PREVIEW ONLY 9/10/2013. OA knee - why physiotherapy should be the first line of treatment. Andrew Ellis. Jenny McConnell

Transcription

1 This webinar will begin in the next few minutes Need technical support for this live event? Please call , then press 1 NOTE: You will be initially asked for the address associated with this webinar account Say I m a webinar attendee I don t have an account OA knee - why physiotherapy should be the first line of treatment Andrew Ellis BSc (Ex. Sci), M. Phty World Health Webinars CEO World Health Webinars Host Musculoskeletal Physiotherapist Sydney CBD Presented by: Jenny McConnell Will commence LIVE from Sydney, AUS at Time 8pm AEDT Be sure to convert to your own time zone at Click red button to minimise Jenny McConnell Dodgy computer speakers? Select Telephone and call in toll - FREE to hear the presentation Specialist musculoskeletal physiotherapist Involved in research into patellofemoral, lower limb, shoulder and lumbar spine problems Published widely in these areas, has been an invited speaker at over 1 conferences both nationally and internationally You will be muted during every webinar. Make as much noise as you like :) Questions? We ll answer them all at the end Specialist Musculoskeletal Physiotherapist Editorial boards of Clinical Journal of Sports Medicine, British Journal of Sports Medicine, The Knee, Manual Therapy and Physical Medicine and Rehabilitation Awarded the prestigious F.E. Johnson Memorial Fellowship by the NSW Sporting Injuries Committee for outstanding achievement by an established researcher in the field of science and medicine in sport (26) Awarded a member of the Order of Australia honour for service to physiotherapy as a practitioner and researcher (29) Need technical support? Please call , then press 1 You will need to tell them that you are a webinar attendee and do not have an account with Citrix. 1

2 Incidence of OA Osteoarthritic Knee Why physiotherapy should be the first line of treatment Over 3.1 million Australians (16.5%) of the population suffer from arthritis. 75+ age group the number with arthritis rises to 53% increasing disability depression isolation increasing risk of falls. Financial burden Cost of arthritis is $9 billion - 1.4% of gross domestic product (GDP) in both direct and indirect (such as loss of income and early retirement) costs $2.24 billion direct cost Slides to the health are limited. system $9 million for hospitalisation $8.5 million spent on GP visits $2.2 million spent on specialist visits $1.4 million on other practitioners Osteoarthritis is the 4th largest contributor to years lost to disability but ranks as the 3rd largest contributor for women behind depression and dementia Incidence of joint replacement 21 Aust govt report Total knee arthroplasty 25,97 Total hip arthroplasty 18,847 TKR increased by 67% in 7 years from THR increased by 4% in same period. 15-3% patients report no or little functional improvement 12 months after TKR (Paulsen et al 211, St Vincents Hospital Melbourne). KNEE PAIN Where Full notes is available it coming after purchase from??? OA knee pain Severity of knee pain ranges widely in knee OA, from none or barely perceptible to immobilizing and disabling. 2

3 Severity of knee OA pain associated with Bone marrow lesions (oedema) with subarticular bone attrition (Torres et al 26, Moisio et al 29, Meredith el al 29) Synovitis/ effusion Degenerative meniscal tears Not associated with presence of osteophytes (Sengupta et al 26) Incidence of OA knee pain 71 adults >5 89% had structural abnormalities on MRI consistent with OA, only 29% complained of pain. most common abnormalities osteophytes (74%) bone marrow Full notes lesions available (52%). after purchase from BMLs fluctuate volume over 6-12 weeks BMLs strongly related to focal overloading of the joint, usually from mal-alignment due to fluctuating mechanical environment or undescribed temporary pathological change causing oedema and inflammation (Felson et al 212) OA knee pain In middle-aged individuals with decreased quadriceps strength increased knee pain (Amin et al 29) MRI demonstrates increased patellofemoral cartilage loss and tibiofemoral joint space narrowing (Segal et al 21) VM size associated with reduced knee pain at 2 years and reduced medial tibial condyle cartilage loss at 4.5 years from baseline MRI 117 OA knees (Wang et al 212) April 211 July 211 3

4 Potential sources of patellofemoral pain Synovium Subchondral bone Lateral retinaculum Infrapatellar fat pad OA knee pain 27 subjects baseline and 3 month F/U no correlation baseline synovitis with baseline pain score Change in synovitis at F/U correlated with change in pain Effusion change not associated with pain change. 3 locations for synovitis (supra, medial, IFP) IFP changes most strongly related to pain. cartilage loss > 5% of knees, but synovitis not associated with cartilage loss in either TF or PF compartments. (Hill et al 27) Anatomy of the infrapatellar fat pad Covers extra-articular part posterior patellar surface Superiorly-merges with the peripatellar fold Posteriorly extends into ligamentum mucosum Lined by synovium Function of the infrapatellar fat pad After fat pad resection facilitates distribution of synovial fluid alters knee biomechanics stabilises the patella in the extremes of knee motion <2o & >1o increases tibial external rotation total resection of the fat pad decreases patellofemoral contact area Bohnsack et al, 25 4

5 Infrapatellar Fat Pad One of the most pain sensitive structures in knee Dye et al (1998), Bohnsack et al, (24) 78% college athletes These diagnosed notes with are patellar a preview. tendinosis over 6 month period, showed increased signal in fat pad Slides on MRI-suggestive are limited. of oedema Brukner et al (21) MRI of fat pad. abnormalities most commonly consequence of trauma and degeneration commonest traumatic lesions follow arthroscopy impingement occurs following patellar dislocation Saddik et al (24) MRI sequelae of knee trauma Post dislocation. shear injury from the inferior pole of the patella intrasubstance disruption with fluid filled clefts diffuse oedema of fat pad. occasionally the damaged fat pad mimicked a loose body (Apostolaki 1999) Post arthroscopy fibrous scar peaks within 6 months Disappears by 12 months on MR in 5% subjects (Tang et al 2) Background Evidence of the fat pad as a pain generating structure German Albert Hoffa forefather of modern orthopaedic surgery after textbook published in described impingement of the fat pad pain is felt quite suddenly on the medial side of the joint; difficulty bending and straightening the knee swelling of the knee joint on both sides of the patella Hoffa s syndrome attributed to direct blow higher numbers of substance-p nerve fibres in PF patients in the medial retinaculum and fat pad. A substance-p-mediated hyper vascularization extravasation of plasmaproteins oedema of the fat pad Chronic hypertrophy of the fat pad with soft tissue impingement chronic compression and ischemia increased distribution of substance-p fibres. Chronic inflammation of the infrapatellar fat pad anterior knee pain. Bohnsack et al, 25 Witonski et al Wojtys et al 199 Infrapatellar Fat Pad One of the most pain sensitive structures in knee Dye et al (1998), Bohnsack et al, (24) 78% college athletes diagnosed These notes with patellar are a tendinosis preview. over 6 month period, showed increased signal in fat pad on MRI-suggestive of oedema Brukner et al (21) MRI of fat pad. abnormalities most commonly consequence of trauma and degeneration commonest traumatic lesions follow arthroscopy impingement occurs following patellar dislocation Saddik et al (24) Method - Evidence of the fat pad as a pain generating structure 11 healthy subjects ml 5% hypertonic saline injection position medial fat pad, superolateral at a 45 o angle, ~ 1 mm depth Examined severity distribution time course of pain Injection site Interactive Knee 1.1 (c) 2 Primal Pictures Ltd. (Bennell et al 24) 5

6 Size of pain region (circle diameter (cm)) VAS (cm) 9/1/213 Conclusions Effects of Pain on Quadriceps amplitude Infrapatellar fat pad is a potent source of anterior knee symptoms - VAS 6 (range 3-1) Pain is not isolated to the fat pad region (2 proximal thigh, 1 groin) Pain is deep and often retropatellar 1.2 VMO VL A Severity of pain Proportion Change from Baseline 1 Pain 4 B Time (min) Size of pain region Time (min).6 * * * p <.5 Treatment Explanation to patient Unload painful structures Stabilising unstable These patella notes are a preview. restore the dynamic balance Slides of are quadriceps limited. muscle inhibit VL improve lower limb mechanics improve anterior hip flexibility - improve gluteal contraction Decrease swelling (home program) Unloading painful fat pad Gluteal taping Effect of gluteal tape on hip extension 15 stroke patients 2 11 years post stroke 2 walking speeds self selected and Full fast notes available after purchase from 3 conditions control, placebo, therapeutic Measured hip extension angle S. Kilbreath, S. Perkins, J. McConnell, J. Crosbie, 26 6

7 Results therapeutic tape inc hip ext from 3 o flexion to 11 o ext (ss) therapeutic tape inc hip ext from 3 o flexion 8 o (fast) JOINT ANGLES Self Selected Speed Fast Speed A. Hip extension B. Pelvic rotation in Angle (degrees) in Angle (degrees) -2 What sort of muscle training??? C. Thigh extension in Angle (degrees) Control Sham Gluteal Tape Tape Condition Control Sham Gluteal Tape Tape Condition Specificity of training Exercise regime for OA knee Limb position Joint angle Velocity of contraction Type and force of contraction how to get in and out of a chair without using the hands instruction to facilitate stair negotiation weight bearing gluteal exercises, which were tailored to the individual prone figure four hip stretches small knee bends with gluteal squeeze. Subjects were also asked to adopt a modified ballet 3 rd position, involving slight femoral external rotation and the legs touching with soft, not locked knees, whenever they had to stand for prolonged periods Evidence for treatment success MRI pre and post 5-6 Rxs of physiotherapy for 12 patients (MRI 1 months after cessation of physio) Patella medial by 1.2mm (p =.1), rolled 2 o more varus (p=.1) 2.5mm higher (p=.5). Fat pad perimeter had decreased by 4.1mm Fat pad signal decreased in all subjects. two distinct patterns of resolving fat pad oedema patellofemoral pattern tibiofemoral pattern Live Q & A With Jenny McConnell 7

8 Coming up next Facebook, Twitter, LinkedIn, Google + Live Q & A With Jenny McConnell Thank you From Jenny McConnell & World Health Webinars Australia 8