Osteoarthritis of the Knee: Arthroplasty Preparation

Transcription

1 Osteoarthritis of the Knee: Arthroplasty Preparation Rebecca Tyers November 2015 Wimbledon, London, UK Comprehensive Training Programme 2015

2 Abstract Osteoarthritis (OA) is a chronic, degenerative disease that occurs when the protective cartilage, that cushions the end of the bones, wears away. OA of the knee causes joint stiffness, pain and swelling, it also restricts the range of motion of the joint. In severe cases, without cartilage, the bone rubs on bone and the knee will eventually need replacing. Approximately 8.75 million people in the United Kingdom have sought treatment for OA and one in five people over the age of 45 years has OA in the knee. A pilates rehabilitation programme can assist to increase quality of life of people living with OA by strengthening and stretching the muscles involved and the whole body. It also works to increase the range of motion of the knee. In severe cases, pilates can help with preparation pre-surgery and with rehabilitation post-surgery. 2

3 Contents Page Abstract 2 Anatomy of the knee 4 Osteoarthritis 7 Arthroplasty 8 Case-Study 9 BASI Pilates Programme 10 Conclusion 12 Bibliography 13 3

4 Anatomy of the knee The knee joint is the largest synovial joint in the body and the most complex in structure. Three bones meet to form the knee joint: the femur, tibia and patella. The ends of the femur, tibia and the back of the patella are covered with articular cartilage, this aids movement by gliding the bones smoothly across each other as the leg bends and straightens. The ligaments stabilise the knee by holding the bones together. The two pieces of meniscal cartilage act as a shock absorber between the condyles of the femur and tibia. The patella, a sesamoid bone, is contained within the tendon of the quadriceps muscle, this continues on as the patellar ligament and inserts into the tibial tuberosity. The structure of the knee 4

5 The knee is a mobile troche-ginglymus (a hinge joint) allowing flexion, extension and medial and lateral rotation. It is formed from three separate joints, which have developed a common synovial cavity: - a medial compartment between the medial condyles of the femur (CF) and tibia (CT) - a lateral compartment, between the lateral condyles of the femur (CF) and tibia (CT) - a joint between the patella and the femur. The stability of the joint between the tibia and femur (tibio-fermoral joint) is governed by four major ligaments: - the medial (tibial) collateral ligament (MCL) prevents abduction of the tibia on the femur - the lateral (fibular) collateral ligament (LCL) prevents adduction of the tibia in extension of the knee - the anterior cruciate ligament (ACL) limits sliding movements that would carry the tibia anteriorly or the femur posteriorly - the posterior cruciate ligament (PCL) limits sliding movements that would carry the tibia posteriorly or the femur anteriorly. 5

6 Movement of the knee: muscle focus Flexion of knee Bicep Femoris Semitendinous Semimembranosus Sartorius Gracilis Popliteus Gastrocnemius Extension of knee Rectus Femoris Vastus Medialis Vastus Intermedius Vastus Lateralis The Gastrocnemius is a dynamic stabiliser preventing hyperextension of the knee and the Gluteus Medius, an abductor and external rotator of the hip when in flexion. 6

7 Osteoarthritis Osteoarthritis (OA) is the most common form of arthritis, affecting approximately 8.75 million people in the United Kingdom (UK). In the UK, one in five people over the age of 45 years has OA in the knee. OA is a chronic, degenerative disease and occurs when the protective cartilage, that cushions the ends of the bones, wears away causing pain and swelling. The cartilage aids frictionless joint motion but in OA the surface of the cartilage is rough, if it wears completely the bone will rub on bone. The joints become stiff, painful and swollen, there will also be limited range of motion of the joint. OA is aggravated by weight-bearing activities such as walking, running, stair climbing and squatting. In some cases patients will be advised to lose weight to reduce the stress on the joints. OA can damage any joint but it is most common in the hands, knees, hips and spine. Risk factors for OA include: age, sex (women are more likely to develop OA), obesity, joint injuries, certain occupations/repetitive stress on the joint, genetics, bone deformities and other diseases such as diabetes or other rheumatic diseases. 7

8 Osteoarthritis in the knee Athroplasty In severe cases, the damaged or diseased surfaces of the knee will be replaced with plastic or metal components (Arthroplasty). This will aim to relieve the pain and disability of OA and allows continued motion of the knee. Knee replacement surgery can be performed as a partial or a total knee replacement. The operation typically involves substantial postoperative pain, and includes vigorous physical rehabilitation. Recovery may take six weeks or longer. Pilates can help with preparation pre-surgery and with rehabilitation post-surgery. 8

9 Case-Study Claire, 46 years old, is awaiting knee replacement surgery. She was previously very active and enjoyed sport, playing hockey, tennis and running. She walks daily with her dog but experiences stiffness in both knees, especially the left knee that is extremely swollen. In the past, Claire has taken part in basic mat pilates classes for a short period of time. She is frustrated as she is a young candidate for arthroplasty and was also concerned about falling over. Claire is not overweight. With five months to prepare before surgery, through a BASI pilates programme, the aim was to increase quality of life, improve posture, realign muscle balance especially in the hips, knees and feet, increase range of movement of the knees and for the body to be stronger to assist post-surgery recovery. In addition to pilates, Claire has been encouraged to swim as an aerobic activity. On presentation, Claire had little range of motion in both knees and she cannot fully straighten her left leg due to the inflammation. Claire s body was compensating in many areas to assist with painful knees when walking. Her posture was slightly hyperlordotic with her right hip rotating forwards. Claire s knees were stiffer as the pain and swelling increased, especially with colder weather. She adducted her knees and lifted her right hip during footwork. 9

10 Claire s programme followed the BASI block system with the goals outlined below: 1. Strengthen core and pelvic girdle (to prevent right hip rotating forwards and for support) 2. Strengthen all lower limb muscles with a focus on the knee flexors and extensors. Also abductors and adductors 3. Increase range of motion of both knees 4. Stretch hip flexors and extensors 5. Avoid high-impact exercises, deep knee bending, kneeling and uni-lateral weight bearing exercises 6. Be conscious of pain and inflammation at each session. BASI Pilates programme Block Equipment Exercise Warm up Mat Pelvic curl (with feet slightly further out than normal to compensate for the angle of bent knees) Spine twist supine (with feet on floor if knees painful) Chest lift Chest lift with rotation Footwork Reformer (with bar set in Parallel heels Parallel toes 10

11 upright position to increase range of movement of the knees) V position toes Open V heels Open V toes Calf raises Prancers Abdominals Reformer Hundred preparation Hundreds with bent legs (as comfortable) Hip work Reformer (with light resistance) Frog Circles (with legs slightly bent if swollen) Spinal articulation Reformer Bottom lift (without knee extensions) Stretches Full body integration 1 Reformer Pole Reformer Short spine (with slightly bent knees) Standing lunge (if not painful) or standing without reformer with hands on wall (adaptation) Shoulder stretch Overhead stretch Side stretch Spine twist Upstretch 1 (with slightly bent knees if required) Elephant Arms Circle (standing) Arms bent Arms straight 11

12 Full body integration 2 Legs N/A Wunda Chair Reformer Arms overhead Single arm side press (right and left) Single arm bicep (right and left) N/A Leg press standing or Terminal knee extension* Sitting knee flexion* Clams level 1* Lateral flexion Wunda Chair Side stretch Back extensors Wunda Chair Swan basic * From Pilates for Injuries and Pathologies course with Samantha Wood Conclusion Claire will continue to prepare for surgery with pilates. As she is reasonably young for a knee replacement, the aim is strengthen and increase the range of motion of the knee for an increased quality of life, especially with walking. Since starting her pilates programme, Claire has seen a significant improvement in her posture, pain, leg strength, and range of movement of her knees. By straightening her posture, strengthening her core, eliminating pelvic compensations her overall stance has improved. She is especially delighted with the increased range of movement of her knees enabling her to walk easier and with less pain. We will continue pilates for an hour once a week until surgery and then amend the programme post-surgery to assist with recovery. 12

13 Bibliography American Academy of Orthopaedic Surgeons. (November 2015) The Knee. University of Glasgow. November 2015 National Institute of Arthritis and Musculoskeletal and Skin Diseases. Osteoarthritis. April 2015 Osteoarthritis. Arthritis Research UK. (November 2015) Leopold SS "Minimally invasive total knee arthroplasty for osteoarthritis". N. Engl. J. Med. (April 2009). 360 (17): A.W.Rogers. Textbook of Anatomy. (1992): Isacowitz, Rael. Body Arts and Science International. Study Guide: Comprehensive Course Wood, Samantha. Body Arts and Science International. Pilates for Injuries and Pathologies