BBUKUUKU IINFORMASINFORMASI SSINGKATINGKAT TTENTANGENTANG OORGANISASI,RGANISASI, KKANTORANTOR PPEMERINTAHAN,EMERINTAHAN, PPENYEDIAENYEDIA LLAYANAN,AYANAN, AAKSESKSES KKESEHATANESEHATAN DDANAN PENDIDIKAN,PENDIDIKAN, SERTASERTA BBEBERAPAEBERAPA IINFORMASINFORMASI LLAINAIN YYANGANG TTERKAITERKAIT TRAINING MODULE Knee Osteoarthritis Treatment for Physiotherapist in Puskesmas

Published by: ©HANDICAP INTERNATIONAL Jl. Prawirotaman III No. 669A Brontokusuman, Mergangsan, Yogyakarta, 55153 Telp.: +62(0)274 376107 +62(0)274 382262

First Edition : December 2013

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Copyright 2013 Handicap International (HI) authorizes the reproduction and the use of this publication for educational and other non-commercial purposes, provided that HI and its donor are fully acknowledged.

Printed by: PERCETAKAN POHON CAHAYA E-mail: [email protected] Website: www.pohoncahaya.com Table Of Content

A. Defi nitions ...... 4 B. Causes ...... 4 C. Symptoms ...... 4 D. TYPES of Osteoarthritis (OA)) ...... 5 1. Primary ...... 5 2. Secondary ...... 5 E. Risk Factors ...... 5 F. PREVENTION of Osteoarthritis (OA) ...... 5 G. Physiotherapy assessment Knee Osteoarthritis ...... 6 1. Anamnesis ...... 6 2. Quick test/orientation test ...... 6 3. Active movements test ...... 6 4. Passive movements test ...... 6 5. Isometric movements test ...... 6 6. Spesifi c test ...... 6 7. Additional Assessment ...... 7 H. Th e purpose of physiotherapy Knee osteoarthritis ...... 8 I. Physiotherapeutic intervention on osteoarthritis knee joint may vary depending on the stage of the disease...... 8 J. Additional Exercises ...... 8 K. Knee Osteoarthritis Calisthenics ...... 9 L. Home Program/Patient Education ...... 11 M. Physiotherapy Intervention on musculoskeletal in Public Health Center (see Annex) ...... 11

TRAINING MODULE Knee Osteoarthritis Treatment for Physiotherapist in Puskesmas 3 Knee Osteoarthritis

A. Definitions Osteoarthritis is a joint condition marked with the damage and missing of articular cartilage which results in the forming of osteophytes, pain, limited movements, deformity, joint infl ammation occurring due to cartilage depletion and damage. Osteoarthritis is also known as a degenerative arthritis, (joint degenerative disease), which is a condition where the joint is felt painful due to mild infl ammation coming from the friction of the cartilages. OA can aff ect all body joints, but most frequently in the weight-bearing joints, such as hips, knees, feet, extremities joint and spine.

B. Causes Th e causes are not obvious, but OA is often related to the degenerative process and other possible conditions, such as metabolic disease and obesity. Th e causes of osteoarthritis may vary. Several researches indicate the connection between osteoarthritis and the reactions of allergy, infection, and the invasion of fungi (mycosis). Other researches also show that hereditary factor (genetic) is involved in the inheriting of this disease. Th e followings are several risk factors of osteoarthritis: • Women at the age of 45 (more vulnerable to OA) • Excessive body weight • Excessive physical activities, as in athletes and rough workers • Repetitive movements and micro-shocks • Suff ering from thigh muscle laxity • Improperly-treated bone fracture around the joint • In most OA cases, the cause is unknown -- and this type of OA is called primary OA. After the cause is acknowledged, the condition is called secondary OA. Th e conditions that can cause secondary OA include congenital abnormal joint (congenital disorder), • Diabetes and other hormonal disturbances, uric acid, obesity, repetitive trauma or surgery at the joint structure.

C. Symptoms OA symptoms may vary for diff erent people. Some people only feel mild pain and stiff ness, some others may experience severe and paralyzing symptoms. • Pain. Th is is a preliminary symptom and usually it is worsened by the mechanical use of the joint and is lessened by body rest. • Temporary joint stiff ness after resting time (such as the one experienced after waking up in the morning or after sitting for a long time). Th e stiff ness tends to disappear after using the joint for 5-15 minutes. • Joint swelling and redness. • Muscle laxity around the impacted joints sometimes infl ict an unstable feel at the joint. • Th e reduction of joint mobility and fl exibility.

4 TRAINING MODULE Knee Osteoarthritis Treatment for Physiotherapist in Puskesmas • Creaking feel or noise when moving the joint. • Fatigue accompanying the pain at the joint. • Diffi culty in moving the joint • Noises in every joint (crepitus). Th is symptom does not infl ict pain, but leaves discomforts at every joint (mostly, the knee). • Bone form change. Th is is due to the deteriorating cartilage; the bone’s form starts to change and infl ame, causing a severe torturing pain. • Specially for knee, pain will be arises when the joint is movement, symptoms like as joint lock, pain when going up from the chair, pain when rising from sitting on the fl oor or the time from standing to sitting on the fl oor , muscle weakness on lower extremity.

D. TYPES of Osteoarthritis (OA) 1. Primary Th e causes are unknown; due to natural aging process. Experienced after the age of 45; its causes are not exactly recognized, it attacks gradually, and can impact numerous joints. Usually it aff ects knee and pelvic joints, but it can also aff ect other joints such as the spine and fi ngers. 2. Secondary Experienced before the age of 45; its cause is trauma (instability) which results in joint injuries (for instance bone fracture or misaligned joint surface), it occurs due to loose joint and joint surgery. Other causes are the genetic factor and metabolic disease.

E. RISK FACTORS • Above 50 years of age. • Being female. • Obesity. • Immobilization history. • Trauma history or previous joint infl ammation. • Prolonged stress at the joint, as in the case of many athletes. • Th e presence of crystal in the joint or bone liquid. • High bone density. • Peripheral neuropathy. • Humid environment • Other factors: racial, hereditary, and metabolic.

F. PREVENTION of Osteoarthritis (OA) By eliminating the above-mentioned predispositional factors. As tips, do the following to avoid as early as possible being attacked by OA or to prevent your OA from relapsing: • Keeping an ideal bodyweight • Doing physical exercises with less joint usage • Physical workouts that match the needs • Avoiding joint injuries • Consuming joint supplements • Consuming healthy food • Choosing the correct and comfortable footie • Exercising relaxation with various techniques

TRAINING MODULE Knee Osteoarthritis Treatment for Physiotherapist in Puskesmas 5 • Avoid stretching fi nger joints • If there is a deformity at the knee, for instance the O-shaped legs, do not leave it ignored. Th at will cause an uneven pressure to all of the bone surfaces.

G. Physiotherapy assessment Knee Osteoarthritis 1. Anamnesis • Sharp ache/stiff ness pains at the tibiofemoral joint • Morning sickness and start pain • Limited movements and crepitus 2. Quick test/orientation test Orientation provocation test is a test to reveal the location of abnormalities of patients complained of both segmental or that is regional general and practical. For example, patients with knee pain, it is the orientation test stand to squat and squat to stand. 3. Active movements test Examination of active movements performed by patients under the guidance of the examiner. Information obtained from this examination is still the global because they involve a variety of structures such as neuromuscular, arthrogen, vegetative mechanism. Th is examination can provide information such as coordination of movements, patterns of movement, crepitus, pain and active ROM 4. Passive movements test Is a movement of the patient’s examination by the examiner without actively involving patient. Th us the examination of many devoted to the structure myotendinogen and arthrogen on passively. Before the examination make sure the region will be moved on relaxed position and try to reach the ROM when optimally movement with respect to the complaints of patient, so that on the one side will be occur stretching and the other side will experiencing compression. Information that can be obtained through this examination is passive ROM, joint stability, pain, crepitus at tibiofemoral joint movement, capsular pattern and fi rm end feel 5. Isometric movements test Isometric motion against resistance or pain provocation test is aimed at checking musculotendinogen and neurogen. Th e trick; patients do move with resistance against given by the examiner without any move that changes the position of joint ROM in the region examined. Information can be obtained from the examination of the pain in musculotendinogen, isometric muscle strength, quality of motor nerve 6. Spesifi c test • Ballotement test recessus suprapatellaris emptied by pressing it with one hand, while with the other hand pressed down patella with fi nger. Under normal circumstances patella cannot be pressed down, but if there is (a lot) of fl uid in the knee joint the patella as lifted a little so that there is a movement up and down and sometimes feels patella such as “typing” on the hard base.

6 TRAINING MODULE Knee Osteoarthritis Treatment for Physiotherapist in Puskesmas • Fluctuation test Th e thumb and index fi nger of one hand is placed on the left and right patella. When it cleared recessus suprapatellaris with other hand, the thumb and index fi nger was driven by the movement of fl uid in the knee join • Pain Test, VAS (Visual Analogue Scale) Th e measurement of the degree of pain by showing a point on a line pain scale (0-10 cm), one of the endpoints showed no pain and the other showed severe pain. Length of the line starting from the point of no pain until the designated point indicates the magnitude of pain by patients. Patients were given an explanation, and then the patient is asked to indicate the degree of pain location.

Remark : 1 : No pain 1-3 : Mild pain: an objective client can communicate well. 4-6 : Moderate pain: an objective clients hissed, grinning, can indicate the location of the pain, can describe it, can follow orders well. 7-9 : Severe pain : an objective sometimes clients are not able to follow commands but still respons to the action, can indicate the location of the pain, cannot describe it, cannot be resolved by performing a deep breath and distraction 10 : Very severe pain: Th e patient is no able to communication, hitting Other Specifi c test can be done • Anterior and posterior draw test • Lachman test • Valgus & varus test • Applay test • McMuray test 7. Additional Assessment If possible, conduct an X-ray (Rontgen photography) assessment at the joint being complained about. Especially for the knee, the assessment is done with the patient standing up and both knees are checked for comparative purpose.

In the X-ray photo of an OA patient, we can fi nd: • osteophytes at the end zone of the joint, • joint space narrowing, • the increase of subchondral bone density, • subchondral cyst formation, • lack of joint liquid.

TRAINING MODULE Knee Osteoarthritis Treatment for Physiotherapist in Puskesmas 7 H. The purpose of physiotherapy Knee osteoarthritis Th e purpose of physiotherapy in the case of osteoarthritis is to increase the muscle strength, coordination, balance, functional activity, and decrease the pain

I. Physiotherapeutic intervention on osteoarthritis knee joint may vary depending on the stage of the disease. Treatment principle: No exercise combining strength and movement. Any muscle reinforcement will be isometric, any mobilization will be with no resistance, movement with no weight-bearing, Isometric muscle strengthening to improve the stability of the knee and decrease pain possibly with weight-bearing but no movement 1. Mild Stage • Weight loss for overweight people. • Exercises to strengthen the thigh and hip muscles to keep the body in shape. • Wearing knee brace whenever necessary. • Active mobilization. • Appropriate medication, or in accord with what the doctor prescribes. 2. Medium stage • Joint mobilization, at the beginning of the oscillation translation intervention in MLPP. • Translation in fl exion limitation, tibiofemoral joint extension. • Active mobilization. • Transverse friction by the way of pushing the patella to lateral and medial. • Strengthening exercise m. Vastus medialis at the extension end-movement knee position. • Medial arc support (correct shoes). 3. Heavy stage Th e best choice of treatment until now is the joint replacement surgery (a surgery conducted to replace the damaged joint by the way of TKR (Total Knee Replacement) prosthesis. At any stage, anti-pain treatment can be done : • Light circulating massage • Heat (under the sun, if no infrared) • Positioning : no excessive fl exion or extension when at rest, surclive when sleeping • Elastic bandage or splint when walking

J. Additional Exercises Moderate workouts can improve function and reduce pain in those with osteoarthritis of the knee. Adequate joint movement and periarticular tissue elasticity are needed for the nutrition and health of the cartilage, to protect the joint structure from burdens with damaging impact, and for function and comfort in daily activities. Exercises to regain or maintain movements and fl exibility with low intensity, controlled movements which do not cause increasing pains.

8 TRAINING MODULE Knee Osteoarthritis Treatment for Physiotherapist in Puskesmas Muscle laxity around the osteoarthritic joint is common. Progressive resistance, or weight training, strengthens the muscles in an adequate way to enable muscle strengthening while limiting tissue injury.

K. Knee Osteoarthritis Calisthenics 1. Th e sitting-on-a-chair position

a. Sit comfortably on a chair. Lift one of your limbs and hold for ten counts for each limb. Repeat for 3-4 times for each limb respectively.

b. Sit on the edge of the chair with both hands holding the chair. Pull one of your feet backward, or parallel to the chair. Rest your foot on its tip. Push downward to the fl oor. Hold for fi ve counts. Repeat 3-4 times for each foot respectively.

c. Sit on the chair. One of your feet is tied with a rubber band. Th en move your foot forward and move it slowly. Repeat the exercise with each foot respectively.

d. Sit on the edge of the chair with both hands holding the chair. Pull one of your feet backward, or parallel to the chair. Rest your foot on its tip. Push backward. Hold for fi ve counts. Repeat 3-4 times for each foot respectively.

TRAINING MODULE Knee Osteoarthritis Treatment for Physiotherapist in Puskesmas 9 2. Th e stand-up position

a. Stand up straight. Lift one of your limbs up to the waist level. Do the same for the other limb. Th is exercise is done for 2 minutes.

b. Stand up straight with both hands holding the waist. Bend your knees. It is not suggested that you bend your knees down to the sitting position. Repeat the movement for 10 times.

c. Stand up straight beside the chair. Tie your feet to the chair leg. Th en, move your foot forward and hold that position for 3 seconds. Repeat the movement for 10 times.

d. Stand behind the chair. Tie your foot by using elastic rope. Move your foot backward and hold that position for 3 seconds. Repeat 10 times.

10 TRAINING MODULE Knee Osteoarthritis Treatment for Physiotherapist in Puskesmas e. Stand beside the chair. Move your limb sideway. Hold for 2-3 seconds. Repeat 10 times.

L. Home Program/Patient Education Patient education has been proven to be helpful in the self-management of patients with arthritis in terms of reducing the pain, improving function, reducing stiff ness and fatigue, and reducing medical usage. A meta-analysis has demonstrated that patient education can provide on average 20% more pain relief when compared to NSAIDs alone in patients with hip or rheumatoid arthritis.

M. Physiotherapy Intervention on musculoskeletal in Public Health Center (see Annex)

TRAINING MODULE Knee Osteoarthritis Treatment for Physiotherapist in Puskesmas 11 Bibliography

Setyohadi, B, (2003); Osteoarthritis Overview; Collection of Rheumatology Scientifi c Meeting Papers, Jakarta. Soeroso, J, et al, (1999); New therapy in OA. In: Rheumatology Proceding toward the 3rd Millennium Suyati and Margono, A, (1999), Th eory and Practice of Gymnastics I: Ministry of Education and Culture of the Republic of Indonesia of March Surakarta. http://www.ilmufi sioterapi.info, Assesment physiotherapy on Knee Joint, access on 6 September 2013 Sugijanto: Training material” Knee Osteoarthritis” on 23rd – 27th January 2013 in RSUZA Banda Aceh

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