Angela Rossi - Knee OA

Question 1

Explain the pathophysiology of ‘age-related’ joint changes in OA and how exercise and physical activity can address these changes.

Answer 1

• Inability of the body to repair the joint tissues (generally over time, our bones and cartilage start to deteriorate. Due to a reduction in growth hormone necessary for tissue turn over resulting in a reduced ability to repair tissue such as the cartilage and bone).
• Changes to activity and fitness levels (this causes muscle weakness in which sarcopenia also contributes to sarcopenia which increases the pressure and decreases joint support)
• Exercise and PA can address these changes, by facilitating the movement of the synovial fluid in the joint which aids in joint health through bone repair. Exercise ensures the strength of the bone tissues by facilitating the production of osteoblasts, and strengthen the surrounding muscles to the joint such as the quadriceps.

Question 2

Describe TWO common misconceptions about OA. Explain why OA is no longer considered a
‘wear and tear’ or ‘degenerative disease’.

Answer 2

• Bone on Bone
• Only age-related and inevitable
• No longer considered a ‘wear and tear’ as it is a condition that encompasses greater complex than just an overuse condition. It involves the pathologic changes in the structures of a joint such as cartilage, bone, synovium, ligaments, adipose tissue and meniscus, as well as neurological pathways which process pain. Changes can arise from external mechanical loads (e.g. obesity), joint malalignment, joint injury, and metabolic and genetic factors.

Question 3

List THREE radiographic features you may observe in a person with knee OA and explain how
these features differ from the radiographic features of RA. In people with OA, how well does the
severity of radiographic features correlate with the severity of symptoms?

Answer 3

OA: Osteophyte formation, narrowing of the joint space (medial OR lateral), subchondral sclerosis of the bone (thickening of bone).

RA: No osteophytes, symmetrical narrowing of the joint space (medial AND lateral), generalised osteopenia (bone density loss)

Although these radiographic features can diagnose OA, the severity of these radiographic features do not always predict the severity of symptoms.

Question 4

List THREE signs and/or symptoms you may observe in a person with OA and explain how these
signs and symptoms differ from RA.

Answer 4

OA: Morning stiffness lasting less than 30 minutes, no warmth of the synovium, pain is asymmetrical (one side usually worse than the other)

RA: Morning stiffness more than 1 hour (unresolved by movement), warmth on palpation, pain is symmetrical in both sides (R & L)

Question 5

List THREE diagnostic criteria for typical knee OA without the need for imaging or other
investigations.

Answer 5

Pain and three other factors such as, above 50 years old, less than 30 minutes morning stiffness, crepitus on active motion.

Question 6

List THREE patient- reported outcomes that are recommended for people with knee OA.

Answer 6

• Numeric rating scale for pain
• KOOS: Knee Injury and Osteoarthritis Outcome Score
• WOMAC: Western Ontario and McMaster University Osteoarthritis Index

Question 7

List THREE examples of the biopsychosocial impacts of OA.

Answer 7

• Biological: Joint changes and pain. These can limit ROM, making it difficult to perform certain activities such as walking, climbing upstairs, or standing from a seated position.
• Psychological: Depression and anxiety. These can develop as the individual may feel that their quality of life has reduced due to not being able to perform activities or participate in activities that they once enjoyed. The individual may experience frustration and helplessness due to this which can lead to the development of depression and anxiety.
• Social: Reduced social interactions. A person can distance themselves from friends and family due to being unable to engage in social activities, social gatherings, playing sports which they previously used to do. This can lead to a sense of loneliness which can further negatively affect mental health and quality of life as they may not a sense of support.

Question 8

Mrs Rossi has knee OA. Explain what OA is to your examiner as if they are Mrs Rossi. Your answer should explain which structures are involved and use reassuring language.

Answer 8

• Knee OA is a condition involving structural changes within the structures that surround your knee. This involves the cartilage, bone, ligaments, capsules & muscles. What happens is that sometimes when there is breakdown in one of these structures, it could have occurred due to an injury, the body will try to repair itself, however, the repair processes cannot keep up with the changes in which the result is the development of OA.

Question 9

List THREE risk factors for developing knee OA that are present in Mrs Rossi. Explain why the risk
factors you have identified are relevant to the management of her OA.

Answer 9

• 63-years-old: Although OA is not just an age-related condition, as we age there is a reduced ability for the body to repair tissue
• High body mass: Increases the amount of pressure onto the knees which can increase risk of OA and can also promote a pro-inflammatory environment (through increase of adipokines).
• Reduced bulk of quadriceps muscle: due to decrease in muscle strength, the muscles act as poor shock absorbers which causes added stress to the joints

Question 10

Mrs. Rossi has chronic knee pain. Define pain and chronic pain as outlined by the International Association for the Study of Pain (IASP). Explain why it is important for healthcare professionals
to understand these definitions.

Answer 10

• Pain: An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.
• Chronic pain: Chronic pain is pain that persists or recurs for longer than 3 months.
• It is important for healthcare professionals to understand these definitions so that patients can be provided with the correct diagnosis and an effective treatment plan that will address the patients concerns.

Question 11

Define the THREE mechanism-based types of pain. Identify which types of pain are present in
Mrs Rossi.

Answer 11

Nociceptive pain: pain resulting from nociceptive stimulus and activation of nociceptors

Neuropathic pain: pain resulting from disease or injury to somatosensory nervous system

Nociplastice pain: pin resulting from activation of the peripheral or central nociceptive pathways despite no nociceptive stimulus

Question 12

Identify THREE risk factors for developing chronic pain. Identify whether Mrs Rossi has any risk
factors for developing chronic pain.

Answer 12

Belief that pain and activity are harmful: Mrs Rossi may have this due to her preconceptions about knee OA and that through use she will damage it
Sickness behaviour (extended rest): Mrs Rossi
Low self-efficacy: yes, she is taking it a bit easier on herself working less hours in the cafe

Question 13

Explain the key treatment goals for a person with OA.

Answer 13

• Improving function - get back to doing what they used to. Reduce activity and participation limitations
• Slowing the progression of the condition
• The treatment goals should be in line with the patient’s own goals, guided by the ICF Framework.

Question 14

Describe common side effects of ibuprofen.

Answer 14

• Headaches, dizziness, (due to reduced blood flow to the kidneys by inhibiting prostaglandins which help maintain blood flow. Lead to reduced fluid retention) drowsiness
• Prolonged use, one can develop abdominal pain due to mucosal erosion

Question 15

Explain the main difference between ibuprofen and COX-2 inhibitors.

Answer 15

• Ibuprofen: Non-selective NSAID – inhibits both COX-1 and COX-2 enzymes. Inhibiting COX-1 may cause gastrointestinal side effects as its role is to protect the stomach lining. Inhibiting COX-2 helps to reduce inflammation and pain.
• COX-2 inhibitors: Selective NSAID – selectively inhibits the COX-2 enzyme. Main role is to reduce inflammation and pain. Lowers risk of gastrointestinal side effects compared to ibuprofen

Question 16

As a physiotherapist, can you advise Mrs Rossi on her medications? If yes, what advice would you give Mrs Rossi? If no, what actions would you take if you were worried that Mrs Rossi was
potentially misusing ibuprofen or was suffering from side effects?

Answer 16

• If Mrs Rossi was potentially misusing her ibuprofen which was causing side effects such as abdominal pain, I would write a report to Mrs Rossi’s doctor to review her use of ibuprofen and to potentially replace it with another medication such as a COX-2 medication which reduces the risk of gastrointestinal side effects.
• As a physiotherapist you can provide general advice to Mrs Rossi about non-prescription medications such as any topical creams to ease inflammation, however I would not go beyond the scope of my own knowledge and accreditation, and always remind them to consult their GP for compatibility with other medicines.

Question 17

Describe the THREE elements of Graded Motor Imagery. Would Mrs Rossi benefit from using Graded Motor Imagery? Justify your answer.

Answer 17

• Laterality recognition: Left/right discrimination – process of recognising one side of the body as distinct from the other and is training by reviewing images of the left and right limb.
• Explicit motor imagery: imagined movements of the affected extremity – thinking about moving a limb without actually moving it.
• Mirror therapy: view reflected movement of the unaffected extremity – movement of the unaffected body part to trick the brain into thinking the affected part is moving. Involves putting the affected limb behind a mirror, and looking at the reflection of movements causes by the unaffected side.
• Meta-analysis conducted by Galonski and colleagues, in which it was demonstrated that individuals with knee OA have poor performance with correctly identifying images of left and right knees. The study showed that GMI is an effective intervention in improving laterality recognition and reducing pain experience by individuals with knee OA. Therefore, GMI can potentially be a beneficial and effective intervention for Mrs Rossi.

Question 18

You would like to provide pain education to Mrs Rossi so that she feels safe exercising. Describe the key principles of ‘explaining pain’ to a patient.

Answer 18

• Providing education which is relevant to the patient
• Multimodal - written, audiovisual, verbal
• Metaphors
  Ensuring that the patient feels validated and believed and that the can learn to manage
• Using appropriate language
• Communication style
• Provide realistic journey

Question 19

Mrs Rossi has reduced muscle strength in her lower limb muscle groups, including the gluteal
muscles, hamstrings, quadriceps, gastrocnemius, and dorsiflexors. List FOUR potential
contributing factors to Mrs Rossi’s muscle weakness.

Answer 19

• Pain causes fear of exercising
• Sarcopenia
• Inadequate protein intake
• Obesity

Question 20

You would like to prescribe exercise for Mrs Rossi to improve her performance of activities of daily living (ADLs). Explain the relationship between strength and capacity for ADLs using the
‘strength threshold model’ and apply this model to a specific weight-bearing ADL.

Answer 20

• The ‘strength threshold model’ explains that individuals who are below the minimum strength requirement for certain activities, their performance will be limited in which strength training will help to increase/improve performance. In addition, individuals who meet or are above the minimum strength requirements, their strength is not related to their performance ability in which an increase in strength will not contribute to an increase/improvement in performance.
• Sit-to-stand: to successfully complete a sit to stand which incorporates all important components, individuals need adequate hip extensor (hamstrings and glute max) strength to propel the body upwards and off the chair. Without adequate hip extensor strength, individuals would need to compensate the weakness by introducing adaptive behaviours such as using the arm rests & uneven weight distribution.

Question 21

You think that Mrs Rossi would benefit from increasing her aerobic capacity. Describe the potential benefits (or lack of benefit) of increasing aerobic capacity in a healthy 20-year-old who
does not play any sport compared with a client whose current aerobic capacity is below the fitness threshold for disability.

Answer 21

• In the client whose current aerobic capacity is below the fitness threshold for disability the benefits of an aerobic capacity training exercise would be the ability to engage in ADLs without experiencing breathlessness (for example, going shopping, walking the dog).
• Conversely in a healthy 20 year old, increasing their aerobic capacity if they don’t play sport would not have much benefit in undergoing ADLs as they already have sufficient aerobic capacity.
• Nonetheless, there are long-term benefits for a healthy person to train aerobic capacity such as improved overall CV health and function and increased life expectancy.

Question 22

You would like to prescribe exercise for Mrs Rossi, but she is apprehensive that exercise will damage her joints. Explain the benefits of physical activity and exercise on joint health to your
examiner as if they are Mrs Rossi.

Answer 22

• Exercise can help to increase bone formation which can help reduce the risk of fractures
• Increases muscle strength to improve shock absorption ability and provide less pressure on joint
• Increase cartilage thickness which can reduce friction between bones which means it reduces the bones from rubbing against each other.
• Reduce overall joint stiffness and increase ROM which will allow you a greater ability to move the joint without trouble and perform activities that you struggle with more easily.

Question 23

Describe the key principles of prescribing exercise for a person with chronic pain, including pacing. Based on these principles, outline a ‘pacing plan’ for Mrs Rossi.

Answer 23

Principles of prescribing exercise:
- A biopsychosocial approach is seen as the most effective.
- Exercise should be safe, individualized, and supervised.
- It should be tailored to the patient’s needs and goals
- Exercise should be coupled with education - that this is safe and helpful
- All exercise is good exercise for someone with chronic pain (limited evidence to show a preferable mode of exercise)

• A pacing plan for Mrs Rossi working at the bakery for example would be for her to measure how long at a time she can stand before she begins to feel pain. Try this 3 times, take the average of these 3 instances and the baseline because 80% of avg.
• Eg. attempt 1 = 8m, attempt 2 = 12 mins, attempt 3 = 10mins, avg = 10mins, baseline = 8mins