We see patients every day at Parkway where arthritis is a contributing factor to why they are visiting us. There are different types of arthritis (Inflammation of the joints) however this piece will speak to the one that we see by far the most in the clinic – Osteoarthritis.
In this article we would like to address osteoarthritis beyond the basics and really do a deeper dive of what we understand about this condition today. We will look at:
- An overview of osteoarthritis including how it progresses
- The 6 subtypes of osteoarthritis
- How physiotherapy can help
What is Osteoarthritis
Osteoarthritis involves a breakdown of the joint at the level of the bone and cartilage.
In the early days patients describe pain that is worsened during or after physical activities. As the joint cartilage thins, the joint capsule that surrounds the joint becomes a bit more lax and this can lead to shearing forces in the joint. Patients describe hearing or feeling some clicks or grinding sensations in the joint and we may also see some signs of warmth and swelling as indicators that the joint is to one degree or another, inflamed and unhappy.
As the condition progresses, the body will try to stabilize the joint by spreading out more bone. These bones spurs might be referred to as osteophytes by your doctor or on an X-ray report. By spreading out the size of the bones, the joint becomes more stable – it also becomes thicker and less mobile with characteristic patterns of limitation that depend on the joint we are speaking of but which are similar across all of us as humans.
Osteoarthritis used to be thought of as a “Wear and tear” type of problem. People still sometimes tell us: “I played a lot of hockey so you know my knees are shot”. Sometimes this is true but then there’s the people who played as much or even more of the same sport and their knees are totally fine. So what is the difference maker between these people?
We also have the wonderful privilege of seeing generations of patients and there are those families where we see the same arthritis across multiple generations. The likelihood of a grandparent, a parent and a child all ending up with left hip arthritis boggles the mind and so we conclude that there may also be genetic or metabolic aspects at play.
6 Subtypes of Osteoarthritis
As the science in the area of osteoarthritis research has progressed, we have come to consider this condition far beyond mere wear and tear.
We now look at arthritis as relating to one or more of the following 6 subtypes (also called the 6 phenotypes of Arthritis):
- Chronic Pain where central mechanisms are present – In these individuals the pain mechanisms in the nervous system have ramped up so that the pain system is increasingly sensitive. The pain is very much real however it takes less and less stimulus to create a pain response. This type of pain is referred to as central sensitization. Central sensitization can occur from arthritis or any number of other injuries.
- Inflammatory with high levels of inflammatory biomarkers – These patients have inflammation in their bodies. We will sometimes see a number of other body systems affected to give us clues or hints that this may be the case. For example there may be dietary allergies or sensitivities along with digestive problems, there may be skin disorders, eye ear nose or throat problems, frequent headaches or migraines, sleep problems, and problems in other joints such as arthritis in the spine, the hips and the knees. Presentations such as these provide clues that there may be high levels of inflammatory markers in the body.
- Metabolic Syndrome with a high prevalence of obesity, diabetes and other metabolic disturbances – Obesity again used to be considered as a simple formula of force = mass x acceleration. Decrease your body weight and you decrease the force on the joints. This is absolutely true however we now understand that obesity also causes inflammation and inflammation in turn is both injurious to the joints and can also ramp up nervous system sensitivity. Diabetes also has inflammatory consequences with similar outcomes in terms of contributing to arthritis.
- Bone and cartilage metabolism alterations – Our bone and cartilage cells go through cell turnover as a normal part of how we function as humans. Sometimes however the process is accelerated and why this occurs is one of the research questions that science is asking right now. In some patients there are proteins expressed that increase the breakdown of cartilage cells in one or more joints.
- Mechanical overload via overload or malalignment (ie wear and tear) – This is the subtype that most of us relate to the easiest. When a joint is overloaded it leads to wear and tear on the joint that eventually can progress to a breakdown of the cartilage in the joint which of course we call arthritis. The malalignment component is speaking to situation where unequal forces are constantly going across a joint. One common example is where the knees frequently bend so that they collapse either inwards or outwards. These so called varus and valgus situations lead to much more force going through one half of the knee rather that being distributed across the joint more evenly. Another example may be a spinal curvature or laxity that leads to alignment issues and increased wear and tear.
- Minimal joint disease characterized as minor clinical symptoms with slow progression over time – These patients often respond incredibly well to therapy and they live and move from day to day with very minor limitations or progressions of the underlaying arthritis. Yes things change slowly over time but physiotherapy via strength and conditioning can help immensely and slow these progressions to maintain quality of life
How Can Physiotherapy Help with Osteoarthritis?
Now that we understand arthritis presentation, progression and now that we see that there are deeper questions to ask regarding the contributing factors to arthritis, the first and perhaps most important way physiotherapy can help is during the initial consultation.
During your first visit, your physiotherapist will ask a number of questions about the joint or joints that are causing issues. We will seek to understand your goals and your lifestyle factors that may be helping or contributing to the situation.
We must also understand your health beyond the old wear and tear model. These questions relate to the 6 subtypes of arthritis mentioned above. There are times, for example, when our clients themselves speak to changing up their diet and finding that all their joint aches and pains are improved markedly!
During the physical exam we will be able consider joint alignment, whether inflammation is present or not, whether there is the loss of range of motion and if it fits the expected capsular pattern or if the joint presentation is something else entirely.
Once we have gone through all these things together, then we can help to build a treatment action plan that are tailored to your goals.
Manual Therapy for Osteoarthritis
Manual therapies are commonly and almost always a part of the treatment plan. There are many reasons for why manual therapy is helpful. For starters when we use joint gliding techniques it contributes to joint lubrication and joint nutrition and also helps restore the biomechanics of how the joint naturally moves.
We also use manual therapies to improve alignment and change the way that forces move through a particular joint.
Finally, manual therapy is an excellent method for improving spinal function. Improving spinal function then improves spinal nerve function. Improved spinal nerve function will improve both the contraction and relaxation of the muscles that cross the joint in question.
A classic example of this is that many shoulder patients also present with a sore neck. The rotator cuff muscles are supplied by the C5 and C6 segments from the neck. As we work to improve function at C5 and C6, we allow the rotator cuff muscles to both gain strength more effectively and also to allow those muscles to relax more fully when not in use. The net result is better tendon and better joint health even though that particular intervention was not to the shoulder directly.
Exercise Prescriptions for Osteoarthritis
The next area of physiotherapy is that of exercise prescription. Exercise therapy is used initially to stabilize the joint to prevent or slow further break down. Well prescribed exercise will also improve joint nutrition and joint lubrication which helps joint health, improves pain and of course strengthens the joint for the demands of your life.
We rarely look at a joint in complete isolation. In other words if you have knee arthritis, we also have to look at the strength of your hip and ankle since these are all part of the chain of joints that must work together to allow you to hike a mountain, kick a ball, or get up from your chair.
The progression and dosing of exercise is very important yet there are no hard and fast rules. Generally speaking we dose towards isometrics in the early days and then towards higher volume and lower resistance as the client progresses. This said, each person is unique and we must balance individual exercise prescriptions according to the availability of time, energy, financial and equipment resources and all the other demands of their life.
Stretching is commonly part of the exercise prescription as well. Back to the knee example, if one’s hip or knee are extremely tight then the forces of each step and stair will be directed more to the knee. Improving the flexibility above and below the knee can significantly improve knee function. Conversely some patients present with hypermobility, or an excess of motion and this is why they are getting more joint wear and tear. Although these individuals feel “tight” around a joint, they in fact do not serve themselves well by further stretching an area that is already too loose. Each person must be evaluated individually.
IMS & Dry Needling for Osteoarthritis
Some physiotherapists offer dry needling treatments often called Intramuscular Stimulation (IMS). This type of therapy can improve muscle function and relaxation, once again helping the joint to enjoy greater periods of rest on the one hand and greater ability to adapt to exercise on the other.
Treating Your Osteoarthritis Pain
In conclusion, arthritis is a complex condition that can benefit profoundly from physiotherapy care. In order to best serve our patients we must first understand many things in order to provide the most appropriate treatment action plan:
- Where are you sore and what is this preventing you from doing? (where are you coming from?)
- What are your goals of treatment? (where are you going?)
- Which of the sub-type(s) of osteoarthritis may be relating to your condition?
- Are there alignment issues, muscle imbalances or stiff joints that can be addressed to improve your quality of life?
- Are there spinal nerve issues that are contributing to your arthritis presentation?
- What are the ideal exercise prescription opportunities based on your specific condition and your specific life demands?
If we can answer these questions well then it’s our experience that your plan of care will almost write itself and your outcome will have the best chance of success. If you’re suffering from osteoarthritis and are looking for support or education, reach out to the team at Parkway Physiotherapy & Performance Centre.