Exercise Prescription In Ostheoarthritis Flashcards
Quickly define Osteoarthritis
- most common form of arthritis
- degenerative joint disease
- most commonly affected joints are hips, knees and hands
- slowly evolving
What is the prevalence and age of osteoarthritis patients ?
- 70% in women
- 60% in men
Age : 40-65 yo
What are the two types of osteoarthritis ?
Primary OA : unknown cause
Secondary OA : known cause (eg: trauma, infection, osteonecrosis)
What causes loss of cartilage due to OA ?
- inflammation
- bone growth (ostéophytes)
- oedema
- progressive muscle weakness and atrophy
- pain an ROM limitation
What are the risk factors of OA ?
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
Describe the pathogenesis of OA
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
What is OA grade 1 ?
Possible ostéophytes no joint space narrowing
What is OA grade 2 ?
Definite ostéophytes, possible narrowing of joint space
What is OA grade 3
Moderate multiple ostéophytes
Definite joint space narrowing
Some sclerosis
Possible deformity of bone ends
What is OA grade 4 ?
Sever sclerosis
Definite deformity of bone ends
What are the sings and symptoms of OA in end stage ?
- 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
What are the signs and symptoms of primary OA?
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
In case of hip OA, what are the findings in physical examination ?
Pain in the lower back, buttock and groin
ROM limited in abduction and IR
Limping gait
Stiffness
«Locking» of the hip
In case of knee OA, what are the findings in physical examination ?
Decreased ROM
Pain
Muscle atrophy
Stiffness
Joint effusion
Crepitus
Difficulty with weight bearing
In case of GHJ AO what are the findings in physical examination ?
ROM globally reduced especially in IR/ER/elevation
Paint with activities
Difficulty with ADLs
In hand OA, what are the findings in physical examination ?
Proximal interphalangeal deformity : Bouchard nodes
Distal interphalangeal deformity : Heberden nodes
Describe the hip OA diagnostic cluster
3/5 within :
- positive Scour test
- passive internal rotation < 25°
- painful hip on squatting
- painful active hip flexion laterally
- painful active hip flexion
Describe the knee OA diagnostic cluster
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
What are the points of focus of OA management ?
- pain relief
- function and independence maintenance
Describe the exercise pyramid for patients with OA
- recreation
- aerobic exercises
- muscle strengthening
- ROM and stretching
What are the WHO recommandations for OA management exercise ?
30 minutes of regular moderate intensity PA 5 days a week
What are the general principles of exercise for OA management ?
Start slow, go slow, progress gradually
Modify activity
Activity must be joint friendly (cycling, dancing)
Recognize safety
Talk to a health care specialist
What are the recommandations in strength training for OA management ?
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
What are the components of training program for OA management ?
- strengthening exercises
- flexibility exercises
- balance exercises
- low impact aerobic exercises (walking, biking, swimming, water aerobics, group class, dance
What is the dosage of aerobic endurance training in OA management ?
150 mn of moderate exercise per week (talk test to test intensity)
10 mn intervals per day
What is the dosage of flexibility exercises in OA management ?
ROM : 5-10 times per day AM or PM
Stretching : 3-5 times per per week, hold for 15-30s
Give 8 practical advices for patients who want to exercise for OA management
- 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
What are the recommandations for Hip OA exercise
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
Give 9 examples of hip exercises for OA management ?
- 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
Which meniscus is more affected by knee OA ? What are specific risks factors ?
More frequent in medial compartment
Higher risk in case of previous ACL/ meniscus injury
Higher risk in obese population
Impaired muscle function
What are the ORSI guidelines for the non-surgical management of knee OA
Land based exercise:
For weight management
And strength
Water based decries:
Self management and education
What exercise or PA is recommended for knee OA management ?
- tai chi
- yoga
- cycling
- walking
- aquatic exercise
- strength training
- neuro muscular training
Give examples of exercises for knee OA management
- straight leg raise
- squats
- sit to stand
- knee extension from sitting
In exercise for knee OA management, what are the important focus ?
- make sure patient achieves full knee extension throughout exercise
- quality over quantity
- add progressive resistance
Describe the NEMEX training
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
What are the NEMEX core stability/ postural function exercises
- Pelvic lift with feet on Swiss ball
- sit ups on Swiss ball
What are the NEMEX exercises for postural orientation ?
- standing slide forward backward (in a lunge with slider)
- standing slide sideways (with slider)
What are the NEMEX exercises for lower extremity muscle strength ?
- 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
What are the NEMEX functional exercises ?
- sit to stand
- stair climbing
What are the goals of exercises in hand OA management ?
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
Give examples of exercises in hand OA management
- 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
