A Physiotherapist’s Guide to Osteoarthritis
“Arthritis” is a term used to describe inflammation of the joints. Osteoarthritis (OA) is the most common form of arthritis and usually is caused by the deterioration of a joint. Typically, the weight-bearing joints are affected, with the knee and the hip being the most common.
An estimated 27 million Americans have some form of OA. According to the Centers for Disease Control and Prevention, 1 in 2 people in the United States may develop knee OA by age 85, and 1 in 4 may develop hip OA in their lifetime. Until age 50, men and women are equally affected by OA; after age 50, women are affected more than men. Over their lifetimes, 21% of overweight and 31% of obese adults are diagnosed with arthritis.
OA affects daily activity and is the most common cause of disability in the US adult population. Although OA does not always require surgery, such as a joint replacement, it has been estimated that the use of total joint replacement in the United States will increase 174% for hips and 673% for knees by 2030.
Physical therapists can help patients understand OA and its complications, and provide treatments to lessen pain and improve movement. Additionally, physical therapists can provide information about healthy lifestyle choices and obesity education. This is important because some research shows that weight loss can reduce the chance of getting OA. One study showed that an 11-pound weight loss reduced the risk of OA in women.
What is Osteoarthritis?
Your bones are connected at joints such as the hip and knee. A rubbery substance called cartilage coats the bones at these joints and helps reduce friction when you move. A protective oily substance called synovial fluid is also contained within the joint, helping to ease movement. When these protective coverings break down, the bones begin to rub together during movement. This can cause pain, and the process itself can lead to more damage in the remaining cartilage and the bones themselves.
The cause of OA is unknown. Current research points to aging as the main cause. Factors that may increase your risk for OA include:
•Age. Growing older increases your risk for developing OA because of the amount of time you’ve used your joints.
•Genetics. Research indicates that some people’s bodies have difficulty forming cartilage. Individuals can pass this problem on to their children.
•Past Injury. Individuals with prior injury to a specific joint, especially a weight-bearing joint (such as the hip or knee), are at increased risk for developing OA.
•Occupation. Jobs that require repetitive squatting, bending, and twisting are risk factors for OA. People who perform jobs that require prolonged kneeling (miners, flooring specialists) are at high risk for developing OA.
•Sports. Athletes who repeatedly use a specific joint in extreme ways (pitchers, football linemen, ballet dancers) may increase their risk for developing OA later in life.
•Obesity. Being overweight causes increased stress to the weight-bearing joints (such as knees), increasing the risk for development of OA.
How Does it Feel?
Typically, OA causes pain and stiffness in the joint. Common symptoms include:
•Stiffness in the joint, especially in the morning, which eases in less than 30 minutes
•Stiffness in the joint after sitting or lying down for long periods
•Pain during activity that is relieved by rest
•Cracking, creaking, crunching, or other types of joint noise
•Pain when you press on the joint
•Increased bone growth around the joint that you may be able to feel
Caution: Swelling and warmth around the joint is not usually seen with OA and may indicate a different condition or signs of an inflammation. Please consult with your doctor if you have swelling, redness, and warmth in the joint.
How Is It Diagnosed?
Osteoarthritis is typically diagnosed by your doctor using an x-ray, but there are signs that may lead your physical therapist to suspect you have OA. Joint stiffness, difficulty moving, joint creaking or cracking, and pain that is relieved with rest are typical symptoms.
How Can a Physical Therapist Help?
Your physical therapist can effectively treat OA. Depending on how severe the OA is, physical therapy may help you avoid surgery. Although the symptoms and progression of OA are different for each person, starting an individualized exercise program and addressing risk factors can help relieve your symptoms and slow the condition’s advance. Here are a few ways your physical therapist can help:
•Your therapist will do a thorough examination to determine your symptoms and what activities are difficult for you. He or she will design an exercise program to address those activities and improve your movement.
•Your therapist may use manual (hands-on) therapy to improve movement of the affected joint.
•Your physical therapist may offer suggestions for adjusting your work area to lessen the strain on your joints.
•Your physical therapist can teach you an aerobic exercise program to improve your movement and overall health, and offer instructions for continuing the program at home.
•If you are overweight, your physical therapist can teach you an exercise program for safe weight loss, and recommend simple lifestyle changes that will help keep the weight off.
In cases of severe OA that are not helped by physical therapy alone, surgery, such as a knee or hip replacement, may be necessary. Your physical therapist will refer you to an orthopedic surgeon to discuss the possibility of surgery.
Can this Injury or Condition be Prevented?
The best way to prevent or slow the onset of OA is to choose a healthy lifestyle, avoid obesity, and participate in regular exercise.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of hip osteoarthritis and hip replacement. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Centers for Disease Control and Prevention. Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation: United States, 2007-2009. Published October 8, 2010. Accessed March 11, 2013. Free Article.
Murphy LB, Helmick CG, Schwartz TA, et al. One in four people may develop symptomatic hip osteoarthritis in his or her lifetime. Osteoarthritis Cartilage. 2010;18:1372–1379. Free Article.
Cibulka MT, White DM, Woehrle J, et al. Hip pain and mobility deficits—hip osteoarthritis: clinical practice guidelines linked to the international classification of functioning, disability, and health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2009;39:A1–A25. Free Article.
Murphy L, Schwartz TA, Helmick CG, et al. Lifetime risk of symptomatic knee osteoarthritis. Arthritis Rheum. 2008;59:1207–1213. Free Article.
Kurtz S, Ong K, Lau E, et al. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89:780–785. Article Summary in PubMed.
Deyle GD, Allison SC, Matekel RL, et al. Physical therapy treatment effectiveness for osteoarthritis of the knee: a randomized comparison of supervised clinical exercise and manual therapy procedures versus a home exercise program. Phys Ther. 2005;85:1301–1317. Free Article.
Authored by Christopher Bise, PT, MS, DPT. Reviewed by the MoveForwardPT.com editorial board.
Some common spinal injuries and conditions we treat:
Acute lower back (lumbar) pain due to spinal disc and/or facet joint injuries
Chronic low back (lumbar) pain
Sciatica – referred pain and symptoms into the lower limb
Pelvic dysfunction syndromes . Often diagnosed in patients who feel ‘out’.
Childbirth related instability and acute pain syndromes of the lower back and pelvis.
Spondylolisthesis (forward slip of one vertebrae on the vertebrae directly below it)
Spondylosis (disc space narrowing combined with degenerative changes in the facet joints common with age)
Acute neck pain due to facet joint and/or spinal disc injury
Chronic neck pain
Brachialgia-referred pain and symptoms into the arm, ‘pinched nerve’ pain and/or pins and needles/numbness (known as paraesthesia)
Mid-back (thoracic) and rib (costovertebral joint) pain (which, in some cases, refer pain around the chest wall)
Acute/chronic (myofascial) trigger point conditions. (These are tender and hypersensitive coin sized zones within the muscle tissue that can cause local pain and tightness and can also refer to distant sites.)
Muscle and joint stiffness
Causes of Spinal Pain
Acute and chronic spinal pain is experienced due to the stimulation, via mechanical or chemical irritation, of small nerve endings, nerve root or spinal cord sheaths, nerve cords, complex pain mechanisms in the central nervous system or a combination of the above.
Acute Spinal Pain
This can involve findings of bulging disc, disc protrusion or disc prolapse/rupture. Disc problems are very common in the lower back (lumbar spine). They are often associated with episodes of bending, bend with twist or prolonged sitting /driving which distorts the rim of the disc causing acute pain. In addition it can produce pressure on the spinal nerves in the lower back which produce symptoms known as sciatica. This is felt as pain, pins and needles sensation, numbness and/or weakness in the leg(s). In the neck (cervical spine), disc injuries can cause debilitating pain into the neck and commonly severe pain into the arm called brachialgia due to compression of the spinal nerves in the neck. This is commonly referred to as ‘pinched nerve’.
These joints are small joints which flank the disc on either side and behind the spinal discs. They are like a finger joint in their structure and when injured swell and inflame and cause acute pain and restriction of movement. They can be sprained in an injury or activities involving twisting, arching and reaching upward movements. In the neck they can become overstrained by an awkward night’s sleep leading to a condition known as ‘Acute Wry Neck’. They can cause local pain and also refer pain to neighbouring and even distant sites.
The joints of the pelvis can suffer acute injuries through high force trauma such as motor vehicle/bicycle accidents, contact sports, slips and falls on to the ground/floor, landing from a height, or when the female pelvis is vulnerable before and after childbirth. Injury and acute instability syndromes can occur which involve the sacroiliac and pubic joints. Lumbo-pelvic dysfunction conditions are common in the sporting population. Muscle imbalance, asymmetrical posture and structural alignment, as well as poor activation and stabilising strength (core control) can create syndromes such as chronic back pain, Osteitis Pubis (OP), recurrent hamstring strains, and contribute to a range of soft tissue injuries/conditions in the lower body.
This refers to the soft tissue layer involving the muscles, tendons and fascial tissues. This can be injured acutely and cause local pain at the site of injury but can also be responsible for ache and pain at distant sites. Myofascial pain is often associated with damage to deeper joint structures, namely disc and facet joints as either a primary (injured tissue) and/or secondary (protective spasm) component of the acute injury.
Our spinal columns are made of twenty four vertebrae stacked one above another on the pelvis. They are joined together at the front by discs and at the back by facet joints. When we bend forward, the vertebra above tilts and slides forward, compressing the disc and stretching the facet joints at the back of the vertebrae. When we bend backward, the disc compression is reduced at the front and the facet joints are compressed at the back. In the upper neck and thoracic areas we tend to have more facet joint strains and in the lower cervical spine and lumbar spine areas, disc injuries are more frequent. This is because our upper spine joints allow us to turn our heads to see, hear and smell, so they need mobility but do not support much weight. Our lumbar spine bears around half our body weight and as we move and sit, there are huge, sustained, compressive loads on our discs.
CAUSES OF BACK PAIN
Disc injuries are the most common cause of low back pain and can range in severity from a mild intermittent ache, to a severe pain where people cannot move. Disc injuries occur mainly during sudden loading such as when lifting, or during repetitive or prolonged bending forces such as when slouching, rowing, hockey and while cycling. They are often aggravated by coughing and running. A flexed posture during slouching, bending or lifting is a frequent cause of disc damage because of the huge leverage and compression forces caused by gravity pulling down on the mass of the upper body.
It is important to understand that damage from small disc injuries is cumulative if discs are damaged at a faster rate than they can heal and the damage will eventually increase until it becomes painful. Pain sensing nerves are only on the outside of the disc, so by the time there is even small pain of disc origin, the disc is already significantly damaged internally where there are no nerve endings to feel pain with.
There may be a previous history of pain coming and going as the damaged area has become inflamed, perhaps was rested or treated, settled for a while but as the underlying problem was not fixed, the pain has flared up repeatedly since. This type of disc injury responds very well to Physiotherapy treatment.
A marked disc injury causes the outer disc to bulge, stretching the outer disc nerves. In a more serious injury, the central disc gel known as the nucleus, can break through the outer disc and is known as a disc bulge, prolapse or extrusion.
Spinal muscles are often blamed as the cause of spinal pain but this is rarely the cause of the pain. Muscle pain may develop as the muscles contract to prevent further damage as they protect the primary underlying painful structures. This muscle pain is secondary to the underlying pathology and when the muscles are massaged, given acupuncture etc, there is temporary relief but the pain will often come back, as the muscles resume their protective bracing. Treatment must improve the structure and function in the tissues which the muscles are trying to protect. The most common sources of primary pain are the discs, facet joints and their ligaments.
There are four facet joints at the back of each vertebra, two attaching to the vertebra above and two attaching to the vertebra below. A facet joint strain is much like an ankle sprain and the joints can be strained by excessive stretching or compressive forces. The joint ligaments, joint lining and even the joint surfaces can be damaged and will then produce pain.
Facet joint sprains can occur during excessive bending but typically occur with backward, lifting or twisting movements. Trauma such as during a car accident or during repetitive or prolonged forces such as when slouching or bowling at cricket.
There are many other sources of back pain including arthritis, crush fractures and various disease processes. Your Physiotherapist will examine your back and advise you should further investigation be necessary.
SYMPTOMS OF BACK PAIN
Symptoms of structural back pain are always affected by movement. This is important to understand. Symptoms, usually pain but perhaps tingling and pins and needles, are often intense and may be sudden in onset but also may be mild and of gradual onset. There are other conditions which can produce back pain such as abdominal problems, ovarian cysts and intestinal issues. If you have symptoms in these areas which are not affected by movement, you must consult with your doctor. If you have chest, jaw or upper limb pain which is unaffected by movement, you must attend your doctor or hospital immediately.
Facet joints, discs, muscles and other structures are affected by our positions and movements. More minor problems produce central low back pain. With more damage, the pain may spread to both sides and with nerve irritation, the pain may spread down into the thigh or leg. As a general rule, disc pain is worse with bending, lifting and slouching and facet joint strains are worse twisting and bending backward or sideways. A severe disc problem is often worse with coughing or sneezing and on waking in the morning.
DIAGNOSIS OF BACK PAIN
Diagnosis of back injuries is complex and requires a full understanding of the onset history and a comprehensive physical examination. It is important for your Physiotherapist to establish a specific and accurate diagnosis to direct the choice of treatment. In some cases, the pain may arise from several tissues known as co-existing pathologies and each of these are treated as they are identified. Where the Physiotherapist requires further information or the management may require injections or surgery, the appropriate x-rays, scans and a referral will be arranged.
UPPER BACK AND LOWER BACK PAIN RELIEF
Eighty percent of adults will experience severe spinal pain at some time in their life. Much of this pain is called non-specific low back pain and is treated with generic non-specific treatment. This type of treatment often fails to provide lasting relief. However, Musculoskeletal Physiotherapists have developed specific diagnostic skills and specific treatment techniques, targeted to specific structures. We identify the structure and cause of the pain producing damage and develop specific advice and strategies to prevent further damage and promote healing.
Specific techniques are chosen to correct the structural and mechanical problems. Among many choices, treatment may include joint mobilisation, stretching, ice, strengthening and education. As normal tissue structure and function returns, there is a reduction in the inflammation and the pain will subside.
When normal movement has been achieved, the inflammation has settled and the structures have healed, your new strategies will reduce the possibility of the problem recurring. We use this specific approach to reduce or stop chronic pain.
While we have the choice to manipulate, adjust or click joints, patients with ongoing pain will seldom benefit from repeating these techniques. This is because our tissues are elastic and the benefit of the quick stretch of manipulation is lost, as the elastic tissues tighten and shorten again. Adjustments of this type have little long term benefit and often lead to an unhealthy dependence on the provider. Your Physiotherapist will choose a safer and more appropriate treatment for you.
PROGNOSIS OF BACK PAIN
Physiotherapy for back pain can provide outstanding results but it is a process, not magic. The damage which produces pain in a back takes time to develop and also time to repair and heal. You will understand there are often several interacting factors to deal with and patient compliance is necessary.
“Tension headaches” are often talked about and we see a lot of patients with these headaches. In our diagnosis of these conditions, about eighty five percent of all headaches arise from the neck, or cervical spine, which refers pain into the head through the nerves which go to both areas. Neck problems cause head pain because some of the nerves which come from the spinal cord have branches which go to the upper neck joints and other branches which spread over the back of the head, with still others going to the front of the head. When one area is sore the brain interprets the pain as coming from all the areas the nerve branches go to.
CAUSES OF TENSION HEADACHES
Patients who have “Tension Headaches” or “stress headaches’’, are often very busy and have work related problems, a tough boss, urgent deadlines, problems with managing work flow and they often have trouble sleeping because of work problems and their worries. This causes the patient to be mentally and emotionally stressed and their relationships at work and with their families suffer.
They develop a headache which they cannot shake and they feel helpless, tired, tense, anxious and in pain. We have seen many cases where the headaches have continued for weeks and frequently kept recurring, sometimes over many years.
It is important to understand that a Tension Headache is due to “physical tension” in the tissues, often from a poor working position and the damage it has caused, not the other mental “tensions” listed above. Once full neck movement has been restored with treatment, the tissues have healed and the postural strains have been removed, patients often cope better with the other aspects of their lives. This is where Physiotherapy can help by breaking the vicious “Physical Tension” cycle. It is better to think of these as “structural headaches”.
Our neck is made of seven vertebrae stacked one above another. They support the head and they are joined together at the front by discs and at the back by facet joints. When we bend forward, the vertebra above tilts and slides forward, compressing the disc and stretching the facet joints which join the back of the vertebrae. When we bend backward, the disc compression is reduced at the front and the facet joints are compressed at the back. The junction of the first vertebra and the head does not have a disc and the joints there are particularly susceptible to leaning forward which causes the weight of the head to strain the joints, ligaments and muscles as gravity causes a shearing force as the head slides downward.
The neck muscles are often blamed as the cause of pain but this is rarely the whole story. Muscle pain often develops as the muscles contract to prevent further damage, as they protect the primary underlying structures. This pain is secondary to the underlying pathology and when the muscles are massaged, given acupuncture, etc, there is temporary relief but the pain will always comes back as the muscles resume their protective bracing. The most common sources of primary pain are the facet joints and their ligaments in the upper neck and the discs in the lower levels of the neck.
A facet joint strain is much like an ankle sprain, strained by excessive stretching or compressive forces. The joint ligaments, joint lining and even the joint surfaces can be damaged.
In the upper neck, facet joint strains typically occur during excessive bending or twisting movements and may follow trauma such as a car accident causing whiplash but generally, Tension Headaches occur with prolonged forces such as slouching, keying and reading.
There is often a previous history of pain coming and going as the damaged area became inflamed, was treated and settled for a while but as the underlying problem still remained, the pain flared up repeatedly every time it was strained. This type of injury, although often chronic, responds very well to specific Physiotherapy treatment.
There are many other sources of headaches and neck pain including arthritis, crush fractures and various disease processes. Your Physiotherapist will advise you should a more serious condition be suspected.
SYMPTOMS OF TENSION HEADACHES
Symptoms of “Tension Headaches” arising in the neck, are always affected by movement of the head and neck. This is important to understand. Symptoms are sometimes severe and may be sudden in onset but also may be mild and of gradual onset. There are other serious conditions which can produce headaches. If you have severe headache symptoms which are not affected by movement and a recent history of fever or nausea, you must consult a doctor urgently.
Facet joints, discs, muscles and other structures are affected by our neck positions and movements and when damaged, will respond very well to Physiotherapy treatment.
DIAGNOSIS OF TENSION HEADACHES
“Tension Headaches” often appear complex and require a full understanding of the history and a comprehensive physical examination. It is important for your Physiotherapist to establish a specific and accurate diagnosis to direct the choice of treatment. In some cases, the pain may arise from several tissues and these coexisting pathologies are treated individually as each is identified. Where the Physiotherapist requires further information or management may require injections or surgery, the appropriate x-rays, scans and a referral will be arranged.
TENSION HEADACHE RELIEF
Some of these cases will temporarily respond to a general non-specific treatment such as bed rest, ice and anti-inflammatories, however Musculoskeletal Physiotherapists have developed diagnostic skills and treatment techniques, targeted to stopping “Tension Headaches”. We will identify the reasons for the development of the pain and advise strategies to promote healing and to prevent further damage.
Specific techniques are chosen to correct the structural and mechanical problems. Among many choices, treatment may include joint mobilisation, stretching, ice, strengthening and education.
When normal function has been achieved, the inflammation and pain has settled and the structures have healed, using your new strategies will reduce the possibility of the headaches ever recurring. We use this approach to reduce or stop chronic pain. While we have the choice to manipulate or “click” joints, those with ongoing pain will seldom benefit from repeated “adjustment”. This is because our tissues are elastic and the benefit of the quick stretch of manipulation is lost as the tissues tighten up again. Potentially dangerous “adjustments” of this type have little long term benefit and can lead to an unhealthy dependence on the provider. Your Physiotherapist will choose a safe and appropriate treatment for you.
PROGNOSIS OF TENSION HEADACHES
Physiotherapy for “Tension Headaches” can provide outstanding results but it is a process, not magic. The damage which produces “Tension Headaches” takes time to develop and time to repair and heal. You will understand there are often several interacting factors to deal with and your compliance is necessary.