Supervisors info:
Παπαϊωάννου Νικόλαος, Αναπληρωτής Καθηγητής,Ιατρική,ΕΚΠΑ
Λυρίτης Γεώργιος, Καθηγητής, Ιατρική,ΕΚΠΑ
Τριανταφυλλόπουλος Ιωάννης, Επίκουρος Καθηγητής, Ιατρική,ΕΚΠΑ
Summary:
Osteoarthritis is the most common degenerative disease. Most frequently affects weight - bearing joints such as medial tibiofemoral compartment of the knee and the hip joint. Osteoarthritis is a progressive disease resulting in the breakdown of joint cartilage and bone.
Biomechanical factors have been suggested as risk factors for OA and sometimes cooperate with systemic risk factors and influence the progression of the disease. Those factors are body weight, physical activity, age, occupation, sedentary lifestyle, genetic predisposition, hormonal status, oestrogen, past history of meniscectomy or other operation or trauma. OA influence negative neuromotor control, kinetic and kinematic function such as:
abnormal patterns during gait (knee adduction or abduction moment)
unstable of the knee in the frontal plane. Unstable is accompanied with pathologies of alignment of the bones (varus - valgus)
increased cocontraction - coordination with specific muscles that leads to increase compressive load of the joints and the progression of the disease
dysfunction of the ability of sense position and balance
Major clinical features are:
Pain (especially after fatique),
Joint stiffness (especially after rest 15’-30’min),
Crepitus, crack,
Swelling,
Muscle weakness,
Decrease range of motion
OA affects especially women aged over 45 and there is a growing output of Metalloproteins, decrease healing articular process, crack, degeneration of the joint and apoptosis of cytocells NO. NO derived with the stimulation of IL-1, TNF-a, inflammatory factors.
There are a number of areas where evidence is limited or research has not been undertaken. Few studies have evaluated the effects of exercise on structural disease progression and there is currently no evidence to show that exercise can be disease modifying. Therefore, questions like which is the best way to exercise, how can patient’s reach the optimal advantages of exercise and which is the correct dosage of exercise, are still unknown. Few studies have compare types of exercise, intensity, duration and frequency in relation to the stage of osteoarthritis. Most studies evaluate the effect of exercise in combination with medication, Manual Therapy or conservative physical therapy. Most research has tended to evaluate exercise therapy in isolation and further research is needed to evaluate the effects of exercise for OA when delivered as part of an overall treatment package. For example, exercise combined with weight loss appears to be more effective than exercise intervention alone. There are some types of exercise in the treatment of OA that need more large-scale rigorous clinical trials before their efficacy can be fully evaluated.
Neuromuscular motor control exercises refer to the enhancement of conscious and subconscious perception of joint or limb position and movement in space, to the enhancement of co-ordination and co-contraction of the correct muscle, the correct on set time, to the enhancement of passive or active instability or laxity of the knee joint, to the improvement of the general balance and to the improvement of the malalignment moment of the knee.
When the knee joint benefits from strength training exercises remains unclear, even exercise prescription is common intervention for medical’s and physiotherapist’s.
According to the literature, Royal Dutch Society for Physical Therapist 2010 advocated specific guidelines for the management of the knee and hip OA. Initial assessment is describing and include: history, observation, physical assessment, data analysis, interventions and measure outcomes.
Physical therapy interventions that are suggested are:
Therapeutic exercise under observation (Level 1)
Education of the patient for auto management (Level 2)
Combination of Manual Therapy & Exercise (Level 2)
Post - operation therapeutic exercise (Level2)
Combination of exercise & bandage of patella, taping (Level 2)
Manual therapy and neuromuscular motor control exercises have been established as an important therapeutic approach for OA of the knee. The exact mechanism that manual therapy and neuromuscular motor control exercises influence OA is still unknown. However, it seems that biomechanics & neurophysiological reactions are responsible. The most appropriate are:
Inhibits and alter pain
Induce controlled inflammatory response for the onset of the healing process
Prime the joint and the surrounding muscle for the optimal response in strength exercise programme
Alter the acute process of inflammatory
Modulate afferents proprioceptive stimulus of the joint structures
Improve neuromuscular control and the reaction time
Improve articular cartilage metabolism as a result of the increase of IL-10 (chondroprotective cytocin) & biochemical serum COMP (protein that is very important for the apoptosis process). Those biochemical index are increased with exercise.
There is currently no evidence to suggest that exercise can also influence structural disease and thus be disease modifying. Neuromuscular motor control exercise’s play an important role to the management of symptoms of OAK and the optimal results are achieve when combined with Manual Therapy.
Keywords:
Knee osteoarthritis, Neuromuscular motor control exercises, Alignment, Manual therapy
