arthritis , lbp
athritis
What is Osteoarthritis (OA) primarily related to?
Wear & tear
Prolonged immobilisation
Continuous pressure,
Impact loading,
Anatomic abnormalities
Previous joint injury
What is the most important risk factor for knee OA?
Obesity; e.g. carrying extra 10kg means 20kg load through knee
How is Rheumatoid Arthritis (RA) characterized?
Chronic systemic inflammatory disorder of unknown aetiology ; inflammatory poly arthritis
What are key features of Juvenile Arthritis?
It's usually associated with RA, begins at or before age 16, and has a female:male ratio of 3:1
What is Fibromyalgia (FM)?
Musculoskeletal pain syndromes or chronic generalised pain syndrome
widespread pain 4 quadrants of body
11/18 tender points on palpation
What are Spondyloarthropathies and what is the most common type?
Ankylosing spondylitis ; inflammatory joint disease that effects axial skeleton
Risk Factors for Arthritis
List systemic risk factors for arthritis.
Age, gender, genetics, race
List local risk factors for arthritis.
Joint injury, obesity, occuputation & muscle weakness
How well is X-ray severity correlated with symptoms in arthritis?
Not well correlated
Pathophysiology & Clinical Features of OA
What are the six key pathophysiological changes in Osteoarthritis?
Cartilage fibrillation and erosion
Subchondral bone sclerosis
Osteophyte formation
Joint space narrowing
Fibrosis of the joint capsule
Mild inflammatory synovitis
What two main pathways lead to OA joint changes?
Increased joint loading (due to weight, activity, biomechanics, injury, quads dysfunction)
Reduced ability of cartilage to withstand load (due to age, metabolic, structural, genetic, gender factors)
Couple with psychological factors; influences response to OA
List common symptoms of OA.
Joint pain, morning stiffness (<30min), gel phenomenon, buckling/instability, loss of function
List common signs of OA upon examination.
Bony enlargement, joint effusion, creptius on motion, pain on motion, decreased ROM, mal alignment/joint deformity
What are common sites affected by OA?
Thumb-CMC
Fingers-DIPs
Hips
Knee-tibiofemoral joint
Cervical/lumbar spine; facet joints
What radiological features confirm a clinical suspicion of OA?
Marginal osteophytes, asymmetrical joint space narrowing, subchrondal bone scerloris, subchondral cysts
What are potential sources of pain in OA?
Anything innervated
Inflammation in synovial membrane & joint capsule
Periarticular ligament stretching
Periarticular muscle spasm
Osteophytes impinging periosteum
Subchondral bone fractures
Management of OA
What are the three general aims for managing OA?
Prevention (e.g., by reducing obesity or avoiding specific activities)
Slowing progression (e.g., with disease-modifying drugs)
Treating symptoms (pain, disability/physical function, psychosocial aspects)
What are key components of conservative OA management?
Improve joint protection; education, rest, exercise
Maintain acceptable body weight
Control pain; medication, physiotherapy, OT, self-management strategies
What are the proven benefits of exercise therapy for OA?
Small to moderate effect sizes to exercise similar to drugs
Strength training, aquatic & hydrotherapy, aerobic, tai chi
Reduce pain, weight management, physical function & strength
What are the goals of physiotherapy in OA management?
Minimise pain
Increase/maintain movement
Increase/maintain muscle strength
Correct/prevent deformity
Educate and advise the patient
Encourage self management
Name some pharmacological options for OA pain management.
NSAIDs ; could just be pain relief
Paracetamol
Intra articular steriod injection
List common surgical interventions for OA.
Arthroscopy: removal of osteophytes
Osteotomy: alternation of bone length or alignment
Arthroplasty: replacement of the knee
Arthrodesis: artificial induction of joint ossification
Rheumatoid Arthritis (RA) Specifics
Who is more at risk of RA?
Female>male, can affect any age, genetic predisposition
Possible triggers
Environment, stress, trauma, diet, viral infection
What are common sites affected by RA?
MCPs, PIPs, MTPs
Atlanta-axial subluxation; ligaments that maintain stability not doing the job
List common symptoms and signs of RA.
Symptoms: Malaise, tiredness, weight loss, pain, swelling, stiffness, reduced function.
Signs: Joint tenderness, heat/erythema, effusion, decreased joint range, muscle wasting, and deformity.
Name some extra-articular features that can occur with RA.
Fatigue, subcutaneous nodules, vasculitits, pulmonary: pleural effusion & nodules cardiac: pericarditis, mitral valve disease, neural skin
its a systemic disease
Diagnostic criteria for RA
ARA diagnostic criteria-at least 4 filled
morning stiffness >1hr for > 6 weeks
Arthritis of at least 3 areas soft tissue swelling & exudation > 3 weeks
Arthritis of hand joints for >6 weeks
Rheumatoid nodules
Serum RF
Radiographic changes
What are the key aims of treatment for RA?
Dependent on stage of RA
symptomatic relief/relieve pain
Maintain function including movement & muscle strength
Prevention of structural damage & deformity
Maintenance of patients lifestyle
Patient education
Multi-disciplinary approach: physiotherapy, occupational therapy, podiatry
What is the physiotherapy approach for an acutely inflamed RA joint?Reduction of stress on joint
Gentle exercises; to not aggravate inflammation
Ice
Balance between activity & rest
Referral to other health professionals: GP/rheumatologist, OT, podiatrist
low back pain is a symptom not a disease, and can result from different known or unknown abnormalities or diseases
what is the evidence for LBP drivers
strong evidence for psycho-social
mod-strong for patho-anatomy
weak on movement based, harder to observe
what is a spondylolisthesis
when a vertebra slips forward or back in relation to the one below
can result from a spondylolysis
clinical features of spondylolisthesis
aggravated by extension movements, heavy lifting, prolonged standing
pain on direct palpation
neurological signs if involving nerve root
compensatory hamstring tightness
restricted lumbar extension
core weakness and poor lumopelvic control
pain can improve in supine positioning
Physiotherapy management (10 marks)
Principles:
Conservative management is first-line for Grade 1 spondylolisthesis (Physiopedia, Rahman et al. 2023).
Focus on pain reduction, spinal stability, flexibility, and functional restoration.
Management strategies:
Education & activity modification
Avoid repetitive lumbar extension, heavy lifting, hyperextension sports.
Encourage pacing and ergonomic strategies at work.
Pain management
Heat/ice, short-term analgesia advice, postural correction.
Core stabilisation exercises
Emphasis on deep abdominal (transversus abdominis) and multifidus activation.
Progress to dynamic stabilisation (bridging, bird-dog, planks).
Evidence: Core stabilisation reduces pain and disability in spondylolisthesis (Rahman et al., 2023; Nishad et al., 2022).
Flexibility training
Stretch hamstrings, hip flexors, ITB to reduce compensatory strain.
Thoracic mobility exercises to offload lumbar spine.
Graded strengthening & functional rehab
Gluteal and hip strengthening to improve lumbopelvic control.
Gradual return to work-related lifting with correct technique.
what is a spondylolysis
a defect or stress fracture in the pars interarticularis
are patho-anatomic findings more common in people with back pain
yes there is a still a higher prevalence of those with symptoms having findings of imaging
List the contraindications to neural tissue provocation testing
recent disc bulge
flexion symptoms
recent trauma, fracture
cauda equina syndrome
discuss the significance of a “positive’ neural tissue provocation test and any implications for treatment
indicates neural involvement
restricted gliding, increased tension or sensitivity of the nerve
helps differentiate between neural involvement and just musc involvement
McKenzie approach
mckenzie assessment process focuses more on…
active movement tests rather than palpation
response of symptoms
pain before and after movement
pain during and end range pain
mckenzie approach treatment focusses on
primarily exercise based
what is posture syndrome
pain due to mechanical deformation of soft tissues from poor posture
worse at end of day
gradual onset
posture syndrome physical examination findings are
active movement tests don't reproduce pain
sustained positions only
what is dysfunction syndrome
adaptive shortening of soft tissues due to trauma, injury, poor posture which results in pain when these shortened structures are stretched
dysfunction syndrome subjective findings
local
intermittent
gradual onset
aggs when end range movements
dysfunction syndrome obj findings
end range active movements
restriction of range
dysfunction syndrome treatment
stretch the stiff movement
flexion, extension
what is derangement syndrome
pain from internal derangement of IVD
repeated movement produce centralisation or reduction of derangement
derangement syndrome subjective findings
constant or intermittent
local and may refer pain
sudden onset
agg by repeated flexion and sustained flexed positions
derangement syndrome objective findings
pain during movement
centralisation with repeated movements
derangement syndrome treatment (posterior derangement)
“reduce” derangement
repeated extension
maintain reduction by
regular extension
postural strategies
prevent reoccurrence
Simon is a thirty two (32) year old clerical assistant who presents with a four (4) year history of bilateral low back and buttock pain (following a lifting injury) which has not responded to mobilisation to his lumbar spine.
With reference to the literature, outline your management approach to Simon’s chronic pain,
Your answer should include:
6a) Principles of management
- Education that pain does not always mean there is tissue damage and reduced fear avoidance
- Prescribing graded exercises programs
6b) Selection of appropriate outcome measures
- Screening psychological factors with the Pain Catastrophizing scale
- Assess AROM?