March 2014

Active Stance: Developing the sustainable knee in an age of early TKA

active-stanceBy John Nyland, DPT, SCS, EdD, ATC, CSCS, FACSM, David N.M. Caborn, MD, and Roland Jakob, MD

To sustain is to endure. Knee osteoarthritis (OA) is a considerable worldwide health concern, as it greatly impacts an individual’s quality of life, general health, and societal role participation. Health may be influenced by the individual patient, their societal interactions, and the environment in which they live. Many public health challenges such as knee OA are too complex to be understood adequately from single analysis levels, requiring more comprehensive and holistic approaches that integrate organizational, cultural, regulatory, psychobehavioral, and community planning perspectives.1,2 Because the compatibility between a patient and his or her surroundings is important to general health, this expanded emphasis on societal and environmental relationships with sociocultural, psycho­­behavioral, and institutional components is important.1,2

Numerous factors may contribute to the development of knee OA, including genetic predisposition, trauma, obesity, and activity selection, including vocation, recreational and sport activities, and lifestyle choices. The end result for the patient with severe knee OA is likely to be an arthroplasty procedure that attempts to salvage healthy tissues adjacent to the knee joint to enable continued function following device implantation. Total knee arthroplasty (TKA) at best represents a semifunctional desensitized substitute for the native knee joint. Some authors of this manuscript have referred to it as an “internal amputation of the knee” since all biological knee tissue is resected (Figure 1).

Sustainability theory

Sustainability theory suggests the rate of available resource use should not exceed the rate at which it can be regenerated, particularly with regard to the most poorly regenerated sources. An analogy for the knee might be maintaining healthy articular cartilage. Since it has a poor capacity for healing, it represents a nonrenewable resource compared with other knee tissues.3 In contrast, the neuromuscular and musculoskeletal systems have a greater capacity for renewal with proper exercise training and activity habits, a nutritional diet, and appropriate daily living routines.4 Appropriate exercise selection, volume, and individualized prescription may be particularly important for preserving healthy articular cartilage and menisci.5,6 Innovative technologies such as knee braces and foot orthoses, designed to eliminate or reduce excessive potentially injurious knee loads during sport, recreational, and vocational activities, may also enhance the preservation of knee function. Environmental sustainability is possible through the development of nature-friendly cities, gardens, athletic fields, and parks.1

Economics, as it applies to sustainability theory, considers the monetary and financial aspects of biological, environmental, and ecological variables from a multidimensional perspective.7 Growth that simultaneously depletes a biological system is not only uneconomic, it also leads to a decline in quality of life.8 This may be analogous to increasing body mass without a concomitant increase in lower extremity neuromuscular strength, power, and endurance; movement coordination; or cardiopulmonary and vascular system functional capacity. Increasing body mass under those conditions could have a negative effect on knee function preservation in addition to having a negative influence on general health. Sustainability theory suggests appropriate resource management better ensures environmental adaptability, preventing irreversible long-term damage to biological systems and human health.

At the knee, maintenance of local factors such as lower extremity strength and full, pain-free, active joint mobility as well as regional factors such as maintaining appropriate walking stride length, forefoot-mediated propulsion, and eccentric lower extremity muscle functional capability,9-12 contribute directly to more effective global physiological system function and healthy aging.13-17

There is little doubt that TKA, when used as an end-stage intervention for knee OA, possesses strong efficacy for alleviating pain and improving function in older patients. Of concern, however, is an expanding market that includes younger patients with quality-of- life and societal interests that necessitate more functionally demanding knee joint impact-generating activities.18 Compared with the low-demand older patient population, there is limited evidence that TKA can provide long-term satisfaction that meets the expectations of a more middle-aged patient population, particularly if they have athletic interests other than golf or recreational tennis.

Figure 1. Questions for patients with knee OA to ask them- selves: Does my condition truly warrant internal amputation of my own knee tissue as the only alternative? Could there be another way that I might manage my condition, preserv- ing knee tissue, function, and quality of life?

Figure 1. Questions for patients with knee OA to ask themselves: Does my condition truly warrant internal amputation of my own knee tissue as the only alternative? Could there be another way that I might manage my condition, preserving knee tissue, function, and quality of life?

Patients need to be informed early in their medical, surgical, and rehabilitative care about potential knee OA progression scenarios and their potentially significant impact on quality of life from a more comprehensive and holistic perspective. This information needs to include appropriate sport or recreational activity selection, knee injury or reinjury prevention methods, and appropriate management of initial lower extremity injury experiences, including education regarding the potential for knee OA. This is particularly true if the patient has high functional activity expectations. It is very important that patients develop a sound understanding that, if left unchecked without dedicated lifestyle and psychobehavioral changes, the condition of the knee will likely have a negative impact on quality of life in terms of activities and interests, societal-role participation, and general health. In today’s society, many individuals who are entering their fifth and sixth decades of life (and even older patients) have expectations of continued sporting activities, such as basketball, soccer, hiking, or higher-demand vocational pursuits, which may not be performed safely with any regularity following TKA. Although elderly patients frequently report excellent pain relief and improved function following TKA, their expectations, which to a large extent dictate satisfaction with an intervention, likely differ considerably from those of  contemporary middle-aged individuals who have higher functional expectations in terms of their choice of activity and its intensity and frequency.

Two likely scenarios

So, when the knee OA diagnosis arises, or even if it has the potential to arise, the medical, surgical, and rehabilitation teams need to inform the patient of two likely scenarios. The first is that he or she agrees to implement needed psychobehavioral and lifestyle changes such as reducing body weight; stopping smoking; participating in an appropriate prescriptive exercise program with regularity; modifying recreational, sporting, or vocational activities to preserve knee function; extending native biological knee tissue longevity; and attempting to implement sustainability concepts to knee health. If successful, this will enable continued participat­ion in highly valued and desired quality-of-life enhancing activities and interests and reception of their multifaceted health benefits.

Figure 2.  Trunk rotation with medicine ball resistance performed in half-kneeling position. This exercise helps integrate core and hip strength, postural control, and coordination to improve dynamic knee stability in standing.

Figure 2. Trunk rotation with medicine ball resistance performed in half-kneeling position. This exercise helps integrate core and hip strength, postural control, and coordination to improve dynamic knee stability in standing.

Concurrently, implementation of positive psychobehavioral and lifestyle changes should improve patients’ general health as well as increasing vitality and physical function; decreasing bodily pain; improving physical, emotional, and social role function; and improving overall mental health. After implementing these changes in a responsible and purposeful manner, the patient also becomes a better candidate for knee joint preservation surgical procedures such as high tibial osteotomy, meniscal transplantation, meniscal repair, chondroplasty, and, in severe cases, unicompartmental knee arthroplasty.19 In this context, the diseased knee can serve as a conduit to effecting comprehensive positive lifestyle and health psycho­behavioral changes.20

In contrast, let’s consider the second option. Suppose that the same patient decides to forgo needed changes, deciding instead to continue down the path of excessive body weight; smoking; poor dietary habits; poor exercise habits in terms of selection, intensity, and frequency; and continued stressful knee joint loading. With this, the knee OA condition is likely to be exacerbated, pain will increase progressively, function will decrease progressively, comorbidities will be more likely to manifest, societal and social roles will begin to diminish, and formerly feasible medical, surgical, and rehabilitative interventions will become less efficacious options. This process lends itself to a self-fulfilling prophecy that eventually leads to TKA. But at what cost, and what benefit?

Pain reduction after TKA will likely be high. Function is also likely to improve significantly, but only in terms of walking, stair climbing, getting up from a commode, and low-level activities of daily living and recreational-level sports such as golf and recreational doubles tennis. More intense recreational, sports, and vocational activities the patient may greatly value as quality-of-life and societal-role enhancing will likely become off-limits to avoid excessive prosthetic wear, loosening, and early failure.21,22   Embedded within the second scenario is the possibility that enhancing the longevity of the prosthesis may take precedent over other highly-valued, functionally relevant, quality-of-life enhancing, and socially desired activities and interests.

The importance of education

Figure 3.  Single-leg dumbbell clean and press on Bozu ball to improve dynamic knee stability, trunk and lower extremity postural alignment, and balance and coordination during single-leg stance.

Figure 3. Single-leg dumbbell clean and press on Bozu ball to improve dynamic knee stability, trunk and lower extremity postural alignment, and balance and coordination during single-leg stance.

What needs to happen to facilitate the first scenario rather than the second?  It begins with effective and sincere patient education. It is important for the patient to understand the potential impact of positive psychobehavioral and lifestyle choices and the potential value of preserving existing biological tissues for as long as possible rather than prematurely surrendering to the lifestyle of an elderly person. To be successful, this educational process should be matter of fact, straightforward, have focused relevance, and be individualized so it is relevant and understandable to each patient. Simply stated, the patient needs to fully understand that if he or she desires the opportunity to save, preserve, and perhaps extend the longevity of the biological knee, he or she must implement the necessary psychobehavioral and lifestyle changes. Patients need to be instructed that, though they may not realize it now, if they successfully implement these changes, future treatment options as they get older will not be limited to only a salvage knee procedure designed solely for elderly individuals.

To do nothing is to follow the second scenario, continuing poor lifestyle habits and pathological knee joint loading, setting the stage for an early TKA procedure. The first scenario is more difficult to accomplish than the second. However, if successful, its positive impact on quality of life and perhaps life expectancy may be enormous. The potential positive impact on quality of life may be greater than the impact restrictions that become mandated when metal and plastic components replace biological knee joint tissues.

Figure 4. To improve self-efficacy and coping skills it is important that patients un- derstand the relevance of each exercise in terms of how it could help improve their knee function and how it might relate to the quality-of-life enhancing vocational, recreational, or sporting activities they value.

Figure 4. To improve self-efficacy and coping skills it is important that patients understand the relevance of each exercise in terms of how it could help improve their knee function and how it might relate to the quality-of-life enhancing vocational, recreational, or sporting activities they value.

A core principle of social ecology is that it identifies an occurrence as a social problem from multiple levels and recognizes human-environmental interactions as dynamic and active processes. This creates interdependencies between physical and social conditions within particular environments in the structure of multiple settings and life domains.1 From the perspective of caring for a patient with knee OA, it is important not to neglect links between the social and physical aspects of environments and the combined influences of those settings on knee function preservation and injury prevention.1 From this perspective, it is important for patients who have the potential to develop knee OA to receive an early education regarding appropriate exercise selection, intensity, frequency, and performance technique.  During this education, it is also important for the patient to develop the ability to make an accurate cognitive appraisal of his or her condition. This may be particularly important if the patient possesses a genetic predisposition to develop knee OA.23 The development of this knowledge early during medical, surgical, and rehabilitative care can empower the patient with diverse self-efficacy, coping, and resilience skills.24 With this knowledge and understanding, patients become more effective in managing their knee condition from a combined personal, societal, and environmental perspective.25

Rehab implications

Use of social cognitive or learning theory concepts as part of a therapeutic exercise environment is essential to increase self-efficacy, coping skills, resilience, and self-education.15,24,26-28  If exercise is truly medicine, then it is essential to properly balance its selection and dosage. Too much or too little in terms of intensity, frequency, or total volume may exacerbate knee joint problems. Related to this is the type of medicine, or mode of exercise, that is selected. What biomechanical and physiological stimulation characteristics do the selected exercises present? Do their potential benefits substantially override any potential for exacerbating the patient’s condition or increasing knee injury risk? Overlying each of these considerations is the question: What will the patient learn from the selected exercises that can improve his or her capacity for knee condition self-management? (Figures 2-4.) These factors may be related to improved postural alignment and control, enhanced dynamic knee stability, improved balance and coordination, and more. Effective rehabilitation clinicians select functional tasks that achieve the biomechanical and physiological needs of the patient, but that also lend themselves to needed central nervous system adaptations, motor learning, self-efficacy and resilience development, and improved decision-making and self-management skills.

Figure 5.  Too often, following seemingly “minor” lower extremity injuries, poorly conditioned patients are allowed to return to unrestricted sports activities, setting the stage for additional, more severe injuries and for the development of knee OA.

Figure 5. Too often, following seemingly “minor” lower extremity injuries, poorly conditioned patients are allowed to return to unrestricted sports activities, setting the stage for additional, more severe injuries and for the development of knee OA.

Another foundational social ecology concept is that health and wellness is a multifaceted phenomenon that encompasses physical health, emotional well-being, and social cohesion.2 Based on this belief, there is value in approaching complex personal, community, and environmental problems such as knee OA from multiple analysis levels rather than from single disciplines or from solely theoretical perspectives. The environment and social group in which the patient resides can serve as either a powerful enabler that helps facilitate healthy behaviors and attitudes or a constraint that negatively influences personal and collective well-being.2

The patient with knee OA and the knee surgeon are known to often have divergent conceptions of satisfaction following knee surgery.29 Prior to any medical, surgical, or rehabilitative intervention, the healthcare team must consider how likely the selected clinical care pathway is to satisfy patient expectations. Satisfaction of a patient’s preoperative expectations is the main factor influencing the subjective result following knee OA surgery. Patients with greater motivation and understanding of their condition are better able to continue sport, recreational, or vocational activity participation.30-34 Matching medical, surgical, and rehabilitative interventions to realistic patient expectations is an essential part of quality care. When considering whether a patient is a candidate for early knee arthroplasty or for a medical, surgical, and rehabilitative clinical care approach to the preservation of knee function, several factors must be considered. It is important to thoroughly analyze patients’ expectations (including how realistic they are), their understanding of knee OA, its likely progression if left unchecked, the benefits and risks of all possible interventions, the relative need for psychobehavioral change with each intervention, and sport, recreational, or vocational activity desires, history, and current habits.30 With this information, the healthcare team will be better able to know what steps are needed to truly achieve patient satisfaction (Figure 5).

Physicians, knee surgeons, rehabilitation clinicians, and others (ie, psychologists, public health educators, social scientists, architects, civil engineers, wellness professionals, and environmentalists) must interact more effectively to develop a more cohesive, better integrated, and shared conceptual framework that draws together discipline-specific theories, concepts, and approaches to address environmental and societal issues associated with preventing or delaying knee OA and preserving knee function. This framework can serve as a comprehensive organizing construct for patient care as well as for research that bridges discipline-specific theoretical and methodological orientations to better define and analyze knee OA as a worldwide health problem.17,35,36 This process can lead to new, more practical and more cost effective approaches to solving societal, environmental, and personal problems related to knee OA.

John Nyland, DPT, SCS, EdD, ATC, CSCS, FACSM, is professor of health and natural sciences and program director of the Athletic Training Program at Spalding University in Louisville, KY. David N.M. Caborn, MD, is clinical professor in the Department of Orthopaedic Surgery at the University of Louisville and director of Sports Medicine at KentuckyOne Health in Louisville. Roland Jakob, MD, is an orthopedic surgeon at the Hôpital Cantonal, Department of Orthopaedic Surgery, in Köniz, Switzerland.

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