A Fresh Outlook on Osteoarthritis and Physical Capabilities

A Fresh Outlook on Osteoarthritis and Physical CapabilitiesRandy Raugh, PT, DPT1Osteoarthritis (OA)37.4% > age 60 with knee OA2030 - 25% of AmericansLeading cause of immobility/disability > 60Symptoms: pain, stiffness, noisy and local swellingWear 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?2CDCOA 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 problems3Excessive stress to entire jointArticular (hyaline) cartilageSynovial liningBone beneath cartilageLigamentsDiagnosed by X-Rays and symptomsJoint space narrowingSclerosis (increased bone density)Spurs, lipping

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Normal kneeOsteoarthritic kneeX-Rays of OA joints5X-Rays dont correlate well to painDecreased space: meniscus or articular cartilageCartilage: no nerves = no pain X-Rays activityFear/anxiety = activityUntreated OA lesions fared no worseWiduckowski et al (2009) 2-4 cm lesions w/out tx no worse in 13 17 year follow-upSurgical debridement of OA no better than physical therapy/medication Risberg et al; Kirkley et al; Moseley et al

6Risks for OAExcess weight For OA riskNot for progression unless misalignments Trauma, surgery, etc. NO movementImmobilizationSedentary lifestyleRepetitive, excessive twistingRapid impact activitiesExcessive Joint flexibilityMisalignments/movement impairments

7Articular cartilageHyaline cartilage bluish, opalescent, glassy, homogenousThinner with ageNo blood vessels / no nervesHeals very slowlyNo pain80% water-filled matrixMust have dynamic (cyclic) loading to move nutrients in/damaged cells/waste products out.

8Functions of articular cartilageAbsorb and distribute compressive forcesLike 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 whiteHelps cartilage resist sliding forces

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Tensile stress-strain curve of articular cartilage10TENSILE FORCES

The non-linear response of articular cartilage to compressive force on fluid flow through the matrix11Compressive forcesStretching (tensile) forces

Compressive forces

Sliding (shear) forces

Types of physical stresses encountered by articular cartilage

12Compressive loadsShort termEckstein 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/immobilizationJortikka 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%.

13CompressionExcess 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 riskFelson et al in Framingham Study (1992), wt loss risk of knee OASharma et al (2000) BMI correlated more with risk than progression except in bowed legs

14Shear (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 sidewaysLess pain with movement impairment corrections

15Causes of compression problemsInadequate (rhythmic) compressionI better not wear it out fasterSedentary lifestyleStatic postures Prolonged standing Excess compressionExcess body weightHigh impact or rapid loading activitiesWeak muscles (or muscles untrained for faster loads)

16Causes of excessive shearActivities which twist joints with compressionSkiingTennisDancingRunning with flexible kneesPoor movement patternsSit stand with knees in/outUp/Down steps with hip/knees in/outPoor body mechanics with activities

17 TISSUE RESPONSE TO PHYSICAL STRESSMore physical stressHealthierOptimum HealthCell deathCell death18General 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 cant find comfort, seek helpStart with conservative care (physical therapy)If no improvement in 6 8 visits, change therapistsTreat it as a mechanical problem19Feet are the foundationDo not tolerate uncomfortable shoes ever!Maintain healthy weightAlternate sport shoes each dayShock absorption is slow to recover after compressionChoose activities that dont hurt.Walking is better than standingFoot exercises? 20Knees to last a lifetimeHealthy weightAvoid unnecessary twistingBiking? Avoid breaststroke, scissor or frog kicks in swimmingFocus on alignmentMaintain strong legs and HIPSWear proper shoes

21Hip, hip hooray!IF flexible, avoid extreme stretches for hipAvoid performing splits, race-walking, extreme yoga asanas that take hips back beyond neutral with pelvicMaintain strong buttock and hip musclesAvoid becoming hamstring dominantJogging worse than runningIF you have very stiff hips with OA, stretch the hips and strengthen them too22Spine painSeek help if:Bowel/bladder problemsDecreased strength in lower extremity or upper extremityTingling/numbness in genital regionSensory changes in both sides of UE or LEStart with conservative care proceed slowly on that route.But my MRI showed that23

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Spine:Spine pain is a mechanical problem tooPostureExercise Avoid heavy liftingNever bend and lift or worse, bend, twist and liftFor heavy objects the Raugh Method

27ShouldersAllow your shoulders to rise when you reach.Lift in line with the shoulder bladesDont keep them down (for your neck too).28Questions?29