Arthritis is nothing but a senile change and its irreversible. So, we are not exactly changing the pathology (which is normal aging here) , but we are just slowing down the process.

Right mam..... but what i want say that in most of clinics physio give treatment like strengthening muscles, mobilization, any electrical modality, stretching exercises and patients get temporary benefit. After 5-6 months again same problems start so again they take same treatment. so during that time pathology of OA goes worst and they do TKR. So is physiotherapy treatment really help to patients or just temporary benefit......? Because in last they have to do TKR.

And all the articles say that this intervention is significantly & clinically improvement but at what extend it...?

I think quads strengthening always play a key role in  knee pathology in patients with OA along with lifestyle modifications like avoid low sitting, excessive knee bending in weight bearing position, weight loss, use of shoe with high sole.

I agree with Ms. Shah. Physiotherapy does not tackle the pathophysiology of OA, it acts rather as a symptomatic measure - pain relief, better ROM, overcoming of contracures, etc.

I agree with Manshi and Panayot. There are lots of evidence on symptom modification or improving quality of life in OA knee, but there is limited literature supporting physical therapy can change or modified disease process in OA.

https://www.essa.org.au/wp/wp-content/uploads/JSAMS-Article-Osteoarthritis-of-the-hip-and-knee1.pdf

Thank you Panayot Tanchev & Ratan khuman sir.....for your suggestions...

This is a philosophical question which can be explained in an easy or complicated way. If we are talking about established tri-compartmental arthritis the answer is a straight "no". The only thing that may happen is for physiotherapy to delay the total knee replacement, as you already mentioned. In a case of post-traumatic uni-compartmental arthritis (either anterior or medial compartments) in a very young patient, the possibility and sometimes necessity is to delay surgery, but again changes are not reversible. The treatment is there only to help the soft tissues, but not the articular cartilage. So again the word is "delay". All this is already rightfully mentioned above. But now, this is the philosophical part of it. Physiotherapy, in the broad spectrum, is possible an educational tool to change the way of life and it can help, as it is changing our attitudes, to prevent OA (although this is not the only way; causes of OA are multifactorial and cannot be answered in such simplistic way). But do we know to whom we will apply this "treatment"? The answer is to all. This is not possible though and so we continue to live and walk towards a total knee replacement.

Agree with all the above listed feedback.

However, as we know OA is the degeneration of the articular cartilage (AC), made up of glycosaminoglycan (GAG). Majority of the bodies GAGs are linked to core proteins, forming proteoglycans; the proteoglycans aggregates (PG) are a major constitution of AC.  The AC, specifically the PG, require mechanical input / stimulation for maintenance.  Research (using sheep) has shown complete unloaded and immobile joints result rapid (within 2-3 weeks) and significant loss (40%) of PG (Houlbrooke K, Vause K, Merrilees M., 1990 – copy of abstract below). However, PG loss can be prevented by passive movement of an unloaded joint and in following these findings, it would seems logical that with combined body weight bearing, mechanical stimulation, and in time the use of additional weight bearing (all physical therapy techniques) the AC longevity can be maintained and further research is required if the AC can be enhanced following the above philosophy.

****

Effects of movement and weightbearing on the glycosaminoglycan content of sheep articular cartilage.

Aust J Physiother. 1990;36(2):88-91. doi: 10.1016/S0004-9514(14)60518-3.

 Abstract

Immobilised non-weightbearing joints show significant loss of proteoglycan. It is unclear whether this is due to a lack of compression, a lack of movement, or both. Evidence suggests that movement alone is insufficient to maintain proteoglycan levels. To investigate this problem, 20 sheep were divided into four groups and the right forelegs subjected to (1) normal weightbearing and movement, (2) movement without weightbearing, (3) weightbearing without movement and (4) non-weightbearing without movement. After one month, full thickness core samples of cartilage taken from the radio-carpal joints of both forelegs were analysed for glycosaminoglycan (GAG) content. Immobilised non-weightbearing joints showed a significant loss of GAG compared with the other groups. More importantly, movement alone without weightbearing was sufficient to maintain GAG content, as was weightbearing without movement.

A proper individualized rehabilitation program based upon each person's unique profile and prioritized needs along with compliance to skilled outpt. P.T. and compliance to a individualized Home Ex program can and has been shown to decrease individual's pain and improve function. The area of confusion comes when one analyzes cartilage thickness, joint spaces, K/L scores, and other static, non-dynamic tests. Thus, functional movements and understanding of flexibility, balance, gait patterns, strength, L.E. power all contribute for the dynamic ability and stability of the joint.

Thank you Paul K Canavan sir for  answer........

Dear Mr Patel,

Generally speaking, we as physiotherapists cannot reverse the degeneration process that occurs with OA (or aging in general). Allow me to explain the effects of each intervention separately :

1. Electrical modalities: They are preferred by patients because they are effortless and numb the pain for a certain period of time after the session. The effect does not go beyond that.

2. US: I don't think it is beneficial in this case. Just a waste of time. 

3. Heat modailities: They are good to reduce pain and improve the circulation, which in return washes away the inflammatory mediators in the joint. It cannot reverse or stop the damaging processes however.

4. Stretching exercises: A good intervention. The muscles tend to get shorter in length when not being used and due to the reduced ROM of the affected joint. Having flexible muscles reduces pressure on the joint.

5. Strengthening exercise: These are the best. Strong muscles support the joint very well and improves the mechanics of mobility. Therefore, 'reduces' the abnormal direct stress on the joint surfaces.

The OA process is a bit complex when you look at it from a mechanical point of view (ignore the histological changes for now). Degeneration leads to uneven force distribution on the joint surfaces, which causes wear and tear over time. This wear and tear exposes the joint surfaces leading to spur formation, inflammation and pain. This in return will lead to changes in joint mechanics and the whole cycle repeats itself again.

By intervening one way or another, we try to break this cycle temporarily. Patients return after months because they stopped doing their exercises at home and because the condition simply got worse. It is as simple as that.

Regards..

It is difficult to make generalized blanket statements about interventions and one should be cautious when reading the literature relating to for example three health care professionals performed the intervention. For example there are Orthopedic surgeons and there are better Orthopedic surgeons related to a specific joint area and condition.  Specific individualized interventions are needed to promote an optimal environment for positive outcomes. A comprehensive examination, evaluation and knowledge of compliance of the patient, and the knowledge of gait assessment, functional assessment, flexibility and strength testing, balance, etc, and the proper development of a individualized rehabilitation program based upon the findings is needed for interventions to have efficacy.

I agree completely with the opinions but the question is if "Physiotherapy on each own can change the course of knee OA". Have I understood the question correctly?

Yes, George, I also share the opinion that we often deviate from the primary question. 

Regards

Physiotherapy causes pain relief and better functional outcome of these disable patients 

The answer for this question, as formulated, is clearly NO. Physiotherapy doesn't have for goal to change pathophysiology for any disease but just to give a possibility of adaptation to new physical "bad" conditions. And it's really important as well! Doing so, we may sometimes delay surgery... We must not forget that orthopaedic surgery is rarely a life-threatening procedure, "just" a functional medical process to improve quality of life. Our clinical scores are so based on day-life items and our decisions are themselves based on these scores. Moreover, it's the same goal after surgery: recover quickly proper ADLS as needed to return to a normal life...

Thank you George Zafiropoulos sir .............yes you understand  correct the question....physio can only change the way of disease not the pathology of disease..... so we can delay the TKR.............

BUT we have lots of article for OA ........can we believe on each and every article............? or is there any method for believe on some articles....thanks for your suggestions. 

 Now-a-days so many articles are in google ............but at extend we follow those articles.....because each and every articles shows statistically  and clinically  significant..

Dear Paul K Canavan, I completely agreed with your statements about the needs and benefits of Physiotherapy interventions in the management of OA knee. As stated in the question itself, available literature support the benefits of Physiotherapy intervention in controlling or managing symptoms related to OA. But the actual question here is whether these Physiotherapy interventions can recover the pathology of OA while resolving the symptoms like pain, muscle imbalance, restricted joint mobility and functional outcomes of knee?

As per available literature about physiotherapy intervention in OA knee, I believe that Physiotherapy intervention can slow down the disease process, improve the quality of life by resolving the symptoms and postpone or delay TKR.

Dear Hemal

Thank you for your correspondence. I know that I understood it well and I had answered in the best of my abilities few days ago, but seems that some responders lost track. The latest question was for those.

I agree with you that a lot of information exists and you have to filter the one that is scientific, suitable and informative to you. Physiotherapy is delaying the progress but cannot reverse the condition of established OA. Prevention with physiotherapy can happen if only all people, and I mean the entire population of the globe, understand the principles of well being and correct physical activity. If this will happen we will not talk of Physiotherapy but possibly Physio-training or Physio-education. But this is utopia. So Physiotherapy and Orthopaedic surgery will go on, as a Team, to play their role in Controlling OA and for us as Orthopaedic surgeons total knee will be the final answer.

Dear Hemal

The aquatic therapy as a treatment in patients with knee osteoarthritis generates benefits such as analgesia, facilitating the movements, muscle strength, decreased weight bearing on the joint, decreased joint stiffness, relaxation and improved functional capacity

Thank you George Zafiropoulos sir for your answer....... And I completely agree with you.....that its a team work of both Physio and orthopedics ....

Dear George Zafiropoulos, Greeting for your statements. Yes we are in serious need of a team of Physio + Ortho Surgeon to educate the entire population to prevent, control & manage the OA. As the pathology is irreversible, prevention programs may help in minimizing the burden on healthcare service, impact on physical & psychological level & cutoff financial burdens.