randy raugh, pt, dpt 1. osteoarthritis (oa) 37.4% > age 60 with knee oa 2030 - 25% of americans...
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A Fresh Outlook on Osteoarthritis and Physical
Capabilities
Randy Raugh, PT, DPT
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Osteoarthritis (OA)37.4% > age 60 with knee OA2030 - 25% of AmericansLeading cause of immobility/disability > 60Symptoms: pain, stiffness, noisy and local swelling“Wear and tear?”CDC:
“Incurable, progressive and degenerative”???“…focal and progressive loss of the hyaline cartilage of
joints, underlying bony changes.”A “disease” or a Mechanical problem?A cartilage problem?
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CDCOA knee: 1 of 5 leading causes of disability among
non-institutionalized adults. ~ 80% of patients - some degree of movement
limitation 25% cannot perform major activities of daily living 11% knee OA need help with personal care14% require help with routine needs. ~ 40% of adults with knee OA reported their
health “poor” or “fair”.1999, knee OA - more than 13 days of lost work
due to health problems
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Excessive stress to entire jointArticular (hyaline) cartilageSynovial liningBone beneath cartilageLigaments
Diagnosed by X-Rays and symptomsJoint space narrowing
Sclerosis (increased bone density) Spurs, lipping
Normal knee Osteoarthritic knee
X-Rays of OA joints
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X-Rays don’t correlate well to painDecreased space: meniscus or articular
cartilageCartilage: no nerves = no pain X-Rays activityFear/anxiety = activityUntreated OA lesions fared no worse
Widuckowski et al (2009) 2-4 cm lesions w/out tx no worse in 13 – 17 year follow-up
Surgical debridement of OA no better than physical therapy/medication Risberg et al; Kirkley et al; Moseley et al
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Risks for OAExcess weight
For OA riskNot for progression unless misalignments
Trauma, surgery, etc. NO movement
ImmobilizationSedentary lifestyle
Repetitive, excessive twistingRapid impact activitiesExcessive Joint flexibilityMisalignments/movement impairments
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Articular cartilageHyaline cartilage – bluish, opalescent, glassy,
homogenousThinner with ageNo blood vessels / no nerves
Heals very slowlyNo pain
80% water-filled matrixMust have dynamic (cyclic) loading to move
nutrients in/damaged cells/waste products out.
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Functions of articular cartilageAbsorb and distribute compressive forces
Like a gel bicycle seatLying down (~0 compressive force) - kneeJumping (~24 x body weight) – kneeFlow of fluid through porous matrix, away from force.Stiffer to higher loadsShock absorption (deformation of cancellous bone most,
then subchondral bone and slightly cartilage (1-3%)Slippery
500 to 2000 x slipperier than ice on ice.Synovial fluid – consistency like egg white
Helps cartilage resist sliding forces
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Tensile stress-strain curve of articular cartilage
TENSILE FORCES
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The non-linear response of articular cartilage to compressive force on fluid flow through the matrix
Compressive forces
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Stretching (tensile) forces
Compressive forces
Sliding (shear) forces
Types of physical stresses encountered by articular cartilage
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Compressive loadsShort term
• Eckstein et al Eckstein et al (2005) – • MRI before/after deep knee bends, squatting, walking, cycling –
decreased thickness 5.0 to 8.8%• After 100 knee bends, return to original thickness took 90
minutes.
• Long term changesInadequate load/immobilization
Jortikka et al (1997) – 11 weeks of immobilization PG in beagle knees – did not fully recover after 50 weeks or remobilization.
Hinterwimmer et al (2004) – 20 patients mean knee cartilage thickness after partial LE immobilization for ankle fx x 7 weeks.
Vanwanseele et al (2002) – after 2 years post-injury, spinal cord patients’ cartilage thickness patella 23%, medial tibia 25%, lateral tibia 19%.
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CompressionExcess load = cartilageLow compression ↑ synthesis; high decreased it.
Weak quadriceps (Youssef et al, 2009) saline or botox injected into quads.
Segal et al (2010) – weak quads correlated to JSN in womenSlemenda et al (1997)- each 10-lb/ft increase knee extensor
strength = 20% knee OAMikesky et al (2006) – 221 older adults, strength vs ROM
Strength group showed slower rate of JSN at 30 months.Excess weight increases load and risk
Felson et al in Framingham Study (1992), wt loss risk of knee OA
Sharma et al (2000) BMI correlated more with risk than progression except in bowed legs
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Shear (sliding force)Wong et al (2008) – cadaveric osteochondral cores
subjected in vitro to shear with 15% compression. More irregular surface had 5 x > shear than normal cartilage. More irregular surface = > friction = more degradation with
shear)Shear more inflammation, production of degrading
enzymes, etc. Shear more common than excess compression with
people over 60?Clinically – patients often report more pain with
movements that increase shear Twisting and bending knees sideways Less pain with movement impairment corrections
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Causes of compression problemsInadequate (rhythmic) compression
“I better not wear it out faster”Sedentary lifestyleStatic postures Prolonged standing
Excess compressionExcess body weightHigh impact or rapid loading activitiesWeak muscles (or muscles untrained for faster
loads)
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Causes of excessive shearActivities which twist joints with compression
SkiingTennisDancingRunning with flexible knees
Poor movement patternsSit stand with knees in/outUp/Down steps with hip/knees in/outPoor body mechanics with activities
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TISSUE RESPONSE TO PHYSICAL STRESS
More physical stress
Healt
hie
r
Optimum Health
Cell death Cell death
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General advice about joint careAvoid static postures – especially bad ones – move!No pain, no gain = no brain. Avoid joint noise if possibleMaintain adequate strengthStretch muscles, not jointsHealthy weightAll joints need regular movement to feel their best.If you can’t find comfort, seek help
Start with conservative care (physical therapy) If no improvement in 6 – 8 visits, change therapists Treat it as a mechanical problem
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Feet are the foundationDo not tolerate uncomfortable shoes – ever!Maintain healthy weightAlternate sport shoes each day
Shock absorption is slow to recover after compression
Choose activities that don’t hurt.Walking is better than standingFoot exercises?
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Knees to last a lifetimeHealthy weightAvoid unnecessary twisting
Biking? Avoid breaststroke, scissor or frog kicks in
swimmingFocus on alignmentMaintain strong legs and HIPSWear proper shoes
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Hip, hip hooray!IF flexible, avoid extreme stretches for hip
Avoid performing “splits,” race-walking, extreme yoga asanas that take hips back beyond neutral with pelvic
Maintain strong buttock and hip musclesAvoid becoming “hamstring dominant”
Jogging worse than runningIF you have very stiff hips with OA, stretch
the hips and strengthen them too
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Spine painSeek help if:
Bowel/bladder problemsDecreased strength in lower extremity or
upper extremityTingling/numbness in genital regionSensory changes in both sides of UE or LE
Start with conservative care – proceed slowly on that route.
“But my MRI showed that…”
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Spine:Spine pain is a mechanical problem too
PostureExercise Avoid heavy lifting
Never bend and lift or worse, bend, twist and liftFor heavy objects – the Raugh Method
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ShouldersAllow your shoulders to rise when you reach.Lift in line with the shoulder bladesDon’t keep them down (for your neck too).
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Questions?