Physical activity Increasing low levels of physical activity is generally considered a beneficial recommendation for patients with knee OA. With the advent of low-cost pedometers and the large number of step-counting smartphone applications, it has become easier for patients and therapists to obtain objective measures of walking activity. A cross-sectional study found that walking fewer than 2,500 steps per day was related to slower walking speeds and worse functional performance. Because this was a cross-sectional study, it cannot be determined whether the low physical activity was the result or cause of the worse functional performance. However, a longitudinal study by White et al. found that low levels of physical activity preceded and predicted worsening of function at future time points (White et al., 2014). The authors of this study concluded that walking at least 6,000 steps per day was a good initial target for preventing functional decline in the future. Each additional 1,000 steps reduced the risk of functional decline by an additional 16% to 18%. Therefore, 6,000 steps Knee joint injections Joint injections are not within the practice guidelines of physical therapists or physical therapist assistants, but it is important to identify patients who may benefit from injections. There are two main types of injections: corticosteroid and hyaluronic acid (HA). Corticosteroid is considered a palliative and analgesic treatment that acts to reduce inflammation and pain within the joint. HA injections may have a palliative effect, but consist of a viscous substance that is normally found within the knee joint, but is reduced in older adults and patients with knee OA. Therefore, HA injections are thought to restore more normal levels of HA within the joint, which may offer some chondroprotective effect. The effect of corticosteroid is believed to be more immediate, but persists for a shorter period of time. For physical therapists, the timing of rehabilitation may be influenced by the timing of these injections. For example, starting exercise therapy in the weeks after a knee injection may allow the individual to tolerate more progressive strengthening exercises. The combination of these treatments may have a more synergistic effect than either intervention alone. The steroid injection may only alleviate pain without addressing weakness
is a good target for patients with knee OA, and it can be used as a starting point when developing a walking intervention for patients with knee OA. There is some concern that more walking may cause the joint to deteriorate faster by increasing the frequency and duration of the load within the joint. However, results from a large observational study found that more walking was not related to worsening of radiographic knee OA. When considering this and other studies on the topic, it suggests that walking is an activity that does not cause destruction of the cartilage within the joint, but rather offers a protection against functional decline in the same group of individuals. Developing walking plans and interventions for patients with knee OA, using pedometers or phone applications to quantify the number of steps per day, should be included as part of a comprehensive rehabilitation strategy for appropriate patients with knee OA. or instability, whereas strengthening alone may not be tolerated without the preceding reduction in joint pain. HA injections often are provided to patients with end-stage knee OA who do not yet wish to undergo TKA and want to pursue additional nonoperative interventions. However, the benefit of performing HA injections for this patient population is conflicting. The American Academy of Orthopaedic Surgeons currently does not recommend the use of HA injections for patients with knee OA because there is no strong research supporting this treatment (Jevsevar et al., 2013). However, there may be some benefit to combining HA injections with other interventions, such as bracing. A 2015 retrospective case series study found that patients who received HA injections, as well as a knee unloader brace, had reduced pain (Morgan, Jensen, Lim, & Riggs, 2015). This was particularly true for patients with end-stage knee OA (Kellgren-Lawrence Grade 4). For patients with end-stage knee OA who do not yet want to undergo TKA, bracing and HA may be a viable option to improve function and reduce pain.
SURGICAL INTERVENTIONS
The focus of this course is on physical therapy management for patients with knee OA. However, it is important for physical therapists and physical therapist assistants to be aware of (1) surgical options that are currently available for patients with knee OA and (2) what characteristics may make a patient more Arthroscopy Despite the prevalence of arthroscopy for patients with knee OA, there is mounting evidence in the literature to support the contention that performing this surgery for patients with knee OA does not improve long-term outcomes. In a landmark study published in the New England Journal of Medicine, a group of individuals with radiographic evidence of knee OA and symptomatic meniscal tears were randomized to receive either surgery and postoperative physical therapy or physical therapy alone (Katz et al., 2013). The group that underwent surgery did not have better outcomes than the group that received physical Knee realignment In order to restore the normal loading environment within the knee joint, patients with a substantial valgus or varus deformity may undergo knee realignment surgery. Although there are several variations, the most common knee realignment surgery is high tibial osteotomy. In this procedure, the surgeon removes a wedge-shaped section of bone from the proximal tibia. The bone is then reunited or “closed” around the wedge-shaped opening. As a result, the angle of the tibia is altered to a more normal position. This is known as a closing-wedge high tibial osteotomy.
appropriate for surgery rather than physical therapy. In the next section, three of the most common surgeries for patients with knee OA will be discussed, as well as what makes someone a candidate for surgery.
therapy alone, and both groups demonstrated improvement at 6- and 12-month follow-ups. Although surgery may be provided as an option, it is important to inform patients that they may benefit from just physical therapy instead of surgery. Although the primary conclusion was to consider physical therapy as an alternative to surgery, nearly 30% of patients in the physical therapy group ended up having surgery for residual symptoms. Therefore, if patients do not make improvements with physical therapy, they can then be referred for surgery and will likely have positive outcomes. Although this procedure can normalize the loads within the knee joint, it is appropriate only for a small subset of patients with knee OA. Because realigning the lower extremity is thought to slow the progression of OA, it is not an appropriate surgery for patients who already have end-stage knee OA and have already lost the majority of the articular cartilage on the tibia and/or femur. A recent meta-analysis compared the outcomes of high tibial osteotomy and unicompartmental knee replacement in order to identify who the best candidate may be for each surgery (Santoso & Wu, 2017). The authors concluded that high tibial osteotomy may be best suited for younger patients who
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Book Code: PTNC1023
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