home use, commonly they do not position themselves properly and often set the NMES at an intensity that does not provide sufficient muscle contraction to enhance strength gains. For patient positioning, consider having the patient sit in a stable chair. The patient can use a Velcro strap or towel to secure their lower leg to the leg of the chair, allowing for 60 degrees of knee flexion. The electrodes should be placed over the lateral thigh proximally (over the quadriceps muscle) and over the medial thigh distally (over the quadriceps muscle; Figure 8). Figure 8: NMES Electrode Placement
intervention, other interventions, such as gait retraining or unloader braces, may be warranted to change the way that the patient moves and to reduce the risk for future OA progression. Stretching and manual therapy The loss of knee range of motion is common among individuals with knee OA. Stretching and joint mobilizations may be a method to help reverse existing joint contractures and limited mobility within the knee joint. Loss of knee extension in patients with knee OA is a risk factor for requiring a total knee arthroplasty (TKA) in the future. It is therefore conceivable that interventions that improve knee extension range of motion and eliminate knee flexion contractures may have a lasting long-term benefit to the patient, although prospective controlled studies on the effect of stretching are limited. One aspect of manual therapy that is applicable to patients with knee OA is joint mobilizations and the restoration of normal arthrokinematic motions. A study by Fitzgerald et al. found that patients who received manual therapy in addition to an exercise program had greater scores on self-reported functional measures and were more likely to respond to the treatment sessions (Fitzgerald et al., 2016). Another recent study found that both exercise and manual therapy improved function for patients with OA compared to usual care (Abbott et al., 2013), but using exercise or manual therapy alone was more cost-effective than using both (Pinto et al., 2013). Including manual therapy appears to be effective for patients with knee OA, and it should be included in a course of care when appropriate. Exercise considerations in therapy Although exercise can be beneficial to the large majority of individuals with knee OA, physical therapists should make sure to screen all patients for contraindications prior to starting any new intervention. Recent surgery, excessive joint laxity, acute inflammatory processes, or history of tendon rupture may make the patient more prone to injury with a strengthening or stretching program. If the physical therapist chooses to include an exercise program, he or she should monitor for negative reactions during the course of care. Soreness rules have been developed to help monitor and appropriately progress patients with musculoskeletal and joint pathology. These rules were originally published for patients with throwing injuries (Fees, Decker, Snyder-Mackler, & Axe, 1998), but they have been adopted for patients with lower extremity musculoskeletal pathology, including anterior ligament reconstruction damage (Adams, Logerstedt, Hunter-Giordano, Axe, & Snyder-Mackler, 2012). The soreness that is evaluated is specific to the area of injury or pathology, not to be confused with muscle soreness that is normal after exercise. In general, these guidelines state that if no soreness is present, the activity can be advanced one level, be it a functional progression or an increase in intensity by increasing the repetitions, sets, resistance, speed, or duration of the exercise. If the patient has soreness during warm-up that does not go away or if soreness redevelops during the activity, then the patient should rest for 2 days and drop down one level in the activity. If the patient has soreness during warm-up that goes away, the activity should not be advanced, but remain the same level. Although there are standard exercise programs, the rate at which the patient progresses will be different for each individual. Implementing guidelines for when to restrict progression, such as the soreness rules or in the presence of persistent effusion, should be considered for all interventions (Table 1).
Large electrodes should be placed on the thigh to improve patient comfort while maximizing intensity during NMES treatment for quadriceps weakness. Note. From Western Schools, 2018. Large electrodes should be used to improve patient comfort during the stimulation. A protocol that includes a few seconds of ramp-up time, 15 seconds of on time, and 45 seconds of off time may be suitable patients with knee OA. The important aspect is the intensity of the treatment. The intensity should be set to the maximum tolerable level, and the patient should be encouraged to increase the intensity during the treatment because the effect often wanes during use. This protocol should be completed twice per week for patients with substantial muscle weakness. Similar protocols can be used in the clinic, but consider placing the patient in a dynamometer during testing so actual force production during the NMES can be monitored. A recent study evaluated the effectiveness of NMES for patients with knee OA (Vaz et al., 2013). These researchers used a progressively greater dose of NMES over the course of 8 weeks. To start, patients had 10 seconds of contraction time followed by 50 seconds off for 18 minutes using rectangular biphasic symmetric current with a pulse duration of 400 µs and 80 Hz frequency. This progressed to 10 seconds of on time followed by only 20 seconds of off time for 32 minutes. Subjects who followed this protocol had improved strength, reduced pain, and greater functional ability at the conclusion of the study. A recent systematic review and meta-analysis evaluated whether strengthening programs improved biomechanics, as well as function and pain (Ferreira et al., 2015). This review found three studies that compared a strengthening intervention to a sham intervention that did not include strengthening for patients with knee OA. In all three of the studies, there was an improvement in clinical measures such as pain and function, but there was no reduction in the adduction moment. As previously described in this course, the adduction moment is a predictor of knee OA progression and higher moments increase this risk. Therefore, even if patients make clinical improvements with a strengthening Modalities Modalities are most commonly applied to patients with knee OA to reduce joint pain and swelling that often accompanies exercise. Ice, heat, and transcutaneous electrical nerve stimulation (TENS) are modalities that are maintained and used by most physical therapists. Ice and heat often are used as adjunct therapies to reduce knee symptoms before or after
exercise in the clinic and at home. Because there is little cost to ice or heat and patients subjectively report relief with these modalities, these are recommended for home-based and clinic treatments of knee OA. However, modalities should not be done in isolation and should accompany exercise therapy.
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