Treatment of osteoarthritis of the hip or knee before surgery a stepped-care strategy

Published in BMC Family Practice, 03/13/2013 Dr. Smink and team from Department of Rheumatology, Orthopaedics, Rehabilitation Medicine and General practice of the Sint Maartenskliniek, University Netherlands discuss a  SCS = stepped care strategy for Osteoarthritis (OA) patients prior to total knee and total hip surgery.

Osteoarthritis (OA) of the hip or knee is a common joint disorder leading to pain and functional impairment. Pharmacological and non-pharmacological treatment modalities are the core treatment for OA including physical therapy. In Holland, patients with OA are treated in general practice for approximately 82 months before they are referred to an orthopaedic department.

The group developed a set of clinical practice guidelines (CPGs) to manage hip or knee OA known as the based stepped-care strategy and BART, i.e. Beating Osteoarthritis, to improve the management of hip or knee OA . SCS includes physical therapy as well as (TENS), hyaluronic acid, and glucocorticoid injection and other pain killers together with lifestyle advice.

Partial and Total Knee replacement

What is the difference between partial and total knee replacement?

A replacement of the weight-bearing surfaces in patients suffering from arthritis mainly osteoarthritis is indicated when the pain is unbearable and effects the patients walking ability and quality of life.

The knee has three compartments – the inside aspect of the knee n the medial compartment , the outside of the knee – the lateral compartmentand the patellofemoral compartment is the front of the knee. The medial compartment is usually affected by osteoarthritis followed by the lateral compartment.

A total knee replacement is when all three compartments of the knee are replaced. In comparison to this a Partial knee replacement or Unicompartmental knee replacement is when one of the knee compartments only is replaced.

By removing less bone and trying to maintain most of the patient’s bone and anatomy a partial knee replacement will cause less trauma or damage than traditional Total knee replacement. This coupled to the potential use of smaller implants will also allow more of the patient’s bone to be kept and can help the patient return to normal function faster.

However a partial knee surgery is only possible if the arthritis in the knee is confined to a limited area.  If the arthritis is more widespread, then the partial knee replacement will not be considered. In addition a partial knee surgery is usually recommended in patients who are older than 55 years and relatively sedentary but not obese.

Partial knee replacement has the following benefits:

* The incision size is about 1/3 of that of a total knee replacement.
* The operation is usually accompanied by less pain and tha patient may leave the hospital the day after surgery.
* The physical rehabilitation process is quicker and patients can expect to be walking with just a stick with a return to their routine activities in just 4 to 6 weeks
* The range of motion of the knee usually approaches that of a normal knee making functional activities easier.

There are risks though which include:

* A higher rate of revising the partial knee replacement than total knee replacement. This revision may be associated with a worse functional outcome than if the total knee had been replaced in the beginning.

Knee Surgery Rehabilitation* Some patients may develop arthritis in other areas of the knee resulting in revision surgery.

*  Some patients may wear out the unicompartmental knee implant resulting in revision surgery.

However long-term results are very good when the minimally invasive Partial knee replacement is done on the right cohort of patient and when a partial knee replacement is done on a properly selected patient the results are quite successful.

Step By Step Osteoarthritis Exercise Program

Always consult with your doctor before beginning an exercise program if you have osteoarthritis.

 

Stretching the Hamstring

 Walk for 5 minutes as a warmup.  Stretch. Lie down. Put a  bed sheet around your right foot and use it to help pull and stretch your leg up. Hold that position for 20 seconds. Repeat this twice, then switch legs. There are 3  important types of exercises for knee OA. Range of motion or stretching exercises which keep you limber. Strengthening exercises which build muscle strength in order to stabilize weak joints. Aerobic exercises, like walking, which help the lung and heart.

Stretching exercises help loosen muscles and improve flexibility. They also help prevent pain and injury.

While using a chair for balance, bend your right leg then step back with your left leg, slowly straightening it behind you. Press your left heel towards the floor. You will now feel the stretch in your back leg.

If you want more of a stretch then lean forward while bending the right knee deeper. However don’t let the right knee go past your toes. Hold this position for 20 seconds. Do it twice and then switch legs.

 Straight Leg Raise

 Lie on the floor and prop your back up on your elbows. Bend your left knee while keeping your foot on the floor. Keep the right leg straight with your toes pointed up. Tighten the thigh muscles of your right leg. Smoothly and slowly  use your thigh muscles — but not your back — to raise your leg.

Pause for five seconds. While your thigh is still tight, slowly lower your leg to the ground. Relax. Repeat this 10 times. Rest. Do another 10 sets; then switch legs.

Quad Set

If the straight leg raise is too tough then do quad sets instead. With these you don’t have to raise your leg. Just tighten the thigh muscles (quadriceps) of one leg at a time.

Begin by lying on the floor keeping both legs on the ground, relaxed. Flex and hold your left leg tense for five seconds and then  relax. Do 2 sets of 10. Then, switch to the other leg.

Seated Hip March

Doing this can strengthen hips and thigh muscles to help you with daily activities, like walking or getting up  from a chair.

Sit up straight in the chair.  Kick back your left foot but keep your toes on the floor. Lift your right foot off the floor while keeping your knee bent. Hold your right leg in the air for five seconds. Slowly lower your foot to the ground. Repeat this 10 times. Then rest and do another 10 after which you should  switch legs. If this is too hard use your hands to help raise your leg.

Pillow Squeeze

This will help strengthen the inside of your legs to give support to your knee. Lie on your back with both knees bent. Put a pillow between your knees.

Squeeze your knees together, squishing the pillow between them. Hold this for five seconds then relax. Repeat the set 10 times. Rest, then do another set of 10.

If this is too hard you can  do this exercise while seated.

Heel Raise

Hold the back of a chair for support. Stand straight and tall. Lift your heels off the ground and rise up on the toes of both feet. Hold it there for five seconds. Slowly lower both heels to the ground. Repeat this 10 times then rest and do another 10.

If this is too hard do the same exercise while sitting in a chair.

Side Leg Raise

Hold the back of a chair for balance. Place your body’s weight on your left leg. Lift the right leg outwards to the side. Keep your right leg straight. Keep your outer leg muscles tensed. Try not to slouch. Lower your right leg and relax. Repeat this 10 times. Rest. Do another 10 sets, then repeat  it with your left leg.

If this is too hard increase the leg height over time. Following a few workouts, you’ll be able to raise your leg higher.

Sit to Stand

Practice this move in order to make standing easier. Put two pillows on a chair. Sit on top of them, with your back straight and feet flat on the floor. While using your leg muscles, slowly and smoothly stand up tall. Then, slowly lower yourself back down to a sitting position. Make sure your bent knees don’t move in front  of your toes. Try this also with arms crossed  or loose to your side.

If this is too hard  add pillows or use a chair with armrests and then  help push up with your arms.

One Leg Balance

Try doing this hands-free or steady yourself on a chair, if necessary. Now, shift your body weight to one leg but don’t lock your knee straight. Then slowly raise the other foot off the ground, balancing on your standing leg. Hold that for 20 seconds then lower your  raised foot to the ground. Do this twice, then switch legs. This move helps you when getting out of cars or bending.

If you find this too easy, balance for a longer time. Or do it with your eyes closed.

Step Ups

This move can help you strengthen your legs for stair climbing. Face a stable step with both feet on the ground. First, step up with your left foot then follow with your right foot. Now, stand on top, tall and while both feet are flat. Climb down in the reverse order: Right foot down first, then left. Do this 10 times then rest and  repeat another 10 times. Now do it starting with your right leg first. If this is too  hard try using a railing, wall, a lower step or lamppost for balance.

Walking

If you have  stiff or sore knees you may not think that walking is a great idea but it actually is one of the best exercises for knee arthritis. Not only  can it reduce joint pain but it can also strengthen your leg muscles and improve flexibility. It’s also good for your heart and the best part is that there are no gym membership fees needed.

Having a good form is key: Look forward, keep your arms and legs moving, relaxed and walk tall.

Low-Impact Activities

Losing weight is a side benefit of being active and exercising. It also takes pressure off your joints. Other exercises that are easy on the knees are  swimming, biking and water aerobics. Water exercise can take weight off painful joints.

It isn’t necessary to give up your favorite activities, like golf. Discuss with  your doctor or physical therapist about modifying painful moves.

How Much Exercise?

Start with just a little. If there is no pain, do more next time. Try to aim for 30 minutes a day.

In the course of time you’ll build your leg muscles which will support your knee and increase flexibility.

It is normal to have some  muscle soreness  but hurting or swollen joints should have rest. Take a break and ask your doctor for advice. Ice painful joints and take ibuprofen, naproxen  or acetaminophen as a pain reliever.

Using physical therapy solutions and products is also an effective way to strengthen leg muscles which can alleviate osteoarthritis pain. The LEGTUTOR is one such device that can be used.

 The LEGTUTOR system is a key component of physical therapy used after total knee or hip  replacement and other knee and hip surgery. The LEGTUTOR is an ergonomic wearable leg brace with dedicated rehabilitation software.  The LEGTUTOR rehabilitation concept is based on performing controlled exercise rehabilitation practice at a patient customized level with real time accurate feedback on the patient’s performance. This means that the LEGTUTOR system allows the physical therapist to prescribe a leg rehabilitation program customized to the patient’s knee and hip movement ability at their stage of rehabilitation. The LEGTUTOR uses biofeedback to keep the patient motivated to do the exercise practice with those that were designed in the form of challenging games. They are suitable for a wide variety of other neurological and orthopedic injuries and diseases as well as post trauma and orthopedic surgery.

 The LEGTUTOR is also used by physical and occupational therapists in combination with the HANDTUTOR, ARMTUTOR and 3DTUTOR for upper and lower extremity rehabilitation. The TUTOR system is used by many leading rehabilitation centers worldwide and has full FDA and CE certification. It is designed for children and adults and can be used at home supported by telerehabilitation. See WWW.MEDITOUCH.CO.IL for more information.

Maintenance Care for Arthritis Sufferers

According to the U.S. Center of Disease Control and Prevention (CDC) arthritis contributes to physical inactivity in the general population. Even though arthritis may prevent adults from engaging in physical activity there are some interventions that can benefit those people. Statistically, more than 30% of adults with arthritis (in 23 states) have no leisure time physical activity. The reasons for inactivity among arthritis sufferers include pain, fear of worsening the arthritis, ignorance of what the best type of exercise is beneficial for them and fear of being injured.

The way to counteract these problems is by having advertising campaigns through health and community organizations. Exercising methods that are safe and effective should be described for arthritis sufferers. The CDC has two such programs  currently in use. One is  ”Physical Activity. The Arthritis Pain Reliever” for English speakers and ”Buenos Dias Arthritis” for Spanish speakers. These programs increase knowledge about and initiate physical activity. Much of the programming is free. Adults with arthritis can become physically active by engaging in safe and effective group exercises. In addition the group provides social support. The venues for these activities are senior centers, Area Agencies on Aging, YMCAs, parks and recreation departments, churches and others.

Although there is no known cure for arthritis there are ways to maintain current strength and that is by having an intensive and customized exercise program. One of the most sophisticated and effective physical therapy solutions available today for that purpose is the HANDTUTOR, ARMTUTOR and LEGTUTOR. These are products that have been designed for patients who have lost  some limb mobility due to stroke, brain or spinal cord injury or upper and lower limb surgeries. However the same device that assists the latter issues can also be effectively used to provide maintenance exercise for arthritis sufferers.

The TUTORs (which also include the 3DTUTOR) are comfortable ergonomically designed gloves or braces that, through the use of sensors connected to dedicated software in the form of games, allow for intensive exercises of affected wrists, fingers, hands, knees and other joints. Physical therapists adjust the exercise program to the ability of the patient and therby customize an individual program.

The TUTOR system is currently in use in leading rehabilitation hospitals and clinics in the U.S. and Europe. It is available at home through telerehabilitation and certified by the FDA and CE. See WWW.MEDITOUCH.CO.IL for more information.

Knee Surgery and Its Prevention

Much has been written about knee surgery and the innovations made to replace them. It’s the largest joint in the  body. The knee helps you stay active, flexible and is an essential role in facilitating movement. And  in spite of the fact that any problem/injury affecting the knee would have the power to  immobilize it, it is one the most overlooked aspects of health care.

 No one can deny that we often worry about our knees only after a crippling pain begins. However at this point, the damage has already been done and replacement surgery is sometimes the only option. However, knee problems don’t happen suddenly. It’s a slow process that occurs within the first 40 years of  life and because of bad lifestyle choices and genetics.

 The knee is  protected by cartilage — a soft, flexible, connective tissue that is softer than bone but harder than muscle. It forms a  cover and links the two major bones of the leg.  Damage to this cartilage can be painful and irreversible and therefore surgery becomes a necessity.

 Knee cartilage health can be affected by many factors, according to Dr. J.V.Srinivas , senior orthopaedic surgeon, Fortis Hospital, Bangalore, India. In osteoarthritis, the … cartilage is completely worn out, until one bone rubs against another. It’s a result of a  process of degeneration,  due either to a very active lifestyle or a severe lack of calcium. Women are particularly at risk. Women in our culture get married early and have on average two or three children in their twenties. These women  lack calcium and by the time they reach 40, they are  affected by osteoporosis, a bone brittling and calcium deficient disease  that can put them at risk for  fractures and degeneration of the knee cartilage. Inflammatory arthritis (which is extreme swelling or pain in addition to the degeneration of cartilage) can cause severe damage as well but  this occurs as a result of genetic factors and diseases and therefore can hardly be avoided.

In most cases, damage to the  cartilage is due to the  process of aging. But there are ways one  can protect himself against the pain and prevent more damage. According to Dr. Srinivas  it’s important to maintain good body weight. Overweight or obese people will only put more pressure on their knees.

Regular exercise  will  help  joints stay mobile and flexible. A timely diagnosis and the control of  diabetes and hypothyroidism are important too, because if not kept in check it could affect healthy cartilage.”

Starting to take care of knee health should occur at childhood. Dr. Srinivas says that the more active one is the more nutrition is being fed to the knee cartilage. A lot  of children lead sedentary lives and stay glued to computer screens and TV. Because bone health peaks between the ages of 20-40, one should maintain participation in sports and be active as much as possible during those years.  After the age of forty,  men and women lose at least 3% of their bone calcium per year. It is impossible  during those years to build calcium reserves and taking calcium pills  won’t work. Most Americans and Europeans  engage in sports during these crucial years, so for this age population, knee problems usually occur in the eighties.  For the average citizen knee problems crop up as early as the forties, which can severely threaten our mobility and add greater discomfort to old age.

Here are some precautions: 1-Don’t worsen knee pain by climbing  stairs or sitting cross-legged on the floor. 2-Try to sit on chairs or a raised surface until the pain recedes. 3-Avoid walking on hard gravelly surfaces or performing strenuous exercises while in pain. 4-Rest is best . 5- Switch to low impact activities like  swimming and walking.

 People that have advanced osteoarthritis can avail themselves of knee replacement surgery. This is fast becoming a common procedure in many countries.

The surgery can be expensive depending on the hospital and post-surgical care. The surgery involves partially or completely replacing the knee. Recovery can take from 3-6 weeks, after which one can usually return to normal life. The pain should have completely receded and the knee should be as good as new. Following surgery, doctors usually advise the patient to have an active lifestyle to help further weight loss and to prevent fresh damage to the knee joints.  Caring for knees is a lifelong process. After all, it’s because of this joint that we have the ease and freedom of mobility.

While recuperating from knee surgery physical rehabilitation will occur. One of the most cost effective and efficient physical therapy solutions is the LEGTUTOR.

 The LEGTUTOR is an ergonomic wearable leg brace with dedicated rehabilitation software.  The LEGTUTOR rehabilitation concept is based on performing controlled exercise rehabilitation practice at a patient customized level with real time accurate feedback on the patient’s performance. This means that the LEGTUTOR system allows the physical therapist to prescribe a leg rehabilitation program customized to the patient’s knee and hip movement ability at their stage of rehabilitation.

The Physical therapist uses the LegTutor before the knee operation to stengthen the knee joint and to teach the patient how to use the LegTutor during physical rehabilitation post knee surgery. The LEGTUTOR uses biofeedback to keep the patient motivated to do the exercise practice in the form of challenging games. The TUTORS, (HANDTUTOR, LEGTUTOR,ARMTUTOR, 3DTUTOR) are suitable for a wide variety of other neurological and orthopedic injuries and diseases as well as post trauma and orthopedic surgery.

  The TUTOR system is used by many leading rehabilitation centers worldwide and has full FDA and CE certification. It is designed for children and adults and can be used at home supported by telerehabilitation. See WWW.MEDITOUCH.CO.IL for more information.

LegTutor Shows Success in Post Knee Surgery Therapy

Dr.Giles R. Scuderi, in an online publication,  August 2011, reported that between May 2001 and June 2004, 388 total knee – arthroplasty cases were enrolled in a prospective, randomized and multicenter investigational device exemption trial. The patients received either a high-flexion mobile-bearing knee or a fixed-bearing control knee. The patients were assessed at 2 to 4 years . The results show 293 patients with degenerative joint disease were compared using Knee Society Assessment and Function scores, radiographic results, complications analysis, and survival estimates. Both the mobile-bearing and fixed-bearing groups demonstrated similar, significant improvement over preoperative assessments in Knee Scores including maximum flexion, and range of motion (ROM).

Post knee surgery physical therapy received a major boost with the advent of the LegTutor. This is a new device that improves motor, sensory and cognitive impairments through intensive active exercises with augmented feedback. The repetitive training is tailored to patient performance and allows the therapist to customize the most suitable rehabilitation program to the patient’s ability. The LegTutor together with its sisters the HandTutor, ArmTutor and 3DTutor are currently in use in major U.S. and foreign hospitals. Used in private clinics and even at home with tele rehabilitation the Tutors are successful for children as well as adults. The LegTutor is used to improve knee and hip movement ability in both neurological and orthopedic injury and disease.

 

HandTutor proven successful for self management, joint protection and exercises in hand osteoarthritis

Image by chris@APL via Flickr

In the July issue of BMC Musculoskeletal Disorders http://www.ncbi.nlm.nih.gov/pubmed/21745357 – Dr. Dziedzic and his group from Arthritis Research UK Primary Care Centre, Keele University, Keele, Staffordshire, United Kingdom discuss their plan to assess self management, joint protection and exercises in hand osteoarthritis: a randomized controlled trial with cost effectiveness analyses.

The HandTutor is used for hand exercises and should be assessed within this trial.

The HandTutor, ArmTutor, LegTutor and 3DTutor are used in many clinics in the USA and worldwide with patients are also using these devices  in private outpatient clinics and the home environment. Home bound patients can use tele rehabilitation that is supported by physical and occupational therapists.