STUDIU PRIVIND EFICIENA TEHNICILOR I METODELOR DE FACILITARE NEUROPROPRIOCEPTIV PENTRU MBUNTIREA FUNCIONALITII GENUNCHIULUI ARTROZIC Mirela DAN1, Ioan-Cosmin

BOCA2
1

STUDY REGARDING THE EFFICIENCY OF NEUROPROPRICEPTIVE FACILITTING TECHNIQUES AND METHODS IN IMPROVING THE ARTHROTIC KNEE FUNCTIONALITY Mirela DAN1, Ioan-Cosmin BOCA2
1

Universitatea de Vest Vasile Goldi din Arad, Romnia kineto2004@yahoo.com 2 Universitatea de Vest Vasile Goldi din Arad, Romnia icboca@yahoo.com

Vasile Goldi University, Arad, Romania kineto2004@yahoo.com 2 Vasile Goldi University, Arad, Romania icboca@yahoo.com

Cuvinte cheie Key words kinetoterapie, osteoartrita genunchiului, tehnici physical therapy, knee osteoarthritis, de facilitare neuroproprioceptiv neuroproprioceptive facilitating techniques Abstract Kinetoterapia, prin intermediul mijloacelor sale fundamentale i/sau ajuttoare, urmrete refacerea funcionalitii genunchiului artrozic, rspunznd modificrilor patologice determinate de procesul degenerativ. Articulaia genunchiul deine un rol primordial n static i locomoie, este cea mai mare articulaie a corpului, dar i cea mai puin protejat de pri moi, fiind din acest motiv una dintre articulaiile cele mai traumatizate i dureroase. Am pornit de la ipoteza c aplicarea unui program kinetoterapeutic complex, care s includ tehnici de facilitare neur oproprioceptiv specifice pentru promovarea mobilitii i a stabilitii, precum i metoda Kabat (diagonalele pentru MI), va duce la mbuntirea strii de funcionalitate a ntregului membru inferior, oprind evoluia sau chiar determinnd regresiunea procesului degenerativ. Dei valorile obinute la finalul acestui studiu nu difer foarte mult ntre subiecii celor dou loturi luate n ansamblu, conform cercetrii i rezultatelor prezentate se poate observa c ipoteza este confirmat, prin urmtoarele: - Imbuntirea nivelului funcional n cazul lotului experimental (24,5), mai semnificativ dect la lotul martor (23), datorat n principal unei mai bune stabiliti n articulaia genunchiului la finalul perioadei de tratament, favorizat de introducerea tehnicilor specifice i a metodei Kabat n progeramul kinetic; - Scderea intensitii durerii reflectat att n evoluia scorului funcional ct i n desfurarea activitilor zilnice. Abstract Physical therapy, through its fundamental and/or helping means, aims at the recovery of arthrotic knee functionality, responding to pathological changes determined by the degenerative process. The knee joint has a major role in statics and locomotion and it is the biggest joint of the body, but it is also the less protected of the soft parts, being thus one of the most traumatized and painful joints. We started from de hypothesis that the application of a complex physical therapeutic program which should include neuroproprioceptive facilitating techniques specific for mobility and stability promotion, as well as the Kabat method (diagonals for lower limb) will lead to the improvement of functionality condition of the entire lower limb, stopping the evolution, or even determining the regression of the degenerative process. Although the values obtained at the end of this study do not differ much between the subjects of the two lots, generally taken, according to the research and to the presented results, it can be noticed that the hypothesis is confirmed through the followings: - Improvement of functional level in the case of the experimental lot (24.5), more significant than at the witness lot (23), mainly due to a better stability in the knee joint at the end of the treatment period, favored by the introduction of specific techniques and of Kabat method in the kinetic program; - Decrease of pain intensity reflected both in the evolution of the functional score and in the ongoing of daily activities

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Introducere Recuperarea este un domeniu de activitate complex, medical, educaional, social i profesional prin care se urmrete restabilirea ct mai deplin a capacitii funcionale pierdute de ctre un individ (adult sau copil) n urma unei boli sau traumatism, precum i dezvoltarea unor mecanisme compensatorii, care sa-i asigure n viitor posibilitatea de munc sau autoservire, respectiv o via independent economic i/sau social [6]. n SUA, mai mult de 6 milioane de oameni se prezint anual la medic acuznd o problem la nivelul genunchiului, osteoartrita fiind una dintre cauzele majore generatoare de dizabilitate, iar numai n 2005, aproximativ 9 milioane de oameni au fost diagnosticai cu osteoartrit la nivelul genunchiului, aproximativ 55% dintre cei diagnosticai cu osteoartrit au peste 65 de ani [12]. n Romnia, aa cum menioneaz Moraru i Pncotan, gonartrozele reprezint 50% din cazurile care se prezint la cabinet pentru dureri ale genunchilor i limitatrea mobilitii [9]. Osteoartrita este termenul medical care descrie anomalii de natur degenerativ caracterizate prin degradarea articulaiilor, inclusiv a cartilajului articular i a osului subiacent acestuia. Osteoartrita afecteaz mai frecvent articulatiile portante, de aceea, cel mai frecvent specialitii folosesc termenul de osteoartrit la nivelul genunchiului (gonartroza), oldului, gleznei i la nivelul coloanei vertebrale lomboscarale [14]. n realizarea cercetrii am pornit de la ipoteza c aplicarea unui program kinetoterapeutic complex, care s includ tehnici de facilitare neuroproprioceptiv specifice pentru promovarea mobilitii i a stabilitii, precum i metoda Kabat (diagonalele pentru MI), va duce la mbuntirea strii de funcionalitate a ntregului membru inferior, oprind evoluia sau chiar determinnd regresiunea procesului degenerativ. Material i metode Studiul s-a desfurat la Spitalul Clinic de Recuperare Medical din Bile Felix n perioada ianuarie - iunie 2010. Selecia subiecilor participani la aceast studiu s-a fcut n funcie de voina liber a fiecruia. Criteriul principal n selecia subiecilor a fost osteoartrita genunchiului, toi subiecii au fost diagnosticai cu gonartroz cu mai mult de un an nainte de nceperea acestui studiu i au mai urmat tratamente recuperatorii n mai multe rnduri. Subiecii selectai provin att din mediul rural ct i din mediul urban i sunt n proporie de 50% pensionari. Programul de recuperare a fost urmat de ctre fiecare subiect al celor dou loturi cu o frecven de 1 edin/zi timp de 18 zile. Programul comun urmat de cele dou loturi de subieci a inclus un

Introduction Rehabilitation is a complex medical, educational, social and professional activity domain, the aim being the recovery as fully as possible of the functional capacity lost by an individual (adult or child) post illness or traumatism, as well as the development of certain compensating mechanisms which, in the future, should provide the working or self-serving possibility, respectively an economically and/or socially independent life [6]. In the USA, more than 6 million people go to the doctor every year accusing a problem at knee level, osteoarthritis being one of the major causes of disability generation. In 2005 alone, approximately 9 million people were diagnosed with osteoarthritis at knee level, approximately 55% of them being aged over 65 [12]. In Romania, as Moraru and Pncotan have mentioned, gonarthroses represent 50% of the cases of knee pain and mobility limitation [9]. Osteoarthritis is the medical term describing anomalies of degenerative nature characterized by degradation of joints, including of the joint cartilage and its subjacent bone. Osteoarthritis affects most frequently the portent joints, that is why, most frequently, specialists use the term osteoarthritis at knee (gonarthrosis), hip, ankle level and at lumbar-sacral spine level [14]. In this study, we started from de hypothesis that the application of a complex physical therapeutic program which should include neuroproprioceptive facilitating techniques specific for mobility and stability promotion, as well as the Kabat method (diagonals for lower limb) will lead to the improvement of functionality condition of the entire lower limb, stopping the evolution, or even determining the regression of the degenerative process. Material and methods The study was carried on at the Medical Rehabilitation Clinical Hospital in Felix Spa during January and June 2010. The selection of subjects participating in the study was made according to free will. The main criterion of subject selection was knee osteoarthritis, all subjects being diagnosed with gonarthrosis for more than a year before the beginning of this study and they had followed rehabilitation treatments several times before. The selected are both from rural and urban environments and they are 50% pensioners. The rehabilitation program was attended by each subject of the two lots with a frequency of one session/day for 18 days. The common program attended by the two lots of subjects included a standard program of 20

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program standard de 20 de exerciii practicat n slile de kinetoterapie ale spitalului, urmat de un program hidrokinetoterapie n bazin (20), completat de o edin de masaj local (5-10). Subiecii lotului experimental au urmat programul kinetic standard la care am adugat exerciii specifice promovrii mobilitii i stabilitii genunchiului, exerciii alctuite pe baza tehnicilor de facilitare neuroproprioceptiv i prin adaptarea diagonalelor Kabat pentru membrul inferior. Metodele de cercetare care au stat la baza realizrii acestui studiu au fost: metoda studiului bibliografic, metoda interviului, metoda observaiei, metoda experimentului, metoda evalurii i testtii funcionale a aparatului locomotor (evaluarea durerii, evaluarea nivelului funcional, evaluarea amplitudinii articulare, evaluarea forei musculare, evaluarea mersului), metoda grafic i imagistic, metoda analizei statistice. Tabel nr.1. Analiza comparativ a celor dou loturi de subieci Parametru Lotul de Lotul cercetare martor Vrsta medie (ani) 59 58 Vechimea medie a 8 9 diagnosticului (ani) Sexul (M/F) 2/8 3/7 MI afectat (drept/stng) 4/6 4/6

exercises practiced in the physical therapy rooms of the hospital, followed by a hydro-physical therapy program in the pool (20), completed by a local massage session (5-10). The subjects in the experimental lot attended a standard kinetic program to which we added exercises specific to knee mobility and stability promotion, exercises devised based by adjusting the Kabat diagonals for the lower limb. The research methods based on which this study was made, were: the method of biographic study, the interview method, the observation method, the experiment method, the evaluation method and the method of functional testing of the locomotor apparatus (evaluation of pain, evaluation of functional level, evaluation of joint amplitude, evaluation of muscle force, evaluation of gait), the graphic and imagistic method, the method of statistical analysis. Table no.1. Comparative analysis of the two lots of subjects Research Witness Parameter lot lot Average age (years) 59 58 Average oldness of 8 9 diagnosis (years) Sex (M/F) Affected lower limb (right/left) 2/8 4/6 3/7 4/6

n cadrul evalurii funcionale a aparatului locomotor am folosit urmtoarele metode: evaluarea durerii conform SVA - Scala Vizual Analogic a lui Huskisson [1]; evaluarea nivelului funcional conform SEGCM - Sistemul de Evaluare a Genunchiului Cincinnati Modificat [13]; evaluarea amplitudinii articulare cu goniometrul; evaluarea manual a forei musculare conform Scalei internaionale de evaluare a forei musculare de la 0 la 5 [7]; evaluarea mersului conform unei scale proprii de evaluare de la 0 la 6 (unde 0 = mers imposibil, iar 6 = mers normal). Analiza i interpretarea rezultatelor Valorile intensitii durerii au cunoscut o scdere n medie cu 41,9 uniti n cazul lotului de cercetare i tot o scdere n medie cu 38,6 uniti n cazul lotului martor, sensibil mai redus dect n cazul lotului de cercetare.

Within the functional evaluation of the locomotor apparatus, we used the following methods: pain evaluation according to AVS Huskissons Analogical Visual Scale [1]; functional level evaluation according to CCKES Cincinnati Changed Knee Evaluation System [13]; joint amplitude evaluation with the goniometer; manual evaluation of muscle force according to The International Scale of Muscle Force Evaluation from 0 to 5 [7]; evaluation of gait according to our own evaluation scale from 0 to 6 (where 0 = impossible gait and 6=normal gait).

Analysis and interpretation of results The pain intensity value decreased with an average of 41.9 units in the case of the research lot and with an average of 38.6 units in the case of the witness lot, sensitively reduced than in the Tabel nr.2. Evaluarea durerii (valori medii) aparut n case of the research lot. timpul activitilor fizice zilnice Table no.2. Evaluation of pain (average values) conform SVA nregistrat la cele dou loturi occurred during daily physical activities according to AVS recorded at the two lots. Evaluare Iniial Final Diferena Differenc Lot de 50 8,1 41,9 Evaluation Initial Final e

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cercetare Lot martor 44 5,4 38,6

Research lot Witness lot

50 44

8,1 5,4

41,9 38,6

Figura nr.1. Reprezentarea grafic a valorilor medii ale intensitii durerii conform SVA nregistrate la cele dou loturi

Witness lot

44

5,4

38,6

Research lot

50 Initial

8,1 Final

41,9 Difference

Figure no.1. Graphic representation of pain intensity average values according to AVS recorded at the two lots. Tabel nr.3. Rezultatele testingului articular Lotul de cercetare Lotul martor Genunchi afectat Genunchi neafectat Genunchi afectat Genunchi neafectat Flexie Extensie Flexie Extensie Flexie Extensie Flexie Extensie A P A P A P A P A P A P A P A P I 33 37,6 -8 -5 50,2 55 -5 -2 32,4 38,6 -7 -5 50 53,8 -5 -3 F 50,1 56,4 -3 0 62,4 70 0 0 48,6 56,6 -3 0 62 68,6 0 0 D 17,1 18,8 5 5 12,2 15 5 2 16,2 18 4 5 12 14,8 5 3 Table no. 3. Joint testing results Research lot Affected knee Unaffected knee Flexion Extension Flexion Extension A P A P A P A P I 33 37,6 -8 -5 50,2 55 -5 -2 F 50,1 56,4 -3 0 62,4 70 0 0 D 17,1 18,8 5 5 12,2 15 5 2 La finalul acestui studiu am ajuns la urmtoarele rezultate n ceea ce privete evoluia amplitudinii articulare: pentru flexia msurat activ s-a obinut o diferen medie de 17,1 (lotul de cercetare), i 16,2 (lotul martor); pentru flexia Witmess lot Affected knee Unaffected knee Flexion Extension Flexion Extension A P A P A P A P 32,4 38,6 -7 -5 50 53,8 -5 -3 48,6 56,6 -3 0 62 68,6 0 0 16,2 18 4 5 12 14,8 5 3 At the end of this study, we have come to the following results regarding the evolution of joint amplitude: for actively measured flexion, there was an average difference of 17.1 (research lot) and 16.2 (witness lot); for passively measured flexion

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msurat pasiv diferena medie n cazul lotului de cercetare a fost de 18,8, iar la lotul martor 18; pentru extensia (revenire din flexie) msurat activ s-a obinut o diferen medie de 5 pentru lotul de cercetare i de 4 pentru lotul martor; pentru extensia msurat pasiv diferena medie pentru ambele loturi a fost de 5. Valorile nregistrate pentru genunchiul membrului inferior neafectat sunt aproximativ egale la cele dou loturi, att pentru flexie, ct i pentru extensie. Pentru a putea reprezenta grafic modificrile de for muscular, avnd n vedere c am utilizat cotaiile + i , am considerat trecerea de la o for cu + la una cu de 0,33 puncte, apoi de la o for cu la urmtoarea valoare tot de 0,33 puncte, i aa mai departe. Exemplu: diferena de la F2 la F2, este de 0,33 puncte; de la F2 la F2+ este tot de 0,33. Conform acestei abordri, n cazul lotului de cercetare la nivelul membrului inferior afectat, ntre evaluarea iniial i cea final am consemnat o cretere medie a forei muchilor flexori ai oldului de 0,59 puncte, pentru extensorii oldului de 0,66, pentru abductorii oldului de 0,59, iar la nivelul genunchiului n cazul flexiei creterea a avut o medie de 0,72, iar extensia de 0,85. Valorile nregistrate n ceea ce privete evoluia forei musculare n cazul lotului martor sunt aproximativ egale cu cele ale lotului experimental; astfel, n cazul membrului inferior afectat am consemnat o cretere medie a forei muchilor flexori ai oldului de 0,59 puncte, pentru extensorii oldului de 0,66, pentru abductorii oldului de 0,59, iar la nivelul genunchiului n cazul flexiei creterea a avut o medie de 0,72, iar extensia de 0,82.

the average difference in the case of the research lot was of 18.8 , and for the witness lot of 18 ; for actively measured extension (returning into flexion), there was an average difference of 5 for the research lot and of 4 for the witness lot; for passively measured extension, the average difference for both lots was of 5 . The values recorded for the unaffected lower limb knee were approximately equal for the two lots, both for flexion and for extension. In order to graphically represent the muscle force changes, considering that we have used + and - quotations, we considered the passing from one force with + to one with - as being of 0.33 points, then from one force with - to the next value as being of also 0.33 points and so on. Example: the difference from F2- to F2 is of 0.33 points; from F2 to F2+ is also of 0.33 points. According to this approach, in the case of the research lot at the level of the affected lower limb, between the initial and final evaluations, we noticed an average increase of force of the hip flexor muscles of 0.59 points, for the hip extensors of 0.66, for the hip abductors of 0.59, and at knee level, in the case of flexion, the average increase was of 0.72, while in the case of extension, of 0.85. The recorded values regarding the evolution of muscle force in the case of the witness lot were approximately equal with those of the experimental lot; thus, in the case of the affected lower limb, ne noticed an average increase of hip flexors muscle force of 0.59 points, for the hip extensors of 0.66 points and for the hip abductors of 0.59, while at knee level in the case of flexion, the average increase was of 0.72 and for extension it was of 0.82 points. Table no. 4. The values of muscle force differences between initial and final evaluations in both lots Tabel nr.4. Valorile diferenelor forei musculare ntre evaluarea iniial i evaluarea final la ambele Affected hip Affected knee loturi old afectat Micare Lot de cercetare Lot martor Flex ie 0,59 0,59 Exte nsie 0,66 0,66 Abd ucie 0,59 0,59 Genunchi afectat Flexi e 0,72 0,72 Exten sie 0,85 0,82 Moveme nt Research lot Witness lot Flex ion 0,59 0,59 Exte nsio n 0,66 0,66 Abd uctio n 0,59 0,59 Flexi on 0,72 0,72 Exten sion 0,85 0,82

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Figura nr.2 Reprezentarea grafic a evoluiei forei musculare ntre evaluarea iniial i evaluarea final la ambele loturi
Hip flexion Hip extension Hip abduction Knee flexion Knee extension

0,85 0,66 0,59 0,59 0,72 0,59 0,66 0,59 0,72

0,82

Research lot

Witness lot

Figure no. 2 Graphic representation of muscle force evolution between the initial and final evaluations in both lots Avnd n vedere impactul funcional al simptomatologiei genunchiului, prin evaluarea celor 6 funcii ale scalei SEGCM, se poate observa n cazul lotului experimental c la evaluarea iniial s-a nregistrat un scor funcional n medie de 28,5 puncte (nivel funcional slab), iar la evaluarea final de 53 puncte (nivel funcional satisfctor), media diferenelor ntre cele dou evalurii fiind 24,5 puncte, uor mai crescut dect n cazul lotului martor care la evaluarea iniial s-a nregistrat un scor funcional n medie de 29 puncte (nivel funcional slab), iar la evaluarea final de 52 puncte (nivel funcional satisfctor), media diferenelor ntre cele dou evalurii fiind 23 puncte. Tabel nr.5. Rezultatele medii ale evalurii funcionale conform SEGCM pentru cele dou loturi Scor Iniial Final Difere funcional na (SEGCM) Lot de 28,5 53 24,5 cercetare (slab) (satisfctor) Lot martor 29 (slab) 52 (satisfctor) 23 Considering the functional impact of knee symptomatology, by evaluating the 6 functions of CCKES scale, it can be noticed in the case of the experimental lot that at the initial evaluation there was recorded an average functional score of 28.5 points (poor functional level) and at the final evaluation the score was of 53 points (satisfying functional level), the average difference between the two evaluations being of 24.5 points, slightely increased than in the case of the witness lot which recorded at the initial evaluation an average functional score of 29 points (poor functional level) and at the final evaluation the score was of 52 points (satisfying functional level), the average difference between the two evaluations being of 23 points. Table no.5. Average results of functional evaluations according to CCKES for the two lots Functional Differ score Initial Final ence (SEGCM) Research lot 28,5 (poor) 29 (poor) 53 (satisfying) 24,5

Witness lot

52 (satisfying)

23

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53 28,5 29

Iniial Final Diferena

52
53 52 29

Initial Final Difference

24,5

23
28,5 24,5 23

Lot de cercetare

Lot martor

Research lot

Witness lot

Figure no.3. Average values of functional scores according to CCKES in both lots Figura nr.3. Media valorilor scorurilor funcionale conform SEGCM la ambele loturi La sfritul programului de recuperare s-a nregistrat o mbuntire semnificativ a mersului la ambele loturi, cu un plus pentru lotul experimental. ntre evaluarea iniial i cea final, n cazul lotului experimental, creterea valorilor pentru mersul lateral n medie cu 2,9 puncte, pentru mersul nainte n medie cu 1,9 puncte, pentru mersul napoi n medie cu 2,1 puncte, iar pentru mersul peste obstacole cu 1,4 puncte. n ceea ce privete lotul martor, ntre evaluarea iniial i cea final, s-a nregistrat o cretere a valorilor pentru pentru mersul lateral n medie cu 2,8 puncte, pentru mersul nainte n medie cu 1,8 puncte, pentru mersul napoi n medie cu 2 puncte, iar pentru mersul peste obstacole cu 1,3 puncte. At the end of the rehabilitation program, it was recorded a significant increase of gait in both lots, with a plus for the experimental lot. Between the initial and final evaluations, in the case of the experimental lot, the average increase of values for lateral walking was of 2.9 points and for walking forward was of 1.9 points, for walking backward was of 2.1 points and for walking over obstacles was of 1.4 points. In the case of the witness lot, between the initial and final evaluations, it was recorded an average increase of values for lateral walking of 2.8 points, for forward walking of 1.8 points, for backward walking of 2 points and for walking over obstacles of 1.3 points.

Tabel nr.6. Valorile medii obinute la mers de ctre subiecii celor dou loturi Lotul de cercetare Lotul martor Evaluare Iniial Final Diferena Iniial Final Diferena Mers n lateral 3 5 2,8 4,6 2 1,8 Mers n spate 3,6 5,5 3,6 5,5 1,9 1,9 Mers n fa 3 5,5 3 5,2 2,5 2,2 Mers peste obstacole 2,8 4,6 2,8 4,4 1,8 1,6

Figura nr.4. Reprezentarea grafic a mediei valorilor obinute la mers pentru ambele loturi

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Table no.6. Average values obtained in walking by the subjects of the two lots Research lot Witness lot Evaluation Initial Final Difference Initial Final Difference Lateral walking 3 5 2,8 4,6 2 1,8 Backward walking 3,6 5,5 3,6 5,5 1,9 1,9 Forward walking 3 5,5 3 5,2 2,5 2,2 Walking over obstacles 2,8 4,6 2,8 4,4 1,8 1,6
Lateral walking Backward walking Forward walking Walking over obstacles 2,5 2 2,2 1,9 1,8 1,8 1,9 1,6

Research lot

Witness lot

Figure no.4. Graphic representation of average values obtained in walking for both lots Concluzii Dei valorile obinute la finalul acestui studiu nu difer foarte mult ntre subiecii celor dou loturi luate n ansamblu, conform cercetrii i rezultatelor prezentate se poate observa c ipoteza este confirmat, prin urmtoarele: mbuntirea nivelului funcional n cazul lotului experimental (24,5), mai semnificativ dect la lotul martor (23), datorat n principal unei mai bune stabiliti n articulaia genunchiului la finalul perioadei de tratament, favorizat de introducerea tehnicilor specifice i a metodei Kabat n progeramul kinetic; scderea intensitii durerii reflectat att n evoluia scorului funcional ct i n desfurarea activitilor zilnice. Propuneri Este deosebit de important nsuirea regulilor de igien ortopedic a genunchiului, pentru a ncetini evoluia sau chiar determina regresiunea procesului degenerativ: meninerea sau scderea greutii corporale; evitarea ortostatismului i mersului prelungit; evitarea poziiei de flexie maxim a genunchiului; realizarea de micri libere de flexie-extensie dup repaus prelungit i nainte de adoptarea poziiei ortostatice; evitatea mersului pe teren accidentat; corectarea piciorului plat prin susintori plantari individualizai; evitarea meninerii prelungite a genunchiului ntr-o anumit poziie; evitarea petrecerii timpului ntr-un climat umed i rece; evitarea consumului exagerat de alcool, tutun, cafea; este recomandat o reevaluare somato-funcional mcar o dat pe an; folosirea Conclusions Although the values obtained at the end of this study do not differ much between the subjects of the two lots, generally taken, according to the research and to the presented results, it can be noticed that the hypothesis is confirmed through the followings: Improvement of functional level in the case of the experimental lot (24.5), more significant than at the witness lot (23), mainly due to a better stability in the knee joint at the end of the treatment period, favored by the introduction of specific techniques and of Kabat method in the kinetic program; Decrease of pain intensity reflected both in the evolution of the functional score and in the ongoing of daily activities. Propositions The acquirement of knee orthopedic hygiene rules is of utmost importance in order to slow down the evolution, or even to determine the regression of the degenerative process: keeping or loosing body weight; avoiding prolonged orthostatism and walking; avoiding the maximum flexion position of the knee; making free movements of flexionextension after prolonged rest and before getting into orthostatic position; avoiding walking on rough terrain; correcting the flat foot by individualized plantar supporters; avoiding prolonged keeping of the knee in a certain position; avoiding spending time in a humid and cold climate; avoiding exaggerated alcohol, tobacco, coffee consumption; a somato-functional reevaluation is recommended at

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bastonului n timpul mersului; adoptarea unei least once a year; using of a cane during walking; alimentaii bogate n vitamine, proteine i sruri eating food rich in vitamins, proteins and mineral minerale. salts. Bibliografie/ References 1. Ando, A.D., Aston, G. L., (2006), Development and use of the standard and modified function and pain inventory, Confidential, Anaheim Hills, CA, USA. 2. Chiriac, M., (2003), Testarea manual a forei musculare, Editura Universitii din Oradea. 3. Cordun, Mariana i colab., (1999), Hidrokinetoterapia n afeciunile reumatismale - ediia a 2-a, Editura ANEFS, Bucureti. 4. Denischi, A., Antonescu, D., (1977), Gonartroza, Editura Medical, Bucureti. 5. Kendall, F.P. et al., (2005), Muscles, testing and function with posture and pain - 5th edition, Lippincott Williams & Wilkins, Baltimore, USA. 6. Kiss, I., (2002), Fiziokinetoterapia i recuperarea medical, Editura Medical, Bucureti. 7. Marcu, V., Dan, Mirela, (2007), Kinetoterapie/Physiotherapy, Editura Universitii din Oradea. 8. Martin, C.W., Noertjojo, K., (2004), Hydrotherapy. Review on the effectiveness of its application in physiotherapy and occupational therapy, WorksafeBC, Richmond, B.C., Canada. 9. Moraru, G., Pncotan, V., (2008), Evaluare i recuperare kinetic n reumatologie, Editura Universitii din Oradea. 10. Moet, D., (2009), Enciclopedia de kinetoterapie - vol. I, Editura Semne, Bucureti. 11. Sbenghe, T., (2002), Kinesiologie - tiina micrii, Editura Medical, Bucureti. 12. http://www.orthopaedicscores.com 13. http://www.sfatulmedicului.ro/Artrita/gonartroza-osteoartrita-genunchiului_4803

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