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Physical Therapy and Rehabilitation: PT 1 Rehabilitation of Arthritis Editing By A.K.A teamdoc, B. Sc., P.T. I. [Structural Understands of Joint] 1. [Joint Classification] A.

1 Physical Therapy and Rehabilitation: PT 1 Rehabilitation of Arthritis Editing By A.K.A teamdoc, B. Sc., P.T. I. [Structural Understands of Joint] 1. [Joint Classification] A. [Diarthrosis]: Synocial Jt. Ex) Hip, knee Jt B. [Synarthrosis]: Fibrous Jt. Ex) Coronal suture C. [Amphiarthrosis]: Cartilagious Jt Ex) Intervetebral disc, Symphysis pubis 2. [Joint structure] A. Cartilage: mm patella: 7.5mm Solid phase: Chondrocyte, collagen, proteoglycan(pg), extracellular matrix(ecm) Fluid phase: Water

Physical Therapy and Rehabilitation: PT 2

lubrication[ ] 2) Cartilage [nutrition] Mechanical

2 Physical Therapy and Rehabilitation: PT 2 Nutrition: infusion & diffusion B. Synovial fluid: Clear, Jt : 0.2ml, knee Jt - 5ml 1) Synovial fluid cartilage Jt lubrication[ ] 2) Cartilage [nutrition] Mechanical pumping effect 3) Collagen: Coiled fiber Collagen type: II, IX, X, XI II - IX - II interaction

3 Physical Therapy and Rehabilitation: PT 3 4) Proteoglycans(PG): [protein], polysaccharide molecule [covalent complex] ( ) 5) (hyaluronate) 6) PG monomer: 150 [Glycosaminnoglygan] (GAG) 7) 2 GAGs:, 8) GAGs: Mc chondrotin-6-sulfate[ ] Immature Vs mature cartilage

Physical Therapy and Rehabilitation: PT 4 Some GAGs Where What large polymer many negative hyaluronic acid synovial fluid vitreus humor ECM charges - self repelling shock absorbing chondroitin

4 Physical Therapy and Rehabilitation: PT 4 Some GAGs Where What large polymer many negative hyaluronic acid synovial fluid vitreus humor ECM charges - self repelling shock absorbing chondroitin sulfate cartilage, bone commonest GAG heparan sulfate basement membranes cell surfaces hepain lines arteries, in mast cells, highly sulfated; impedes clotting dermatan sulfate skin heart valves 3. [articular cartilage] A. Superficial layer: 10-20% B. Middle layer: 40-60% C. Deep layer: 30% 4. Synovial joint [lubrication] II. [Rheumatic Arthritis] 1. [Arthritis Classification] A. Inflammation groups 1) Inflammation connective tissue disease

5 Physical Therapy and Rehabilitation: PT 5 : RA, JRA, SLE, DM-PM, Mixed CT Ds. 2) Inflammation crystal-inducted disease: Gout, Pseudogous. 3) Inflammation inducted by infectious agents. : Bacterial, viral, tuberculous, fungal arthritis. 4) [Seronegative] spondyloarthropathy : AS, Psoriasis arthritis, Reiter's Ds, IBS. B. Non-inflammation group 1) Degenerative arthritis: OA, post-traumatic aseptic necrosis 2) Metabolic disease : Lipid storage Ds, hemochromatosis, Ochronosis, hypogammaglobulinemia, hemoglobinopathy C. Symmetric VS Asymmetric D. Articular VS Extraarticular 2. [Rheumatoid Arthritis] A. [American College of Rheumatology Criteria: 1987] 3. CRITERIA FOR THE CLASSIFICATION OF RHEUMATOID ARTHRITIS(1987, ACR) 30 [Morning stiffness] Morning stiffness in and around the joints, lasting at least 1 hour before maximal improvement. 3 [Arthritis of 3 or more joint areas] Atleast3jointareassimultaneously have had soft tissue swelling or fluid (not bony overgrowth alone) observed by a physician; the 14 possible joint areas are right or left proximal interphalangeal (PIP) joints, metacarpophalangeal (MCP) joints, wrist, elbow, knee, ankle, and metatarsophalangeal (MPT) joints. [Arthritis of hand joints] At least I area swollen (as defined above) in a wrist, MCP or PIP joint. [Symmetric arthritis] Simultaneous involvement of the same joint areas (see 2 above) on both sides of the body (bilateral involvement of PIPs, MCPs, or MTPs is acceptable without absolute symmetry). [Rheumatoid nodules] Subcutaneous nodules, over bony prominences, or extensor surfaces, or in juxta-articular regions, observed by a physician. [Serum rheumatoid factor] Demonstration of abnormal amounts of serum rheumatoid factor by any method for which the result has been positive in <5% of normal control subjects. [Radiographic changes] Radiographic changes typical of RA on posteroanterior hand and wrist radiographs, which must include erosions or unequivocal bony decalcification localized to or most marked adjacent to the involved joints (osteoarthritis changes alone do not qualify).

6 Physical Therapy and Rehabilitation: PT 6 B. RA 1) [Definition] Etiology inflammatory polyarthritis peripheral Joint Systemic autoimmune disease 2) Universal 3) All age involved Male : Female = 1 : 3 4) African black < israeli < Rural German 5) [inheritance], Chromosome 6(HLA-DR4), 25% HLA-DR4 C. Etiology 1) [Unclear] a. Autoimmune disease Lymphoid cell [infiltration] of the synovium Synthesis of IgG & (RF: Rheumatoid Factor) by plasma cell IgG & IgM in the cell of synovium lining, leukocyte, synovial fluid IgG , 15. IgG, 70%.. IgM IgM,. 2. IgG IgM b. Autologous lgg antibody 2) Specific external agent: Infection source 3) (RF: Rheumatoid Factor) Large molecular weight anti-immunoglobulin(igm) Producted by involved synovium B cell 4) : [Proliferation of synovium] & spread over cartilage

7 Physical Therapy and Rehabilitation: PT 7 D. [Pathophysiology] 1. (synovial membrane) (joint capsule) (ligament), (tendon) 2. (joint cartilage) E. Symptoms & sign Young middle-age woman Fatigue Weight loss Low-grade fever Stiffness of hand upon awakening ROM limitation d/t pain & swelling, early stage F. Lab findings Normocytic, Normochromic anemia Elevated ESR(Erythrocyte Sedimentation Rate : ) RF(+) on 80% X-ray findings 1) Early stage: some osteopenia with soft-tissue swelling 2) late stage: Jt space affected Synovial fluid: Elevated WBC(MCHC, neutrophils)

Physical Therapy and Rehabilitation: PT 8 MCHC,, MCV( ),

MCHC [Neutrophils] Neutrophils 3. [RA] A.

8 Physical Therapy and Rehabilitation: PT 8 MCHC,, MCV( ), MCH MCHC ( ),MCHC( ). Neutrophil( ) (,, ).,. 3. MCHC [Neutrophils] Neutrophils 3. [RA] A. Rheumatoid shoulder 1) Early stage a. Shoulder girdle pain & referral pain b. Limitation of Int. Rot 2) late stage a. Proximal subluxation of humeral head b. Rotator cuff weakness: 33% c. Rotator cuff tear: 21% d. Tendon fraying: 24% Signs and Symptoms: shoulder is a stiff or frozen shoulder. 2. Impingement and Partial Rotator Cuff Tears 3. Full Thickness Rotator Cuff Tears 4. Instability 5. OA & RA

Physical Therapy and Rehabilitation: PT 9 B.

full extension 3) Frequently bursitis & epicondylitis develop

Capsuloligamentous tissue deformity d/t inflammation & effusion c.

migration Distal row: dorsal migration d.

9 Physical Therapy and Rehabilitation: PT 9 B. Rheumatoid elbow 1) 20-65% involvement 2) Early stage: limitation of full extension 3) Frequently bursitis & epicondylitis develop Rheumatoid nodules of elbow (left) X-ray images (right) C. Rheumatoid hand 1) Wrist a. Carpal bone deformity d/t ligamentous weakness b. Capsuloligamentous tissue deformity d/t inflammation & effusion c. Distal radioulnar articulation instability Proximal row: volar migration Distal row: dorsal migration d. ECU(extensor carpi ulnaris) muscle slip Volar direction slip d/t laxity e. Proximal carpal row radial deviation 1. Signs and Symptoms: common soft tissue swelling 2. X-ray on wrist 3. Radiographic changes (angulation)

Physical Therapy and Rehabilitation: PT 10 2) Thumb a.

Boutonniere deformity MCP Jt flexion, IP hyperextension d.

Real aspect of RA arthritis pain, swelling thumb 3.

MCP proximal part's normal inclination Difference of

end angulation except) 4th finger 1. Hand deformity 2.

10 Physical Therapy and Rehabilitation: PT 10 2) Thumb a. 1st metacarpal adduction & flexion deformity d/t adductor pollicis spasm & contracture b. MCP hyperextension & IP flexion d/t tenodesis action c. Boutonniere deformity MCP Jt flexion, IP hyperextension d. Disbility on tip-to-tip & Grasp 1. Symptoms of RA: 2. Real aspect of RA arthritis pain, swelling thumb 3. X-ray on wrist 3) MCP(metacarpal phalangeal) joint a. MCP proximal part's normal inclination Difference of collateral ligament length Difference of metacarpal distal end angulation except) 4th finger 1. Hand deformity 2. Before surgery and After sugery 3. X-ray on MCP ulnar deviation b. Physiologic ulnar deviation Collateral ligament

Physical Therapy and Rehabilitation: PT 11 Intrinsic muscle insertion Flexor tendon's

Volar subluxation & dislocation factor weakness of collateral ligament Flexion force

Ulnar deviation MCP Jt capsule & collateral ligament laxity Problem in cosmetic area,

Symptoms: severe or shooting pain 2. PIP of Ulnar deviation 3.

11 Physical Therapy and Rehabilitation: PT 11 Intrinsic muscle insertion Flexor tendon's ulnar bend c. Volar subluxation & dislocation factor weakness of collateral ligament Flexion force of intrinsic muscle Extrinsic factor 4) PIP(proximal interphalangeal) joint a. Ulnar deviation MCP Jt capsule & collateral ligament laxity Problem in cosmetic area, but no problem in functional activity (Early stage) 1. Symptoms: severe or shooting pain 2. PIP of Ulnar deviation 3. Inflammation of PIP Jt In late stage, finger extension loss d/t dislocation of extensor mechanism Finger tip-to-tip activity impairment b. Boutonniere deformity laxity of PIP joint capsule 1. Boutonniere deformity

Physical Therapy and Rehabilitation: PT 12 Volar movement of lateral band Shortening of oblique retinacular ligament

Swan-neck deformity Flexor tenosynovitis with laxity of PIP Jt capsule & accessory collateral ligament Dorsal

Swan-neck deformity 3. RA deformity of Finger d.

12 Physical Therapy and Rehabilitation: PT 12 Volar movement of lateral band Shortening of oblique retinacular ligament Some elongation of central extensor tendon c. Swan-neck deformity Flexor tenosynovitis with laxity of PIP Jt capsule & accessory collateral ligament Dorsal movement of lateral band Lengthening of oblique retinacular ligament Synovitis of flexor tendon 28% of RA 2. Swan-neck deformity 3. RA deformity of Finger d. Mallet finger Laxity of DIP capsule Rupture or stretch of extensor tendon 4. Mallet finger D. Rheumatoid hip 1) 50% involvement 2) Hip synovitis: refer to groin pain 3) Trochanteric bursitis: refer to lateral thigh 4) 5%: femoral head collapse & remodeling of acetabulum

Physical Therapy and Rehabilitation: PT 13 5) Early stage:

Symptoms of RA hip :arthritis pain & loss of motion 2.

Rheumatoid knee 1) Phase I a. Soft tissue involvement b.

Capsular Swollen & Stret surrounding ligament e.

13 Physical Therapy and Rehabilitation: PT 13 5) Early stage: limitation of Int. Rot. 1. Symptoms of RA hip :arthritis pain & loss of motion 2. X-ray on pelvis 3. Bone eaten of RA hip E. Rheumatoid knee 1) Phase I a. Soft tissue involvement b. Synovial hyperemia with effusion c. Swollen, hot, tender d. Capsular Swollen & Stret surrounding ligament e. Soft tissue swelling on x-ray 2) Phase II a. Synovial stage b. Pannus formation c. Some underlying bone destruction on x-ray d. Synovitis & Pannus on arthroscopy e. Cartilage damage on MRI 1. Normal, OA, RA Joint 2. Pannus formation 3) Phase III

Physical Therapy and Rehabilitation: PT 14 a. Cartilage destruction b.

Periarticular swelling d/t induration 4) Phase IV a. Cartilage destruction b.

Symptoms : pain, swelling & stiffness 2. X-ray on foot 3.

14 Physical Therapy and Rehabilitation: PT 14 a. Cartilage destruction b. Narrowing of Jt space c. Jt instability d. Periarticular swelling d/t induration 4) Phase IV a. Cartilage destruction b. Decalcification of bone x-ray c. Marked Jt laxity d. Osterophyte on marginal border F. Rheumatoid foot & ankle Less frequently involvement 1. Symptoms : pain, swelling & stiffness 2. X-ray on foot 3. Foot deformity Involvement in Sever RA Foot problem: 50% 1) Widening at metatarsal area 2) prominent MTP Jt d/t subluxed metatarsal head 3) Hammer toe deformity 4) Hallux valgus 1. Cartilage Destruction 2. MRI on ankle rheumatoid pannus

Physical Therapy and Rehabilitation: PT 15 4. [Pharmacologic management] A.

NSAIDs 1) Inhibition of PG synthesis 2) Inhibit cyclo-oxygenase effect on platelet 3) Effect on leukocyte

humoral factors 2) Inhibition recruitment of neutrophils & monocyte in inflamed site 3) Modify increased capillary

15 Physical Therapy and Rehabilitation: PT [Pharmacologic management] A. Aspirin 1) Pain control by block synthesis of PG 2) Influence leukocyte migration & vascular permeability B. NSAIDs 1) Inhibition of PG synthesis 2) Inhibit cyclo-oxygenase effect on platelet 3) Effect on leukocyte migration C. Steroid 1) Effect on a. leukocyte movement b. leukocyte function c. humoral factors 2) Inhibition recruitment of neutrophils & monocyte in inflamed site 3) Modify increased capillary & membrane permeability 4) Reduce edema 5) Antagonize histamine-induced vasodilation 6) Inhibited PG 1. Cartilage Destruction 2. Aspirin to Prevent Blood Clots 3. Mechanism of desired actions NSAIDs

Physical Therapy and Rehabilitation: PT 16 5.

[Synovectomy] 1) For retardation of Jt destruction 2) 1877 Volkmann

State IV Jt destruction B. [Arthrodesis] : rare. 1. Synovectomy 2.

16 Physical Therapy and Rehabilitation: PT [Surgical management] A. [Synovectomy] 1) For retardation of Jt destruction 2) 1877 Volkmann 3) No cure! - d/t regrowth of synovium 4) Contraindication a. Very active polyarticular disease b. Poor general medical condition c. Poor motivation d. State IV Jt destruction B. [Arthrodesis] : rare. 1. Synovectomy 2.Arthrodesis 6. Rehabilitation interventions A. Rest 1) Local rest by cast or splint a. Reduce pain & inflammation b. For painful periarticular syndrome Ex) [De Quervain Ds], CTS 2) Total Rest

17 Physical Therapy and Rehabilitation: PT 17 a. Systemic rest b. Maximum 4 weeks 3) Short rest Cost-effective treatment strategy 4) Strict bed rest a. up to 5% decrease of strength daily b. up to 30% loss of muscle bulk weekly B. Exercise 1) Cause of Strength decrease a. Myositis b. Myopathy 2' to steroid c. Inhibition of muscle contracture by Jt effusion d. Direct effect to muscle 2) Exercise purpose a. Increase & maintain ROM b. Re-education & strengthen muscle c. Decrease Jt to function better biomechanically d. Increase bony density e. Increase patient's overall function & well-being f. Condition of cardiorespiratory system 3) Progressive Exercise Program a. Relieve pain with appropriate modality b. Progress to increase ROM c. (Prn), stretching & AAROM Ex d. Increase muscle tone by muscle re-education e. Increase Strength & endurance by isometirc Ex f. Recreational program 4) ROM Ex a. Passive ROM Ex b. Avoid at acute inflamed stage c. Increase inflammation & intra-articular pressure 5) Active Ex a. Isometric Ex

18 Physical Therapy and Rehabilitation: PT 18 Static Ex Start in acute phase Minimize muscle fatigue & Jt stress by minimal work & maximize muscle tension b. Isotonic Ex Dynamic Ex Avoid at biomechanically deranged Ex Avoid at acute inflamed state c. Isokinetic Ex Not recommend to rheumatoid arthritis! muscle rebuilding. 6) Strengthening Ex a. Isometric Ex Hold at 2/3 of maximal contraction 1-6 sec/day(muller) Quadriceps strength: increase by 27%(Machover) Cross-over effect :Holdcontractedstate6sec/3time&rest20sec Contralateral side: 17% increase! Isometric Ex Increase oxidative damage of hyaluronate & Glucose b. Isotonic Ex Low weight isotonic Ex start [Indication] Non-inflamed Jt Few ligament problem Minimal x-ray change Dynamic isotonic high-resistance Ex Increase inflammation Increase muscle fatigue & pain Reduce Jt ROM c. Isokinetic Ex Not benefit to arthritic patients Consider to mild RA patient Medium isokinetic program( deg/sec)

19 Physical Therapy and Rehabilitation: PT 19 Avoid low velocity program(30-90 deg/sec) d/t high torque to Jt Contraindication Jt effusion Baker cyst Ligament laxity Acute injury Jt replacement d. Endurance Ex Stage II & III Bicycle ergometer, 6 weeks Quadriceps strengthening Ex e. Stretching Ex Prevent contracture & maintain ROM Avoid! At acute inflammation At mechanical Jt deranged state Large Jt effusion f. Jogging Avoid dry land jogging Induce repetitive Jt motion Few increase in strength g. Change Ex protocol by below signs Post-Ex pain > 2 hour Excessive fatigue Increase weakness Decrease ROM Jt swelling(+) h. Modality Superficial heat : hands and feets. Three mechanisms: conduction, convection, or conversion. Conduction Method Warm body tissue: Hot moist pack(hydrocollator packs) > Dry pack,. Paraffin wax heats: distal Jt of UE, LE

20 Physical Therapy and Rehabilitation: PT 20 Hollander study Decrease 2.2 (-16.5 ) of Jt temperature But, increase at paraffin bath Dorwart study Increase temperature(duration: 4 hrs) Mainardi study No change at superficial heat(duration: 20 min) 4. Modality of Superficial heat effect on articles. Contrast baths: produce reflex hyperemia. Convective methods: Hydrotherapy - Whirlpool baths(partial body emersion), Hubbard tanks (whole body emersion) contrast baths: RA, neurogenic pain, sprain, strai -n, Mild peripheral vascular Ds. Fluidotherapy: warm, air-fluid mixture(fluidization), (ROM Ex ) Conversion methods: IR(infrared) Radiant heat:, superficial heat Deep heat Skin subcutaneous fat overheating deep level tissue te -mperature increase Ultrasound: Jt contracure, scar tissue, periarticular inflammation, bursitis, muscle spasm and pain, OA, tendonitis, fasciitis, adhesions. With medications: Corticosteroids, local anesthetics Diathermy(high-frequency electromagnetic: biologic tissue heating) Shortwave Shortwave and microwave. radiation to heat tissue. Cold Acute inflamed & early subacute Jt Cryotherapy: Hemodynamic effects - reflexive vasoconstriction Superficial: Cold pack, ice massage, Cold baths Others: Vacocoolant sprays(ethyl chloride or florimethane),

Physical Therapy and Rehabilitation: PT 21 Stretch technique for areas of spasm Decrease pain threshold Relax surrounding spastic muscle

Nerve Stimulation: TENS Iontophoresis: transcutaneous delivery of charged medications lidocaine, corticosteroids, salicylate, antibiotics

[Degenerative Arthritis] 1. General consideration A. Asymmetric non-inflammatory Ds without systeminc component B. Three type 1) Primary a.

21 Physical Therapy and Rehabilitation: PT 21 Stretch technique for areas of spasm Decrease pain threshold Relax surrounding spastic muscle Decrease Jt temperature Decrease collagenase activity Decrease cell count in Jt fluid Electrical Stimulation: Gate theory of pain Electrical Nerve Stimulation: TENS Iontophoresis: transcutaneous delivery of charged medications lidocaine, corticosteroids, salicylate, antibiotics Interferential current (ICT): musculoskeletal or neurologic conditions 1. Electrical Stimulation 2. Iontophoresis 3. Iontophoresis mechnism III. [Degenerative Arthritis] 1. General consideration A. Asymmetric non-inflammatory Ds without systeminc component B. Three type 1) Primary a. Peripheral Jt b. Spine e. variant subsets 2) Secondary a. Trauma b. Other Jt Ds c. Systemic metabolic Ds d. Endocrine disorder e. Miscellaneous 3) Erosive inflammatory

Physical Therapy and Rehabilitation: PT 22 1.

>, 3) Genetic factor: 4) Obesity: 2 5) Specific Jt: 3.

22 Physical Therapy and Rehabilitation: PT The joints most often affect ed by OA 2. How weakened ligament lead to OA C. Primary Osteoarthritis(OA) (epidemiology) 1) Age: 2) Sex: >, 3) Genetic factor: 4) Obesity: 2 5) Specific Jt: 3. Comparison of Normal Jt OA Jt. 4. The joint most often affected by OA 5. Progression of OA D. Secondary OA 1) Congenital: Dysplastic hip, genu varum & valgus 2) Ds: (AVN: avascularnecrosis) 3) Metabolic Ds: acromegaly, DM, Gout

23 Physical Therapy and Rehabilitation: PT Characteristics A : 0.1% 55 : 80% (National Health and Nutrition Examination Survey) 65 : B. - > < ( ) C. : Heberden's nodes 10 OA 2. D. : OA E. :, F. : ( 5 kg OA odd ratio 50% ) G. / H. I. / J. - : Hip Jt : DIP,PIP,1stCMC,1stMTP 3. Etiology A. Physical stress on Jt following cartilage biomechanical failure B. Cartilage chondrocyte degeneration C. Secondary change by bony remodelling, synovial response, vascular change, extracartilage change. D. Etiopathogenic factors E. Relationship of physical force & chondrocyte response F. Bony remodelling, synovial response, vascular change, extracartilage factor. 4. Pathophysiology A. Collagen IX fiber degradation Degenerative arthritis basis B. Genetic factor Female dominate C.

Physical Therapy and Rehabilitation: PT 24 1) Phase I [collagen bond]. (MMPs). (MMPs) (TIMP 1,2). 2) Phase II (fibrillation) (erosion) PG. 3) Phase III. -1(IL-1), (TNF-a) (MMPs).

24 Physical Therapy and Rehabilitation: PT 24 1) Phase I [collagen bond]. (MMPs). (MMPs) (TIMP 1,2). 2) Phase II (fibrillation) (erosion) PG. 3) Phase III. -1(IL-1), (TNF-a) (MMPs). (pro-inflammatory molecules ;, NO, ).. Figure 1. Histological examination of tendon tissue from patients with knee joint osteoarthritis (OA) and controls (a) Haematoxylin and eosin (b) Normal tendon tissue (c) OA (d) Non-OA (e) Pancreatic tissue (f) primary antibody was replaced by an isotype matched immunoglobulin TIMP: inhibitor metalloproteinase, regulation to proteinase

25 Physical Therapy and Rehabilitation: PT 25 Proteinase: release form chondrocyte, synovial cell, neutrophils collagenase: destroy collagen stromelysin: destroy matrix neutrophil elastase: destroy elastin. TIMP & Proteinase imbalance weak collagen bond D. External neuromuscular stress action Musculoligamentous reaction Cartilaginous degenration factor 1) Longitudinal force: mechanical & muscular contract 2) Compressive force upon cartilage 3) Impact on subchondral bone microfx Matrix pore size change 1) [osmotic pressure change] lytic action E. [Histologic change] 1) Early change : flaking & pitting of the suface Deep fissuring Fibrilation Erosion of cartilage Exposure of subchondral bone 2) Loss of PG : PG synthesis rate, 3) Loss of tidemark intergrity 4) Subchondral cyst 5) & [Disequilibrium of catabolism & anabolism] Cytokine interleukin I, TNF(tumor necrosis factor) Increase loss rate of polysaccharide protein from articular cartilage Inhibit re-synthesis 6) Large amount of chondroithin-4-sulfate in OA F. Inflammation evidence 1) Inflammation sign on synovial cell & cartilage cell 2) Chronic inflammation on Bx 3) Increase interleukin-1, TNF, prostagladin degradative product G. Pain syndrome

26 Physical Therapy and Rehabilitation: PT 26 Inflammation is secondary feature of repair process 5. General symptom & sign A. Symptoms 1) Pain a. Deep, aching, poorly localized b. Early, pain with use: later, pain at rest 2) Stiffness a.localizedtoinvolvedjt. b. Rarely exceeds min duration c. Related weather change 3) Crepition, cracking 4) Limitation of Jt motion 5) Giving way of weight-bearing Jt. B. Signs 1) Tenderness 2) Pain on passive motion 3) Crepitus, crutching on Jt motion 4) Jt enlargement & limitation of motion 5) Deformity 6. Radiologic findings Stage Destruction Repair Fibrillation of cartilage Osteophyte Early stage Erosion(minimal) Surface bumps Marginal Erosion & Exposure of bone Sclerosis Intermediate stage Focal osteonecrosis Osteophyte enlarge & coalesce, & femoral neck migrate Fibrous & cartilage marrow metaplasia Buttressing Progression Progression Late stage Collapse & deformity of femoral Spontaneous subsidence head Resurfacing of Jt 7. Pain in the knee with OA

27 Physical Therapy and Rehabilitation: PT 27 A. Loss of cartilage B. Mechanical compression of the medial or lateral knee compartment varusorvalgusdeformity C. Stretch on the medial & lateral collateral ligament D. MicroFx & subchondral Fx E. Capsular distension by effusion F. Chondromalacia patellae G. PPD(80 : 28%): Pyrophospate dihydrate deposition 8. [Management principles] A. Decrease pain B. Preserve & restore ROM & strength C. Reduce Jt load D. Prevent or reduce contracture E. Preserve Jt alignment 9. [Pharmacologic management] A. Analgesics 1) Acetaminophen(tylenol, etc) a. 650 mg per 4-6 hrs b. Maximum < 4g / day c. Caution - warfarin interaction, decrease half-life of caumadin 2) Codein:, morphine morphine. aspirin. 3) Salicylate:,. B. NSAIDs Indole derivatives Pyrazolones Phenylpropionic Acids Fenamates Oxicam Indomethansin Phenylburazone Ibuprofen Mefenamic acid Piroxicam Sulindac Naproxen Meclofenamate Tolmetin Fenoprofen Zoepirac C. COX-s inhibitions D. Intrarticular injection with corticosteroid

28 Physical Therapy and Rehabilitation: PT 28 1) Reduce effusion of Jt = pain relieg 2) Reduce synovial permeability 3) Inhibition of release of hyaluronic acid 4)! Articular damage progress! E. Chondroprotection by DMOAD(Disease Modifying Osteoarthritis Drugs) Tamoxifen( ) Diacerhein(IL-1 metalloproteinase ) Chloroquine( ) Glucocorticoids( ) Tranexamic acids( ) Heparinoids Tetracycline Glycoxaminoglycan derivatives Growth hormone( ) Interleukin-1 inhibition TNF inhibitions Hyaluronic Acid(pain inhibitor) F. Intrarticular injection with hyaluronic acid 1) Major protion of synocium & cartilagenous surface 2) Glycosaminoglycan 3) Function a. Lubrication of Jt b. Shock absorption of cartilage c. Protection of cartilagenous surface d. Induce aggregation & synthesis of PG e. Enhance synthesis of hyaluronic acid of synovial cell

29 Physical Therapy and Rehabilitation: PT 29 f. Remove free oxygen radical in Jt g. Anti-inflammation function G. Glucosamine 1) Glucosaminoglycan polysulfate(gags) precursor 2) Function a. Stimulate collagen & proteoglycan synthesis b. Stimulate synovial cell c. Anti-inflammation H. Chondrotin sulfate Function 1) Inhibition osteolytic cell activity 2) Inhibition enzymatic activity 3) Increase GAGs pool 10. [Operation] A. : B. : 1) (arthroscopic synovectomy) :. matrix debris. 2) (joint replacement) : OA ) (osteotomy) :. 11. Rehabilitation Management A. Education of Pts. B. Rest: short period rest C. Brace & orthosis D. Weight control E. Physical modality

f. h.,, 2) Bicycle a. Pedal Jt b. Hip, knee, ankle OA walk c. Heel (5-10 min) d.

30 Physical Therapy and Rehabilitation: PT 30 1) ROM, Decrease pain, 2) 3) 30 4) TENS F. Ex 1) Walk a. Aerobic ex b. Running Jt c. test( ): walking. d. walking - 2 times / day e. f. h.,, 2) Bicycle a. Pedal Jt b. Hip, knee, ankle OA walk c. Heel (5-10 min) d. Pedal knee Flextion. e. Pedal,. f., 1. Walking 3) hydrotherapy a. Ex b. : Decrease Pain Muscle Relaxation

31 Physical Therapy and Rehabilitation: PT "V" Ex 2. Hip-hinging Ex 3. Wall walking Ex 4. The Rocking horse Aquatic Ex 5. Calf Strench Ex 6. Chair Rise Ex Jt c. (aerobic fitness) 4) a. b. c. Muscle arthritis d. 6 e. 5) Stretching Ex a. b. c. Muscle tension stretching 30 d. stretching. e.

32 Physical Therapy and Rehabilitation: PT 32 f. PNF g. 20 min /, 3 times h. Pain. 6) Quadriceps Femoris muscle strengthening Ex a. knee Jt Extension b. femur patellar Jt surface. knee extension, / day knee flex, sidelying,. knee extension, sidelying,. Prone position,. Supine position,.. Supine position,.. Sitting position, 45. Standing position, 45. Sitting position,. Standing position,.

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untitled Ankylosing Spondylitis 1 Ankylosing Spondylitis Marie-strumpell, Bechterew, (pelvospondylitis ossificans). (ossification), (sacroiliac joint),.,.,,.,.., NSAIDs(Non-Steroidal Anti-Inflammatory Drugs),.