COMPREHENSIVE

MANAGEMENT IN KNEE OA:

BEYOND THE MEDICINE
TA N T I A J O E
KESOEMA
 INTRODUCTION

OSTEOARTHROSIS
Or
OA
O = OLD
A = ARTHRITIS
 HOW COMMON IS OA?
• 1 in 8 people have osteoporosis
• 1 in 10 people have osteoarthrosis
• 1 in 33 people have fibromyalgia
• 1 in 100 people have rheumatoid arthritis
• 1 in 1.000 people have ankylosing spondilytis
• 1 in 2.000 people have systemic lupus erythematosus
• 1 in 10.000 people have scleroderma
 TISSUE INVOLVED IN OA
TISSUE PATHOLOGY
Cartilage Focal softening and loss
Bone Osteophyt, sclerotis, subchondral osteopenia
Capsule Thickening
Synovium Thickening and modest inflammation
Muscle Athrophy and weakness
Ligament Degeneration
Bursae Secondary bursitis
Vessel Angiogenesis, avascular necrosis, venous
hypertension
CLINICAL FEATURES
• Pain
• Muscle spasm, weakness
• Stiffness
• Inflammation
• Loss of ROM
• Crepitus
• Joint instability
• Deformity
• Reduced function
 PAIN
• It is a common and most importance complain of the
patient
• Increased by activity/movement and relieved by resting
• Many structures may give rise to pain in OA:
• Periarticular soft tissue – ligament strain
• Muscular pain and weakness
• Inflammed and overstretch synovium
• Inability to cope
D
MUSCLE SPASM
E
F
E
Stop
N
movement
S
E

M
E Prolonged
– pain &
C
fatique
H
A
N Adaptive
I shorthening
S
M
 STIFFNESS
• Loss of joint mobility due to subcondral micro-fractures heals and
callus form  deprivation of normal movement
 INFLAMMATION & EFFUSION
• It is not always present unless the joint is underwent over
activity
• Sign and symptoms include are:
Heat
Erythema
Tenderness
Effusion
Discomfort & pain
 LOSS OF RANGE OF MOTION
• Combination of joint pain, stiffness &
possible effusion will often cause
limitation of end ROM
• Certain joint may develop capsular
pattern with restriction in certain
ROM  for Knee usually flexion
contracture
 CREPITUS

The flake cartilage & eburnated bone end grate

against each other characterized sound
Mild cracking – indicate synovitis
Loud cracking – indicate advance disease
 JOINT INSTABILITY
• Surrounding muscle weaken & imbalance
• Pain episode are unpredictable causing joint to give away
• This process together with chronic stretch of soft tissue will
alter joint alignment
• These will lead to instability & possibly subluxation
 DEFORMITIES
• Osteophyte development reduce joint instability by increasing
the articular surface area
• Such deformities are more profound in
established OA but may not develop on
medial & lateral compartment equally
 this may contribute to varus & valgus
deformities
• Together with the soft tissue laxity. It
will alter normal joint biomechanic
 REDUCE FUNCTION
• All the clinical features described above can result
in functional difficulty
• Often described problems are: walking a distance,
climbing stairs, getting out of chair or vehicle, etc
• So most patient compensate by alternative ways of
achieving the task
 INTER-RELATIONSHIP OF SYMPTHOM & SIGN IN OA

Inflammation Effusion

Pain

Instability Loss of ROM Muscle inhibition

Muscle atrophy

Reduce function
MANAGEMENT OF KNEE OA

Pharmacological
Conservative
Surgical
 PHARMACOLOGIC IN OA
• Acetaminophen
NSAID
Non selective NSAID
• COX-2 selective
• Tramadol, opiods
• Joint injection
• Supplements
Glucosamine
Chondroitin sulfate, etc
 CONSERVATIVE - REHABILITATIVE
• AIMS:
To educate patient
To reduced pain, inflammation & stiffness
To eliminate aggravating factors
To maintain & improve ROM
To maintain & improve muscle strength
To restore muscle balance
To reduce stress on the joints
To retrain gait
To maintain & improve functional independence, including
restore participation in vocational and social activities
 PATIENT EDUCATION
• A major objectives in patient education is to improve
patient/caregiver knowledge in order to integrate
him/her in to decision making team
• Content should include information concerning OA
pathophysiology, clinical presentation, natural course
& the indications and expected results of various
treatment modalities
• Can be presented with discussion, booklet or website
sharing
 REDUCE INFLAMMATION
• In acute condition: PRICE
• Protection: to defense the joint from weight bearing activity
• Rest: to preserved knee from aggravated activities/movements
• Icing: to relieved inflammed tissue and pain
• Compression: to reduced edema
• Elevation: to assist fluid circulation
• In case of pain in chronic condition: warm pad to facilitate
vascularization, relieve pain
 EXERCISE
GOAL: to prevent or delay disability
• An exercise program should incorporate to:
• Lessen pain during activity
• Increase or maintain joint ROM
• Strengthen muscle
• Stabilize joint
• Improve aerobic capacity or level of conditioning
Exc in OA should be adapted according to the presence
and severity of pain
 EXERCISE cont.
• In painful episode
• Isometric exercise
• Non weight bearing exercise (OKC): biking, rowing
• Partial weight bearing exercise (CKC): aquatic exc
• In painless (or less painful) periods
• Exercise program may include progressive muscle performance exc
 STRENGTHENING SPECIFIC MUSCLE
• Quadriceps muscle: stronger quad significantly reduce pain &
improve physical function whilst reduced the risk of progressivity
• Hamstring muscle: co-contraction with quad will control varus-
valgus laxity therefore less deterioration in function
• Hip abductor muscles: reduce knee loads by controlling pelvic
position in frontal plane and increasing toe out during gait which
slow disease progression
• Hip adductor muscles: reduce knee varus by their distal attachment
to proximal femur by resisting knee abduction moment
• Hip extensor muscles: minimize deformity in sagittal plane: hip &
knee flexion deformity
 STRETCHING EXERCISE
• Stretching aim for:
• Hip flexor muscles
• Hamstring
• Calf musculature
• In order to improving ROM, pain & flexibility of knee joint
• It should be made as a routine part of treatment
 STRETCHING EXERCISE cont
• Exercise prescription recommendation:
• Mode: Gentle static stretching
• Frequency: minimum 2-3 days/week
• Intensity: stretch to position of mild tension/discomfort
• Time: Hold position for 10-30 sec
• Repetition: 3-4 repetitions for each stretch
 GAIT RETRAINING
• Gait pattern can influence loading at
knee joint, thus changing them through
gait retraining could slow disease
progression
• Parameter altering include:
• Lateral trunk leaning
• Toe-out/toe-in angle
• Medial knee thrust
• Should be performed not only while
training in clinic but also become
habitual
 AEROBIC EXERCISE
• BENEFIT:
• Relieving symptoms in knee OA
• Long-term joint health by assisting weight reduction
• Combination with dietary weight loss & exercise  more
effective improving function and pain
• Modes: cycling, swimming and walking
 ORTHOSES/KNEE BRACING
• Support, braces & corrective devices assist in relieve
pain & improve function of affected joint
• BENEFIT:
• Reduce vertical forces at knee joint during heel strike
• Realign unstable or structurally deficient joint with
restoration of normal force distribution
• Improve proprioception which then improve stability
and perception of instability
 FOOT WEAR & INSOLE
• LATERAL WEDGES
• Wedges insoles were first proposed as a
treatment for knee OA in 1980 by Japanese
researchers
• It exerts mechanical effect on lower limb by
altering magnitude, temporal pattern and
plantar location of GRF acting on the foot
during gait
• LW increase the subtalar joint valgus moment
thereby reducing moment arm of knee AM
arm in the frontal plane
 SHOCK-ABSORBING INSOLE
• Viscoelastic materials used in footwear or insoles augment body
tissues (particularly the heel pad) in reducing the magnitude of the
heel-strike transient
• With age, heel pad structure alters and results in a loss of shock
absorbing capacity
• Viscoelastic insoles can attenuate transient forces incurred during
walking, running, stair climbing activities
 PHYSICAL MODALITIES
• Electrotherapy: alleviate pain by stimulation large nerve fibers
to close the pain gate(TENS)
• Diathermy: deep heating therapy to alter cell function, increase
vascularity, collagen extensibility
• Thermotherapy: superficial heating therapy also reduce pain by
gate theory control
• Light Therapy – Low level laser Therapy deliver photochemical
reactions at cellular level which produce anti-inflammatory
effect
 HYDROTHERAPY
• One of the oldest recorded treatments for rheumatic
condition
• It utilizes buoyancy – the assistant and resistant
properties offered by water  healing effect
• The aim is to relieve muscle spasm, increase joint
ROM & muscle strength, thus improvement in
function
 WALKING AIDS
• Used to reduce the stress applied to weight-
bearing joint and improve stability during
ambulation
• Unfortunately, walking aids are not always
popular since using one perceive them as being
elderly and infirm
• Type can be used:
• Canes
• Crutches
• Walker
 WALKING AIDS cont.
• Patients were encouraged to use walking aids on the
contralateral side to affected joint to support weight
distribution and energy efficient gait pattern
• For OA knee, it functions as vertical load-sharing
implement and cannot effect forces in the frontal plane
 PATELLAR TAPING
• Aim: to control patellar tracking and
minimize contact stress
• Direct effect on pain through cutaneous
stimulation  Significant improvments in
pain and physical function
• Most common method is applied medially
directed taping to offload lateral
compartment of PFJ
 CONCLUSION
• Knee OA is a quiet common disabling health cases
among older population
• It’s pathophysiology affected many structures even in
the further part of the involved region
• The management should eliminates other possibilities
source of pain and emphasis in overall individual
aspects as focusing in functional limitation and
progressivity of the disease
Thank you

Page
 REFERENCES
• Dr. Bukh5ari M. The NICE guideline on osteoarthritis: treatment and
management in primary care. 2008
• Royal college of physicians, osteoarthritis. National clinical guideline for
care and management in adults. 2008
• Maheswari J. essential orthopaedics, 3rd ed. 2008
• Corrigan P. Reducing knee pain and loading with a gait retraining
program for individuals with knee osteoarthritis: Protocol for a
randomized feasibility trial. Osteoarthritis and Cartilage Open 2
(2020) 100097
notes