OA Source

Antalgic gait -> gait that develops as a way to

avoid pain while walking (antalgic = anti- +
alge, "against pain"). It is a form
of gaitabnormality where the stance phase
of gait is abnormally shortened relative to the
swing phase. It can be a good indication of
pain with weight-bearing.
Hip flexor extensor weakness
Rom limita
Genu varus
Inflamation sign
Medial vastus atrofi
Special test
Circumference
Q angle
leg length
Krepitus
TENS
Gait aids
Isotonik
RA GOUT
 DEFINITION
Is a heterogenous condition with variable
presentation and variety of patterns of
expression
group of disorders with different etiologies
but similar pathologic changes (delisa)
Non erosive non inflamatory progressive
disorder of the joint surface and margin.
Disease of cartilage initially. (cucurullo)
 Prevalence/profile/RF - Cucu
Most common arthritis, 2nd disabling ds in us
Increased w/ AGE (70% radiologic + > 65yo)
M:F ratio = (45-55), >55 F>M. More common in
women
Repetitive trauma occupation
Obes -> knee OA

Age, obes, trauma, genetic, muscle weakness,

repetitive use, infection, metabolic cause, neuropatic
disorder, morfologic, bone, surgical procedure
 Sign Symptom - cucu
Sign
Dull ache, activiities>, rest<
Joint stiff after immobility<30
Symptom
 Medscape
line drawn from central patella to tibial tubercle;
- an increased Q angle is a risk factor for patellar subluxation;
- normally Q angle is 14 deg for males and 17 deg for females;
- Agliettis et. al. Clin. Ortho 1983:
- 75 normal males: Q angle = 14 deg (+/- 3)
- 75 normal females: Q angle = 17 deg (+/- 3)
- biomechanics of patellofemoral joint are effected by patellar tendon length & the Q
angle;
- q angle is increased by:
- genu valgum
- increased femoral anteversion
- external tibial torsion
- laterally positioned tibial tuberosity
- tight lateral retinaculum

- Clincal Determination: (see examination of the patellofemoral joint)

- deficiency of vastus medialis oblique is best assessed while leg is suspended in 15-20
deg of flexion;
- large convexity at superomedial corner of patella indicates vastus medialis deficiency;
- this is best measured both w/ the knee in extension as well as flexion;
- Q angle may not be accurrate in extension, since a laterally dislocated patella may give
false impression that the Q angle is normal;
- in flexion, this is not a problem since the patella is well seated in the trochlear
groove;
- a sitting Q angle of more than 8 deg is abnormal
 - an increased Q angle is a risk factor
for patellar subluxation;
- normally Q angle is 14 deg for males
and 17 deg for females;
- Agliettis et. al. Clin. Ortho 1983:
- 75 normal males: Q angle = 14
deg (+/- 3)
- 75 normal females: Q angle = 17
deg (+/- 3)
- biomechanics of patellofemoral joint
are effected by patellar tendon length &
the Q angle;
 Q angle is the angle formed by a line drawn
from the ASIS to central patella and a second
line drawn from central patella to tibial
tubercle;
 Definition
Degenerative condition of the joint
articular cartilage with subsequent
formation of marginal osteophytes,
sub chondral bone changes, fibrous
reaction of synovium and capsular
thickening.
 a. Early
- Hypercellulary of chondrocytes
- Cartilage breakdown
- Minimal inflamation
b. Later
- Cartilage fissuring, pitting,
erosing
- Hypocellulary of chondrocytes
- Inflamation synovitis
- Osteophyte spur formation at
joint margins
- Subchondral bone sclerosis
Increase water of cartilage lead to damage
of the collagen network
Loss of proteoglycans
 Predisposing factor:
Age
Obesity : weight bearing joint; (hip,
knee, hand)
Trauma
Repetitive stress and joint overload
Genetic factors
Metabolic disorder
 Criteria for Classification of Osteoarthritis of the Knee: (ARA)
Clinical and Clinical and Clinical
laboratory radiographic
Knee pain Knee pain Knee pain
+ at least 5 of 9: + at least 1 of 3: + at least 3 of 6:
1. Age > 50 years 1. Age > 50 years 1. Age > 50 years
2. Stiffness < 30 2. Stiffness < 30 2. Stiffness < 30
3. Crepitus 3. Crepitus 3. Crepitus
4. Bony Tenderness + Osteophytes 4. Bony Tenderness
5. Bony Enlargement 5. Bony Enlargement
6. No palpable 6. No palpable
warmth warmth
7. ESR < 40 mm/hour
8. RF < 1:40
9. SF OA
Kellgren and Lawrence grading criteria for radioghraphic
severity of OA knee :

Grade Radioghrapic findings

Grade 0 No features of OA
Grade I Joint in normal limit with minimal osteophyte
Grade II Theres osteophyte, subchondral sclerosis, good joint
space, no deformity
Grade III Theres osteophyte, deformity of bone ends, joint
space narrowing
Grade IV Theres osteophyte, deformity of bone ends, loss of
joint space
 I. Physical rehabilitation program
A. Pain management:
i. Medikamentosa
- NSAID: oral, topical analgesic
- Chondroprotective
- Steroid oral or intra articular
- Muscle relaxant
ii. Physiatric Intervention
- Modality : Icing (acute), Diathermi, TENS
- Exercises
- Physical support (knee brace)
B. Joint conservation
II. Surgery :
Arthroscopy (debridement and joint
lavage)
Osteotomy
Arthroplasty
 Goal of Exercise for OA
Muscle Strengthening
help to minimize the adverse effects of weight
bearing on the joints by reducing the amount of
force that is transmitted across the affected joints.
Improving Flexibility and Joint Motion
when people do not use their muscles, not only do
the muscles become weak, but they can also
change shape and shorten to the point where they
limit normal movement.
 Improve Aerobic Functioning
It is important that patients with osteoarthritis
find ways to maintain cardiovascular fitness.
Weight Loss
Thus, through weight loss, there is a decrease in
forces across the joint.
Quadriceps
1) Quad sets: while in a seated position, with legs fully extended in front of you,
make a muscle with your thighs trying to push the back of your knee down towards
the floor. Hold for 10 seconds, relax and then repeat.

2) Wall slide: place your back up against the wall with your hips and knees bent
to a 90 degree angle as if you were sitting in a chair. Hold this position for 10
seconds, then come up and relax. Repeat.
3) Isotonic Quad exercise: sitting in a chair with your feet planted flat on the floor,
raise your right leg straight out in front of you. Relax and bring back to the
floor. Repeat on the left. As you are able to you can add ankle weights to
increase resistance.
Hamstrings
1 Isometric: while lying on the floor place heels on surface such as a couch or an exercise
ball. Press down using the backs of your thighs and hold contraction for 10 seconds. Relax
and then repeat.

2 Isotonic: lying on your belly with a pillow under your abdomen to support your back, ben
your knee and bring your foot back towards your buttock. Bring back down to the floor repeat
on the other side.
Gluteal Muscles
1) Isometric: Lying down on a flat surface back flat on the floor, bend your knees so that your
feet are flat on the floor. Raise your buttocks up off the ground contracting your butt muscles
together. Hold for 10 seconds then relax.
Calf muscles (gastrocnemius)
1) Using a wall or chair for balance, go up on your toes using your calf
muscles hold yourself. Contract for 10 seconds, relax and repeat.
 Isometric quadriceps (quads) contraction

Position: Initially the exercise should be done Iying down or sitting comfortably. Once
you can do the exercise comfortably it can be done while standing.

Repetitions: You should start by doing ten contractions at a time. Increase the number by
one repetition per day as tolerated. The exercise can be done many times during the day.
If knee pain occurs decrease the number of repetitions per day.

Exercise: Contract the quadriceps muscles in the front of your knee attempting to
maximally straighten out the knee. While you tighten the quadraceps muscle, pull your
toes and foot toward your face. Push your heel down against the surface upon which
your leg rests. Hold the contraction for a count of 5, then relax.
 Isometric Quadriceps Strengthening
Position: Sitting. One leg on top of the other
Repetitions: Start with ten repetitions. Increase the
number of repetitions as your strength increases.
Exercise:
Start with your right leg straight. Put your left leg and foot
over the top of the right leg. Push down with the left leg
and up with the right leg. Hold the contraction for a count
of three. Relax for a count of two, then repeat the exercise.
ACR DIAGNOSTIC CRITERIA for OA of the KNEE :

KNEE PAIN
and
OSTEOPHYTES
+
one of the following

1. Age > 50
2. Stiffness < 30
3. Crepitus
 PROBLEMS IN OA :

1. Damage of joint cartilage

2. Joint immobilization
3. Changes of the joint architecture
 Biomechanical

Matrix degradation : Chondrocytes Matrix synthesis :

Cytokines IGF-1
Enzymes TGF-
Nitric oxide

Loss of matrix integrity

Genetic Metabolic

OA
 Local
biomechanical
G enetics factors

A ging

M etabolism (cartilage)
Site and
severity of
E xessive movements OA

7 juli2001 kongres ira 2001 sby 36

 MECHANISMS OF CARTILAGE DAMAGE :

1. Interfacial wear :
Direct contact between joint surfaces
due to reduced lubricants
2. Fatigue wear : repetitive stresses
3. Impact loading : heavy and quick loads
 WHAT TO DO ?

1. Avoid further joint damage

2. Do not let the joint rest/immobilized
too long
3. Maintain the joint alignment
GENERAL OBJECTIVES OF REHABILITATION
MEDICINE PROGRAM :

1. To eliminate disability
2. To minimize disability
3. To reach the maximal independence
functions
4. To improve QoL
 THE OBJECTIVES OF R.M.
PROGRAM in Mx. of OA :
1. To reduce pain
2. To maintain joint ROM
3. To strengthen muscles surrounding
the joint
4. To maintain joint function
5. Education for joint conservation
 TO REDUCE PAIN :
1. Joint rest
2. Pharmacological agents : Analgesics
NSAIDs
3. Physical modalities :
Thermal Tx. : Cold / heat
TENS
Laser
Orthotics
Exercise
 DIATERMI
Diatermi (Yunani: dia = through = melalui; therme = heat =
panas).
Target jaringan pada KFR otot, tendo, ligamen, atau tulang.
Target temperatur terapi antara 40-45 C.
< target = tidak menghasilkan vasodilatasi dan
metabolisme yang adekuat.
> target = merusak jaringan
Terbagi atas 3:
Ultrasound Diathermy (USD)
Microwave Diathermy (MWD)
Shortwave Diathermy (SWD)
 SWD

Deep heating mll konversi energi

elektromagnetik gelombang radio
energi panas
 Indikasi swd

Chronic Prostatitis
Pelvic Inflamatory Dis. (PID)
Myalgia
KONTRAINDIKASI
 ENERGI ELEKTROMAGNETIK
Radiasi elektromagnetik adalah gelombang elektromagnetik
antara 10 kHz 300 GHz.
Gel. elektromagnetik antara 100 kHz 100 MHz Gelombang
radio
Gelombang radio dibagi menjadi long, medium, dan shortwave
bands.

Semua dengan freq 10-100 MHz disebut shortwave.

FCC membatasi penggunaan SWD secara umum baik industri, riset dan
medis pada 13,56 MHz, 27,12 MHz, dan 40,68 MHz.

Frekuensi 27,12 MHz yang paling sering digunakan.

 PRINSIP SWD
Aplikasi energi elektromagnetik dengan
frekuensi tinggi
 Produksi PANAS mesin SWD
Osilasi
Arus
radiasi
Energi listrik frekuensi
elektro
tinggi
magnetik

Pergerakan ion,
Generator Rotasi molekul polar,
Panas Distorsi molekul non-polar

Kedalaman panas 4-5 cm.

Suhu lemak subkutan akan meningkat s/d 15C.
Suhu pada otot meningkat 46C .
GERAK ION

ROTASI
DIPOLAR

DISTORSI
MOLEKUL
 TIPE ELEKTRODA

Capacitive Inductive
Electrode Electrode
 1. CAPACITIVE ELEKTRODA
Menghasilkan medan elektrik >> medan magnet.
Osilasi pd medan elektrik di antara 2 plat
panas.
Bagian tubuh yg akan diterapi berada di antara 2
plat kondensor metal.
Jenis : air space plat & pad electrode.
Efektif pada water-poor tissues (jaringan
subkutan/ lemak, tulang)
 2. ELEKTRODE INDUKTIF
Applikator menghasilkan medan magnet >>
medan listrik medan elektrik sirkular pd
jaringan.
Gelombang yg dihasilkan disebut eddy currents
medan elektrik sirkuler yg kecil yg terbentuk
saat medan magnet dihasilkan dari osilasi
intermolekular pada jaringan panas.
Aplikator : kabel atau drum.
Efektif pd water-rich tissues (otot, kulit, darah)
 Contra planar

SETTING
1. Capasitor :
Co planar
Contraplanar
Coplanar
Cross-fire
2. Inductothermy
Monode/ drum type
Coil dililitkan sbg flat Inductothermy
spiral
Coil mengelilingi tungkai.
 CARA PENGGUNAAN
Persiapan pasien :
Bebas logam dan bahan sintetik
Tes sensorik suhu
Kulit yang lembab dikeringkan
Kulit bebas dari bahan absorban
Kain terry digunakan sbg pembatas dan utk
menyerap keringat .
 CARA PENGGUNAAN (2)
Setelah alat dinyalakan, panas disesuaikan pada
intensitas yang sesuai dgn pasien.
Saat terjadi vasodilatasi, panas mungkin
menghilang, maka intensitas dapat dinaikkan
(jangan terlalu tinggi).
Lama terapi umumnya 20-30 menit.
Tidak ad dosis yg tepat utk SWD, persepsi panas
digunakan sbg monitor.
Tanda panas meluas : erytema, peningkatan
temperatur kulit.
Tabel Dosis SWD

Dosage Description of heat to patient

Moderate heating Comfortable warmth

Mild heating Mild gentle warmth
Minimal perceptible heating So that you can only just feel
the warmth
Imperceptible heating No feeling of warmth at all
Definition

Osteoarthritis is an inflammatory
progressive disorder of the joints
leading to deterioration of the articular
cartilage and new bone formation at
the joint surfaces and margins.
Prevalence

Prevalence increase with :

Age, 70% population > 65 y.o have
radiographic evidence of OA.
Obesity
Trauma and repetitive stress
Genetic factor
Diabetes Mellitus
Anatomy
Mechanism of cartilage damage :

1. Interfacial wear :
Direct contact between joint surfaces
due to reduced lubricants
2. Fatigue wear : repetitive stresses
3. Impact loading : heavy and quick loads
CLINICAL

The major symptoms of OA in a joint are:

pain,
stiffness, and
loss of movement.

Major signs are:

bony swelling,
crepitus,
joint margin tenderness,
cool effusion,
decreased range of movement, and
instability.
Diagnose
Criteria for Classification of Idiophatic Osteoarthritis of
the Knee ( American Rheumatism Association)
Clinical and laboratory :
Knee pain
+ at least 5 of 9 :
Age > 50 years
Stiffness < 30 minutes
Crepitus
Bony tenderness
Bony enlargement
No palpabe warmth
ESR < 40 mm/hour
RF 1:40
SF OA
Clinical and radiographic :

Knee pain
+ at least 1 of 3 :
Age > 50 years
Stiffness < 30 minutes
Crepitus
+ Osteophytes
Clinical :
Knee pain
+ at least 3 of 6 :
Age > 50 years
Stiffness < 30 minutes
Crepitus
Bony tenderness
Bony enlargement
No palpabe warmth
Radiographic criteria (Kellgren -Lawrence)

1. Grade 0 Normal
2. Grade 1 Normal joint except for one
minimal osteophyte
3. Grade 2 Definite osteophyte on 2
point with minimal subchondral
sclerosis, no deformity
4. Grade 3 Moderate osteophyte,
narrowing joint space, deformity
5. Grade 4 Large osteophyte, deformity,
loss of joint space, sclerosis,
cyst
Treatment
Education :
- Weight control
- Joint conservation :
Chairs must not too low
Avoid squatting
Avoid too much climbing stairs
Reduce body weight
Walk with cane/walker
If necessary with knee brace
Swimming
Treatment
Physical therapy :
- ROM exercise
- Quadriceps strengthening exercise
Medication
- Paracetamol
- NSAIDs
- Narcotic preparation
- Intraarticular injection of corticosteroid
Surgery