A progressive joint disease due to
failure in repair of joint damage.
Ministry of Health, Malaysia
• Commonly found after 40 years old
• Widespread in adults after 65 years old
• Affect men more than women before age of 50
• Affect women more than men after age of 50
[Sullivan]
• 524 million of people suffered from knee OA (aged 65 or older) in 2010
• Expected going to represent 16% of world’s population in 2050
[World Health Organization ]
Wear-and-tear process (ageing)
↓
Micro trauma
↓
Cartilage substance decreases
↓
Bone surface affected
↓
Development of osteophytes (bone spurs)
↓
[Kirstin uth et al, 2014]
Osteoarthritis symptoms
(GRADED ON THE RADIOGRAPHS)
Grades of OA Descriptions
Grade 0 Normal Radiography
Grade 1 Doubtful narrowing of joint space; Possible of osteophytes
Doubtful
Grade 2 Absent or questionable narrowing of joint space; Definite Osteophytes
Mild
Grade 3 Narrowing of joint space; Moderate Osteophytes; Some sclerosis; Possible deformity
Moderate
Grade 4 Marked narrowing of joint space; Large osteophytes; Severe sclerosis; Definite deformity
Severe
[CPG, MOH, Malaysia]
NON-MODIFIABLE MODIFIABLE
• Ageing • Body Mass Index – Obesity
• Genetics • Previous knee injury
• Malalignment of the knee
*Enable to prevent the progressions of OA*
[CPG, MOH, Malaysia]
CREPITUS JOINT
STIFFNESS
KNEE PAIN
BONY
TENDERNESS
SWELLING
LOSS OF
NO MUSCLES
PALPABLE BULK FIBERS
LIMB WARMTH
DEFORMITY [CPG, MOH, Malaysia]
TYPE
RHEUMATOID ARTHRITIS KNEE AVASCULAR NECROSIS GOUT
• Chronic systemic inflammatory • Cellular death of bone components • It is caused by monosodium urate
disease of unknown cause d/t interruption of the blood supply monohydrate crystals
• Trigger an autoimmune reaction,
leading to synovial hypertrophy and
chronic joint inflammation
[Medscape]
• Nonsteroidal Anti-inflammatory Drugs (NSAIDS)
• Oral Analgesics (Acetaminophen) Relieve pain
• Corticosteroid injections (Intra-articular) and inflammation
• Topical Analgesics (Capsaicin gel)
[AAOS, Clinical Practice Guideline]
PRIMARY INDICATIONS
1. Pain (Disturb sleep quality)
2. Loss of function (Limitation to ADL)
3. Progression of deformity
High Tibial Osteotomy Total Knee Replacement Partial Joint Replacement
(HTO) (TKR)
• Isolated medial • For severe OA that failed • Less blood loss intra-
compartment arthritis to other therapies operatively
• Upper tibia is cut and • Reduction of pain • Less pain at post-surgery
realigned to glide freely dramatically and with fast recovery
• Relieve pain and may improvement of ADL • Less predictable pain
delay the progression of relief and potential need
OA for subsequent surgery
[CPG, MOH, Malaysia]
• Knee may look
asymmetrical
According to the summarization of CPG of (Ministry of Health, Malaysia), (American Academy of
Orthopaedic Surgeons, AAOS) and America College of Rheumatology, below are the findings of the
current physiotherapy management
MANAGEMENT
Pain Management Strength Training Land-based Exercise
• Thermotherapy as an agent in • Outcome measures such as VAS, • Joint ROM, strength exercise and
combination of the exercise WOMAC Pain and function was low impact aerobic exercise
found significantly improved • Benefits in reducing the pain and
• Isotonic strength group has lower improve the physical function
VAS score than the isometric
strength groups
MANAGEMENT (Cont’)
Aquatic Exercise Weight Control Patient Education
• It is proved than aquatic exercise • Weight loss program with the • Educating the patient on the
works better in reducing the knee aerobic exercise yield a better information of diagnosis, nature of
OA pain than land-based exercise outcome on reducing OA symptoms disease that enable the patient to
cope better
• Educating the patient about the
importance of exercise and taking
medications regularly
• Deal with the emotional
consequences of chronic illness such
as depression, fear and frustration
CASE
PRESENTATION
DEMOGRAPHIC
DATA
DEMOGRAPHIC DATA
Name Paramasivam A/L Apparu
Age 55 y/o
Gender Male
Occupation Taxi Driver (More than 5 years)
R/N SB 00811543
D.O.R. 4th July 2017 (Tues)
D.O.Ãx 21st Aug 2017 (Mon)
Dr. ∆ Left Knee Osteoarthritis
Dr. Mx. Conservative and Refer to Physiotherapy
SUBJECTIVE
ASSESSMENT
C/C Feel difficulty and pain in the both knees when climbing up & down the
stairs, squatting and getting in & out of the car
Left knee is more severe than the right knee
Current Hx Pt realized the first pain came during playing badminton in few months ago
Frequency of playing badminton: Twice a week previously, then reduce to
once a week after getting mild pain, then recently not playing anymore
Past Hx Had many falls and twisted injuries over the BL knees while playing
football in the teenage time
Physiotherapy Mx 1st visit to physio
Other Mx Done Ointment and Traditional Chinese Medicine (Using Moxa Stick)
Found improvement in reduction of pain temporarily
PMHx High Cholesterol (At borderline, diagnosed in 10 years ago, not on
medications)
Medications NIL
Family Hx NIL
Surgical Hx NIL
Investigation Took 2 months ago (Showed positive of Lt OA)
Personal Hx Sitting and walking around the house compound (Sedentary Lifestyle)
Functional Limitation Climbing up & down the stairs, and squatting
Social Hx Smoking (5 sticks / day), Alcohol drinking (Once a fortnight)
Environmental Hx Living in 3rd floor of flat, difficulty in climbing the stairs, no difficulty in
sitting toilet
Working Hx Difficulty in getting in & out from the Taxi car
Socioeconomic Hx Married, living with wife and 2 children. (Have 4 children in total, another
two are working and studying outside)
PAIN
ASSESSMENT
Location BL anterior knee
Course Does not radiate, only localized pain inside of the anterior knee joints
Onset Gradually
Nature On & Off, Intermittently
Type Dull aching pain
24-hours behavior No morning stiffness, disturb sleep sometimes
Aggravating factors Climbing up & down the stairs, getting in & out of the car
Relieving factors Ointment and rest
Irritability Moderate (Need 30 minutes)
Current
Relieving Aggravating
• GENERAL HEALTH
• GOOD
• TYPE OF CAR USED IN WORKING
• MANUAL CAR (NEED TO USE MORE LEFT LEG TO PRESS THE CLUTCH)
OBJECTIVE
ASSESSMENT
GENERAL LOCAL
• Patient walked to the department in slow gait • No swelling in BL knee
speed (Normal gait pattern) with good ambulatory • No deformity is seen in BL knee
• Body size is endomorphic
• No muscle wasting is found
• Posture
• Anterior
• Rt sh. Is elevated, genu valgus
• Lateral
• Normal
• Posterior
• Rt sh. Is elevated, genu valgus
• No muscle spasm at BL knee
• No warmness at BL knee
• No tenderness is found around the BL knee joints
• Crepitus is present in BL knee when doing knee extension
Joints Movements Left Right
Hip Flexion
Extension
Abduction
Adduction
External Rotation
Internal Rotation AFROM AFROM
Knee Flexion
Extension (ERP) (ERP)
Ankle Dorsiflexion
Plantarflexion
Eversion
Inversion
Interpretation: ROM of BL LL have NAD, only BL kn. Ext. has end range pain (ERP) due to the
increase of friction between the degenerated joint surfaces.
Joints Movements Left Right
Hip Flexion 5/5 5/5
Extension 5/5 5/5
Abduction 5/5 5/5
Adduction 5/5 5/5
External Rotation 5/5 5/5
Internal Rotation 5/5 5/5
Knee Flexion 3/5 3/5
Extension 3/5 3/5
Ankle Dorsiflexion 5/5 5/5
Plantarflexion 5/5 5/5
Eversion 5/5 5/5
Inversion 5/5 5/5
Interpretation: Muscle strength is reduced in BL Kn. Jt. muscle groups
d/t the pain present that reduce the muscle strength.
R R
LT RT
N N N N
R R
Interpretation: Patellar mobility in the superior & inferior glide is
reduced d/t the pain present and lack of mobility.
Measurement Left Right
Q - angle 20 ᵒ 20 ᵒ
Interpretation: Q – angle is higher than the normal range among the males (13 ᵒ), thus genu valgus for BL
knee joints are present.
Muscles Left (cm) Right (cm) Differences (cm)
VMO 44 44 0
Quads 48 48 0
Hamstrings 52 52 1
Gastrocnemius 37 38.5 1.5
Interpretation: The muscles bulks have NAD, below 2cm of differences is considered as normal
Test Left (seconds) Right (seconds)
Standing on single leg > 10 > 10
Interpretation: This patient has good balance
SIT – TO – STAND TEST SLR 90 ᵒ - 90 ᵒ ALGOFUNCTIONAL INDEX
11 counts in 30 seconds -Ve for BL hamstrings Total score of 10
No signs of hamstrings tightness Grading of severe osteoarthritis
ANALYSIS
• Pain in the BL anterior knee, d/t the degenerative of joint surface causes the
pain symptoms that lead to increasing of the friction, as well as the obese that
putting more weight on the weight bearing joints
• Reduced muscle strength in BL knee joints, d/t the pain present that reduced
the muscle strength
• Patellar mobility is limited BL, d/t the pain present that lead to lack of
mobility during the daily life
PLAN OF CARE
• PAIN MANAGEMENT
• STRENGTH TRAINING
• PT EDUCATION ON HEP
SHORT TERM
GOALS
• To reduce the pain from 8/10 to 6/10 during the working hours in 1/52
• To maintain and improve the BL knee jt. muscles strength from 3/5 to 4/5 in 2/52
LONG TERM
GOALS
• To improve the ADL like climbing up & down the stairs and squatting with less or no pain
in 2/12
• To prevent complications like knee joint stiffness in 1/12
• To achieve the patient's goal of getting in & out of the car during the working with less
pain in 1/12
INTERVENTION
• PAIN MANAGEMENT
• Hot pack
• Supine lying, BL kn. jt. with hot pack, 15 minutes
• STRENGTH TRAINING
• Static quads exercise (SQE)
• Supine lying, contracting the quads and press on the bed alternatively, hold for 10 secs x 10 reps
• Inner range quads (IRQ)
• Supine lying, with knee slight flexed with a bolster under it, contracting the muscles alternatively,
hold for 10 secs x 10 reps
• Vastus medialis oblique (VMO)
• Sitting, with both legs holding a light ball, extending the knee joints BL, hold for 10 secs x 10 reps [CPG, MOH, Malaysia]
[Bennell K, et al., 2011]
• Knee flexion and extension isotonic strengthening exercise
• Sitting, BL leg wrapped with yellow Thera band, alternatively single knee extend and flex while
another leg is supported on the ground
• Hold for 10 secs x 10 reps
• Straight leg raising in 4 points (for the hips BL)
• Flexion – supine lying
• Extension – prone lying
• Abduction – side lying, exercising leg on top
• Adduction – side lying, exercising leg on bottom
• Hold for 10 seconds x 10 reps
• PT EDUCATION ON HEP
• Importance of exercise
• Complications of not exercising
[CPG, MOH, Malaysia]
• HEP – must do all the exercises above at least once in 2 hours daily, except for sleeping [Bennell K, et al., 2011]
hours
EVALUATION
• Pain has reduced to 4/10 after the pain management
• Patellar mobility has improved after the hot pack
• Patient was cooperative with the treatment
REVIEW
• VAS
• ROM
• MMT
• PATELLAR MOBILITY TEST
• BALANCE – TUG
• NEXT APPOINTMENT: 25TH AUG 2017 (8.30AM)
FOLLOW UP
ASSESSMENT
DEMOGRAPHIC
DATA
DEMOGRAPHIC DATA
Name Paramasivam A/L Apparu
Age 55 y/o
Gender Male
Occupation Taxi Driver (More than 5 years)
R/N SB 00811543
D.O.R. 4th July 2017 (Tues)
D.O.Ãx 25th Aug 2017 (Fri)
Dr. ∆ Left Knee Osteoarthritis
Dr. Mx. Conservative and Refer to Physiotherapy
SUBJECTIVE
ASSESSMENT
C/C Feel difficulty and pain in the both knees when climbing up & down the
stairs, squatting and getting in & out of the car
Left knee is more severe than the right knee
Current Hx Pt realized the first pain came during playing badminton in few months ago
Frequency of playing badminton: Twice a week previously, then reduce to
once a week after getting mild pain, then recently not playing anymore
Past Hx Had many falls and twisted injuries over the BL knees while playing
football in the teenage time
Physiotherapy Mx 2nd visit to physio
Other Mx Done Ointment and Traditional Chinese Medicine (Using Moxa Stick)
Found improvement in reduction of pain temporarily
PMHx High Cholesterol (At borderline, diagnosed in 10 years ago, not on
medications)
Medications NIL
Family Hx NIL
Surgical Hx NIL
Investigation Took 2 months ago (Showed positive of Lt OA)
Personal Hx Sitting and walking around the house compound (Sedentary Lifestyle)
Functional Limitation Climbing up & down the stairs, and squatting
Social Hx Smoking (5 sticks / day), Alcohol drinking (Once a fortnight)
Environmental Hx Living in 3rd floor of flat, difficulty in climbing the stairs, no difficulty in
sitting toilet
Working Hx Difficulty in getting in & out from the Taxi car
Socioeconomic Hx Married, living with wife and 2 children. (Have 4 children in total, another
two are working and studying outside)
PAIN
ASSESSMENT
Location BL anterior knee
Course Does not radiate, only localized pain inside of the anterior knee joints
Onset Gradually
Nature On & Off, Intermittently
Type Dull aching pain
24-hours behavior No morning stiffness, disturb sleep sometimes
Aggravating factors Climbing up & down the stairs, getting in & out of the car
Relieving factors Ointment and rest
Irritability Moderate (Need 30 minutes)
Current
Relieving Aggravating
• GENERAL HEALTH
• GOOD
• TYPE OF CAR USED IN WORKING
• MANUAL CAR (NEED TO USE MORE LEFT LEG TO PRESS THE CLUTCH)
OBJECTIVE
ASSESSMENT
GENERAL LOCAL
• Patient walked to the department in slow gait • No swelling in BL knee
speed (Normal gait pattern) with good ambulatory • No deformity is seen in BL knee
• Body size is endomorphic
• No muscle wasting is found
• Posture
• Anterior
• Normal, genu valgus
• Lateral
• Normal
• Posterior
• Normal, genu valgus
• No muscle spasm at BL knee
• No warmness at BL knee
• No tenderness is found around the BL knee jt
• Crepitus is present in BL knee when doing knee extension
Joints Movements Left Right
Hip Flexion
Extension
Abduction
Adduction
External Rotation
Internal Rotation AFROM AFROM
Knee Flexion
Extension (ERP) (ERP)
Ankle Dorsiflexion
Plantarflexion
Eversion
Inversion
Interpretation: ROM of BL LL have NAD, only BL kn. Ext. has end range pain (ERP) due to the
increase of friction between the degenerated joint surfaces.
Joints Movements Left Right
Hip Flexion 5/5 5/5
Extension 5/5 5/5
Abduction 5/5 5/5
Adduction 5/5 5/5
External Rotation 5/5 5/5
Internal Rotation 5/5 5/5
Knee Flexion 4/5 4/5
Extension 4/5 4/5
Ankle Dorsiflexion 5/5 5/5
Plantarflexion 5/5 5/5
Eversion 5/5 5/5
Inversion 5/5 5/5
Interpretation: Muscle strength is improved in the knee jt. muscles BL
after the prescription of strengthening exercise in the first visit.
N N
LT RT
N N N N
N N
Interpretation: Patellar mobility in BL are improved in all gliding directions
Muscles Left (cm) Right (cm) Differences (cm)
VMO 44 44 0
Quads 48.5 48 0.5
Hamstrings 53 53 0
Gastrocnemius 37.5 38.5 1
Interpretation: The muscles bulks have NAD, below 2cm of differences is considered as normal
Test Seconds to complete
Time up and go test 10
Interpretation: This patient has good balance, not at risk of falling
ANALYSIS
• Pain in the BL anterior knee, d/t the degenerative of joint surface causes the
pain symptoms that lead to increasing of the friction, as well as the obese that
putting more weight on the weight bearing joints
• Reduced muscle strength in BL knee joints, d/t the pain present that reduced
the muscle strength
PLAN OF CARE
• PAIN MANAGEMENT
• STRENGTH TRAINING
• ENDURANCE TRAINING
• PATIENT EDUCATION ON WEIGHT CONTROL
SHORT TERM
GOALS
• To reduce the pain from 8/10 to 6/10 during the working hours in 1/52
• To maintain and improve the BL knee jt. Muscles strength from 3/5 to 4/5 in 2/52
LONG TERM
GOALS
• To improve the ADL like climbing up & down the stairs and squatting with less or
no pain in 2/12
• To prevent complications like knee joint stiffness in 1/12
• To achieve the patient’s goal of getting in & out of the car during the working with
less pain in 1/12
• To reduce the patient’s body weight according to the BMI from obese groups to
overweight groups in 6/12
INTERVENTION
• PAIN MANAGEMENT
• Hot pack
• Supine lying, BL kn. Jt. with hot pack, 15 minutes
• STRENGTH TRAINING
• Static quads exercise (SQE)
• Supine lying, contracting the quads and press on the bed
alternatively, hold for 10 secs x 10 reps
• Inner range quads (IRQ)
• Supine lying, with knee slight flexed with a bolster under it,
contracting the muscles alternatively, hold for 10 secs x 10 reps
• Vastus medialis oblique (VMO)
[CPG, MOH, Malaysia]
• Sitting, with both legs holding a light ball, extending the knee joints [Bennell K, et al., 2011]
BL, hold for 10 secs x 10 reps
• Knee flexion and extension isotonic strengthening exercise
• Sitting, BL leg wrapped with yellow Theraband, alternatively single knee extend and flex while another
leg is supported on the ground
• Hold for 10 secs x 10 reps
• Straight leg raising in 4 points (for the hips BL)
• Flexion – supine lying
• Extension – prone lying
• Abduction – side lying, exercising leg on top
• Adduction – side lying, exercising leg on bottom
• Hold for 10 seconds x 10 reps
ADDITION OF STRENGTH TRAINING
• QUADS BENCH
• Sitting, knee extension alternatively, 0.5kg, hold for 10 seconds x 10 reps
• SQUATTING WITH HOLDING THE LADDER BARS [CPG, MOH, Malaysia]
• Mild squatting, hold for 10 seconds x 10 reps [Bennell K, et al., 2011]
• ENDURANCE TRAINING
• Static cycling, manual settings ( 55 y/o, 0.8kg/m², 15 minutes)
[CPG, MOH, Malaysia]
• PATIENT EDUCATION ON WEIGHT CONTROL
• Patient’s data
Data Findings
Height 170cm
Weight 91 kg
BMI 31.49 (Obese)
• Patient’s daily meal: 3 – 4 meals per day, more carbohydrate and
less veggies and fruits
• Encourage to take low dietary diet to control the weight
• Educate on the impact of heavy body weight on the knee joint
[Robin C, et al., 2015]
EVALUATION
• Pain has reduced to 4/10 after the pain management
• Patient was cooperative with the treatment
• Patient reported grade 3 of dyspnoea using Borg scale after the endurance training
• Patient able to perform the exercise taught in the first visits perfectly
REVIEW
• VAS
• MMT
• INCREASE THE RESISTANCE OF THE STRENGTH
TRAINING
• NEXT APPOINTMENT: 21ST SEPT 2017 (9.00AM)
• Bennell, K., Egerton, T., Wrigley, T., Hodges, P., Hunt, M., & Roos, E. Et al. (2011). Comparison of
Neuromuscular and Quadriceps Strengthening Exercise in the Treatment of Varus Malaligned knees with
medial knee osteoarthritis: a randomised controlled trial protocol, from
https://www.Ncbi.Nlm.Nih.Gov/pmc/articles/PMC3247187/
• Management of osteoarthritis (second edition), (Dec, 2015), Ministry of Health Malaysia,
file:///C:/users/user/downloads/draft_cpg_oa.Pdf
• Robin C, Marius H, Anthony R, et al.(2015), Effect of weight maintenance on symptoms of knee
osteoarthritis in obese patients: A twelve-month randomized controlled trial, Arthritis Care & Research
Vol. 67, no. 5, pp 640–650
• Treatment of Osteoarthritis of the Knee: Evidence-Based Guideline 2nd Edition, (May 2013), America
Academy of Orthopaedic Surgeons,
https://www.Aaos.Org/research/guidelines/treatmentofosteoarthritisofthekneeguideline.Pdf
• Carlos J, Schartess S, (Mar 2017), osteoarthritis differential diagnoses, medscape,
http://emedicine.Medscape.Com/article/330487-differential
• Hochberg, M., Altman, R., April, K., Benkhalti, M., Guyatt, G., & McGowan, J. et al. (2012). American
College of Rheumatology, Recommendations for the use of nonpharmacological and pharmacologic
therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care & Research, 64(4), 465-474.
http://dx.doi.org/10.1002/acr.21596
• Knee Osteoarthritis - Physiopedia. (2017). Physio-pedia.com, from https://www.physio-
pedia.com/Knee_Osteoarthritis
• Uth, K. (2014). Stem cell application for osteoarthritis in the knee joint: A minireview. World Journal Of
Stem Cells, 6(5), 629. http://dx.doi.org/10.4252/wjsc.v6.i5.629
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