Osteoarthritis (OA) is a fact of life for most Canadians. “Live long enough and you can pretty much count on developing arthritis.”1 Over 4 million Canadians or 1 in 6 people need to seek treatment for OA.2 The arthritis burden has been exacerbated with the difficulties associated with both the Non-Steroidal Anti-Inflammatory and Cox-2 inhibitors prescriptive treatment.2 At EPA we have reviewed our OA – Hip and Knee program that was initiated 10 years ago and are pleased to update our physicians with the benefits of physiotherapy. Our OA program educates and counsels patients on the detrimental effects of under-using a joint. Patients are taught an exercise regime that balances rest with activity, joint protection with joint unloading, weight-bearing with non-weight bearing, and finally aerobic with non-aerobic exercise. Through our extensive exercise component we achieve our first goal of increasing our patient’s function. Our second goal of pain reduction can be achieved with the above and in conjunction with additional interventions such as manual therapy, taping, acupuncture and transcutaneous nerve stimulation.
In 2004 The Cochrane Database of Systematic Reviews detailed the effects of exercise for osteoarthritis of the hip or knee. 3 Their overall objective was to “determine whether land based therapeutic exercise is beneficial for people with OA of the hip or knee in terms of reduced joint pain, improved physical function and/or the patient’s global assessment of therapeutic effectiveness.”3 A closer examination at the 17 studies with 2562 participants with knee OA who reported improvements in pain and self reported function, will form the foundation for our land based exercise regime. Consistent with the OA knee literature4, graduated quadriceps exercises are utilized to achieve both unloaded joint strengthening and closed chain functional strengthening. The graduation progresses from isometric quadriceps (Figure 1) and hamstring contractions, to dynamic resistance exercises and finally to closed chain functional exercises like a unilateral step- ups (Figure2). Studies confirm that over a 16-week period significant strength changes that correlate to increase ability to climb stairs and get up from a floor level position5 are attainable with these exercises.
In addition to our strong exercise component, our OA-Hip and Knee program has a component of manual therapy. As a result of our mission statement to provide manual therapy and the ongoing skill level of our physiotherapists, we can offer consistent with the literature6 manual therapy to address any lumbar spine, knee, and ankle restrictions. Deyle et al. found that patients who were examined by a physiotherapist and received manual therapy when combined with similar exercises as described above, achieved greater distances in a 6 minute walk test and improvements in their pain and function that were found to be maintained over a year.6
To ensure completeness, other interventions that were not specifically addressed in the Cochrane review were evaluated. Clinically, compliance with an exercise regime is often compromised by pain. The addition of transcutaneous nerve stimulation (TENS) has shown positive effects of pain with the knee OA population. TENS gets its analgesic affects through the activation of endogenous opioid system in the body, in addition to a pain gating theory utilizing the faster type I-II nerve endings activated by the TENS which compete with the slower type III pain nerve endings. A study by Gladys et al7 utilized TENS daily for 2 weeks and reassessed patients pain responses. They found that significant analgesic affects were noted, particularly with TENS applied for duration of 40 minutes.7 Although this study did not combine TENS with exercise, clinically the addition of TENS can increase a patients’ compliance to their routines. As a result TENS is a consideration for both home use and clinic use for pain control. Similarly, acupuncture has been accumulating several studies that conclude patients can experience reductions in pain and improvements with function in such activities like walking.8,9
Lastly, taping has been used widely in the patellofemoral syndrome population and clinically is used with OA of the patellofemoral joint. The patellar is assessed for position, which often is combined with resisted quadriceps contraction and passive overpressure to ensure neutral patellar positions. Taping the patella medially to decrease lateral tracking and consequently irritation to the retropatellar border (Figure 3) will often decrease pain on a one-time isometric quadriceps contraction. Similarly, taping to unload the inferior pole of the patellar will decrease impingement to the highly innervated infrapatellar fat pad. Recently Hinman et al10 showed that taping added to patients “current treatments” demonstrated significant reductions in pain.
Our program would not be complete without addressing the importance of a home exercise program and an educational component. Several of the studies in the Cochrane review3 highlighted the effectiveness between individual verses group and clinic verses home based programs. Studies that focused on home based programs continued to have several dedicated treatments to initial instruction and follow-up. There is agreement in the literature that short term gains can be made with home based exercises, however, a recent study showed that these gains progressively decrease 12 and 24 weeks post exercise intervention time that were included in the patient follow-up.11 It is important to establish a program that the patient is competent with, but the previous findings may be evidence for the need of a follow up to establish ongoing compliance and reassessing the need to progress exercises to continue to make further gains.
In summary EPA is excited to announce their updated OA-Hip and Knee program. The main components include an evidence based exercise prescription program, manual therapy, taping, pain control, education and a home program with follow-up. The evidence is unanimous that exercise intervention has the same effect for self-reported pain and self reported physical function when compared to reported estimates for pharmacological treatments.3 We look forward to working with you to offer your patients another alternative in the management of hip and knee osteoarthritis.
Author: J. Sinkeldam
- Arthritis Society of Canada. www.arthritis.ca/introduction to arthritis.
- Arthritis Society of Canada. www.arthritis.ca/executive summary, pg iv.
- Fransen M, McConnell S, and Bell M. Exercise for osteoarthritis of the hip and knee. The Cochrane Database of Systematic Reviews 2004Vol (4).
- O’Reilly, Muir KR and Doherty M. Effectiveness of home exercise on pain and disability from osteoarthritis of the knee: a randomized controlled trial. Ann Rheum Dis 1999;58:15-19.
- Topp et al. The Effect of Dynamic Versus Isometric Resistance Training on Pain and Functioning Among Adults with Osteoarthritis of the Knee. Arch Phys Med Rehabil 2002, Vol 83: 1187-1195.
- Deyle et al. Effectiveness of Manual Physical Therapy and Exercise in Osteoarthritis of the Knee. Annals of Internal Medicine 2000, Vol 132(3):173-181.
- Gladys L et al. Optimal Stimulation Duration of TENS in the Management of Osteoarthritic Knee Pain. J Rehabil Med 2003, 35:62-68.
- Berman BM et al. Effectiveness of Acupuncture as Adjunctive Therapy in Osteoarthritis of the Knee. A Randomised Controlled Trial. Annals of Internal Medicine 2004, Vol 141(12): 901-910.
- Vas J et al. Acupuncture as a complementary therapy to the pharmacological treatment of osteoarthritis of the knee: randomized controlled trial. BMJ, doi:10.1136/bmj.38238.601447.3A (published 19 October 2004).
- Hinman RS et al. Efficacy of knee tape in the management of osteoarthritis of the knee: blinded randomized controlled trial. BMJ 2003, Vol 327: 135.
- van Baar ME et al. Effectiveness of exercise in patients with osteoarthritis of hip or knee: nine month’s follow up 2001, 60:1123-113