Osteoarthritis Flashcards
With the goal to improve knee extension in OA:
- what types of manual mobs (~3)
- what type of STM (1)
- what types of exercises; 2-3 examples
- AP, AP w/ add/abd, extension w/ tibial ER
- posterior knee STM
- quad sets, TKE, calf/hamstring stretches (repeated extension challenge)
With the goal to improve knee flx in OA:
- what types of manual mobs (~4)
- what type of STM
- what types of exercises; 2-3 examples
- knee flx, knee flx w/ add/abd, flexion w/ tibial IR, patellar mobs
- anterior knee STM
- mini-squats, bike, quad stretch prone (repeated flx challenge)
With the goal of improving patellar mobility, what types of exercise challenge is recommended; flexion or extension?
- flexion
Strengthening exercise has effects for:
- Grade A (5)
- Grade C (2)
Grade A • Pain (rest and w/ functional activities) • Function • ROM • Grip force • Level of energy
Grade C
• Quad peak torque
• Specific and timed functional activities
General physical activity has positive effects for:
- Grade A (6)
- Grade C (1)
Grade A • Pain (functional activities) • Stride length • Functional status • Energy level • Aerobic capacity • Medication use
Grade C
• Disability in ADL
Manual therapy combined with exercise has positive effects for:
- Grade A (1)
*arguably other effects depending on other studies
Grade A
- pain
T or F
Manual therapy plus exercise is no better than exercise or strength training alone.
F;
Manual therapy w/ exercise has greater effects on pain, although exercise/strength training does still have positive effects on pain and function.
How long can the effects of manual therapy last for pain/function?
Studies have shown lasting effects out to a year
Is there a benefit for manual therapy over HEP after a year?
- A year out, the benefits of manual therapy plus HEP were equivalent to just HEP, but in the shorter term (4 and 8 weeks), there was an increased positive effect for manual therapy
T or F
Manual therapy for knee OA can follow a protocol.
- Eh, F; more effective if tailored to the individual
Arguably, what is the greatest measurable effect that manual therapy can have for pts with knee OA?
- pain reduction; hypoalgesic effects
- could also say improving joint tissue quality, however that’s less measureable
- also likely, ROM, but that wasn’t cited in the medbridge presentation in this section at least
T or F;
Accessory mobilization to an osteoarthritic knee only produces local hypoalgesic effects
- F; both local and widespread effects
What are recommended interventions for PF OA? (5)
- patellar mobs
- taping
- exercise
- stretching
- daily HEP
What are 3 examples of appropriate exercise for PF OA?
- quad strengthening
- seated hip ER
- standing hip abd
With conservative management, __% of pts can see __% improvement of their symptoms, while __% can see at least __% improvement.
~60% of pts can see an improvement of 50% in their symptoms; 80% see an improvement of at least 12%
T or F:
Knee OA causes the most disability of any involved joint or body region
T
TKA earlier than __ years of age is associated with increased risk of mortality
55 yo
What are the strongest predictors of knee OA? (4) Other predictors? (3)
Strongest predictors of OA o Female gender o Increased body mass index o Knee injury that changes biomechanics o Early degenerative changes (chondromalacia)
Other predictors of OA
o Occupations requiring frequent kneeling/squatting
o High impact sports
o Altered joint mechanics
T or F;
ACL reconstruction reduces the risk of OA development
F
A high percentage of pts w/ ACL reconstruction can develop OA within ___ years
10-15 years
Is the prognosis better after ACL reconstruction for younger or older patients?
- older
- younger patients have higher risk of revision and a worse prognosis
What are the recommendations for orthotics with knee OA?
- mixed evidence. Might be helpful, but not conclusive.
Are there benefits for corticosteroid injection for knee OA before starting exercise therapy?
- no; measured at 2, 14, 26 weeks
Is surgery w/ post-op PT better than just PT for knee OA?
- no; not sure how long out this was measured
Describe the differences between Grade I through IV mobilizations.
- I and IV are small amplitude
- I and II are prior to tissue resistance
- III and IV are into tissue resistance
What is the difference between:
- sign
- symptom
- comparable sign
Sign: anything within a joint/structure or regarding its movement that is abnormal
- Hypomobility, palpable soft tissue change, quad weakness - An objective physical exam finding
Symptom: something the patient complains of
- Pain, dizziness, weakness, N/T
Comparable sign: sign found on exam that reproduces the pt’s pain/symptoms, or demonstrates an abnormality at an appropriate level for the pain/symptom
- Does not necessarily have to reproduce the exact symptoms
Hip OA is most common in pts over the age of ____
60
___% of pts over the age of ___ will have hip OA
- 28% of pts with OA over the age of 45 will have hip OA
Hip OA is more common in males or females?
- females
The risk factors for hip OA include: (4)
- Age
- Previous hx of
Developmental disorders
• Developmental dysplasia
• Congenital dislocation
• Legg-calve-perthes
• SCFE
Trauma (e.g., fx)
High impact athletics
What is the relationship between obesity and hip OA risk?
- conflicting evidence for whether obesity increases risk of developing hip OA, but it may be associated with the progression of OA
What are the anatomical structural changes that occur with hip OA? (5)
Synovial inflammation Articular cartilage degradation Development of osteophytes Sclerotic changes to subchondral bone Bony cysts in later stages
What is the standard for imaging classification for severity of OA in the hip? What is it based on?
- joint space narrowing
Normal: 3-5 mm
Significant change: greater than 0.5 mm change
Moderate: less than 2.5 mm (osteophytes likely present)
Severe: less than 1.5 mm (sclerotic hardening)
If a pt is complaining of morning stiffness that lasts for hours, is this indicative of OA?
- no; typically OA morning stiffness resolves in 30-60 minutes.
What are Altman’s criteria for hip OA diagnosis? (5)
Hip pain
Internal rotation ROM difference of 15* or >
Pain with IR
AM stiffness (typically less than 60 minutes)
ESR
*this is the clinical + lab decision tree…which has more clinical than the clinical alone…unsure why
What are the standard complaints for hip OA on initial hx? (6)
o Difficulties with walking on level, uneven surfaces, and stairs (no directional preference)
o Problems with sustained positioning like driving, sitting
o Difficulties getting dressed or lifting the leg
o Groin pain that may refer to the medial knee
o AM pain and stiffness that decreases after one hour
o Pain at end range of motion (IR most painful)
Do people with hip OA usually have a greater problem going up or down the stairs?
- not usually; maybe one will hurt more than the other, but no clear trend
What is the typical pain pattern associated with hip OA?
Where might it refer to?
- groin pain
- medial knee
An arthritic hip typically hurts most with which movement?
- internal rotation
What is the capsular pattern of restriction for the hip?
- IR > ABD > flx
How much difference in internal rotation between hips is considered pathological?
> 15*
What muscles are most often found to be weak with hip OA? (2; movements)
- abduction
- extension
What is the CPR for hip OA diagnosis? (5)
o Painful squatting o Painful flexion o Scour test that produces groin pain o Painful extension o IR <25*
What is the effect of education for hip OA?
Exercise therapy may postpone THR surgery in patinets with hip OA
Education seems to have an effect on joint survival rates
Exercise and education (5.4 years) are better than education alone (3.5 years)
How long can pain relief be expected to last following a land-based exercise program for hip/knee OA?
2-6 months
Is there a relationship between the number of face-to-face visits with a PT and the magnitude of a treatment effect for exercise with knee or hip OA?
- yes; a higher number of visits will typically increase the effect
Are there certain types of exercise programs that are more beneficial for hip OA than others?
- sort of. Any supervised regularly performed exercise program is likely to be beneficial
Exercise programs conducted regularly have impacts on which factors in patients with hip OA? (3)
Are these short, or long-term effects?
- pain
- function
- QoL
- Short term
Is manual therapy beneficial for hip OA? Is it better than exercise?
- it does seem to be beneficial. It does not seem to be more beneficial than exercise, when looking at the whole body of research.
There is one study that showed greater improvements with manual therapy compared to exercise therapy in pain, stiffness, ROM, and function when measured out to 29 weeks. Other evidence is mixed.
Is heat or ice better for hip OA?
- doesn’t matter. Whatever feels better.
Is TENS recommended for hip OA management?
- eh. It’s not, not recommended. It can be used for short-term symptom management, but there’s not super strong support for it.
Are modalities appropriate to use to treat hip OA?
- yes, in support of other interventions (exercise, manual, education)
- not super effective on their own
Are walking aids recommended for use with hip or knee OA?
- sort of. They can be used. A crutch or cane in the contralateral hand is recommended. Otherwise a walker or frame for B disease.
Should patients with hip or knee OA who are overweight be encouraged to lose weight?
- yes, per OARSI recommendations. Doesn’t seem associated with risk of development of hip OA, but likely associated with progression
With GH OA, do the humeral head and glenoid typically need to both be replaced at the same time, if the pt is getting a replacement?
- nope. Usually one surface is more worn out than the other.
What are the standard PT interventions for GH OA?
- per medbridge
Modalities (short term help)
Joint mobilization (usually global stiffness)
Range of motion
Strengthening
What is the current level of evidence in the literature for recommendations for total shoulder arthroplasty rehabilitation?
- expert opinion. There’s not much research into best practices for protocols
Is pre-habilitation effective for shoulder OA prior to replacement?
- not usually. Typically restricted by pain
After a TSA, how long can a pt expect to be in a sling?
- 1-2 weeks, 24/7
- out to 4-6 weeks at night
When is strengthening usually introduced into TSA protocols?
- 4-6 weeks
What are usually the general restrictions for Phase I of a TSA protocol?
- no forced motion (passive or active); avoid significant tissue resistance or muscle contraction
- no IR past the frontal plane
What are usually the general restrictions for Phase II of a TSA protocol?
- no lifting over 2-3 lbs
- but can push ROM a bit more
When can an individual expect to return to sports /recreational activities following a TSA?
- 4-5 months
How long does phase I of a TSA protocol typically last?
~4 weeks
When is phase II typically for a TSA protocol?
- 4-6 weeks
What types of exercise are appropriate for initiating strengthening exercises for a TSA? What phase can this happen in?
- submaximal isometrics in neutral positioning
- phase II
In Phase II, AROM can be initiated (in the later stage) for which movements initially? Is pain ok?
- flexion, abduction, ER, IR
- should be pain-free
What are the AROM goals in phase III of TSA for:
- flexion
- abduction
- ER
- IR
- elevation
o 140* flexion
- 120* abduction in supine
o 60* ER in scapular plane supine
o 70* IR in scapular plane supine in 30* abd
o 120* active elevation with no substitution
What is currently more common; reverse TSA, or traditional TSA?
- reverse TSA has become more common
A rTSA places the demand for shoulder elevaiton on what muscle?
- deltoid
What is a significant concern for rTSA that is less a concern in TSA?
- dislocation
What movements are more concerning for dislocation of rTSA?
- IR/add with extension
How long to ROM precautions usually last for rTSA to minimize risk of dislocation?
- 12 weeks
What ROM can be expected for functional elevation ROM following rTSA?
- ~105*
External rotation following rTSA is dependent on which muscle?
- teres minor
When is PROM usually initiated with rTSA?
- around 4 weeks. generally in the 3-6 week timeframe, but delayed to allow for deltoid tissue to heal
Can you do distal AROM in phase I of rTSA rehab?
- yes, that’s allowed
What are the Phase I PROM limitations for rTSA? How long are they in place?
- flexion elevation <90*
- ER: 20-30* ( may be different if subscap repair)
- no IR
- 6 weeks
In the second portion of Phase I (how long?) rTSA, what are the new ROM restrictions?
- 6 weeks
- elevation in scapular plane 120-140*
- ER 35-40*
- IR passively with shoulder in 60* abd
In late phase II rTSA, what kind of strengthening exercises? Low weight, high rep; or high weight, low rep?
- low weight, high rep
What is often the weight limits associated with rTSA for functional activity? Is it bimanual or unilateral? How long should this be followed?
- lift no > 10-15lbs; bimanual; indefinitely
What are the standard tests for symptoms of GH OA?
- compression (scour)
- distraction for alleviation
What location of pain is characteristic for shoulder OA?
- pain deep in the shoulder
What are standard PT interventions for elbow OA? (4)
Modalities
Joint mobilization
ROM
Strengthening
What are the standard PT interventions for wrist OA? (6-ish)
Modalities
• Parrafin wax/dipping
Joint mobilization
ROM
Strengthening
SplintingWrist fusion is more typical for those with degeneration at which bones?
- carpals
What are the standard PT interventions for hand OA? (6-ish)
Modalities
• Parrafin wax/dipping
Joint mobilization
ROM
Strengthening
SplintingWhat 3 modalities are often used to manage hand OA?
- parrafin wax
- heat
- ultrasound
What is the most common site of OA joint pain?
- hand
Aside from the hand, what are the next three most common sites of chronic joint pain?
- knee
- shoulder
- hip
1 in __ women and 1 in __ men over the age of ___ will have an osteoporosis related fx with ___% mortality rate within ___ months
- 1 in 2 women, and 1 in 4 men over 50yo will have an osteoporosis related fx w/ 20% mortality rate within 12 months of hip fx
___% of people over the age of ____ have chronic joint pain
40% of people over the age of 65 have chronic joint pain
The rate of OA is > __% in people over the age of ___
> 50% in people over the age of 65
OA is more common in ______ (men/women)
- more common in women
The risk for knee OA increase __x w/ a hx of non-specific injury.
3x
The risk for knee OA increase __x w/ a hx of meniscal injury, ACL injury, or femur fx.
6x
Prevalence of hip OA is __% in people over the age of ___
Prevalence of hip OA is ~28% in people over the age of 45
Articular cartilage is more specifically referred to as ______ cartilage
- hyalin
Hyalin cartilage is present in all ________ joints.
- diarthrodial joints
Cartilage nutrition occurs through ________, which requires __________
diffusion, which requires compression
Reduced loading of cartilage can result in: (2)
- reduced nutrition; potential degenerative changes
- reduced lubrication
Impact loading can be detrimental to cartilage if frequency is too high, because:
- cartilage may not be able to deform and redistribute pressure quickly enough, resulting in smaller areas being exposed to stress/loading
What occurs to cartilage when joints are immobilized in the short term, and how long do the changes take to occur?
- atrophy/thinning of articular cartilage
- increased water content
- can occur within a few weeks
Is AROM enough to maintain cartilage health if a joint is NWB?
- not likely; can still see cartilage atrophy/thinning even with joint ROM
- compressive forces are really important.
What occurs to cartilage with prolonged immobilization? (3)
- fibrofatty build up in the joint spaces/tissues
- adhesion formation
- arthrofibrosis (joint scarring)
What are three physiological changes that occur with aging that are thought to contribute to development of OA?
- loss of proteoglycans
- loss of water content
- reduction in the integrity of collagen fibers
What are 4 primary influences for the development of OA?
- aging
- genetics
- abnormal joint mechanics/loading
- obesity
What is the general physiological progression of OA? (4 stages)
- increased water content, with decreased proteoglycans
- fibrillation, fissuring, and erosion of the articular cartilage surface (roughening)
- calcification of the subchondral bone
- chondrocyte proliferation, hypertrophy of osseous tissue, apoptosis of articular cartilage
Grade I OA is characterized by
- Mild fibrillation or cracks in the superficial zone; mild roughness
- Proteoglycan degradation has begun
Grade II OA is characterized by
- Discontinuity of the cartilage in the superficial zone
- Chondrocytes in the mid-zone now start to show changes
Grade III OA is characterized by
- Extensions of the cracks in the superficial zone into the mid-zone
- Cell disruption/death in mid-zone
- Progression of chondrocyte changes
Grade IV OA is characterized by
- Significant cartilage erosion; delamination/loss of superficial zone
- Much larger cracks in the superficial zone
Grade V OA is characterized by
- Total loss of the hyaline cartilage
- Often microfractures along the surface of the bone
- Bone on bone
Grade VI OA is characterized by
- Changes in the bony structure
- Bone remodeling; subchondral bone formation, cyst formation
- Palpable changes around the bone
What changes occur with the synovium in OA? (4)
- synovial hyperplasia; increased proliferation of synovial tissue
- inflammatory cell infiltration
- thickening/fibrosis of synovium
- cartilage/bone fragments lodged in the synovium can perpetuate these changes
What are the two main changes that occur in subchondral bone in OA?
- Sclerosis (hardening)
- cyst formation
What are the nutrition recommendations for OA management?
- none that have solid support/evidence. Most supplements won’t hurt
Which structures in the joint that are affected by OA are innervated?
- bone and synovium
- cartilage is not innervated
Bone marrow lesions are found in ___% of people with knee pain.
-77%
Are pain and OA severity related?
- kind of, but not as cleanly as we’d like it to be.
- pain severity can seems to be related to OA severity. There is a relationship between pain and radiographic severity.
People with OA and medial regional pain are most at risk for what structural defect?
- bone marrow lesion, followed by meniscal extrusion, and then meniscal damage
People with OA and medial joint line pain are at risk for what structure defect?
- bone marrow lesion
What characterizes radiographic stage I OA?
o Stage I: minute osteophytes with normal joint space
What characterizes radiographic stage II OA?
o Stage II: identifieable osteophytes but joint space still maintained (Mild)
What characterizes radiographic stage III OA?
o Stage III: moderate reduction in joint space (Moderate)
What characterizes radiographic stage IV OA?
o Stage IV: severe reduction in joint space (Severe)
The clinical dx of knee OA requires knee pain with at least ___ of what 6 signs?
- knee pain with at least 3 of the following:
- Over 50 yo
- AM Stiffness for < 30 minutes
- Crepitus
- Bony tenderness
- Bony enlargement
- No palpable warmth
The clinical plus radiographic dx for knee OA requires knee pain with at least ___ of what signs?
- knee pain with at least 1 of the following:
- Over 50 yo
- AM Stiffness for < 30 minutes
- Crepitus and osteophytes
What is the CPR for pts with knee OA that may benefit from hip mobs? (4)
- Hip or groin pain or paresthesia
- Anterior thigh pain
- Passive knee flexion less than 122*
- Passive hip internal rotation <17*
- Pain with hip distraction
Is there a synergistic effect for manual therapy and exercise?
- not convincingly per the current literature, but as both provide an effect, it’s a good idea to do both.
Do booster sessions make a difference with pain or function?
- current research doesn’t show a significant effect at one year, however, there is a potential relationship between reduced pain and booster sessions a year out
What are the effects of bracing on knee OA?
- shown to change compartmental loading, however, only marginal benefits for pain or function
- generally inconclusive effects
Are lateral wedges recommended for use in knee OA management?
- used to be prescribed regularly, but currently they are not supported to have any significant effect
Is acupuncture effective for OA treatment?
- statistically significant effect on pain, but not to the level of MCID in current research
What are 7 risk factors for the development of OA? What are their characteristics?
- Age
o Increases with age - Sex
o 70:30 female:male - Obesity
o Associated with increased incidence of knee OA
o Associated with greater progression if you already have OA - Genetics
o 40-65% of OA may be attributed to genetic factors (more so in the hip and hand than the knee)
o Overall, not well understood - Bone Mineral Density (BMD)
o Higher BMD is associated with 2.3x greater incidence of knee OA
o Not associated with progression of OA in those who already have OA - Occupation
o Occupations that require lots of squatting, kneeling, combined with heavy lifting - Previous knee injuries
o ACL and/or meniscal injury significantly increases the risk of knee OA
o Surgical management does not prevent the incidence of OA
Genetics is attributed to OA development in what regions the most?
- hip and hand, more than knee
Is physical activity associated with development of knee OA?
- mildly. No evidence that a physically active lifestyle increases risk
- some higher risk with vigorous/sports activity, but may be related to other risk factors as well (obesity, injury)
What are the grades and descriptions of the Kellgren-Lawrence scale for OA?
- Grade 0: No radiographic findings of OA
- Grade 1: minute osteophytes of doubtful clinical significance
- Grade 2: Definite osteophytes with unimpaired joint space
- Grade 3: Definite osteophytes with moderate joint space narrowing
- Grade 4: Definite osteophytes with severe joint space narrowing and subchondral sclerosis
What are some limitations of radiographs for knee OA diagnosis?
- may have early cartilage degeneration that doesn’t show up. MRI is a better tool; best tool would be MRI with contrast. Standard MRI may miss this too.
What is the age cut-off associated with increased risk of developing knee OA?
- 55; at least in women.
Altman’s radiographic diagnostic criteria look for which criteria?
- presence of osteophytes
- does NOT include joint space narrowing
What are some potential modifiable pre-treatment factors that influence knee OA outcomes? (5)
o Obesity o Joint mobility o Alignment o Knee instability o Psychosocial factors (self-efficacy)
