관절염의재활 Rehabilitation of ArthritisPhysical Therapy and Rehabilitation: PT 1질 InfoPT : infoPT.cyworld.com : Teamdoc 's Present : [email protected] 관절염의재활관절염의재활

질Physical Therapy and Rehabilitation PT 1

InfoPT infoPTcyworldcom Teamdoc s Present teamdoc20hotmailcomtrade

관절염의 재활관절염의 재활

Rehabilitation of ArthritisRehabilitation of ArthritisEditing By AKA teamdoc B Sc PT

관절의 구조적 이해I [Structural Understands of Joint]관절 분류법1 [Joint Classification]가동관절A [Diarthrosis] Synocial Jt

Ex) Hip knee Jt

부동관절B [Synarthrosis] Fibrous Jt

Ex) Coronal suture

반관절C [Amphiarthrosis] Cartilagious Jt

Ex) Intervetebral disc Symphysis pubis

Picture 1 Joint structure

관절의 구조2 [Joint structure]A Cartilage 05-15mm

patella 75mm

Solid phase Chondrocyte collagen proteoglycan(PG) extracellular

matrix(ECM)

Fluid phase Water



Nutrition infusion amp diffusion

색이 없거나 약간 노란색B Synovial fluid Clear

대부분 내Jt 02ml knee Jt - 5ml

의 특성1) Synovial fluid

닮게 됨으로써 를 보호cartilage

윤활 에 아주 중요한 작용Jt lubrication[ ]

좌측 통풍 우측Picture 2 RA( ) [gout]( )

환자의 synovial fluid

와 의 접촉면Picture 3 Cartilage synovial fluid

연골에 영양을 공급

에 영양 을 공급2) Cartilage [nutrition]

수동 확산

Mechanical pumping effect

3) Collagen Coiled fiber

Collagen type II IX X XI

II - IX - II interaction

의Picture 4 Collagen fiber Structure



변화된 단백질4) Proteoglycans(PG) [protein] polysaccharide molecule

결합조직 세포의 기질에 있어서 볼 수 있는 공유결합형착물 [covalent

의 단백질 사슬에서 결합한 글라이코아미노글라이칸 뮤코다당질complex] ( )

하이알루론산염 필라멘트 집합체5) (hyaluronate)

황산화 글라이코스아미노글라이칸6) PG monomer 150 [Glycosaminnoglygan]

가 포함된 긴 단백질 사슬(GAG)

개의 황산화 케라탄 황산화물 콘드로이틴 황산화물7) 2 GAGs

Picture 5 PG aggregate Figure 6 Structure of large hyaluronan

aggregating proteoglycans (PG-LA)

Picture 7 Interweaving of PG and Collagen

fibrils

와 콘드로이친 황산Picture 8 Hyaluronic acid

화물

황산화물8) GAGs Mc chondrotin-6-sulfate[ ]

Immature Vs mature cartilage

병 안을 닦는 솔처럼 생겼음



Some GAGs Where What

hyaluronic acid synovial fluid vitreus humor ECMlarge polymer many negativecharges - self repelling shockabsorbing

chondroitin sulfate cartilage bone commonest GAGheparan sulfate basement membranes cell surfaces

hepain lines arteries in mast cellshighly sulfated

impedes clottingdermatan sulfate skin heart valves

관절연골 의 초미세구조3 [articular cartilage]A Superficial layer 10-20

B Middle layer 40-60

C Deep layer 30

의 윤활4 Synovial joint [lubrication]

의 다양한 방식들Picture 9 lubrication

류마티스 관절염 의 이해II [Rheumatic Arthritis]관절염의 분류1 [Arthritis Classification]A Inflammation groups

1) Inflammation connective tissue disease



RA JRA SLE DM-PM Mixed CT Ds

2) Inflammation crystal-inducted disease Gout Pseudogous

3) Inflammation inducted by infectious agents

Bacterial viral tuberculous fungal arthritis

혈청반응음성4) [Seronegative] spondyloarthropathy

AS Psoriasis arthritis Reiters Ds IBS

B Non-inflammation group

1) Degenerative arthritis OA post-traumatic aseptic necrosis

2) Metabolic disease

Lipid storage Ds hemochromatosis Ochronosis hypogammaglobulinemia

hemoglobinopathy

C Symmetric VS Asymmetric

D Articular VS Extraarticular

류마티스성 관절염2 [Rheumatoid Arthritis]미국 류미티스학회 기준A [American College of Rheumatology Criteria 1987]

표 3 CRITERIA FOR THE CLASSIFICATION OF RHEUMATOID ARTHRITIS(1987 ACR)분 이상 지속되는 조조강직30 [Morning stiffness]

Morning stiffness in and around the joints lasting at least 1 hour before maximal

improvement개 이상의 관절에 침범3 [Arthritis of 3 or more joint areas]

At least 3 joint areas simultaneously have had soft tissue swelling or fluid (not bony

overgrowth alone) observed by a physician the 14 possible joint areas are right or

left proximal interphalangeal (PIP) joints metacarpophalangeal (MCP) joints wrist

elbow knee ankle and metatarsophalangeal (MPT) joints손가락의 관절염 [Arthritis of hand joints]

At least I area swollen (as defined above) in a wrist MCP or PIP joint대칭적인 관절 침범 [Symmetric arthritis]

Simultaneous involvement of the same joint areas (see 2 above) on both sides of the

body (bilateral involvement of PIPs MCPs or MTPs is acceptable without absolute symmetry)류마티스 결절 [Rheumatoid nodules]

Subcutaneous nodules over bony prominences or extensor surfaces or in juxta-articular

regions observed by a physician혈액 검사상 류마티스 인자의 검출 [Serum rheumatoid factor]

Demonstration of abnormal amounts of serum rheumatoid factor by any method for which the

result has been positive in lt5 of normal control subjects방사선학적 변화 [Radiographic changes]

Radiographic changes typical of RA on posteroanterior hand and wrist radiographs which must

include erosions or unequivocal bony decalcification localized to or most marked adjacent to

the involved joints (osteoarthritis changes alone do not qualify)



의 특성B RA

정의1) [Definition]

상에 잘 알려지지 않은Etiology inflammatory polyarthritis

비대칭적으로 분포된 전형적인 질환peripheral Joint

Systemic autoimmune disease

2) Universal

3) All age involved

Male Female = 1 3

4) African black lt israeli lt Rural German

유전성 의 특별한 패턴이 없음5) [inheritance]

그러나 와 관련 환자의 가 라는 조직 Chromosome 6(HLA-DR4) 25 HLA-DR4

적합성 항원

C Etiology

모호함1) [Unclear]

a Autoimmune disease

침윤Lymphoid cell [infiltration] of the synovium류마티스 인자검사Synthesis of IgG amp (RF Rheumatoid Factor)

by plasma cell

IgG amp IgM in the cell of synovium lining leukocyte synovial fluid

IgG

는 분자량 약 만 의 가벼운 펩티드 사슬 쌍과 분자량 약 만의 무거운IgG 2 5000 1 5

펩티드 사슬 쌍으로 되어 있고 전체 분자량은 약 만이다1 15

양서류 이상의 고등동물에서 중요한 면역글로불린으로 사람에서는 면역글로불린

의 약 를 차지하고 있으며 태반을 통과하며 여러 형태의 항체활성을 지닌다70

그러나 어류에서는 보이지 않는다

IgM은 분자량 만인 기본구조의 량체이고 진화상 원시적인 것이라 생각된다 척IgM 18 5

추동물에 존재하며 특히 적혈구나 세균과 같은 입자상 항원에 대한 항체이다 표 면역 글로블린 과2 IgG IgM

b Autologous lgG antibody

2) Specific external agent Infection source

류마티스 인자검사3) (RF Rheumatoid Factor)

Large molecular weight anti-immunoglobulin(IgM)

Producted by involved synovium B cell

특징 활액막의 증식4) [Proliferation of synovium] amp spread over cartilage



병리 생리학D [Pathophysiology]

활막 의 염증이 관절막 과 인대 건1 (synovial membrane) (joint capsule) (ligament)

으로 퍼짐(tendon)

관절연골 의 점차적인 파괴로 관절 간격이 좁아지고 관절막과2 (joint cartilage)

인대의 장력소실

염증이 뼈로 침범하여 뼈의 부분적 침식3

관절기능의 소실4

E Symptoms amp sign

Young middle-age woman

Fatigue

Weight loss

Low-grade fever

Stiffness of hand upon awakening

ROM limitation dt pain amp swelling early stage

F Lab findings

Normocytic Normochromic anemia

적혈구 침강반응Elevated ESR(Erythrocyte Sedimentation Rate )

RF(+) on 80

X-ray findings

1) Early stage some osteopenia with soft-tissue swelling

2) late stage Jt space affected

Synovial fluid Elevated WBC(MCHC neutrophils)



MCHC는 적혈구색소농도 빈혈이 있는 경우 적혈구 용적MCHC MCV( ) MCH

적혈구색소 적혈구색소농도 는 빈혈의 원인을 찾기 위한 첫번( )MCHC( )

째 지표가 된다

Neutrophils

중성구 는 백혈구의 한종류로서 대표적으로 몸에 염증 예를Neutrophil( ) (

들어 감기 종기 등등 이 있는 경우에 증가합니다 많이 감소한 경우 )

이때 전체 백혈구 수치도 많이 떨어진 경우는 조혈기능의 이상을 보여

주기도 합니다표 와 중성구3 MCHC [Neutrophils]

류마티스 관절염 의 부위별 특성3 [RA]A Rheumatoid shoulder

1) Early stage

a Shoulder girdle pain amp referral pain

b Limitation of Int Rot

2) late stage

a Proximal subluxation of humeral head

b Rotator cuff weakness 33

c Rotator cuff tear 21

d Tendon fraying 24

1

1 2 3

4 5

1 Signs and Symptoms

shoulder is a stiff or

ldquofrozenrdquo shoulder

2 Impingement and Partial

Rotator Cuff Tears

3 Full Thickness Rotator

Cuff Tears

4 Instability

5 OA amp RA



B Rheumatoid elbow

1) 20-65 involvement

2) Early stage limitation of full extension

3) Frequently bursitis amp epicondylitis develop

Rheumatoid nodules of elbow (left) X-ray images (right)

C Rheumatoid hand

1) Wrist

a Carpal bone deformity dt ligamentous weakness

b Capsuloligamentous tissue deformity dt inflammation amp effusion

c Distal radioulnar articulation instability

Proximal row volar migrationDistal row dorsal migration

d ECU(extensor carpi ulnaris) muscle slip

Volar direction slip dt laxitye Proximal carpal row radial deviation


common soft tissue

swelling

2 X-ray on wrist 3 Radiographic changes

(angulation)



2) Thumb

a 1st metacarpal adduction amp flexion deformity dt adductor pollicis spasm

amp contracture

b MCP hyperextension amp IP flexion dt tenodesis action

c Boutonniere deformity

MCP Jt flexion IP hyperextensiond Disbility on tip-to-tip amp Grasp

1 Symptoms of RA

arthritis pain swelling

2 Real aspect of RA

thumb

3 X-ray on wrist

3) MCP(metacarpal phalangeal) joint

a MCP proximal parts normal inclination

Difference of collateral ligament length①

Difference of metacarpal distal end angulation②

except) 4th finger

1 Hand deformity 2 Before surgery and

After sugery

3 X-ray on MCP ulnar deviation

b Physiologic ulnar deviation

Collateral ligament①



Intrinsic muscle insertion②

Flexor tendons ulnar bend③

c Volar subluxation amp dislocation factor

weakness of collateral ligament①

Flexion force of intrinsic muscle②

Extrinsic factor③

4) PIP(proximal interphalangeal) joint

a Ulnar deviation

MCP Jt capsule amp collateral ligament laxity①

Problem in cosmetic area but no problem in functional activity②

(Early stage)

1 Symptoms

severe or shooting pain

2 PIP of Ulnar deviation 3 Inflammation of PIP Jt

In late stage finger extension loss dt dislocation of extensor③

mechanism

Finger tip-to-tip activity impairment④

b Boutonniere deformity

laxity of PIP joint capsule①

1 Boutonniere deformity



Volar movement of lateral band②

Shortening of oblique retinacular ligament③

Some elongation of central extensor tendon④

c Swan-neck deformity

Flexor tenosynovitis with laxity of PIP Jt capsule amp accessory①

collateral ligament

Dorsal movement of lateral band②

Lengthening of oblique retinacular ligament③

Synovitis of flexor tendon④

28 of RA⑤

2 Swan-neck deformity 3 RA deformity of Finger

d Mallet finger

Laxity of DIP capsulebull

Rupture or stretch of extensor tendonbull

4 Mallet finger

D Rheumatoid hip

1) 50 involvement

2) Hip synovitis refer to groin pain

3) Trochanteric bursitis refer to lateral thigh

4) 5 femoral head collapse amp remodeling of acetabulum



5) Early stage limitation of Int Rot

1 Symptoms of RA hip

arthritis pain amp loss

of motion

2 X-ray on pelvis 3 Bone eaten of RA hip

E Rheumatoid knee

1) Phase I

a Soft tissue involvement

b Synovial hyperemia with effusion

c Swollen hot tender

d Capsular Swollen amp Stret surrounding ligament

e Soft tissue swelling on x-ray

2) Phase II

a Synovial stage

b Pannus formation

c Some underlying bone destruction on x-ray

d Synovitis amp Pannus on arthroscopy

e Cartilage damage on MRI

1 Normal OA RA Joint 2 Pannus formation

3) Phase III



a Cartilage destruction

b Narrowing of Jt space

c Jt instability

d Periarticular swelling dt induration

4) Phase IV


b Decalcification of bone x-ray

c Marked Jt laxity

d Osterophyte on marginal border

F Rheumatoid foot amp ankle

Less frequently involvement

1 Symptoms

pain swelling amp stiffness

2 X-ray on foot 3 Foot deformity

Involvement in Sever RA

Foot problem 50

1) Widening at metatarsal area

2) prominent MTP Jt dt subluxed metatarsal head

3) Hammer toe deformity

4) Hallux valgus

1 Cartilage Destruction 2 MRI on ankle rheumatoid

pannus



약리학적 관리4 [Pharmacologic management]A Aspirin

1) Pain control by block synthesis of PG

2) Influence leukocyte migration amp vascular permeability

B NSAIDs

1) Inhibition of PG synthesis

2) Inhibit cyclo-oxygenase effect on platelet

3) Effect on leukocyte migration

C Steroid

1) Effect on

a leukocyte movement

b leukocyte function

c humoral factors

2) Inhibition recruitment of neutrophils amp monocyte in inflamed site

3) Modify increased capillary amp membrane permeability

4) Reduce edema

5) Antagonize histamine-induced vasodilation

6) Inhibited PG

1 Cartilage Destruction

2 Aspirin to Prevent Blood Clots 3 Mechanism of desired actions NSAIDs



외과적 관리5 [Surgical management]활액막 절제술A [Synovectomy]

1) For retardation of Jt destruction

년 에 의해 시작2) 1877 Volkmann

3) No cure - dt regrowth of synovium

4) Contraindication

a Very active polyarticular disease

b Poor general medical condition

c Poor motivation

d State IV Jt destruction

관절 고정술B [Arthrodesis] rare

1 Synovectomy 2Arthrodesis

6 Rehabilitation interventionsA Rest

1) Local rest by cast or splint

a Reduce pain amp inflammation

b For painful periarticular syndrome

드 꾀르벵병Ex) [De Quervain Ds] CTS

2) Total Rest



a Systemic rest

b Maximum 4 weeks

3) Short rest

Cost-effective treatment strategy

4) Strict bed rest

a up to 5 decrease of strength daily

b up to 30 loss of muscle bulk weekly

B Exercise

1) Cause of Strength decrease

a Myositis

b Myopathy 2 to steroid

c Inhibition of muscle contracture by Jt effusion

d Direct effect to muscle

2) Exercise purpose

a Increase amp maintain ROM

b Re-education amp strengthen muscle

c Decrease Jt to function better biomechanically

d Increase bony density

e Increase patients overall function amp well-being

f Condition of cardiorespiratory system

3) Progressive Exercise Program

a Relieve pain with appropriate modality

b Progress to increase ROM

수시로 필요한 때c (Prn) stretching amp AAROM Ex

d Increase muscle tone by muscle re-education

e Increase Strength amp endurance by isometirc Ex

f Recreational program

4) ROM Ex

a Passive ROM Ex

b Avoid at acute inflamed stage

c Increase inflammation amp intra-articular pressure

5) Active Ex

a Isometric Ex



Static Ex①

Start in acute phase②

Minimize muscle fatigue amp Jt stress by minimal work amp maximize③

muscle tension

b Isotonic Ex

Dynamic Ex①

Avoid at biomechanically deranged Ex②

Avoid at acute inflamed state③

c Isokinetic Ex

Not recommend to rheumatoid arthritis①

그러나 때때로 이 처방될 수 있음 muscle rebuilding ②

6) Strengthening Ex

a Isometric Ex

Hold at 23 of maximal contraction 1-6 secday(muller)①

Quadriceps strength increase by 27(Machover)②

Cross-over effect③

Hold contracted state 6 sec 3 time amp rest 20 sec

Contralateral side 17 increase

그러나 Isometric Ex Increase oxidative damage of hyaluronate amp④

Glucose

b Isotonic Ex

Low weight isotonic Ex start①

적응증 [Indication]②

Non-inflamed Jt

Few ligament problem

Minimal x-ray change

Dynamic isotonic high-resistance Ex③

Increase inflammation

Increase muscle fatigue amp pain

Reduce Jt ROM

c Isokinetic Ex

Not benefit to arthritic patients①

Consider to mild RA patient②

Medium isokinetic program(120-180 degsec)



Avoid low velocity program(30-90 degsec) dt high torque to Jt

Contraindication③

Jt effusion

Baker cyst

Ligament laxity

Acute injury

Jt replacement

d Endurance Ex

Stage II amp IIIBicycle ergometer 6 weeks

Quadriceps strengthening Ex

e Stretching Ex

Prevent contracture amp maintain ROM①

Avoid②

At acute inflammation

At mechanical Jt deranged state

Large Jt effusion

f Jogging

Avoid dry land joggingInduce repetitive Jt motion①

Few increase in strength②

g Change Ex protocol by below signs

Post-Ex pain gt 2 hour①

Excessive fatigue②

Increase weakness③

Decrease ROM④

Jt swelling(+)⑤

h Modality

Superficial heat hands and feets①

Three mechanisms conduction convection or conversionConduction Method

Warm body tissue Hot moist pack(Hydrocollator packs) gtbull

그러나 치료적 효과는 차이 없다Dry pack

Paraffin wax heats distal Jt of UE LEbull



Hollander study Decrease 22 (-165 ) of Jt temperaturebull

But increase at paraffin bathbull

Dorwart study Increase temperature(duration 4 hrs)bull

Mainardi study No change at superficial heat(duration 20 min)bull

표 4 Modality of Superficial heat effect on articles

Contrast baths produce reflex hyperemiabull

Convective methods

Hydrotherapy - Whirlpool baths(partial body emersion)bull

Hubbard tanks (whole body emersion)

contrast baths RA neurogenic pain sprain strai

-n Mild peripheral vascular Ds

기포를 이용Fluidotherapy warm air-fluid mixture(fluidization)bull

한 마사지 효과 효과(ROM Ex )

Conversion methods

같은IR(infrared) Radiant heatbull 주로 핫팩의 무게를 견딜 수 없는 사

람에게 사용

에너지가 피부에 흡수되고 로 변환 superficial heatrarr

Deep heat②

과 에 없이 까지Skin subcutaneous fat overheating deep level tissue te를-mperature increase

Ultrasound Jt contracure scar tissue periarticular inflammation

bursitis muscle spasm and pain OA tendonitis fasciitis

adhesions

With medications Corticosteroids local anestheticsbull

Diathermy(high-frequency electromagnetic biologic tissue heating)

와 비슷한 효과Shortwavebull

Shortwave and microwave

radiation to heat tissuebull

Cold③

Acute inflamed amp early subacute JtCryotherapy Hemodynamic effects - reflexive vasoconstrictionSuperficial Cold pack ice massage Cold bathsOthers Vacocoolant sprays(ethyl chloride or florimethane)



Stretch technique for areas of spasm

Decrease pain threshold

Relax surrounding spastic muscle

Decrease Jt temperature

Decrease collagenase activity

Decrease cell count in Jt fluid

Electrical Stimulation Gate theory of pain④

Electrical Nerve Stimulation TENS

Iontophoresis transcutaneous delivery of charged medications

lidocaine corticosteroids salicylate antibioticsbull

Interferential current (ICT)

musculoskeletal or neurologic conditionsbull

1 Electrical Stimulation 2 Iontophoresis 3 Iontophoresis mechnism

퇴행성 관절염III [Degenerative Arthritis]1 General consideration

A Asymmetric non-inflammatory Ds without systeminc component

B Three type

1) Primary

a Peripheral Jt

b Spine

e variant subsets

2) Secondary

a Trauma

b Other Jt Ds

c Systemic metabolic Ds

d Endocrine disorder

e Miscellaneous

3) Erosive inflammatory



1 The joints most often affect

ed by OA

2 How weakened ligament lead to OA

C Primary Osteoarthritis(OA)

역학(epidemiology)

나이가 들수록 발생빈도 증가1) Age

여성 남성 나이가 많을수록 심함2) Sex gt

가족력3) Genetic factor

정상보다 배4) Obesity 2

체중 부하를 받는 부위5) Specific Jt

3 Comparison of Normal Jt

OA Jt

4 The joint most often affected

by OA

5 Progression of OA

D Secondary OA

1) Congenital Dysplastic hip genu varum amp valgus

무혈관성괴사2) Ds (AVN avascularnecrosis)

3) Metabolic Ds acromegaly DM Gout



2 Characteristics연령 세 이하의 유병률A - 25-34 01

세 여성55 80 (National Health and Nutrition Examination Survey)ge

세 이후 남성이 더 많음65

인종 미주 원주민 백인B - gt

홍콩거주 중국인 백인 고관절lt ( )

유전적 소인 의 발병률은 여성에서 남성의 배 이상으로 나타C Heberdens nodes 10

나며 여성의 어머니가 환자인 경우 배의 유병률을 나타낸다OA 2

주관절의 외상 전십자인대 부전증과 슬관절반월판제거술 등 주관절의 외상 후D

슬개골의 유발OA

반복되는 관절사용 직업상의 문제 관절의 사용 유형에 의한 영향E

비만 슬관절과 수관절에 영향 체중 감량으로 슬관절의 증상적 의F ( 5 kg OA odd

를 낮춤ratio 50 )

선천성 발육상의 결함G

기존의 염증성 관절질환H

대사성 내분비성 장애I

성별 발생 부위 남성J - Hip Jt

여성 DIP PIP 1st CMC 1st MTP

3 EtiologyA Physical stress on Jt following cartilage biomechanical failure

B Cartilage chondrocyte degeneration

C Secondary change by bony remodelling synovial response vascular change

extracartilage change

D Etiopathogenic factors

E Relationship of physical force amp chondrocyte response

F Bony remodelling synovial response vascular change extracartilage factor

4 PathophysiologyA Collagen IX fiber degradation

Degenerative arthritis basis

B Genetic factor

Female dominate

기전C



1) Phase I

연골기질 의 단백분해 파괴가 일어난다[collagen bond]

연골대사는 영향을 받아 연골기질을 파괴하는 금속단백분해효소 를(MMPs)

포함한 효소가 증가된다

연골세포는 금속단백분해효소 의 조직 억제제 를 포함한 단(MMPs) (TIMP 12)

백효소 억제제가 동시에 생산되지만 단백분해효과를 상쇄할 만큼 충분치

못하다

2) Phase II

연골표면의 연축 과 진무름 이 있으며 이어서 활액내로(fibrillation) (erosion)

과 교원질의 조각을 유리시킨다PG

3) Phase III

연골의 파괴 산물은 활막의 만성적인 염증 반응을 일으킨다

활막대식세포 에서 인터루킨 종양괴사인자 와 금속단백효소-1(IL-1) (TNF-a)

같은 사이토카인의 생산이 일어난다(MMPs)

염증 전구분자 예 산화질소 무기물(pro-inflammatory molecules NO

자유라디칼 역시 요인이 될수있다)

결과적으로 이러한 현상은 관절의 구조를 변화시키고 더 많은 기계적이고

염증성 스트레스가 관절표면에서 일어나게 된다

Figure 1 Histological examination of

tendon tissue from patients with

knee joint osteoarthritis (OA) and

controls

(a) Haematoxylin and eosin

(b) Normal tendon tissue

(c) OA

(d) Non-OA

(e) Pancreatic tissue

(f) primary antibody was replaced by

an isotype matched immunoglobulin

TIMP inhibitor metalloproteinase regulation to proteinase



Proteinase release form chondrocyte synovial cell neutrophils

collagenase destroy collagen

stromelysin destroy matrix

neutrophil elastase destroy elastin

TIMP amp Proteinase imbalance weak collagen bond rarr

D External neuromuscular stress action

Musculoligamentous reaction

에 영향을 미친 로 기능Cartilaginous degenration factor

1) Longitudinal force mechanical amp muscular contract

2) Compressive force upon cartilage

3) Impact on subchondral bone microFxrarr

Matrix pore size change

삼투압 변화 를 야기하여1) [osmotic pressure change] lytic action

조직학적 변화E [Histologic change]

1) Early change flaking amp pitting of the suface

Deep fissuring

Fibrilation

Erosion of cartilage

Exposure of subchondral bone

2) Loss of PG

는 증가하지만 반감기는 감소 PG synthesis rate

3) Loss of tidemark intergrity

4) Subchondral cyst

이화 동화작용의 불균형5) amp [Disequilibrium of catabolism amp anabolism]

Cytokine interleukin I TNF(tumor necrosis factor)

Increase loss rate of polysaccharide protein from articular cartilage

Inhibit re-synthesis

6) Large amount of chondroithin-4-sulfate in OA

F Inflammation evidence

1) Inflammation sign on synovial cell amp cartilage cell

2) Chronic inflammation on Bx

3) Increase interleukin-1 TNF prostagladin degradative product

G Pain syndrome



Inflammation is secondary feature of repair process

5 General symptom amp signA Symptoms

1) Pain

a Deep aching poorly localized

b Early pain with use later pain at rest

2) Stiffness

a Localized to involved Jt

b Rarely exceeds 16-30 min duration

c Related weather change

3) Crepition cracking

4) Limitation of Jt motion

5) Giving way of weight-bearing Jt

B Signs

1) Tenderness

2) Pain on passive motion

3) Crepitus crutching on Jt motion

4) Jt enlargement amp limitation of motion

5) Deformity

6 Radiologic findings

Stage Destruction Repair

Early stageFibrillation of cartilage OsteophyteErosion(minimal) Surface bumps

Marginal

Intermediate stage

Erosion amp Exposure of bone SclerosisFocal osteonecrosis Osteophyte enlarge amp coalesce amp

femoral neck migrateFibrous amp cartilage marrow metaplasiaButtressing

Late stage

Progression ProgressionCollapse amp deformity of femoral

headSpontaneous subsidence

Resurfacing of Jt

7 Pain in the knee with OA



A Loss of cartilage

B Mechanical compression of the medial or lateral knee compartment

varus or valgus deformityrarr

C Stretch on the medial amp lateral collateral ligament

D MicroFx amp subchondral Fx

E Capsular distension by effusion

F Chondromalacia patellae

세 이상G PPD(80 28) Pyrophospate dihydrate deposition

관리 원칙8 [Management principles]A Decrease pain

B Preserve amp restore ROM amp strength

C Reduce Jt load

D Prevent or reduce contracture

E Preserve Jt alignment

약리학적 관리9 [Pharmacologic management]A Analgesics

1) Acetaminophen(tylenol etc)

a 650 mg per 4-6 hrs

b Maximum lt 4g day

c Caution - warfarin interaction decrease half-life of caumadin

진통제나 진해제 등으로 쓰임 마취 진통작용은 에 뒤떨어2) Codein middot morphine

지지만 호흡 및 기침에 대한 진정작용은 보다 강하다morphine

과 함께 복용하면 그 작용이 증강된다aspirin

소염제로도 쓰이는데 특히 신경통 치료 등에 연고 도포제의 형태3) Salicylate middot

로도 사용된다

B NSAIDs

Indole derivatives Pyrazolones Phenylpropionic Acids Fenamates OxicamIndomethansin Phenylburazone Ibuprofen Mefenamic acid Piroxicam

Sulindac Naproxen MeclofenamateTolmetin FenoprofenZoepirac

C COX-s inhibitions

D Intrarticular injection with corticosteroid



1) Reduce effusion of Jt = pain relieg

2) Reduce synovial permeability

3) Inhibition of release of hyaluronic acid

그러나4) Articular damage progress

E Chondroprotection by DMOAD(Disease Modifying Osteoarthritis Drugs)

항암제Tamoxifen( ) 과 합성과 작용 억제Diacerhein(IL-1 metalloproteinase )말라리아 치료약Chloroquine( ) 염증 저해제Glucocorticoids( )

트라넥삼산Tranexamic acids( ) HeparinoidsTetracycline Glycoxaminoglycan derivatives

성장호르몬Growth hormone( ) Interleukin-1 inhibitionTNF inhibitions Hyaluronic Acid(pain inhibitor)

F Intrarticular injection with hyaluronic acid

1) Major protion of synocium amp cartilagenous surface

2) Glycosaminoglycan

3) Function

a Lubrication of Jt

b Shock absorption of cartilage

c Protection of cartilagenous surface

d Induce aggregation amp synthesis of PG

e Enhance synthesis of hyaluronic acid of synovial cell



f Remove free oxygen radical in Jt

g Anti-inflammation function

G Glucosamine

1) Glucosaminoglycan polysulfate(GAGs) precursor

2) Function

a Stimulate collagen amp proteoglycan synthesis

b Stimulate synovial cell

c Anti-inflammation

H Chondrotin sulfate

Function

1) Inhibition osteolytic cell activity

2) Inhibition enzymatic activity

3) Increase GAGs pool

수술10 [Operation]적응증 다른 치료방법으로 증상 완화에 효과가 없거나 악화되어 활동성이 저하A

된 심한 통증이 있는 환자를 대상으로 실시

종류B

관절경 수술1) (arthroscopic synovectomy)

관절경을 통한 관절 부산물의 세척제거 및 관절강의 세척으로 수술을 할 수

없는 경우실시한다 관절강의 세척으로 와 염증 매개물질을 제 matrix debris

거할 수 있다

관절교체술2) (joint replacement)

고관절과 슬관절의 심한 환자에서 뚜렷한 증상의 개선을 나타낸다 이 효 OA

과는 수술 년 후에 최대 효과를 발현하여 년 동안 지속된다1 3

골절단술3) (osteotomy)

관절교체술이 불가능한 환자에 대하여 질환의 악화를 예방하기 위해 실시한다

11 Rehabilitation ManagementA Education of Pts

B Rest short period rest

C Brace amp orthosis

D Weight control

E Physical modality



유지 근육경축을 감소1) ROM Decrease pain

온수 목욕이나 통증부위의 온침으로 통증과 강직을 감소2)

온열기구를 사용할 때는 화상 예방을 위해 분 이상 지속하지 않도록3) 30

4) TENS

F Ex

1) Walk

으로 같은 거리를 달리는 것과 같은 칼로리 소모a Aerobic ex

에 비해 충격이 적고 에 부담이 적음b Running Jt

말하고 노래하기 속도 결정 동안 말할 때 숨이 가쁘지 않고c test( ) walking

노래를 할 때 가쁨

서서히 하는 거리를 늘림d walking - 2 times day

평평하고 단단한 길을 우선적으로 선택e

안정성을 고려하여 낮에 실시f

편안한 운동화를 신고 발뒤꿈치 발바닥 엄지 발가락 순으로h

2) Bicycle

을 밟는 동안 발과 다리에 체중이 가해지지 않으므로 에 가해지는a Pedal Jt

압력과 긴장이 적어짐

에 가 심한 경우 보다 권유b Hip knee ankle OA walk

을 오르기 전이나 저항력을 올리기 전에 준비 운동c Heel (5-10 min)

이 가장 낮은 지점에 있을 때 가 약간d Pedal knee Flextion

을 밟을 때 너무 힘들지 않게e Pedal

시작할 때 속도를 잘 조절f

1 Walking

3) hydrotherapy

통증 없이 할 수 있는 좋은a Ex

장점b

Decrease Pain①

Muscle Relaxation②



1 V Ex 2 Hip-hinging Ex 3 Wall walking Ex

4 The Rocking horse Aquatic Ex 5 Calf Strench Ex 6 Chair Rise Ex

에 압력을 줄여줌Jt③

심혈관 건강에 장점이 있는 유산소 적합성c (aerobic fitness)

역기 운동4)

처음에는 무게가 거의 나가지 않게 시작a

이후 서서히 무게를 증가b

의 힘을 향상시켜 를 예방하는 목적c Muscle arthritis

처음 시작할 때 종류로 운동을 제한d 6

상하체를 모두 사용e

5) Stretching Ex

절대 차가운 상태에서 하지 말 것a

올바른 자세 교육b

없이 멀리 하면서 그 자세를 초간 유지c Muscle tension stretching 30

자세에서 갑자기 자세 전환 하지 말 것d stretching

심호흡을 같이 병행e



기술을 사용f PNF

최소 주g 20 min 3 times回

이 있으면 쉬어야 한다h Pain

6) Quadriceps Femoris muscle strengthening Ex

a knee Jt Extension

무리 하면 와 에 부담b femur patellar Jt surface

의자에 앉아 초 가량 무릎에 힘을 준뒤 초간 풀knee extension 15 2-3①

어 주는 동작을 회씩 회20 3-4 day

위쪽 무릎을 쭉 편채 발끝을 몸쪽으로 당기면서knee flex sidelying②

들어 올린다

위쪽 무릎을 구부려 앞쪽으로 교차한 후 아knee extension sidelying③

래쪽 다리의 발끝을 몸쪽으로 당기면서 들어 올린다

한쪽 무릎을 직각으로 구부린채 그대로 들어 올린다Prone position ④

무릎을 편상태에서 발끝을 몸쪽으로 당기면서 허벅지Supine position⑤

에 힘을 준다 다리는 들지 않는다

한쪽 발은 무릎을 구부리고 다른 쪽은 무릎을 편상태Supine position⑥

에서 발끝을 몸쪽으로 당기면서 들어올린다

양다리를 편채 바닥에 엎드려서 한쪽다리의 발끝을 몸쪽으로 당기면서⑦

들어 올린다

한쪽 무릎의 발끝을 몸쪽으로 당긴채 도 정도 편다Sitting position 45 ⑧

양쪽 무릎을 도 정도 구부린다Standing position 45 ⑨

983689983698 한쪽 무릎을 직각으로 구부린채 수직으로 들어 올린Sitting position

다

983689983699 한쪽 무릎을 직각으로 구부려 뒤로 굽힌다Standing position



Nutrition infusion amp diffusion

색이 없거나 약간 노란색B Synovial fluid Clear

대부분 내Jt 02ml knee Jt - 5ml

의 특성1) Synovial fluid

닮게 됨으로써 를 보호cartilage

윤활 에 아주 중요한 작용Jt lubrication[ ]

좌측 통풍 우측Picture 2 RA( ) [gout]( )

환자의 synovial fluid

와 의 접촉면Picture 3 Cartilage synovial fluid

연골에 영양을 공급

에 영양 을 공급2) Cartilage [nutrition]

수동 확산

Mechanical pumping effect

3) Collagen Coiled fiber

Collagen type II IX X XI

II - IX - II interaction

의Picture 4 Collagen fiber Structure













fibrils


화물













C Deep layer 30

















hemoglobinopathy























의 특성B RA





2) Universal

3) All age involved

Male Female = 1 3




적합성 항원

C Etiology




by plasma cell


IgG























E Symptoms amp sign


Fatigue

Weight loss

Low-grade fever



F Lab findings



RF(+) on 80

X-ray findings









Neutrophils






1) Early stage



2) late stage




d Tendon fraying 24

1

1 2 3

4 5





Rotator Cuff Tears


Cuff Tears

4 Instability

5 OA amp RA



B Rheumatoid elbow





C Rheumatoid hand

1) Wrist








common soft tissue

swelling


(angulation)



2) Thumb


amp contracture




1 Symptoms of RA


2 Real aspect of RA

thumb

3 X-ray on wrist





except) 4th finger


After sugery











Extrinsic factor③


a Ulnar deviation



(Early stage)

1 Symptoms




mechanism












collateral ligament




28 of RA⑤


d Mallet finger



4 Mallet finger

D Rheumatoid hip

1) 50 involvement









of motion


E Rheumatoid knee

1) Phase I






2) Phase II

a Synovial stage

b Pannus formation





3) Phase III





c Jt instability


4) Phase IV



c Marked Jt laxity




1 Symptoms




Foot problem 50




4) Hallux valgus


pannus






B NSAIDs




C Steroid

1) Effect on



c humoral factors



4) Reduce edema


6) Inhibited PG









4) Contraindication



c Poor motivation









2) Total Rest



a Systemic rest

b Maximum 4 weeks

3) Short rest


4) Strict bed rest



B Exercise


a Myositis




2) Exercise purpose














4) ROM Ex

a Passive ROM Ex



5) Active Ex

a Isometric Ex



Static Ex①



muscle tension

b Isotonic Ex

Dynamic Ex①



c Isokinetic Ex



6) Strengthening Ex

a Isometric Ex







Glucose

b Isotonic Ex



Non-inflamed Jt






Reduce Jt ROM

c Isokinetic Ex







Contraindication③

Jt effusion

Baker cyst

Ligament laxity

Acute injury

Jt replacement

d Endurance Ex



e Stretching Ex


Avoid②



Large Jt effusion

f Jogging







Decrease ROM④

Jt swelling(+)⑤

h Modality














Convective methods







Conversion methods


람에게 사용


Deep heat②




adhesions






Cold③



















B Three type

1) Primary

a Peripheral Jt

b Spine

e variant subsets

2) Secondary

a Trauma

b Other Jt Ds



e Miscellaneous





ed by OA










OA Jt


by OA

5 Progression of OA

D Secondary OA
































B Genetic factor

Female dominate

기전C



1) Phase I






못하다

2) Phase II



3) Phase III











controls



(c) OA

(d) Non-OA






















Deep fissuring

Fibrilation



2) Loss of PG



4) Subchondral cyst










G Pain syndrome





1) Pain



2) Stiffness







B Signs

1) Tenderness




5) Deformity




Marginal

Intermediate stage



Late stage



Resurfacing of Jt




A Loss of cartilage










C Reduce Jt load






b Maximum lt 4g day






로도 사용된다

B NSAIDs



C COX-s inhibitions















3) Function

a Lubrication of Jt









G Glucosamine


2) Function



c Anti-inflammation


Function






종류B




거할 수 있다









D Weight control

E Physical modality






4) TENS

F Ex

1) Walk









2) Bicycle








1 Walking

3) hydrotherapy


장점b

Decrease Pain①








역기 운동4)






5) Stretching Ex












a knee Jt Extension





들어 올린다









들어 올린다




다














fibrils


화물













C Deep layer 30

















hemoglobinopathy























의 특성B RA





2) Universal

3) All age involved

Male Female = 1 3




적합성 항원

C Etiology




by plasma cell


IgG























E Symptoms amp sign


Fatigue

Weight loss

Low-grade fever



F Lab findings



RF(+) on 80

X-ray findings









Neutrophils






1) Early stage



2) late stage




d Tendon fraying 24

1

1 2 3

4 5





Rotator Cuff Tears


Cuff Tears

4 Instability

5 OA amp RA



B Rheumatoid elbow





C Rheumatoid hand

1) Wrist








common soft tissue

swelling


(angulation)



2) Thumb


amp contracture




1 Symptoms of RA


2 Real aspect of RA

thumb

3 X-ray on wrist





except) 4th finger


After sugery











Extrinsic factor③


a Ulnar deviation



(Early stage)

1 Symptoms




mechanism












collateral ligament




28 of RA⑤


d Mallet finger



4 Mallet finger

D Rheumatoid hip

1) 50 involvement









of motion


E Rheumatoid knee

1) Phase I






2) Phase II

a Synovial stage

b Pannus formation





3) Phase III





c Jt instability


4) Phase IV



c Marked Jt laxity




1 Symptoms




Foot problem 50




4) Hallux valgus


pannus






B NSAIDs




C Steroid

1) Effect on



c humoral factors



4) Reduce edema


6) Inhibited PG









4) Contraindication



c Poor motivation









2) Total Rest



a Systemic rest

b Maximum 4 weeks

3) Short rest


4) Strict bed rest



B Exercise


a Myositis




2) Exercise purpose














4) ROM Ex

a Passive ROM Ex



5) Active Ex

a Isometric Ex



Static Ex①



muscle tension

b Isotonic Ex

Dynamic Ex①



c Isokinetic Ex



6) Strengthening Ex

a Isometric Ex







Glucose

b Isotonic Ex



Non-inflamed Jt






Reduce Jt ROM

c Isokinetic Ex







Contraindication③

Jt effusion

Baker cyst

Ligament laxity

Acute injury

Jt replacement

d Endurance Ex



e Stretching Ex


Avoid②



Large Jt effusion

f Jogging







Decrease ROM④

Jt swelling(+)⑤

h Modality














Convective methods







Conversion methods


람에게 사용


Deep heat②




adhesions






Cold③



















B Three type

1) Primary

a Peripheral Jt

b Spine

e variant subsets

2) Secondary

a Trauma

b Other Jt Ds



e Miscellaneous





ed by OA










OA Jt


by OA

5 Progression of OA

D Secondary OA
































B Genetic factor

Female dominate

기전C



1) Phase I






못하다

2) Phase II



3) Phase III











controls



(c) OA

(d) Non-OA






















Deep fissuring

Fibrilation



2) Loss of PG



4) Subchondral cyst










G Pain syndrome





1) Pain



2) Stiffness







B Signs

1) Tenderness




5) Deformity




Marginal

Intermediate stage



Late stage



Resurfacing of Jt




A Loss of cartilage










C Reduce Jt load






b Maximum lt 4g day






로도 사용된다

B NSAIDs



C COX-s inhibitions















3) Function

a Lubrication of Jt









G Glucosamine


2) Function



c Anti-inflammation


Function






종류B




거할 수 있다









D Weight control

E Physical modality






4) TENS

F Ex

1) Walk









2) Bicycle








1 Walking

3) hydrotherapy


장점b

Decrease Pain①








역기 운동4)






5) Stretching Ex












a knee Jt Extension





들어 올린다









들어 올린다




다











C Deep layer 30

















hemoglobinopathy























의 특성B RA





2) Universal

3) All age involved

Male Female = 1 3




적합성 항원

C Etiology




by plasma cell


IgG























E Symptoms amp sign


Fatigue

Weight loss

Low-grade fever



F Lab findings



RF(+) on 80

X-ray findings









Neutrophils






1) Early stage



2) late stage




d Tendon fraying 24

1

1 2 3

4 5





Rotator Cuff Tears


Cuff Tears

4 Instability

5 OA amp RA



B Rheumatoid elbow





C Rheumatoid hand

1) Wrist








common soft tissue

swelling


(angulation)



2) Thumb


amp contracture




1 Symptoms of RA


2 Real aspect of RA

thumb

3 X-ray on wrist





except) 4th finger


After sugery











Extrinsic factor③


a Ulnar deviation



(Early stage)

1 Symptoms




mechanism












collateral ligament




28 of RA⑤


d Mallet finger



4 Mallet finger

D Rheumatoid hip

1) 50 involvement









of motion


E Rheumatoid knee

1) Phase I






2) Phase II

a Synovial stage

b Pannus formation





3) Phase III





c Jt instability


4) Phase IV



c Marked Jt laxity




1 Symptoms




Foot problem 50




4) Hallux valgus


pannus






B NSAIDs




C Steroid

1) Effect on



c humoral factors



4) Reduce edema


6) Inhibited PG









4) Contraindication



c Poor motivation









2) Total Rest



a Systemic rest

b Maximum 4 weeks

3) Short rest


4) Strict bed rest



B Exercise


a Myositis




2) Exercise purpose














4) ROM Ex

a Passive ROM Ex



5) Active Ex

a Isometric Ex



Static Ex①



muscle tension

b Isotonic Ex

Dynamic Ex①



c Isokinetic Ex



6) Strengthening Ex

a Isometric Ex







Glucose

b Isotonic Ex



Non-inflamed Jt






Reduce Jt ROM

c Isokinetic Ex







Contraindication③

Jt effusion

Baker cyst

Ligament laxity

Acute injury

Jt replacement

d Endurance Ex



e Stretching Ex


Avoid②



Large Jt effusion

f Jogging







Decrease ROM④

Jt swelling(+)⑤

h Modality














Convective methods







Conversion methods


람에게 사용


Deep heat②




adhesions






Cold③



















B Three type

1) Primary

a Peripheral Jt

b Spine

e variant subsets

2) Secondary

a Trauma

b Other Jt Ds



e Miscellaneous





ed by OA










OA Jt


by OA

5 Progression of OA

D Secondary OA
































B Genetic factor

Female dominate

기전C



1) Phase I






못하다

2) Phase II



3) Phase III











controls



(c) OA

(d) Non-OA






















Deep fissuring

Fibrilation



2) Loss of PG



4) Subchondral cyst










G Pain syndrome





1) Pain



2) Stiffness







B Signs

1) Tenderness




5) Deformity




Marginal

Intermediate stage



Late stage



Resurfacing of Jt




A Loss of cartilage










C Reduce Jt load






b Maximum lt 4g day






로도 사용된다

B NSAIDs



C COX-s inhibitions















3) Function

a Lubrication of Jt









G Glucosamine


2) Function



c Anti-inflammation


Function






종류B




거할 수 있다









D Weight control

E Physical modality






4) TENS

F Ex

1) Walk









2) Bicycle








1 Walking

3) hydrotherapy


장점b

Decrease Pain①








역기 운동4)






5) Stretching Ex












a knee Jt Extension





들어 올린다









들어 올린다




다














hemoglobinopathy























의 특성B RA





2) Universal

3) All age involved

Male Female = 1 3




적합성 항원

C Etiology




by plasma cell


IgG























E Symptoms amp sign


Fatigue

Weight loss

Low-grade fever



F Lab findings



RF(+) on 80

X-ray findings









Neutrophils






1) Early stage



2) late stage




d Tendon fraying 24

1

1 2 3

4 5





Rotator Cuff Tears


Cuff Tears

4 Instability

5 OA amp RA



B Rheumatoid elbow





C Rheumatoid hand

1) Wrist








common soft tissue

swelling


(angulation)



2) Thumb


amp contracture




1 Symptoms of RA


2 Real aspect of RA

thumb

3 X-ray on wrist





except) 4th finger


After sugery











Extrinsic factor③


a Ulnar deviation



(Early stage)

1 Symptoms




mechanism












collateral ligament




28 of RA⑤


d Mallet finger



4 Mallet finger

D Rheumatoid hip

1) 50 involvement









of motion


E Rheumatoid knee

1) Phase I






2) Phase II

a Synovial stage

b Pannus formation





3) Phase III





c Jt instability


4) Phase IV



c Marked Jt laxity




1 Symptoms




Foot problem 50




4) Hallux valgus


pannus






B NSAIDs




C Steroid

1) Effect on



c humoral factors



4) Reduce edema


6) Inhibited PG









4) Contraindication



c Poor motivation









2) Total Rest



a Systemic rest

b Maximum 4 weeks

3) Short rest


4) Strict bed rest



B Exercise


a Myositis




2) Exercise purpose














4) ROM Ex

a Passive ROM Ex



5) Active Ex

a Isometric Ex



Static Ex①



muscle tension

b Isotonic Ex

Dynamic Ex①



c Isokinetic Ex



6) Strengthening Ex

a Isometric Ex







Glucose

b Isotonic Ex



Non-inflamed Jt






Reduce Jt ROM

c Isokinetic Ex







Contraindication③

Jt effusion

Baker cyst

Ligament laxity

Acute injury

Jt replacement

d Endurance Ex



e Stretching Ex


Avoid②



Large Jt effusion

f Jogging







Decrease ROM④

Jt swelling(+)⑤

h Modality














Convective methods







Conversion methods


람에게 사용


Deep heat②




adhesions






Cold③



















B Three type

1) Primary

a Peripheral Jt

b Spine

e variant subsets

2) Secondary

a Trauma

b Other Jt Ds



e Miscellaneous





ed by OA










OA Jt


by OA

5 Progression of OA

D Secondary OA
































B Genetic factor

Female dominate

기전C



1) Phase I






못하다

2) Phase II



3) Phase III











controls



(c) OA

(d) Non-OA






















Deep fissuring

Fibrilation



2) Loss of PG



4) Subchondral cyst










G Pain syndrome





1) Pain



2) Stiffness







B Signs

1) Tenderness




5) Deformity




Marginal

Intermediate stage



Late stage



Resurfacing of Jt




A Loss of cartilage










C Reduce Jt load






b Maximum lt 4g day






로도 사용된다

B NSAIDs



C COX-s inhibitions















3) Function

a Lubrication of Jt









G Glucosamine


2) Function



c Anti-inflammation


Function






종류B




거할 수 있다









D Weight control

E Physical modality






4) TENS

F Ex

1) Walk









2) Bicycle








1 Walking

3) hydrotherapy


장점b

Decrease Pain①








역기 운동4)






5) Stretching Ex












a knee Jt Extension





들어 올린다









들어 올린다




다




의 특성B RA





2) Universal

3) All age involved

Male Female = 1 3




적합성 항원

C Etiology




by plasma cell


IgG























E Symptoms amp sign


Fatigue

Weight loss

Low-grade fever



F Lab findings



RF(+) on 80

X-ray findings









Neutrophils






1) Early stage



2) late stage




d Tendon fraying 24

1

1 2 3

4 5





Rotator Cuff Tears


Cuff Tears

4 Instability

5 OA amp RA



B Rheumatoid elbow





C Rheumatoid hand

1) Wrist








common soft tissue

swelling


(angulation)



2) Thumb


amp contracture




1 Symptoms of RA


2 Real aspect of RA

thumb

3 X-ray on wrist





except) 4th finger


After sugery











Extrinsic factor③


a Ulnar deviation



(Early stage)

1 Symptoms




mechanism












collateral ligament




28 of RA⑤


d Mallet finger



4 Mallet finger

D Rheumatoid hip

1) 50 involvement









of motion


E Rheumatoid knee

1) Phase I






2) Phase II

a Synovial stage

b Pannus formation





3) Phase III





c Jt instability


4) Phase IV



c Marked Jt laxity




1 Symptoms




Foot problem 50




4) Hallux valgus


pannus






B NSAIDs




C Steroid

1) Effect on



c humoral factors



4) Reduce edema


6) Inhibited PG









4) Contraindication



c Poor motivation









2) Total Rest



a Systemic rest

b Maximum 4 weeks

3) Short rest


4) Strict bed rest



B Exercise


a Myositis




2) Exercise purpose














4) ROM Ex

a Passive ROM Ex



5) Active Ex

a Isometric Ex



Static Ex①



muscle tension

b Isotonic Ex

Dynamic Ex①



c Isokinetic Ex



6) Strengthening Ex

a Isometric Ex







Glucose

b Isotonic Ex



Non-inflamed Jt






Reduce Jt ROM

c Isokinetic Ex







Contraindication③

Jt effusion

Baker cyst

Ligament laxity

Acute injury

Jt replacement

d Endurance Ex



e Stretching Ex


Avoid②



Large Jt effusion

f Jogging







Decrease ROM④

Jt swelling(+)⑤

h Modality














Convective methods







Conversion methods


람에게 사용


Deep heat②




adhesions






Cold③



















B Three type

1) Primary

a Peripheral Jt

b Spine

e variant subsets

2) Secondary

a Trauma

b Other Jt Ds



e Miscellaneous





ed by OA










OA Jt


by OA

5 Progression of OA

D Secondary OA
































B Genetic factor

Female dominate

기전C



1) Phase I






못하다

2) Phase II



3) Phase III











controls



(c) OA

(d) Non-OA






















Deep fissuring

Fibrilation



2) Loss of PG



4) Subchondral cyst










G Pain syndrome





1) Pain



2) Stiffness







B Signs

1) Tenderness




5) Deformity




Marginal

Intermediate stage



Late stage



Resurfacing of Jt




A Loss of cartilage










C Reduce Jt load






b Maximum lt 4g day






로도 사용된다

B NSAIDs



C COX-s inhibitions















3) Function

a Lubrication of Jt









G Glucosamine


2) Function



c Anti-inflammation


Function






종류B




거할 수 있다









D Weight control

E Physical modality






4) TENS

F Ex

1) Walk









2) Bicycle








1 Walking

3) hydrotherapy


장점b

Decrease Pain①








역기 운동4)






5) Stretching Ex












a knee Jt Extension





들어 올린다









들어 올린다




다











E Symptoms amp sign


Fatigue

Weight loss

Low-grade fever



F Lab findings



RF(+) on 80

X-ray findings









Neutrophils






1) Early stage



2) late stage




d Tendon fraying 24

1

1 2 3

4 5





Rotator Cuff Tears


Cuff Tears

4 Instability

5 OA amp RA



B Rheumatoid elbow





C Rheumatoid hand

1) Wrist








common soft tissue

swelling


(angulation)



2) Thumb


amp contracture




1 Symptoms of RA


2 Real aspect of RA

thumb

3 X-ray on wrist





except) 4th finger


After sugery











Extrinsic factor③


a Ulnar deviation



(Early stage)

1 Symptoms




mechanism












collateral ligament




28 of RA⑤


d Mallet finger



4 Mallet finger

D Rheumatoid hip

1) 50 involvement









of motion


E Rheumatoid knee

1) Phase I






2) Phase II

a Synovial stage

b Pannus formation





3) Phase III





c Jt instability


4) Phase IV



c Marked Jt laxity




1 Symptoms




Foot problem 50




4) Hallux valgus


pannus






B NSAIDs




C Steroid

1) Effect on



c humoral factors



4) Reduce edema


6) Inhibited PG









4) Contraindication



c Poor motivation









2) Total Rest



a Systemic rest

b Maximum 4 weeks

3) Short rest


4) Strict bed rest



B Exercise


a Myositis




2) Exercise purpose














4) ROM Ex

a Passive ROM Ex



5) Active Ex

a Isometric Ex



Static Ex①



muscle tension

b Isotonic Ex

Dynamic Ex①



c Isokinetic Ex



6) Strengthening Ex

a Isometric Ex







Glucose

b Isotonic Ex



Non-inflamed Jt






Reduce Jt ROM

c Isokinetic Ex







Contraindication③

Jt effusion

Baker cyst

Ligament laxity

Acute injury

Jt replacement

d Endurance Ex



e Stretching Ex


Avoid②



Large Jt effusion

f Jogging







Decrease ROM④

Jt swelling(+)⑤

h Modality














Convective methods







Conversion methods


람에게 사용


Deep heat②




adhesions






Cold③



















B Three type

1) Primary

a Peripheral Jt

b Spine

e variant subsets

2) Secondary

a Trauma

b Other Jt Ds



e Miscellaneous





ed by OA










OA Jt


by OA

5 Progression of OA

D Secondary OA
































B Genetic factor

Female dominate

기전C



1) Phase I






못하다

2) Phase II



3) Phase III











controls



(c) OA

(d) Non-OA






















Deep fissuring

Fibrilation



2) Loss of PG



4) Subchondral cyst










G Pain syndrome





1) Pain



2) Stiffness







B Signs

1) Tenderness




5) Deformity




Marginal

Intermediate stage



Late stage



Resurfacing of Jt




A Loss of cartilage










C Reduce Jt load






b Maximum lt 4g day






로도 사용된다

B NSAIDs



C COX-s inhibitions















3) Function

a Lubrication of Jt









G Glucosamine


2) Function



c Anti-inflammation


Function






종류B




거할 수 있다









D Weight control

E Physical modality






4) TENS

F Ex

1) Walk









2) Bicycle








1 Walking

3) hydrotherapy


장점b

Decrease Pain①








역기 운동4)






5) Stretching Ex












a knee Jt Extension





들어 올린다









들어 올린다




다







Neutrophils






1) Early stage



2) late stage




d Tendon fraying 24

1

1 2 3

4 5





Rotator Cuff Tears


Cuff Tears

4 Instability

5 OA amp RA



B Rheumatoid elbow





C Rheumatoid hand

1) Wrist








common soft tissue

swelling


(angulation)



2) Thumb


amp contracture




1 Symptoms of RA


2 Real aspect of RA

thumb

3 X-ray on wrist





except) 4th finger


After sugery











Extrinsic factor③


a Ulnar deviation



(Early stage)

1 Symptoms




mechanism












collateral ligament




28 of RA⑤


d Mallet finger



4 Mallet finger

D Rheumatoid hip

1) 50 involvement









of motion


E Rheumatoid knee

1) Phase I






2) Phase II

a Synovial stage

b Pannus formation





3) Phase III





c Jt instability


4) Phase IV



c Marked Jt laxity




1 Symptoms




Foot problem 50




4) Hallux valgus


pannus






B NSAIDs




C Steroid

1) Effect on



c humoral factors



4) Reduce edema


6) Inhibited PG









4) Contraindication



c Poor motivation









2) Total Rest



a Systemic rest

b Maximum 4 weeks

3) Short rest


4) Strict bed rest



B Exercise


a Myositis




2) Exercise purpose














4) ROM Ex

a Passive ROM Ex



5) Active Ex

a Isometric Ex



Static Ex①



muscle tension

b Isotonic Ex

Dynamic Ex①



c Isokinetic Ex



6) Strengthening Ex

a Isometric Ex







Glucose

b Isotonic Ex



Non-inflamed Jt






Reduce Jt ROM

c Isokinetic Ex







Contraindication③

Jt effusion

Baker cyst

Ligament laxity

Acute injury

Jt replacement

d Endurance Ex



e Stretching Ex


Avoid②



Large Jt effusion

f Jogging







Decrease ROM④

Jt swelling(+)⑤

h Modality














Convective methods







Conversion methods


람에게 사용


Deep heat②




adhesions






Cold③



















B Three type

1) Primary

a Peripheral Jt

b Spine

e variant subsets

2) Secondary

a Trauma

b Other Jt Ds



e Miscellaneous





ed by OA










OA Jt


by OA

5 Progression of OA

D Secondary OA
































B Genetic factor

Female dominate

기전C



1) Phase I






못하다

2) Phase II



3) Phase III











controls



(c) OA

(d) Non-OA






















Deep fissuring

Fibrilation



2) Loss of PG



4) Subchondral cyst










G Pain syndrome





1) Pain



2) Stiffness







B Signs

1) Tenderness




5) Deformity




Marginal

Intermediate stage



Late stage



Resurfacing of Jt




A Loss of cartilage










C Reduce Jt load






b Maximum lt 4g day






로도 사용된다

B NSAIDs



C COX-s inhibitions















3) Function

a Lubrication of Jt









G Glucosamine


2) Function



c Anti-inflammation


Function






종류B




거할 수 있다









D Weight control

E Physical modality






4) TENS

F Ex

1) Walk









2) Bicycle








1 Walking

3) hydrotherapy


장점b

Decrease Pain①








역기 운동4)






5) Stretching Ex












a knee Jt Extension





들어 올린다









들어 올린다




다




B Rheumatoid elbow





C Rheumatoid hand

1) Wrist








common soft tissue

swelling


(angulation)



2) Thumb


amp contracture




1 Symptoms of RA


2 Real aspect of RA

thumb

3 X-ray on wrist





except) 4th finger


After sugery











Extrinsic factor③


a Ulnar deviation



(Early stage)

1 Symptoms




mechanism












collateral ligament




28 of RA⑤


d Mallet finger



4 Mallet finger

D Rheumatoid hip

1) 50 involvement









of motion


E Rheumatoid knee

1) Phase I






2) Phase II

a Synovial stage

b Pannus formation





3) Phase III





c Jt instability


4) Phase IV



c Marked Jt laxity




1 Symptoms




Foot problem 50




4) Hallux valgus


pannus






B NSAIDs




C Steroid

1) Effect on



c humoral factors



4) Reduce edema


6) Inhibited PG









4) Contraindication



c Poor motivation









2) Total Rest



a Systemic rest

b Maximum 4 weeks

3) Short rest


4) Strict bed rest



B Exercise


a Myositis




2) Exercise purpose














4) ROM Ex

a Passive ROM Ex



5) Active Ex

a Isometric Ex



Static Ex①



muscle tension

b Isotonic Ex

Dynamic Ex①



c Isokinetic Ex



6) Strengthening Ex

a Isometric Ex







Glucose

b Isotonic Ex



Non-inflamed Jt






Reduce Jt ROM

c Isokinetic Ex







Contraindication③

Jt effusion

Baker cyst

Ligament laxity

Acute injury

Jt replacement

d Endurance Ex



e Stretching Ex


Avoid②



Large Jt effusion

f Jogging







Decrease ROM④

Jt swelling(+)⑤

h Modality














Convective methods







Conversion methods


람에게 사용


Deep heat②




adhesions






Cold③



















B Three type

1) Primary

a Peripheral Jt

b Spine

e variant subsets

2) Secondary

a Trauma

b Other Jt Ds



e Miscellaneous





ed by OA










OA Jt


by OA

5 Progression of OA

D Secondary OA
































B Genetic factor

Female dominate

기전C



1) Phase I






못하다

2) Phase II



3) Phase III











controls



(c) OA

(d) Non-OA






















Deep fissuring

Fibrilation



2) Loss of PG



4) Subchondral cyst










G Pain syndrome





1) Pain



2) Stiffness







B Signs

1) Tenderness




5) Deformity




Marginal

Intermediate stage



Late stage



Resurfacing of Jt




A Loss of cartilage










C Reduce Jt load






b Maximum lt 4g day






로도 사용된다

B NSAIDs



C COX-s inhibitions















3) Function

a Lubrication of Jt









G Glucosamine


2) Function



c Anti-inflammation


Function






종류B




거할 수 있다









D Weight control

E Physical modality






4) TENS

F Ex

1) Walk









2) Bicycle








1 Walking

3) hydrotherapy


장점b

Decrease Pain①








역기 운동4)






5) Stretching Ex












a knee Jt Extension





들어 올린다









들어 올린다




다




2) Thumb


amp contracture




1 Symptoms of RA


2 Real aspect of RA

thumb

3 X-ray on wrist





except) 4th finger


After sugery











Extrinsic factor③


a Ulnar deviation



(Early stage)

1 Symptoms




mechanism












collateral ligament




28 of RA⑤


d Mallet finger



4 Mallet finger

D Rheumatoid hip

1) 50 involvement









of motion


E Rheumatoid knee

1) Phase I






2) Phase II

a Synovial stage

b Pannus formation





3) Phase III





c Jt instability


4) Phase IV



c Marked Jt laxity




1 Symptoms




Foot problem 50




4) Hallux valgus


pannus






B NSAIDs




C Steroid

1) Effect on



c humoral factors



4) Reduce edema


6) Inhibited PG









4) Contraindication



c Poor motivation









2) Total Rest



a Systemic rest

b Maximum 4 weeks

3) Short rest


4) Strict bed rest



B Exercise


a Myositis




2) Exercise purpose














4) ROM Ex

a Passive ROM Ex



5) Active Ex

a Isometric Ex



Static Ex①



muscle tension

b Isotonic Ex

Dynamic Ex①



c Isokinetic Ex



6) Strengthening Ex

a Isometric Ex







Glucose

b Isotonic Ex



Non-inflamed Jt






Reduce Jt ROM

c Isokinetic Ex







Contraindication③

Jt effusion

Baker cyst

Ligament laxity

Acute injury

Jt replacement

d Endurance Ex



e Stretching Ex


Avoid②



Large Jt effusion

f Jogging







Decrease ROM④

Jt swelling(+)⑤

h Modality














Convective methods







Conversion methods


람에게 사용


Deep heat②




adhesions






Cold③



















B Three type

1) Primary

a Peripheral Jt

b Spine

e variant subsets

2) Secondary

a Trauma

b Other Jt Ds



e Miscellaneous





ed by OA










OA Jt


by OA

5 Progression of OA

D Secondary OA
































B Genetic factor

Female dominate

기전C



1) Phase I






못하다

2) Phase II



3) Phase III











controls



(c) OA

(d) Non-OA






















Deep fissuring

Fibrilation



2) Loss of PG



4) Subchondral cyst










G Pain syndrome





1) Pain



2) Stiffness







B Signs

1) Tenderness




5) Deformity




Marginal

Intermediate stage



Late stage



Resurfacing of Jt




A Loss of cartilage










C Reduce Jt load






b Maximum lt 4g day






로도 사용된다

B NSAIDs



C COX-s inhibitions















3) Function

a Lubrication of Jt









G Glucosamine


2) Function



c Anti-inflammation


Function






종류B




거할 수 있다









D Weight control

E Physical modality






4) TENS

F Ex

1) Walk









2) Bicycle








1 Walking

3) hydrotherapy


장점b

Decrease Pain①








역기 운동4)






5) Stretching Ex












a knee Jt Extension





들어 올린다









들어 올린다




다









Extrinsic factor③


a Ulnar deviation



(Early stage)

1 Symptoms




mechanism












collateral ligament




28 of RA⑤


d Mallet finger



4 Mallet finger

D Rheumatoid hip

1) 50 involvement









of motion


E Rheumatoid knee

1) Phase I






2) Phase II

a Synovial stage

b Pannus formation





3) Phase III





c Jt instability


4) Phase IV



c Marked Jt laxity




1 Symptoms




Foot problem 50




4) Hallux valgus


pannus






B NSAIDs




C Steroid

1) Effect on



c humoral factors



4) Reduce edema


6) Inhibited PG









4) Contraindication



c Poor motivation









2) Total Rest



a Systemic rest

b Maximum 4 weeks

3) Short rest


4) Strict bed rest



B Exercise


a Myositis




2) Exercise purpose














4) ROM Ex

a Passive ROM Ex



5) Active Ex

a Isometric Ex



Static Ex①



muscle tension

b Isotonic Ex

Dynamic Ex①



c Isokinetic Ex



6) Strengthening Ex

a Isometric Ex







Glucose

b Isotonic Ex



Non-inflamed Jt






Reduce Jt ROM

c Isokinetic Ex







Contraindication③

Jt effusion

Baker cyst

Ligament laxity

Acute injury

Jt replacement

d Endurance Ex



e Stretching Ex


Avoid②



Large Jt effusion

f Jogging







Decrease ROM④

Jt swelling(+)⑤

h Modality














Convective methods







Conversion methods


람에게 사용


Deep heat②




adhesions






Cold③



















B Three type

1) Primary

a Peripheral Jt

b Spine

e variant subsets

2) Secondary

a Trauma

b Other Jt Ds



e Miscellaneous





ed by OA










OA Jt


by OA

5 Progression of OA

D Secondary OA
































B Genetic factor

Female dominate

기전C



1) Phase I






못하다

2) Phase II



3) Phase III











controls



(c) OA

(d) Non-OA






















Deep fissuring

Fibrilation



2) Loss of PG



4) Subchondral cyst










G Pain syndrome





1) Pain



2) Stiffness







B Signs

1) Tenderness




5) Deformity




Marginal

Intermediate stage



Late stage



Resurfacing of Jt




A Loss of cartilage










C Reduce Jt load






b Maximum lt 4g day






로도 사용된다

B NSAIDs



C COX-s inhibitions















3) Function

a Lubrication of Jt









G Glucosamine


2) Function



c Anti-inflammation


Function






종류B




거할 수 있다









D Weight control

E Physical modality






4) TENS

F Ex

1) Walk









2) Bicycle








1 Walking

3) hydrotherapy


장점b

Decrease Pain①








역기 운동4)






5) Stretching Ex












a knee Jt Extension





들어 올린다









들어 올린다




다









collateral ligament




28 of RA⑤


d Mallet finger



4 Mallet finger

D Rheumatoid hip

1) 50 involvement









of motion


E Rheumatoid knee

1) Phase I






2) Phase II

a Synovial stage

b Pannus formation





3) Phase III





c Jt instability


4) Phase IV



c Marked Jt laxity




1 Symptoms




Foot problem 50




4) Hallux valgus


pannus






B NSAIDs




C Steroid

1) Effect on



c humoral factors



4) Reduce edema


6) Inhibited PG









4) Contraindication



c Poor motivation









2) Total Rest



a Systemic rest

b Maximum 4 weeks

3) Short rest


4) Strict bed rest



B Exercise


a Myositis




2) Exercise purpose














4) ROM Ex

a Passive ROM Ex



5) Active Ex

a Isometric Ex



Static Ex①



muscle tension

b Isotonic Ex

Dynamic Ex①



c Isokinetic Ex



6) Strengthening Ex

a Isometric Ex







Glucose

b Isotonic Ex



Non-inflamed Jt






Reduce Jt ROM

c Isokinetic Ex







Contraindication③

Jt effusion

Baker cyst

Ligament laxity

Acute injury

Jt replacement

d Endurance Ex



e Stretching Ex


Avoid②



Large Jt effusion

f Jogging







Decrease ROM④

Jt swelling(+)⑤

h Modality














Convective methods







Conversion methods


람에게 사용


Deep heat②




adhesions






Cold③



















B Three type

1) Primary

a Peripheral Jt

b Spine

e variant subsets

2) Secondary

a Trauma

b Other Jt Ds



e Miscellaneous





ed by OA










OA Jt


by OA

5 Progression of OA

D Secondary OA
































B Genetic factor

Female dominate

기전C



1) Phase I






못하다

2) Phase II



3) Phase III











controls



(c) OA

(d) Non-OA






















Deep fissuring

Fibrilation



2) Loss of PG



4) Subchondral cyst










G Pain syndrome





1) Pain



2) Stiffness







B Signs

1) Tenderness




5) Deformity




Marginal

Intermediate stage



Late stage



Resurfacing of Jt




A Loss of cartilage










C Reduce Jt load






b Maximum lt 4g day






로도 사용된다

B NSAIDs



C COX-s inhibitions















3) Function

a Lubrication of Jt









G Glucosamine


2) Function



c Anti-inflammation


Function






종류B




거할 수 있다









D Weight control

E Physical modality






4) TENS

F Ex

1) Walk









2) Bicycle








1 Walking

3) hydrotherapy


장점b

Decrease Pain①








역기 운동4)






5) Stretching Ex












a knee Jt Extension





들어 올린다









들어 올린다




다







of motion


E Rheumatoid knee

1) Phase I






2) Phase II

a Synovial stage

b Pannus formation





3) Phase III





c Jt instability


4) Phase IV



c Marked Jt laxity




1 Symptoms




Foot problem 50




4) Hallux valgus


pannus






B NSAIDs




C Steroid

1) Effect on



c humoral factors



4) Reduce edema


6) Inhibited PG









4) Contraindication



c Poor motivation









2) Total Rest



a Systemic rest

b Maximum 4 weeks

3) Short rest


4) Strict bed rest



B Exercise


a Myositis




2) Exercise purpose














4) ROM Ex

a Passive ROM Ex



5) Active Ex

a Isometric Ex



Static Ex①



muscle tension

b Isotonic Ex

Dynamic Ex①



c Isokinetic Ex



6) Strengthening Ex

a Isometric Ex







Glucose

b Isotonic Ex



Non-inflamed Jt






Reduce Jt ROM

c Isokinetic Ex







Contraindication③

Jt effusion

Baker cyst

Ligament laxity

Acute injury

Jt replacement

d Endurance Ex



e Stretching Ex


Avoid②



Large Jt effusion

f Jogging







Decrease ROM④

Jt swelling(+)⑤

h Modality














Convective methods







Conversion methods


람에게 사용


Deep heat②




adhesions






Cold③



















B Three type

1) Primary

a Peripheral Jt

b Spine

e variant subsets

2) Secondary

a Trauma

b Other Jt Ds



e Miscellaneous





ed by OA










OA Jt


by OA

5 Progression of OA

D Secondary OA
































B Genetic factor

Female dominate

기전C



1) Phase I






못하다

2) Phase II



3) Phase III











controls



(c) OA

(d) Non-OA






















Deep fissuring

Fibrilation



2) Loss of PG



4) Subchondral cyst










G Pain syndrome





1) Pain



2) Stiffness







B Signs

1) Tenderness




5) Deformity




Marginal

Intermediate stage



Late stage



Resurfacing of Jt




A Loss of cartilage










C Reduce Jt load






b Maximum lt 4g day






로도 사용된다

B NSAIDs



C COX-s inhibitions















3) Function

a Lubrication of Jt









G Glucosamine


2) Function



c Anti-inflammation


Function






종류B




거할 수 있다









D Weight control

E Physical modality






4) TENS

F Ex

1) Walk









2) Bicycle








1 Walking

3) hydrotherapy


장점b

Decrease Pain①








역기 운동4)






5) Stretching Ex












a knee Jt Extension





들어 올린다









들어 올린다




다






c Jt instability


4) Phase IV



c Marked Jt laxity




1 Symptoms




Foot problem 50




4) Hallux valgus


pannus






B NSAIDs




C Steroid

1) Effect on



c humoral factors



4) Reduce edema


6) Inhibited PG









4) Contraindication



c Poor motivation









2) Total Rest



a Systemic rest

b Maximum 4 weeks

3) Short rest


4) Strict bed rest



B Exercise


a Myositis




2) Exercise purpose














4) ROM Ex

a Passive ROM Ex



5) Active Ex

a Isometric Ex



Static Ex①



muscle tension

b Isotonic Ex

Dynamic Ex①



c Isokinetic Ex



6) Strengthening Ex

a Isometric Ex







Glucose

b Isotonic Ex



Non-inflamed Jt






Reduce Jt ROM

c Isokinetic Ex







Contraindication③

Jt effusion

Baker cyst

Ligament laxity

Acute injury

Jt replacement

d Endurance Ex



e Stretching Ex


Avoid②



Large Jt effusion

f Jogging







Decrease ROM④

Jt swelling(+)⑤

h Modality














Convective methods







Conversion methods


람에게 사용


Deep heat②




adhesions






Cold③



















B Three type

1) Primary

a Peripheral Jt

b Spine

e variant subsets

2) Secondary

a Trauma

b Other Jt Ds



e Miscellaneous





ed by OA










OA Jt


by OA

5 Progression of OA

D Secondary OA
































B Genetic factor

Female dominate

기전C



1) Phase I






못하다

2) Phase II



3) Phase III











controls



(c) OA

(d) Non-OA






















Deep fissuring

Fibrilation



2) Loss of PG



4) Subchondral cyst










G Pain syndrome





1) Pain



2) Stiffness







B Signs

1) Tenderness




5) Deformity




Marginal

Intermediate stage



Late stage



Resurfacing of Jt




A Loss of cartilage










C Reduce Jt load






b Maximum lt 4g day






로도 사용된다

B NSAIDs



C COX-s inhibitions















3) Function

a Lubrication of Jt









G Glucosamine


2) Function



c Anti-inflammation


Function






종류B




거할 수 있다









D Weight control

E Physical modality






4) TENS

F Ex

1) Walk









2) Bicycle








1 Walking

3) hydrotherapy


장점b

Decrease Pain①








역기 운동4)






5) Stretching Ex












a knee Jt Extension





들어 올린다









들어 올린다




다







B NSAIDs




C Steroid

1) Effect on



c humoral factors



4) Reduce edema


6) Inhibited PG









4) Contraindication



c Poor motivation









2) Total Rest



a Systemic rest

b Maximum 4 weeks

3) Short rest


4) Strict bed rest



B Exercise


a Myositis




2) Exercise purpose














4) ROM Ex

a Passive ROM Ex



5) Active Ex

a Isometric Ex



Static Ex①



muscle tension

b Isotonic Ex

Dynamic Ex①



c Isokinetic Ex



6) Strengthening Ex

a Isometric Ex







Glucose

b Isotonic Ex



Non-inflamed Jt






Reduce Jt ROM

c Isokinetic Ex







Contraindication③

Jt effusion

Baker cyst

Ligament laxity

Acute injury

Jt replacement

d Endurance Ex



e Stretching Ex


Avoid②



Large Jt effusion

f Jogging







Decrease ROM④

Jt swelling(+)⑤

h Modality














Convective methods







Conversion methods


람에게 사용


Deep heat②




adhesions






Cold③



















B Three type

1) Primary

a Peripheral Jt

b Spine

e variant subsets

2) Secondary

a Trauma

b Other Jt Ds



e Miscellaneous





ed by OA










OA Jt


by OA

5 Progression of OA

D Secondary OA
































B Genetic factor

Female dominate

기전C



1) Phase I






못하다

2) Phase II



3) Phase III











controls



(c) OA

(d) Non-OA






















Deep fissuring

Fibrilation



2) Loss of PG



4) Subchondral cyst










G Pain syndrome





1) Pain



2) Stiffness







B Signs

1) Tenderness




5) Deformity




Marginal

Intermediate stage



Late stage



Resurfacing of Jt




A Loss of cartilage










C Reduce Jt load






b Maximum lt 4g day






로도 사용된다

B NSAIDs



C COX-s inhibitions















3) Function

a Lubrication of Jt









G Glucosamine


2) Function



c Anti-inflammation


Function






종류B




거할 수 있다









D Weight control

E Physical modality






4) TENS

F Ex

1) Walk









2) Bicycle








1 Walking

3) hydrotherapy


장점b

Decrease Pain①








역기 운동4)






5) Stretching Ex












a knee Jt Extension





들어 올린다









들어 올린다




다








4) Contraindication



c Poor motivation









2) Total Rest



a Systemic rest

b Maximum 4 weeks

3) Short rest


4) Strict bed rest



B Exercise


a Myositis




2) Exercise purpose














4) ROM Ex

a Passive ROM Ex



5) Active Ex

a Isometric Ex



Static Ex①



muscle tension

b Isotonic Ex

Dynamic Ex①



c Isokinetic Ex



6) Strengthening Ex

a Isometric Ex







Glucose

b Isotonic Ex



Non-inflamed Jt






Reduce Jt ROM

c Isokinetic Ex







Contraindication③

Jt effusion

Baker cyst

Ligament laxity

Acute injury

Jt replacement

d Endurance Ex



e Stretching Ex


Avoid②



Large Jt effusion

f Jogging







Decrease ROM④

Jt swelling(+)⑤

h Modality














Convective methods







Conversion methods


람에게 사용


Deep heat②




adhesions






Cold③



















B Three type

1) Primary

a Peripheral Jt

b Spine

e variant subsets

2) Secondary

a Trauma

b Other Jt Ds



e Miscellaneous





ed by OA










OA Jt


by OA

5 Progression of OA

D Secondary OA
































B Genetic factor

Female dominate

기전C



1) Phase I






못하다

2) Phase II



3) Phase III











controls



(c) OA

(d) Non-OA






















Deep fissuring

Fibrilation



2) Loss of PG



4) Subchondral cyst










G Pain syndrome





1) Pain



2) Stiffness







B Signs

1) Tenderness




5) Deformity




Marginal

Intermediate stage



Late stage



Resurfacing of Jt




A Loss of cartilage










C Reduce Jt load






b Maximum lt 4g day






로도 사용된다

B NSAIDs



C COX-s inhibitions















3) Function

a Lubrication of Jt









G Glucosamine


2) Function



c Anti-inflammation


Function






종류B




거할 수 있다









D Weight control

E Physical modality






4) TENS

F Ex

1) Walk









2) Bicycle








1 Walking

3) hydrotherapy


장점b

Decrease Pain①








역기 운동4)






5) Stretching Ex












a knee Jt Extension





들어 올린다









들어 올린다




다




a Systemic rest

b Maximum 4 weeks

3) Short rest


4) Strict bed rest



B Exercise


a Myositis




2) Exercise purpose














4) ROM Ex

a Passive ROM Ex



5) Active Ex

a Isometric Ex



Static Ex①



muscle tension

b Isotonic Ex

Dynamic Ex①



c Isokinetic Ex



6) Strengthening Ex

a Isometric Ex







Glucose

b Isotonic Ex



Non-inflamed Jt






Reduce Jt ROM

c Isokinetic Ex







Contraindication③

Jt effusion

Baker cyst

Ligament laxity

Acute injury

Jt replacement

d Endurance Ex



e Stretching Ex


Avoid②



Large Jt effusion

f Jogging







Decrease ROM④

Jt swelling(+)⑤

h Modality














Convective methods







Conversion methods


람에게 사용


Deep heat②




adhesions






Cold③



















B Three type

1) Primary

a Peripheral Jt

b Spine

e variant subsets

2) Secondary

a Trauma

b Other Jt Ds



e Miscellaneous





ed by OA










OA Jt


by OA

5 Progression of OA

D Secondary OA
































B Genetic factor

Female dominate

기전C



1) Phase I






못하다

2) Phase II



3) Phase III











controls



(c) OA

(d) Non-OA






















Deep fissuring

Fibrilation



2) Loss of PG



4) Subchondral cyst










G Pain syndrome





1) Pain



2) Stiffness







B Signs

1) Tenderness




5) Deformity




Marginal

Intermediate stage



Late stage



Resurfacing of Jt




A Loss of cartilage










C Reduce Jt load






b Maximum lt 4g day






로도 사용된다

B NSAIDs



C COX-s inhibitions















3) Function

a Lubrication of Jt









G Glucosamine


2) Function



c Anti-inflammation


Function






종류B




거할 수 있다









D Weight control

E Physical modality






4) TENS

F Ex

1) Walk









2) Bicycle








1 Walking

3) hydrotherapy


장점b

Decrease Pain①








역기 운동4)






5) Stretching Ex












a knee Jt Extension





들어 올린다









들어 올린다




다




Static Ex①



muscle tension

b Isotonic Ex

Dynamic Ex①



c Isokinetic Ex



6) Strengthening Ex

a Isometric Ex







Glucose

b Isotonic Ex



Non-inflamed Jt






Reduce Jt ROM

c Isokinetic Ex







Contraindication③

Jt effusion

Baker cyst

Ligament laxity

Acute injury

Jt replacement

d Endurance Ex



e Stretching Ex


Avoid②



Large Jt effusion

f Jogging







Decrease ROM④

Jt swelling(+)⑤

h Modality














Convective methods







Conversion methods


람에게 사용


Deep heat②




adhesions






Cold③



















B Three type

1) Primary

a Peripheral Jt

b Spine

e variant subsets

2) Secondary

a Trauma

b Other Jt Ds



e Miscellaneous





ed by OA










OA Jt


by OA

5 Progression of OA

D Secondary OA
































B Genetic factor

Female dominate

기전C



1) Phase I






못하다

2) Phase II



3) Phase III











controls



(c) OA

(d) Non-OA






















Deep fissuring

Fibrilation



2) Loss of PG



4) Subchondral cyst










G Pain syndrome





1) Pain



2) Stiffness







B Signs

1) Tenderness




5) Deformity




Marginal

Intermediate stage



Late stage



Resurfacing of Jt




A Loss of cartilage










C Reduce Jt load






b Maximum lt 4g day






로도 사용된다

B NSAIDs



C COX-s inhibitions















3) Function

a Lubrication of Jt









G Glucosamine


2) Function



c Anti-inflammation


Function






종류B




거할 수 있다









D Weight control

E Physical modality






4) TENS

F Ex

1) Walk









2) Bicycle








1 Walking

3) hydrotherapy


장점b

Decrease Pain①








역기 운동4)






5) Stretching Ex












a knee Jt Extension





들어 올린다









들어 올린다




다





Contraindication③

Jt effusion

Baker cyst

Ligament laxity

Acute injury

Jt replacement

d Endurance Ex



e Stretching Ex


Avoid②



Large Jt effusion

f Jogging







Decrease ROM④

Jt swelling(+)⑤

h Modality














Convective methods







Conversion methods


람에게 사용


Deep heat②




adhesions






Cold③



















B Three type

1) Primary

a Peripheral Jt

b Spine

e variant subsets

2) Secondary

a Trauma

b Other Jt Ds



e Miscellaneous





ed by OA










OA Jt


by OA

5 Progression of OA

D Secondary OA
































B Genetic factor

Female dominate

기전C



1) Phase I






못하다

2) Phase II



3) Phase III











controls



(c) OA

(d) Non-OA






















Deep fissuring

Fibrilation



2) Loss of PG



4) Subchondral cyst










G Pain syndrome





1) Pain



2) Stiffness







B Signs

1) Tenderness




5) Deformity




Marginal

Intermediate stage



Late stage



Resurfacing of Jt




A Loss of cartilage










C Reduce Jt load






b Maximum lt 4g day






로도 사용된다

B NSAIDs



C COX-s inhibitions















3) Function

a Lubrication of Jt









G Glucosamine


2) Function



c Anti-inflammation


Function






종류B




거할 수 있다









D Weight control

E Physical modality






4) TENS

F Ex

1) Walk









2) Bicycle








1 Walking

3) hydrotherapy


장점b

Decrease Pain①








역기 운동4)






5) Stretching Ex












a knee Jt Extension





들어 올린다









들어 올린다




다










Convective methods







Conversion methods


람에게 사용


Deep heat②




adhesions






Cold③



















B Three type

1) Primary

a Peripheral Jt

b Spine

e variant subsets

2) Secondary

a Trauma

b Other Jt Ds



e Miscellaneous





ed by OA










OA Jt


by OA

5 Progression of OA

D Secondary OA
































B Genetic factor

Female dominate

기전C



1) Phase I






못하다

2) Phase II



3) Phase III











controls



(c) OA

(d) Non-OA






















Deep fissuring

Fibrilation



2) Loss of PG



4) Subchondral cyst










G Pain syndrome





1) Pain



2) Stiffness







B Signs

1) Tenderness




5) Deformity




Marginal

Intermediate stage



Late stage



Resurfacing of Jt




A Loss of cartilage










C Reduce Jt load






b Maximum lt 4g day






로도 사용된다

B NSAIDs



C COX-s inhibitions















3) Function

a Lubrication of Jt









G Glucosamine


2) Function



c Anti-inflammation


Function






종류B




거할 수 있다









D Weight control

E Physical modality






4) TENS

F Ex

1) Walk









2) Bicycle








1 Walking

3) hydrotherapy


장점b

Decrease Pain①








역기 운동4)






5) Stretching Ex












a knee Jt Extension





들어 올린다









들어 올린다




다



















B Three type

1) Primary

a Peripheral Jt

b Spine

e variant subsets

2) Secondary

a Trauma

b Other Jt Ds



e Miscellaneous





ed by OA










OA Jt


by OA

5 Progression of OA

D Secondary OA
































B Genetic factor

Female dominate

기전C



1) Phase I






못하다

2) Phase II



3) Phase III











controls



(c) OA

(d) Non-OA






















Deep fissuring

Fibrilation



2) Loss of PG



4) Subchondral cyst










G Pain syndrome





1) Pain



2) Stiffness







B Signs

1) Tenderness




5) Deformity




Marginal

Intermediate stage



Late stage



Resurfacing of Jt




A Loss of cartilage










C Reduce Jt load






b Maximum lt 4g day






로도 사용된다

B NSAIDs



C COX-s inhibitions















3) Function

a Lubrication of Jt









G Glucosamine


2) Function



c Anti-inflammation


Function






종류B




거할 수 있다









D Weight control

E Physical modality






4) TENS

F Ex

1) Walk









2) Bicycle








1 Walking

3) hydrotherapy


장점b

Decrease Pain①








역기 운동4)






5) Stretching Ex












a knee Jt Extension





들어 올린다









들어 올린다




다





ed by OA










OA Jt


by OA

5 Progression of OA

D Secondary OA
































B Genetic factor

Female dominate

기전C



1) Phase I






못하다

2) Phase II



3) Phase III











controls



(c) OA

(d) Non-OA






















Deep fissuring

Fibrilation



2) Loss of PG



4) Subchondral cyst










G Pain syndrome





1) Pain



2) Stiffness







B Signs

1) Tenderness




5) Deformity




Marginal

Intermediate stage



Late stage



Resurfacing of Jt




A Loss of cartilage










C Reduce Jt load






b Maximum lt 4g day






로도 사용된다

B NSAIDs



C COX-s inhibitions















3) Function

a Lubrication of Jt









G Glucosamine


2) Function



c Anti-inflammation


Function






종류B




거할 수 있다









D Weight control

E Physical modality






4) TENS

F Ex

1) Walk









2) Bicycle








1 Walking

3) hydrotherapy


장점b

Decrease Pain①








역기 운동4)






5) Stretching Ex












a knee Jt Extension





들어 올린다









들어 올린다




다






























B Genetic factor

Female dominate

기전C



1) Phase I






못하다

2) Phase II



3) Phase III











controls



(c) OA

(d) Non-OA






















Deep fissuring

Fibrilation



2) Loss of PG



4) Subchondral cyst










G Pain syndrome





1) Pain



2) Stiffness







B Signs

1) Tenderness




5) Deformity




Marginal

Intermediate stage



Late stage



Resurfacing of Jt




A Loss of cartilage










C Reduce Jt load






b Maximum lt 4g day






로도 사용된다

B NSAIDs



C COX-s inhibitions















3) Function

a Lubrication of Jt









G Glucosamine


2) Function



c Anti-inflammation


Function






종류B




거할 수 있다









D Weight control

E Physical modality






4) TENS

F Ex

1) Walk









2) Bicycle








1 Walking

3) hydrotherapy


장점b

Decrease Pain①








역기 운동4)






5) Stretching Ex












a knee Jt Extension





들어 올린다









들어 올린다




다




1) Phase I






못하다

2) Phase II



3) Phase III











controls



(c) OA

(d) Non-OA






















Deep fissuring

Fibrilation



2) Loss of PG



4) Subchondral cyst










G Pain syndrome





1) Pain



2) Stiffness







B Signs

1) Tenderness




5) Deformity




Marginal

Intermediate stage



Late stage



Resurfacing of Jt




A Loss of cartilage










C Reduce Jt load






b Maximum lt 4g day






로도 사용된다

B NSAIDs



C COX-s inhibitions















3) Function

a Lubrication of Jt









G Glucosamine


2) Function



c Anti-inflammation


Function






종류B




거할 수 있다









D Weight control

E Physical modality






4) TENS

F Ex

1) Walk









2) Bicycle








1 Walking

3) hydrotherapy


장점b

Decrease Pain①








역기 운동4)






5) Stretching Ex












a knee Jt Extension





들어 올린다









들어 올린다




다



















Deep fissuring

Fibrilation



2) Loss of PG



4) Subchondral cyst










G Pain syndrome





1) Pain



2) Stiffness







B Signs

1) Tenderness




5) Deformity




Marginal

Intermediate stage



Late stage



Resurfacing of Jt




A Loss of cartilage










C Reduce Jt load






b Maximum lt 4g day






로도 사용된다

B NSAIDs



C COX-s inhibitions















3) Function

a Lubrication of Jt









G Glucosamine


2) Function



c Anti-inflammation


Function






종류B




거할 수 있다









D Weight control

E Physical modality






4) TENS

F Ex

1) Walk









2) Bicycle








1 Walking

3) hydrotherapy


장점b

Decrease Pain①








역기 운동4)






5) Stretching Ex












a knee Jt Extension





들어 올린다









들어 올린다




다






1) Pain



2) Stiffness







B Signs

1) Tenderness




5) Deformity




Marginal

Intermediate stage



Late stage



Resurfacing of Jt




A Loss of cartilage










C Reduce Jt load






b Maximum lt 4g day






로도 사용된다

B NSAIDs



C COX-s inhibitions















3) Function

a Lubrication of Jt









G Glucosamine


2) Function



c Anti-inflammation


Function






종류B




거할 수 있다









D Weight control

E Physical modality






4) TENS

F Ex

1) Walk









2) Bicycle








1 Walking

3) hydrotherapy


장점b

Decrease Pain①








역기 운동4)






5) Stretching Ex












a knee Jt Extension





들어 올린다









들어 올린다




다




A Loss of cartilage










C Reduce Jt load






b Maximum lt 4g day






로도 사용된다

B NSAIDs



C COX-s inhibitions















3) Function

a Lubrication of Jt









G Glucosamine


2) Function



c Anti-inflammation


Function






종류B




거할 수 있다









D Weight control

E Physical modality






4) TENS

F Ex

1) Walk









2) Bicycle








1 Walking

3) hydrotherapy


장점b

Decrease Pain①








역기 운동4)






5) Stretching Ex












a knee Jt Extension





들어 올린다









들어 올린다




다















3) Function

a Lubrication of Jt









G Glucosamine


2) Function



c Anti-inflammation


Function






종류B




거할 수 있다









D Weight control

E Physical modality






4) TENS

F Ex

1) Walk









2) Bicycle








1 Walking

3) hydrotherapy


장점b

Decrease Pain①








역기 운동4)






5) Stretching Ex












a knee Jt Extension





들어 올린다









들어 올린다




다






G Glucosamine


2) Function



c Anti-inflammation


Function






종류B




거할 수 있다









D Weight control

E Physical modality






4) TENS

F Ex

1) Walk









2) Bicycle








1 Walking

3) hydrotherapy


장점b

Decrease Pain①








역기 운동4)






5) Stretching Ex












a knee Jt Extension





들어 올린다









들어 올린다




다







4) TENS

F Ex

1) Walk









2) Bicycle








1 Walking

3) hydrotherapy


장점b

Decrease Pain①








역기 운동4)






5) Stretching Ex












a knee Jt Extension





들어 올린다









들어 올린다




다








역기 운동4)






5) Stretching Ex












a knee Jt Extension





들어 올린다









들어 올린다




다








a knee Jt Extension





들어 올린다









들어 올린다




다


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