Osteoarthritis

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Search Strategy

• Databases: Pubmed, Library of the VUB, Pedro, Medscape
• Keywords: osteoarthritis(upper extrimity, lower extrimity), therapy, management, 

Definition/Description

Osteoarthritis or degenerative arthritis is a heterogeneous group of conditions that lead to joint symptoms and signs which are associated with degeneration of articular cartilage, in addition to related changes in the underlying bone and at the joint margins.

Epidemiology /Etiology

• Epidemiology:
  As highlighted by Peyron, one adult on three has osteoarthritis and above 55 years, this disease has a prevalence of 4 times more than the total population. Professionals in collaboration mentioned that people from the United States and black people from Jamaica and Africa has the highest prevalence. Further on, woman has a higher prevalence as well. Race- and genderdifferences are more clearly than climatic differences.
  Allander et al. approved that age has an influence on the severity of osteoarthritis at the level of hands and feet. This proves the relation between age and gender with osteoarthritis. Further on, research from Kelsey et al. proved that arthritis and musculoskeletal diseases are the most common chronic diseases and causes of physical disability in the United States.
   

• Etiology:
  We can make out two forms of osteoarthritis:
  A. Primary osteoarthritis:
  This is the form of osteoarthritis in which you don't know what could trigger the disease. You can't infer anything from history, nor clinical or radiographic examination.
  B. Secondary osteoarthritis
  This last form can be caused by trauma, metabolic disease, congenital malformations, premature menopause, etc. Sometimes, it can happen that a patient is suffering from secondary ostheoarthrits before the age of 40.

Characteristics/Clinical Presentation

Clinical signs depend mainly to the affected joint but usually, they show some common characteristics. They're mainly local. Symptoms are:

• Pain:
  This is a 'mechanical' type of pain which is genarated by mobilization, increases with fatigue and decreases with rest. Pain occurs in the morning or after a period of inactivity. Mostly, there's no overnight pain. The intensity of pain is variable. Sometimes it's dull and tolerable, other times it's very heavy with short peaks. It can be stimulated by cold, trauma and fatigue.
  This pain occurs at the level of the subchondral bone and in capsuloligamentar and muscular structures.

• Limiation in movement (loss of ROM):
  Limitation in movements expires insidious, progressive and  will be noticed after serveral years. This limitation is mainly related to the blocking of voluntary muscle functioning and the reflexcontracture. It's also the result of changes in the articular spaces, with incongruention of  joint surfaces. Some patients complain about stifness in the morning, which holds on for a longer period but is less severe than the morningstifness from rheumatoïd arthritis or ankylosing spondylitis. In most of the patients the limitation in movement is progressive. The severity increases with time and is accompanied with the joint deformities and wear of the cartilage.

• Sounds: 
  The sounds you can hear are cracking, scraping and sounds from crepitation. They're generated by mobilization of the joint. You can even hear them when you palpate the joint. Irregularities in the articulating joint surfaces and poor quality of the remaining cartilage is very likely to be the cause.

• Difficult and painful mobilization:
  It's important to differentiate between total blocking and limited mobility, due to immobilisation for a longer period. Total blocking is caused by the prescence of meniscus, unusual structuers, etc.

• Morphological deformities:
  The affected joint is only in a few cases red and feels warm. Normally, it has a normal coulour and temperature. The increase in volume is due to changes in ratio between the joint surfaces. There may also be moisture in the arthritic joint, caused by irritation, mechanical and/or biochemical phenomena at the synovial membrane.
  

There are no biological characteristics of osteoarthritis. There are no inflammatory signs nor immunological disorders or abnormalities of phosphocalium metabolism.

Differential Diagnosis

Osteoarthritis is a degenerative process at the level of the cartilage and should be well distinguished from arthritis, where it’s about a synovial inflammatory process.

Abrasive, scraping sensations of the patella during mobilization of the knee joint can also occur in patients with Chondromalacia_Patellae, with preservation of the articular cartilage.

Diagnostic Procedures

The severity of osteoarthritis can be evaluated by radiography, according the Kellgren. By this way, we can discriminate four degrees of severity in osteoarthritis:
Degree I: normal joint with a minimal osteophyte.
Degree II: osteophytose on two points with minimal subchondral sclerosis, proper joint space and no deformity.
Degree III: moderate osteophytose, early deformity of the bone endigs and a joint space which narrows.
Degree IV: large osteophytes, deformity of bone endings, narrowing joint space, sclerosis and cysts.

Outcome Measures

Hip Disability and Osteoarthritis Outcome Score

Knee Injury and Osteoarthritis Outcome Score

Examination

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Medical Management

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Therapy Management

Basic Therapy

• Muscle stretching (quadriceps femoris, hamstring, and calf muscle stretching) 
• Strengthening (quad sets,supine straight leg raises, prone hip extensions, seated isometric knee extensions, single-leg leg presses,standing hamstring curls, and standing heel raises)

• Long-sitting knee flexionand extension range of motion, and treadmill walking.
• All lower-extremityexercises need to be performed bilaterally.

Agility and Perturbation TrainingTechniques

Agility techniques:

• Side stepping
• Braiding (lateral stepping combined with forward and backward crossover steps)
• Front crossover steps during forward ambulation
  
• Back crossover steps during backward ambulation
• Shuttle walking(forward and backward walking to and from designated markers)
• A drill requiring multiple changesin direction

Perturbation techniques:

Key Research

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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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