OA Flashcards
(26 cards)
incidence and aetiology
Very common
> 55 years: 44 -70%
> 75 years: 85%
Associated with increase age / weight
Knee> Hip> Hand (DIPJ and CMC)
However, multisite pain is common (hips, knees, hands, feet): 60-80% reported
pathology
Biochemical changes
Articular cartilage = water +collagen +proteoglycans
Loss of proteoglycan relative to collagen
Decrease in water content and permeability
85% in younger people, 70% in older people
Reduction in collagen tensile stiffness and strength
Proteolytic enzymes-Matrix mettalloproteases (MMPs).
Pro-inflammatory cytokines; TNF, IL-1 (some inflammatory component)
metabolic changes
Most critical changes occur in hyaline cartilage
Fibrillation in superficial layers deeper layers
Joint Space Narrowing
Bony sclerosis
Excessive shear at the joint space
osteoblast activity as attempt to redistribute load
Osteophyte formation
risk factors
intrinsic - jt vulnerabilities previous damage bridging muscle weakness increasing bone density malalignment proprioceptive deficiencies
systemic factors: age female ethnicity
genetics
nutritional
use (loading on joints)
obesity
injuries
activities
unmodifiable- genetics ethnicity age early menopause diabetes local mechanical factors
genu varum/ valgum
increase medial knee loading
previous trauma
modifiable
- obesity
- occupational - squatting, kneeling and heavy liftin
excess PA - soccer
diagnosis
clinical - history of jt pain stiffness <30 mins am /prolonged rest \+/- crepitis on mvmt bony enlargement little/no swelling radiological - joint space narrowing \+/- osteophyte formation \+/- bony sclerosis
Classification of OA
primary: idiopathic spontaneous onset small joints hand hip and knee may affect >1 joint stront link with genetics
secondary OA specific to jt causes - several - trauma? - knee/ hip occupations post inflammatroy arthritis
diagnosis OA
clinical - Hx PE radiology - jt space narrowed osteophyte formation sclerosis subchondral bone altered alignment subchondral cyts loose body
lab - ESR CRP
differential from inflammatory arhtritis
other - acthroscopy
CT
MRI + US better at detecting early signs not detected by plain xray
differential diagnosis
inflammatory arthritis
other intra-articular jt disorders
hip - labral tear
knee - meniscal injury
Hand OA
most commonin PIP DIP and thumb CMC
co-morbidity
Having at least one co-morbidity significantly associated with worse, or greater deterioration, of symptoms of pain and physical function
pain
Activity-related pain initially -worse end of day / after rest
Eased by movement
As disease progresses, night pain and rest pain are present
Cartilage is aneural so what causes pain?
Peri-articular-capsule/ligaments Periosteal Muscular Compensatory e.g LBP assoc with hip OA: why? Inflamed tissue
stiffness SE PE
SE
subjective
differentiate from inflammatory by duration of stiffness
PE
- can be physical sign tested on physio assessment
loss of PROM
end-feel
fatigue
Subjective sensation of generalized tiredness or exhaustion
Less commonly reported in OA than auto-immune related arthritis e.g. RA
Can be a barrier to physical activity
exam findings
Inflammation / effusion (will be minor compared with inflamm arthritis) Heat Erythema Tenderness Effusion Discomfort Pain
loss of ROM Pain, stiffness +/- effusion may limit ROM Compare Active vs Passive ROM loss Capsular patterns Lower limb Upper limb
muscle weakness Muscle weakness/atrophy (Hurley, 1997) Pain inhibition Disuse Atrophy Inhibition 2 effusion Reduced function (related back to S/E) Specific to body region e.g. UL vs LL
Deformity - knee valgus/ varus
hand
joint instability - ligament laxity
compounded by muscle weakness
deformity
Hip - flexion / adduction contracture, loss of MR Knee – flexion, genu varum and valgum. Loss of extension>flexion Ankle - inversion / supination Foot - hallux valgus
Hands - Heberden’s (DIP) & Bouchard’s (PIP) nodes
Shoulder - abduction / rotation
mgmt of OA
Combination of Non-Pharmacological and Pharmacological interventions
Numerous clinical guidelines available
Currently no ‘cure’ for OA
Aim
Manage symptoms
Reduce deterioration
Enhance functional ability and quality of life
Due to its chronicity emphasise self-management
core recommended mgmt
exercise
education self mgmt
weight mgmt
exercise
aerobic and strengthening exercise water-based exercise min 30 mins 5 days/week tailored to persons problems supervised 12 wks
- aerobic
- muscle strengthening - bdy weight/ weights bands
- balance and flexibility
pharm mgmt
Oral NSAIDS – Difene, Aulin, Mobic
GI and CVS side-effects
May need Proton Pump Inhibitor (PPI) drug
Topical NSAIDS – Feldene, Voltarol
Strongly recommended for Knee OA patients with GI or CV comorbidities
Intra-articular steroid injections
Recurrent cortisone injections into the knee decrease cartilage volume (McAlindon et al, 2018)
DMOADS; Glucosamine and Chondroitin sulphate
No evidence of benefit vs placebo
Paracetamol (previously recommended) now shown to have no clinical benefit
High quality evidence from 10 RCTs in 2019 Cochrane Review
Topical or Oral opioids not recommended
Strong evidence for limited or no benefit on OA symptoms
Concerns re dependence and addition
surgical mgmt
osteotomy arthroplasty THR TKR athrodesis
Subjective assessment
Problems arising Symptoms body chart One joint or multiple joints ? Pain behaviour (24 hour, aggs/eases, quality of pain) Stiffness, Swelling? Crepitus, weakness etc Functional difficulty History of onset General health- co-morbidities common due to age profile Heart disease, BP, Diabetes etc. Investigations Management to date Outcome measures: WOMAC, KOOS, AUSCAN
physical assessment
Observation- gait, posture, functional difficulties ROM Strength Palpation Special tests – consider pathology and outrule other pathologies Exercise tolerance- examples? QoL, psychological health Problem list & Goals Treatment plan
physio intervention
Education
Self-management NB
Cognitive Behavioural principles
Exercise therapy Hydrotherapy ROM Strengthening Aerobic
Posture re-education ? Manual therapy Pain Stiffness Gait re-education/Mobility aids Joint protection Orthotics/Braces/Insoles Assistive devices Hand splints
Electrotherapy
Pain
Evaluate rx effectiveness with validated outcomes
e.g WOMAC, KOOS, HOOS, VAS, Aggregate physical performance tests
exercise therapy
knee hip strengthening quads for knee OA - lots of evidence glute strengthening aerobic exercise hydrotherapy
