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2 | www.sportsmedarthro.com Sports Med Arthrosc Rev Volume 21, Number 1, March 2013
Sports Med Arthrosc Rev Volume 21, Number 1, March 2013 Physical Therapy Management of Knee Osteoarthritis
with knee OA, joint capsule extensibility and quadricep, THERAPEUTIC EXERCISE
hamstring, hip flexor, gastrocnemius, and soleus muscle Research has reported a correlation between increased
length must be assessed because of their impact on knee physical activity and decreased pain levels, improved
function and their function when participating in athletics. function, and delayed disability. At least 30 minutes of
Reid and McNair demonstrated a significant increase in moderate physical activity over a minimum of 5 d/wk is
knee extension ROM (mean, 7.7 degrees) after a 6-week recommended by the Centers for Disease Control in specific
stretching program focusing on the above-mentioned regards to OA.23 Participation in regular physical activity
lower-extremity muscle groups. The stretching intervention has been shown to provide significant benefits in the
utilized supervised and independent stretching sessions. The treatment of knee OA, whereas failure to remain active may
relevance of the study demonstrates the importance of exacerbate impaired joint mechanics and potentially result
independent stretching exercises as an effective piece of in articular cartilage softening and matrix dysfunction,
long-term knee OA management.21 leading to accelerated cartilage degeneration.24 Also, indi-
Weng and colleagues compared isokinetic muscular viduals without knee OA who opt to exercise will not have
strengthening exercise (group I), isokinetic exercise with increased progression of joint degeneration as a result of
static stretching (group II), and isokinetic exercise with their increased physical activity; indeed, they can poten-
PNF stretching (group III) in patients with knee OA. All tially expect reductions in knee pain and disability as the
groups demonstrated a significant reduction in knee pain years progress.25
and disability with increased peak muscle torques after Repetitive loading of the arthritic knee joint can force
treatment and at follow-up. However, only groups II and compensatory movement and muscular recruitment
joint motion deficits, muscle weakness, and reduced aerobic Exercise prescription for individuals with knee OA has
capacity.28 Although these impairments are associated with been studied regarding the frequency, intensity, and mode
the majority of patients with knee OA, many exercise of resistance and strength training has been found to be
programs inadequately focus on other aspects of ambula- beneficial for patients with knee OA. A study by Farr and
tion and higher level activity such as turning, quick stop- colleagues looked at resistance training on overall moderate
ping, negotiating obstacles, or change in surface con- and vigorous physical activity in 171 patients with early
sistency. Fitzgerald et al29 reports that a range of 11% to knee OA. Patients (mean age, 55 y) participated in a
44% of patients with knee OA will experience mechanical resistance-training program, a self-management program,
symptoms of giving way or buckling during activities of and a combined program. The resistance-training group
daily living. participated in 1-hour exercise sessions that included leg
Similar mechanical symptoms are reported in patients press, leg curl, hip abduction and adduction, straight leg
with a deficient anterior cruciate ligament (ACL). Extensive lift, incline dumbbell press, seated row, and calf raise. The
research supports the application of perturbation training self-management group was given educational classes. The
with nonoperative, ACL-deficient patients. The study groups were tested at baseline, 3 months, and 9 months and
results by Axe and Snyder-Mackler30 demonstrate a more both the self-management and resistance-training groups
effective return to high-level physical activity than an were effective in raising moderate to vigorous physical
impairment-based standard program by exposing individ- activity levels in the short term. However, the resistance-
uals to activities that challenge the knee to potentially training group proved significantly more effective in main-
destabilizing loads during therapy. Although there appears taining these results long term. The results by Farr and
to be a correlation between the ACL-deficient knee and colleagues suggest that functional exercises targeting per-
knee OA symptomology, there is limited research measur- formance can be useful in managing knee OA.32
ing the proprioceptive decline in patients with knee OA and Sayers and colleagues conducted a study comparing
its subsequent effect on agility (Table 3). high-speed versus slow-speed power training in 33
participants with mean age of 67 years with knee OA. The MODALITIES
high-speed group performed a greater number of repeti- The trend of increased incidence of knee OA in a
tions at 40% of 1 repetition maximum on a leg press “as younger, more active population has developed a role for
fast as able,” whereas the slow-speed group performed therapeutic modalities in the conservative management of
fewer repetitions at 80% of 1 repetition maximum slowly. functionally limiting impairments associated with knee OA.
The high-speed group improved muscle strength, power, ES, therapeutic ultrasound (US), LLLT, and thermo-
and speed over the 12-week period. These findings are therapeutic agents such as heat and ice packs represent
particularly relevant in effectively treating a recreationally common noninvasive, nonpharmacological treatment app-
active population performing high-speed movements.33 roaches often coupled with therapeutic exercise to treat
High-resistance training is shown to be equally effec- patients with articular degradation and other joint changes
tive as low-resistance training in people with knee OA. Jan associated with knee OA.
et al34 looked at the effects of pain, function, muscle torque, ES is a commonly used treatment option to relieve pain
and walk time in high-resistance versus low-resistance and improve function in patients with knee OA. Three pri-
training over an 8-week period. The 2 groups performed mary forms of ES were identified during this article’s liter-
isokinetic knee flexion and extension training at high- ature review: interferential current (IFC), neuromuscular
resistance (mean age, 63 y) and low-resistance (mean age, electrical stimulation (NMES), and transcutaneous electrical
63 y) session over 3 episode/wk. Both groups improved in nerve stimulation (TENS).
all categories compared with the control group (mean age, The effectiveness of IFC treatment in patients with knee
62 y). In another study regarding resistance training, Gur OA has been researched extensively with variable results
and colleagues looked at the effects of concentric versus suggesting short-term improvement in pain and function.
concentric-eccentric quadricep and hamstring strengthening However, as Adedoyin and colleagues comment in their
on functional capacity and pain levels in patients aged 41 to paper, studies have largely failed to show benefit over con-
75 years old with knee OA. They determined an 8-week trolled groups receiving an exercise program or sham treat-
program of isokinetic quadriceps and hamstring strength- ment. In a randomized control trial (RCT) of 46 subjects
ening performed 3 times/wk resulted in the concentric- with mean age of 55 years, subjects in 3 groups receiving
eccentric group displaying a greater effect on functional IFC, TENS, or exercise program alone all reported improved
activities, including stair ascension and descension while levels of pain and function as defined by the WOMAC.38
concentric training exhibited improvements in overall pain To further highlight inconsistencies in this field of study,
rating. The results of the study show that extensive training consider a recent RCT by Gundog and Atamaz of 60 patients
involving high number of repetitions and eccentric con- with median age of 60 years and mild to moderate knee OA.
tractions are safe, effective, and productive in patients with Patients were treated 5 times/wk for 3 weeks consecutively
knee OA.35 with IFC treatment and compared with a sham-controlled
Isokinetic versus progressive resistance exercise (PRE) group. The authors concluded that IFC treatment was an
of the quadriceps and hamstrings was studied by Eiygor. effective intervention in the management of knee OA, while
Knee flexion and extension strengthening was assessed also noting both IFC and controlled groups demonstrated
3 times/wk in the isokinetic group (mean age, 53 y) and significant improvements in pain and function as defined by
5 times/wk in the PRE group (mean age, 51 y) over a 6-week the WOMAC.39 Related systematic reviews conducted by
period. Both modes of strengthening were found to be Hawker and Mian40 and Jamtvedt and Dahm41 support these
effective in achieving strength gains and subjective findings, concluding that results in patients with knee OA are
decreases in pain and function. There was no significant unclear because of low quality of evidence and a general
difference found between the 2 groups in overall reports of heterogeneity of study parameters.
pain, function, or peak torque of the tested muscles.36 Less empirical data exist to support NMES as an
Consideration of the surrounding musculature of the effective therapeutic agent to improve pain or function
hip and ankle joints when prescribing exercise for the scores in patients with knee OA. In a RCT conducted by
patient with knee OA is also important. Both dynamic and Palmieri-Smith and Thomas, 30 women with mean age of
isometric training of the entire lower extremity represent 57 years and radiographic evidence of knee OA were pro-
effective modes of resistance strengthening in people with vided either NMES treatment 3 times/wk for 4 weeks or no
knee OA. Topp and colleagues conducted a 16-week study treatment over the same time period. The authors
comparing dynamic and isometric training, specific to hypothesized that the group receiving NMES would dem-
effects on pain level and physical function. Two groups onstrate improved quadriceps activation and strength when
trained the same 6 lower-extremity muscle groups: ankle compared with the controlled group. After a priori power
plantar and dorsiflexors, knee extensors and flexors, and analysis, the research group determined no statistically
hip extensors and flexors. The isometric group (mean age, significant increase in quadriceps activation or strength in
64 y) used maximum resistance Thera-band (The Hygienic the intervention group of patients receiving NMES.42
Corporation, Akron, OH), whereas the dynamic group Although patients in this study, and the IFC trials men-
(mean age, 66 y) used appropriate-level resistance Thera- tioned above, are slightly older than middle-aged athletes,
band to achieve the desired muscle activation. Both resist- principles of efficacy with respect to individuals with mild to
ance-training groups exhibited similar, significant declines moderate knee OA are expected to remain constant.
in reported knee pain and decrease in time to perform TENS represents another commonly used modality in
functional tasks, whereas the control group remained treatment of knee OA, although efficacy with respect to
unchanged over the duration of the study. Only the functional mobility and joint stiffness is generally incon-
dynamic training reduced perceived functional limitations, clusive. In a meta-analysis by Brosseau and Yonge, the
and the control group (mean age, 61 y) did not change their reviewers reported a statistically significant reduction in
measures on any of the outcome variables over the duration pain levels in the treatment of patients with knee OA. As
of the study.37 such, the authors recommended TENS as an adjunct
therapy for the treatment of knee OA.43 Similarly, a sys- OA was discussed with respect to knee ROM, pain,
tematic review by Jamtvedt and Dahm concluded that there strength, edema, and function. Brosseau and Yonge deter-
is moderate evidence that TENS reduces pain when com- mined that ice massage, compared with control, had a
pared with a placebo intervention in treatment of knee statistically significant effect on knee ROM and function.
OA.41 However, in contrast, a 2010 Cochrane review by The authors concluded that ice massage (20 min/session,
Rutjes and Nüesch concluded that the current level of 5 sessions/wk for 2 wk) represents an effective adjunct
evidence to support the efficacy of TENS treatment in treatment in patients with knee OA demonstrating deficits
patients with knee OA with respect to pain and function is associated with knee ROM and function. However, the
inadequate because of inclusion of small trials with uncer- authors do acknowledge a general heterogeneity in study
tain methodology.44 parameters, citing variable methodology with respect to
The efficacy of therapeutic US treatment in patients with outcome results and test administration.43 Discrepancy in
knee OA has been sharply contended over the past several research standards is echoed in a systematic review by
decades. Both nonthermal and thermal effects on localized Jamtvedt and Dahm,41 who concluded due to small sample
pain, inflammation, and tissue repair remain in question. In a sizes and low quality of studies, the efficacy of thermo-
randomized, placebo-controlled, double blind study by therapeutic agents on pain and function in patients with
Tascioglu and Kuzgun, the short-term effectiveness of ther- knee OA is inconsistent and therefore unclear.
apeutic US was tested in 90 patients with moderate knee OA. Ultimately, there is low-quality evidence to support the
The patients with a mean age of 62 were treated with either use of IFC, NMES, and thermotherapy38–44; variable low-
continuous, pulsed, or sham US for a duration of 5 min/ quality to moderate-quality evidence to support therapeutic
session, 5 d/wk for 2 weeks. The authors reported significant US and TENS38,41,44–48; and, moderate-quality evidence to
improvements in pain levels, via the VAS, and functional support LLLT in the treatment of patients with knee OA.41,48
status, via the WOMAC, across all the 3 groups. When Currently, therapeutic exercise and weight reduction possess
compared with the placebo group, patients receiving pulsed the highest quality of evidence with respect to effects on pain,
US reported significantly improved scores on the VAS and inflammation, and stiffness in patients with knee OA.41 In
WOMAC. Thus, Tascioglu and Kuzgun45 determined that light of these findings, further studies are needed to
pulsed US represents an effective short-term treatment unequivocally substantiate the use of therapeutic modalities
approach for decreasing pain and improving function in in treating middle-aged athletes with knee OA.
patients with moderate knee OA.
In another Cochrane review by Rutjes and Nüesch and
a systematic review of RCTs with meta-analysis by Loyola- PATIENT EDUCATION, WEIGHT MANAGEMENT,
Sanchez and colleagues therapeutic US in patients with ORTHOTICS
knee OA was investigated. Both reviews report that ther- OARSI recommends patients with knee OA to be
apeutic US may represent an efficacious treatment modality provided with information pertaining to treatment options
in the management of patients with knee OA.46,47 Specifi- and lifestyle modifications related to functional impair-
cally, Loyola-Sanchez et al47 concluded that pulsed US at ments and excessive joint loading.11 Arguably, the most
low intensities has a significant effect on pain reduction in influential risk factor associated with increased internal
patients with knee OA when compared with continuous US knee adductor moments (KAM), a clinically accepted
and sham. Despite the findings, both authors acknowledge identifier of moderate to advanced medial joint knee OA, is
a low quality of evidence and a large degree of hetero- increased body mass. Research consistently substantiates
geneity in study parameters, ultimately conceding to the obesity correlating significantly with both the incidence and
need for additional study in this field.45,47 progression of knee OA. Weight management, and ulti-
Several studies have reported positive effects from mately weight loss, therefore represents the treatment
LLLT including influences on fibroblast propagation, option of choice in patients presenting with knee OA. In a
osteoblast production, and collagen synthesis as well as study by Aaboe and Blidda, the authors found a significant
revascularization in wound healing. In a double blind, reduction in knee joint loads during walking among sub-
randomized, placebo-controlled trial by Hegedüs and jects with an average body weight reduction of 13.7 kg
Viharos, 27 patients with mean age of 42 years and mild to (13.5% decrease relative to baseline) after a 16-week dietary
moderate knee OA received either LLLT or placebo LLLT. intervention course. Aaboe and Blidda49 conclude that
Patients received treatment twice a week over a 4-week weight loss represents an excellent short-term approach to
period at a continuous wave form and dose of 6 J/point. decreasing functional limitations associated with increased
Hegedüs and Viharos found patients treated with the active joint loading in patients with knee OA.
laser diode demonstrated a significant improvement in pain, Alternative approaches to decrease joint loading forces
knee circumference, point pressure sensitivity, and knee in patients with knee OA include utilization of shoe wedges,
flexion compared with the control group. Still more knee braces, and assistive devices. Although the level of evi-
impressive is that the authors report patients in the active dence supporting these intervention strategies remains vari-
LLLT group continued to present with improved test var- able, the biomechanical advantage gained by redistributing
iables 2 months after treatment.48 Further, Jamtvedt and ground reaction forces (GRFs) during contact phase of gait is
colleagues discussed similar findings in their systematic supported by experts in their respective fields.11 This bio-
review, concluding that moderate-quality evidence supports mechanical understanding of GRFs during gait reveals
the positive anti-inflammatory effects of LLLT on pain and another rehabilitation trend found in literature; namely, that
function in patients with knee OA.41,48 all patients with knee OA be educated on appropriate foot-
Thermotherapy produces localized thermal effects on wear as pertains to specific activity demands and impairments
superficial target areas, depending on clinical indications associated with articular changes found in with knee
and desired therapeutic outcomes. In a Cochrane review by OA.11,50–52 Although authors agree that footwear recom-
Brosseau and Yonge, thermotherapeutic treatment of knee mendations should be provided to all patients with knee OA,
the most effective type of shoe (ie, stability, cushioned, min- stretching in the management of knee OA. Also, ther-
imalist) remains in question.50–52 An individualized inter- apeutic exercise, including resistance (ie, closed-chain, iso-
vention approach is required when assessing middle-aged kinetic, and PRE) training and cardiovascular training has
patients with knee OA, specific to activity demands, pro- been suggested in many studies. Other strongly supported
gression of disease, body composition, work/sport environ- interventions include patient education regarding activity
ment, and foot strike pattern. modification/pacing and symptom management and weight
A shock-absorbing insole may represent the ideal foot- management strategies, particularly in an overweight/
wear choice for an obese, heel-striking patient with increased obese, middle-aged population.
internal KAM and moderate medial tibiofemoral joint Other nonpharmacologic management techniques for
compartment narrowing, while a shoe designed to simulate treatment of knee OA include modalities, such as ES,
barefoot mechanics may represent the desired footwear therapeutic US, LLLT, and thermal agents. In many
approach in a midfoot-strike athletic population presenting instances, conflicting evidence abounds and often neither
with early evidence of knee OA. The latter example describ- supports nor refutes the benefit provided by many of the
ing innovative footwear is more specific to this paper and has modality interventions. Although an abundance of evi-
recently been reported to significantly reduce dynamic knee dence-based research on OA has been developed, a void
loads during gait through proposed increased sensorimotor remains in the research within a middle-aged athletic pop-
input and neuromuscular communication.50,51 ulation in the context of knee OA and conservative
In addition to KAM-modifying and GRF-reducing management.
wedges and supports, the importance of activity modification
represents an essential educational component when treating
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