Osteoarthritis (OA) is a common degenerative disorder affecting joint cartilage, underlying bone and is characterised by chronic structural and functional degeneration of a joint. OA does attempts to repair damaged joints, but chronic levels of inflammation affects this cycle, and chronic progressive tissue degradation results. More recently, OA has been defined as a multifactorial, complex disorder, which includes genetics, aging, obesity, biomechanics, joint laxity and malalignment. Studies show that excessive stress can alter the joint balance ultimately resulting in cartilage damage.
During the early stages of OA there is an initial increase in inflammation, which triggers the body's natural immune system to recognise the presence of damage. This results in an influx of inflammatory mediators, ultimately, affecting the repair process and leading to further degradation.
Regenerative medicine, with the use of orthobiologics, is a rapidly growing field and it is very important that rehabilitation protocols are fully understood and adopted. The management of OA using various rehabilitative methods is extremely important for controlling and reducing symptoms of pain and ultimately improving quality of life. The ultimate goal of regenerative medicine is to effectively support and promote the body's natural healing mechanisms. Regenerative rehabilitation interventions involve treating all structures that surround the affected joint to achieve pain relief and prevention from further deterioration.
This article will provide an understanding for the rehabilitative management of knee osteoarthritis following treatments in regenerative medicine. This will review of the current best practices of rehabilitative methods and nonsurgical management with an emphasis on promoting tissue healing and restoring natural function.
Regenerative Rehabilitation in Knee Osteoarthritis
Exercise, strengthening and weight management
Moderate well-controlled physical exercise is associated with a decreased risk of severe knee osteoarthritis. Physical exercise will stimulate the production of joint synovial fluid which has a protective effect against cartilage degradation. An exercise program that combines endurance work and strength in arthritic patients has been shown to increase function and reduce pain. furthermore, patients with me osteoarthritis often present with supporting muscle weakness and wasting - therefore, appropriate strength training is necessary. Other benefits include improvement in bone mineral density, decreased risk of falling, increased walking speed, better balance, and increased stair-climbing ability.
Although physical exercise has been shown to be beneficial, appropriate exercises should involve gradual loading and be specific to the individual. Excessive mechanical stress can directly damage the cartilage and affect joint balance. Decreasing body weight also has huge benefits. A complete rehabilitative exercise therapy program typically focuses on strengthening muscles of the knee, hip and pelvis. A regenerative medicine/rehabilitation protocol is strongly recommended following on from a procedure in regenerative medicine.
Stability, balance and control
The majority of patients over 60 with knee osteoarthritis report knee joint instability, which is commonly associated with pain and poor function. Reductions in control and strength associated with knee osteoarthritis patients can often result in impaired balance and therefore neuromuscular training orientated around balance control is needed.
Initial knee stabilisation training will provide added value over standard exercises (i.e. strength/functional training). Patients with muscle weakness around the knee and instability, should focus on muscle strengthening, whereas in patients with knee instability and strong muscles, initial knee stabilisation training can be beneficial. A combination of lower extremity strengthening and balance control training is essential in patients with the osteoarthritis. As with strength training, the mechanical stimulation of the joint cartilage generates biochemical signals which increase the growth activity of cartilage cells.
A combination of strength, stability, balance and neuromuscular training is recommended in post regenerative medicine/rehabilitation intervention due to the role in cartilage cell stimulation and role in improving function.
Manual therapy
Manual therapy is skilled hands-on techniques that are commonly used to treat pain and dysfunction. Manual therapy is used to treat soft tissue injury and joint dysfunction by increasing mobility, reducing pain/inflammation, and increasIng circulation/fluid dynamics that ultimately improves function and movement. Patients with knee osteoarthritis who are treated with manual therapy and rehabilitation exercise experience clinically lasting improvements in pain, stiffness, and functional ability. The mechanisms of manual therapy are to improve tissue repair, stability and functions.
Acupuncture and dry needling
Musculoskeletal acupuncture and dry needling are treatment modalities that are often used in the treatment of muscle pain conditions. Clinical trials conducted by Scharf et al. and Chen et al. concluded that acupuncture in combination to exercise in the treatment for knee osteoarthritis has benefits for improving pain and function, at the same time as reducing sensitivity.
Taping and bracing
Support tape is used to provide support, increase local circulation, reduce pain, reduce swelling, provide sensory input, however, it isn’t hugely used within osteoarthritis. Knee bracing has been advocated as an effective device for the management of knee osteoarthritis to achieve sensory balance changes, muscle activation and pain reduction stemming from joint unloading. Bracing has been shown to effectively reduced symptoms of medial compartment degradation in both short-term (6 weeks) and medium-terms.
Corrective Rehab Program
Phase 1 should begin immediately after procedure and can last up to a week depending on pain and inflammation. In the acute phase it is advantageous to begin weight-bearing and loading as soon as tolerable. This is because early gentle mobility exercises and tissue loading will have a positive Benefits on tissue remodelling and healing.
The rehabilitation program for knee osteoarthritis must fully incorporate strength, stability, and inter-muscular balance of core, hips and surrounding joints. Early implementation of these corrective exercises will prepare the body for further progression of joint loading exercises. Exercises will progress to functional multi-jointed exercises focusing.
Phase 1) will focus on reducing pain and inflammation as well as early loading exercises, as tolerated. Full functional weight bearing exercises should include squats, lunges, single leg step downs, glute bridges, and single leg dead lifts. Exercise progressions will depend on neuromuscular control and functional mobility.
Phase 2) can begin once pain and inflammation is much less, and neuromuscular control and static stability reach adequate levels.
Phase 3) can begin once the individual has achieved full mobility.
Phase 4) can be initiated when the individual attains non-painful ROM. The 2016 consensus statement on return to sport was used to inform the rehabilitation and return to sport protocols (see table below). The main treatment modalities included were active rehabilitation to promote tissue healing in conjunction with PRP or stem cell therapy. Early mobilisations and in acute phases loading as pain permits. A graded load progression and cardiovascular exercise are recommended.
Rehabilitation methods should be focused around facilitating healing and functional strength. Gradual load progression plays a significant role in the rehabilitation framework model. Cardiovascular training is recommended to maintain and improve aerobic capacity in conjunction with neuromuscular training to maintain overall muscle strength, flexibility, and functional control. Sufficient loading will result in strength changes through adaptation.
Conclusions
Conventional methods of mild to moderate osteoarthritis of knee are focused on short term symptomatic relief and does not promote regeneration. Regenerative treatments are focused more specifically on stimulating regenerative potential. Regenerative treatments involve using blood based procedure like platelet rich plasma (PRP), stem cell and cell based or tissue bio-engineering procedures. This being said, to maximise clinical success of these regenerative procedures - standardisation in preparation, administration, and follow on treatment protocols or imperative. Our proposed rehabilitation program is based on current evidence and clinical experience related to rehabilitation for individuals suffering from osteoarthritis. There are some interventions that appears to be promising to support the joint until regeneration or restoration.
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