Physical Therapy Management of Knee Osteoarthritis.2

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Physical Therapy Management of Knee Osteoarthritisin the Middle-aged Athlete

Thomas Adams, PT, DPT, CSCS,* Debra Band-Entrup, PT, BS,*wScott Kuhn, PT, MS, ATC,*Lucas Legere, PT, MS,wKimberly Mace, PT, MS, CSCS,wAdam Paggi, PT, DPT,wand

Matthew Penney, PT, DPT, SCS, ATC*

Abstract: Osteoarthritis (OA) is prevalent in todays population,including the athletic and recreationally active middle-agedpopulation. OA is a degenerative condition of the articular/hyalinecartilage of synovial joints and commonly affects the knee joint. Ingeneral, athletic participation does not specifically influence ahigher incidence of knee OA in this population; however, traumatic

injury to the knee joint poses a definitive risk in developing early-onset OA. The purpose of this article is to review evidence-basednonpharmacological interventions for the conservative manage-ment of knee OA. Manual therapy, therapeutic exercise, patienteducation, and weight management are strongly supported in theliterature for conservative treatment of knee OA. Modalities[thermal, electrical stimulation (ES), and low-level laser therapy(LLLT)] and orthotic intervention are moderately supported in theliterature as indicated management strategies for knee OA. Whilemany strongly supported conservative interventions have beenpublished, additional research is needed to determine the mosteffective approach in treating knee OA.

Key Words: osteoarthritis, knee, athlete, physical therapy, reha-

bilitation, intervention, manual therapy, therapeutic exercise,

modalities

(Sports Med Arthrosc Rev 2013;21:210)

Arthritis is the most common cause of disability amongUS adults1 with costs attributable to arthritis and otherrheumatic conditions estimated at $128 billion in 2003. 2 In2005, approximately 27 million US adults were diagnosedwith clinical osteoarthritis (OA) affecting quality of lifethrough pain and functional limitations.3 The number ofUS adults with arthritis is projected to rise to 67 million by2030.4

Recent research reports increased prevalence of kneeOA among middle-aged athletes and former professional

athletes. In a New Zealand study of 22 male ex-table tennisplayers, 78% of the players displayed radiologic evidence ofknee OA as compared with 36% in age-matched and sex-matched controls.5 In a 2012 systematic review out of theNetherlands, between 60% and 80% of former elite soccerplayers developed radiologic evidence of knee OA.6 Inaddition, a study in the United Kingdom in 1996 suggestedhigher incidence of OA in female, ex-athletes (tennis playersand middle- distance, long-distance runners) aged 40 to 65compared with age-matched controls.7

The Osteoarthritis Systematic International Reviewand Synthesis Organization (OASIS) in 2006 presentedrecommendations for patients with knee OA regardingappropriate physical activity participation. They concludedthe 3 highly modifiable risk factors for symptomatic kneeOA are obesity, injury, and occupations involving excessivemechanical stress.8

For sports and recreational activity, OASIS suggests acorrelation between activities representing risk factors forknee OA and intensity and duration of exposure. The groupalso states that risk of OA is associated more with history oftrauma and obesity than with sport participation in general.The group recommends athletes to be informed that jointtrauma is a greater risk factor than mere activity or sportparticipation. Additional evidence concludes that OA riskis associated with duration and intensity of exposure inhigher level activities. The clinical consensus of OASISstated patients with OA participate regularly in recreationalsports as long as the activity does not cause pain, butshould be encouraged to change sports that involve activ-ities at risk for joint trauma.8

Other research groups have studied OA to compiletreatment protocols and interventions for conservativemanagement of the disease. For example, the AmericanCollege of Rheumatology in 2010 to 2011, convened aTechnical Expert Panel to update recommended guidelinesfor nonpharmacological and pharmacological managementof OA of the hand, hip, and knee. The Technical ExpertPanel performed extensive literature reviews and evaluatedthe best available evidence for specific interventions for theconservative management of hand, hip, and knee OA9

(Table 1).Another scientific study group, the Osteoarthritis

Research Society International (OARSI), developedguidelines for conservative management of hip and kneeOA. The OARSI group first released their guidelines in2007 with updated recommendations in 2008. Overall, theypresented 23 recommended interventions for the treatmentof hip and/or knee OA, based on opinion alone, researchevidence or both. However, despite the groups high ratingsfor a core set of pharmacologic and nonpharmacologicrecommendations, OARSI admits that the consensus rec-ommendations are not always supported by the bestavailable evidence.10 Other recommended interventionsinclude patient education regarding lifestyle modification,activity pacing, exercise, weight reduction, knee bracing,and appropriate footwear/orthoses/wedging devices.11

MANUAL THERAPYSymptoms associated with knee OA may result from

restricted soft-tissue mobility and adhesions as a result of

From the *Advanced Sports Therapy, Wellesley; and wOrthopedic andSports Physical Therapy, Boston, MA.

Disclosure: The authors declare no conflict of interest.Reprints: Matthew Penney, PT, DPT, SCS, ATC, Advanced SportsTherapy, 62 Walnut Street, Wellesley, MA 02481.

Copyright r 2013 by Lippincott Williams & Wilkins

REVIEW ARTICLE

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recurrent inflammation of both intra-articular and peri-articular tissue. Resultant adhesions may alter bio-mechanical forces on articular surfaces by restricting jointmovement therefore creating additional symptoms. Manualtherapy has been hypothesized to counteract some of thesephysiological changes through reduction of adhesions andimproved range of motion (ROM), therefore breaking theinflammatory cycle associated with progressive OA.12

Benefits of manual therapy include improved joint

mobility and ROM, reduced soft-tissue contracture andfibrosis, decreased pain, and improved function. Althoughsome might propose that knee OA symptom relief mayoccur with rest or knee joint unloading, research byMangione and Axen13 has shown that unweighting of theknee through deweighted treadmill training has not relievedpain in patients with knee OA. Deyle and colleagues havereported 20% to 40% pain relief from patients in 2 to 3clinical treatments of manual therapy and exercise. Thisrapid reduction in symptoms implies the structuresresponsible for at least a portion of patients pain are notuncontrollable aspects of OA pathology; therefore peri-articular connective or muscular tissue could potentiallygenerate symptoms.14 Repeated tension challenges to these

tissues with manual therapy techniques such as end-rangepassive stretching and active ROM provide a strong stim-ulus for pain relief.

Other proposed benefits of manual therapy includemechanical alteration of tissue, neurophysiological effects,and psychological influence. Joint mobilization has beenshown to induce immediate hypoalgesia in individuals withknee OA with a concurrent improvement in function.15

Moss and colleagues demonstrated immediate reduction in

pain pressure threshold after joint mobilization in patientswith knee OA, further supporting hypoalgesic effects foundin other studies. The positive hypoalgesic affects arebelieved to occur through stimulation of mechanorecep-tors and activation of pain inhibitory cortical systems.16

Sambajon and colleagues has demonstrated nearly 70%decreased concentration of prostaglandin PGE2 24 hoursafter repetitive mobilization in a healthy in vitro animalstudy. As an inflammatory mediator, prostaglandin PGE2is implicated in arthritic hyperalgesia, which may sensitizeperipheral nociceptors.17 The authors of this study havefound that the hypoalgesic effects of manual therapy oftenimprove patients participation in therapeutic exercise inthose who are limited by pain.

Knee joint mobilization techniques focus on accessorymovement of both the tibiofemoral joint and the patello-femoral joint as both articulations have been shown to beaffected by soft-tissue restrictions associated with kneeOA.18 Benefits have been reported for various amplitudesof joint mobilization. Moss and colleagues concluded thatlarge amplitude (Maitland Grade III19) anterior-posteriorglide of the tibia on femur (supine, slight knee flexion)combined with pain-free oscillatory glides (Maitland GradeI, II19) of the tibia improved pain levels 3 to 4 times greaterthan a control group not receiving joint mobilization.Performance during Sit-To-Stand and Timed Up and Gotesting also showed significant improvement in the jointmobilization group.15

Pollard and colleagues demonstrated that a combina-tion of knee joint mobilization techniques decreasedpatients pain and crepitus, while also improving patientssatisfaction, general function, and joint mobility. The firsttechnique in the study was active knee ROM from 90degrees of flexion (Fig. 1) through as much pain-freeextension possible while a sustained inferior patella glidewas applied to the superior pole of the patella (Fig. 2). Thetechnique was performed to minimize the natural superiorglide of the patella and to decrease compressive forces ofthe patella into the femoral trochlea. The second techniqueconsisted of a grade IV posterior tibial mobilization whileapplying a tibial traction force near full knee extension20

(Fig. 3) (Table 2).

Connective tissue is known to lose extensibility relatedto the physiological aging process and is believed to occursecondary to collagen adaptation. The diminished extensi-bility combined with joint degeneration in patients withknee OA may cause loss of terminal knee extension andflexion ROM.21 Loss of full knee extension ROM has beenshown to result in abnormal joint arthrokinematics withsubsequent increases in patellofemoral and tibiofemoral

joint contact pressure.22 Weng and colleagues has demon-strated ROM of the arthritic knee joint as the main factorresulting in muscular weakness during isokinetic exercise.Therefore, when developing a program for an athletic orrecreationally active patient with knee OA, improving knee

joint ROM is a vital consideration.20

The authors of this study include static and proprio-ceptive neuromuscular facilitation (PNF) stretching torestore muscle length of the lower extremity. In athletes

TABLE 1. Nonpharmacologic Recommendations for theManagement of Knee Osteoarthritis

We strongly recommend that patients with knee osteoarthritis(OA) should do the followingParticipate in cardiovascular (aerobic) and/or resistance land-

based exerciseParticipate in aquatic exerciseLose weight (for persons who are overweight)We conditionally recommend that patients with knee OA should

do the followingParticipate in self-management programsReceive manual therapy in combination with supervised exerciseReceive psychosocial interventionsUse medially directed patellar tapingWear medially wedged insoles if they have lateral

compartment OAWear laterally wedged subtalar strapped insoles if they have

medial compartment OABe instructed in the use of thermal agentsReceive walking aids, as neededParticipate in tai chi programs

Be treated with traditional Chinese acupuncture*Be instructed in the use of transcutaneous electrical stimulation*We have no recommendations regarding the followingParticipation in balance exercises, either alone or in combination

with strengthening exercisesWearing laterally wedged insolesReceiving manual therapy aloneWearing knee bracesUsing laterally directed patellar taping

*These modalities are conditionally recommended only when the patientwith knee OA has chronic moderate to severe pain and is a candidate fortotal knee replacement but either is unwilling to undergo the procedure, hascomorbid medical conditions, or is taking concomitant medications that leadto a relative or absolute contraindication to surgery or a decision by thesurgeon no to recommend the procedure.

Reprinted from Hochberg et al

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with permission from publisher JohnWiley & Sons Inc. This material is copyrighted and any further reproductionor distribution requires written permission from John Wiley & Sons Inc.

Sports Med Arthrosc Rev Volume 21, Number 1, March 2013 Physical Therapy Management of Knee Osteoarthritis

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with knee OA, joint capsule extensibility and quadricep,hamstring, hip flexor, gastrocnemius, and soleus muscle

length must be assessed because of their impact on kneefunction and their function when participating in athletics.Reid and McNair demonstrated a significant increase inknee extension ROM (mean, 7.7 degrees) after a 6-weekstretching program focusing on the above-mentionedlower-extremity muscle groups. The stretching interventionutilized supervised and independent stretching sessions. Therelevance of the study demonstrates the importance ofindependent stretching exercises as an effective piece oflong-term knee OA management.21

Weng and colleagues compared isokinetic muscularstrengthening exercise (group I), isokinetic exercise withstatic stretching (group II), and isokinetic exercise withPNF stretching (group III) in patients with knee OA. All

groups demonstrated a significant reduction in knee painand disability with increased peak muscle torques aftertreatment and at follow-up. However, only groups II and

III had significant improvements in knee extension andflexion ROM, with group III demonstrating the greatestincrease in ROM. Group III also demonstrated the greatestincrease in muscle strength gain during 180 degrees/secondangular velocity peak torque testing.20 The study resultsprovide evidence that PNF stretching may be more effectivethan static stretching in the treatment of knee OA.

THERAPEUTIC EXERCISE

Research has reported a correlation between increased

physical activity and decreased pain levels, improvedfunction, and delayed disability. At least 30 minutes ofmoderate physical activity over a minimum of 5 d/wk isrecommended by the Centers for Disease Control in specificregards to OA.23 Participation in regular physical activityhas been shown to provide significant benefits in thetreatment of knee OA, whereas failure to remain active mayexacerbate impaired joint mechanics and potentially resultin articular cartilage softening and matrix dysfunction,leading to accelerated cartilage degeneration.24 Also, indi-viduals without knee OA who opt to exercise will not haveincreased progression of joint degeneration as a result oftheir increased physical activity; indeed, they can poten-tially expect reductions in knee pain and disability as the

years progress.25Repetitive loading of the arthritic knee joint can force

compensatory movement and muscular recruitment

FIGURE 1. Sustained inferior patella glide in 90-degree kneeflexion.

FIGURE 2. Sustained inferior patella glide nearing terminal kneeextension.

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patterns of the lower extremity. Liikavaino studied gait andmuscle activation changes in subjects with knee OA toexamine both level and stair walking biomechanics. Theauthors observed minor differences in gait kinetics duringlevel-walking at each predetermined gait speed in patients(mean age 59 y) with knee OA as compared with healthyage-matched and sex-matched control subjects. However,patients with knee OA exhibited approximately 18% to

26% lower maximal loading rate, indicative of lighterloading of their lower extremities. The differences in forceloading parameters were magnified during more demandingmotor tasks such as stair descension at higher speeds.Patients with knee OA demonstrated significantly higherinitial peak and maximal horizontal acceleration and

decreased attenuation of the shock wave. Furthermore,these findings were supported by changes in muscularrecruitment during all activity. The authors hypothesizedthat an overall decrease in muscle strength and power insubjects with knee OA was secondary to both vastusmedialis and biceps femoris infrequent muscle activationwhile using different strategies to execute the same tasks.26

Lower-extremity strength disparities also were high-lighted by Costa who studied 25 patients with unilateralknee OA,25 with bilateral knee OA (both with mean age56 y) and 50 matched controls by using a Visual AnalogScale (VAS), Knee Lequesne Index, Western Ontario andMcMaster University Arthritis Index (WOMAC) ques-tionnaire, and a Cybex (Chattanooga, TN) isokinetic

assessment. For the unilateral and bilateral knee OAgroups, significantly lower peak torque was found for hipflexion, extension, abduction, adduction, medial rotation,and lateral rotation at all velocities on the ipsilateral side.Even in patients with unilateral knee OA, a similar decreasein peak torque was found on the contralateral hip whencompared with controls, potentially suggesting whypatients with knee OA have both impaired lower-extremitymuscular strength and biomechanics.27

Traditionally, exercise programs for knee OA havefocused on impairments associated with lower-extremity

FIGURE 3. Caudal tibial traction coupled with posterior tibialglide.

TABLE 2. Common Knee Impairments Addressed by Manual Therapy

Impairments Manual Intervention Typical Delivery

Loss of kneeextension

Manual mobilization through range of motion(ROM) and knee extension at end rangeKnee extensionKnee extension with valgus or abductionKnee extension with varus or adduction

Mobilizations grades III and IV to III ++ and IV ++ 2-6 bouts of30 s/manual technique

Clinical observation: this manual intervention may provide near-immediatedecrease of symptoms and may be approached with relatively more vigorthan knee flexion

Loss of kneeflexion

Manual mobilization through ROM and kneeflexion at end rangeKnee flexionKnee flexion plus medial (internal) rotation

Mobilization grades of III and IV to III+ and IV 2-6 bouts of30 s/manual technique

Clinical observation: pain with end-range knee flexion may be due todegenerative meniscal tears: end-range techniques should be utilized withcaution

Loss ofpatellarglides

Manual mobilization of the patella in 5-10degrees of knee flexionMedialLateral

CaudalCephalad

Mobilization grades of IV to IV ++ 2-6 bouts of 30 s/manual techniqueClinical observation: some patients may be intolerant of even slight

compressive forces over the patella; therapist hand placement isimportant

Muscletightness

Manual stretches at end length of muscleQuadriceps femoris

HamstringsGastrocnemiusAdductorsIliopsoasTensor fascia latae and iliotibial band

Sustained manual stretches of 12-30 s duration repeated 1-3 times permanual technique

Clinical observation: the lumbar spine should be manually stabilized andprotected during all extremity stretches; particularly hip flexor stretches;many of these patients also will have arthritic changes in the spine, andsymptoms can be increased without care in positioning

Soft-tissuetightness

Soft-tissue mobilizationSuprapatellar and peripatellar regionsMedial and lateral joint capsulePopliteal fossa

Circular fingertip and palm pressure mobilization at the depth of thecapsule or retinaculum for 1-3 bouts of 30 s/area

Clinical observation: the soft-tissue work in the popliteal fossa seems towork best when performed slowly with occasional sustained positions of10-12 s, this technique works well when combined with the manualmobilizations into knee extension

Reprinted from Deyle et al12 with permission from the American Physical Therapy Association. This material is copyrighted and any further reproductionor distribution requires written permission from APTA.




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joint motion deficits, muscle weakness, and reduced aerobiccapacity.28 Although these impairments are associated withthe majority of patients with knee OA, many exerciseprograms inadequately focus on other aspects of ambula-tion and higher level activity such as turning, quick stop-ping, negotiating obstacles, or change in surface con-

sistency. Fitzgerald et al29 reports that a range of 11% to44% of patients with knee OA will experience mechanicalsymptoms of giving way or buckling during activities ofdaily living.

Similar mechanical symptoms are reported in patientswith a deficient anterior cruciate ligament (ACL). Extensiveresearch supports the application of perturbation trainingwith nonoperative, ACL-deficient patients. The studyresults by Axe and Snyder-Mackler30 demonstrate a moreeffective return to high-level physical activity than animpairment-based standard program by exposing individ-uals to activities that challenge the knee to potentiallydestabilizing loads during therapy. Although there appearsto be a correlation between the ACL-deficient knee and

knee OA symptomology, there is limited research measur-ing the proprioceptive decline in patients with knee OA andits subsequent effect on agility (Table 3).

Exercise prescription for individuals with knee OA hasbeen studied regarding the frequency, intensity, and modeof resistance and strength training has been found to bebeneficial for patients with knee OA. A study by Farr andcolleagues looked at resistance training on overall moderateand vigorous physical activity in 171 patients with early

knee OA. Patients (mean age, 55y) participated in aresistance-training program, a self-management program,and a combined program. The resistance-training groupparticipated in 1-hour exercise sessions that included legpress, leg curl, hip abduction and adduction, straight leglift, incline dumbbell press, seated row, and calf raise. Theself-management group was given educational classes. Thegroups were tested at baseline, 3 months, and 9 months andboth the self-management and resistance-training groupswere effective in raising moderate to vigorous physicalactivity levels in the short term. However, the resistance-training group proved significantly more effective in main-taining these results long term. The results by Farr andcolleagues suggest that functional exercises targeting per-

formance can be useful in managing knee OA.32Sayers and colleagues conducted a study comparing

high-speed versus slow-speed power training in 33

TABLE 3. Evidence-based Clinical Practice Guidelines

Strengthening exercisesLower-extremity strengthening vs. control, level 1 (RCT, n_345): grade A for pain getting up from floor and functional status (clinically

important benefit); grade C for pain during walking, pain while climbing stairs, functional tasks, and quadriceps femoris muscle peaktorque (clinical benefit); grade C for stiffness, mobility, quadriceps femoris muscle force, muscle activation, and quality of life (nobenefit). Patients with a diagnosis of osteoarthritis (OA) of the knee

Lower-extremity isometric strengthening vs. control, level 1 (RCT, n_102): grade A for pain getting down to and up from floor (clinicallyimportant benefit); grade C for pain getting down and up stairs and timed functional tasks (clinical benefit); grade C for stiffness andfunctional status (no benefit). Patients with a diagnosis of OA of the knee

Isotonic resistance training vs. isotonic combined with isokinetic (Kinetron) resistance training for knee, level 1 (RCT, n_32): grade C forquadriceps femoris muscle peak torque (no benefit). Patients with a primary diagnosis of OA of the knee

Isotonic combined with isokinetic (Kinetron) resistance training for knee vs. control, level 1 (RCT, n_32): grade C for muscle force (nobenefit). Patients with primary diagnosis of OA of the knee

Eccentric resistance training (Cybex) for knee vs. control, level 1 (RCT, n_32): grade C for muscle force (no benefit). Patients with primarydiagnosis of OA of the knee

Concentric resistance training for knee vs. control, level 1 (RCT, n_23): grade A for pain at rest and during activities (clinically importantbenefit); grade C for global functional status (no benefit). Patients with knee OA bilaterally and grade II or III OA

Concentric-eccentric resistance training for knee vs. control, level 1 (RCT, n_23): grade A for pain at rest and during specific functionalactivities: 15-m walk and stair climbing/descending time (clinically important benefit). Patients with knee OA bilaterally and grade II orIII OA

Home program strengthening for knee vs. control, level 1 (RCT, n_81): grade A for pain, functional status, energy level, and ROM in flexion(clinically important benefit); grade C for physical mobility, muscle force, swelling, and exercise (no benefit). Patients with knee OA

General lower-extremity exercise program (including muscle force, flexibility, and mobility/coordination) vs. control, level 1 (RCT,n_490): grade A for pain at night and ability on stairs (clinically important benefit); grade C for knee flexion range of motion (ROM),muscle force, knee joint position, gait, functional status, quality of life, muscle activation, stiffness, and physical activity (no benefit).

Patients with OAProgression vs. no-progression lower-extremity strengthening exercises, level 1 (RCT, n_179): grade A for pain at rest and ROM

(clinically important benefit); grade C for stiffness and functional status (no benefit). Patients with radiographic evidence of OA in thetibiofemoral compartment

General physical activity, including fitness and aerobic exercisesWhole-body functional exercise vs. control, level 1 [RCT, n_864): grade A for pain and functional status (mobility, walking, work,

disability in activities of daily living (ADL)] (clinically important benefit); grade C for knee flexor ROM, quadriceps femoris muscleforce, hamstring muscle force, gait, and quality of life (no benefit). Patients with OA of the knee

Walking program vs. control, level 1 (RCT, n_1,089): grade A for pain, functional status, stride length, disability transferring from bed,disability bathing, aerobic capacity, energy level, and medication use (clinically important benefit); grade C for disability in ADL(clinical benefit); grade C for walking speed, disability toileting, disability dressing, blood pressure, morning stiffness, and quality of life(no benefit). Patients with OA

Jogging in water vs. control, level 1 (RCT, n_115): grade A for physical activity and aerobic capacity (clinically important benefit); gradeC for morning stiffness, pain, grip force, trunk ROM, functional status, and exercise endurance (no benefit). Patients with currentsymptoms of chronic pain and stiffness in involved weight-bearing joints

Reprinted from Brosseau et al31 with permission from the American Physical Therapy Association. This material is copyrighted and any further repro-duction or distribution requires written permission from APTA.




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participants with mean age of 67 years with knee OA. Thehigh-speed group performed a greater number of repeti-tions at 40% of 1 repetition maximum on a leg press asfast as able, whereas the slow-speed group performedfewer repetitions at 80% of 1 repetition maximum slowly.The high-speed group improved muscle strength, power,

and speed over the 12-week period. These findings areparticularly relevant in effectively treating a recreationallyactive population performing high-speed movements.33

High-resistance training is shown to be equally effec-tive as low-resistance training in people with knee OA. Janet al34 looked at the effects of pain, function, muscle torque,and walk time in high-resistance versus low-resistancetraining over an 8-week period. The 2 groups performedisokinetic knee flexion and extension training at high-resistance (mean age, 63 y) and low-resistance (mean age,63 y) session over 3 episode/wk. Both groups improved inall categories compared with the control group (mean age,62 y). In another study regarding resistance training, Gurand colleagues looked at the effects of concentric versus

concentric-eccentric quadricep and hamstring strengtheningon functional capacity and pain levels in patients aged 41 to75 years old with knee OA. They determined an 8-weekprogram of isokinetic quadriceps and hamstring strength-ening performed 3 times/wk resulted in the concentric-eccentric group displaying a greater effect on functionalactivities, including stair ascension and descension whileconcentric training exhibited improvements in overall painrating. The results of the study show that extensive traininginvolving high number of repetitions and eccentric con-tractions are safe, effective, and productive in patients withknee OA.35

Isokinetic versus progressive resistance exercise (PRE)of the quadriceps and hamstrings was studied by Eiygor.

Knee flexion and extension strengthening was assessed3 times/wk in the isokinetic group (mean age, 53 y) and5 times/wk in the PRE group (mean age, 51 y) over a 6-weekperiod. Both modes of strengthening were found to beeffective in achieving strength gains and subjectivedecreases in pain and function. There was no significantdifference found between the 2 groups in overall reports ofpain, function, or peak torque of the tested muscles.36

Consideration of the surrounding musculature of thehip and ankle joints when prescribing exercise for thepatient with knee OA is also important. Both dynamic andisometric training of the entire lower extremity representeffective modes of resistance strengthening in people withknee OA. Topp and colleagues conducted a 16-week study

comparing dynamic and isometric training, specific toeffects on pain level and physical function. Two groupstrained the same 6 lower-extremity muscle groups: ankleplantar and dorsiflexors, knee extensors and flexors, andhip extensors and flexors. The isometric group (mean age,64 y) used maximum resistance Thera-band (The HygienicCorporation, Akron, OH), whereas the dynamic group(mean age, 66 y) used appropriate-level resistance Thera-band to achieve the desired muscle activation. Both resist-ance-training groups exhibited similar, significant declinesin reported knee pain and decrease in time to performfunctional tasks, whereas the control group remainedunchanged over the duration of the study. Only thedynamic training reduced perceived functional limitations,

and the control group (mean age, 61 y) did not change theirmeasures on any of the outcome variables over the durationof the study.37

MODALITIESThe trend of increased incidence of knee OA in a

younger, more active population has developed a role fortherapeutic modalities in the conservative management offunctionally limiting impairments associated with knee OA.ES, therapeutic ultrasound (US), LLLT, and thermo-

therapeutic agents such as heat and ice packs representcommon noninvasive, nonpharmacological treatment app-roaches often coupled with therapeutic exercise to treatpatients with articular degradation and other joint changesassociated with knee OA.

ES is a commonly used treatment option to relieve painand improve function in patients with knee OA. Three pri-mary forms of ES were identified during this articles liter-ature review: interferential current (IFC), neuromuscularelectrical stimulation (NMES), and transcutaneous electricalnerve stimulation (TENS).

The effectiveness of IFC treatment in patients with kneeOA has been researched extensively with variable resultssuggesting short-term improvement in pain and function.

However, as Adedoyin and colleagues comment in theirpaper, studies have largely failed to show benefit over con-trolled groups receiving an exercise program or sham treat-ment. In a randomized control trial (RCT) of 46 subjectswith mean age of 55 years, subjects in 3 groups receivingIFC, TENS, or exercise program alone all reported improvedlevels of pain and function as defined by the WOMAC. 38

To further highlight inconsistencies in this field of study,consider a recent RCT by Gundog and Atamaz of 60 patientswith median age of 60 years and mild to moderate knee OA.Patients were treated 5 times/wk for 3 weeks consecutivelywith IFC treatment and compared with a sham-controlledgroup. The authors concluded that IFC treatment was aneffective intervention in the management of knee OA, while

also noting both IFC and controlled groups demonstratedsignificant improvements in pain and function as defined bythe WOMAC.39 Related systematic reviews conducted byHawker and Mian40 and Jamtvedt and Dahm41 support thesefindings, concluding that results in patients with knee OA areunclear because of low quality of evidence and a generalheterogeneity of study parameters.

Less empirical data exist to support NMES as aneffective therapeutic agent to improve pain or functionscores in patients with knee OA. In a RCT conducted byPalmieri-Smith and Thomas, 30 women with mean age of57 years and radiographic evidence of knee OA were pro-vided either NMES treatment 3 times/wk for 4 weeks or notreatment over the same time period. The authors

hypothesized that the group receiving NMES would dem-onstrate improved quadriceps activation and strength whencompared with the controlled group. After a priori poweranalysis, the research group determined no statisticallysignificant increase in quadriceps activation or strength inthe intervention group of patients receiving NMES.42

Although patients in this study, and the IFC trials men-tioned above, are slightly older than middle-aged athletes,principles of efficacy with respect to individuals with mild tomoderate knee OA are expected to remain constant.

TENS represents another commonly used modality intreatment of knee OA, although efficacy with respect tofunctional mobility and joint stiffness is generally incon-clusive. In a meta-analysis by Brosseau and Yonge, the

reviewers reported a statistically significant reduction inpain levels in the treatment of patients with knee OA. Assuch, the authors recommended TENS as an adjunct




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therapy for the treatment of knee OA.43 Similarly, a sys-tematic review by Jamtvedt and Dahm concluded that thereis moderate evidence that TENS reduces pain when com-pared with a placebo intervention in treatment of kneeOA.41 However, in contrast, a 2010 Cochrane review byRutjes and Nu esch concluded that the current level of

evidence to support the efficacy of TENS treatment inpatients with knee OA with respect to pain and function isinadequate because of inclusion of small trials with uncer-tain methodology.44

The efficacy of therapeutic US treatment in patients withknee OA has been sharply contended over the past severaldecades. Both nonthermal and thermal effects on localizedpain, inflammation, and tissue repair remain in question. In arandomized, placebo-controlled, double blind study byTascioglu and Kuzgun, the short-term effectiveness of ther-apeutic US was tested in 90 patients with moderate knee OA.The patients with a mean age of 62 were treated with eithercontinuous, pulsed, or sham US for a duration of 5 min/session, 5 d/wk for 2 weeks. The authors reported significant

improvements in pain levels, via the VAS, and functionalstatus, via the WOMAC, across all the 3 groups. Whencompared with the placebo group, patients receiving pulsedUS reported significantly improved scores on the VAS andWOMAC. Thus, Tascioglu and Kuzgun45 determined thatpulsed US represents an effective short-term treatmentapproach for decreasing pain and improving function inpatients with moderate knee OA.

In another Cochrane review by Rutjes and Nu esch anda systematic review of RCTs with meta-analysis by Loyola-Sanchez and colleagues therapeutic US in patients withknee OA was investigated. Both reviews report that ther-apeutic US may represent an efficacious treatment modalityin the management of patients with knee OA.46,47 Specifi-

cally, Loyola-Sanchez et al47 concluded that pulsed US atlow intensities has a significant effect on pain reduction inpatients with knee OA when compared with continuous USand sham. Despite the findings, both authors acknowledgea low quality of evidence and a large degree of hetero-geneity in study parameters, ultimately conceding to theneed for additional study in this field.45,47

Several studies have reported positive effects fromLLLT including influences on fibroblast propagation,osteoblast production, and collagen synthesis as well asrevascularization in wound healing. In a double blind,randomized, placebo-controlled trial by Hegedu s andViharos, 27 patients with mean age of 42 years and mild tomoderate knee OA received either LLLT or placebo LLLT.

Patients received treatment twice a week over a 4-weekperiod at a continuous wave form and dose of 6 J/point.Hegedu s and Viharos found patients treated with the activelaser diode demonstrated a significant improvement in pain,knee circumference, point pressure sensitivity, and kneeflexion compared with the control group. Still moreimpressive is that the authors report patients in the activeLLLT group continued to present with improved test var-iables 2 months after treatment.48 Further, Jamtvedt andcolleagues discussed similar findings in their systematicreview, concluding that moderate-quality evidence supportsthe positive anti-inflammatory effects of LLLT on pain andfunction in patients with knee OA.41,48

Thermotherapy produces localized thermal effects on

superficial target areas, depending on clinical indicationsand desired therapeutic outcomes. In a Cochrane review byBrosseau and Yonge, thermotherapeutic treatment of knee

OA was discussed with respect to knee ROM, pain,strength, edema, and function. Brosseau and Yonge deter-mined that ice massage, compared with control, had astatistically significant effect on knee ROM and function.The authors concluded that ice massage (20 min/session,5 sessions/wk for 2 wk) represents an effective adjunct

treatment in patients with knee OA demonstrating deficitsassociated with knee ROM and function. However, theauthors do acknowledge a general heterogeneity in studyparameters, citing variable methodology with respect tooutcome results and test administration.43 Discrepancy inresearch standards is echoed in a systematic review byJamtvedt and Dahm,41 who concluded due to small samplesizes and low quality of studies, the efficacy of thermo-therapeutic agents on pain and function in patients withknee OA is inconsistent and therefore unclear.

Ultimately, there is low-quality evidence to support theuse of IFC, NMES, and thermotherapy3844; variable low-quality to moderate-quality evidence to support therapeuticUS and TENS38,41,4448; and, moderate-quality evidence to

support LLLT in the treatment of patients with knee OA.41,48Currently, therapeutic exercise and weight reduction possessthe highest quality of evidence with respect to effects on pain,inflammation, and stiffness in patients with knee OA.41 Inlight of these findings, further studies are needed tounequivocally substantiate the use of therapeutic modalitiesin treating middle-aged athletes with knee OA.

PATIENT EDUCATION, WEIGHT MANAGEMENT,

ORTHOTICS

OARSI recommends patients with knee OA to beprovided with information pertaining to treatment optionsand lifestyle modifications related to functional impair-

ments and excessive joint loading.11 Arguably, the mostinfluential risk factor associated with increased internalknee adductor moments (KAM), a clinically acceptedidentifier of moderate to advanced medial joint knee OA, isincreased body mass. Research consistently substantiatesobesity correlating significantly with both the incidence andprogression of knee OA. Weight management, and ulti-mately weight loss, therefore represents the treatmentoption of choice in patients presenting with knee OA. In astudy by Aaboe and Blidda, the authors found a significantreduction in knee joint loads during walking among sub-

jects with an average body weight reduction of 13.7 kg(13.5% decrease relative to baseline) after a 16-week dietaryintervention course. Aaboe and Blidda49 conclude that

weight loss represents an excellent short-term approach todecreasing functional limitations associated with increased

joint loading in patients with knee OA.Alternative approaches to decrease joint loading forces

in patients with knee OA include utilization of shoe wedges,knee braces, and assistive devices. Although the level of evi-dence supporting these intervention strategies remains vari-able, the biomechanical advantage gained by redistributingground reaction forces (GRFs) during contact phase of gait issupported by experts in their respective fields.11 This bio-mechanical understanding of GRFs during gait revealsanother rehabilitation trend found in literature; namely, thatall patients with knee OA be educated on appropriate foot-wear as pertains to specific activity demands and impairments

associated with articular changes found in with kneeOA.11,5052 Although authors agree that footwear recom-mendations should be provided to all patients with knee OA,




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the most effective type of shoe (ie, stability, cushioned, min-imalist) remains in question.5052 An individualized inter-vention approach is required when assessing middle-agedpatients with knee OA, specific to activity demands, pro-gression of disease, body composition, work/sport environ-ment, and foot strike pattern.

A shock-absorbing insole may represent the ideal foot-wear choice for an obese, heel-striking patient with increasedinternal KAM and moderate medial tibiofemoral jointcompartment narrowing, while a shoe designed to simulatebarefoot mechanics may represent the desired footwearapproach in a midfoot-strike athletic population presentingwith early evidence of knee OA. The latter example describ-ing innovative footwear is more specific to this paper and hasrecently been reported to significantly reduce dynamic kneeloads during gait through proposed increased sensorimotorinput and neuromuscular communication.50,51

In addition to KAM-modifying and GRF-reducingwedges and supports, the importance of activity modificationrepresents an essential educational component when treating

middle-aged athletes with knee OA. As Vignon and his col-leagues reported in their 2006 international systematic review,athletes should be made aware that the risk of knee OA isassociated with duration and intensity of joint exposure;however, this risk is considerably less than being overweightor having a history of joint trauma. Further, middle-agedathletes with knee OA should be encouraged to engage reg-ularly in recreational sport, provided the activity does notcause pain. No specific sport (long-distance running, tennis,soccer, field hockey, basketball, track and field, cross-countryskiing, and hockey) demonstrated a significantly increasedrisk of knee OA when compared with others, but patientsshould be encouraged to change sport involving high risk of

joint trauma.8

Middle-aged athletes are encouraged to continue rec-reational sport as no correlation exists between practice of aregular sport and clinical or radiographic progression ofknee OA.13 In adddition, as highlighted earlier in thispaper, the role of exercise in treating impairments asso-ciated with knee OA has been well established and coincideswith improved functional outcomes. Therefore, as a pre-ventative measure and rehabilitation staple, we recommendthat the middle-aged athlete continue recreational sportina pain-free contextas research substantiates the associa-tion between increased physical activity and improvedreports of pain, physical function, physical performance,and perceived effect in patients with knee OA.53

CONCLUSIONS

In summary, knee OA is a prevalent condition in themiddle-aged, athletic population causing significant phys-ical impairments and functional limitations in fitness, rec-reational, and competitive activities. Many nonpharmacologicinterventions for the management of knee OA have beenresearched in the past decade. Several research groups andorganizations, including OASIS, OARSI, and AmericanCollege of Rheumatology, have developed guidelines basedupon available evidence-based information in the literature.

Conservative interventions such as manual therapy,therapeutic exercise, thermal and electromagnetic modal-ities, patient education, weight management, and orthotic/

bracing/supports have been investigated. Overall, strongevidence exists for utilization of manual therapy techniquesof joint and soft-tissue mobilization and passive and PNF

stretching in the management of knee OA. Also, ther-apeutic exercise, including resistance (ie, closed-chain, iso-kinetic, and PRE) training and cardiovascular training hasbeen suggested in many studies. Other strongly supportedinterventions include patient education regarding activitymodification/pacing and symptom management and weight

management strategies, particularly in an overweight/obese, middle-aged population.

Other nonpharmacologic management techniques fortreatment of knee OA include modalities, such as ES,therapeutic US, LLLT, and thermal agents. In manyinstances, conflicting evidence abounds and often neithersupports nor refutes the benefit provided by many of themodality interventions. Although an abundance of evi-dence-based research on OA has been developed, a voidremains in the research within a middle-aged athletic pop-ulation in the context of knee OA and conservativemanagement.

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