Table 1: Soreness Rules Patient-Reported Soreness During Exercise Therapy
Recommendation for Activity Progression
No soreness.
Advance one level when patient meets milestones or as recommended by healthcare professional.
Soreness 1 day after exercise.
1 day off, no progression to next level.
Soreness during warm-up that goes away. 2 days off, decrease one level. Soreness during warm-up that goes away, but returns during exercise session. Stay at current level, do not progress. Soreness during warm-up that does not resolve during warm-up or exercise. 2 days off, decrease one level. Note. Adapted from Adams, Logerstedt, Hunter-Giordano, Axe, & Snyder-Mackler, 2012.
Several clinical trials have explored the ability of TENS to reduce pain for patients with knee OA. TENS has been shown to reduce pain for patients with knee OA (Cherian et al., 2016), and the use of TENS may have a lasting and positive effect on functional ability and medication use (Cherian, Harrison, et al., Bracing There are several reasons bracing may be appropriate for patients with knee OA: to improve joint stability, to reduce joint loading, or some combination of the two. Feelings of instability, varus thrust gait, hyperextension, and knee buckling are all indications that patients may have a knee that requires external support to allow for normal activity. The braces that may be best suited for these patients consist of rigid arms on either side of the knee to reduce frontal plane motion (Figure 9). Locks at the axis of rotation may be appropriate to limit the amount of extension (for patients with hyperextension) or flexion (for recurrent knee buckling). Braces can also be prescribed to unload compartments of the knee that may be painful or show signs of OA damage. For example, medial compartment unloader braces are designed to reduce the load in the medial tibiofemoral compartment during weight-bearing activity. These braces have rigid supports on the medial and lateral side of the knee to reduce frontal plane motion. Dynamic components built into these braces, such as straps, pneumatic devices, or dials/cranks, change the angle to reduce the knee varus position and place the knee in a more abducted or valgus position. By changing the joint angle, the forces in the medial knee compartment, along with the adduction moment, are reduced. Because the adduction moment and compressive forces in the medial compartment are thought to play a role in OA initiation and progression, these devices may provide a mechanism to prevent worsening of Shoe wedges and footwear Wedges placed inside of the shoe can change how the foot interacts with the ground. By moving the center of pressure of the foot more laterally, as done with laterally wedged insoles, the adduction moment at the knee can be reduced. There have been numerous studies over the past 10 years evaluating whether or not shoe wedges produce a clinically meaningful change in function, pain, or biomechanics, but to date, these wedges have not consistently shown benefit for patients with knee OA. For this reason, the American Academy of Orthopaedic Surgeons has a recommendation with a moderate level of evidence against the use of laterally wedged insoles for patients with knee OA (Jevsevar et al., 2013). There are other methods of reducing the adduction moment by manipulating shoe properties. Variable-stiffness shoes have a medial portion of the sole that is softer and more compliant than the lateral side. This produces a similar effect to laterally wedged insoles and shifts the center of pressure toward the Movement retraining Movement retraining is an umbrella term that encompasses many different types of treatments, including balance exercises, gait training, perturbation training, Tai Chi, and others. The appropriateness of these interventions is based on patient
2015). A recent review that also included a cost-benefit analysis found that TENS was a modality that demonstrated a treatment effect, while being of low cost (Woods et al., 2017). From an economic standpoint, this is a high-value modality that should be considered for appropriate patients with knee OA. radiographic and symptomatic OA. Recently, a clinical trial that evaluated the effect of unloader braces found that it reduced pain, improved function (Cherian, Bhave, et al., 2015), and delayed the need for TKA in patients with knee OA (Chughtai et al., 2016). Despite the potential benefit of these braces, many patients do not wear them as prescribed, and there is low adherence outside of the clinic (Squyer, Stamper, Hamilton, Sabin, & Leopold, 2013). The therapist should educate the patient about the benefit of the device, as well as ensure proper fit and comfort to help encourage patient use. Figure 9: Unloader-Type Knee Brace
An unloader knee brace can be used to provide stability to the knee joint, while also reducing the forces through one side of the tibiofemoral articulation. Note. From Western Schools, 2018.
lateral side of the foot and reduces the adduction moment at the knee (Teoh et al., 2013). While these changes to the shoe may alter biomechanics, longitudinal studies are needed to determine whether or not they have a protective effect against OA progression at the knee. A recent systematic review of the effect of footwear on joint pain and function was unable to draw any definitive conclusions. The authors found that there was growing evidence to support the notion that shock-absorbing insoles and avoidance of high heels and sandals may have some protective effect later in life, but there was no conclusive evidence that lateral wedges for patients with existing knee OA had a beneficial effect (Wagner & Luna, 2016). When talking with patients at risk for OA due to abnormal knee alignment, obesity, or joint pain, recommending the use of accommodating footwear and recommending against wearing high heels may have future benefit.
impairments, patient needs, and patient goals. For example, for a patient who presents with quadriceps weakness, knee pain, and a history of multiple falls, it may be beneficial to include balance training in addition to quadriceps strengthening and
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Book Code: PTNC1023
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