randy raugh, pt, dpt 1. osteoarthritis (oa) 37.4% > age 60 with knee oa 2030 - 25% of americans...

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A Fresh Outlook on Osteoarthritis and Physical

Capabilities

Randy Raugh, PT, DPT

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Osteoarthritis (OA)37.4% > age 60 with knee OA2030 - 25% of AmericansLeading cause of immobility/disability > 60Symptoms: pain, stiffness, noisy and local swelling“Wear and tear?”CDC:

“Incurable, progressive and degenerative”???“…focal and progressive loss of the hyaline cartilage of

joints, underlying bony changes.”A “disease” or a Mechanical problem?A cartilage problem?

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CDCOA knee: 1 of 5 leading causes of disability among

non-institutionalized adults. ~ 80% of patients - some degree of movement

limitation 25% cannot perform major activities of daily living 11% knee OA need help with personal care14% require help with routine needs. ~ 40% of adults with knee OA reported their

health “poor” or “fair”.1999, knee OA - more than 13 days of lost work

due to health problems

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Excessive stress to entire jointArticular (hyaline) cartilageSynovial liningBone beneath cartilageLigaments

Diagnosed by X-Rays and symptomsJoint space narrowing

Sclerosis (increased bone density) Spurs, lipping

Normal knee Osteoarthritic knee

X-Rays of OA joints

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X-Rays don’t correlate well to painDecreased space: meniscus or articular

cartilageCartilage: no nerves = no pain X-Rays activityFear/anxiety = activityUntreated OA lesions fared no worse

Widuckowski et al (2009) 2-4 cm lesions w/out tx no worse in 13 – 17 year follow-up

Surgical debridement of OA no better than physical therapy/medication Risberg et al; Kirkley et al; Moseley et al

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Risks for OAExcess weight

For OA riskNot for progression unless misalignments

Trauma, surgery, etc. NO movement

ImmobilizationSedentary lifestyle

Repetitive, excessive twistingRapid impact activitiesExcessive Joint flexibilityMisalignments/movement impairments

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Articular cartilageHyaline cartilage – bluish, opalescent, glassy,

homogenousThinner with ageNo blood vessels / no nerves

Heals very slowlyNo pain

80% water-filled matrixMust have dynamic (cyclic) loading to move

nutrients in/damaged cells/waste products out.

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Functions of articular cartilageAbsorb and distribute compressive forces

Like a gel bicycle seatLying down (~0 compressive force) - kneeJumping (~24 x body weight) – kneeFlow of fluid through porous matrix, away from force.Stiffer to higher loadsShock absorption (deformation of cancellous bone most,

then subchondral bone and slightly cartilage (1-3%)Slippery

500 to 2000 x slipperier than ice on ice.Synovial fluid – consistency like egg white

Helps cartilage resist sliding forces

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Tensile stress-strain curve of articular cartilage

TENSILE FORCES

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The non-linear response of articular cartilage to compressive force on fluid flow through the matrix

Compressive forces

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Stretching (tensile) forces

Compressive forces

Sliding (shear) forces

Types of physical stresses encountered by articular cartilage

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Compressive loadsShort term

• Eckstein et al Eckstein et al (2005) – • MRI before/after deep knee bends, squatting, walking, cycling –

decreased thickness 5.0 to 8.8%• After 100 knee bends, return to original thickness took 90

minutes.

• Long term changesInadequate load/immobilization

Jortikka et al (1997) – 11 weeks of immobilization PG in beagle knees – did not fully recover after 50 weeks or remobilization.

Hinterwimmer et al (2004) – 20 patients mean knee cartilage thickness after partial LE immobilization for ankle fx x 7 weeks.

Vanwanseele et al (2002) – after 2 years post-injury, spinal cord patients’ cartilage thickness patella 23%, medial tibia 25%, lateral tibia 19%.

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CompressionExcess load = cartilageLow compression ↑ synthesis; high decreased it.

Weak quadriceps (Youssef et al, 2009) saline or botox injected into quads.

Segal et al (2010) – weak quads correlated to JSN in womenSlemenda et al (1997)- each 10-lb/ft increase knee extensor

strength = 20% knee OAMikesky et al (2006) – 221 older adults, strength vs ROM

Strength group showed slower rate of JSN at 30 months.Excess weight increases load and risk

Felson et al in Framingham Study (1992), wt loss risk of knee OA

Sharma et al (2000) BMI correlated more with risk than progression except in bowed legs

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Shear (sliding force)Wong et al (2008) – cadaveric osteochondral cores

subjected in vitro to shear with 15% compression. More irregular surface had 5 x > shear than normal cartilage. More irregular surface = > friction = more degradation with

shear)Shear more inflammation, production of degrading

enzymes, etc. Shear more common than excess compression with

people over 60?Clinically – patients often report more pain with

movements that increase shear Twisting and bending knees sideways Less pain with movement impairment corrections

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Causes of compression problemsInadequate (rhythmic) compression

“I better not wear it out faster”Sedentary lifestyleStatic postures Prolonged standing

Excess compressionExcess body weightHigh impact or rapid loading activitiesWeak muscles (or muscles untrained for faster

loads)

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Causes of excessive shearActivities which twist joints with compression

SkiingTennisDancingRunning with flexible knees

Poor movement patternsSit stand with knees in/outUp/Down steps with hip/knees in/outPoor body mechanics with activities

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TISSUE RESPONSE TO PHYSICAL STRESS

More physical stress

Healt

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r

Optimum Health

Cell death Cell death

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General advice about joint careAvoid static postures – especially bad ones – move!No pain, no gain = no brain. Avoid joint noise if possibleMaintain adequate strengthStretch muscles, not jointsHealthy weightAll joints need regular movement to feel their best.If you can’t find comfort, seek help

Start with conservative care (physical therapy) If no improvement in 6 – 8 visits, change therapists Treat it as a mechanical problem

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Feet are the foundationDo not tolerate uncomfortable shoes – ever!Maintain healthy weightAlternate sport shoes each day

Shock absorption is slow to recover after compression

Choose activities that don’t hurt.Walking is better than standingFoot exercises?

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Knees to last a lifetimeHealthy weightAvoid unnecessary twisting

Biking? Avoid breaststroke, scissor or frog kicks in

swimmingFocus on alignmentMaintain strong legs and HIPSWear proper shoes

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Hip, hip hooray!IF flexible, avoid extreme stretches for hip

Avoid performing “splits,” race-walking, extreme yoga asanas that take hips back beyond neutral with pelvic

Maintain strong buttock and hip musclesAvoid becoming “hamstring dominant”

Jogging worse than runningIF you have very stiff hips with OA, stretch

the hips and strengthen them too

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Spine painSeek help if:

Bowel/bladder problemsDecreased strength in lower extremity or

upper extremityTingling/numbness in genital regionSensory changes in both sides of UE or LE

Start with conservative care – proceed slowly on that route.

“But my MRI showed that…”

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Spine:Spine pain is a mechanical problem too

PostureExercise Avoid heavy lifting

Never bend and lift or worse, bend, twist and liftFor heavy objects – the Raugh Method

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ShouldersAllow your shoulders to rise when you reach.Lift in line with the shoulder bladesDon’t keep them down (for your neck too).

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Questions?