Cliborne et al. (2004) investigated the role of the hip in treatment of patients with knee OA. The investigators found that some patients benefit from mobilization of the hip joint to provide relief of knee OA pain and mechanical dysfunctions, while others did not. Further investigation was carried out by another research group, and a clinical prediction rule was created to identify patients with knee OA who would benefit from mobilization of the hip. Five variables were identified as indicators of patients likely to benefit from hip mobilization including: ● Hip or groin pain or paresthesia. ● Anterior thigh pain. ● Passive knee flexion <122°. ● Passive hip internal rotation <17°. ● Pain with hip distraction. (Currier et al., 2007) If two variables are present the likelihood ratio is 12.9 with a 97% probability of success with hip mobilization. Exercises should consist of active range of motion stretches, muscle strengthening, stretching, and lower-extremity aerobic exercise such as working out on a stationary bicycle or elliptical machine. Home exercises may be prescribed by the supervising physical therapist to support progression of functional ability. Prescribed strengthening exercises may include the quadriceps, hamstrings, gluteals, hip rotators, hip abductors, hip adductors, and core-stabilizing muscles. Quadriceps strengthening should include (at a minimum) static quad sets and standing terminal knee extensions performed with a resistance band. Progression of closed- chain exercises should be performed to enhance functional activity tolerance. These may include partial squats, using upper-extremity support if needed, and step-ups with verbal and visual cuing to maintain proper knee alignment. Lower- extremity stretches may include the gastrocnemius, soleus, hamstrings, and quadriceps muscles. A systematic review of the scientific literature reveals high- level evidence for exercise and patient education to reduce body weight, reduce pain, and improve functional abilities in patients with knee OA. There is mid-level quality evidence that acupuncture and transcutaneous electric stimulation is beneficial for pain reduction in patients with this impairment. Furthermore, there is moderate-level evidence that low-level laser and psycho-educational interventions are helpful in lowering pain levels (Jamtvedt et al., 2008). A randomized trial of arthroscopic surgery for the treatment of knee OA revealed no additional benefit over physical or medical therapies. In this study, participants were randomized into either the surgical group, or an “optimized physical therapy and medical therapy group” in which they received one hour of physical therapy once per week for 12 weeks. These participants each received a home exercise program focusing on areas of impairment unique to them. Instruction was provided for activity modification including activities of daily living, stair use, and modalities for pain modulation. Surgical participants received synovectomy, debridement, excision of degenerative tears of menisci, fragments of articular cartilage, or osteophytes, depending on impairments unique to the patient. The surgical participants also received physical therapy and medication following their procedure. Post-treatment WOMAC scores were not significantly different between the two groups, demonstrating equal effectiveness of conservative management for the treatment of moderate knee OA (Kirkley et al., 2011).
pain and classical radiographic findings of OA of the knee, including articular cartilage degradation, joint-space narrowing, and osteophyte formation. Radiographic findings are considered the gold standard in diagnosing knee OA; however, the causal relationship between radiographic OA and its primary clinical signature (patient report of pain) remain poorly understood. This is mostly because in several large-scale studies of adults with knee pain, only about half demonstrated evidence of OA on radiographic films. On the other hand, of all subjects demonstrating radiographic evidence of OA, only half reported pain (Swagerty & Hellinger, 2001). It is thought that there is a relationship between severity of knee OA and pain, as research subjects with severe OA were more likely to report pain than subjects with less severe OA. Similarly, MRI studies have identified relationships between pain and findings of synovial thickening, effusion, bone marrow lesions, and meniscal tears; however, converse studies demonstrated similar findings on MRI, yet no patient-reported pain or radiographic evidence of degeneration (Kittleson et al., 2014). There has been a movement recently toward phenotyping pain in patients with knee OA, promoting the idea that tailoring pain care to each person’s experience will result in better targeted pain therapy. Different phenotypes currently being analyzed for sub-categorization include pain, stiffness, knee instability, and functional deficits. A new conceptual model for knee OA pain emphasizes the importance of contributing factors from three domains: (1) knee OA pathology, (2) psychological distress, and (3) neurophysiological changes in pain processing (Kittleson, 2014). Knee pathology includes structural abnormalities, joint loading and alignment, quadriceps dysfunctions, and joint inflammation. Quadriceps muscle weakness appears to be strongly related to presence of pain, which suggests that the inability to attenuate forces surrounding the knee joint could play a crucial role in the patient’s experience of pain. Psychological distress includes fear and avoidance beliefs, pain catastrophizing, self-efficacy issues, and depression. There is evidence that high levels of self-efficacy and successful self-management strategies are associated with improved pain levels and better functional outcomes. Pain neurophysiology includes reduced pain thresholds, temporal summation, spreading sensitization, and impaired descending modulation. Descending modulation of nociception has been shown to be disrupted in people with OA (Kittleson et al., 2014). Management of patients with knee OA should include a comprehensive program of manual therapy and supervised clinical exercise. Deyle et al. (2005) demonstrated that patients receiving manual therapy and clinical exercise vs. exercise alone showed two times greater improvement on the WOMAC outcome measure. Manual therapy should be tailored to the needs of the patient based on objective findings and may include passive physiological and accessory movements, muscle stretching, and soft-tissue mobilization. Specifically, mobilization Grades III and IV performed for 2 to 6 rounds of 30 seconds per technique may be performed for loss of knee extension or flexion. Grade IV patellar glides performed with the knee in 5 to 10° of flexion may be performed in the direction of determined restriction to promote knee flexion and extension, including medial, lateral, caudal, and cephalad. Graded joint mobilizations to the hip, lumbar spine, and ankle, depending on limitation in passive or active movement, should be provided as well (Deyle et al., 2005).
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