Effect of manual therapy with proprioceptive training in a patient with osteoarthritis knee with pedal oedema: A case report
Simran Purswani1 , Bodhisattva Dass1, Tajuddin Chitapure2, Rinkle Malani*3
1. Resident, Department of Musculoskeletal Physiotherapy, School of Physiotherapy, MGM Institute of Health Sciences, Aurangabad, Maharashtra, India.
[email protected] [email protected]
2. Assistant Professor, Department of Orthopedic Physiotherapy, School of Physiotherapy, MGM Institute of Health Sciences, Aurangabad, Maharashtra, India.
3. Professor & Principal, School of Physiotherapy, MGM Institute of Health Sciences, Aurangabad, Maharashtra, India.
[email protected] Abstract:
A 59 years old female patient with complaint of stiffness of back and severe left knee pain with bilateral pedal edema. In subjective examination, she had given history of obesity, diabetes, hypertension and palpitation might lead to an alteration in the biomechanics in the kinetic chain during the posture and gait analysis.
Although there might be an effect of age in the biomechanics, but presence or involvement of any type of pathology depicts another symptom leading to complete alteration in the biomechanics. A treatment session of 7 days was given along with proprioceptive training for 3 days and there was a difference in both that the patient had complained of and also in the biomechanics as well. Thereby study showing the use and importance of manual therapy for reducing edema and bosuball training for improving the chief complaints. According to the subjective and objective examination and ACR diagnostic guidelines for OA knee, the case was diagnosed as left OA knee and mechanical low back pain. The therapeutic interventions taken were manual therapy-MET with mulligan technique for knee joint, joint distraction (with and without belt), patellar mobilization and proprioceptive training. Outcomes used were Romberg test, NPRS scale, joint circumference. In cases of OA knee, primary concern is always for reduction of pain and stiffness but the proprioception playing a major role during locomotion and also the altered biomechanics is neglected and hence recurrence of OA symptoms is evitable. So the proprioceptive component and working on the biomechanics should be taken into consideration in any type of arthritic cases of lower extremity.
Key Words: Knee osteo-arthritis, manual therapy , proprioceptive training
Introduction
Osteoarthritis (OA) is a chronic degenerative disorder associated with multifactorial etiology characterizing the articular cartilage loss, bone margins hypertrophy, subchondral sclerosis, and alterations in biochemical and morphological norms of the synovial membrane and joint capsule (Sangha, 2000). Being the second most common rheumatologic problem osteoarthritis is the most prevalent joint disease with a incidence of 22% to 39% in India (Mathers et al., 2002).
Women are more prone to OA than men however the frequency alters drastically with age (Pal et al., 2016). Around 45% of women over 65 years of age have symptoms while radiological evidence support 70% of those over 65 years (Davis et al., 1988).
Manual therapy demonstrates soft tissue hands on or techniques for mobilization of joint resulting in pain modulation, an improve extensibility of contractile tissues and movement of joints (French et al., 2011). Manual therapy includes neurophysiological effects in the form of blocking nociception mechanoreceptor mediated pain gate at spinal cord dorsal horn;
periaqueductal grey matter and rostroventral medulla leading to inhibition in mediating
descending pain because of active noradrenaline and slight opioids and serotonin resulting in corrections in cognitive-affective mechanisms presented in pain neuromatrix (Rao et al., 2018).
The concept of Mulligan Mobilization with Movement (MWM) is that articulating surfaces may show minor position faults followed by the malalignment leading to injury or strains developing pain and movement restriction because of active muscle contraction along the faulty limiting joint positions (Bhagat et al., 2020). Hence, MWM demonstrates corrective gliding techniques involving passive accessory glide, applied passively by the therapist to correct the positional fault in perpendicular to the joint plane in addition with the restricted active movement performed and sustained by the patient for required repetitions, the concentration always should remain in pain-free restoration of limiting movement (Bhagat et al., 2020).
Patient is 59 year old female with multiple complications including obesity, diabetes, hypertension, and palpitation on subjective examination. On prolonged standing, she was experiencing pedal edema. Due to presence of having muscle imbalances and all these pathologies, there is an alteration in the biomechanical analysis in the kinetic chain concerned during the gait analysis. No doubt there will be an effect of age in the biomechanics but somewhere and other due to the presence or involvement of one pathology shall depict another symptom leading to complete alteration in the biomechanics.
In this study treatment was mainly focusing on realigning the posture and biomechanics by correcting the muscle imbalances. Altered proprioception can be caused by tissue damage or presence of edema. Balance and proprioception decreases with age and also in patients with knee osteoarthritis. In this study we are focusing on improving balance and proprioception with Bosu ball and also decreasing pedal edema with manual therapy. If the oedema is reduced then it can help in improving joint proprioception.
Patient Information
A 59 year old female, housewife with standing habit for nearly one hour for cooking daily was not able to do any other household work because of pain in knee joint along with swelling (fig.
1). Her socioeconomic status comes under upper middle class residing in a bungalow. She has nearly 24 steps to ascend and descend on everyday basis. As part of her prolong pain and affected activities of daily living, she was been asked to use western toilet for preventing the further worsening of the condition.
Patient’s primary complaint involves left knee pain since 15 years(pain aggravated past 15 days) and secondary complaint includes unilateral low back pain (left side) since 15-20 days. Her family history demonstrates mother was having the history of hypertension and diabetes. She had taken allopathy and ayurvedic treatment intermittently because of which she got temporary relief from that pain
Clinical Findings
On objective examination: Posture analysis with the plumb line: On anterior view (fig. 2) left shoulder was depressed than right shoulder. Left ASIS was depressed lower than right. Lateral patellar tracking was seen. Pronated foot was also observed. Knee varus deformity (fig. 3) was observed. On lateral view (fig. 4) thoracic kyphosis was observed. On posterior view left shoulder was depressed than right. Left PSIS was depressed than right. Shifting of TA tendon medially was also observed. Tightness of piriformis, IT band and gastro-soleus muscle was found. Muscle spasm was present for quadriceps, hamstrings, gastro-soleus muscles. Resisted
isometrics were weak and painful for knee musculature. Knee joint range of motion was restricted with empty end-feel. According to MMRC scale knee musculature strength was grade 3 and the hip abductors were found to be weak i.e Grade 3. Clarke’s sign (patellar grind test) was positive. Joint play was found to be grade 2 for tibiofemoral and patellar joints. In gait analysis the patient was walking in an antalgic gait pattern with slight circumduction of left hip.There was no swing phase on left side. There was 1 cm difference in the limb girth. Knee joint circumference was having difference of 1 cm and ankle joint circumference was having difference of 3 cm. The core strength i.e the upper and lower abdominals and the back extensors was grade 1. She had low back pain while forward bending and during long standing with NPRS 3.
Fig. 1. Swelling over left knee joint
Fig. 2. Postural analysis-anterior view
Fig.3. Genu Varus seen on left knee
Fig.4. Postural analysis-lateral view
Diagnostic Assessment: There was no radiological diagnostic testing. As the patient had no radiological findings she did not face any diagnostic challenges.
Diagnosis: Diagnosis was done on the basis of subjective and objective examination for mechanical low back pain and ACR diagnostic guidelines for Knee Osteoarthritis. The physiotherapy treatment was more of biomechanical correction and patient’s prognosis was considered to be good.
Therapeutic Intervention
She is on medications for hypertension and diabetes. Earlier she had taken medications for pain and swelling for knee joint prescribed by the orthopedic. For herself care she is also using western toilet and having meals by sitting on a chair to avoid pain. Mulligan mobilization was given in 3 sets. In one set 5 glides were given. Joint distraction for 5-10s for 3 sets. Muscle energy technique 3 sets 5 repetitions and 5sec hold. Bosuball exercises 30s 2 sets. After the treatment sessions are over the patient was given a home program along with the education regarding lifestyle modifications. In home program static quadriceps and hamstring exercises were given along with static abdominal exercises to be performed twice a day. The patient will be also advised about the breathing exercises and modified aerobic exercises to improve the
cardiopulmonary endurance. Breathing exercises will be performed for 2-3 times a day and modified aerobic exercises 2-3 times a week.
Follow-up and Outcomes
Outcomes used were Romberg test, NPRS scale , joint circumference. On daily follow up basis there was immediate effect of manual therapy on reducing pedal edema. Joint circumference was measured pre and post treatment. There was difference of 1 cm after treatment. Patient was well adhered with number of physiotherapy days. Patient had well co operated through manual therapy and exercises.
Discussion
As per the researches, there is not only the initiation of local physiological mechanisms by joint mobilization but also there is involvement of central mechanisms like facilitation of inhibitory pathways in the spinal cord or descending inhibitory pathways from higher levels in the brainstem. Skyba et al. reported that serotonergic and noradrenergic receptors in the spinal cord mediate analgesia produced by knee joint mobilization (Alkhawajah and Alshami, 2019).
Many of the researches are still unclear with the mechanisms for how the KJD(knee joint distraction) works. Biomarker analysis had reported that KJD decreases the collagen type II breakdown marker which is observed coupled with an increase in the collagen type II synthesis marker. While these findings suggest that KJD changes the intra-articular environment to one that favors cartilage repair (Takahashi et al., 2019).
Muscle energy technique involves proprioceptors of muscle fibers which might lead to pain relief via pain gate control theory. Immediately following an isometric contraction, a muscle in hypertonic state could be lengthened passively to a new resting length. This might explain how there were changes in pain and hamstring flexibility after muscle energy technique (Khuman et al., 2014).
During the static abdomen exercise, it’s a known fact that there is activation of the core muscles but the activation of the core muscles also enhance the muscles controlling the gait of the individual by the force-couple theory and in-turn improving the stature of the muscle activity and also the biomechanics of the extremity concerned as well, as the core stability exercise is completely based on motor control theory and there by leading to both reduction of low back pain and strengthening of the quadriceps muscles and leading to decreased knee pain.
The pedal oedema is the accumulation of fluid in the foot area and by joint mobilization, there is decrease in the pedal oedma. There was decrease in the pedal oedema by joint mobilization because by mobilization the part that had got stiff and due to which there was improper transmission of fluid leading to oedema,the stiffness got reduced and thereby improving the circulation as well and hence reduction in the pedal oedema.
Conclusion: In cases of OA knee, the main concern is always of pain and stiffness reduction, however during locomotion the proprioception being in major role and thorough neglection results in altered biomechanics and hence recurrence of OA. So working on the proprioception and the biomechanics together should be taken into consideration while managing arthritic cases of lower extremity.
Author’s Contribution: All authors contributed equally to the manuscript.
Conflict of Interest: The authors declare no conflict of interest.
Funding Source: The research has not received any external funding.
Acknowledgement: We thank the patients who participated and contributed samples to the study.
Informed Consent: Written & Oral informed consent was obtained from all individual participants included in the study. Additional informed consent was obtained from all individual participants for whom identifying information is included in this manuscript.
References:
1. Alkhawajah, H.A., Alshami, A.M., 2019. The effect of mobilization with movement on pain and function in patients with knee osteoarthritis: a randomized double-blind controlled trial.
BMC Musculoskelet. Disord. 20, 452. https://doi.org/10.1186/s12891-019-2841-4
2. Bhagat, M., Neelapala, Y.V.R., Gangavelli, R., 2020. Immediate effects of Mulligan’s techniques on pain and functional mobility in individuals with knee osteoarthritis: A randomized control trial. Physiother. Res. Int. J. Res. Clin. Phys. Ther. 25, e1812.
https://doi.org/10.1002/pri.1812
3. Davis, M.A., Ettinger, W.H., Neuhaus, J.M., Hauck, W.W., 1988. Sex differences in osteoarthritis of the knee. The role of obesity. Am. J. Epidemiol. 127, 1019–1030.
https://doi.org/10.1093/oxfordjournals.aje.a114878
4. French, H.P., Brennan, A., White, B., Cusack, T., 2011. Manual therapy for osteoarthritis of the hip or knee - a systematic review. Man. Ther. 16, 109–117.
https://doi.org/10.1016/j.math.2010.10.011
5. Khuman, R., Devi, L., Patel, P., Chavda, D., 2014. Immediate Effects of Single Session Post Isometric Relaxation Muscle Energy Technique Versus Mulligan’s Bent Leg Raise Technique on Pain and Hamstring Flexibility in Knee Osteoarthritis Participants: A Randomised Controlled Study. Int. J. Sci. Res. 3, 310–313.
https://doi.org/10.15373/22778179/September2014/97
6. Mathers, C.D., Stein, C., Fat, D.M., Rao, C., Inoue, M., Tomijima, N., Bernard, C., Lopez, A.D., Murray, C.J.L., n.d. Global Burden of Disease 2000: Version 2 methods and results.
108.
7. Pal, C.P., Singh, P., Chaturvedi, S., Pruthi, K.K., Vij, A., 2016. Epidemiology of knee osteoarthritis in India and related factors. Indian J. Orthop. 50, 518–522.
https://doi.org/10.4103/0019-5413.189608
8. Rao, R.V., Balthillaya, G., Prabhu, A., Kamath, A., 2018. Immediate effects of Maitland mobilization versus Mulligan Mobilization with Movement in Osteoarthritis knee- A Randomized Crossover trial. J. Bodyw. Mov. Ther. 22, 572–579.
https://doi.org/10.1016/j.jbmt.2017.09.017
9. Sangha, O., 2000. Epidemiology of rheumatic diseases. Rheumatol. Oxf. Engl. 39 Suppl 2, 3–12. https://doi.org/10.1093/rheumatology/39.suppl_2.3
10. Takahashi, T., Baboolal, T.G., Lamb, J., Hamilton, T.W., Pandit, H.G., 2019. Is Knee Joint Distraction a Viable Treatment Option for Knee OA?-A Literature Review and Meta- Analysis. J. Knee Surg. 32, 788–795. https://doi.org/10.1055/s-0038-1669447
