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Did therapy help your knee pain? If no…continue to read. 

Did therapy help your knee pain?

“Knee osteoarthritis (OA) is one of the leading causes of pain and disability worldwide”

This is an indication of how prevalent this condition is in the world. Arthritis is seen as a byproduct of aging, but this doesn’t mean that it directly causes pain.

“…exercise intervention has been shown to be efficacious and is recommended in multiple guidelines; however, its treatment effect has been reported to be modest.”

Everyone can benefit from exercise, but the extent of the benefit for patients with knee pain may not be that “miracle” that people expect.

“Although the statistical effectiveness of exercise for knee OA has been clearly demonstrated and may be equivalent or better than commonly prescribed medications, the effect on pain reduction and function remains modest.”

Exercise is a powerful tool or at least among the most powerful that we have now. In saying this though, it is not a magic elixir.

“The MDT approach has been extensively used to classify and treat patients with spinal pain. Studies have shown the MDT approach to be valid, reliable, able to successfully predict outcomes and associated with decreased lumbar surgery rates, pain, and disability.”

If this doesn’t sound great, then I don’t know what does! MDT (Mechanical Diagnosis and Therapy) is a specific assessment and treatment style that Is not taught in school. One must go through advanced courses and take a test to say that they are competent at using the method. Ask your therapist if they have taken any courses in the method and if they have achieved the certification through the Institute. This is the only way to determine if the therapist that you are seeing is competent to utilize the principles of the system.

“The most prevalent and well-studies MDT subgroup is the ‘derangement’ classification. This classification has been described in all joints and has been associated with a rapid response to specific end-range exericses…”

Would you like your symptoms to rapidly improve? Who wouldn’t? Roughly 40% of patients with knee pain may have symptoms that respond rapidly to a single exercise. Turning off pain doesn’t have to be difficult. In many patients, it only takes a single exercise to reduce or turn off the pain. This has to be followed-up with a constant assessment in order to determine which exercises the joint will tolerate at a specific point in time in order to ensure that the symptoms do not return when not in the clinic. There has been a lot of research in the medical world regarding Low Back Pain, but this article is the first that I have seen using the same principles for osteoarthritic knees.

“…significant treatment main effects were present for all primary outcomes. The MDT derangement subgroup had improved scores at 2 weeks and 3 months compared to the MDT nonresponder subgroup for all primary outcomes”

This is huge! This sentence essentially states that doing one exercise is more beneficial than doing many for a small subset of patients. Now for a little more information on a derangement. If there is one exercise that can greatly improve your pain, then there will be multiple exercises that either have no effect or make the pain worse. If your therapist is not at least looking for and ruling out this preferential exercise or direction of movement, you may be in therapy for a longer period with a longer list of home exercises. These exercises may or may not have a positive or negative effect on patient’s whose symptoms are rapidly reducible.

“The physical therapists were credentialed in the McKenzie system, and results may not be applicable to non-McKenzie-trained therapists.”

This sentence stands on its own. Anyone claiming to use a method should at least be trained and credentialed in using the method. In the Joliet area, there are only two of us endorsed by the McKenzie Institute to utilize this method.

 

In short, this study was performed on patients waiting to receive a total knee replacement, which means that they were shown to have severe arthritis on an X-ray. The patients receiving McKenzie-based treatment outperformed those receiving traditional evidence based guideline therapy and those that received no therapy. Seek out an MDT trained clinician if you are experiencing knee pain.

 

I can be found at:

Functional Therapy and Rehabilitation

903 N. 129th Infantry Dr

Suite 500

Joliet, IL

815-483-2440

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Do you suffer from knee pain?

Do you “suffer” from knee pain?

“Within this new paradigm, overweight and obesity contribute to OA through biomechanical (increased joint load) and inflammatory mechanisms.”

​There is newer research that indicates body fat can release inflammation. Think about this, inflammation can cause pain and there has been the old wives tale that being overweight can be the cause of pain, but now there is research to back up the claim that excess body fat can be a factor in having increased pain.

“Years lived with disability due to high body mass index have also increased markedly for males and females aged 15-49 years since 1990, emphasizing the potential contribution of rising obesity levels to global OA (osteoarthritis) burden among younger people”

​Being obese takes a toll on health. This is not a surprise. The heavier a person is, the more energy and work required in order to just move. Pair this with increased pain sensation and movement may actually decrease over time.

“Research has shown that the greatest risk factor predicting the development of knee OA in young an middle-aged people is a previous traumatic knee injury”.

​If you injure your knee traumatically, the research covers ACL surgeries and meniscus surgeries, then there is a high likelihood of developing knee osteoarthritis.

“Radiographic findings are not well correlated with symptoms and are unlikely to alter the management plan or predict future disease progression”

​THIS MAY BE THE MOST IMPORTANT MESSAGE FOR PATIENTS TO UNDERSTAND. Just because an X-ray shows “degeneration”, “osteoarthritis”, “joint narrowing”, “bone spurs”…so on and so forth…doesn’t mean that this is causing pain. What we now is that these findings are common as we age. There’s an analogy that these findings are similar to wrinkles on the skin, they are just wrinkles on the inside. Not too many people worry about skin degeneration in the form of wrinkles. The same should hold true regarding some of the results of an X-ray or MRI.

“Overuse of MRI is costly for health systems and may lead to unwarranted surgical intervention.”

​The most important part of this is that MRI’s may lead to surgeries that aren’t needed. Let’s go back to the wrinkle analogy. Just because something doesn’t look young and supple…like it does in the textbooks, doesn’t mean that everyone should have a surgery to remove wrinkles. The same holds true for wrinkles on the inside.

“…comprehensive assessment of young patients should include 3 key components: 1. A patient-centered history; 2. Physical examination, including performance-based tests; and 3. Administration of appropriate patient-reported outcome measures (PROMs).”

​I challenge this sentence in that it is only limited to young patients. This 3 step process should be performed on every patient, REGARDLESS OF DIAGNOSIS! Every patient should be treated as an individual and not as a diagnosis. Everyone has a different story. Every patient has different needs. Every patient has different goals that are specific to that patient in front of you. The only way that this can be learned by the therapist is by performing a patient-specific evaluation.

​The only way that we know if a patient is actually improving, aside from simply asking them, is to perform tests and measures. When your internet isn’t going as fast as we think it should, we can always run an internet speed test. This is an unbiased way to test the thought that it is running slow. We need the same types of tests and measures in physical therapy. These should be performed by your PT within the first 2 visits.

​Finally, there is a patient reported outcome. This is a way for the patient to answer questions in order to determine if the patient actually believes that they are better or not. The questions have been validated by some research and the form should be universally known.

“…education about the neurophysiology of chronic pain and contribution of emotional and social factors to the pain experience may be relevant for some patients.”

​Many people still believe that an injury happens and therefore there must be pain. It doesn’t quite work this way. The brain can overcome any of those “inputs” that theoretically can cause pain. For instance, we’ve all heard the story of a person performing feats of strength like lifting a car off a child, but few people hear about the injuries that tend to happen after this feat of strength. The brain can overpower the body’s ability to feel pain. On the flip side, the brain can cause pain without injury. This is a little known fact by many PT’s unfortunately. This type of pain requires a completely different type of treatment than someone that is actively experiencing an injury. This is more complex than can be described in this article, but there will be future posts to describe this phenomenon.

“…exercise can reduce pain and improve physical function for knee and hip OA…Muscle strengthening can play a role in managing symptoms…Neuromuscular training programs can address sensorimotor deficits often associated with knee injury, including altered muscle activation patterns, proprioceptive impairment, functional instability, and impaired postural control”

​This is a mouthful. To summarize, there is rarely a reason not to “get stronger”. Being strong enables people to do more than being weak. Don’t get me wrong, there are multiple ways to get strong, but there are also multiple ways to get injured while getting strong. Please, if you have little/no experience with strengthening exercises, see a PT or CSCS in order to obtain quality information prior to starting the program.

​Neuromuscular training can be replaced by balance activities. This can teach patients how to utilize the “somatosensory system”, which is the communication that takes place between the muscles, bones and brain in order to remain in a certain position.

“…neuromuscular exercises can improve knee cartilage quality (glycosaminoglycan content) in middle-aged adults following partial meniscectomy.”

​Every once in a while I learn something new when reading orthopedic research. (just kidding, I am learning every day from the stuff I read). This is a new concept to me. This means that by performing balance training, we can improve the quality of the knee cartilage (meniscus). This is huge because as a health professional, we were always taught that the cartilage has poor blood flow and we can’t really impact healing of this tissue. Who know that balance and exercise were good for you?

“..combining strengthening exercise with exercises aimed at increasing aerobic capacity and flexibility may be the best exercise approach for managing lower-limb OA”

​This has been challenged in the research lately. There is an article by Richard Rosedale (JOSPT 2014) that demonstrates that using MDT can provide superior results. The original advice of diet, exercise and balance is probably still the best advice until more research comes out to show that specific exercises are better than others.

Hope this synopsis was helpful. If you are experiencing knee pain or have been told that you have arthritis, there are options. Come see me at FTR in Joliet, now a member of the Goodlife Family.

Dr. Vince Gutierrez, PT, cert. MDT

903 129th Infantry Dr.

Unit 500

Joliet, IL 60435

815-483-2440

QUOTES TAKEN FROM:

Ackerman IN, Kemp JL, Crossley KM, et al. Hip and Knee Osteoarthritis Affects Younger People, Too. J Orthop Sports Phys Ther 2017;47(2): 67-79.

Revision ACL surgery

“anterior cruciate ligament… Sixth most common procedure performed by orthopedist, with more than 100,000 ACL reconstruction’s being performed annually in the United States”

In comparison to other types of surgeries, this is not a large prevalence. Anytime there is a surgery though, that injury is important to that one patient. This article cut my attention because of the author Dr. Bach. He practices fairly close to my region and I’ve seen previous patients from him. It’s always helpful to learn about the procedures that physicians perform in your area so that way you can be better prepared to treat the patients that these physicians operate on.

“The definition of ACL failure in simple terms includes symptomatic instability, pain, extensor dysfunction, and arthrofibrosis.”
This essentially means that if there are continued symptoms after the surgery, that the surgery was a failure. I treated one patient previously, not from this doctor, in which the screw from the initial ACL reconstruction was never moved. The patient continues to have pain immediately upon starting therapy and I was beating my head against the wall trying to figure out why the patient continued to have pain. As a physical therapist we hate seeing patients experience symptoms that we can’t control. After sending the patient back to the doctor, it was found that the previous screw was in the joint space and causing the patient’s symptoms.

“Failures that occur within six months of reconstruction can be due to surgical technique, incomplete graft incorporation, and excessive rehabilitation or premature for trying to athletic competition.”

The case described above, is an example of an error with surgical technique. I have also seen cases in which the patient was progressed through rehab to aggressively and the patient continued to worsen over the course of time. We have to honor the patient’s pain response when giving exercises and trying to make progressions.

“Revision ACL reconstruction’s are a “salvage” procedure to allow the patient to perform activities of daily living… Only 54% returned to their pre-injury level of activity”

To phrase this bluntly, let’s get it right the first time. As a physical therapist I will take part of the blame because sometimes our profession may progress patient a little to rapidly. We have to honor the patient’s pain and movement response.
There are a few parts of this article that I found very interesting. The doctors described patient positioning on the table and we are making conscious effort’s in order to reduce lumbar extension for prolonged periods of time in order to reduce strain on the lumbar spine. They went into great detail to describe how they remove the screw or insert the screw deeper from the initial ACL reconstruction surgery. I didn’t know that they could insert the screw deeper instead of just remove the screw all together.

“with the help of a physical therapist, and emphasis is placed on achieving full extension and equaling the opposite knee. Full flexion is usually achieved by 6 to 10 weeks.”

I fully appreciate the special mention a physical therapist in this article. The physicians did not have to describe this portion at the end of the article. PT’s are part of the medical team. If you or anyone you know is recovering from an ACL reconstruction, please seek out a physical therapist by word-of-mouth or through recommendations from friends and family. One could also look online to investigate the therapist that is treating you or your family member. The therapist that you were seeing should be educating you or your family member at each session and explaining the rationale behind each exercise, movement or hands on technique.

Excerpts taken from:

Creighton RA, Bach BR. Revision anterior cruciate ligament reconstruction with patellar tendon allograft: surgical technique. Sports med are thre revision anterior cruciate ligament reconstruction with patellar tendon allograft: surgical technique. Sports med arthrosc review. 2005;13(1):38-45.

Considering a total knee replacement?

 

Considering a total knee replacement?

 

There are increasing numbers of total knee replacements performed yearly. Medicare is initiating a bundled payment initiative for all facilities in 2017 and many are participating for the previous 2 years. What does this mean for the patients? Theoretically, it means more efficient care, with better outcomes, because patients will be more closely monitored. For instance, the hospital, and those employed by the hospital, stands to profit moreso than normal when patients have great success rates with more efficient care (see fewer visits performed).   From my perspective it is about 2 things: 1. Improve patient’s outcomes 2. Do this with less expense. Our country spends a large percentage of our money on healthcare, but when looked at from a broad perspective, we do a poor job of keeping our people healthy. Whatever the reason, this needs to change.

 

Those of us in healthcare understand that the insurance company drives the type of treatment that a patient can receive. Most patients, in my experience, will not pay out of pocket for care that they feel entitled to and will stop care when the entitlement is exhausted. We, as healthcare professionals, have to do a better job of demonstrating value to patients. I spend, like many people, over $1,500/year in order to have a cell phone with internet access. This amount of money would pay for 1 visit of PT per week for almost 6 months, if the patient paid out of pocket. BLASPHEMY! Why should I pay for something that the insurance company will cover?

 

The insurance companies are becoming more aware of our downfalls as a profession. One major downfall is one of the deadly sins…GREED! When patient’s have to take more responsibility for their own health care and have to share more of the costs of health care, then the patient will become more aware of how his/her dollars are being spent…or go broke in the process. Gratefully, I work for a company that doesn’t push profit as much as it pushes “right patient, right time, right treatment”. Patients need to see that not all therapy is the same and sometimes…just sometimes…the patient can have both high quality therapy at a low cost.

 

Bringing us to today’s post. Come and knock on our door…we’ve been waiting for your…and the kisses are hers and hers and his…three’s company too. When I think of single leg stance, I think of the flamingo stance. When I think of the flamingo stance, I think of terri/torrie/cindy (blond from the show) standing on one leg while at the zoo. Moral of the story is: patients with better balance do better overall. Patients can achieve better balance by working on the skill over time. Depending on the source, the NIH reports that it takes upwards of 50 hours of practice to improve balance. Go practice now.

 

Can you stand on one foot?

Can you do this with eyes closed?

Can you do this equally on both sides?

Can you do the eyes closed version for at least half as long as the eyes opened version?

 

If not, go see a PT. You can look at the APTA website or your state’s local website (Illinois Physical Therapy Association) in order to find a provider.

 

Piva SR, Gil AB, Almeida GJM, et al. A Balance Exercise Program Appears to Improve Function for Patients With Total Knee Arthroplasty: A Randomized Clinical Trial. Phys Ther. 2010;90:880-894.

 

Intro: 37% of TKA’s still have functional limitations p one year. Diminished walking speed, difficulty ascending/descending stairs, inability to return to sport are chief functional complaints. During TKA surgery several tendons, capsule, and remaining ligaments are retightened to restore the joint spaces deteriorated by the arthritis. Some of the knee ligaments are removed or released, which may affect mechanoreceptors/balance.

 

PURPOSE:

  1. To determine the feasibility of applying a balance exercise program in patients with TKA
  2. To investigate whether an F (functional) T (training) program supplemented with a balance exercise program (FT+B) could improve function compared to FT program alone
  3. To test the method and calculate a sample size for a future RCT with a larger sample size

 

METHOD: Double-blind pilot RCT (very strong evidence)

Inclusion: TKA in the previous 2-6 months (meaning not eligible for study if the TKA was before 2 months previous)

Exclusion: 2 or more falls in the previous year. Unable to ambulate 100 feet with an AD or rest period, acute illness or cardiac issues, uncontrolled HTN, severe visual impairment, LE amputation, progressive neurological disorder or pregnant (interesting exclusion criteria).

 

All went through a quadriceps muscle-sparing incision (cuts through the fascia of the patella instead of the quadriceps) this may be a factor in reducing rehab stay.

 

See the appendix for the protocol (6 weeks).

 

Testing measures:

  1. Self-selected gait speed (interesting, but probably not feasible for our clinic)
  2. Timed chair rise test (5 repetitions): easily added to our testing.
  3. single leg stance time: easily added in
  4. LEFS
  5. WOMAC

 

RESULTS:

  1. Adherence for both groups is 100% and the HEP adherence was similar (filled out logs)
  2. walking speed continued to improve over the course of 6 months for the FT+B group and was 25% better than the FT only group.
  3. The interesting fact is that improvement continued up to 6 months, when previous literature describes 3 months and done.
  4. Single leg stance: FT+B improved (as expected due to SAID), but the FT group either maintained or worsened on speed and balance.

 

DISCUSSION: FT+B demonstrates clinically important differences in walking speed, SLS, stiffness and pain, without adverse events. Subjects in the FT+B could balance on average 4 seconds longer than baseline. This may be important for weight bearing during the stance phase of walking. Performance-based measures should be used in place of subjective measures.

 

TAKE HOME: Patients will benefit from the addition of balance exercises post-surgically. It may be prudent to discuss with the surgeons of increasing the length of stay in therapy and decreasing the number of visits per week, as progress continues to occur past the 3 months initially surmised. Each patient should be tested with one or more of the following:

  1. SLS
  2. Chair rise test
  3. Gait speed: important indicator of function/independence/death
  4. Balance test (excluding Tinetti due to possible ceiling affect when the patient no longer needs an AD).

Do you run loudly?

Shhhhhh…quiet. Tread lightly and land softly. May your joints forever feel young.

  1. “Several of these programs instruct participants to land softly in an attempt to teach proper landing technique and reduce impact forces. Mandelbaum et al reported an 88% decrease in anterior cruciate ligament injuries in 1041 female subjects using soft landing cues”

Are you thinking what I’m thinking? Seinfeld? Mandelbaum seriously?! This was the family of old guys in the hospital with Jerry that kept hurting themselves trying to lift the t.v. I thought it was funny.

What the above is saying is that the sound of your landing can directly indicate your injury risk. Don’t go jumping off buildings to test this theory! I won’t be held liable.

 

  1. “13% decrease in peak vGRF during a drop-landing task when 80 adult recreational athletes were instructed to listen to the sound of their landing…reduced by 24% in a stud in which 12 female recreational athletes were asked to land softly…”

What this means is that the softer you land the quieter you land. vGRF is vertical Ground Force Reaction (some people really hate it when I mix up the letters, but oh well…You know who you are!). This is it this way. For every action, there is an equal and opposite reactions. This means that if you land with a heavy load, the ground pushes back up at you with an equal load. If you absorb some of the load with your joints by bending, then the ground doesn’t push back as hard. Think of dropping a stick vertically from a specific height. The stick will actually bounce a little after it hits the ground, because the ground pushes back. Now do the same experiment with a wet noodle and you will get a totally different result. This may not be an exact science, but at least it makes sense to me. When you land quietly (wet noodle), you don’t get the jarring force from the ground as when you land loudly.

  1. “Initially, the participants were instructed to perform drop landings (with no instruction) to obtain a baseline, normal sound amplitude of landing…then instructed to …create a quieter or louder sound from this normal landing condition”

For those of you that perform high-intensity exercise of varying modes under time domains-based exercises, (I am unsure that if I use the word crossfit that I may be sued like those before me) such as box jumps, that this study will apply to you.

  1. “quiet-landing instruction results in significantly greater joint excursion at the ankle and knee when compared to a normal landing sound instruction”

Essentially, the quieter that you try to land, the more that you perform a squatting based movement on the land. The stiffer you land, the louder you are. The louder you are, the more force (think jarring) that your joints have to endure.

MORAL: Be quiet! Tread lightly!

Excerpts taken from: Wernli K, NG L, Phan X, et al. The Relationship Between Landing Sound, Vertical Ground REaction Force, and Kinematics of the Lower Limb During Drop Landings in Healthy Men. J Orthop Sports Phys Ther. 2016;46(3):1945-199.

 

 

Rehab post TKA

Piva SR, Gil AB, Almeida GJM, et al. A Balance Exercise Program Appears to Improve Function for Patients With Total Knee Arthroplasty: A Randomized Clinical Trial. Phys Ther. 2010;90:880-894.

Intro: 37% of TKA’s still have functional limitations p one year. Diminished walking speed, difficulty ascending/descending stairs, inability to return to sport are chief functional complaints. During TKA surgery several tendons, capsule, and remaining ligaments are retightened to restore the joint spaces deteriorated by the arthritis. Some of the knee ligaments are removed or released, which may affect mechanoreceptors/balance.

PURPOSE:

  1. To determine the feasibility of applying a balance exercise program in patients with TKA
  2. To investigate whether an F (functional) T (training) program supplemented with a balance exercise program (FT+B) could improve function compared to FT program alone
  3. To test the method and calculate a sample size for a future RCT with a larger sample size

METHOD: Double-blind pilot RCT (very strong evidence)

Inclusion: TKA in the previous 2-6 months (meaning not eligible for study if the TKA was before 2 months previous)

Exclusion: 2 or more falls in the previous year. Unable to ambulate 100 feet with an AD or rest period, acute illness or cardiac issues, uncontrolled HTN, severe visual impairment, LE amputation, progressive neurological disorder or pregnant (interesting exclusion criteria).

All went through a quadriceps muscle-sparing incision (cuts through the fascia of the patella instead of the quadriceps) this may be a factor in reducing rehab stay.

See the appendix for the protocol (6 weeks).

Testing measures:

  1. Self-selected gait speed (interesting, but probably not feasible for our clinic)
  2. Timed chair rise test (5 repetitions): easily added to our testing.
  3. single leg stance time: easily added in
  4. LEFS
  5. WOMAC

RESULTS:

  1. Adherence for both groups is 100% and the HEP adherence was similar (filled out logs)
  2. walking speed continued to improve over the course of 6 months for the FT+B group and was 25% better than the FT only group.
  3. The interesting fact is that improvement continued up to 6 months, when previous literature describes 3 months and done.
  4. Single leg stance: FT+B improved (as expected due to SAID), but the FT group either maintained or worsened on speed and balance.

DISCUSSION: FT+B demonstrates clinically important differences in walking speed, SLS, stiffness and pain, without adverse events. Subjects in the FT+B could balance on average 4 seconds longer than baseline. This may be important for weight bearing during the stance phase of walking. Performance-based measures should be used in place of subjective measures.

TAKE HOME: Patients will benefit from the addition of balance exercises post-surgically. It may be prudent to discuss with the surgeons of increasing the length of stay in therapy and decreasing the number of visits per week, as progress continues to occur past the 3 months initially surmised. Each patient should be tested with one or more of the following:

  1. SLS
  2. Chair rise test
  3. Gait speed: important indicator of function/independence/death
  4. Balance test (excluding Tinetti due to possible ceiling affect when the patient no longer needs an AD).

Dr. Vince Gutierrez, PT, cert. MDT

Goodliferehab.com for more information