Osteoarthritis is a very complex synovial joint which

Osteoarthritis (OA) is an asymmetric rheumatic disease which
affects the functional ability of a joint, usually causing pain and stiffness. Osteoarthritis
is caused by progressive loss of hyaline cartilage, alteration of subchondral
bone, synovial inflammation and local biomechanics (injuries, malalignment,
limb length discrepancy, and joint overload). 

A normal knee joint is a very complex synovial joint which
provides stability for load-bearing activities and allows frictionless
articulation to occur. Synovial fluid is found at the centre cavity of the
joint acting as a lubricant and supplying oxygen and nutrients to the
cartilage. Articular hyaline cartilage lines the end of each bone in the joint
and at the lower levels of cartilage, away from the joint cavity, this
cartilage becomes calcified at a point known as the ‘tidemark’. This area from
the ‘tidemark’ point to the bone marrow is known as the subchondral bone,
comprised of a subchondral plate, an important structure for load transmission.
Between the medial and lateral tibiofemoral joint surfaces lies crescent shaped
tissues, known as menisci, which aid in the distribution of load,
proprioception and stability at the knee joint as well as support lubrication
of the joint. In an osteoarthritic knee joint there is degradation of the
hyaline cartilage due to a breakdown of the collagen network, which results in
the formation of fibrillated areas and clefts on the cartilage surface. As
progression of the disease occurs, the sporadic loss of hyaline cartilage can
expose the underlying subchondral bone, causing eburnation. As loss of
cartilage continues to progress further, damage will transpire on the
subchondral bone, resulting in the formation of osteophytes and sclerosis. Cartilage
fragments can sometimes be found in the synovial fluid and it is also common
for meniscus damage or tears to ensue in OA patients.  Biomechanics of the knee joint are also important
to consider when examining the pathology of joint function, in particular joint
alignment, ligamentous strength, and interaction of the peri-articular muscles.
(Conaghan et al 2012) Malalignment of the knee results in an increase in load
through the medial aspect of the joint, therefore, influencing the structural
degradation at the joint. Valgus or varus knees cause friction and again
increase the load on the joint, most noticeably during gait; in varus knees the
ground force reaction increases knee adduction, thus, resulting in medial
compartment compression forces, a cause of medical compartment OA.
Biomechanical changes in the knee joint may also be a source of knee
instability, decreased range of movement and strength and potential narrowing
of the medical joint space. (Conaghan et al, 2012)

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Osteoarthritis is the most common
synovial joint disorder in the Western world, with 8.5million affected in the
U.K. and an estimated 27million patients in the U.S.A. (Conaghan et al, 2015;
Oral, A & Ilieva, E, 2011; Hart, J., 2008) It is a disorder of joint pain
and stiffness associated with locomotor disability, causing great impact on the
individuals quality of life (QoL). The knee joint is the most commonly affected
joint, with 4 million new patient visits annually in the U.S. (Lu et al, 2015; Harzy
et al, 2009) According to the Centers for Disease Control and Prevention data,
approximately 40% of individuals with OA of the knee noted “poor” or “fair”
health in relation to the impact OA has on their QoL. OA is noted to
be more prevalent in females than males. (Conaghan et al, 2012) The prevalence
of OA increases due to age, with Reid et al noting 70% of individuals over
65-year olds affected by knee OA. Due to the increasing age in the population,
there is a corelating rise in the number of OA patients and thus, a
corresponding stress put on the healthcare systems to provide treatment
services. (Conaghan et al, 2012; Ng, Heesch & Brown, 2012) A 2004
National report in the U.K. found 2million individuals visit their GP annually
due to OA, generating 3 million consultations. Similarly, there is a surgical
impact due to OA treatment, with 44,000 hip replacements and 35,000 knee
replacements in the U.K. the year 2000 costing the healthcare £405million.
(Peat, McCarney & Croft, 2001) Some further indirect costs due to OA
include community services, social services and the impact of lost working
days.The
most prevalent symptom of OA is joint pain (Sinusas, K, 2012) The pathogenesis
of OA consists of a ‘locking’ or joint instability and pain, morning stiffness
(lasting no longer than 30 minutes), increased pain on exercises creating
limits on individuals’ activities of daily living (ADLs), reduced QoL,
crepitus, valgus or varus deformity and resulting gait changes. (Mayiero et al
2017; Sinusas, K, 2012) Some of the risk factors for OA include age,
overweight/obesity, family history of condition, prior joint injury or overuse
and other medical conditions such as rheumatoid arthritis. (Hart, J 2008 ) Previous
studies have suggested there is a strong link between obesity and OA, with Masiero
et al stating an estimated “29% of cases of knee OA may be prevented by
reducing body mass index (BMI) from 30 to 25”. (Coggon et al, 2001; Gelber et
al, 1999) Both OA and obesity have similar impact on an individuals’
participation levels in physical activity, resulting in a further loss of
muscle strength and increase in fat mass, creating a continuous cycle and
reducing a patients QoL. (Wildman et al, 2008; Abbate et al, 2006)

The main goal of OA managements
is decreasing pain/stiffness, improving joint mobility and flexibility,
limiting joint damage by slowing down the progression of disease, increasing muscle
strength, decreasing functional activity limitations and therefore resulting in
a greater quality of life. (Ng, Heesch & Brown, 2011; Hart, 2008) There
have been several guidelines produced based on evidence for various
interventions, such as OARSI and XXXXXX. These guideline protocols have divided
treatment into 4 sub categories; surgical, non-pharmacological, pharmacological
and finally complementary and alternative medicine (CAM) treatment. (Oral et
al, 2011) The initial treatment for osteoarthritis aims to focus on self-help
and patient driven treatments rather than interventions delivered passively by
a therapist or another health professional. Examples of non-pharmacological
treatment of knee OA, include patient education, self-management, weight loss
interventions, exercise programmes, manual therapy, braces and orthotics,
hydrotherapy and balneotherapy. (Oral et al, 2011)

Weight loss intervention –
Research conducted on gait analysis demonstrated weight loss can decrease load
in the knee joint resulting in a decrease in clinical symptoms and OA
progression. (Messier et al, 2005; Aaboe et al, 2011)

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