case study ita
TRANSCRIPT
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Case study
GERIATRICS WITH BILATERAL KNEE OSTEOARTHRITIS.
Introduction
Joint composed of articular cartilage, subchondral bone, synovial membrane, synovial fluid
and joint capsule. Normal synovial joints allow a significant amount of motion along extremely smooth
articular surface. The articular surface of synovial joints consists of articular cartilage that protects the
subchondral bone by distributing large loads, maintaining low contact stresses, and reducing friction at
the joint. Synovial fluid is formed through a serum ultrafiltration process by cells that form the synovial
membrane. It supplies nutrients to the avascular articular cartilage and provides the viscosity to absorb
shock and elasticity required to absorb shock from rapid and slow movements.
Carlos,2012 state osteoarthritis(OA) is a degenerative disorder that results from the
biochemical breakdown of articular cartilage in the synovial joints. Although, the current concept holds
that OA involves not just the articular cartilage but the entire joint organ, including the subchondral
bone and synovium. Mostly patient having OA due to advancing age, obesity, trauma, menopause,
muscle dysfunction and genetics. High risk patient include sex hormones, muscle weakness, repetitive
use and Infection.
The early stage, chondrocyte will repair damage cartilage while increase production of
proteoglycans and resulting in swelling of the cartilage in most cases and may last for a years or
decades. Progressing stage, proteoglycans level will dropped and cause soften and lose elasticity of
cartilage and increase joint surface integrity. Flaking and fibrillations will develop along the joint and
resulting loss of the joint space. In major weight bearing joint greater loss joint space subject greatest
pressure and contrast imflammatory arthrides and uniform joint space narrowing. Erosion of the
damaged cartilage progress until the underlying bone is exposed and denuded of its protective
cartilage continues to articulate with the opposing surface. The increasing stresses exceed the
biomechanical yield strength of the bone and responds with vascular invasion and increased
cellularity, becoming thickened and dense at areas of pressure.It may undergo cystic degeneration,
due to either osseous necrosis secondary to the intrusion of synovial fluid.
Typically, it will develops gradually over a period of years through feeling of pain, stiffness,
limited range of motion and localised swellings. Pain is mostly worse following activity, especially
overuse of the affected knee. Stiffness can worsen after sitting for prolonged periods of time. As it
progresses over time, symptoms generally become more severe and continuous rather than during
weight-bearing.
Knee OA cant be cured but relieve the symptoms by taking medication such as
acetaminophen, NSAIDs (nonsteroidal anti-inflammatory drugs), and analgesic medication include
intraarticular injection of steroids or viscosupplements, topical creams, glucosamine and chondroitin
sulfate. Lastly, by surgery as a last result such as TKR.
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Physical management on OA patient generally on lifestyle modification, weight reduction and
particular exercises. Strengthening exercises and stretching to improve ROM. Aerobic and low impact
exercises mostly stress patient on weight bearing joints. Weight bearing and non-weight bearing
exercises has been proved in improvement of function, walking speed and muscle torque.
Furthermore, there is more improvement in knee-related quality of life was noted in the strength-training group than in the balance-training group.(Todd 2011(Jan et all)).
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Subjective assessment
Name: Mr X.
Age : 75 years old
R/N : XXXX
D.O.Ax : 3 disember 2011
Dr diagnose : R kn OA
Dr management : refer to physio
Problem
Pt c/o of pain at bilateral knee and difficulty during bending knee after prolonged walking around 15
mins and sitting on the chair during prayer
Current hx
Gradual onset of pain during prolonged walking around julai 2011
Past hx
No hx of fell down or fracture
Pmhx
Nil history of rheumatoid arthritis
DM, HPT around 3 years ago ( follow up 3 months )
Operation/ Surgery : nil
Medication : drugs for DM and HPT more 6 months
X ray done on september 2011, Ix: reduce joint space
No cord and cauda equina syndrome symptoms
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Home /social hx
Pt live at rumah kampung and no stairs
Pt live alone without any carer ur wife
Pt retired from being a teacher, currently being imam
Use to travel from batu pahat to kl for visiting daughter and grandchild
Pt is a non smoker and non alcohol
Body chart
Pain scale
VAS 5/10 during activity
VAS 0/10 during resting
Area: bilateral anterior knee
Type of pain: pulling pain
Aggravating factors : difficulty from sitting to standing
Prolonged walking ( around 15 mins)
VAS 5/10 ,
pulling pain
during activity
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Difficulty during squating
Unable to lift heavy object ( 2 kg )
Ease factores : pain killers ( release after 10 mins)
Ointment( release after 10 mins)
Irritability: medium, do no disturb sleeping
Observation
General : pt comes to department independently without using walking aids
Pt is a moderate male size with slightly limping gait pattern
Local : Rt shoulder level and Lt shoulder level align
Bilateral iliac crest level are align
Rt knee level higher than Lt knee level
J curve shaped is normal
Thoracic slightly kyphosis
bilateral knee have no redness
Slightly swelling on Lt knee
No bony deformity of bilateral knee
No muscle wasting of bilateral knee
Observation of gait
reduce time of stance phase
reduce step length
reduce gait speed widened base of support
no VBI sx
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Palpation
No pain at bilateral knee
Pain at metacarpal base of index and middle finger of left hand
Crepitus sound on bilateral knee
No increase in temperature
No muscle spasm
No edema or effusion
No dry skin
Active physiological movements
Bilateral knee flexion crepitus sound and ERP
Bilateral Knee extension crepitus sound and no pain
Passive physiological movement
Rt flexion/abduction
Rt flexion/adduction
Rt extension/abduction
Rt extension/adduction
Pain and restricted opposite directions
No pain but slightly restricted
Lt flexion/abduction
Lt flexion/adduction
Lt extension/abduction
Lt extension/adduction
Pain and restricted opposite directions
No pain but slightly restricted
Muscle length
Piriformis test : tightness of piriformis
Accesory movement
Patella mobility - Restricted at bilateral knee inferior and posteriorly
Tibiofemoral joint normal at bilateral knee
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ROM
Joint movt Right Left Overpressure
Active Passive Active Passive Right Left
Hip flexion 0-120deg 0-120deg 0-120deg 0-120deg // //
Hip
extension
0-35deg 0-35deg 0-35deg 0-35deg // //
Hip
abduction
0-45deg PFROM 0-45deg PFROM // //
Knee flexion 0-135deg 0-140deg 0-115deg 0-125deg ERP ERP
Knee
extension
// //
Ankle
dorsiflexion
// //
Ankle
plantarflexion
AFROM AFROM // //
Ankle
inversion
// //
Ankle
eversion
// //
Intrepretation : Limited ROM of Hip movement and knee flexion d/t muscle tightness
Manual muscle testing
Joint movement Right Left
Knee flexor 3/5 within the
range
3/5 within the
range
Knee extensor 3/5 3/5
Hip flexor
Hip extensorHip abductor
Hip adductor
Ankle dorfiflexor 4/5 4/5
Ankle
plantarflexor
Ankle inversor
Ankle invertor
Intrepretation : reduce muscle strength d/t pain
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Q-angle
Rt 20deg Lt 25 deg
Functional strength test
Sit to stand
1st trials : 7 rep of 30sec
2nd trials : 6 rep of 30sec
3rd trials : 5 reps of 3sec
Pt impression
Problem listing Limitation social activities
Pain at bilateral knee d/t
degenerative changes
Difficulty during prolonged
walking
Difficulty during praying at
mosque and need to use chair
Limited ROM on Rt knee d/t
muscle tightness
Unable to bent bilat. Knee Unable to use squating toilet
Reduce muscle strength d/t pain Unable to lift heavy object
Unable to do squating
Abnormal gait pattern d/t poor
posture awareness
Short term goal
1. To relieve pain on the bilateral knee within 1/52
2. To increase ROM on bilat knee within 2/52
3. To increase muscle strength on both LL within 2/52
4. to improve gait pattern within 2/52
Long term goal
To improve functional ability in ADLS
To prevent joint stiffness and bone defomity
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To maintain ROM on bilateral knee
Plan of tx
Heat therapy
Massage
Exs
Hep
Intervention
1. heat therapy ; supine ly. post. bilateral knee elevated with pillow HP at bilateral knee for 20mins
2. Effluarage massage ; supine ly. position with Lt knee supported with pillow; massage from distal to
proximal; 5 times
2.EXS
Supine ly. position; SQE at bilateral knee; straighten the knee and hold 10 sec; 10 repetitions
Supine ly. position; SLR at bilateral knee; raise LL and hold 5sec ;10 repetitions
IRQ exs;Supine ly. post; towel supported below the knee ; ankle DF and straigthen knee bilaterally;
hold 10 sec ;10 repetitions
Stretching exs using gymball; supine ly position with LL suported with gymball; knee flexion and
extension using gymball ; hold 10sec; 10 repetitions
Sit to stand exs; sitting on the chair at wall; ask patient to repeat step up and down without touch the
chair
Static cycling,10 mins
4. HEP
Advice to immersed to towel in a warm water and apply at bilat knee if pain;20 mins
Cont exs as taught at home 3 times daily
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Evaluation
Pain is reducing after done hot pack to VAS 4/10 and able to do all exs as taugh
Teach patient on normal gait pattern,patella mob and other exs
Reassessment
Progress case on 13 disember 2011
Subjective
Pt still c/o of pain but reducing than previous visit to VAS 4/10 during activity. Claimed not regularly doall exs at home but slightly improve in bending bilateral knee. Pt still prayer in sitting at chair due to
pain. Claimed do not take pain killers anymore.
Objective
Slightly limping gait pattern
Still having swelling on Lt knee
No redness
Gait analysis
Wide base support
Reduce knee flexion on stance phase
Reduce gait speed
Reduce step length
Palpation
No increase in temp
No musle tenderness
No muscle wasting
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Accesory movement
Patella mobility - Restricted bilateral at bilat. Knee
Muscle length
Piriformis test : tightness of piriformis
Q-angle
Rt 20deg Lt 25 deg
ROM
Joint movt Right Left Overpressure
Active Passive Active Passive Right Left
Hip abduction 0-45deg PFROM 0-45deg PFROM // //
Knee flexion 0-140deg 0-140deg 0-115deg 0-125deg ERP ERP
Intrepretation : limited ROM of Lt knee d/t muscle tightness
Manual muscle testing
Joint movement Right Left
Knee flexor 3/5 within the
range
Knee extensor
Hip flexor
Hip extensorHip abductor 4/5
Hip adductor
Ankle dorfiflexor 4/5
Ankle
plantarflexor
Ankle inversor
Ankle invertor
Interpretation : reduce muscle strength d/t deconditioning secondary to ageing
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Functional strength test
1 trials : 7 repetitions ( 30sec )
2 trials : 7 repetitions ( 30sec )
3 trials : 5 repetitions ( 30sec )
Analysis
Pain is reducing than previous visit
Improving in muscle strength
Abnormal gait patern d/t poor posture awareness
Plan of tx
Ice packs
Ice massage
Joint mobilization
Exs
Gait training
HEP
Intervention
1. ice packs
supine ly post. Knee elevated with pillow, ice wrap with towel at bilateral knee;20 mins
2. ice massage
long sitting position; massage around Lt knee in circular motion; 10 mins
3. joint mobilisation
Long sitt position ; patella mobility technique at bilateral knee ; 30 sec hold; 5 rep ; 3 set
4. Exs
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Sitting position; Piriformis strecth,SLR and SQE ; 10 sec hold; 10 repetitions
High sitting position; IRQ bilateral LL; 10 sec hold and 10 repetitions
Static cycling; 20 mins
Wall squating exs ; standing positions and lean back at the wall; hold 5 sec ; 10 repetitions
Sit to stand exs; 3 repetitions
5. gait training
Teach normal gait pattern infront of mirror at parallel bar
6. HEP
advice pt to cont exs at home regularly
Do ice massage for 20mins a days for 2 weeks
Evaluation
Pt claimed pain is slightly reducing after being teach about normal gait pattern and ice massage
Reassessment (progress case on 16/12/2011)
Subjective
Pt claimed the pain is reducing than at bilateral knee to VAS 3/10 during activity.
Pt claimed of slightly improvement in bending his Lt knee. Claimed able to walk prolonged walking
Around 1 hour and lift heavy object more than 4 kg.
Objective
Joint movt Right Left Overpressure
Active Passive Active Passive Right Left
Hip abduction 0-45deg PFROM 0-45deg PFROM // //
Knee flexion 0-140deg 0-140deg 0-125deg 0-125deg ERP ERP
Interpretation : limited ROM on knee flexion d/t joint stiffness
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Manual muscle testing
Joint movement Right Left
Knee flexor
Knee extensor
Hip flexor
Hip extensor
Hip abductor
Hip adductor 4/5 4/5
Ankle dorfiflexor
Ankle
plantarflexor
Ankle inversor
Ankle invertor
Interpretation : reduce muscle strentgh d/t deconditioning secondary to ageing
Functional strength test
Chair stand test
1 trials : 7 rep
2 trials : 7 rep
3 trials : 7 rep
Analysis
Pain is reducing
Maintenance of functional activities
Plan of tx
Exs
HEP
Interventions
1. Exs
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Sitting position; Piriformis strecth,SLR and SQE ; 10 sec hold; 10 repetitions
High sitting position; IRQ bilateral LL; 10 sec hold and 10 repetitions
Static cycling; 20 mins
Wall squating exs ; standing positions and lean back at the wall; hold 5 sec ; 10 repetitions
Sit to stand exs; 3 repetitions
2. HEP
advice pt to cont exs at home regularly
Do ice massage for 20mins a days for 2 weeks
Evaluation
Pt able to do all exs and remember all the exs teach before
Reassessment (progress case on 22/12/2011)
Subjective
No new c/o of pain, condition still remains the same and able to walk prolonged walking around 1 hourand lift heavy object more than 4 kg.
Objective
Joint movt Right Left Overpressure
Active Passive Active Passive Right Left
Hip abduction 0-45deg PFROM 0-45deg PFROM // //
Knee flexion 0-140deg 0-140deg 0-125deg 0-125deg ERP ERP
Interpretation : limited ROM on knee flexion d/t joint stiffness
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Manual muscle testing
Joint movement Right Left
Knee flexor
Knee extensor
Hip flexor
Hip extensor
Hip abductor
Hip adductor 4/5 4/5
Ankle dorfiflexor
Ankle
plantarflexor
Ankle inversor
Ankle invertor
Interpretation : reduce muscle strentgh d/t deconditioning secondary to ageing
Functional strength test
Chair stand test
1 trials : 9 rep
2 trials : 8 rep
3 trials : 7 rep
Analysis
Increase in muscle strength
Maintenance of functional activities
Plan of tx
Joint mobilization
Exs
HEP
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Interventions
1. Exs
Sitting position; Piriformis strecth,SLR and SQE ; 10 sec hold; 10 repetitions
High sitting position; IRQ bilateral LL; 10 sec hold and 10 repetitions
Static cycling; 20 mins
Wall squating exs ; standing positions and lean back at the wall; hold 5 sec ; 10 repetitions
Sit to stand exs; 3 repetitions
2. HEP
advice pt to cont exs at home regularly
Do ice massage for 20mins a days for 2 weeks
Evaluation
Pt able to do all exs and remember all the exs teach before
Reassessment
To review exs next visit
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Discussion
Mr. Z is a old male,72 years old and diagnosed with knee OA and undelying DM and HPT. He
complaint of pain at bilateral knee and limited functional activites that need to used strength and
bending knee such as prayer and walking. Patient complaint on gradual onset of pain during
prolonged walking more than 15 mins, difficulty in lifting heavy object more than 2 kg and difficulty
during sitting to standing on julai 2011. Pt have no history of fall or pain before julai 2011. The goals of
treatment is relief pain, reduce swelling, improve Range of Motion, improve muscle strength and
improve functional activities. After physical management, there is findings on pain, limited knee flexion
motion and patella mobility. Pt also reduce in muscle strength that affect on his functional performance
such as prolonged walking and prayer.
Treatment apply to patient on the first attend is heat therapy to relief his pain by improving
circulation and relaxing muscles while, effluerage to reduce swelling but i certainly change the
treatment for second attend using cryotherapy due to no improvement are seen after previous
treatment. By using cold packs and ice massage from cochrane reviews written by Brosseau,2003
finds that ice massage helps in improve muscle strength, improved ROM, and resulted in less time
needed to walk 50 feet. It also stated that cold packs were useful for reducing knee swelling.
This patient is having restricted patella mobility that will influenced in pain and limited range of
motion. Houlgham ,2010 state that patella restriction will reduce the tibiofemoral joint full flexion motion
ability and by apply soft-tissue mobilization helps in improve knee range of motion.He had be given on
patella mobilization of multi direction glide for 30 sec hold; 5 repetitions and 3 set. This will affects the
ROM of knee flexion and extension while decrease soreness due to James,2012 on his written of
managing patient with knee OA. The used of superior glide is to facilitate knee extension while inferior
glide facilitates the knee flexion. I also apply mediolateral glide to restore the normal patella translation
based on David,2009 on his book of pathology and intervention in musculoskeletal rehabilitation.
Exercises that i prescribe to patient composed of stretching exs and strengthening exs. Based
on Jan et. all,2008 on the research of resistance training for knee OA found that increase muscle
strength on both flexor and extensor muscle will increase the knee stability. From resistance training
study conclude that it help in reduce pain and improve functional performance. Moreover,
strengthening exs improve the walking speed on a curved path and uneven floor which demands
higher neuromuscular control of the lower extremity. While from brosseau et all,2005 found that
exercises and physical activity are promising in reduce pain,improve functional status, aerobic
capacity, quality of life, potential to reduce body weight and prevent further joint damage at knee.
Strengthening exs can be classified into three categories which is isometric, isokinetic and
isotonic exs. I treat patient with isometric,isotonic and isokinetics exs due to age and pain. For
isometric exs i teach on SQE exs based on Patrick,2005 the isometric strengthening exs are puposelyused with to minimize the adverse effects of weight bearing on the joints by reducing the amount of
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force that is transmitted across the affected joints. It was the best type of exercise to begin with in a
strengthening program, particularly in patients who can not tolerate repetitive joint motion. Then, i
progress the exs by prescribe the isotonic exs of SLR, IRQ and wall squating for 10 seconds hold with
10 repetition based on the research done by Robert,2005(Huang et all) found that the isotonic
exercise had the greatest effect on reducing pain, while the isokinetic exs had the greatest increase inwalking speed and decrease of disability after treatment and follow-up. For the isokinetics exs i
prescibe on static cycling and sit to stand due to patient reduce endurance secondary to ageing.
Besides that, stretching exs for knee flexion are used to increase ROM and prevent the abnormal
muscle shape and length that can contribute to the visible joint deformities that result from severe
arthritis due to Robert,2005.
Lastly, i train patient on a normal gait pattern due to pain and abnormal gait pattern. From the
research of gait training and hyperextension by Teran,2009 found that normal gait training improved
awareness in knee alignment when standing and reduce pain at night. Furthermore, patient also
claimed that pain is reduce after being teach on gait training for the second attend while, do exs as
teach before. Teran also found that gait training improved ability to stand for a longer periods of time
without pain on either knee. It is also found that gait training addressed the modifications during heel
contact and forward progression to develop confidence in the stance-phase on the controlling for
pelvic rotation, hip extension, and dorsiflexion range.
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Summary/Conclusion
OA patient will facing the pain at joint, swelling and limited ROM which will influenced on their
posture and functional activities. OA management more in reduction of pain and improve the functional
activites. To improve the functional activities the symptoms should be treated first.
Based on the practice, it shown that exercises gave higher implication in reduction pain and
improve the functional performance. While, cryotherapy is the best treatment to relief pain and
swelling. Even thought physical training such as exercises help in reduction of pain and improve
functional performance. The personal, socioeconomic, and environmental is a barrier to elderly
patients ondoing exercises. Most older adults claimed on discomfort or disability as a reason for not
exercising. So,by prescribe the suitable intensity and range of exercises influenced in reducing the
discomfort.
Based on the research of Silvia, 2008 about hydrotherapy vs conventional land based
exercise for the management of patient with osteoarthritis of the knee shown that hydrotherapy is a
suitable and effective exercise for patients with OA knee and should be included in the therapeutic
approaches recommended for the management. However, due to incompleted equipment
hydrotherapy unable to apply to the patient.
Aquatic exercises will limit the weight-bearing load while, cross-training, using a combination
of activities, balances the risks and benefits of weight and nonweight-bearing activities, uses a wider
range of muscle groups, decreases the risk of overuse injury, and is less boring based on Robert,2002. Older persons comfortable in a role of dependence and feel threatened by the charge of
increased activity. Building on previous activities can help overcome the dominant influence of habit on
activity levels. An active lifestyle also has health benefits comparable with formal exercise regimens,
but with improved rates of long-term compliance by prescribing on routine exercises, that are simple
which requires specific instructions and repetititions this is based on Robert, 2002.
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References
Journal
John Albright, (2001) Philadelphia Panel Evidence-Based Clinical Practice Guidelines on Selected
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Lucie Brosseau, (2005) Ottawa Panel Evidence-Based Clinical Practice Guidelines for
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Web
http://osteoarthritis.about.com/od/kneeosteoarthritis/Knee_Osteoarthritis_Causes_Diagnosis_
Symptoms_Treatment.htm
http://www.osteoarthritisremedy.com/herbal-remedies/osteoarthritisremedy/osteoarthritis-
pathophysiology