Knee Osteo - Arthritis

Knee Osteo Arthritis is the result of interaction between mechanical loading, articular cartilage damage, and incomplete repair mechanisms. It occurs when the protective cartilage that cushions the ends of your bones wears down over time. Eventually, these changes cause joint degeneration, chronic knee pain and a reduction in quality of life for those suffering from it. Currently, there is no cure and ultimately, treatment is a total knee replacement.

Did you know?

• OA is the most common disease of the joints worldwide, with the knee being the most commonly affected joint in the body.

• It mainly affects people over the age of 45

• OA affects nearly 6% of all adults

• Women are more commonly affected than men

• Roughly 13% of women and 10% of men 60 years and older have symptomatic knee osteoarthritis.

• Among those older than 70 years of age, the prevalence rises to as high as 40%.

• Prevalence will continue to increase as life expectancy and/or obesity rises

Common Clinical Symptoms may include?

• Knee pain that is gradual in onset and worse with activity,

• Knee stiffness and swelling,

• Pain after prolonged sitting or resting

• Pain on movement

• Stiffness, particularly early morning stiffness

• Loss of range of movement

• Joint swelling

So what can you do to reduce your pain and improve your outcome?

The Osteoarthritis Research Society International (OARSI) noted several interventions (massage, ultrasound etc) that are universally recommended to help with pain and functionality. However, recent reviews indicate that these treatments are likely to only provide placebo affects. Exercise on the other hand, has been seen to have a positive effect in terms of pain and quality of life for patients with knee OA.

Although many different exercise interventions have been suggested, resistance training (strength training, but not necessarily with weights) has been seen to be effective in reducing pain and increasing functionality. The evidence-based consensus guidelines provided by the Osteoarthritis Research Society International (OARSI) for nonsurgical management of knee OA includes resistance exercise training as a core treatment.

Quadriceps (the group of muscles located in the front of the thigh, starting above the hip and ending below the knee) weakness is widely recognised as a risk factor for OA development, it is also associated with increased pain and decreased function in an OA affected knee. For this reason quad strengthening is a widely used in the management of OA. In addition, hip strengthening, either as a stand – alone programme or in conjunction with quad strengthening were shown to have a positive effect on the symptoms of OA.

There is no specific programme outlined that has been shown to be effective across the board. Different studies suggest different rep ranges, sets and exercises. Many reviews have noted that inconsistencies in the exercise programmes in the literature makes it difficult to suggest a specific programme that should be implemented for patients presenting with knee OA.

It has been seen that although many papers have noted that strength training leads to significant improvements in older adults, less than 10% of papers designed a programme that actually fit the parameters needed to acquire true “strength gains”. Many papers’ programme design would actually enhance muscular endurance with a “low resistance and high reps” approach.

It has been suggested that the reason for this lower load and higher reps approach was to avoid a pain response or the possibility of injury caused by excessive strain. It seems that this rationale is flawed given that there is a wealth of research supporting the efficacy of progressive strength programmes, even in the elderly. Interestingly, Ferraz et. al, 2018 found that patients with OA who were completing a high intensity strength plan ((4 – 5 sets) x 10reps @ 80% of 1 rep max) (1 Rep Max = maximum amount of weight that a person can possibly lift for one repetition) had increased functionality but pain was unchanged. In fact, 25% of patients enrolled in this plan dropped out of the study due to exercise – related pain. From this, it appears that, although the evidence suggests that there may be a benefit to a higher intensity plan, pain – free training may increase compliance in patients suffering with OA and may be a more effective approach, particularly when some studies have noted no major difference between strength training and other types of exercise (aerobic, aquatic, intervals etc.)

However, there may be a way to overcome these issues by implementing “Blood Flow Restriction” training. (Blood flow restriction training involves the application of a pneumatic cuff (tourniquet) to the top of the muscle that is being trained. The cuff is then inflated to a specific pressure and exercises are performed with reduced blood flow going to the working muscle.) It has been found that, by implementing the same protocol as the low impact training ( (4 – 5 sets) x 15 reps @ 30% 1RM) using BFR cuffs, it elicited all the same results as high intensity training (increasing muscle strength, quadriceps muscle mass, and functionality ) along with decreased pain and less joint stress. It seems that BFRT may be a promising option for conservative management of knee OA.

Benner et. al, 2019 have suggested a protocol that can be used as a stand-alone treatment or as a pre – operative management plan for patients with OA. This is a “Range of Motion” based plan whereby the focus is to attain full extension (including hyperextension), flexion, swelling reduction and then strength (in that order) in the effected knee before moving on to a maintenance plan. A lack of extension may cause a patient to limp and over – use the unaffected knee. The lack of normal use and movement can cause a patient to develop a deconditioned knee over time. In addition, it has been seen that pre – operative knee R.O.M dictates post – operative R.O.M and greater post – operative R.O.M has positive outcome measures for total knee replacement surgery.

This plan is structured with specific goals to be met in each stage before moving forward. Notably, this programme focuses on achieving hyperextension of the effected knee where there is hyperextension available in the unaffected knee where other studies use 0° as their gold standard.

Before a patient moves to a maintenance plan, they must achieve 90% strength in their affected knee compared to their unaffected knee. This programme has been effective for improving R.O.M, pain and functionality in patients with OA. This study suggests that 76% of participants were prevented from undergoing total knee replacement surgery.

In my practice, I implement a mixture of the programmes mentioned above, after assessing each client individually. Every person will have a different set of symptoms and in my opinion, a “one size fits all” approach will not yield the best results.

If you are suffering from knee arthritis and would like to implement a programme to help with pain and improve your day to day life, please don’t hesitate to get in touch!

Thanks for reading,

Edel.

References:

1. https://www.physio-pedia.com/Knee_Osteoarthritis

2. Topp, R. and Pifer, M., 2017. A preliminary study into the effect of 2 resistance training modes on proprioception of subjects with knee osteoarthritis.

3. Bartholdy, C., Juhl, C., Christensen, R., Lund, H., Zhang, W. and Henriksen, M., 2017, August. The role of muscle strengthening in exercise therapy for knee osteoarthritis: a systematic review and meta-regression analysis of randomized trials. In Seminars in arthritis and rheumatism (Vol. 47, No. 1, pp. 9-21). WB Saunders.

4. Ferraz, R.B., Gualano, B., Rodrigues, R., Kurimori, C.O., Fuller, R., Lima, F.R., De Sa-Pinto, A.L. and Roschel, H., 2018. Benefits of resistance training with blood flow restriction in knee osteoarthritis. Med Sci Sports Exerc, 50(5), pp.897-905

5. Vincent, K.R. and Vincent, H.K., 2020. Concentric and Eccentric Resistance Training Comparison on Physical Function and Functional Pain Outcomes in Knee Osteoarthritis: A Randomized Controlled Trial. American journal of physical medicine & rehabilitation, 99(10), pp.932-940.

6. Minshull, C. and Gleeson, N., 2017. Considerations of the principles of resistance training in exercise studies for the management of knee osteoarthritis: a systematic review. Archives of Physical Medicine and Rehabilitation, 98(9), pp.1842-1851.

7. Benner, R.W., Shelbourne, K.D., Bauman, S.N., Norris, A. and Gray, T., 2019. Knee osteoarthritis: alternative range of motion treatment. Orthopedic Clinics, 50(4), pp.425-432.

8. Neelapala, Y.R., Bhagat, M. and Shah, P., 2020. Hip Muscle Strengthening for Knee Osteoarthritis: A Systematic Review of Literature. Journal of Geriatric Physical Therapy, 43(2), pp.89-98.

9. Turner, M.N., Hernandez, D.O., Cade, W., Emerson, C.P., Reynolds, J.M. and Best, T.M., 2020. The Role of Resistance Training Dosing on Pain and Physical Function in Individuals With Knee Osteoarthritis: A Systematic Review. Sports Health, 12(2), pp.200-206.