(I) Overview
Osteoarthritis (OA) is one of the most common, slowly developing chronic degenerative arthritis of the knee, also known as degenerative knee arthropathy and osteoarthropathy. It is characterized by primary or secondary degenerative changes in the knee cartilage, subchondral bone sclerosis or cystic changes, osteophytes at the joint edges, synovial hyperplasia, narrowing of the joint space, joint capsule contracture, ligament relaxation or contracture, muscle atrophy and weakness, etc., resulting in varying degrees of pain, tenderness, swelling, friction sounds, deformation, knee flexion or extension disorders, joint stiffness and instability, leading to reduced function or even loss of The degeneration affects the patient’s self-care and participation in social activities. The cause of degeneration is still unknown, but the strain on the joint surface and nutritional disorders are important predisposing factors.
Primary OA occurs mostly in middle-aged and elderly people, the incidence increases with age, more women than men, and the prevalence can reach 50% in people over 60 years of age and 80% in people over 75 years of age. The disability rate of the disease can be as high as 53%. There is no clear systemic or local cause, and there is a relationship with genetics, obesity, endocrine, metabolic disorders and trauma, wear and tear, etc. OA is more likely to occur in joints with high load and high activity, such as the knee, spine (cervical and lumbar spine), hip, ankle, hand and other joints. The incidence of the knee joint is the highest. Epidemiological surveys show that the incidence of OA in the knee is 44% to 70% in people over 55 years of age. The disease is closely related to the stress load on the joints, obese people have a greater stress load on the joints of the lower limbs, prone to the disease.
Secondary OA can occur at any age, often secondary to the following conditions: (1) congenital joint deformity; (2) various causes of uneven joint surface; (3) extra-articular deformity resulting in poor joint alignment; (4) joint instability; (5) certain joint diseases that damage the articular cartilage; (6) medical factors, such as the long-term inappropriate use of corticosteroids caused by articular cartilage lesions.
(B) Main functional disorders
1.Joint pain and pressure pain The most prominent symptom is pain in the affected joints, which is mild or moderate intermittent hidden pain at the beginning, improving at rest and worsening after activity. In the late stage, the pain and muscle spasm are aggravated and persistent, and cannot be relieved quickly after rest. Nocturnal pain is common in this stage. The cartilage is not innervated and insensitive to pain, and the pain comes from intra-articular and periarticular structures. The pain comes from the intra-articular and peri-articular structures. As the synovial membrane is congested after the cartilage injury, it causes joint adhesions, thickening of the joint capsule and shortening due to the fibrosis of the joint capsule, which stimulates the nerves in the capsule when the joint moves and causes pain. There is localized pressure pain in the joint, which is especially obvious when accompanied by joint swelling.
2. Stiffness At the beginning of the disease, stiffness and tightness in the hip and knee may occur after rest or when the position changes, such as when rising in the morning or when sitting for a long time, and improves after activity. The stiffness of the joints increases when the air pressure decreases or the air humidity increases. In the late stage, the symptoms become worse, the intervals become shorter, the stiffness time is prolonged, and finally it can be continuous as the disease develops.
3.Sensory-motor disorders Disuse atrophy of muscles around the affected joints, swollen and deformed joints, restricted movement, decreased skin elasticity, localized coldness and numbness.
4.X-ray changes The clinical symptoms are not proportional to the changes in the X-ray film. In the early stage of the disease, X-ray examination can be normal; as the disease progresses, the following changes may occur: asymmetric joint space narrowing, subchondral bone sclerosis and/or cystic changes, irregular joint surface, sharp or blunt intercondylar elevation, joint edge hyperplasia and bone superfluous formation or with varying degrees of joint effusion, some of the joints can be seen free bodies, and even joint deformation (knee inversion).
Osteoarthritis usually progresses slowly and only affects the affected joint itself, but very few patients have joint destruction and joint deformity.
(iii) Rehabilitation assessment
The assessment of knee OA should focus on the biomechanics of the joint and the impact of its dysfunction on the adjacent joints, as well as the degree of impact on the patient’s independence and quality of life.
Pain assessment can be based on the patient’s assessment of the location, nature, degree, duration, relief, type and amount of pain medication, etc., and can also be assessed by visual analogy scoring (VAS).
2. Assessment of joint pressure pain Ritchie joint index is mostly used.
3. Muscle strength measurement The degree of muscle strength loss can be judged by the freehand muscle strength test method or isometric muscle strength tester.
4. Evaluation of joint range of motion (ROM) The range of motion of the joint can be measured with a protractor as a comparison before and after rehabilitation treatment.
5.Deformity analysis Knee inversion deformity is the most common, which affects normal gait, and also affects the normal biological force line and load of hip and ankle joints.
6.Walking ability The ability to stand, complete the transition from sitting to standing position, walking distance, indoor and outdoor walking, going up and down stairs, etc., and combined with 15 meters walking time to assess.
7.Ability to perform activities of daily living (ADL) assessment For symptom onset and remission period with dysfunction or deformity, the patient’s ADL should be directly tested. Although muscle strength and joint ROM assessments have some reference value for inferring joint function, such inferences are often not definitive enough. Because pain often affects the functional performance of patients with OA, direct testing of the patient’s joint motion necessary for independent living is needed.
(iv) Rehabilitation therapy
The disease is characterized by intermittent episodes. For those with local pain and swelling and other symptoms and functional impairment, rehabilitation treatment based on drug therapy can reduce or eliminate pain, correct deformity, delay the progress of the disease, improve or restore joint function and improve the quality of life.
Rehabilitation treatment goals: ① Reduce inflammation and swelling, relieve pain. ②Reducing joint load, maintaining and restoring joint and limb movement functions. ③Enhance the muscle strength of the affected limb and prevent and treat muscular atrophy. ④Increase joint stability, prevent joint deformity and pain recurrence.
1. Rehabilitation treatment during the attack period
(1) Balance between rest and braking: bed rest is generally not necessary. Once the joint swelling and pain worsen, bed rest should be appropriate to reduce activities, pay attention to maintaining the correct position of the joint, and short-term fixation with braces or splints if necessary. Too much rest will cause stiffness, and too much activity will aggravate the symptoms, so rest and activity should be reasonably arranged. In the early stage, muscle isometric contraction exercises can be performed, especially for quadriceps, or active plus assisted exercises to relieve pain, prevent muscle atrophy and adhesions, and maintain joint ROM.
(2) Drug therapy: ① Topical drug therapy: emulsions, creams, patches and non-NSAIDs rubs (capsaicin, Qingpeng cream, etc.) of various non-steroidal anti-inflammatory drugs (NSAIDs) can be used. Topical topical medications can effectively relieve mild to moderate joint pain with mild adverse effects. ② Systemic analgesic drugs: based on the route of administration, they are divided into oral drugs, injections, and suppositories. Risk assessment should be conducted before drug administration to pay attention to the risk of potential medical diseases; dose should be individualized according to the patient’s condition; the lowest effective dose should be used as much as possible to avoid overdose and repeated or superimposed use of similar drugs. In mild cases, acetaminophen (paracetamol) is generally used, and NSAIDs are used on a case-by-case basis in more severe cases or when the efficacy is poor. In patients with OA who are ineffective or intolerant to NSAIDs treatment, other analgesic drugs such as @@@@@@, opioid analgesics, or a combination of acetaminophen and opioids may be used. (③ joint cavity injection: such as sodium hyaluronate class viscoelastic supplement injection, the joint fluid should be aspirated before injection, once a week, 5 times for a course of treatment, the efficacy lasts about six months to 1 year; for NSAIDs treatment for 4-6 weeks is not effective in severe OA or can not tolerate NSAIDs treatment, persistent pain, inflammation is obvious, intra-articular injection of glucocorticoids is also feasible, but any intra-articular injection per year The maximum number of intra-articular injections should not exceed 3~4 times per year. (4) Condition improving drugs and chondroprotective agents: glucosamine, diacerein, doxycycline, etc. These drugs can slow down the course of the disease and improve the patient’s symptoms to a certain extent. They can be used as basic and long-term drugs.
(3) Physical factor treatment: application of low and medium frequency electrotherapy (audio electricity, interference electricity, modulated medium frequency electricity, etc.) can promote local blood circulation and relieve pain; application of high frequency electrotherapy (such as short wave, ultra short wave, microwave therapy, etc.) has anti-inflammatory and analgesic effects, relieves muscle spasm and improves blood circulation, and it is appropriate to use no heat in the acute stage; and hydrotherapy [hot water bath (water temperature at 36. ~ 38.), mineral bath, drug bath The use of appropriate techniques can not only reduce joint pain, but also effectively relieve joint swelling and improve joint movement function.
(4) Exercise therapy: joint mobility training, muscle strengthening training mainly for quadriceps, muscle strengthening training for quadriceps is not advocated in the early stage of knee flexion disorder, and should be performed after the knee joint is flexed to a more ideal angle. The amount of activity indicated: it is appropriate to have mild pain after the activity. If the pain does not disappear the day after the activity, the activity is too much and should be adjusted.
The remission period is the period when the symptoms are obviously reduced and the functional disorders remain.
(1) Prevention of joint flexion deformity
The flexion deformity of the knee joint not only seriously affects the patient’s walking function, but also is a problem that is difficult to be solved by rehabilitation and surgical treatment.
1）Active knee extension training: supine position, extend the affected limb to the maximum angle possible, while stirring the heel and hooking the toe, each action time to feel fatigue. 10pcs/group, 3 groups/time, 2-3 times/day.
2) Manipulative treatment.
Supine position: with relaxation of the thigh flexor group, use continuous stretching techniques to straighten the knee joint.
Prone position: first relax the thigh flexor group, move the affected knee to the edge of the bed with the upper edge of the patella on the edge of the bed, the therapist fixes one hand on the thigh and acts on the calf with the other hand to straighten the knee.
3) Weighted compression straightening.
In the supine position, the affected limb is extended and a sandbag is added above the knee joint, the weight of which is determined by the patient’s tolerance. Generally the weight of the pressurized weight to be able to continue to pressurize the weight for 30 minutes is appropriate. In the first ten minutes there is no obvious pain, the joint is basically in a relaxed state, in the middle ten minutes mild pain, after ten minutes obvious pain, but not barely tolerated. If the duration is too short, the weight is too large; if the duration is too long and there is no response, the weight is too small. Sui is improved by padding the heel to obtain a greater effect.
(2) Maintenance of joint mobility
(1) Active training.
The magnitude of joint training is appropriate to produce mild pain, not forced to do large flexion and extension activities.
(2) Manipulation: Use various manipulative techniques to improve knee flexion function.
Knee flexion techniques
a. Prone knee flexion: ① prone position, fixed thigh, passive flexion of the lower leg; ② prone position, passive flexion of the knee while extending the hip joint, while flexing the knee can stretch the muscles of the anterior thigh group.
b. Seated knee flexion: sitting position, knee placed on the side of the treatment table, fixed thigh therapist with hand or N fossa to add force to the affected limb in front of the tibia to flex the knee.
c. Patellar sliding: supine position, knee padded with a small pillow, causing slight flexion. ① Patella slides downward; ② Patella slides in multiple directions see Chapter 2, Section 5. ③ patella sliding laterally; ④ patella sliding medially: place one hand on the N fossa to fix the knee joint, place the palm root of the other hand on the lateral patella, straighten the elbow, and push the patella in the medial direction.
d. Tibial sliding: ① Tibial sliding posteriorly: supine position, bend the knee about 25ο . One hand is placed on the outside of the thigh at the lower femur N fossa to fix the knee, the other hand is placed at the tibial ridge with the tiger’s mouth, elbow straightened, and force towards the posterior tibia to make it slide backward. ②The tibia slides medially, see Chapter 2, Section 5. ③ tibia sliding to the lateral side: the same method as above, in the opposite direction.
e. Knee concave sliding method: prone position with knee flexed. The distal calf of the affected limb is placed under the armpit of the therapist, and the therapist places one hand behind the proximal calf and the other hand in front of the proximal calf. While the upper body exerts force on the distal calf to make the knee flex, the hand in front of the tibia simultaneously exerts force to the posterior tibia, causing the tibia to slide backward.
f. Femoral-tibial separation exercise: prone position, thigh fixed, knee flexed about 25ο The therapist holds the affected condyle with both hands and pulls along the long axis of the lower leg to separate the femoral-tibial joint surface. The amount of force used depends on the condition and the patient’s pain.
Knee extension technique
a. In the supine position, place both hands on the knee and apply downward pressure to straighten the knee.
b. In the prone position, with the thighs fixed, the hands are placed behind the distal calf and downward pressure is applied to straighten the knee.
c. Proximal sliding of the hip: supine position with a small pillow under the knee to make it slightly flexed. The heel of the palm of one hand is placed on the lower pole of the hip bone, the other hand is placed on the back of its hand, both elbows are straightened, and the hip bone is pushed in the direction of the upper pole.
d. Anterior sliding of the tibia: supine position with the knee flexed about 25°. One hand is placed on the lower femur in front of the thigh to fix the knee, and the other hand is placed on the proximal N fossa of the calf, pushing toward the front of the tibia to make the tibia slide forward.
e. Lateral sliding of the tibia: as described previously.
3) CPM.
Used as an adjunctive treatment device to maintain joint mobility, not for increasing joint mobility. Set the angle to cause mild joint pain and not to produce significant pain. The speed should be as low as possible.
CPM produces cyclic pressure changes that promote synovial fluid circulation, diffusion, and improved cartilage nutrition and metabolism. Promotes repair of full-layer articular cartilage defects, collagen and proteoglycan synthesis.
4) Joint traction.
Joints with flexion or extension disorders, where the above methods are ineffective, can use joint traction. At present, intelligent joint rehabilitation system is used for joint traction treatment is more ideal.
(3) Maintain and increase muscle strength
(1) Isometric contraction training: knee extension position, static isometric contraction.
2) Isotonic training: strengthen muscle strength and enhance knee joint stability.
3) Multi-angle (multi-point) resistance training
Multi-angle resistance training can effectively improve the end strength of the joint, enhance the maximum load in knee extension, and also avoid the angle that produces joint pain. The patient is seated with the knee at the side of the treatment bed, and at different angles of knee extension, a certain amount of resistance is applied to keep the knee extension muscles in an isometric contraction. This exercise is focused on the angles where muscle strength is significantly weakened. In angles where pain is present, this training is not done, but resistance training is done in positions greater and less than the painful angle, which can lead to pain relief.
4) Hyperextension training
Knee hyperextension training helps to improve the end angle weakness of the quadriceps.
(4) Joint stability training
(1) Strengthening medial femoral muscle training
Low-frequency modulated medium-frequency electrical stimulation of the medial femoral muscle can enhance knee stability.
2）Standing position weight shift
3）Training with foot pads of different textures
(4) Practicing joint control in different positions with the help of apparatus.
(5) Occupational therapy
Although exercise therapy is most commonly used in the treatment of knee osteoarthritis, occupational therapy should not be ignored. Depending on the specific condition, treatment methods can be designed to increase the patient’s ability to perform daily activities.
(6) Orthopedic braces and aids
Used to reduce the weight-bearing of the affected joint.
Knee brace: For patients with knee OA and unstable knee joints. It can improve the stability of the knee joint, reduce pain and improve walking ability after use.
Cane: For patients with knee OA who have difficulty in supporting weight due to joint pain or muscle weakness caused by weight-bearing on the lower limbs while walking. The cane is used to reduce the load on the joint.
Wheelchair: used by those who cannot walk on the knee.
(7) Psychotherapy
Knee OA patients, often depressed anxiety and other symptoms, should be timely psychological counseling, so that patients in the awareness of self-adjustment, enhance confidence in the treatment. The improvement of the psychological state can help prevent and control pain and improve the therapeutic effect.
(8) Health education
(1) Regulation of lifestyle.
Reduce unreasonable exercise, reduce the total amount of daily exercise, and use movements that reduce joint load to complete daily life activities. Avoid risk factors and protect the knee joint.
2) Appropriate aerobic exercise: cycling, swimming, walking, tai chi, etc.
3) Weight reduction: to reduce the load on the knee joint.
(4) Quit smoking: smoking can promote osteoarthritis symptoms.
(9) Surgical treatment
If non-surgical treatment is ineffective, and the condition is progressively aggravated and seriously affects daily life and work, surgical treatment can be considered. For example, the use of arthroscopy can clarify the diagnosis, make flushing treatment, remove the free body and remove bone superfluous. If necessary, surgical treatment can be considered, such as high tibial osteotomy and knee arthroplasty to change the line of force.
The purpose of surgical treatment: (1) to reduce or eliminate pain and improve joint function; (2) to prevent further aggravation of joint damage; (3) to prevent and correct deformity; and (4) to improve the patient’s quality of life.
(10) Other treatments
Autologous or allogeneic tissues and artificial matrix for biological repair of articular cartilage defects have entered the clinical application stage and have a certain role in promoting cartilage repair. In addition, gene therapy is also being studied.
(V) Prevention methods
1, functional training The muscle strength of the distal lower extremity can protect the knee joint to reduce the occurrence of OA, and for patients who already suffer from osteoarthritis of the knee, it can stop its progress. Aerobic exercise can help improve osteoarthritis-related joint dysfunction and overall condition.
2, reduce body weight can considerably reduce the occurrence of symptomatic knee OA. The average weight of people has been on the rise in recent years, and obesity is the main reason for the high incidence of knee OA in middle-aged and older women. Therefore, the implementation of weight loss measures and weight control in this age group is one of the effective prevention methods.
3, to develop the correct posture of life and work, reduce sports injuries, can somehow reduce the incidence of knee OA, especially in men. Joint trauma poses a greater risk to the development of knee OA in men. Factors such as bending the knee to carry heavy objects, wrong training and exercise methods, and unprotected work practices are all factors that contribute to the high incidence of knee OA. Changing the work style, reasonable exercise training will help reduce the occurrence of osteoarthritis of the knee.
4, good education to strengthen the correct exercise of muscles and joints, develop the correct posture of life and work to reduce the possibility of injury, reasonable and timely supplementation of calcium and microestrogens, adjust the nutritional structure and make it balanced and enhance the overall function of the knee OA prevention and treatment methods.