Physiotherapy for osteoarthritis

Physiotherapy is especially useful for osteoarthritis of large joints of the lower extremities. To relieve pain, reduce swelling of periarticular tissues, reflex spasm of periarticular muscles, improve microcirculation, and treat mild or moderate synovitis, use:

• exposure to electromagnetic fields of ultra-high and high frequencies,
• ultrasound therapy (including phonophoresis of anti-inflammatory drugs),
• short-wave diathermy (in the absence of synovitis),
• microwave therapy,
• electrophoresis of anti-inflammatory drugs (voltaren, hydrocortisone, dimethyl sulfoxide),
• laser therapy,
• applications of heat carriers (silt and peat mud, paraffin, ozokerite),
• balneotherapy (radon, hydrogen sulphide, sodium chloride, turpentine, iodine-bromine baths),
• hydrotherapy (reduces the gravitational load on the joints, primarily the hip).

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Ultraviolet irradiation

During the period of exacerbation of osteoarthrosis caused by reactive synovitis, it is possible to use ultraviolet irradiation in erythemal doses (5-6 procedures), electric field and decimeter waves in a weak thermal dose (8-10 procedures), magnetic therapy (10-12 procedures), phonophoresis or electrophoresis of metamizole sodium, procaine, trimecaine, dimethyl sulfoxide on the area of the affected joint. Contraindications to the use of ultraviolet therapy are concomitant ischemic heart disease, transient cerebrovascular accidents, thyrotoxicosis, kidney disease. Exposure to an UHF electric field is contraindicated in case of severe vegetative-vascular dystonia, cardiac arrhythmia, hypertension stage IIB-III.

Electrophoresis

Among the various physiotherapeutic methods, electrophoresis has proven itself well, combining the therapeutic effect of direct electric current and the administered drug. The following physical and chemical effects can be distinguished from the mechanisms of biological action of direct electric current:

• electrolysis - the movement of charged particles (cations and anions) to an oppositely charged electrode and their transformation into atoms with high chemical activity;
• the movement of charged particles under the influence of direct electric current causes a change in the ionic environment in tissues and cells. The accumulation of oppositely charged particles at biological membranes leads to their polarization and the formation of additional polarization currents;
• as a result of changes in the permeability of biological membranes, passive transport of large protein molecules (ampholytes) and other substances through them increases - electrodiffusion;
• electroosmosis is the multidirectional movement of water molecules included in the hydration shells of ions (mainly Na ⁺, K ⁺, Cl).

Under the influence of electric current, local blood flow regulation systems are activated in the underlying tissues and the content of biologically active substances (bradykinin, kallikrein, prostaglandins) and vasoactive mediators (acetylcholine, histamine) increases. As a result, the lumen of the skin vessels expands and hyperemia occurs.

The expansion of capillaries and the increase in the permeability of their walls due to local neurohumoral processes occur not only at the site of application of the electrodes, but also in the deep tissues through which the direct electric current passes. Along with the increase in blood and lymph circulation, the increase in the resorption capacity of tissues, a weakening of muscle tone, an increase in the excretory function of the skin and a decrease in edema in the inflammation focus are observed. In addition, due to electroosmosis, the compression of pain conductors is reduced, which is more pronounced under the anode.

Direct electric current enhances the synthesis of macroergic compounds in cells, stimulates metabolic and trophic processes in tissues, increases the phagocytic activity of macrophages, accelerates regeneration processes, stimulates the reticuloendothelial system, and increases the activity of nonspecific immunity factors.

Thus, direct electric current has the following therapeutic effects: anti-inflammatory, metabolic, vasodilating, sanitizing (draining-dehydrating), analgesic, muscle relaxant, sedative (at the anode).

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Electromagnetic fields of high and ultra-high frequencies

During the period of "subsidence" of exacerbation, as well as in the initial stage of the disease, when the phenomena of synovitis are weakly expressed or absent, the effects of electromagnetic fields of high and ultra-high frequencies (inductothermy, decimeter and centimeter wave therapy), pulsed currents of low frequency - sinusoidal modulated and diadynamic, magnetotherapy, laser action, phonophoresis of hydrocortisone are indicated. To stimulate the trophism of articular cartilage, electrophoresis of lithium, calcium, sulfur, zinc salts, 0.01% solution of humic acid fractions of the Haapsalu sea therapeutic in an isotonic solution of sodium chloride is carried out. To potentiate the analgesic effect, electrophoresis of procaine, metamizole sodium, salicylic acid is used.

Electromagnetic fields of high and ultra-high frequencies - inductothermy, decimeter- and centimeter-wave therapy - when applied to joints with low-heat and heat doses (12-15 procedures per course of treatment) have a pronounced thermal effect on articular and periarticular tissues, increase blood flow to joint tissues, enhance lymph drainage, diffusion processes, and eliminate muscle spasm. This improves cartilage nutrition, has a resolving effect on synovitis, and also has a positive effect on periarticular proliferative processes. Inductothermy is used in patients with stage I-II osteoarthrosis, in the absence or mild secondary synovitis, the presence of pain syndrome, and periarticular changes. Inductothermy is not indicated in cases of exacerbation of secondary synovitis, as well as in elderly patients, with ischemic heart disease, atherosclerotic lesions of the heart vessels, heart rhythm disorders, severe cerebral atherosclerosis, transient cerebrovascular accident, climacteric disorders, fibromyoma, thyrotoxicosis. These patients are prescribed decimeter- or centimeter-wave exposure.

Decimeter- and centimeter-wave therapy is used for osteoarthritis of stages I-IV in the absence or mild manifestation of secondary synovitis, as well as for coronary heart disease with frequent attacks of angina pectoris, in patients with severe climacteric disorders, fibroids.

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Low frequency pulse currents

Low-frequency pulsed currents - sinusoidal modulated and diadynamic - have an analgesic effect and a beneficial effect on hemodynamics and metabolic processes in the joint. Sinusoidal modulated currents are tolerated better than diadynamic currents. They are less likely to cause tissue "habituation", so they are preferable. Low-frequency pulsed currents are indicated for elderly and senile patients with stage I-IV osteoarthrosis, severe pain syndrome, and changes in periarticular tissues. Pulsed currents are not prescribed for secondary synovitis, or for patients with heart rhythm disorders with bradycardia or a tendency to bradycardia.

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Ultrasound therapy

Ultrasound therapy is often used in the treatment of various acute and chronic diseases of the musculoskeletal system. Ultrasound has a thermal (increased blood flow, increased pain threshold, increased metabolic rate) and non-thermal (increased permeability of cell membranes, calcium transport through the cell membrane, supply of nutrients to tissues, phagocytic activity of macrophages) effect. With the pulsed method of ultrasound delivery, thermal effects are reduced, while non-thermal effects remain unchanged, therefore, the use of pulse ultrasound is indicated for patients with osteoarthrosis in the presence of synovitis. Ultrasound is indicated for patients with stages I-IV osteoarthrosis without synovitis with severe pain syndrome, proliferative changes in periarticular tissues. Ultrasound therapy is contraindicated in cases of exacerbation of synovitis, as well as in elderly patients with severe atherosclerotic lesions of the heart and brain vessels, stage III hypertension, transient cerebrovascular accidents, thyrotoxicosis, vegetative-vascular dystonia, climacteric disorders, fibroids, and mastopathy.

Massage

Muscle spasm is one of the sources of pain and the cause of limitation of joint function in patients with osteoarthritis. Spasm of periarticular muscles causes an increase in intra-articular pressure and load on the articular surface, as well as a decrease in blood flow in the muscle, resulting in local ischemia. Therefore, the elimination of muscle spasm is of great importance in the treatment and rehabilitation of patients with osteoarthritis.

Massage, deep and superficial warming (thermal applications, infrared radiation, short-wave or microwave diathermy, sauna or steam room) are used to relax spasmodic muscles. Local application increases blood flow in the affected area, reduces pain and muscle spasm, and causes general relaxation. Increased blood flow in muscles promotes the elimination of metabolites (lactic acid, CO2, _etc. ) and the influx of energy sources (O2 _, glucose, etc.). In addition, superficial warming, affecting nerve endings, has a sedative and analgesic effect. Another mechanism for muscle relaxation using application is a decrease in the excitability of neuromuscular spindles.

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Applications

Applications of silt or peat mud (temperature 38-42 °C), paraffin and ozokerite (temperature 50-55 °C) are prescribed in the amount of 10-15 procedures on the affected joint or on the part of the body including the affected joints. Applications of mud, ozokerite and paraffin are indicated for patients with stage I-II OA without synovitis or with minor manifestations, with severe pain syndrome, proliferative phenomena, reflex changes in skeletal muscles. They are not used in case of significant changes in joints affected by osteoarthrosis, severe synovitis, as well as in ischemic heart disease, hypertension stage IIB-III, circulatory failure, varicose veins, CNS vascular disease, acute and chronic nephritis and nephrosis, etc.

As has been noted many times, articular cartilage does not have nerve endings and therefore the degradation process occurring in it is not the cause of pain in osteoarthritis. The causes of pain can be divided into two groups:

Intra-articular:

• increased intra-articular pressure caused by joint effusion,
• overload on the subchondral bone,
• trabecular microfractures,
• rupture of intra-articular ligaments,
• pinching of synovial villi,
• joint capsule stretching,
• inflammation of the synovial membrane;

Non-articular:

• decreased venous outflow with subsequent stagnation of blood in the subchondral bone,
• muscle spasm,
• inflammation of the periarticular tendons (tendinitis).

Before choosing adequate pain-relieving therapy, the doctor must determine the source of the pain. Among physiotherapeutic methods, the pain-relieving effect is provided by the application of heat carriers and cold sources, ultrasound, pulse electromagnetic field, ionization, electrotherapy, electroacupuncture and vibration therapy.

Cold can be used to reduce pain and inflammation - ice packs, cryogel, local cooling spray, a system of refrigerated gas supply. Surface cooling reduces muscle spasm, reduces the activity of neuromuscular spindles and increases the pain threshold. In osteoarthritis, spraying cooling sprays over the area where the trigger points of the painful muscle are located is effective.

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Shortwave diathermy

Deep warming is achieved with shortwave, microwave and ultrasound therapy. According to K. Svarcova et al. (1988), shortwave diathermy caused a significant decrease in pain in patients with osteoarthritis of the knee and hip joints. Superficial warming with infrared radiation also reduces pain and improves the function of the affected joints in osteoarthritis of the knee joints and hand joints.

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Balneotherapy

Balneotherapy has a beneficial effect on metabolic processes, cartilage metabolism, peripheral hemodynamics and microcirculation - sulphide, radon, iodine-bromine, sodium chloride, turpentine baths. If OA has developed in young patients (35-40 years) without concomitant cardiovascular diseases, then baths with an average concentration of substances and gases are used, with a sufficiently long duration of exposure (15-20 minutes) and a course of treatment (12-14 procedures). For patients over 45 years old, as well as young people with residual effects of secondary synovitis, balneotherapy is prescribed using a gentle technique: baths with a low concentration of substances and gases, lasting no more than 8-10 minutes, for a course of treatment - 8-10 procedures. Taking into account the patient's age, concomitant cardiovascular diseases, half-baths, four- and two-chamber baths can be prescribed, which are easier for patients to tolerate.

Radon baths are recommended for patients with stage I-II osteoarthrosis with residual synovitis, severe pain syndrome and without it, muscle changes, impaired locomotor function of the joints, with concomitant vegetative disorders, climacteric disorders. Sulfide, sodium chloride and turpentine baths are indicated for patients with stage I-II osteoarthrosis without secondary synovitis, with impaired locomotor function, obesity, atherosclerotic vascular lesions. Iodine-bromine baths are prescribed for patients with osteoarthrosis without synovitis, with concomitant functional changes in the central nervous system, thyrotoxicosis, climacteric disorders, atherosclerotic vascular lesions, etc.

Contraindications to balneotherapy are exacerbation of synovitis, as well as ischemic heart disease, hypertension stage IIB-III, severe atherosclerotic lesions of the coronary and cerebral vessels, acute and subacute inflammatory diseases, and for sulphide and turpentine baths - also diseases of the liver and bile ducts, kidneys.

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Use of assistive devices

These include various bandages, knee pads, canes, crutches, orthopedic shoes, etc. All of them help reduce the load on the affected joint, thereby reducing pain. Instead of special orthopedic shoes, the patient may be recommended to wear sports shoes (sneakers) equipped with special pads that reduce the load on the joints of the lower extremities. DA Neumann (1989) found that when using a crutch, the load on the hip joint decreases by 50%. A wedge-shaped pad made of elastic material, which is placed in the shoe under the heel area at an angle of 5-10 °, is effective in patients with osteoarthritis of the medial TFO of the knee joint, especially at stages I-II according to Kellgren and Lawrence. In case of instability of the knee joint or isolated damage to the medial or lateral part of the joint, the use of knee pads is effective.

Patellar stabilization

When the knee joint is affected by the PFO, patients often develop instability of the patella. Stabilization of the patella by various methods leads to a significant reduction in pain in the affected joint and a decrease in the need for painkillers. One way to stabilize the patella is to fix it with a strip of wide adhesive tape. The stabilization method is as follows: one end of a long strip of adhesive tape is fixed to the outer surface of the knee joint, then with the thumb of the right hand the doctor moves the patella medially and fixes it in this position with adhesive tape, the second end of which is fixed to the inner surface of the knee joint.

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