Department of Physical Therapy

Knee Pain/OA
Physical Therapy
Approaches
G. Kelley Fitzgerald, PT, PhD, FAPTA

Professor, Department of Physical Therapy, School of

Health and Rehabilitation Sciences
Director, Physical Therapy Clinical and Translational
Research Center
 Department of Physical Therapy

• Dosage
• Manual Therapy
• Motor Learning
 Department of Physical Therapy

Strength Training Dosage

• % of a repetition maximum
• Perceived Exertion Scales
• For our patients with arthritis, these
should be “pain-free” entities
 Department of Physical Therapy

Strength Training Dosage

• American College of Sports Medicine
Recommendations for Older Adults
– 60-80% 1 RM, 8-12 reps, 1-3 sets, with 1-3
min rest between sets.
– Can also incorporate power programs of 30-
60% 1 RM, 6-10 reps, 1-3 sets at higher
repetition velocity.
– For endurance training, use lighter loads
(50-60%) with higher reps (10-15 or more)
 Department of Physical Therapy

Progression of Strength Training

Intensity
• When patient can perform 1-2 reps over
the target reps for 2 consecutive
sessions, training load should be
increased by 2 to 10%.
• Recommend re-establishing the 1 RM
every 2 to 4 weeks to re-adjust training
loads appropriately.
 Department of Physical Therapy

Alternative to Repetition
Maximum for Dosing
Borg Perceived Exertion Scale
• Modified Borg 0 Nothing at all
Perceived Exertion 1 Very light

Scale 2 Fairly light

3 Moderate
4 Somewhat Hard
5 Hard
6
7 Very Hard

8
9
10 Very very hard
Borg, G. (1982) Psychophysical bases of perceived exertion. Medicine and Science in Sports and Exercise, 14 (5), p. 377-81
 Department of Physical Therapy

Alternative to Repetition
Maximum for Dosing
Borg Perceived Exertion Scale
• Emphasize gains in
0 Nothing at all
muscle force output 1 Very light
• Increase resistance as 2 Fairly light
3 Moderate
patient progresses and
4 Somewhat Hard
RPE falls below
5 Hard
desired level. 6
7 Very Hard

8
9
10 Very very hard
 Department of Physical Therapy

Alternative to Repetition
Maximum for Dosing
• Emphasize gains in Borg Perceived Exertion Scale
endurance 0 Nothing at all
1 Very light
• Increase resistance as 2 Fairly light
patient progresses and 3 Moderate
RPE falls below 4 Somewhat Hard

desired level. 5 Hard

6
7 Very Hard

8
9
10 Very very hard
 Department of Physical Therapy

Alternative to Repetition
Maximum for Dosing
• Potential Advantages • Potential
of RPE Disadvantages of RPE
– Can dose without need – Not yet known if it will
for major testing produce the same
equipment strength outcomes as
%RM approach
– Easy to teach patient
for independent
exercise and activity
programs
 Department of Physical Therapy

Aerobic Training Dose

• 30 to 60 minutes per week
• 50-70% of heart rate
reserve (HRR)
• Target HR = 220- Age –
(Resting HR x %HRR) +
Resting HR
• Example: 60 y/o with
resting HR of 80, exercise
at 60% of HRR:

220 – 60 – (80 X .60) + 80 =128 beats/min

 Department of Physical Therapy

Manual Therapy

• Techniques include accessory and physiologic

motion techniques, manual stretching techniques,
and soft tissue manipulation techniques
 Department of Physical Therapy

Examples of Manual Therapy

Techniques

Manually applied stretch to the P-A glide of tibia on femur with

hamstrings and posterior medial tibial rotation: Target
capsule anterior-lateral capsule
 Department of Physical Therapy

Examples of Manual Therapy

Techniques

Accessory Motion: Soft tissue manipulation

Patellofemoral inferior glides with manual stretching
 Department of Physical Therapy

Manual Therapy: Joint Mobilization

• Can be used to induce relaxation and reduce
pain (grades 1 and 2)
• Can be used to improve joint mobility (grades
3-5)
• Objective of treatment is to manually
reproduce joint accessory motions such as
distractions and joint surface translations.
• Can also be used to apply more targeted
stretching of joint capsule
Moss P, et al, Manual Therapy. 2007;12:109-118
Deyle G, et al, Phys Ther. 2005;85:1301-1317
 Department of Physical Therapy

Joint Mobilization: Indications

• Hypomobility on accessory motion

testing (reproduction of joint translatory
movements)
• Measureable reduction in joint motion
even after de-emphasizing contribution
from tight muscles
• Pain/stiffness in specific portions of the
peri-articular soft tissue on joint motion
 Department of Physical Therapy

Deyle, et al. Phys Ther. 2005; 85:

1301-1317.
• Compared group with knee OA receiving
supervised manual therapy and exercise to
group receiving home exercise.
• Manual therapy and exercise delivered to
lumbo-pelvic, hip, knee, foot and ankle
regions based on reduced motion or pain in
these regions.
 Department of Physical Therapy

Deyle, et al. Phys Ther. 2005; 85:

1301-1317.
• Both groups improved
function scores.
• Group receiving
supervised manual
therapy and ex had
greater improvements.
(52% vs 26%)
• Larger effect compared
with many other exercise
studies.
 Department of Physical Therapy

Abbott JH, et al. Osteoarthritis

Cartilage. 2013;21:525-534

Usual Care (UC) UC + Manual Therapy (MT)

N =54
N = 51

UC + Exercise (Ex) UC+MT+Ex

N = 51 N = 50

• Included subjects with knee or hip OA

• 9 sessions (7 in first 9weeks +2
boosters at 16 weeks)
 Department of Physical Therapy

Abbott JH, et al. Osteoarthritis

Cartilage. 2013;21:525-534
ONE YEAR FOLLOW-UP CHANGES
UC MT Ex MT + Ex
WOMAC -12.9 -41.4 -29.3 -27.4
(51.8) (55.5) (50.4) (41.1)
30s sit to .02 .67 1.6 1.59
stand (# stands) (-.79;.84) (-.12;1.45) (.80;2.40) (.60;2.59)
40m walk (sec) .78 -.50 -3.18 -.61
(-1.40;2.95) (-3.70;2.70) (-4.41; -1.99) (-2.22; 1.00)

NNT* 5 6 8
* Number needed to treat for achieving responder to treatment status based
on OMERACT-OARSI responder criteria
 Department of Physical Therapy

Enhancing the Effectiveness of

Physical Therapy in People with
Knee Osteoarthritis
1 RO1 HS019624-01
University of Pittsburgh, Pittsburgh PA- Data Coordinating
Center (PI: G. Kelley Fitzgerald)
Other Study Sites:
University of Utah/Intermountain Healthcare, Salt Lake City,
UT (PI: Julie M. Fritz)
Army-Baylor University, San Antonio, TX (PI: John Childs)
University of Otago, Dunedin NZ (PI: Haxby Abbott)
 Summary of Experimental Design
Baseline Testing
R

Exercise MT +Exercise Exercise MT+ Exercise

+Booster +Booster
12 Rx Sessions 12 Rx Sessions 8 Rx Sessions 8 Rx Sessions

9 Wk 9 Wk 9 Wk 9 Wk
F/U F/U F/U F/U
Home Program Home Program Home Program Home Program

5 mo Booster – 2Rx 5 mo Booster – 2Rx

8 mo Booster – 1Rx 8 mo Booster – 1Rx

11 mo Booster – 1Rx 11 mo Booster – 1Rx

1 YR F/U 1 YR F/U 1 YR F/U 1 YR F/U

2 YR F/U 2 YR F/U 2 YR F/U 2 YR F/U

 Department of Physical Therapy

Motor Learning Approaches

• Biomechanical unloading
• Task Specific Training
 Department of Physical Therapy

Contralateral Cane Use

• ↓ KAM by 7-10%
• ↓ cumulative loading by:
– ↑ stride length
– ↓ cadence

• ↓ GRF by 25%-35%
during gait
• Most effective if placed as
far laterally as possible
without inducing sx.
 Department of Physical Therapy

Gait Retraining Approaches

• Goal to reduce knee adduction moment

• Foot progression angle (toe out)
• Trunk sway (lateral)
 Department of Physical Therapy

• Motion capture and instrumented

treadmill
• Patient tailored altered foot progression
angle or lateral trunk to get 10% ↓ in
KAM
• Vibration motors on tibia (foot angle) and
scapula (trunk sway) for feedback during
training

Shull PB, et al. J Orthop Res. 2013;31:1020-1025

 Department of Physical Therapy

• 1x/week, 6 weeks
• 10 min practice daily
• Subject selected
method of alteration
– Foot progression angle
– Trunk sway
– Both

• Fading feedback
training design
Shull PB, et al. J Orthop Res. 2013;31:1020-1025
 Department of Physical Therapy

Shull PB, et al. J Orthop Res. 2013;31:1020-1025

Department of Physical Therapy
Department of Physical Therapy
Department of Physical Therapy
 Department of Physical Therapy

Task-Specific Training
 Department of Physical Therapy

Traditional Premise

↓Physical
Function +
Performance
 Department of Physical Therapy

Traditional Premise

↑Physical
Function +
Performance
 Department of Physical Therapy

• Changes in impairments (muscle

strength, flexibility, joint mobility) not
associated with clinical outcome of pain
and function in subjects with knee OA.

Fitzgerald GK, White DK, Piva SR. Associations for change

in physical and psychological factors and treatment
response following exercise in knee osteoarthritis: An
exploratory study. Arthritis Care Res. 2012;64:1673-1680
 Department of Physical Therapy

• Impairment-based rehabilitation
approach yielded only modest self-
reported improvements in functional
task performance ability

Teixeira PEP, Piva SR, Fitzgerald GK. Effect of

impairment-based exercise on performance of specific self-
reported functional tasks in individuals with knee
osteoarthritis. Phys Ther. 2011;91:1752-1765
 Department of Physical Therapy

Task-Specific Training
• Use the specific task that is problematic
as the training tool
• Can work on strength and joint mobility
in context of the task
• Provide opportunity to improve motor
patterns in context of task
• May consider task modifications
 Department of Physical Therapy

Chair Rise Task

Step 1: Moving to Edge of Seat
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Chair Rise Task Step 2: Lift Off

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Chair Rise Task

Step 3: Terminal Stand
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Chair Rise Task

Full Task Practice
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Floor Transfers
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THANK YOU!!!