Knee Osteoarthritis: Implementing Research Into Practice
Osteoarthritis (OA), a progressive joint disease leading to chronic pain and disability, is the most common type of arthritis in both developed and developing countries with 250 million adults affected worldwide (1). Knee OA accounts for more than 80% of the disease’s total burden and affects at least 19% of American adults aged 45 years and older (2). Despite having such a burden and a close link with lifestyle related factors, knee OA management is often at odds with the current evidence advocating non-surgical interventions and involving an exercise focused approach to improve function.
We need to make our knees great again!
The aim of this blog is to bridge the gap between current evidence and patient care by discussing a case study and how Physio Network’s Research Reviews helped me understand and navigate this gap.
My patient was a 55-year old female with bilateral knee pain for 2 months. She presented with the diagnosis of bilateral knee OA confirmed via x-ray. The pain was 4/10 at its best and 8/10 at its worst. Aggravating factors included continuous standing for more than 20 minutes and light jogging was quite painful. Walking short distances was manageable but there was intermittent pain which made walking downstairs difficult. Crepitus was heard in the right knee with a lack of knee extension and there was tenderness along the jointline with swelling.
She was prescribed NSAIDs and was recommended rest. She also tried an Ayurvedic treatment (an Indian natural remedy) which led to some short term relief. She tried physiotherapy which consisted of TENS and ultrasound with some basic exercises which didn’t help. She is a housewife and does physical work along with cleaning and cooking. She was informed by her doctor that her “knee arthritis is bone on bone” and she shouldn’t be loading it too much. She was overly protective about her knee and believed that she would require knee replacement surgery.
Core treatment approach
This Physio Network review helped me realize that she never received the first-line treatment approaches for management of knee OA. In light of this review, I refrained from using the same cookie-cutter method of electrotherapy and quad setting exercises we were taught to manage knee OA and followed the guidelines in this review to better inform my clinical practice.
This Physio Network review by Dr. Jarod Hall brilliantly discusses how believing that one has “bone on bone changes in the knee caused by wear and tear, that will only get worse over time” can lead to patients seeking surgery and avoiding physical activity. Improving our clinical communication skills is the key in order to not add more fear-avoidance behavior towards movement. This review encouraged me to ask my patient about her beliefs and educate her about the condition. She had a misconception that exercise can’t regenerate cartilage, a belief not consistent with current evidence (3).
Make patient education a tradition
I focused on identifying and addressing the beliefs and perceptions of my patient regarding her condition. I was able to explain the diagnosis and prognosis of knee OA along with discussing the effect of physical activity and modifying other lifestyle factors including her nutrition habits, stress and weight management. We talked about flare ups and how we should be progressively loading the joint. I was able to provide reassurance and achieve informed goal setting all the while keeping the patient as the decision maker in her rehab process.
Will exercise worsen my knee and MRI?
The patient was apprehensive about physical activity and one of the reasons was her belief that exercise will further damage her knee and worsen her OA progression on MRI. This is a very common misconception in the Indian population. Even though the findings of this Physio Network review by Anthony Teoli cannot be generalized, I was able to address this fear and have a positive conversation while giving her confidence, encouragement and reassurance.
This review stated that engaging in moderate-to vigorous physical activity, consistent with the physical activity guidelines, was not associated with radiographic knee OA progression and is safe.
PT does not stand for passive therapy
“ ..but what about TENS, Ultrasound, Laser, Acupuncture?”
“ How can they be ineffective when patients seem to feel better?”
“What does the evidence say about these treatments which were taught to us?”
These were some of the questions which continued to linger in my head during the rehab process. This Physio Network review by Todd Hargrove sheds some light on a different perspective. It states that pain reduction is unlikely due to direct physiological effects but rather the placebo effect, total effect of co-therapies, natural history of OA altogether classed as “contextual effects” of treatment. Use of such passive therapies can reduce self-efficacy and contribute to confusion about the cause of knee pain. It helped me check my biases and make an evidence based decision aligning with my patient’s preferences.
Exercise: what & how much?
Like many of my colleagues, I’ve always had doubts regarding what form of exercise is the best for managing knee OA. When it comes to high-intensity training and its ability to provide more pain relief compared to low-intensity training, which one should I opt for? This Physio Network review suggested that there is no best exercise for patients with knee OA and the type of exercise chosen should be in line with the patient’s goals and preferences, their current physical capacities and limitations, their previous exercise levels etc.
My patient had a supportive husband who encouraged her to go to the gym with him and she started with lower extremity strengthening at 40% of her 1RM and progressing to 60% of 1RM (2/week for 8 weeks). She was able to slowly build up to 150 min/week of moderate intensity aerobic training (stationary bike). At the end of 4 weeks, we started with moderate-to-vigorous physical activity of about 10 minutes. I referred her to a nutritionist to address her diet for weight loss (BMI:26kg/m2) and she was encouraged to maintain her training program moving forward (4).
Motion is lotion
This Physio Network review containing information about the Good Life with osteoArthritis in Denmark (GLA:D®), helped with educating the patient about the benefits of regular exercise, creating a roadmap for rehab and in positively impacting the life and function of the patient. Taking certain aspects from the program given in the review, I was able to find an entry point with the patient and progress her gradually towards high-intensity gym based activities. The program was flexible and crucial for me in making sure she received exercise prescriptions as the first line of treatment.
Ready to make knees great again?
The key message of this Physio Network review is straightforward. It is time to change the narrative about knee OA. It is time to change the treatment focus to first line treatment (weight loss & patient’s self-management) and put the patient in the “drivers’ seat of their treatment plan. Physio Network’s Research Reviews helped me immensely in changing the message and my treatment aiding my patient’s recovery without need of surgery. Realizing that knee OA related pain is a modifiable symptom related to sensitized knee structures rather than damaged structures helped improve my understanding and improve exercise adherence for my patient.
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- Neogi T. The epidemiology and impact of pain in osteoarthritis. Osteoarthritis Cartilage. 2013 Sep;21(9):1145-53.
- Wallace IJ, Worthington S, Felson DT, Jurmain RD, Wren KT, Maijanen H, Woods RJ, Lieberman DE. Knee osteoarthritis has doubled in prevalence since the mid-20th century. Proc Natl Acad Sci U S A. 2017 Aug 29;114(35):9332-9336.
- David J Hunter, Osteoarthritis: time for us all to shift the needle, Rheumatology, Volume 57, Issue suppl_4, May 2018, Pages iv1–iv2.
- Young JL, Rhon DI, Cleland JA, Snodgrass SJ. The Influence of Exercise Dosing on Outcomes in Patients With Knee Disorders: A Systematic Review. J Orthop Sports Phys Ther. 2018 Mar;48(3):146-161.
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