one of the risk factors in this group of patients (HKCOS & HKOA, 2003). However, the prevalence and the natural history of steroid-induced osteonecrosis are still not certain (Assouline-Dayan et al, 2002). The presence or absence of pain symptoms in post-SARS patients is not a reliable indicator for detecting osteonecrosis, especially in the early stages. At present, the MRI is considered as the first choice of diagnostic method to detect early osteonecrosis (Pavelka, 2000). The successful management of osteonecrosis would depend on the early detection with treatment in influencing the natural history of the disease (Lavernia et al, 1999). The orthopaedic surgeons of the Hospital Authority have come to a consensus of management protocols on osteonecrosis of knee and hip based on the staging systems (HKCOS & HKOA, 2003). Table 1: Classification and Staging of Osteonecrosis of Knee based on Mont et al (1997) Stage I II Criteria Normal x-ray but abnormal MRI Sclerotic or cystic changes, or both, on plain x-ray; normal contour of articular surface and no subchondral fracture Subchondral collapse or crescent sign Narrowing of joint space with secondary changes of articular surface Recommended Treatment by HKCOS & HKOA (2003) Observation Observation or core decompression or osteotomy Observation or osteotomy Observation or knee joint replacement

III IV

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Table 2: Classification and Staging of Osteonecrosis of Hip based on the University of Pennsylvania System Stage Stage 0 Stage I A B C Stage II A B C Stage III A B C Stage IV A B C Stage V A B C Stage VI Criteria Normal MRI Normal radiograph; abnormal MRI Mild (<15% of head affected) Moderate (15% to 30% of head affected) Severe (>30% head affected) Lucent and sclerotic changes in femoral head Mild (<15% of head affected) Moderate (15% to 30% of head affected) Severe (>30% head affected) Subchondral collapse Mild (<15% of head affected) Moderate (15% to 30% of head affected) Severe (>30% head affected) Flattening of femoral Head Mild (<15% of head affected & <2mm depression) Moderate (15% to 30% of head affected or 2 to 4-mm depression) Severe (>30% head affected or > 4mm depression) Joint narrowing and/or acetabular change Mild Moderate Severe Advanced degenerative changes Observation or vascularized bone graft or hip joint replacement Observation or vascularized bone graft Observation or core decompression or vascularized bone graft Observation if asymptomatic Observation or core decompression if asymptomatic Recommended Treatment by HKCOS & HKOA (2003) Observation

This document is developed by the Physiotherapy Working Group on SARS of the Coordinating Committee in Physiotherapy, Hospital Authority for the management of osteonecrosis in post-SARS patients. It serves as the guidelines for physiotherapists working in the Hospital Authority to offer appropriate advice and interventions for post-SARS patients with suspected or confirmed diagnosis of osteonecrosis.

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Physiotherapy Treatment Goals
The treatment goals of physiotherapy for post-SARS patients with osteonecrosis are to: 1. Maintain the muscle strength and joint range of motion; 2. Prevent or retard the deterioration of osteonecrosis from early to late stages; 3. Maintain the physical functions to cope with daily activities; and 4. Manage symptoms.

Physiotherapy Treatments - Recommendations
The physiotherapy treatments for SARS patients with suspected osteonecrosis will depend on the presence of symptoms and MRI status: Screening for Osteonecrosis by MRI

MRI +ve

MRI -ve

Pending MRI

Operative Treatment - Follow post-op protocol - Protected weight bearing for 6-12/weeks - ROM ex. - Symptoms management

Conservative Treatment - Crutch/stick walking if indicated - ROM ex. - Activity & ergonomic advice - Symptoms management - Avoid high joint loading exercises or activities

If asymptomatic - Activity & ergonomic advice If symptomatic - Symptoms management - ROM Ex. - Consider modify mode of training in avoiding high joint loading exercises or activities

If asymptomatic - Activity & ergonomic advice

If symptomatic - Symptoms management - ROM Ex. - Suspend high joint loading exercises or activities - Crutch/stick walking if symptoms can be improved

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Considerations of Joint Loading During Therapeutic Exercises and Activities
In order to minimize the deleterious effect of inactivity and immobilization while to minimize the hazard of aggravating the process of osteonecrosis, the limit of acceptable joint loading for post-SARS patients with knee or hip osteonecrosis of stage I or less is set to the level comparable to walking with slow speed (i.e. < 2 km/h) (Fagerson, 1997; Kuster 2002). With a slow walking speed, the joint loading of the knee or hip is about double of the body weight (Fagerson, 1997). Activities or exercises which create loading at knee or hip below 2 body weight (BW) are classified as low impact while those generate loading ranged from 2 to 5 BW are classified as medium impact. Activities or exercises which create loading above 5 BW are classified as high impact. The knee and hip joint impacts in various exercises and activities are shown as follows: Table 3: Knee Joint Impact in Various Exercises and Activities (Fagerson, 1997; Kuster 2002) Knee Joint Force Activities/Exercises A. Exercises B. Walking

Low Impact (< 2 BW)

Medium Impact (2 to 5 BW)
• •

High Impact (> 5 BW) Isokinetic knee extension

Slow or free speed walking (speed: 1-2 km/hr) Low to high resistance Free exercises in water at low speed

Walking at >2 – 5 km/hr

C. Cycling D. Hydrotherapy#

• •

Exercises against buoyancy or resistance at moderate to high speed Stair climbing Ramp

E. Other Activities

• •

Jogging/Running

#

Hydrotherapy can be an effective means of limited weight-bearing in patients with orthopaedic conditions. The percentages of weight bearing during immersed walking at different level of immersion are estimated as follows (Harrison et al, 1992):

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Level of Immersion C7 Xiphisternum ASIS

Static 0% - 25% 25% - 50% 50% - 75%

Slow walking 0% - 25% 25% - 50% 50% - 75%

Fast walking 0% - 25% 50% -75% 75% - 100%

Table 4: Hip Joint Impact in Various Exercises and Activities (Fagerson, 1997; Kuster 2002) Hip Joint Force Activities/Exercises A. Exercises

Low Impact (< 2 BW) Gravity free ROM exercises Supine SLR Prone hip extension Protected weight-bearing walking with crutches or sticks Slow or free speed walking (speed: 1-2 km/hr) Low to high resistance Free exercises in water at low speed
• • •

Medium Impact (2 to 5 BW) Bridging

High Impact (> 5 BW) Isometric resisted hip exercises at 100% MVC

• • •

B. Walking

Walking at > 2 – 5 km/hr

Walking at > 5 km/hr

C. Cycling D. Hydrotherapy

• •

Exercises against buoyancy or resistance at moderate to high speed
• • •

E. Other Activities

Jogging/Running Stair climbing Bath/Car entry

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General Considerations in Physiotherapy Interventions
The treatments for each post-SARS patient would be individualized and based on his/her clinical signs and symptoms, and the status of osteonecrosis detected with MRI. The followings are general principles and considerations for selected types of treatments for post-SARS patients: Muscle Strengthening Exercises In strengthening the muscles of patients with rheumatoid arthritis, it is recommended that the goal for the load level of strengthening exercises should be moderate to hard (i.e. 50% to 80% of a maximal voluntary contraction) with a frequency of 2 to 3 times per week (Stenström & Minor 2003). Physiotherapists can base on this general guideline to recommend the load level of strengthening exercises to post-SARS patients, taking into considerations of any contraindications or precautions. Because there is a paucity of information on the loading duration (either continuous or accumulative) that may cause adverse effects on osteonecrotic joints. The duration and repetitions of exercise will be individualized and guided by subjective complaint and / or signs of muscle fatigue. The joints in upper limbs are essentially non-weight bearing joints and the exercise prescription of muscles of upper limbs will follow the same principles as in lower limbs. Cardiopulmonary Fitness Training Cycle ergometer would be the choice of modality for cardiopulmonary fitness training because of its known low impact on lower limb joints (Ercison, 1986; Westby, 2001; ACSM 1998). The recommended training intensity would be 50% or 60% to 85% of maximum heart rate for 30 minutes and three times a week (Stenström & Minor 2003). Aquaerobics (pool aerobic exercise) at target heart rate of 70% of maximal heart rate is also shown to be effective in improving exercise tolerance (Smith et al, 1998). Activity Modification, Ergonomic Advice & Risk Management Post-SARS patients with osteonecrosis should: • avoid extreme flexion positions like squatting or kneeling • avoid shoulder abduction and external rotation (for patients with AVN of humeral head) • avoid carrying loads in contralateral hand to their bad hip because of higher loading induced (Neumann, 1996)

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• • • • •

sit-to-stand transfer from a high chair (62 cm) because of less contact pressure is created at hip joint (Fagerson, 1995) avoid prolonged exposure of weight bearing minimize additional vertical loading such as heavy lifting avoid risk factors of fall avoid high impact activities or movements and follow the recreational sports guidelines for patients having total knee replacement and total hip replacement:
(1) High impact sports are not recommended such as baseball, basketball, climbing,

football, downhill skiing, parachuting, racquetball, jogging, running, weight lifting, soccer, sprinting, volleyball, high impact aerobics, gymnastics, handball and hockey. (2) Allowable sports activities include: archery, bicycling, billiards, pool exercises, swimming, bowling, croquet, shuffleboard, fishing, golf, hunting, low-impact aerobics, most shooting sports, scuba diving & walking.

Potential Beneficial Physiotherapeutic Modality - Application of Pulsed Electromagnetic Field (PEMF)
The beneficial effect of pulsed electromagnetic fields (PEMFs) in treating non-union has been shown in the literature (Bassett, 1993). Several models of Electrical Bone Growth Stimulator using non-invasive PEMF were approved by the U.S. Food and Drug Administration (FDA) in the treatment of non-unions, congenital pseudoarthroses and promotion of spinal fusion (Polk, 2000). However, no optimal frequency and intensity can be identified for bone healing due to diversified parameters used in those studies with positive results (Polk, 2000). With the potential effect on stimulating osteogenesis, PEMFs could be considered as one of the modalities in treating osteonecrosis. Details of the clinical application of PEMFs is described in the Appendix.

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Specific Recommended Treatments for Post-SARS Patients with Suspected or Confirmed Osteonecrosis of Hip (Stage 0 to Stage 1)
Table 5: Recommended Treatments for Post-SARS Patients with Suspected or Confirmed Osteonecrosis of Hip
Patient Subgroups Pending MRI Asymptomatic Symptomatic Exercises Walking Cycling Hydrotherapy Advice

Low to medium impact Low impact

Comfortable speed* (4.5-5 km/h) Slow speed ± crutches/stick (<2 km/h)

Low to high resistance Pain-free Low to Medium resistance

Free exercises at low speed Free exercises at low speed, pain-free

Normal activities as usual Avoid prolonged weight bearing, e.g. standing > 15-20 min

MRI received Stage 0 Asymptomatic

Low to medium impact

Comfortable speed (4.5-5 km/h) Slow speed ± crutches/stick (<2 km/h)

Low to high resistance

Symptomatic

Low impact

Low to Medium resistance, pain-free

Free active & resisted exercises below medium speed Free exercises at low speed, pain-free

Normal activities as usual

Avoid prolonged weight bearing, e.g. standing > 15-20 min Avoid prolonged weight bearing, e.g. standing > 15-20 min Avoid prolonged weight bearing, e.g. standing > 15-20 min

Stage 1 A & B Asymptomatic Symptomatic Stage 1 C Asymptomatic Symptomatic

Low impact

Comfortable speed (4.5-5 km/h) Crutch Walking Comfortable speed (4.5-5 km/h) Crutch Walking

Low to Medium resistance Low resistance Low resistance

Free exercises at low speed, pain-free

Low impact

Pain-free, free exercises at low speed

* based on Bohannon (1997)

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Appendix: Clinical Application of Pulsed Electromagnetic Field (PEMF)
The duration of application of PEMF ranged from 3 hours to 24 hours as described in various studies. Contra-indications
• • • •

Patents having implanted pacemaker or defibrillator Haemorrhage Pregnancy Tumors

There are 6 factors to be considered in the application of PEMFs (Magnetopluse™): 1. Frequency around 4 to 6 Hz should be used to combat inflammatory conditions (acute or chronic); 2. Frequency above 10 Hz cause vasodilatation; 3. Acute conditions generally respond best to lower frequencies; 4. Chronic conditions generally require higher frequency; 5. Traumatic conditions usually require longer treatment time (30 minutes); 6. This therapy is safe to use with stainless steel or plastic implants, as there is no immediate thermal effect. Recommended treatment with PEMFs (Magnetopluse™)
• • •

Treatment in 2 phases The first phase is the first week post fracture (operation). Lower frequency range (4-6 Hz) is used to treat tissue damage. The second phase starts from second week onwards. Higher frequency range (>10 Hz) is used to cause promotion of osteogenesis.

Phase I
• • •

30 minutes 60 Gauss 5 Hz 30 minutes 80 Gauss 8 Hz 30 minutes 99 Gauss 12 Hz

Phase II
• • •

30 minutes 99 Gauss 12 Hz 30 minutes 99 Gauss 25 Hz 30 minutes 99 Gauss 50 Hz

Two to three sessions per week is recommended. Daily treatment more than 14 days is not recommended by the manufacturer of Magnetopulse™.

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References
American College of Sports Medicine (1998) Position Stand: the recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in healthy adults, Med Sci Sports Exerc 30: 975-991. Assouline-Dayan Y, Chang C, Greenspan A (2002) Pathogenesis and natural history of osteonecrosis, Semin Arthritis Rehum 32: 94-124. Bassett CA (1993) Beneficial effects of EMFs, J Cell Biochem Apr 51: 387-393 Bohannon RW (1997) Comfortable and maximum walking speed of adults aged 20-79 years: reference values and determinants, Age Ageing 26: 15-19. Delanois RE (1998) Atraumatic osteonecrosis of the talus, J Bone Joint Surg Am 80A: 529-536. Ericson MO, Nisell R (1986) Tibiofemoral force during ergometer cycling, Am J Sports Med 14: 285-293. Escamilla RF (2000) Knee biomechanics of the dynamic squat exercise, Med Sci Sports Exerc 33: 127-141. Fagerson TL (1997) Range of in vivo forces and pressures at hip for various activities. Hip Symposium, APTA Conference, San Diego, 31 May. Harrison RA, Hillman M, Bulstrode S (1992) Loading of the lower limb when walking partially immersed: application for clinical practice, Physiotherapy 78: 164-166. Hong Kong College of Orthopaedic Surgeons, Hong Kong Orthopaedic Association (2003) Fact Sheet on Avascular Necrosis in Patients Recovered from SARS, 5 November. Hospital Authority (2003) HA is committed to providing comprehensive follow-up services for SARS patients. Press release on 6 November. Kuster MS, Wood GA, Stachowiak GW, Gachter A (1997) Joint load consideration in total knee replacement, J Bone Joint Surg Br 79B: 109-113. Kuster MS (2002) Exercise recommendations after total joint replacement – a review of the current literature and proposal of scientifically based guideline, Sports Med 32: 433 – 445. Lavernia CJ, Sierra RJ and Grieco FR. (1999) Osteonecrosis of the femoral head, J Am Acad Orthop Surg 7: 250-261. Lee JA, Farooki, Ashman CJ, Yu JS (2002) MR patterns of involvement of humeral head osteonecrosis, J Comput Assist Tomogr 26: 839-842. Lieberman JR, Berry DJ, Mont MA, Aaron RK, Callaghan JJ, Rayadhyaksha A, Urbaniak JR (2002) Osteonecrosis of the Hip: Management in the twenty-first century, J Bone Joint Surg Am 84A: 834-853.

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Mont MA, Baumgarten KM, Rifai A, Bluemke DA, Jones LC and Hungerford DS (2000) Atraumatic osteonecrosis of the knee, J Bone Joint Surg Am 82A: 1279-1290. Mont MA, Hungerford DS (1997) Osteonecrosis of the shoulder, knee, and ankle. In Urbaniak JR, Jones JP (eds) Osteonecrosis: Etiology, Diagnosis, and Treatment, Rosemont IL: America Academy of Orthopaedic Surgeons, p.429. Neumann DA (1996) Hip abduction muscle activity in person with a hip prosthesis while carrying loads in one hand, Phys Ther 76: 1320-1330. Pavelka K (2000) Osteonecrosis, Bailliere’s Clin Rheumatol 14: 399-414. Polk C (2000) Therapeutic applications of low frequency sinusoidal and pulsed electric and magnetic fields. In Bronzino JD (ed) The Biomedical Engineering Handbook, 2nd ed, pp.91-1 to 91-13. Smith SS, Mackay-Layons & Nunes-Clement S (1998) Therapeutic benefit for individuals with rheumatoid arthritis, Physiother Canada 50: 40-46. Stenström CH, Minor MA (2003) Evidence for the benefit of aerobic and strengthening exercise in rheumatoid arthritis, Arthritis Care Res 49: 428-434. Westby MD (2001) A health care professional’s guide to exercise prescription for people with arthritis: a review of aerobic fitness activities, Arthritis Care Res 45: 501-511.

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