case study ita

8/2/2019 Case Study Ita

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Case study

GERIATRICS WITH BILATERAL KNEE OSTEOARTHRITIS.

Introduction

Joint composed of articular cartilage, subchondral bone, synovial membrane, synovial fluid

and joint capsule. Normal synovial joints allow a significant amount of motion along extremely smooth

articular surface. The articular surface of synovial joints consists of articular cartilage that protects the

subchondral bone by distributing large loads, maintaining low contact stresses, and reducing friction at

the joint. Synovial fluid is formed through a serum ultrafiltration process by cells that form the synovial

membrane. It supplies nutrients to the avascular articular cartilage and provides the viscosity to absorb

shock and elasticity required to absorb shock from rapid and slow movements.

Carlos,2012 state osteoarthritis(OA) is a degenerative disorder that results from the

biochemical breakdown of articular cartilage in the synovial joints. Although, the current concept holds

that OA involves not just the articular cartilage but the entire joint organ, including the subchondral

bone and synovium. Mostly patient having OA due to advancing age, obesity, trauma, menopause,

muscle dysfunction and genetics. High risk patient include sex hormones, muscle weakness, repetitive

use and Infection.

The early stage, chondrocyte will repair damage cartilage while increase production of

proteoglycans and resulting in swelling of the cartilage in most cases and may last for a years or

decades. Progressing stage, proteoglycans level will dropped and cause soften and lose elasticity of

cartilage and increase joint surface integrity. Flaking and fibrillations will develop along the joint and

resulting loss of the joint space. In major weight bearing joint greater loss joint space subject greatest

pressure and contrast imflammatory arthrides and uniform joint space narrowing. Erosion of the

damaged cartilage progress until the underlying bone is exposed and denuded of its protective

cartilage continues to articulate with the opposing surface. The increasing stresses exceed the

biomechanical yield strength of the bone and responds with vascular invasion and increased

cellularity, becoming thickened and dense at areas of pressure.It may undergo cystic degeneration,

due to either osseous necrosis secondary to the intrusion of synovial fluid.

Typically, it will develops gradually over a period of years through feeling of pain, stiffness,

limited range of motion and localised swellings. Pain is mostly worse following activity, especially

overuse of the affected knee. Stiffness can worsen after sitting for prolonged periods of time. As it

progresses over time, symptoms generally become more severe and continuous rather than during

weight-bearing.

Knee OA cant be cured but relieve the symptoms by taking medication such as

acetaminophen, NSAIDs (nonsteroidal anti-inflammatory drugs), and analgesic medication include

intraarticular injection of steroids or viscosupplements, topical creams, glucosamine and chondroitin

sulfate. Lastly, by surgery as a last result such as TKR.


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Physical management on OA patient generally on lifestyle modification, weight reduction and

particular exercises. Strengthening exercises and stretching to improve ROM. Aerobic and low impact

exercises mostly stress patient on weight bearing joints. Weight bearing and non-weight bearing

exercises has been proved in improvement of function, walking speed and muscle torque.

Furthermore, there is more improvement in knee-related quality of life was noted in the strength-training group than in the balance-training group.(Todd 2011(Jan et all)).


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Subjective assessment

Name: Mr X.

Age : 75 years old

R/N : XXXX

D.O.Ax : 3 disember 2011

Dr diagnose : R kn OA

Dr management : refer to physio

Problem

Pt c/o of pain at bilateral knee and difficulty during bending knee after prolonged walking around 15

mins and sitting on the chair during prayer

Current hx

Gradual onset of pain during prolonged walking around julai 2011

Past hx

No hx of fell down or fracture

Pmhx

Nil history of rheumatoid arthritis

DM, HPT around 3 years ago ( follow up 3 months )

Operation/ Surgery : nil

Medication : drugs for DM and HPT more 6 months

X ray done on september 2011, Ix: reduce joint space

No cord and cauda equina syndrome symptoms


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Home /social hx

Pt live at rumah kampung and no stairs

Pt live alone without any carer ur wife

Pt retired from being a teacher, currently being imam

Use to travel from batu pahat to kl for visiting daughter and grandchild

Pt is a non smoker and non alcohol

Body chart

Pain scale

VAS 5/10 during activity

VAS 0/10 during resting

Area: bilateral anterior knee

Type of pain: pulling pain

Aggravating factors : difficulty from sitting to standing

Prolonged walking ( around 15 mins)

VAS 5/10 ,

pulling pain

during activity


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Difficulty during squating

Unable to lift heavy object ( 2 kg )

Ease factores : pain killers ( release after 10 mins)

Ointment( release after 10 mins)

Irritability: medium, do no disturb sleeping

Observation

General : pt comes to department independently without using walking aids

Pt is a moderate male size with slightly limping gait pattern

Local : Rt shoulder level and Lt shoulder level align

Bilateral iliac crest level are align

Rt knee level higher than Lt knee level

J curve shaped is normal

Thoracic slightly kyphosis

bilateral knee have no redness

Slightly swelling on Lt knee

No bony deformity of bilateral knee

No muscle wasting of bilateral knee

Observation of gait

reduce time of stance phase

reduce step length

reduce gait speed widened base of support

no VBI sx


6/22

Palpation

No pain at bilateral knee

Pain at metacarpal base of index and middle finger of left hand

Crepitus sound on bilateral knee

No increase in temperature

No muscle spasm

No edema or effusion

No dry skin

Active physiological movements

Bilateral knee flexion crepitus sound and ERP

Bilateral Knee extension crepitus sound and no pain

Passive physiological movement

Rt flexion/abduction

Rt flexion/adduction

Rt extension/abduction

Rt extension/adduction

Pain and restricted opposite directions

No pain but slightly restricted

Lt flexion/abduction

Lt flexion/adduction

Lt extension/abduction

Lt extension/adduction

Pain and restricted opposite directions

No pain but slightly restricted

Muscle length

Piriformis test : tightness of piriformis

Accesory movement

Patella mobility - Restricted at bilateral knee inferior and posteriorly

Tibiofemoral joint normal at bilateral knee


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ROM

Joint movt Right Left Overpressure

Active Passive Active Passive Right Left

Hip flexion 0-120deg 0-120deg 0-120deg 0-120deg // //

Hip

extension

0-35deg 0-35deg 0-35deg 0-35deg // //

Hip

abduction

0-45deg PFROM 0-45deg PFROM // //

Knee flexion 0-135deg 0-140deg 0-115deg 0-125deg ERP ERP

Knee

extension

// //

Ankle

dorsiflexion

// //

Ankle

plantarflexion

AFROM AFROM // //

Ankle

inversion

// //

Ankle

eversion

// //

Intrepretation : Limited ROM of Hip movement and knee flexion d/t muscle tightness

Manual muscle testing

Joint movement Right Left

Knee flexor 3/5 within the

range

3/5 within the

range

Knee extensor 3/5 3/5

Hip flexor

Hip extensorHip abductor

Hip adductor

Ankle dorfiflexor 4/5 4/5

Ankle

plantarflexor

Ankle inversor

Ankle invertor

Intrepretation : reduce muscle strength d/t pain


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Q-angle

Rt 20deg Lt 25 deg

Functional strength test

Sit to stand

1st trials : 7 rep of 30sec

2nd trials : 6 rep of 30sec

3rd trials : 5 reps of 3sec

Pt impression

Problem listing Limitation social activities

Pain at bilateral knee d/t

degenerative changes

Difficulty during prolonged

walking

Difficulty during praying at

mosque and need to use chair

Limited ROM on Rt knee d/t

muscle tightness

Unable to bent bilat. Knee Unable to use squating toilet

Reduce muscle strength d/t pain Unable to lift heavy object

Unable to do squating

Abnormal gait pattern d/t poor

posture awareness

Short term goal

1. To relieve pain on the bilateral knee within 1/52

2. To increase ROM on bilat knee within 2/52

3. To increase muscle strength on both LL within 2/52

4. to improve gait pattern within 2/52

Long term goal

To improve functional ability in ADLS

To prevent joint stiffness and bone defomity


9/22

To maintain ROM on bilateral knee

Plan of tx

Heat therapy

Massage

Exs

Hep

Intervention

1. heat therapy ; supine ly. post. bilateral knee elevated with pillow HP at bilateral knee for 20mins

2. Effluarage massage ; supine ly. position with Lt knee supported with pillow; massage from distal to

proximal; 5 times

2.EXS

Supine ly. position; SQE at bilateral knee; straighten the knee and hold 10 sec; 10 repetitions

Supine ly. position; SLR at bilateral knee; raise LL and hold 5sec ;10 repetitions

IRQ exs;Supine ly. post; towel supported below the knee ; ankle DF and straigthen knee bilaterally;

hold 10 sec ;10 repetitions

Stretching exs using gymball; supine ly position with LL suported with gymball; knee flexion and

extension using gymball ; hold 10sec; 10 repetitions

Sit to stand exs; sitting on the chair at wall; ask patient to repeat step up and down without touch the

chair

Static cycling,10 mins

4. HEP

Advice to immersed to towel in a warm water and apply at bilat knee if pain;20 mins

Cont exs as taught at home 3 times daily


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Evaluation

Pain is reducing after done hot pack to VAS 4/10 and able to do all exs as taugh

Teach patient on normal gait pattern,patella mob and other exs

Reassessment

Progress case on 13 disember 2011

Subjective

Pt still c/o of pain but reducing than previous visit to VAS 4/10 during activity. Claimed not regularly doall exs at home but slightly improve in bending bilateral knee. Pt still prayer in sitting at chair due to

pain. Claimed do not take pain killers anymore.

Objective

Slightly limping gait pattern

Still having swelling on Lt knee

No redness

Gait analysis

Wide base support

Reduce knee flexion on stance phase

Reduce gait speed

Reduce step length

Palpation

No increase in temp

No musle tenderness

No muscle wasting


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Accesory movement

Patella mobility - Restricted bilateral at bilat. Knee

Muscle length

Piriformis test : tightness of piriformis

Q-angle

Rt 20deg Lt 25 deg

ROM



Hip abduction 0-45deg PFROM 0-45deg PFROM // //


Intrepretation : limited ROM of Lt knee d/t muscle tightness



Knee flexor 3/5 within the

range

Knee extensor

Hip flexor

Hip extensorHip abductor 4/5

Hip adductor

Ankle dorfiflexor 4/5

Ankle

plantarflexor

Ankle inversor

Ankle invertor

Interpretation : reduce muscle strength d/t deconditioning secondary to ageing


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1 trials : 7 repetitions ( 30sec )



Analysis

Pain is reducing than previous visit

Improving in muscle strength

Abnormal gait patern d/t poor posture awareness

Plan of tx

Ice packs

Ice massage

Joint mobilization

Exs

Gait training

HEP

Intervention

1. ice packs

supine ly post. Knee elevated with pillow, ice wrap with towel at bilateral knee;20 mins

2. ice massage

long sitting position; massage around Lt knee in circular motion; 10 mins

3. joint mobilisation

Long sitt position ; patella mobility technique at bilateral knee ; 30 sec hold; 5 rep ; 3 set

4. Exs


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Sitting position; Piriformis strecth,SLR and SQE ; 10 sec hold; 10 repetitions

High sitting position; IRQ bilateral LL; 10 sec hold and 10 repetitions

Static cycling; 20 mins

Wall squating exs ; standing positions and lean back at the wall; hold 5 sec ; 10 repetitions

Sit to stand exs; 3 repetitions

5. gait training

Teach normal gait pattern infront of mirror at parallel bar

6. HEP

advice pt to cont exs at home regularly

Do ice massage for 20mins a days for 2 weeks

Evaluation

Pt claimed pain is slightly reducing after being teach about normal gait pattern and ice massage

Reassessment (progress case on 16/12/2011)

Subjective

Pt claimed the pain is reducing than at bilateral knee to VAS 3/10 during activity.

Pt claimed of slightly improvement in bending his Lt knee. Claimed able to walk prolonged walking

Around 1 hour and lift heavy object more than 4 kg.

Objective





Interpretation : limited ROM on knee flexion d/t joint stiffness


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Knee flexor

Knee extensor

Hip flexor

Hip extensor

Hip abductor

Hip adductor 4/5 4/5

Ankle dorfiflexor

Ankle

plantarflexor

Ankle inversor

Ankle invertor

Interpretation : reduce muscle strentgh d/t deconditioning secondary to ageing


Chair stand test

1 trials : 7 rep

2 trials : 7 rep

3 trials : 7 rep

Analysis

Pain is reducing

Maintenance of functional activities

Plan of tx

Exs

HEP

Interventions

1. Exs


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2. HEP



Evaluation

Pt able to do all exs and remember all the exs teach before

Reassessment (progress case on 22/12/2011)

Subjective

No new c/o of pain, condition still remains the same and able to walk prolonged walking around 1 hourand lift heavy object more than 4 kg.

Objective





Interpretation : limited ROM on knee flexion d/t joint stiffness


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Knee flexor

Knee extensor

Hip flexor

Hip extensor

Hip abductor

Hip adductor 4/5 4/5

Ankle dorfiflexor

Ankle

plantarflexor

Ankle inversor

Ankle invertor

Interpretation : reduce muscle strentgh d/t deconditioning secondary to ageing


Chair stand test

1 trials : 9 rep

2 trials : 8 rep

3 trials : 7 rep

Analysis

Increase in muscle strength

Maintenance of functional activities

Plan of tx

Joint mobilization

Exs

HEP


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Interventions

1. Exs






2. HEP



Evaluation

Pt able to do all exs and remember all the exs teach before

Reassessment

To review exs next visit


18/22

Discussion

Mr. Z is a old male,72 years old and diagnosed with knee OA and undelying DM and HPT. He

complaint of pain at bilateral knee and limited functional activites that need to used strength and

bending knee such as prayer and walking. Patient complaint on gradual onset of pain during

prolonged walking more than 15 mins, difficulty in lifting heavy object more than 2 kg and difficulty

during sitting to standing on julai 2011. Pt have no history of fall or pain before julai 2011. The goals of

treatment is relief pain, reduce swelling, improve Range of Motion, improve muscle strength and

improve functional activities. After physical management, there is findings on pain, limited knee flexion

motion and patella mobility. Pt also reduce in muscle strength that affect on his functional performance

such as prolonged walking and prayer.

Treatment apply to patient on the first attend is heat therapy to relief his pain by improving

circulation and relaxing muscles while, effluerage to reduce swelling but i certainly change the

treatment for second attend using cryotherapy due to no improvement are seen after previous

treatment. By using cold packs and ice massage from cochrane reviews written by Brosseau,2003

finds that ice massage helps in improve muscle strength, improved ROM, and resulted in less time

needed to walk 50 feet. It also stated that cold packs were useful for reducing knee swelling.

This patient is having restricted patella mobility that will influenced in pain and limited range of

motion. Houlgham ,2010 state that patella restriction will reduce the tibiofemoral joint full flexion motion

ability and by apply soft-tissue mobilization helps in improve knee range of motion.He had be given on

patella mobilization of multi direction glide for 30 sec hold; 5 repetitions and 3 set. This will affects the

ROM of knee flexion and extension while decrease soreness due to James,2012 on his written of

managing patient with knee OA. The used of superior glide is to facilitate knee extension while inferior

glide facilitates the knee flexion. I also apply mediolateral glide to restore the normal patella translation

based on David,2009 on his book of pathology and intervention in musculoskeletal rehabilitation.

Exercises that i prescribe to patient composed of stretching exs and strengthening exs. Based

on Jan et. all,2008 on the research of resistance training for knee OA found that increase muscle

strength on both flexor and extensor muscle will increase the knee stability. From resistance training

study conclude that it help in reduce pain and improve functional performance. Moreover,

strengthening exs improve the walking speed on a curved path and uneven floor which demands

higher neuromuscular control of the lower extremity. While from brosseau et all,2005 found that

exercises and physical activity are promising in reduce pain,improve functional status, aerobic

capacity, quality of life, potential to reduce body weight and prevent further joint damage at knee.

Strengthening exs can be classified into three categories which is isometric, isokinetic and

isotonic exs. I treat patient with isometric,isotonic and isokinetics exs due to age and pain. For

isometric exs i teach on SQE exs based on Patrick,2005 the isometric strengthening exs are puposelyused with to minimize the adverse effects of weight bearing on the joints by reducing the amount of


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force that is transmitted across the affected joints. It was the best type of exercise to begin with in a

strengthening program, particularly in patients who can not tolerate repetitive joint motion. Then, i

progress the exs by prescribe the isotonic exs of SLR, IRQ and wall squating for 10 seconds hold with

10 repetition based on the research done by Robert,2005(Huang et all) found that the isotonic

exercise had the greatest effect on reducing pain, while the isokinetic exs had the greatest increase inwalking speed and decrease of disability after treatment and follow-up. For the isokinetics exs i

prescibe on static cycling and sit to stand due to patient reduce endurance secondary to ageing.

Besides that, stretching exs for knee flexion are used to increase ROM and prevent the abnormal

muscle shape and length that can contribute to the visible joint deformities that result from severe

arthritis due to Robert,2005.

Lastly, i train patient on a normal gait pattern due to pain and abnormal gait pattern. From the

research of gait training and hyperextension by Teran,2009 found that normal gait training improved

awareness in knee alignment when standing and reduce pain at night. Furthermore, patient also

claimed that pain is reduce after being teach on gait training for the second attend while, do exs as

teach before. Teran also found that gait training improved ability to stand for a longer periods of time

without pain on either knee. It is also found that gait training addressed the modifications during heel

contact and forward progression to develop confidence in the stance-phase on the controlling for

pelvic rotation, hip extension, and dorsiflexion range.


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Summary/Conclusion

OA patient will facing the pain at joint, swelling and limited ROM which will influenced on their

posture and functional activities. OA management more in reduction of pain and improve the functional

activites. To improve the functional activities the symptoms should be treated first.

Based on the practice, it shown that exercises gave higher implication in reduction pain and

improve the functional performance. While, cryotherapy is the best treatment to relief pain and

swelling. Even thought physical training such as exercises help in reduction of pain and improve

functional performance. The personal, socioeconomic, and environmental is a barrier to elderly

patients ondoing exercises. Most older adults claimed on discomfort or disability as a reason for not

exercising. So,by prescribe the suitable intensity and range of exercises influenced in reducing the

discomfort.

Based on the research of Silvia, 2008 about hydrotherapy vs conventional land based

exercise for the management of patient with osteoarthritis of the knee shown that hydrotherapy is a

suitable and effective exercise for patients with OA knee and should be included in the therapeutic

approaches recommended for the management. However, due to incompleted equipment

hydrotherapy unable to apply to the patient.

Aquatic exercises will limit the weight-bearing load while, cross-training, using a combination

of activities, balances the risks and benefits of weight and nonweight-bearing activities, uses a wider

range of muscle groups, decreases the risk of overuse injury, and is less boring based on Robert,2002. Older persons comfortable in a role of dependence and feel threatened by the charge of

increased activity. Building on previous activities can help overcome the dominant influence of habit on

activity levels. An active lifestyle also has health benefits comparable with formal exercise regimens,

but with improved rates of long-term compliance by prescribing on routine exercises, that are simple

which requires specific instructions and repetititions this is based on Robert, 2002.


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References

Journal

John Albright, (2001) Philadelphia Panel Evidence-Based Clinical Practice Guidelines on Selected

Rehabilitation Interventions for Knee Pain, PHYS THER, 81:1675-1700.

Lucie Brosseau, (2005) Ottawa Panel Evidence-Based Clinical Practice Guidelines for

Therapeutic Exercises and Manual Therapy in the Management of Osteoarthritis, PHYS THER.

85:907-971.

Linda L Currier, (2007) Development of a Clinical Prediction Rule to Identify Patients With Knee

Pain and Clinical Evidence of Knee Osteoarthritis Who Demonstrate a Favorable Short-Term

Response to Hip Mobilization, PHYS THER. 87:1106-1119.

Mei-Hwa Jan, (2008) Investigation of Clinical Effects of High- and Low-Resistance Training for

Patients With Knee Osteoarthritis: A Randomized Controlled Trial, PHYS THER. 88:427-436.

Luciana E Silva, (2008) Hydrotherapy Versus Conventional Land-Based Exercise for the

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THER. 88:12-21.

Katherine Beissner, (2009) Physical Therapists' Use of Cognitive-Behavioral Therapy for Older

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Terry Malon, (1980) Knee Rehabilitation, PHYS THER. 60;1602-1610.

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Book

David J. Magee, Pathology and intervention in musculoskeletal rehabilitation, (2009); United

States : Saunders Elsevier

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States : Thomson-shore, Inc.

Articles

Todd P Stitik (2011). WebMD : Rehabilitation for osteoarthritis overview osteoarthritis

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Neil segal (2007), Improving walking in older adults with knee OA


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Web

http://osteoarthritis.about.com/od/kneeosteoarthritis/Knee_Osteoarthritis_Causes_Diagnosis_

Symptoms_Treatment.htm

http://www.osteoarthritisremedy.com/herbal-remedies/osteoarthritisremedy/osteoarthritis-

pathophysiology

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