Physical Therapy Protocols

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Osteoarthritis (OA) is the most common form of chronic noninflammatory progressive disorder of the joints leading to deterioration of the articular cartilage and new bone formation at the joint surfaces and margins [1]. 

• It is one of the most common causes of chronic disability among older persons in the United States [2].  
• Affects middle-aged or elderly. Before age 45, more frequent in males & after age 55 years, more common in females [3].
• OA is a localized, rather than systemic, disease.

  

  (WebMD - Internet) - Click on image to enlarge

• Joint involvement is usually asymmetric, with a predilection for weight-bearing joints.
  • Common sites - hip, knee, distal and proximal interphalangeal joints, and facet joints of the spine.
  • Less common sites - ankle, wrist, and shoulder.

 ♦ Classification of Osteoarthritis:

  The American College of Rheumatology has classified OA into PRIMARY (OA appears without obvious cause) and SECONDARY (OA caused by something known).

 

 » Involvement of Peri-Articular Structures:

• The peri-articular musculature atrophies over time, presumably  as a result of disuse due to pain and decrease range of motion.
• Peri-articluar muscular atrophy leads to a loss of joint protection that further contributes to joint destruction associated with OA.

 » Symptoms:

• Dull aching joint pain
  • Early Disease Condition - Gradual onset, mild in intensity, brought on by joint usage, and relieved with rest.
  • May be vague around joint
  • Self-limited or intermittent
  • Severe Disease Condition - pain at rest & during night
  • Severity of pain does not reflect the severity of the disease
• Joint stiffness < 30 minutes in the morning and becomes worse as the day goes on.
• Loss of normal function of the joint and the person as a whole.
• Advanced Condition - Sense of grinding or locking of a joint, and buckling or instability of joints during demanding tasks.
• Fatigue - if biomechanical changes lead to increased energy requirements for activities of daily living.
• Overuse of alternative muscle groups can lead to development of pain syndromes in other parts of the musculoskeletal system.

 

 » Signs:

• Pain on movement
• Swelling of the joint
• Articular gelling - stiffness lasting short periods and dissipates after initial ROM.
• Spasm of periarticular muscles
• Bony enlargement of the joint
• Limitation of range of movement - End ROM mostly affected
• Crepitus when moved - loud cracks & crunches if the arthritis is severe.
• Tenderness to pressure
  • Around the joint margins
  • Very sore if knocked or injured in any way
• Joint Deformity or poor alignment
  • Genu Varum (Bow Legs)
  • Genu Valgum (Knock Knees)

 ♦ Classification Criteria for Osteoarthritis:

 » Criteria for OA of Hip:

(Altman, R., et al., 1991 [4]) - Click on image to enlarge

 » Criteria for OA of Knee:

(Altman, R., et al., 1986 [5]) - Click on image to enlarge

 » Criteria for OA of Hand:

 

(Altman, R., et al., 1990 [6]) - Click on image to enlarge

The hallmark radiological features of  Osteoarthritis are as follows, which requires antero-posterior and lateral view:

• Laboratory Findings are usually normal 
  • Sometimes a slight elevation of C-reactive protein
  • Some elevation of the erythrocyte sedimentation rate 

Especially in patients with more generalized OA, with combined erosive osteoarthritis of the hands or in patients with associated crystal arthropathy.

• Newer imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI) provide additional insight into the degree or nature of damage to the cartilage, subchondral bone, and soft tissues.
• MRI shows great promise for detecting early changes in OA, especially with regard to the articular cartilage softtissue involvement and bone narrow abnormalities.

 

• Orthopaedic Physical Examination 
  • Inspection
  • Palpation
  • Movement
  • Measurement
• Remember to use the opposite limb for comparison and (to gain the patient's trust) leave any possibly painful tests to the end.
• The examination should start immediately the patient enters the clinic to assess their gait, walking aids, and general mobility.
• HERE WE WILL BE CONCENTRATING ON KNEE MOST COMMON IN CLINICAL SETTING.

» Pain Assessment:

• Chief presenting complaint - in patients word
• Duration of Symptoms
• The site of pain within the knee - indication as to the structure damaged
• Type of Pain - pain is constant or intermittent and whether it occurs at night.
• Aggravating & Relieving Factors - Relate the pain to the level and type of activity, such as whether the symptom appears after few steps of walking or only after running.
• Referred Pain - possibility of referred pain from the hip or lumbar spine, particularly when assessing a patient with degenerative symptoms.
• Self-Report Pain Rating Scale - use any one of the below.

 

(Hand Book of Pain Assessment [10]) - Click on each image to enlarge

• Upper Block 1: Verbral Rating Scale (VRSs) for Pain Assessment. [11,12,13,14]
• Upper Block 2:  Descriptor Differential Scale of Pain Intensity (DDS-I). [15]
• Lower Block 1: Facial Expressions of a Picture Scale. [12]
• Lower Block 2: Visual Analogue Scale (VAS) and Graphic Rating Scale (GRSs) 

» Inspection:

• STANDING
  • Observe for Limb Length Descripancy
  • Femoral or Tibial Rotational Malalignments
  • Check foot positions (Hyperpronation)
  • Bowing of Knees
  • Fixed Flexion Deformity (from side view)
• SUPINE
  • Make sure patient is not straining to watch an examination which might increase muscle tone, affecting observation such as joint laxity. 
  • Swelling around the involved joint
  • Muscle wasting
  • Position of the limb in relaxed posture
  • Fixed Flexion Deformity (how much gap between plint and knee)
• GAIT

• Observe when patient walks both away and towards the examiner 
• Gait Pattern (Antalgic Gait or Waddling Gait)
• Assistive devices 

» Palpation:

• Temperature (Sign of inflammation)
• Feel systematically around the knee joint for tenderness. Bend the knee to 90 degrees and feel around the medial and lateral joint lines for tenderness.
• Tenderness Grading
  • Grade I - Patient complains of Pain
  • Grade II - Patient complains of Pain & Winces
  • Grade III - Patient Winces & Withdraws
  • Grade IV - Patient will not allow palpation of the joint
• Look for Muscle Atrophy (Quadriceps)
• Patellar Tap Test: Slide your hand down the patients thigh, pushing down over the suprapatellar pouch, so that any effusion is forced behind the patella. When you reach the upper pole of the patella, keep your hand there and maintain pressure. Using the index & middle finger of the other hand push the patella down gently.
  Does it bounce? If so this may indicate the presence of an effusion.

• Bulge Test: Using your thumb and index finger - milk down any fluid from above the knee. Keep this hand in this position.

  

Now with the other hand stroke the medial side of the knee to empty the medial compartment of fluid then stroke the lateral side. Observe the medial side of the knee for any bulging? This may indicate an effusion.

» Movement:

• Normal ROM of Knee is from 0 degrees (Extension) to 135 degrees (Flexion).
• Active Movement: Ask the patient to fully bend (flex) then straighten (extend) their knee. Always compare the range of movement with the other knee. Is there any reduced range of movement?
• Passive Movement: Place one hand on the patients knee and then with the other hand flex (bend) the knee as far as possible & then extend the knee. With the hand that is placed over the knee do you feel a 'grinding' sensation? Such a grinding sensation (crepitus) is usually indicative of degenerative knee disease (osteoarthritis) which reflects a loss of the normal smooth movement between the articulating structures (i.e. femur, tibia, and patella).
• Quadriceps Lag: [16]
  • Method I: The heel is placed on a small raised block and the relaxed limb allowed to fall into extension under its own weight (A). The active test involves having the subject attempt to hold the knee straight whilst raising the heel off the block (B). The magnitude of quadriceps lag is determined by subtracting the angle of active knee flexion at the instant the heel leaves the block from the angle at the limit of passive extension.
  • Method II:  The thigh is initially positioned over a substantive block so that the knee is in approximately 45 degrees flexion. The test for quadriceps lag starts with the active component (A). The subject is asked to actively straighten the knee as far as possible. After determining the limit of active extension, the examiner places a hand behind the heel and straightens the knee (B). In this method it is best if the subject does not relax when the examiner lifts the leg with a hand behind the heel (this minimises any jerking of the limb between the end of the active and start of the passive phase). Also, the examiner should raise the leg with a hand behind the heel until the thigh just lifts off the block.

» Health Status Assessment Instruments commonly used for OA:

» Arthritis Impact Measurement Scales 2 (AIMS 2)

» Health Assessment Questionnaire (HAQ)

» McMaster Toronto Arthritis Patient Preference Disability Questionnaire (MACTAR)

» Western Ontario & McMaster Universities Osteoarthritis Index (WOMAC)-VA3.0

» Short Arthritis Assessment Scale

  PHYSICAL EXAMINATION VIDEOS FOR KNEE:

 

» Knee Examination (DMS)

» Knee Examination (WISC)

» Knee Examination

 NOTE: Videos are live streaming videos so please do allow sometime for buffering depending on your internet speed. You will also need Windows Media Player and Web Plug-in to play this videos.