Role of Physiotherapy in Management of Osteoarthritis of Knee

Knee Osteo Arthritis:

·       Osteoarthritis of the knee (OA) is the most common type of osteoarthritis (OA), and its prevalence is rising in parallel with the increasing age of the population.

Andrianakos A, et al 2003, Felson DT, et al 2000

·   The condition is associated with pain and inflammation of the joint capsule, impaired muscular stabilisation, reduced range of motion, and functional disability.

Naredo E, et al 2005, Brandt KD, et al. 2000, Cowan SM et al. 2001, Steultjens MP et al. 2000

Physiotherapeutic approaches have been extensively researched and have level IV to level I B evidences and are globally accepted as therapeutic procedures for the conservative management in Knee Osteoarthritis.

Conservative Management of OA Knee:

·        a.  Knee Exercises for Function and Rehabilitation

·     b. Physical Agents and Modalities for Pain Management

·     c. Bracing and Taping Techniques for the Knee

·     d. Supports

·     e. Footwear Modifications

Knee Exercises for Function and Rehabilitation:

·      Non-pharmacologic, behavioral treatments of knee OA are recommended not only in rehabilitation but also in prevention because many risk factors, such as excess weight, obesity and joint tissue inflammation, can be monitored and thus prevented.

·         All data suggest that physical exercise is an effective, economical and accessible tool to everyone, in the treatment and prevention of knee OA.

Musumeci G, et al. 2014

·   

  Appropriate treatment modalities for all individuals with knee OA include bio-mechanical interventions, intra-articular corticosteroids, exercise (land-based and water-based), self-management and education, strength training, and weight management.

·         Treatment appropriate for specific clinical knee of OA includes cane (walking stick), transcutaneous electrical nerve stimulation, ultrasound and medications.

·     Electrotherapy (neuromuscular electrical stimulation) has been found moderately effective in Knee management.

McAlindon TE, et al. 2014

Function and Rehabilitation:

·         Exercises for Knee Mobility

·         Exercises for Hip, Knee & Core Muscles Strengthening

·       Strengthening the hamstring muscles in addition to strengthening the quadriceps muscles proves to be beneficial for perceived knee pain, range of motion, and decreasing the limitation of functional performance of patients with knee OA.

·    Exercises have beneficial role on pain intensity, gait velocity, maximum isometric strength, and activities of daily living of patients with knee osteoarthritis (OA).

Hafez AR et al 2013

Suryanamaskar for weight management:

·    Suryanamaskar training is an effective tool in weight management and improvisation of physical fitness parameters in over weight and obese females, especially in improving Cardio- respiratory fitness, upper limb muscle endurance and body flexibility.

Jakhotia K, Shimpi A, Sancheti P et al 2015

Physical Agents (Modalities) and Pain Management:

·   European League Against Rheumatism (EULAR) recommends both pharmacological and non-pharmacological interventions are needed for optimal treatment of OA Knee.

·         Interventions listed in physical agents are:

1.         Low level laser therapy (LLLT)

2.         Pulsed electromagnetic fields (PEMF, including shortwave therapy  SWD)

3.         Transcutaneous electrical nerve stimulation (TENS),

4.         Ultrasound (US)

5.         Thermal Therapy

Jordan KM, et al. 2003

Modalities – Low Level Laser Therapy:

·     Modalities [thermal, electrical stimulation (ES), and low- level laser therapy (LLLT)] and orthotic intervention are moderately supported in the literature as indicated management strategies for knee OA. 

Adams T et al 2013

·      Studies show that LLLT reduces pain in Knee OA and improves microcirculation in the irradiated area.

Béla Hegedűs et al

·         

     Studies show a statistically significant difference favoring laser treatment when compared to placebo, especially for joint stiffness and pain relief.

Brosseau L, et al 2007, Zhao L, et al 2010

·    

    Therefore, LLLT is an effective modality for short-term pain relief and function improvement in patients with chronic knee OA.

Alghadir A, et al

Modalities – Ultrasound:

·       There are contradictory evidences for the role of Ultrasound in management of the knee wherein the modality cannot be considered as the best option in knee care.

John Z Srbely

Modalities – Interferential Current Therapy (IFT):

·        Patients with Knee OA show a equal benefit when treated with electrical stimulation, IFT and SWD along with exercises.

Atamaz FC, et al 2012

Modalities – Manual Therapy:

·         Manual physiotherapy (including Mulligans MWM’s) provided benefits over usual care in Range of Motion and Pain in individuals with Knee OA, which are long time effective & sustained.

Abbott JH et al 2013, Takasaki H et al 2013, Brakke R et al 2012, Deyle GD et al 2012, French HP et al 2011

Supports: Canes/ Sticks:

·     Although not many researches are available on this, cane can be used to diminish pain, improve function and quality of life in patients with knee osteoarthritis.

·        The prescription of a cane should take into account the substantial increase in energy expenditure in its use.

A Jones et al

·         The cane should always be used on the opposite side of the pain for a biomechanical benefit.

·         But patients may prefer to use it mainly on the dominant side for comfort.

Bracing the Knee:

·         Knee taping applied with the aim of realigning the patella and unloading soft tissues can reduce pain.

·         There is also evidence to support the use of knee braces in people with knee OA.

·         Biomechanical studies show that lateral wedge shoe insoles reduce knee load but clinical trials do not support symptomatic benefits.

·      Recent studies suggest individual shoe characteristics also affect knee load and there is current interest in the effect of modified shoe designs.

Page CJ 2011

BRACING AND TAPING:

·       Use patellar taping for short term relief of pain and improvement in function.

·      Use of brace with a valgus directing force may help for patients with medial uni-compartmental OA of the knee

Knee brace:

·   Level IV evidence studies suggest that bracing the knee in OA is effective in improving clinical outcome and therefore should continue to be prescribed to patients.

Haladik JA et al 2013

·        Patients demonstrated a significant decrease in pain and disability.

·      

         Braces specifically designed to unload the degenerative compartment of the knee can be an effective treatment to decrease pain and maintain activity level to increase overall physical health.

Briggs KK et al 2012

Knee taping:

·        Patellar tape (medially-directed force on the patella) reduces mal-alignment and pain associated with patello femoral joint OA.

Crossley KM et al 2009, Warden SJ et al 2008

·    Therapeutic knee tape is a simple, inexpensive strategy that increases the treatment options for therapists and patients in the conservative management of knee OA.

·       Therapeutic tape may be used as an adjunct to drug and exercise therapies, potentially augmenting the individual benef

its of each.

Hinman RS et al 2003

Foot Alteration in OA Knees: The hyper pronated foot.

Images courtesy: Ms. Ashwini Marathe, Kaizer™ - Sancheti Hospital

Static Foot pressures analysis

Dynamic Foot pressures analysis

FOOTWEAR MODIFICATION:

·        Lateral heel wedges may help patients with symptomatic medial compartmental OA of the knee.

·        Changing the lever arm contributes the most at the foot in the OA participants.

·        This can be obtained by modifying shoes.

Kean CO et al 2013

·      Studies show that footwear have a substantial impact on the overall disease process in knee OA and represent a novel therapeutic target for the treatment of knee OA.

·         The types of shoes worn by patients with knee OA should be evaluated more closely in terms of their contribution to the disease, and long-term intervention trials to evaluate the clinical effects of shoe design on pain and disease progression in OA should be considered.

Najia Shakoor, et al 2010, Shakoor N et al 2013

Stability Shoe

Flexibility Shoe

Current trends in rehabilitation:

·      Shift towards individually tailored/ modified programs depending on functional requirement of the individual

·         Functional training programs – exercises similar to ADL’s of the individual

·         Emphasis on Proprioceptive Training

·         ROM, muscle strength and patient’s perception most important criteria for exercise progression.

Things to remember!

·         No fixed Protocol for rehab

·         Modify Exercises by regular patient evaluation

·         Task Specific and Functional Exercises more effective

·         Rehabilitation greatly influenced by level of motivation of the patient and compliance to the exercise program

References:

Available on Request

Dr. Apurv Shimpi (PT)

Dr. Parag Sancheti