b ing, degeneratuve arthropathies

8/3/2019 b Ing, Degeneratuve Arthropathies

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Introduction

Rheumatic diseases constitute one of thecommonest causes of pain, disability and economic lossin mankind. Rheumatism in its broadest sense has beenrecognized since the fifth century BC. Today there is awide range of treatments, some of which are verysuccessful. The bewildering nature of rheumatism is thatpeople with apparently identical clinical features benefitfrom different treatment. Acupuncture, ultrasound,cortisone injections, manipulation - all have theirdevotees as constituting the cure for them.

Physiotherapy for soft-tissue rheumatism is closelyrelated to soft-tissue injury and therefore features inChapter 6. Chapters 8-11 cover physiotherapy for jointdisorders or diseases.


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Anatomy and physiology

Joints are fibrous, cartilaginous or synovial.

Synovial joints

1. Articular surfaces are covered in hyaline cartilage.

2. Joint capsule and ligaments unite the bones, provide stability anddirect movement.

3. Synovial membrane lines the capsule and secretes synovial fluid.

4. Intra-articular structures are present in some joints such asmenisci and cartilaginous discs.

5. Nerve supply is generally from the nerves supplying the musclesacting on the joints (Hiltons law).

6. Nerve endings in the capsule and ligaments aremechanoreceptors. which register movement, proprioceptors toregister the position of the joint and nociceptors to register pain.There are also autonomic (sympathetic) nerve endings onbloodvessels.


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Joint lubrication and nutrition

All joint components are supplied with blood

vessels except for the articular cartilage.

Synovial fluid provides both joint lubrication and

nutrition for articular cartilage. Movement of

joint surfaces over one another, compression

and distraction are all important in the provision

of synovial fluid sweep and thereforemaintenance of healthy cartilage.


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Cartilaginous joints of the vertebral

column

Articular surfaces are superior and inferior

surfaces of vei tebral bodies, which are covered

by cartilage endplates. The intervertebral disc is

between the two bodies.


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Osteoarthritis (OA)

Definition :

A chronic degenerative disease of joints with

exacerbations of acute inflammation. Synonyms

- Degenerative arthritis, degenerative joint

disease, arthritis deformans.


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Cause

The cause is unknown but a number of predisposing factors may beconsidered:

1. Conditions already mentioned in relation to secondary arthritis.

2. Hereditary. There is a significantly higher mcidence of thecondition in families.

3. Poor posture.4. The ageing process in joint cartilage.

5. Climate has not been shown to be related to the pathologicalchanges but pain is greater in cold, damp climates.

6. Defective lubricating mechanism and uneven nutrition of the

articular cartilage.7. Crystals (calcium pyrophosphate and hydroxyapatite) have been

associated with synovitis in osteoarthritic joints.


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Pathology

This will be considered in relation to each jointstructure as follows :

1. Articular cartilage.

2. Bone.

3. Synovial membrane.

4. Capsule.

5. Ligaments.

6. Muscles.


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Articular cartilage

Erosion occurs, often central and frequently in theweight-bearing areas. Cartilage is usually the firststructure to be affected. Fibrillation which causessoftening, splitting and fragmentation of the cartilageoccurs in both weight-bearing and non-weight-bearingareas.

Collagen fibres split and there is disorganization ofthe proteoglycan collagen relationship such that wateris attracted into the cartilage which causes furthersoftening and flaking. Flakes of cartilage break off andmay be impacted between the joint surfaces causinglocking and inflammation.

Proliferation occurs at the periphery of thecartilage.


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Bone

Eburnation - The bone surfaces become hard andpolished as there is loss of protection from the cartilage.

Cystic cavities form in the subchondral bonebecause eburnated bone is brittle and microfractures

occur allowing the passage of synovial fluid into the bonetissue. There can also be venous congestion in thesubchondral bone.

Osteophytes form at the margin of the articularsurfaces where they may project into the joint or into the

capsule and ligaments. Bone of the weightbearing jointsalters in shape - the femoral head becomes flat andmushroom shaped. The tibial condyles become flattened.


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Synovial membrane

This undergoes hypertrophy and becomes

oedematous. Later there is fibrous

degeneration. Reduction of synovial fluid

secretion results in loss of nutrition and

lubrication of the articular cartilage.


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Capsule

This undergoes fibrous degeneration and there

are lowgrade chronic inflammatory changes.


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Ligaments

These undergo the same changes as the capsule

and according to the aspect of the joint become

contracted or elongated.


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Muscles

These undergo atrophy which may be related to

disuse because pain limits movement and

function. Without adequate exercise the

muscles may undergo fibrous atrophy.


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Coordination

Frenkels exercises can be used to work the joints andmuscles through smooth coordinated purposeful movements.Stabilizations in standing hep to gain cocontraction around the hip,knce and ankle joints. Balance-board work is also of value in re-educating proprioceptor function. Damage to these nerve endings inthickened fibrous tissue may possibly be a contributing factor to afeeling of instability at the lower limb joints. The patient may betaught to stand on one leg for 2-3 minutes at home with corrected legposture. PNF slow reversals and correctly performed free activeexercise also contribute to coordination.

Gait re-education may include teaching the patient to takeslightly shorter steps so that there is a relatively shorter hip

movement during stance phase. A walking stick may be necessary torelieve weight and pain, held in the hand opposite to the affected joint(where there is only one limb affected) so that gait pattern can besmooth. It is sometimes necessary to persuade the patient that thisreduces stress on the joints and therefore reduces the rate of wearand tear.


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Maintenance offunction

As already explained this is achieved by the

patient following a programme of exercise, rest

and diet.

Replacement arthroplasty is very effective inrelievingpain. Osteotomy may be performed (see

below).

Surgery


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Spondylosis

Not to be confused with spondylosis, spondylitis,

or spondylolysis. All is the same.


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Definition

Spondylosis is a condition in which there are

degenerative changes in the intervertebral joints

between the bodies and the discs. OA results in

degenerative changes in synovial joints andtherefore can occur in the apophyseal joints of

the spine. Clinically the two conditions often

occur together.


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Clinicalfeatures

These vary according to the site and will be

considered such as :

1. Cervical

2. Lumbar

3. Thoracic


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Cervical spine - clinical features

Onset

This may be precipitated by fatigue or worry and may be traced toan episode in the patients life.

Pain

1. Headaches due to upper cervical pathology.

2. Neck-ache usually due to mid-cervical pathology.

3. Shoulder girdle, shoulder and arm pain due to pathology from C4to T2.

Muscle weakness

Neck postural muscles are often weak, i.e. the upper cervicalspine flexors, lower cervical spine extensors and the side-flexors. Ifthere is pressure on a nerve root, there may be weakness in themuscles (myotome) supplied by that root.


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Treatment

Physiotherapy is directed at:

1. Relief of pain.

2. Restoration of movement.3. Strengthening of muscles.

4. Education of posture.

5. Analysis of precipitating factors to reducerecurrence of the patients problems.


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Examination

A scrupulous examination is essential to identifyprecipitating factors in the patients lifestyle; forexample:

1. Working conditions that demand concentrationresulting in poking chin and round shoulders.

2. Habit of holding the telephone on one shoulder.

3. Sitting or standing ctill for long times.

4. Driving for a long time, especially in traffic jams.

5. Sleeping in awkward positions.


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Limitation of movement

1. Neck movements are all limited ojten bilaterally butduring an acute episode of pain one side is more affectedthan the other. It is important to note that upper cervicalspine fiexion is often very limtied together with lower

cervical spine extension.2. Muscle spasm and muscle tightness.

3. Limitation of movements, including limiting factors andexact vertebral levels affected.

4. Loss of accessory intervertebral movements detected bypalpation.

5. Loss of soft-tissue mobility also detected by palpation.

These findings are assessed together with the details of thepain picture and a logical treatment programme is planned.

The following treatments may be used.


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Movement

Hold-relax technique is necessary to lengthen the musclesespecially the side-flexors and upper cervical spine extensors.Lengthening the shoulder girdle elevators is achieved by thephysiotherapist holding the head steady and applying hold-relax togain shoulder girdle depression. Lengthening the upper cervicalextensors is achieved by deep longitudinal stroking and by teachingthe patient to lift the head out of the shoulders pushing the back ofthe head backwards and upwards. Generally these techniques areapplied with the patient in lying but half-lying or sitting can be used.Stabilizations are helpful to retrain correct muscle balance so that theupper cervical spine flexors and lower cervical extensors work tocounteract the hypertonia in their antagonists. Free active exercisesshould be practised every day particularly oblique patterns (flexion,sideflexion rotation right to extension, side-flexion rotation left andrepeat opposite way).


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Advice

The patient who sleeps supine should haveone or two (at the most) pillows under the head. Inside-lying, two pillows should fill the gap betweenthe neck and shoulder. A pillow to support the top

arm and another to support the top knee helps toprevent the trunk rolling forward and twisting theneck. During the day, every half hour or so, the neckshould be stretched and moved through full range

especially in sitting, reading, writing,.car driving andsimilar activities. If the neck starts to feel stiff it isadvisable to see a physiotherapist soon so thatmovement can be restored before a severe acuteepisode of pain ensues.


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Lumbar spine - clinical features

Onset

Usually the pain starts as a niggle and does notbecomea problem until a few months have passed whenitbecomes constant. Acute pain may be precipitated

byunaccustomed activity, e.g. a weekend of gardening.

Pain

A common site for pain is across the sacrumbetweenthe sacroiliac joints. It may radiate down one orbothbuttocks and to the lateral aspects of one or bothhips.Central pain can occur at L4, 5 Si level.


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Referred pain

1. Pain may radiate into a leg because of nerve root irritation. Ittends to be dermatomal.

2. Groin - Li.

3. Anterior aspect thigh - L2.

4. Lower third anterior aspect thigh and knee - L3.

5. Medial aspect leg to the big toe - L4.6. Lateral aspect leg to the middle three toes - L5.

7. Little toe, lateral border foot lateral side posterior aspectwhole leg - Si.

8. Heel, medial side posterior aspect whole leg - 52.

Nature of the pain

Dull or severe ache superimposed from time to time by sharpstabbing pain.


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Limitation of movement

All lumbar spine movements tend to be

limited on attempted flexion there is often no

movement between Si and Li. Hip movements

are often limited asymmetrically. Limiting factorsare generally softtissue tightness more than

spasm or pain (except during an episode of

acute pain).


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Muscle weakness

The abdominal muscles have poor tone and may

be weak. The gluteal muscles are often on one

side. The muscles of the leg with referred pain

are usually weaker than the other. Pressure on anerve root can result in weakness of the muscles

supplied by that root (myotome).


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Examination

This, as in cervical spondylosis, identifies:

1. The pain picture.

2. Precipitating factors at work or leisure.

3. Posture abnormalities.

4. Muscle spasm and tightness.

5. Limitation of movements and the limiting factors.

6. Loss of accessory movement and soft-tissue mobilityby palpation.

A logical treatment programme can be plannedonly after these findings are assessed.

The following treatments may be used.


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Heat

A heat pad can help to relieve the aching which comesfrom prolonged muscle spasm. The best position is lying withone pillow under the head and two or three under the knees.Sometimes it is helpful to warm tight muscles in a stretchedposition. For the lumbar spine extensors pulsed or continuouselectromagnetic energy can be applied to the patient,supported in side-lying with the knees, hips and lumbar spineflexed. If the patients pain is relieved by warmth it issensibleto discuss wearing a vest or woollen body belt, especially

during the winter. Often, there is a gap between shirt andtrousers which chills the very muscles that are working, e.g.during gardening or DIY in the house. Chilling of the lumbarspine area is particularly common in the tee shirt and jeansbrigade.


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Posture educationAs in all postural deformities this includes training the patient in

total body alignment. Foot and leg positions affect pelvic balance and canoften be the underlying problem even when the patient insists that the

pain is in the back and there is nothing wrong with the legs. (See

Intervertebral disc lesions and postural deformities.)

For example, a habit of standing with the right knee slightly bent

causes shortening of the hamstrings which pull on the ischial tuberosityattachments tending to cause backward rotation of the right hip bone

which pulls on the quadratus lumborum and these muscles start to ache.

Standing habitually on the right leg with the knee straight causes

shortening of the right hip abductors and the left trunk side-flexors. Aching

can then start in both these muscle groups. Breaking these habits of a

liftime may not be possible but the patient can certaiidy be trained in the

habit of regular stretching in the opposite direction. Mobility of joints and

soft tissues must be gained before posture training is possible. At first

correct alignment feels squint to the patient but it is essential to persevereuntil good alignment feels normal.


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Movement

Hold - relax can be applied to gain flexion. At first the patient is inlying with the knees flexed and crossed. The physiotherapist applies thetechnique by pushing on the knees. Later, provided there is no danger ofdisc prolapse, the technique can be applied in long sitting. The side-flexorscan be lengthened by hold relax applied to alternate hip updrawing. Activeexercise comprises teaching the patient pelvic tilting forwards, backwardsand sideways in crook lying, pronekneeling, sitting and standing. Thensmooth pelvicmovement needs to be re-educated i.e. backwards toallowforward flexion, forwards to allow extension andsideways to allow side-flexion. Oblique movementsshould be taught for daily practice afterdischarge, i.e.standing hands clasped, feet astride - touch left foot,stretchup and back to the right, repeat to the oppositeside. Also combinedmovements can be appropriate forsome patients - especially younger agegroups. Theseare standing - bend forwards then side to side in theflexedposition, repeat in extension, bend sidewaysthen bend forwards andbackwards maintaining sideflexed position, repeat to opposite side.

Together with mobility, the patient should practise strengtheningexercises for all the lumbar andhip muscles.


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Advice

Sleeping on a firm mattress generally helps the patientwhose problem is backache on waking, especially when theache is aggravated by prolonged flexion. If the ache isaggravated by extension (where lordosis is the problem) ahard mattress can be quite wrong. If the patient sleeps in

side-lying rather than supine the mattress should be softenough to accommodate the body contour. Also the patientshould try supporting the waist with a roll and the top aimand leg with pillows. During the treatment programme thephysiotherapist and the patient should work out the

precipitating factors, e.g. car seat, desk height, shape sizeand weight of objects handled at work, sitting position(including side-sitting always one way). Also the patientshould understand the importance of general fitness in theprevention of recurrence.


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Spondylolysis


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Clinicalfeatures1. Often there are none attributable to the defect

directly.

2. The condition can be seen on radiographs and may

be discovered by chance.

3. Commonest site affected is L415 and L5/S1.

Prognosis

1. The condition may not give rise to any symptoms.2. The part of the vertebra above the defect may slip

forwards and the condition isthen known as

spondylolisthesis.


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Spondylolisthesis


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Definition

This means that the body of a vertebra slips on the one

below. Generally the direction of the slip is forwards;

occasionally there is a backward slip (retrolysthesis).

Aetiology

Common sites are L5/S1 and L4/L5. The stability of the

L4/5/S1 part of the lumbar spine depends on the

pedicle, pars interarticularis and inferior articular facet

locking over the superior facet of the vertebra below

(Figure 8.7(a)). When the pars interarticularis gives, the

vertebra slips forwards (Figure 8.7(b)).


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Clinicalfeatures

These vary according to the cause:1. Younger age groups are affected. Pain is in the back.

2. Females are much more commonly affected than males:

A. Age group is 40 plus.

B. Backache is characteristic with muscle spasm adominant feature.

C. Sometimes it feels as if the lumbar spine is locked inextension and the patient has alordosis at MIS/Si.

D. Pain is relieved on lying and aggravated by prolonged

standing. Sitting may at first relieve but lateraggravates.

E. Referred root pain in the legs can occur.


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Treatment

Cause 21. Pain can be relieved by warmth. A lumbo-sacral support also

helps to relieve pain.

2. Active exercises are essential when acute pain has subsidedto strengthen abdominal and back extensor muscles.

3. Advice on posture, back care and lifting is essential.

4. Loss of weight is usually appropriate.

5. Mobilizations and soft-tissue techniques may be appropriateto restore movement to levels of the lumbar spine above the

level of the lesion.6. If root pain is severe or neurological deficit develops, spinal

fusion may be appropriate.

Causes 1 and 3

These may need to be treated by decompression and fusion.


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Joint surgery

1. Replacement.

2. Arthrodesis.

3. Osteotomy.


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Replacement arthroplasty

The joints that are replaced most commonly are hips andknees. Shoulders, elbows, metacarpophalangeal jointsand ankles are also replaced with varying degrees ofsuccess. The diseases that lead to joint replacement are

rheumatoid arthritis, osteoarthritis, psoriatic arthritis,ankylosing spondylitis (hips) and juvenile arthritis.

The indications for surgery are:

1. Severe disabling pain.

2. Loss of range of movement causing severeimpairment of function.


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Arthrodesis

also known as artificial ankylosis or syndesis, is theartificial induction of joint ossification between two bones viasurgery. This is done to relieve intractable pain in a joint whichcannot be managed by pain medication, splints, or othernormally-indicated treatments. The typical causes of such pain

are fractures which disrupt the joint, and arthritis. It is mostcommonly performed on joints in the spine, hand, ankle, andfoot. Historically, knee and hip arthrodeses were alsoperformed as pain relieving procedures, however with thegreat successes achieved in hip and knee arthroplasty,

arthrodesis of these large joints has fallen out of favour as aprimary procedure, and now are only used as procedures oflast-resort in some failed arthroplasties.


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Osteotomyis a surgical operation whereby a bone is cut to shorten,

lengthen, or change its alignment. It is sometimes performed tocorrect a hallux valgus, or to straighten a bone that has healedcrookedly following a fracture. It is also used to correct a coxavara, genu valgum, and genu varum. The operation is done undera general anaesthetic.

Osteotomy is one method to relieve pain in arthritis,especially of the hip and knee. It is being replaced by jointreplacement in the older patient.

Due to the serious nature of this procedure, recovery maybe extensive. Careful consultation with a physician is important inorder to ensure proper planning during a recovery phase. Toolsexist to assist recovering patients who may have non weightbearing requirements and include bedpans, dressing sticks, long-handled shoe-horns, grabbers/reachers and specialized walkersand wheelchairs.


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Cemented

This is good, but if the parts become loose,

removing the old cement may be difficult,

especially if the bone is poor. If revision is not

possible a girdlestone operation may berequired.

b ing, degeneratuve arthropathies

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