Osteoarthritis ; causes, treatment and pain managment

Osteoarthritis—Degenerative Joint Disease


Osteoarthritis (OA) is a chronic degenerative disorder primarily affecting the articular cartilage of synovial joints, with eventual bony remodeling and overgrowth at the margins of the joints (spurs and lipping) There is also progression of synovial and capsular thickening and joint effusion.



Characteristics of OA

With degeneration, there may be capsular laxity as a result of bone remodeling and capsule distention, leading to hypermobility or instability in some ranges of joint motion. With pain and decreased willingness to move, contractures eventually develop in portions of the capsule and overlying muscle, so as the disease progresses motion becomes more limited. Although the etiology of OA is not known, mechanical

injury to the joint due to a major stress or repeated minor stresses and poor movement of synovial fluid when the joint is immobilized are possible causes. Rapid destruc- tion of articular cartilage occurs with immobilization because the cartilage is not being bathed by moving synovial fluid and is thus deprived of its nutritional supply. OA is also genetically related, especially in the hands and hips and to some degree in the knees. Other risk factors that show a direct relationship to OA are obesity, weakness of the quadriceps muscles, joint impact, or sports with repetitive impact and twisting (e.g., soccer, baseball pitching, football), and occupational activities such as jobs that require kneeling and squatting with

heavy lifting. The cartilage splits and thins out, losing its ability to withstand stress. As a result, crepitation or loose bodies may occur in the joint. Eventually, subchondral bones becomes exposed. There is increased density of the bone along the joint line, with cystic bone loss and osteoporosis in the adjacent metaphysis. During the early stages, the joint is usually asymptomatic because the cartilage is avascular and aneural, but pain becomes constant in later stages. Affected joints may become enlarged. Heberden’s nodes (enlargement of the distal interphalangeal joint of the fingers) and Bouchard’s nodes (enlargement of the proximal interphalangeal joints) are common. Most commonly involved are weight-bearing joints (hips and knees), the cervical and lumbar spine, and the distal interphalangeal joints of the fingers and carpometacarpal joint of the thumb.



Principles of Management—Osteoarthritis

Pain, joint stiffness, decreased muscle performance, and decreased aerobic capacity affect the quality of life and increase the risk for disability for the individual with OA. Therapeutic exercise and manual therapy interventions are important in the comprehensive management of OA.


Patient instruction

 Education includes teaching the patient about the disease of OA, how to protect the joints while remaining active, and how to manage the symptoms. The patient is instructed in a home program of safe exercises to improve muscle performance, ROM, and endurance.


Pain management—early stages

 Pain and feelings of “stiffness” are common complaints during the early stages. Pain usually occurs because of excessive activity and stress on the involved joint and is relieved with rest. Brief periods of stiffness occur in the morning or after periods of inactivity. This is due to gelling of the involved joints after periods of inactivity. Movement relieves the stasis and feelings of stiffness. It is important to find a balance between activity and rest and to correct biomechanical stresses in order to prevent, retard, or correct the mechanical limitations.


Pain management—late stage

 During the late stages of the disease, pain is often present at rest. The pain is probably from secondary involvement of subchondral bone, synovium, and the joint capsule. In the spine, if bony growth encroaches on the nerve root, there may be radicular pain. Pain that cannot be managed with activity modification and analgesics is usually an indication for surgical intervention.


Assistive and supportive devices and activity

 With progression of the disease, the bony remodeling, swelling, and contractures alter the transmission of forces through the joint, which further perpetuates the deforming forces and creates joint deformity. Functional activities become more difficult; and adaptive or assistive devices, such as a raised toilet seat, cane, or walker, may be needed to decrease painful stresses and maintain function. Shock absorbing footwear may decrease the stresses in OA of the knees. Aquatic therapy and group-based exercise in water decreases pain and improves physical function in patients with lower extremity OA.


Resistance exercise

Progressive weakening in the muscle occurs either from inactivity or from inhibition of the neuronal pools. Weak muscles may add to the joint dysfunction. Strong muscles protect the joint. Resistance exercises, within the tolerance of the joint, should be part of the patient’s exercise program. When performing

resistive exercises, it is important to avoid deforming forces and heavy weights that the patient cannot control or that cause joint pain. Adaptations include the use of multiple-angle isometrics in pain-free positions, applying resistance only through arcs of motion that are not painful, and use of a pool to decrease weight-bearing stresses and improve functional performance.

Stretching and joint mobilization

 Stretching and joint mobilization techniques are used to increase mobility. The patient should be taught self-stretching/flexibility exercises and the importance of movement to counteract the developing restrictions.

Balance activities.

 Joint position sense may be impaired. Nontraditional forms of exercise such as Tai Chi have been found to be effective for improving balance in patients with OA.

Aerobic conditioning

 The patient should be instructed in low-, moderate-, or high-intensity exercises designed to improve cardiopulmonary function. The choice of exercise should have low impact on the joints, such as walking, biking, and swimming. Jogging, jumping, and activities that cause repetitive intensive loading should be avoided.



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