Osteoarthritis is a degenerative joint disease, often referred to as “wear and tear arthritis”. It occurs when the layer of cartilage covering joint ends break down, leading to friction with the bone ends in joints, causing pain and swelling. Osteoarthritis has no clear cause but multiple risk factors have been identified. Nick Claus’ case shows many of the risk factors associated with the development of osteoarthritis. Firstly is Nick’s weight. Being overweight/obese is associated with 24.6% of new cases of knee osteoarthritis. Article 1. This is likely due to the increased weight, and resulting stress put onto the joints during movement of a heavier body. This results in more pressure being put on the Joint ends, increasing friction which would lead to the breakdown of the cartilage.
A second known risk factor is history of a previous knee injury. Nick sustained an ACL injury 15 years prior. Nick’s Rehab history of this injury, but any surgery that could of occurred could also play a role in the development of OA.Article 1 also shows that previous knee injury is related to 5.1% of new OA cases. Nick’s farming lifestyle would also likely be a risk factor. The Large, rolling hills of his farm would result in stress being applied to Nick’s knee off axis, which could lead to increased stress applied to the joint.
In Nick’s objective examination, it is likely that we would see mechanical-related pain in the joint, due to cartilage not providing smooth, frictionless movement of the bone ends. Swelling around his knee could be present, or Nick could be asked if he has any flare-ups. Crepitus and reduced range of motion of the joint, either due to pain, swelling, or restriction of the joint would also be seen during mechanical movements of Nick’s knee. Nick could also show instability on his right leg because of the pain, so compensatory signs, such as limping, or reduced movement in knee may be seen when he stands or walks.
When planning Nick’s holistic treatment, It is important to take into consideration his beliefs when looking at treatment options for both his knee osteoarthritis and his type II diabetes. Because we know some information about Nick’s home life, and the area in which he lives, we would need to plan treatments that are accessible to him, such as using the pool and recreation centre that are close by to him. This would make it more likely for him to carry out his rehabilitation because the facilities are closer to hand. Another factor that should be taken into account is how Nick said that he takes little pleasure in his usual activities, and prefers sitting around at home. A way that we could approach this is by incorporating aspects of activities he used to enjoy, like cricket and skiing to make the activities more functional and enjoyable. We could also get him to try something new, such as hydrotherapy, and to get him up out of the house and to be doing something he likely hasn’t done before to get him interested
SECTION 2
The treatment plan for Nick’s knee Osteoarthritis would involve a mixture of physiotherapist applied therapies, including Manual therapy of the joint and massage of the surrounding muscle, and also an exercise/activity plan written for Nick to follow outside of the sessions. The mixture of these would aim to decrease the pain the Nick is experiencing because of the Arthritis, increase the range of motion in his knee, and improve nick functional ability to allow him to return to his usual activities.
Firstly are the techniques that the physiotherapist would use on Nicks knee. Mulligans concept of ‘Mobilisations with movement’ or “MWM’s” is the concept of the Physiotherapist applying an accessory movement, a movement of the bone ends which cannot be done by the patient, while the patient performs a physiological movement, in this case flexion and extension of the knee. When the Physiotherapist would work with Nick using this, the therapist would apply have Nick standing, with his right leg up on a 30 cm high stool. The Physio would apply pressure to the tibia medially while supporting the thigh, and Nick would squat down, flexing his knee. Mulligan explained in a video of one of his courses video #2 that doing this stops the meningie of the knee bulging out during flexion, resulting in more cushioning for the joint during movement, which helps reduce pain due to the Osteoarthritis. A lot of evidence exists showing the benefits of Mulligans techniques, One article published in the ‘International journal of Physiotherapy’ in 2017 showed the benefits of MWM’s of the knee joint specifically when treating Osteoarthritis. Article 3 The article shows that the application of MWM’s along with conventional physical therapy over 7 days resulted in a significantly higher increase in results of VAS (visual analog scale of pain), WOMAC score (a questionnaire covering pain, stiffness, physical function) and 6 minute walk test distance compared to a control group who only received conventional physical techniques over the same period. Over the 7 days the trial was undertaken, the trial group saw an decrease in mean VAS score of 3.6 (p = <0.01) and mean WOMAC score of 19 (p= <0.01). This compared to a difference in the control group of 0.6 (p=<0.05) and 4.4 (p=<0.05) respectively. This data shows a statistically significant improvement in pain, stiffness, and function of patients with Osteoarthritis in the knee when using Mulligans MWM techniques. Because of this evidence, I believe that the use of these techniques as part of Nick’s treatment plan would be hugely beneficial towards regaining his function.
Following Nick’s treatment with the physio, it is important that we would prescribe him an exercise/activity routine to further aid his rehabilitation and improve him function. I believe hydrotherapy exercises would be beneficial. Hydrotherapy is the concept of completing exercise and movements while in a pool as to create a weightless environment. This is beneficial for people with osteoarthritis as it means that weight is not being put onto their affected joints, especially when exercising under normal conditions of gravity is difficult and painful. (4) Hydrotherapy pools are also heated to around 35 degrees celsius to help relax muscle and sooth pain, But if the pool in Alexandra that Nick has access to is only a normal temperature or has a spa instead, they would still offer him the benefits of using a pool for therapy. The exercises prescribed to Nick would be focused around his knee joint, but exercises for other areas of the body, such as arms, shoulders, or back could also be incorporated into the routine. I would begin by having Nick work on unresisted exercises, such as squats of lunges to begin with. This would give a baseline of his strength: if he found it too easy he could progress, if it was working him he could continue with those before progressing. Progressing the exercises would be done by either adding resistance, such and ankle weights, or by adding more functional elements, such and walking lunges, or stepping. The evidence for hydrotherapy being beneficial is shown in a 2008 article in the journal Physical therapy. ARTICLE 4. This article looks at the comparison of hydrotherapy and land-based exercises. The patients in this study were those who had not had physical therapy intervention for their knee in the preceding 6 months or practiced regular physical activity (3 times a week or more) for more than 1 month. (4) Because Nick fits this criteria, the outcomes from this study can be applied to Nicks case. The outcomes of this study showed a decrease in pain before and after a 50-foot (15.24m) walk test decreased throughout the study more in the hydrotherapy participants compared with the land-based participants. A decrease of mean VAS score of 21.8 over the 18 weeks compared to 27.2. Though these numbers don’t show too drastic of a change, the land-based group mean VAS increased between weeks 9 to 18, while the hydrotherapy group constantly decreased over the trial. This could show that Hydrotherapy has a more long last effect than land based exercise. From this evidence I would prescribe hydrotherapy for Nick to aid in his pain management and to regain functional ability. Hydrotherapy would also give Nick an opportunity to get out out of the house and away from the farm, and also be a new activity that could peak his interest, as he said his usual activities he is not finding pleasure in anymore.
Nick’s type II diabetes is something that we could also focus on to help improve his general wellbeing. Focusing on exercises and the resulting weight loss to help control his diabetes to help improve his general well being, and also trying to help rehabilitate his osteoarthritis. Low to medium intensity exercise would be the best choice for Nick’s exercise program for his Diabetes. In early exercise, stored glucose provides the bulk of energy that muscles use to contract. After glucose stores are depleted, muscles use circulating blood glucose, as well as FFA from adipose tissues. ARTICLE 5. For Nick to use excess blood glucose due to his diabetes, he would need to use exercises and intensities that use this as a primary fuel source. If Nick were to focus on long duration exercise, e.g. long-distance running, he would primarily be using fats as a fuel source. The use of both blood glucose and free fatty acids would also facilitate weight loss. This resulting weight loss would further help nick manage his diabetes, as well as reducing the effects of his knee osteoarthritis as less weight is being loaded on the joint. The exercises I would prescribe for Nick would likely tie into his osteoarthritis treatment, such as the hydrotherapy program, but exercises outside of this, such as a 30 minute moderate-intensity walk 5 days a week, as per the World Health Organisation guidelines Article 6. Once Nick has build up his level of fitness, we could look at bringing in resistance training a couple times per week, as well as getting back into some of the activities he used to enjoy, such as skiing. Weight loss is thought to be one of the primary controllable factors of type 2 diabetes. A 2017 cohort study of more than 33,000 people showed there is a strong link between weight maintenance/moderate weight loss and decreased diabetes risk. If the populations mean weight could decrease by 1-2kg/m2, 2 in 5 diabetes cases could be prevented. ARTICLE 7.With a cohort this large showing these results, the data from this can be used as evidence for prescribing Nick exercise with the goal of weight loss to help further control his diabetes.
Additionally to Nick’s treatment with the physiotherapist, a ‘transcutaneous electrical nerve stimulation’ device (TENS) could be prescribed for Nick’s home use to supplement his exercise. The role of TENS is a non-invasive pain relief, which acts by stimulating nerve fibers to act as a ‘pain gate’ which inhibits signals from nociceptive pain fibres, resulting in a reduction in pain felt. TENS also has no adverse drug interactions. For Nick I would prescribe to use of acupuncture-like TENS, which uses low frequency (<10Hz) which activates smaller diameter fibres in the muscle. The activation of these fibres leads to activation of endogenous pain mechanisms which cause the release of opioids to inhibit pain. Because of this, the acupuncture-like tens causes a long lasting pain relief. Conventional TENS and acupuncture-like TENS have similar pain relieving ability when compared to a placebo, but because of acu-TENS having longer lasting pain relief, showed greater improvement in functional mobility and range of motion. Article 8 This article comparing the use of conventional TENS and acupuncture-like TENS with a placebo showed improvements in pain scores, with no one being better than the other. The benefit for Nick using long-lasting, acuTENS is that he would be able to get back on to the farm after using TENS and not having to wear it on him for continuous use. The benefit of this is that the device would not get damaged while working, and would allow nick to operate machinery, which should not be done while wearing convTENS as it can cause shocks which could put him in danger. The TENS unit would have the electrodes placed one on either side of Nick’s knee, instructing him to have the frequency set to 2Hz and intensity turned up to tolerance without pain for 30 minutes. Nick would see muscle twitching in his quads when using this, so would be instructed to be sitting when using the device. TENS is able to be used alone to relieve pain, but can also be supplemented with either heat or cold, which Nick could already be using as an easy way to relieve his OA pains. Article 9. Thisstudy from 2017 of TENS use with knee OA shows that TENS alone can assist in decrease of pain. the TUG results suggest that only the TENS simultaneously combined with local heat can improve dynamic balance and gait ability. Article 9 explores the use of heat prior to TENS treatment, which could be tied in with Nick Aqua Therapy sessions to apply the heat, then using TENS once he is out of the pool.