Although not considered required items in the OARSI recommendations, two additional measures should be considered if time allows and the space is available. The TUG test commonly is used for older adults. Normative values and cutoff values for fall risk in older adults are available. This test evaluates not only the ambulation portion of mobility, but also the ability to transition from a seated to standing position and vice versa. Transitional activities can be difficult for patients with knee stiffness, quadriceps weakness, or poor balance, which are common in individuals with knee OA. The 6-minute walk test is an important addition to the functional evaluation of patients with knee OA. Although this test was originally developed as a test for cardiac and pulmonary patients with endurance problems, it is also beneficial for evaluating patients with knee OA. Walking distance often is limited in patients with knee OA,
whether it is secondary to pain, weakness, or cardiopulmonary deconditioning. The 6-minute walk test may serve as an important objective measure of walking ability for patients with knee OA before and after physical therapy interventions. Before performing any performance-based tests of function with patients who have knee OA, the therapist should evaluate whether the test is appropriate. Patients who have additional comorbidities that affect cardiovascular function, balance, or vision should be screened for safety prior to any activity. Additional safety devices, including gait belts or additional supervision, may be warranted for patients with a history of falling, knee buckling, balance deficits, or severe mobility impairments.
PHYSICAL THERAPY INTERVENTIONS FOR KNEE OA
Physical therapy treatments for patients with knee OA can be broadly classified into either palliative or preventive. Palliative interventions primarily target symptoms such as pain or stiffness. Preventive interventions are designed to prevent or slow the onset or progression of the disease. Because knee OA is considered a progressive condition, interventions that slow or halt the symptomatic and structural progression are extremely valuable. There is no evidence to support claims that Exercise Exercise is a core component of interventions for many musculoskeletal conditions. A systematic review and analysis published in 2015 found that exercise is beneficial for individuals with knee OA (Fransen et al., 2015). The authors concluded that land-based exercises for patients with knee OA resulted in immediate improvement in pain and function and, in many cases, had a sustained benefit up to 6 months after the intervention. A different study that evaluated what type of exercise was optimal for patients with knee OA concluded that programs that target muscle strengthening, lower extremity function, or aerobic capacity provide equivalent pain relief and functional improvement. The study also found that single-type exercise programs were best, meaning that the physical therapy intervention should focus on doing one type of exercise well, rather than a multitude of different exercises. The term “exercise” can encompass many different physical therapy interventions. This section will specifically focus on strengthening and stretching interventions. Additional general exercises that can be classified as physical activity or movement retraining exercises will be discussed in subsequent sections of this course. Strengthening Muscle weakness is present in almost all patients with lower extremity knee OA. As previously discussed, this weakness may arise from disuse atrophy, neuromuscular activation deficits, muscle inhibition due to pain or swelling, or from morphological changes to the muscle tissue, including increased intramuscular fat deposits. Addressing lower extremity weakness in patients with knee OA is an essential component of rehabilitation. Patients with knee OA who are weaker have worse functional performance (Ruhdorfer et al., 2016) and weakness may actually be a risk factor for future OA (Øiestad et al., 2015). Muscle strengthening can take many forms; it can be land-based or aquatic, consist of closed- or open-chain activities, and include muscle-specific training or global lower extremity exercises. Whether the program consists of targeted or general muscle training (Lun, Marsh, Bray, Lindsay, & Wiley, 2015) or open- vs. closed-chain exercises (Tanaka, Ozawa, Kito, & Moriyama, 2013), the patient will likely receive some benefit. Recent clinical practice guidelines that evaluated treatments for patients with knee OA concluded that there was strong evidence to support strengthening exercises and recommended including them as part of care for patients with knee OA (Brosseau et al., 2017).
any intervention, physical therapy or otherwise, can reverse the structural damage caused by the disease, but interventions that reduce symptoms, prevent functional decline, and reduce abnormal joint loads are recommended for patients with knee OA. Most physical therapy programs for patients with knee OA have focused on a combination of palliative and preventive treatments to allow patients to resume functional activities with lower levels of pain. When performing strengthening exercises with patients with knee OA, it is important that the exercises be progressive. The intensity, duration, resistance, or number of repetitions should be progressed when implemented as part of a rehabilitation program. A recent randomized controlled trial compared progressive resistive exercises for patients with knee OA to a control group that did not receive therapy (Jorge et al., 2015). The authors performed all exercises at 50% to 70% of the patient’s one-repetition maximum for the knee extensors, knee flexors, hip abductors, and hip adductors. This was reassessed every other week to make sure the resistance progressed as patients got stronger. Patients who received the progressive strengthening demonstrated a significant improvement in not only strength, but also pain, function, and quality of life. The authors comment that the progressive nature of the intervention is important for patients to make continued gains with treatment. There has been emerging evidence to support the use of eccentric strength training for patients with knee OA. A recent case study found that eccentric strengthening for a patient with knee OA improved pain, function, and muscle morphology (Hernandez, McIntosh, Leland, & Harris-Love, 2015). There are ongoing clinical trials to determine whether using an eccentric strengthening program for patients with knee OA is more beneficial than traditional concentric strengthening interventions (Jegu, Pereira, Andant, & Coudeyre, 2014). Strengthening programs for patients with knee OA can be augmented with the use of neuromuscular electrical stimulation (NMES). A recent randomized controlled trial compared an exercise intervention alone to an exercise intervention that included NMES to the quadriceps femoris. This study found that patients who received NMES had less pain and greater voluntary muscle activation of the quadriceps femoris at the end of the study (Elboim-Gabyzon, Rozen, & Laufer, 2013), but patients in both groups showed improvement for all other measures. A 3-month follow-up study found that subjects who also received NMES had lower pain, but there were no differences in strength or function between groups. Therefore, NMES may have the largest effect on pain, rather than improving muscle strength for patients with knee OA. When using NMES to improve muscle strength, there are many different protocols that can be used at home or in the clinic. Specific actions can be taken to help standardize NMES treatment, maximize patient benefit, and reduce patient discomfort. When patients have a portable NMES unit for at-
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Book Code: PTNC1023
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