Rehabilitation for Osteoarthritis: The Cornerstone of Joint Care

Introduction

Rehabilitative therapy has become the cornerstone of post-surgical care and arthritic patients. Physical therapists guide the patient through acquiring sufficient knowledge about their condition, providing treatment to decrease the pain, improving the range of mobility, and introducing lifestyle modifications.

What Is Osteoarthritis?

Osteoarthritis is an age-related musculoskeletal degenerative disorder that causes a breakdown of articular cartilage in a diseased joint and compromises the periarticular structures. The condition is mostly seen in the elderly, especially in women. Knee osteoarthritis is the most common variant. Other factors like previous connective tissue injuries and obesity increase the incidence of osteoarthritis.

What Are the Goals of Rehabilitation?

1. A thorough examination is to determine the problem and needs of the patient.

2. Determine the activities that have become difficult.

3. Design customized exercise programs to address the specific needs of the patients.

4. Manual therapy to improve the range of movement of the affected joint.

5. Teach aerobic and strengthening exercises to improve motion and health.

6. Design customized home exercise programs to improve strength and movement.

7. Design exercise programs for weight loss, if indicated.

8. Pinpoint the red flags in lifestyle and implement lifestyle modification.

What Are the Rehabilitation Modalities for Osteoarthritis?

1. Pharmacological:

• NSAIDs (non-steroidal anti-inflammatory drugs): Anti-inflammatory and analgesic.

• Intra-articular glucocorticoids: Anti-inflammatory and analgesic.

• Opioids: Analgesic.

2. Nutraceutical:

• Blueberries: Analgesic.

• Montmorency Cherry Juice: Anti-inflammatory and analgesic.

• Glucosamine or Chondroitin: Anti-inflammatory and analgesic.

• Curcumin or turmeric: Anti-inflammatory and analgesic.

3. Biological:

• Platelet-Rich Plasma: Anti-inflammatory.

• Stem-cell therapy: Potential tissue regrowth and analgesic.

• Nerve Growth Factor Antibodies: Anti-inflammatory and analgesic.

• Interleukin 1 Alpha or Beta Antagonists: Anti-inflammatory.

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4. Physical Therapy:

• Aquatic Exercise: Analgesic and improved physical function.

• Aerobic Exercise with Weights: Analgesic and improved physical function.

• Resistance Training: Analgesic and improved physical function.

• Blood Flow Restriction: Analgesic and improved physical function.

What Are the Treatment Protocols for Osteoarthritis Based on Its Progression?

Minor or Mild Osteoarthritis

1. Education:

• Healthy living standards.

• Weight management for overweight individuals.

• Dietician consultation for obesity.

• Implementing dietary restrictions and supplements.

• Plant-based diet to promote anti-inflammation.

• Use of assistive devices like cane, walker, and braces.

2. Treatment:

• Heat and ice for comfort or swelling as indicated.

• ROM (range of motion): Passive, AROM (active range of motion), and AAROM (active-assisted range of motion) within pain tolerance.

• Manual therapy: Joint mobilization, patellofemoral tracking, taping, and soft tissue workaround, along with an exercise program.

3. Exercises:

(to be combined with blood flow restriction training as required).

• Knee, ankle, and hip mobility.

• Squats or wall squats.

• Lunges.

• Leg extensions or curls.

• Clamshells.

• Calf raises.

• Balance for joint stability like a single-leg stand.

• Biking, swimming, walking, hiking, or elliptical.

Moderate Osteoarthritis:

1. Treatment:

• Heat and ice for comfort or swelling as indicated.

• ROM: Passive, AROM, and AAROM within pain tolerance.

• Manual therapy: Joint mobilization, patellofemoral tracking, taping, and soft tissue workaround, along with an exercise program.

2. Exercises:

(with varying weight and ROM specific to the patient's tolerance).

• Knee, hip, and ankle mobility.

• Half squats.

• Wall squats.

• Seated leg press.

• Leg extensions or curls.

• Straight leg raises.

• Calf raises.

• Balance exercises.

• Hip adduction or abduction: side-lying leg raises, fire hydrants, clamshells, etc.

• Biking, swimming, walking, hiking, or elliptical.

Severe Osteoarthritis:

Patients in this stage do not respond as positively as in the previous stages to resistance training. Any kind of physical activity that does not cause pain should be promoted, and complete dietary modification needs to be implemented.

Along with that, knee arthroscopy may be indicated, followed by physical therapy.

1. Treatment:

• Heat and ice for comfort or swelling as indicated.

• ROM: passive, AROM, and AAROM within pain tolerance.

• Manual therapy: joint mobilization, patellofemoral tracking, taping, and soft tissue workaround, along with an exercise program.

2. Exercises:

(with varying weight and ROM specific to the patient's tolerance).

• Knee, hip, and ankle mobility.

• Quad sets.

• Seated marches.

• Pillow-squeeze between legs while sitting or lying down.

• Side-lying straight leg raise.

• Sit to stand.

• Step-ups.

• Hip adduction or abduction: side-lying leg raises, fire hydrants, clamshells, etc.

• Any exercises from mild and moderate phases can be implemented, subject to the patient's tolerance.

• Biking, swimming, walking, or elliptical.

Exercise Modalities Based on the Joint Involved:

Knee Osteoarthritis:

• Regular individualized exercise regimen.

• Overall exercise.

• Low-impact aerobic exercise.

• Aerobic activity and exercise.

• Land-based exercises like strength training, active ROM exercise, and aerobic activity.

• Water-based exercise.

• Strength training includes resistance-based lower-limb and quadriceps strengthening exercises and both weight-bearing and non-weight-bearing interventions.

• Strengthening exercise for both legs, including the quadriceps and proximal hip girdle muscles

• Adjunctive ROM or stretching exercises.

• Mixed programs.

• Balance exercises.

• Supervised exercise with manual therapy.

• Manual therapy alone.

Hip Osteoarthritis:

• Regular individualized exercise regimen.

• Overall exercise.

• Low-impact aerobic exercise.

• Land-based exercise.

• Water-based exercise.

• Endurance or strengthening exercises.

• Mixed programs.

• Supervised exercise with manual therapy.

Hand Osteoarthritis:

• Education and exercise.

What Are the Other Forms of Rehabilitation Therapy?

• TENS: Transcutaneous electrical nerve stimulation. TENS reduces the pain in osteoarthritis by selectively stimulating larger non-noxious afferent fibers with a low threshold and increases the excitability of motor neurons. It targets opioid receptors with high and low-frequency electrical pulses.

• LLLT: Low-level laser therapy is a non-invasive physiotherapy technique that emits low-power lasers or LEDs on the surface of the body. LLLT has a strong analgesic and pain-relieving effect, a bio-modulatory effect on microcirculation, and improves tissue healing and lymphedema.

• Ultrasound Therapy: It is a non-invasive and safe form of physical therapy used against various musculoskeletal conditions, including osteoarthritis. Ultrasound therapy provides potential cartilage reparation effects, promotes collagen formation, regulates inflammatory responses, and induces cartilage repair.

• Cryotherapy: It is a non-pharmacological intervention to control inflammation, edema, and management of pain. The technique is considered safe, inexpensive, and easy to administer for physiotherapists over patients.

Visco-supplementation with Hyaluronic acid products is being practiced worldwide to protect articular cartilage in the synovial joints, control the pain, and stimulate joint tissues.

Conclusion

Knee, hip, or hand arthritis can develop as a result of old age or due to any systematic underlying condition. Although osteoarthritis is often considered a disease of the elderly, there have been reported cases of juvenile cases. Through several studies and experiments, it has been crystal clear that physical therapy has been greatly appreciated by patients in improving their quality of life. Hence, ideally, a multimodal approach has proven to have the greatest life-altering effect on the patient's condition.