Exercise Prescription In Ostheoarthritis

Question 1

Quickly define Osteoarthritis

Answer 1

• most common form of arthritis
• degenerative joint disease
• most commonly affected joints are hips, knees and hands
• slowly evolving

Question 2

What is the prevalence and age of osteoarthritis patients ?

Answer 2

• 70% in women
• 60% in men
  Age : 40-65 yo

Question 3

What are the two types of osteoarthritis ?

Answer 3

Primary OA : unknown cause
Secondary OA : known cause (eg: trauma, infection, osteonecrosis)

Question 4

What causes loss of cartilage due to OA ?

Answer 4

• inflammation
• bone growth (ostéophytes)
• oedema
• progressive muscle weakness and atrophy
• pain an ROM limitation

Question 5

What are the risk factors of OA ?

Answer 5

Multi factorial etiology :
- genetics
- aging
- nutrition
- weight control
- œstrogen deficiency (menopause ?)
- bone density
- immune system response
- bio mechanical factors
- smoking
- high intensity sports (contact sports ? )
- occupational activities
- labral tear/ femoroacetabular impingement
- general ligament laxity/ hyper mobility
- patella alignement (in PFJ OA)
- previous knee injury

Question 6

Describe the pathogenesis of OA

Answer 6

1) chondropathy : cartilage softening and thinning; failure of chondrocytes to control degradation and repair of cartilage
2) subchondral changes : bone structure changes, bone remodeling is disorganized, increase in abnormal type I collagen
3) synovial membrane changes : hyperplasia of the synovial membrane

Question 7

What is OA grade 1 ?

Answer 7

Possible ostéophytes no joint space narrowing

Question 8

What is OA grade 2 ?

Answer 8

Definite ostéophytes, possible narrowing of joint space

Question 9

What is OA grade 3

Answer 9

Moderate multiple ostéophytes
Definite joint space narrowing
Some sclerosis
Possible deformity of bone ends

Question 10

What is OA grade 4 ?

Answer 10

Sever sclerosis
Definite deformity of bone ends

Question 11

What are the sings and symptoms of OA in end stage ?

Answer 11

• total loss of cartilage
• structural changes
• instability
• loss of muscle function
• severe pain at night and during activity
• impaired physical function
• reduced quality of life

Question 12

What are the signs and symptoms of primary OA?

Answer 12

SUBJECTIVE Ax
- sudden or insidious onset
- deep ache, difficulty with standing, walking and stairs
- stiffness lasting less than 30mn in the morning or after prolonged inactivity
- aggravating factors : post exercise pain, prolonged sitting
- easing factors : rest, medication

OBJECTIVE Ax
- no increase in temperature
- bone enlargement
- limited ROM
- crepitus
- tenderness on palpation
- joint effusion
- mal alignement and joint deformity

Question 13

In case of hip OA, what are the findings in physical examination ?

Answer 13

Pain in the lower back, buttock and groin
ROM limited in abduction and IR
Limping gait
Stiffness
«Locking» of the hip

Question 14

In case of knee OA, what are the findings in physical examination ?

Answer 14

Decreased ROM
Pain
Muscle atrophy
Stiffness
Joint effusion
Crepitus
Difficulty with weight bearing

Question 15

In case of GHJ AO what are the findings in physical examination ?

Answer 15

ROM globally reduced especially in IR/ER/elevation
Paint with activities
Difficulty with ADLs

Question 16

In hand OA, what are the findings in physical examination ?

Answer 16

Proximal interphalangeal deformity : Bouchard nodes
Distal interphalangeal deformity : Heberden nodes

Question 17

Describe the hip OA diagnostic cluster

Answer 17

3/5 within :
- positive Scour test
- passive internal rotation < 25°
- painful hip on squatting
- painful active hip flexion laterally
- painful active hip flexion

Question 18

Describe the knee OA diagnostic cluster

Answer 18

Pain

+ 3/6 within :

Âge > 50 yo
Morning stiffness < 30 mn
Crepitus during ROM examination
Tenderness on palpation
Bony enlargement of knee joint
No increase of temperature

Question 19

What are the points of focus of OA management ?

Answer 19

• pain relief
• function and independence maintenance

Question 20

Describe the exercise pyramid for patients with OA

Answer 20

• recreation
• aerobic exercises
• muscle strengthening
• ROM and stretching

Question 21

What are the WHO recommandations for OA management exercise ?

Answer 21

30 minutes of regular moderate intensity PA 5 days a week

Question 22

What are the general principles of exercise for OA management ?

Answer 22

Start slow, go slow, progress gradually
Modify activity
Activity must be joint friendly (cycling, dancing)
Recognize safety
Talk to a health care specialist

Question 23

What are the recommandations in strength training for OA management ?

Answer 23

F: 2-3 ltimes a week
I: 1 set of 8 to 12 reps
T: resistance = sufficient to challenge muscle in pain free ROM
T: body weight, T-band
P: gradual

Question 24

What are the components of training program for OA management ?

Answer 24

• strengthening exercises
• flexibility exercises
• balance exercises
• low impact aerobic exercises (walking, biking, swimming, water aerobics, group class, dance

Question 25

What is the dosage of aerobic endurance training in OA management ?

Answer 25

150 mn of moderate exercise per week (talk test to test intensity) 10 mn intervals per day

Question 26

What is the dosage of flexibility exercises in OA management ?

Answer 26

ROM : 5-10 times per day AM or PM Stretching : 3-5 times per per week, hold for 15-30s

Question 27

Give 8 practical advices for patients who want to exercise for OA management

Answer 27

- exercise should be tailored to your preferences - consider water exercises if on land exercises are too painful - supervised exercise-therapy over 6 weeks when getting started - supervised exercise-therapy over 12 weeks may be needed for some patient when getting started - after supervised exercise-therapy is completed, patient may need booster cessions to help with long term management - home exercises should be performed - learn how to adapt training load during flare ups

Question 28

What are the recommandations for Hip OA exercise

Answer 28

HEP : 1h/week for 8 weeks Group strengthening and stretching class : 45mn cessions for at least 12 weeks Patient education + strengthening exercises + flexibility exercises + functional exercises : 2 times per week for at least 10 months

Question 29

Give 9 examples of hip exercises for OA management ?

Answer 29

- hip extension in standing - hip abduction in standing - hip flexion standing - hamstring curls in standing - bridging in supine - clam in side lying - squat with or without support - sit to stand with or without support - heel raises with or without support

Question 30

Which meniscus is more affected by knee OA ? What are specific risks factors ?

Answer 30

More frequent in medial compartment Higher risk in case of previous ACL/ meniscus injury Higher risk in obese population Impaired muscle function

Question 31

What are the ORSI guidelines for the non-surgical management of knee OA

Answer 31

Land based exercise: For weight management And strength Water based decries: Self management and education

Question 32

What exercise or PA is recommended for knee OA management ?

Answer 32

- tai chi - yoga - cycling - walking - aquatic exercise - strength training - neuro muscular training

Question 33

Give examples of exercises for knee OA management

Answer 33

- straight leg raise - squats - sit to stand - knee extension from sitting

Question 34

In exercise for knee OA management, what are the important focus ?

Answer 34

- make sure patient achieves full knee extension throughout exercise - quality over quantity - add progressive resistance

Question 35

Describe the NEMEX training

Answer 35

Neuromuscular exercise training program for patients with knee or hip osteoarthritis after total joint replacement based on principles of neuromuscular training with the aim of improving sensorimotor control and achieving compensatory functional stability. It takes place in groups under the supervision of a physical therapist. Consists of 3 parts : - warm up : ergo meter cycling for 10 mn to perceived exertion of somewhat hard - circuit program : 4 exercises circles with key elements, core stability/postural function, postural orientation, lower extremities muscle strength and functional exercises. 2 exercises per circle, perform 2-3 sets X 10-15 reps and rest time corresponding to one set in between set and exercises. 3 levels of progression given. - cooling down : walking exercises forward and backward about 10 meters in each direction, mobility exercises in the lower extremities, stretching exercises for lower extremities muscles for a total of 10 mn

Question 36

What are the NEMEX core stability/ postural function exercises

Answer 36

- Pelvic lift with feet on Swiss ball - sit ups on Swiss ball

Question 37

What are the NEMEX exercises for postural orientation ?

Answer 37

- standing slide forward backward (in a lunge with slider) - standing slide sideways (with slider)

Question 38

What are the NEMEX exercises for lower extremity muscle strength ?

Answer 38

- For hip abductors and adductors : crab walks with t-band around legs - for knee extensors and flexors : siting knee extension with t-band around legs

Question 39

What are the NEMEX functional exercises ?

Answer 39

- sit to stand - stair climbing

Question 40

What are the goals of exercises in hand OA management ?

Answer 40

Maximizing a stable and pain free functional ROM of the fingers joints Increasing functional strength Maintaining joint stability Preventing or delaying the development of fixed deformities

Question 41

Give examples of exercises in hand OA management

Answer 41

- make a hook fist - make a full fist - wrist extension and flexion - thumb flexion - thumb adduction and abduction - thumb opposition - fingers abduction adduction - forearm supination