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MSK 1 > 11/4 - Management of Knee OA > Flashcards

11/4 - Management of Knee OA Flashcards

1
Q

what is the pathology of OA

A

erosion of articular cartilage
sclerosis of bone underneath cartilage
formation of osteophytes

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2
Q

why do you see osteophyte formation with OA

A

as get abnormal wear on bone, think Wolf’s law - bone grows when force is applied
- results in osteophyte formation

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3
Q

what s/sx can osteophyte formation cause

A

get osteophytes along margin of joint
- disrupts mobility
- lead to discomfort w movements into end range

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4
Q

how does OA typically present in the knee

A

usually in med compartment
- varus deformity

lat compartment (5-10%)
- valgus deformity

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5
Q

what dictates the presentation of OA w varus vs valgus deformity and why

A

get more load on different areas depending on if they have varus or valgus alignments

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6
Q

what are risk factors that inc risk of knee OA

A
  1. age
  2. joint injury, prev menisectomy, past surgery
  3. obesity
  4. occupational activity (ie heavy lifting, squatting, kneeling, stairs, cramped spaces)
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7
Q

why would a past surgery be a risk factor for knee OA

A

surgery changes original make up of joint
- disrupts biomechanics
- not sure why

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8
Q

relationship of physical activity/sports as a risk factor for OA?

A

inconclusive findings
- benefits of physical activity outweighs the load that could potentially cause OA

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9
Q

what is the general takeaway of the criteria for OA

A

all different
see pain/stiffness in morning that gets better w movement
- then worse again w more movement throughout the day

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10
Q

what does crepitus indicate

A

changes in articular cartilage

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11
Q

onset and course of OA

A

insidious
- progressively worsens

chronic presentation
- can have acute flare ups, but typically chronic

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12
Q

if there isn’t a clear mechanism of injury w anything, what is the first thing you want to do

A

clear lumbar spine

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13
Q

localized vs diffuse sx of OA

A

localized - varus/valgus alignment that loads specific compartment

diffuse - other involvment (ie meniscal)

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14
Q

why is swelling an important thing to manage asap

A

can inhibit ms and joint motion

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15
Q

WOMAC vs KOOS pt outcome measures

A

WOMAC - OA and TKA
- pain, function, stiffness

KOOS - OA, TKA, ACLR, meniscectomy, tibial osteotomy
- higher activity level pts
- pain, other sx, ADLs, QOL

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16
Q

what is the problem w patient reported outcome measures like the WOMAC and KOOS

A

people tired of filling out forms, but important thing to use in evaluation

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17
Q

classifications of OA

A

minimal = no radiological narrowing
mild = loss 1/3 joint space
mod = loss 2/3 joint space
severe = bone to bone contact

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18
Q

what does joint space between femur and tib indicate

A

amt of cartilage that is there

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19
Q

what is an important view of XR with OA

A

in WB-ing
- so you can appreciate joint space (how much cartilage is there)

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20
Q

how do you assess ROM in a PT exam and why

A

AROM -> PROM -> RROM

they are in control when you ask them to move
- if do PROM, they may be guarding

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21
Q

how should resistance be applied to assess strength in an exam

A

isometric resistance in resting position

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22
Q

why is erythema something to assess in a PT exam

A

palpable warmth
how active is inflammatory process

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23
Q

what is a consideration when assessing ROM

A

caution w overpressure

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24
Q

how can joint effusion present in OA (3)

A

intra-articular swelling
distended & thickened joint capsule
popliteal cyst

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25
Q

how can joint effusion limit knee flexion

A

only place for fluid to go in knee is post
- this can limit flex as bend knee, fluid disperses and pushes outward - only so much flex is possible

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26
Q

what relationship does joint effusion have to the quads and why is this important to consider

A

doesn’t take a lot of fluid to limit quads
- from mobility standpoint and ms ability to work stand point

no matter how much strengthening you do, if fluid is sitting there, gains are limited

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27
Q

what should be avoided when testing ms strength in OA

A

avoid resistance in full ext
- screw-home mechanism and closed pack position

test in mid range

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28
Q

what are 3 common impairments seen in OA

A

ROM
strength
balance

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29
Q

what relationship does meniscal path have to OA

A

meniscal path inc risk of early onset OA

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30
Q

what are 5 results from a deficient ACL d/t its neuromuscular characteristics

A
  1. dec capsular mechanoreceptors
  2. difficulty detecting joint motion/position
  3. dec proprioception
  4. dec neuromuscular control
  5. hamstring length changes
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31
Q

what does a brighter area on a radiograph tell you? what are the implications of this for OA?

A

more load or some inflammation/reaction there

less cartilage there
big component to creating sx

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32
Q

what can radiographic OA changes indicate

A

if changes present in TF and PF compartments, knee pain and function loss more likely

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33
Q

what are 5 characteristics of radiograph studies of OA

A
  1. dec radiographic joint space
  2. sclerosis of subchondral bone
  3. osteophyte formation @ joint margins
  4. subchondral cyst formation
  5. genu varus or valgus deformity
34
Q

what are your basic principles of management of OA (8 - don’t overthink it)

A
  1. soft tissue healing
  2. control pain and swelling
  3. limit ms inhibition and atrophy
  4. early controlled ROM
  5. early initiation of ms activity and neuromuscular control
  6. proprioceptive training
  7. cardiovascular training
  8. sport-specific training
35
Q

what are some interventions while managing swelling and pain

A

want to maximize mobility (both joint mobility and ms length)
- redistribute load
- get ms stronger and dec amt of load put on joint

36
Q

why is it important to control inflammation acutely

A
  • 1ml fluid associated w reflexive inhibition of quad
  • 60% dec in knee ext strength d/t pain and fluid retention
37
Q

what is the value of using NMES as an adjunct acutely

A

integrating estim w pts who are having difficulty w ms activation
- accelerate functional recovery
- prevent disuse atrophy
- reduce ROM deficits
- improve motor control

38
Q

what is the value of using TENS in conjunction w exercise

A

benefit to this if pain is limiting factor
- dec pain
- inc quad activation and function
- dec knee stiffness

39
Q

why is aerobic conditioning an intervention thrown in here w OA

A

superior to or equivalent to strengthening exercises

40
Q

how would you prescribe aerobic conditioning for OA

A

endurance*
- UBE initially
- cycling - less impact than walking, but greater knee flex needed
- walking program

consider irritability when deciding walking or cycling

41
Q

what are some ther-ex interventions (3)

A

proprioception
strengthening
- prox: hip ABD
CKC progression
- mod WB -> FWB -> r - WB

42
Q

what are return to sport considerations when prescribing ther-ex

A

generate and dissipate forces
- eccentric ms actions
- sub max plyometrics (improve dynamic strength)

43
Q

why do we want to work on eccentric ms actions in OA

A

shock attenuation impaired in individuals w joint dz
- we want to improve ability to generate and dissipate forces if return to sport

44
Q

what is a consideration when prescribing sub max plyometrics in OA

A

rest interval should allow for full recovery

45
Q

what should be considered about the plane of motion activities are in

A

in runners - frontal plane/lateral motions may be more difficult bc mostly doing sagittal movements

consider if sport is in one plane primarily and have motions be in other planes

46
Q

why is manual therapy and joint mobs helpful in OA

A

mobilizations provide local and widespread hypoalgesic effects
- inc mobilit/ROM, distributing forces over larger area

47
Q

what was the best use of manual therapy and exercise therapy as for freq in OA

A

manual therapy best in consecutive sessions (2x/wk)

exercise therapy best using booster sessions
- retest and progress exercise in booster sessiosn

48
Q

what joint mobilizations are we going to do for knee OA and why

A

hip
- distraction: pain, all motions
- post glide: flex, IR

knee
- tibfem distraction
- ant tibfem: ext
- post tibfem: flex
- patellofem glides: sup/ext, inf/flex

49
Q

what are the many number of reasons that ROM could be limited in knee (4)

A

swelling
quad weakness
ms length
limited ant glide of tib

50
Q

what are 2 benefits of aquatic therapy over others

A

pain relief
reduced load on joint surfaces

51
Q

what is the point of injections

A

neither are long-term solutions

think ab these things to inc tolerance to therapy to make meaningful change

52
Q

when you use a cortisone injection and why

A

corticosteroid = anti-inflammatory

short term most effective to dec pain and swelling
- ex: walk daughter down aisle in 2wks

53
Q

when would you use a hyaluronic acid (HA) injection and why

A

components of building blocks of articular cartilage
“lubricating joint” - helping w joint mobility

takes awhile for effectiveness to kick in - ramp up effect
- some people benefit and some don’t so insurance own’t cover
- ex: avoid surgery

54
Q

what is a consideration of someone getting a cortisone injection in terms of surgery

A

most of the time surgeons will want pts to wait several months before TKA
- anti-inflammatory, disrupts healing
- don’t want to do something that requires robust healing response

55
Q

what are 3 possible injections for OA

A

cortisone
HA
PRP

56
Q

varus vs valgus loading on the bone

A

valgus inc load in lat compartment
varus inc load in med

getting more compressive load

57
Q

when would you recommend an unloader brace for someone and why

A

if had varus/valgus alignment
if person had sx when active but fine walking around
- recommend unloader brace during those activities

brace only works when on
would be annoying to wear all the time for someone who has brace on all the time

58
Q

what must be done before prescribing lateral shoe wedges

A

must assess mobility at subtalar joint

59
Q

who is a lateral shoe wedge appropriate for and why does it work

A

if have varus alignment and good subtalar motion

creates eversion of calcaneus and more pronation at foot
- aka unload med compartment to change moment arm at knee

60
Q

why wouldn’t a lateral shoe wedge work in some people

A

if don’t have subtalar joint motion, heel won’t move and this does nothing and could create problems elsewhere

61
Q

what should you educate the patient on

A

no cure, only management
the benefits of the interventions you are giving

62
Q

what is an OA arthroscopy/chondroplasty and when is this recommended

A

surgical debridement of arthritic areas

recommended for:
- meniscal tear or loose bodies
- pt c/o “catching/locking”

rarely done in isolation, see this when already having surgery on something else done and just “clean up”

63
Q

rehab for a OA arthoscopy/chondorplasty

A

restore ROM
hip and quad strength

not waiting for anything to heal

64
Q

who is an osteotomy indicated in

A

unicompartment OA
pts too young for TKA

bony malalignment contributing to valgus/varus force

65
Q

what is an osteotomy

A

induced fx to remove/add wedge of bone to tibia or femur
- changes forces to preserve cartilage

66
Q

rehab for osteotomy

A

healing time is similar to fx
- restricted WB for 4 wks
- no resistance distal to osteotomy to protect surgical site for ~4wks

CPM and early ROM
NMES for quads in full ext

67
Q

what is removed and what is spared in a TKA

A

removed:
- distal fem to shape prosthetic
- prox tib
- menisci
- ACL

spared:
- PCL may be

68
Q

patello femoral joint and TKA

A

TKA can be w or w/o patella resurfacing

69
Q

cemented vs uncemented vs hybrid TKA

A

cemented
- most common
- most stable

uncemented
- higher failure rate
- younger pts

hybrid
- uncemented fem component
- cemented tib and pat components

70
Q

cemented/uncemented TKA in outcomes and rehab

A

no difference in outcome

difference in what can do immediately post op
- cemented: load sooner
- uncemented: wait until bone heal around it

71
Q

LOS after TKA

A

typically 0-3days in hospital
- dc home w services or rehab

72
Q

WBing guidelines after TKA

A

cemented
- immediate WBAT

uncemented/hybrid
- TDWB or PWB up to 6wks

73
Q

when do you dc knee immobilizer after TKA

A

usually until able to maintain TKE

74
Q

TKA acute rehab interventions (3)

A

ROM
light strengthening
functional amb

75
Q

6 outpatient rehab interventions after TKA

A
  1. progress ROM and strength
  2. scar mob when healed
  3. patella mob - all directions, prn
  4. normalize gait
  5. light aerobic exercise - bike, elliptical, walk
  6. sports - golf, low intensity
76
Q

what joint mobs do you do after TKA

A

patellofemoral - ALWAYS and IMMEDIATELY

tibfem - NEED post op report
- if PCL sacrificing, will stress TKA mechanism

77
Q

what are 6 complications of a TKR

A
  1. excessive blood loss
  2. DVT, PE
  3. infection - look at incision
  4. arthrofibrosis
  5. patella adhesions (mobs)
  6. failure
78
Q

why can you see arthrofibrosis after a TKR and why should this be avoided

A

lot of scar tissue can form bc aggressive surgery w a lot of bleeding

once scar tissue forms, difficult to get rid of and mobilize

79
Q

what are 6 causes of TKR failure

A
  1. loosening of components
  2. instability
  3. improper component placement
  4. infection
  5. osteolysis
  6. trauma
80
Q

what is a partial knee replacement

A

unicondylar replacement

81
Q

what are requirements for good candidates of partial knee replacements (5)

A
  1. OA limited to 1 compartment
  2. low impact sports/work activity
  3. minimal varus/valgus
  4. intact ACL
  5. BMI <32
82
Q

what are the benefits to a partial knee replacement

A

immediate WB post-op
can be converted to TKA

spares a lot of ligamentous components bc not taking away lot of bone

MSK 1 (31 decks)

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