Efficiency of combined treatment and conventional physical treatment in bilateral knee arthrosis

© 2013 Bojièiæ et al.; licensee University of Sarajevo Faculty of Health Studies. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. UNIVERSITY OF SARAJEVO FACULTY OF HEALTH STUDIES ABSTRACT


INTRODUCTION
Arthroses are degenerative joint diseases with progressive character, also one of the most frequent diseases in orthopedics.Th e disease fi rst aff ects the articular cartilage, then the bony edges of the articu-lar surfaces, and then the articular lining.Arthroses represent a huge socio-medical problem (1).Th ey are medical problem because their cause is still not known, and social due to the fact that there are many arthroses,that in industrially and economically developed countries appearing in increasing numbers, that the hardest of them aff ect people of mature age (maximum working ability and productivity), that are progressive in their course and eventually cause increasing damage to the locomotor organs.Arthroses usually occur in the joints of the knee (gonarthrosis), hip, hand, and spine joints, but can aff ect any joint (2).Gonarthroses are divided into a primary and secondary.Th e cause of knee arthrosis (gonarthrosis) is not known.Most likely there are more and interdependent.In most of the gonarthrosis we do not know the cause and their formation (primary arthroses).In a small number of these disorders the cause that contributes to the development of the disease is known (secondary arthroses) (3).Past experiences show that more frequently approaches to the patients with diagnosis of gonarthrosis are from aspects of treatment of the symptoms and rehabilitation of consequences of the disease.Much less attention has been paid to the education and prevention which would reduce the risk of the disease and thereby increase the social and economic benefi ts of the population (4).Untill today it has not been found a way of treatment that can change, stop or reverse the processes that are the basis for the emergence of degenerative changes.Extensive study of the essence of the emergence and development of arthrosis and a better understanding of the process arouse hope in developing the specifi c treatments that will stop and fi x a degenerative damages.Until then, it remains a number of measures and procedures that can reduce pain, repair function of the musculoskeletal system and improve patient's quality of life.In the therapy of gonarthrosis we use conservative methods and surgical approach (5).Th ere are several modalities in the approach to treatment of the knee arthrosis but the two approaches proved the most successful: the conventional approach used in D.Z. " Novi Grad " and combined treatment in clinics "Praxis" treating bilateral knee arthrosis.In conventional physical method of treatment of the knee arthrosis, which is used in the D.Z. " Novi Grad ", is most often used: Ultrasound, IFS, TENS, DDS, manual massage, cryo massage or paraffi n (6).From kinesitherapeutic procedures are used: pendulous exercises active and actively assisted exercises, thigh and popliteal muscle strengthening exercises.Th is method, although yielding results in the treatment of knee gonarthrosis, has certain disadvantages.Th e disadvantage of this method is that it does not have the breadth in applying of therapeutic meth-ods due to limited equipment owned by clinics D.Z."Novi Grad ".Also, due to the large number of patients they are not able to devote enough time to each patient, as well as educate patients about preventive measures and activities of daily living.Combined approach in the treatment of knee arthrosis includes non-pharmacological and pharmacological phase of conservative treatment, and can be divided into: general measures, treatment by systemic supplying with medications, local injection of drugs into joints, physical therapy which has given the best results so far.Combined treatment of knee arthrosis which is implemented in the clinics "Praxis" has a wider range of treatment procedures.In addition to standard procedures of physical therapy, combined treatment has a general measures which include besides the treatment, education and training of patients.Th e nature and main characteristics of the disease should be explained and familiar the patient with current methods and possibilities of treatment.Tips on the proper way of life are often very importante, maintaining ideal body weight, the daily regime of movement and resting in order to avoid or delay disability and immobility and to change the way of work or occupation if necessary.According to epidemiological studies obesity is the most important single factor in emerging arthrosis that can be infl uenced on.Increased body weight increases the risk of knee arthrosis in both sex.Reduction in body weight can reduce symptoms and possibly slows down disease progression (7).Th e research aims were to estimate the effi ciency of the conventional physical treatment in D.Z. "Novi Grad" and combined treatment in the clinics "Praxis" in treating bilateral knee arthrosis, and estimate the effi ciency of the combined treatment in both gender, age groups and professions.

Respondents
Th e study included all patients who contacted the CBR clinic "Praxis" because of the pain in the knee joint and verifi ed diagnosis of bilateral knee arthrosis (gonarthrosis) in the period of time from 01.01.2000 to 31.12.2010,79 patients.Th e control group consisted of all patients who contacted CBR clinic D.Z. "Novi Grad" because of the pain in the knee joint and verifi ed diagnosis of bilateral knee arthrosis (gonarthrosis) in the period from 01.01.2000 to 31.12.2010,81 patients.

Procedures
Standard physical therapy of knee arthrosis used in D.Z. "Novi Grad" is a routine treatment where from physical procedures ultrasound, IFS, TENS, DDS, manual massage, cryo massage or paraffi n were used.Kinesitherapeutic procedures were also performed i.e. pendulous exercises active and actively assisted exercises, thigh and popliteal muscle strengthening exercises (8)."Th e Praxis" method in the treatment of knee arthrosis is a special (combined) method, where in addition to standard physical procedures : local installation of drugs intrarticular installation of medicines, acupuncture, DDS, electromagnetic therapy are used.From kinesitherapeutic procedures, in addition to standard procedures, there are also applied active exercises of load, special exercises for spinal correction and patient education about the disease, method of treatment and programming of load in daily and working activities (9).

Research instruments
Condition of patients before treatment was verifi ed by the following scale: • score "0" -unable to perform DA (daily activities), dependent on others assistance • score "1" -permanently unable to work, capable of DA • score "2" -temporarily unable to work • score "3" -capable of DA with limited working ability • score "4" -supplementary qualifi cation or retraining required • score "5" -capable of DA and work • score "6" -left treatment • score "7" -further medical rehabilitation needed Instruments to demonstrate the effi ciency of the treatment: Th e effi ciency of the treatment is expressed with the assessment of the results of the clinical condition after the treatment objectively valorised according to the following scheme: • score "0" zero: unchanged condition (without treatment results), • score "2": minimal improvement, • score "3": satisfactory functional improvement with sequels, (sensory or motor), • score "4": good improvement and satisfactory functional restitution with minimal sequels, • score "5": good restitution without consequences of injury or disease.Th e criteria for inclusion into the study were patients who have pain and limited mobility in the knee joint and patients with verifi ed diagnosis of bilateral knee arthrosis (gonarthrosis).Th e criteria for exclusion were inadequate diagnosis, lost follow up, incomplete medical history.

DISCUSSION
In respondents with bilateral gonarthrosis treated in clinics "Novi Grad", out of the 81 respondents 50.6% were retired and 23.4% housewives.In respondents with the same diagnosis treated in the clinics "Praxis," out of the 79 respondents only 27.8% were retired, housewives and offi cers each with 18.9% and 16% of employees.Analysis of the data obtained in the clinics D.Z. "Novi grad" and "Praxis", showed that the most respondents suff ering from knee arthrosis are elderly.Th e respondents diagnosed with bilateral knee arthrosis over 65 years old,who were treated in the clinic "Novi grad", amounts 55.5% and in the clinic "Praxis" 39.2%.From the processed data we obtained that the average age of the patients in the clinic "Novi grad" is X 1 = 71.26,and in the clinic "Praxis" X 2 = 63.76 years.We can conclude that the respondents treated of bilateral knee gonarthrosis in D.Z. "Novi grad", are older on average than patients treated in the clinic "Praxis".
Respondents treated with the standard method applied in the clinic "Novi grad" ,after treatment, diagnosed with bilateral knee arthrosis, 56.7% of them have been rated 3.In the clinic "Praxis", which applied a combined approach to treatment, after performed therapeutic procedures, the obtained results are that 62% of patients diagnosed with bilateral knee arthrosis has a rating of 4. Functional status of patients diagnosed with bilateral knee arthrosis in the clinics "Novi grad", after treatment, with score of 3 remained 70.3%, while a score 4 gained 12.3% of the respondents.Also score 5 gained 12.3% of the patients.After performed therapy,with combined approach in the treatment in the clinic "Praxis", 12.6% of respondents remained with a score of 3, 69.6% with a score of 4 and 17.7% with a score of 5.

CONCLUSIONS
From the total number of respondents, in both clinics,women make up 75% so we can conclude that they suff er more often than men.Respondents with certain professions suff er more than others.With age increase the number of patients with knee arthrosis increases, so the most of the respondents had over 65 years of age 46.8%.Respondents in the clinics "Novi grad", on average had a 71, and in the clinics "Praxis" 63 years.Both, clinics D.Z. "Novi grad" and clinics "Praxis", had success in the treatment of knee arthrosis.We can conclude that the functional status is a lot better in the clinic "Praxis" in relation to the clinic "Novi grad", after completed therapy.
A combined approach in the treatment of knee arthrosis has a wider range of treatment procedures, comprehensively approaches to the problem and gives better results, so we can say that this method has priority compared to the standard approach to the knee arthrosis treatment.

TABLE 1 .
Presentation of prevalence of the billateral primary gonarthrosis in both gender in the clinics D.Z. "Novi Grad"

TABLE 2 .
Presentation of prevalence of the billateral primary gonarthrosis in both gender in the clinics "Praxis".

TABLE 3 .
Presentation of respondents with bilateral gonarthrosis by occupations in clinics D.Z. "Novi Grad","Praxis" and total.

TABLE 4 .
Presentation of respondents with bilateral gonarthrosis by age group in clinics D.Z. "Novi Grad" and "Praxis".

TABLE 5 .
Presentation of treatment results in average in respondents with bilateral gonarthrosis in clinics D.Z. "Novi Grad" and "Praxis".

TABLE 6 .
Functional status before therapy in respondents with bilateral gonarthrosis in clinics D.Z. "Novi Grad" and "Praxis".

TABLE 7 .
Functional status after therapy in respondents with bilateral gonarthrosis in clinics D.Z. "Novi Grad" and "Praxis".