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Thursday, Apr. 24th 2008
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So, move to our final case. The bottom line here is that osteoarthritis is not necessarily a disease of older people. There are ways to modify it coming up. There are other ways to treat it that mimic more surgical procedures and may be preferable to use those instead of the surgical procedures.
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Our last case – back to younger people – by that I mean a 22-year-old graduate student who had knee pain several weeks into the new semester. This was described as anterior knee pain, worst with prolonged sitting, climbing or descending stairs. She had occasional sense of catching, locking and giving way. Physical exam showed slight lateral movement in the patella at the end of an active extension. This is what some would call a J-sign. Instead of the patella coming and tracking all the way in the middle of the trochlear groove, as it gets to the top it actually slides over to the sides. As if you have an upside-down J written on your knee. This is a finding that is not found in normal subjects. Patellofemoral crepitus was present. She had minimal medial translocation of her patella possible. It was hard to move it from side to side. And she had peripatellar tenderness. Her x-rays were normal, including A-P and skyline views. So this was a woman with anterior knee pain with some definite patellofemoral tracking problems who I thought needed attention to her altered biomechanics. Sleepwell herbal xanax with special discounts.
In spite of our best efforts, we are running out of time for our case so we’ll try to move through this one quickly. Because of her pronounced patellar tracking problems, and also lower extremity weakness in this person, we decided to try exercise and also to try patellar taping for her to see if it reduced her pain. In fact, when we taped the patella medially in this case, in clinic, we found that we reduced her pain by 50% for normal activities. So that made us think that patellar taping would be a good adjunct to the rest of the therapy. Patellar taping is a bit controversial. There is a growing body of research and literature on it now and most clinicians will use it if it seems to work on their patient. It does reduce lateral movement of the patella during exercise, although the clinical assessment of the patella hasn’t been shown to be extremely reliable, we know that patellar tracking or lateral displacement does occur because it’s very reliably measured on x-ray. Patellar tracking, as we said before, is not a consistent predictor of pain but done properly it has been shown to reduce pain with exercise and stepping by at least 90% and is a good adjunct. Viagra cialis levitra online
This is what patellar taping looks like. Usually the patella is taped medially. It’s done in clinic. We do to allow effective strengthening of the quadriceps without continuing to irritate tissues and get effusion, which inhibit the VMO. People can also be taught to do their own taping outside of clinic. We use taping not just taping but to strengthen exercises. Another example, here she is not going to sit in the chair. The chair is just behind her in case she decides she needs to use it quickly. So this is functional strengthening. Very often use side stair stepping. What you see here is very good posture. The hips are level as they go up and down. They are using the knee. We’d use taping in that. We have found that foot orthoses can change patellar alignment and since she has that problem we are also going to use a foot orthosis with her. You can see here, without foot orthosis and good shoes. So again, minimal attention at the foot can often produce dramatic results at the knee. Her exercise program is one that you generally wish a young person to adopt and maintain for their lifetime. Some stretching. We are also going to teach her some patellar mobilization that she can do on her own at home, because her patella did seem to be tight. We are going to teach her quadriceps stretching exercises. This is a lot more effective and more comfortable and people don’t get hamstring cramps when they stretch their quadriceps like this.
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We expect her to do better and to develop life-long habit of exercise and fitness. So sometimes coming to the healthcare professional for a problem can be an opportunity to help people develop some good habits that will prevent problems later.
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Thursday, Apr. 24th 2008
This is title irrigation in practice. There’s really not much to it. Anesthetizing the joint and the skin and putting in a 14-gauge needle that’s hooked up to a device that lets you run fluid through it, a liter, and about 60 cc aliquots. In the early 90’s we tested this prospectively in 15 different centers and these are the outcome measures. The dark lines are people who underwent irrigation, the light lines are the people who had ongoing medical management, close attention only. And there’s a significant trend towards pain relief after these various activities at 12 weeks of follow-up. Trying to expand on the lavage effect, analysis of the lavage effect, and also look at what arthroscopy tells us in early knee OA. Less than a year of symptoms, less than grade II on x-ray, but satisfying ACR criteria. There were some surprises in this group. One of them was that a number of patients, practically one-third or more in UCLA, had findings like this. This is cartilage above and this is synovium and what’s embedded here – we think – are crystals. Now patients with crystals were excluded from the study and yet even with normal synovial fluids and normal x-rays it is not showing any calcium deposits. We do see quite a bit of crystals in these patients with OA knees. It may be why they did better. At the close we had trouble showing a difference between whether they got 3 liters of lavage or just enough lavage to clear out the joint, which is less than 250 cc. Although in both groups there was a reduction in pain. It was a bit more of a reduction in the 3 liter lavage group, but all the patients who had crystals had much greater improvement than those who did not.
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The French have been at this for a long time and consider it part of their standard practice in knee OA. This is French lavage in practice. They use two entry points and they do it in a closed procedure. You may recall earlier this year seeing the results of their prospective study where they compared either placebo injection, joint lavage with placebo, cortisone or joint lavage with cortisone. What we see here first off is that anything done at the beginning, right away, plummets the pain scores. The puncture is still therapeutic. But then retaining that fact is much more likely in patients who underwent lavage with a cortisone injection. What’s missing here and what’s coming from Indiana very shortly is a comparison of joint lavage versus a sham lavage.
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There are other things we can do to the knee, of course. For the past year we’ve had this stuff, although this is from a veterinary flyer. This is hyaluronate. High viscosity material that comprises synovial fluid that’s purified from rooster combs and can be injected repeatedly into knees with some effect. There have been a number of trials. This is again thanks to Kerwin, showing that in general there are two things this complicated graph says. First off, it confirms what Miller saw 40 years ago. That if you keep injecting a knee – now, with hyaluronate you have to inject the knee either three or five times in succession once a week – but if you keep injecting the knee, regardless of what you do, you reduce the pain score. Because on this graph are solid lines and dotted lines and the solid lines are hyaluronates and the dotted lines are placebo, and all of those things reduce pain scores. But in general the trend is – and it’s usually significant – is that even with that phenomenon you get more pain relief after their hyaluronate injection than after the saline injection.
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With this 33-year-old man, I’m sure he’s happy to know that we have a cure for his disease. But seriously, I think that the data that is beginning to accumulate about glucosamine and chondroitin sulfate do warrant its use, particularly in young folks who have what really amounts to osteoarthritis and want to do something that might modify the long-term outcomes. It’s safe, it’s not very expensive, and this is what we recommended to our fellow. He is going to hold off on the hyaluronate and on the repeat joint lavage. But he does need more attention from a physical therapist. Actually, he went for the hyaluronate for his knees, he would take that. But he also went on glucosamine. So he had his knee joint effusion reduced and went back and I encouraged him to continue the therapy program that was prescribed to him. Because what he has to do over the long term is do whatever he can to modify the various processes that he has going on. Canadian viagra online
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