Although yoga is typically thought of as an exercise that involves movements that require significant flexibility, it can be safe and ef- fective for patients with OA, including those with knee OA (Bhatia et al., 2013). Yoga can help to improve strength, flexibility, and balance, and reduce symptoms of arthritic pain and stiffness (Bha- tia et al.). Yoga requires slow, controlled movements, which can help arthritic patients by improving blood flow in joints and by re- moving unwanted toxins and other waste products (Bhatia et al.). Yoga can be modified for patients with arthritis. Patients should be encouraged to continue to do movements that they are able to do instead of avoiding movement all together. Avoiding move- ment all together can further increase the symptoms of arthritis and decrease a patient’s range of motion. Yoga can provide de- creased pain, improved function, and improved mood in patients with OA and should be considered for patients with knee OA even though it is not often thought of as a mode of exercise that patients with limited range of motion and flexibility can partici- pate in. Treatment of knee OA with autologous mesenchymal stem cells Cell therapy by surgically implanting autologous chondrocytes has been used to regenerate local cartilage defects for more than 20 years (Orozco et al., 2013). A study performed by Orozoco and col- leagues aimed to assess the feasibility and safety of OA treatment with mesenchymal stromal cells (MSCs) in humans and to obtain early efficacy information for this type of treatment. This study in- cluded 12 patients, a low number of participants, who had chronic knee pain that was unresponsive to conservative treatments and radiographic evidence of OA. These 12 patients were treated with autologous expanded bone marrow MSCs by intra-articular injec- tion. The clinical outcomes – an evaluation of pain, disability, and quality of life – were looked at one year following. Articular car- tilage quality was also looked at during the one-year follow–up, which was assessed by quantitative magnetic resonance imaging T2 mapping. The results of the study confirmed feasibility and safe- ty. Strong indications of clinical efficacy were also identified. The articular cartilage in these patients demonstrated a highly signifi- cant decrease of poor cartilage area with improvement of cartilage quality in 11 of the 12 patients (Orozoco et al.). The conclusion of this study was “MSC therapy may be a valid alternative treatment for chronic knee OA” (Orozoco et al., p. 1535). This intervention may be beneficial for patients who are not looking to undergo sur- gery because this type of therapy does not require hospitalization or surgery but still provides pain relief and improves cartilage qual- ity in patients with knee OA (Orozoco et al.). Surgical interventions for knee OA Surgical intervention for patients with knee OA is often thought to be only a total knee arthroplasty(TKA); however, other surgi- cal interventions are sometimes used before a patient needs this procedure. One of these surgical treatment techniques, though controversial, is the arthroscopic debridement of the knee. Ac- cording to studies, arthroscopic debridement of the knee in pa- tients with OA can provide beneficial effects. Certain factors have predicted better outcomes with arthroscopic debridement of the knee, including younger age; mechanical symptoms, such as lock- ing; medial joint line tenderness; mild to moderate radiographic evidence of knee OA; and presence of an unstable degenerative tear of the meniscus (Hussain et al., 2016). Another intervention that may be performed is an osteotomy. The goal of an osteotomy is to transfer the mechanical axis from the pathological area to the normal compartment (Hussain et al., 2016). Besides a TKA, two other types of arthroplasties are performed: a unicompartmental knee arthroplasty and a patellofemoral ar- throplasty. A patient who has unicompartmental arthritis may undergo a unicompartmental knee arthroplasty if he has a stable joint, cor- rectable valgus deformity, fixed flexion less than 10 degrees, and minimal lateral compartment disease (Hussain et al., 2016). The advantages of having a unicompartmental procedure over a TKA
showed significant improvements in balance and risk of falls (Mat et al.). Aerobics, resistance training, NMES with squat exercises, weight- bearing exercises, and squat exercises with vibration – all limb strength training – were also found to improve balance and de- crease fall risk (Mat et al., 2015). The conclusion of this systematic review determined that strength training, tai chi, and aerobics exer- cises improved balance and falls risk in older individuals with knee OA. Water-based exercises and light treatment did not significantly improve balance outcomes (Mat et al.). Modalities are often performed in physical therapy for patients with knee OA to relieve pain and decrease inflammation associ- ated with the disease. The primary reasons for physical therapy for patients with knee OA are to decrease pain and improve func- tion. Modalities have the goal of decreasing pain, which in turn can improve a patient’s functional activity tolerance and abilities. “Thermal therapies are widely used in knee OA for these pur- poses (decrease pain and improve function) since it is well known that heat increases tissue metabolism, collagen elasticity, capillary blood flow and decreases muscle spasms” (Rand et al., as written in Cakir et al., 2014, page 406). Ultrasound is often used as one of the thermal modalities to treat the symptoms of pain and inflammation associated with knee OA. Overall, there is limited evidence to support the use of ultrasound in the treatment of knee OA. One study by Cakir and colleagues (2014) looked to compare the effectiveness of continuous ultra- sound and pulsed ultrasound in the treatment of knee OA while comparing both treatments to sham ultrasound in the addition of exercise training. All of the treatments provided were performed five times per week for two weeks with continuous ultrasound per- formed at a frequency of 1 MHz with an intensity of 1 W/Cm2 and with the pulsed ultrasound performed at the same frequency and intensity but at 1:4 pulse ratios (Cakir et al.). The sham group was identical to the other two groups in that the participants received treatment five times per week for two weeks with the same equip- ment but with the power switch shut off. Each treatment for all three groups lasted 12 minutes each time. All of the patients in the study were also instructed in a home exercise program that included quadriceps isometric exercise, muscle strength exercise, and stretching exercises for the lower extremity muscles at least three times per week (Cakir et al.). The results of this study showed improvement in all three groups without showing a significant dif- ference among groups. The results having been similar across all three treatment groups suggest that therapeutic ultrasound does not provide any additional benefit in improving pain and function in addition to exercise training. If physical therapists use evidence-based practice in their treat- ment protocols, therapeutic ultrasound should not be included because of the lack of evidence. One issue with providing evi- dence for the use of ultrasound for patients with knee OA is the lack of standardization in the research in regards to intensity, mode, and therapeutic dose. This makes it difficult to compare studies to one another and does not provide therapists with prop - er protocols to provide the best outcomes. Ultrasound is often performed in addition to exercise in many studies, which makes it difficult to determine whether the ultrasound improves a patient’s symptoms or if the exercise is more of a contributing factor in decreasing symptoms. Another type of pain relieving agent often used to treat knee OA in a physical therapy clinical setting is electrical stimulation. Trans- cutaneous electric nerve stimulation (TENS) is a physical modality used in the treatment of knee OA. Some of the studies on the use of TENS and patients with OA advocate that alternating stimula- tions of TENS produces analgesic effects (Bhatia et al., 2013). The conclusion of one study showed that there were no differences in the effects of the varying sets of frequencies, but it did show that TENS does work. The optimal frequency and pulse of TENS has yet to be determined based on a study performed by Law and Cheing (2004).
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