Management

Once the diagnosis of OA is established the therapeutic programm is then designed on the basis of different

✓symptoms, ✓signs and ✓functional limitations.

When different joints are affected different therapeutic options are used.

The correlation of pain severity, functional limitation, impaired health-related quality of life with the extent of structural changes as measured by the radiograph is only modest.

Hence management decision should not be made solely on the presence and severity of radiographic changes.

Treatment Options

1. Non-

Pharmacological

2. Pharmacological

3. Surgical

Non-pharmacological treatment modalities should include:

1. Patient Education

2. Weight Reduction

3. Physiotherapy/Exercise

4. Appliances

Patient Education

Education is most important intervention for all people with OA.

Education of the patient with OA can increase the

✓practice of healthy behavior, ✓improve health status and ✓decrease health care utilization.

Weight Loss

Over weight is the single most important potentially modifiable risk factor for the development of lower limb OA.

Felson et al revealed that a weight loss of 11.2 pounds over a 10-year period decreased the likelihood of developing knee OA by 50%.

A decrease in body mass is associated with a significant r e d u c t i o n i n compress ive and r e s u l t a n t k n e e forces.

A 9.8N (equivalent to a 1 kg) reduction in body weight, is associated with a 40.6N reduction in compressive force and a 38.7N reduction in resultant force.

Thus, each unit of weight loss is associated with 4-unit reduction in knee forces

T h e a c c u m u l a t e d

reduction in knee load for

a 1-pound loss in weight

would be more than 4,800

pounds per 1 mile walked

(assuming1,200strides/

mile)

Arthritis, Diet and Activity Promotion Trial a single blinded, randomized controlled trial designed to compare the effect of exercise, dietary weight loss and the combination of both to the usual care in sedentary patient with symptomatic knee OA with BMI over 25kg/meter square;

concluded that the combination of weight loss programme plus moderate exercise provide better improvement in both symptoms and function.

Physical Therapy

American College of Rheumatology recommend

that patients with symptomatic lower limb OA

must be enrol led in a Phys iotherapy

Programme.

Recommendation for Exercise

1.Exercise therapy should be individualized and patient

Centered . age, comorbidity and over all mobility.

2.To be effective exercise programme should include

advice and education to promote a positive life style

change with an increase in physical activity.

3.Group exercise and home exercise are equally

effective and patient preference should be considered.

4.Adherence is the principle predictor of long term

outcome from exercise.

5.Strategies to improve and maintain adherence

Should be adopted.

Although an exact physical therapy formula for OA patient has not been developed.

A general principle is that a Physiotherapy programme should consist of at least following.

1. Specific Modalities

2. ROM Exercise

3. Stretching Exercise

4. Muscle Strengthening Exercises

5. Mobility Training

6. Aerobic Conditioning

7. Home Exercise Programme.

Specific Modalities (Thermotherapy/Cryotherapy/Electr ica l Stimulation)

Cold: is more likely than heat to benefit in acute arthritic flares characterized by pain and swelling.

Principle: cold induced vasoconstriction which helps to limit tissue edema and has anti-inflammatory effect by lowering joint temperature, collagenase activity and WBC count with in arthritic joint.

A Cochrane Systematic Review , examining effect

of cold, heat and placebo on patient with

radiological confirmation of OA concluded that

ice has a statistically significant beneficial effect

on

✓range of motion,

✓function and

✓knee strength as compared to

control.

Heat: is used in OA patients in order to enhance stretching exercises by increasing tissue elasticity and in order to provide analgesia.

Principle: Heat induced analgesia occurs as a result of direct suppression of free nerve endings via vasodilation.

It also suppress skeletal muscle hyperactivity through activation of descending pain –inhibitory system.

Therapeutic ultrasound

Therapeutic ultrasound is the most commonly used deep heating modality.

In this the high frequency sound wave produce heat at deep tissue

TENS

TENS has been found superior to placebo and

useful as an effective adjunct to therapeutic

exercise or NSAIDs with respect to pain relief by

many studies.

TENS Techniques

TENS is a technique to stimulate different categories of nerve fibers.

1. Conventional TENS:

Low-intensity pulsed currents are administered

at high- frequencies (between 10-200 pulses per

second, pps) at the site of pain.

The user experiences a “strong, non- painful sensation often described as ‘’tingling’ or pleasant ‘electrical paraesthesiae’.

Physiologically, conventional TENS activates large diameter non-noxious afferents which has been shown to close the pain gate at spinal segments related to the pain .

2. Acupuncture-like TENS (AL-TENS)

High-intensity and low-frequency (less than 10pps, usually 2pps) administered over muscles, acupuncture and trigger points.

The purpose of AL-TENS is to activate small diameter afferents which has been shown to close the pain gate using extra- segmental mechanisms.

3. Intense TENS

TENS can also be used as a counter-irritant,

termed intense TENS, using high-intensity and

high-frequency currents.

Pulse Electrical Stimulation Pulse Electrical Stimulation act at the level of hyaline cartilage by maintaining proteoglycan composition of articular cartilage via the down regulation of its turnover

ROM Exercise

ROM exercise are generally given to prevent

motion loss with in the osteoarthritic joint.

Physiotherapy programme should be tailored

according to a patient’s ability to independently

perform range of motion.

Stretching Exercise To prevent abnormal force generation to develop across a joint because of muscle tightness.

S t r e t c h i n g i s m o s t effective if performed o n a d a i l y b a s i s particularly after tissue has been heated as heating enables collagen t o b e m a x i m a l l y stretched.

Muscle Strengthening Exercises

A meta-analysis by Roddy at.al found that strengthening exercise plays an important role in the management of hip and knee OA.

There are evidence that open chain kinematic exercise may pathologically increase forces with in the knee like tibiofemoral compressive forces, patel lofemoral compressive forces and tibiofemoral shear forces.

Mobility Training (Ambulation, elevation,stairs, assistive devices)

Assistive devices are capable of partially unloading painful weight bearing joints.( 15% of body weight)

Use of assistive cane on contralateral side is most effective.

Unfortunately compliance with assistive devices for ambulation is less

Aerobic Conditioning

Aerobic conditioning programme counteracts the decreased aerobic capacity that may have an adverse impact on overall morbidity and mortality.

It also provides analgesic effect by releasing endogenous opioids.

It also counteracts depression and anxiety.

Home Exercise Programme.

Long term compliance with a home exercise

programme is a major goal as good exercise

compliance has been found to be associated with

improved physical function in overweight and

obese.

Orthotic Management

Orthotic intervention is recommended for some patients with knee and hip OA.

Lateral wedge foot orthoses have been shown in some biomechanical and clinical studies to reduce load on the medial compartment of the knee.

Pharmacological Management

1. Opioids may be considered when other oral

treatment is unsuccessful.

Codine one to two 30mg tablets every 4 to 6 hrly to a maximum of 240mg (60mg codine =6mg morphine)

2. Intra-articular injections may be useful in severe

pain.

Intra-articular injections with corticosteroids can be given when patient have moderate to severe pain and when there are local signs of inflammation and joint effusion.

Surgical Management

Surgery is deployed both early in the course of disease as well as later, when joint destruction occurs.

Surgery may also have a preventive role prior to the onset of OA.

Arthroscopic procedures for OA the most common indication for arthroscopic surgery in patients with OA of the knee is, concomitant meniscal tear.

Procedures to alter mechanical environment

Malalignment is a well-recognized risk factor for OA: incidence and progression .

Osteotomy is performed to realign joints with the goals of relieving pain in symptomatic patients and delaying OA onset or progression.

Methods of evaluating the alignment of the whole lower extremity.

Two lines are drawn from the center of the femoral head to the center of the distal femur and from the center of the distal femur to the center of the ankle mortise.

The mechanical axis (degrees varus) is measured at the intersection of these lines.

The load bearing axis deviation of the lower limb is the perpendicular distance from the weight-bearing line (hip-to-ankle line) and the center of the knee.

The weight-bearing ratio is calculated by measuring the distance from the medial edge of the proximal tibia to the point where the weight-bearing line intersects the proximal tibia (B), and dividing the measurement by the entire width of the tibia (A).

A percentage is calculated by multiplying this ratio by 100%

TJR for advanced OA Total ankle, elbow, and wrist replacements are per- formed less frequently for several reasons.

Principally, OA occurs less commonly at these sites than at the hip or knee. Second, arthrodeses of the ankle and wrist joints are reliable, reproducible, and effective alternatives to TJR and restore a reasonable level of function with good relief of pain.

A fused elbow, on the other hand, is quite functionally limiting, and as a result, elbow arthrodesis has a limited role.

Innovative joint arthroplasty technologies.

1. Hip resurfacing.

This procedure does not require complete resection of the femoral head. The femoral component of a hip resurfacing implant has a cap that covers the femoral head, replacing the cartilage surface, and a much shorter stem that anchors the implant in the femoral neck.

2. Minimally invasive TJR is another area of innovation. “Minimally invasive” implies a smaller incision with less soft tissue disruption than occurs in the usual TJR procedure.

3. Reverse total shoulder A major limitation of total shoulder

replacement is that the implant requires an intact rotator cuff for shoulder abduction. This presents a problem for patients who have advanced rotator cuff degeneration, which is a major cause of OA in the shoulder.

Reverse total shoulder replacement changes the biomechanics such that the humeral component serves as the new socket and the glenoid component serves as the ball. This reversal permits the deltoid to be used as the shoulder abductor, restoring active elevation of the shoulder

Surgical and biologic procedures

Autologous chondrocyte implantation (ACI). This procedure attempts to repair a symptomatic cartilage defect through implantation of chondrocytes grown ex vivo from a small cartilage biopsy sample obtained from the patient in a through arthroscopy.

Appropriate patients for this procedure are younger individuals, typically age 50 years, with isolated cartilage defects typically greater than 3 cm2 in size.

Rehabilitation following ACI is demanding; patients cannot be fully weight bearing for two months, and return to athletic activities is delayed for 12–18 months until the cartilage has fully matured.

Meniscal transplantation is performed in an open or arthroscopic-assisted procedures. The transplanted meniscal t issue is ordered specifically for the individual patient and is side and size matched in order to fit the anatomy of the recipient knee.

The grafts are harvested from organ donors with intact knee joints and processed sterilely to reduce the risk of contamination, then frozen for storage until matching recipients can be found.

Osteoarthritis Guidelines Development Group(OAGDG)

Thirteen experts from relevant medical disciplines (primary care, rheumatology, orthopedics, physical therapy, physical medicine and rehabil itation, and evidence-based medicine), three continents and ten countries (USA, UK, France, Netherlands, Belgium, Sweden, Denmark, Australia, Japan, and Canada) and a patient representative comprised the Osteoarthritis Guidelines Development Group(OAGDG)

Osteoarthritis Research Society

International (OARSI)

OARSI has developed guidelines for the non-surgical

treatment of osteoarthritis of the knee that are

stratified to each of four patient groups: 

➢patients with knee-only OA and no comorbidities,

➢patients with knee-only OA with comorbidities,

➢patients with multi-joint OA and no

comorbidities, and

➢patients with multi-joint OA with comorbidities.  

Comorbities included

✓diabetes, ✓hypertension, ✓cardiovascular disease, ✓renal failure, ✓GI bleeding, ✓depression, or ✓ a physical impairment limiting activity, including obesity.