By Keith Loria and Janice T. Radak
Osteoarthritis (OA) of the knee is a progressive disease caused by a breakdown of joint cartilage and ultimately, the underlying bone. The cartilage of a joint can become thin, cracked, and frayed, allowing the bones of the knee to rub together, which can lead to pain, inflammation, and stiffness. Therefore, people diagnosed with knee OA often become less active, which leads to physical deconditioning and loss of strength. So, keeping patients active is a fundamentally important component of managing knee OA.
Today, nearly 24% of the U.S. population has knee OA (more than double the number in 1940), and that is expected to increase to nearly 50% by 2040, making knee OA a major public health burden.
At a recent lerEXPO educational event, “Keeping Knee OA Patients Active,” sponsored by Bauerfeind, a trio of authorities in the field offered a comprehensive overview of relevant modalities that can impact patient care and play a positive role in keeping patients moving, thereby increasing their overall quality of life.
The symposium showed how regular exercise and physical activity can help maintain and increase strength, endurance, and range of motion for OA patients. Selected highlights are presented here.
The Orthopedic Surgeon’s Perspective
Michael Oberlander, MD, FAAOS, chief medical officer at Boston-based FIGUR8, Inc., delivered a talk on the pathology, pathophysiology, diagnosis, evaluation, and myriad treatment options for this common condition. He also discussed both prescription and over-the-counter drug therapies and recent recommendations from the American Academy of Orthopedic Surgeons.
The sports medicine specialist noted that orthopedic surgeons often see patients in the later stages of knee OA, so fewer options are available, and surgical treatment is more the norm than the exception. Oberlander focused his talk on conservative treatments of knee OA and what can be done before patients get to those end stages.
Emphasizing the conservative treatment, Oberlander added it’s very important to educate patients on the importance of low-impact exercise, weight loss, and biomechanical aids, such as walking sticks.
“Our goal in conservative treatment for our patients is really to keep them active and keep those joints moving,” he said. “You want to keep them limber with low impact exercise, so biking, hiking, sometimes using assisted aids like walking sticks. There’s also Pilates, yoga, and pool exercises, which significantly decrease the stresses on the joint and are really quite therapeutic as well.”
“We really want to individualize our treatment with our patients,” he said. “We want to talk to them about weight loss as that makes a significant difference in terms of joint longevity and preserving the articular cartilage and decreasing their pain level.”
He acknowledged the challenge of talking about weight loss with patients who have a body mass index over 25 and are considered obese. “A lot of our patients are significantly overweight—30 pounds, 50 pounds, even 100 pounds plus,” he said. “You can’t really talk about losing large amounts of weight. So, I like to talk about what does your joint see?”
He tells patients that excess weight can add excess pressure to the knee joint, depending on the activity:
- Contact pressure is 3–7 times non-weight bearing pressure
- Squatting and kneeling add 7 times
- Stairs can add 5 times
“So, a 10-pound weight loss is like taking 30–70 pounds of pressure off your knees. Patients get this message and often report back on what they notice.”
For patients who remain physically active and even athletes, bracing can be an option. Key challenge is they must be worn correctly and consistently. “If [braces] slip and they are not in place, they’re not going to be helping. But in the right patient population, they are very effective. For patients who want to increase their activity level, that unloader brace can be life saving for them in terms of saving their golf game.”
By using patient-reported outcomes, Oberlander noted it’s easier to follow patients longitudinally, deciding when the conservative management is no longer helping, and knowing when it’s time to send them to orthopedic colleagues for surgical options.
“Start with the simplest [treatments] and least expensive and get more complex as you progress through this disease along with your patient,” Oberlander said.
The PT’s Perspective
Kevin E. Wilk, PT, DPT, FAPTA, associate clinical director of Champion Sports Medicine in Birmingham, AL, looked at conservative treatment modalities clinicians should consider for short-term symptom relief as well as midterm management strategies to keep knee OA patients active. In general, he noted that cycling, which loads only 1.2 times body weight (BW), can be a nice alternative. The pool is another option, he said, adding that waist-deep water is only 50% BW and water to the shoulders is only 25% BW, making both options extremely joint friendly.
“There’s also a new unloading treadmill,” he said, explaining that it was comparable to running in waist-deep water. He also likes the elliptical (2.2x BW) and rowing (0.85 BW).
Wilk compared different patients with articular cartilage defects, detailing how treatments varied for
- a 37-year-old recreational skier who works in the kitchen of a restaurant and has had anterior cruciate ligament reconstruction, a meniscus debridement twice, and articular cartilage procedures
- a former NFL player who suffers from lateral compartment problems
- an 18-year-old soccer player in college with no previous knee injuries or pain, who was diagnosed with a meniscal tear.
- The question becomes, “Is surgery indicated?”
“There are numerous studies that have looked at the long-term effects of articular cartilage defects, and it’s a mixed bag,” Wilk said. “Some people do very, very well without any type of intervention, and others have some significant problems.”
The challenges with articular cartilage procedures, he noted, are myriad: slow healing potential, pain with loading, and a long duration for recovery. Add in that few patients use crutches for the 6 weeks as directed, which leads to more consequences.
“As clinicians, we need to recommend low to moderate impact loading exercises as well as proper exercise, lower sets, meaning a little bit more repetition, lower weights, and doing more body weight types of activities,” he said. “Coping skills and strategy to control pain, and a positive attitude—all those have been shown to be very beneficial for the OA patient or the rheumatoid arthritis patient as well.”
Of course, he stressed that leading an active lifestyle is paramount to long-term success with knee OA patients.
“People often say, ‘I can’t do this because my knee hurts,’ so we have to find a level of activity that they can do with minimal to no discomfort,” Wilk said. “If running hurts, then walk. If walking hurts, cycle. But we want to keep the joint moving. Motion is lotion for the joint. It helps stimulate articular cartilage over the articular surfaces and low-intensity, long-duration exercise is extremely beneficial.”
“We want to promote healing, but we don’t want to overload,” Wilk said. “We don’t want somebody to have a stiff joint as stiff joints don’t do very well. So, we want people to stretch and gain motion and get extension and flexion back. We also want to have good hip, foot, and ankle range of motion.”
Wilk said he has had success with unloading braces in his patients with articular cartilage issues. Patients have reported improved knee function, reduction of pain, and increased activity. His patients have also found medial pain symptom relief with lateral heel wedge orthotics—something he noted there is evidence to support.
The challenge with braces, he noted, is that patients don’t like to wear them when they don’t fit properly, so fit is critical. He noted that you have to work with the patient: “I tell them, ‘You don’t have to wear it all the time, wear it for long walks or hiking; but when your knee is feeling fine, put the brace aside until the next activity.’”
“I find that braces help keep patients in the zone of function,” Wilk said.
Principles in OA bracing
Torsten Krapf, PT, an international trainer for Bauerfeind, offered insights into the use of bracing—as both a rehabilitative and preventive tool for patients with knee OA, because maintaining motion is important for quality of life.
“Braces are an addition, not a replacement,” he said, for rehabilitation and muscle strengthening. “Several published studies show that with the help of corrective forces introduced from the outside, the abduction moment in the knee joint could be reduced. This relieves the knee joint during movement.”
The relief from OA braces, he continued, leads to a clinically relevant, “moderate” improvement in pain perception and the functionality of the patient’s knee joint. “When you decrease pain, the patient can increase activity.”
Once they start wearing a brace, the patient will say, “I can feel it right away, this helps a lot,” Krapf said. “For long-term use, braces must provide more comfort without sacrificing the mechanical offloading effort.”
Krapf discussed different types of braces (support sleeves, hinged, single upright, double upright) that can provide symptom relief for OA patients, as well as the pros and cons of different technology concepts from a product development standpoint. He also discussed the process used by the international development team that worked on Bauerfeind’s GenuTrain, GenuTrain S, and GenuTrain A3, which he noted are proven to relieve OA pain and improve knee stability while their anatomical shape and donning aids make them easy and comfortable to wear.
Krapf, like the prior speakers, emphasized that proper measuring and fit accuracy of the brace is very important for a strong outcome.
“Braces can increase the mobility for patients,” Krapf said. “It will increase muscle strength, but only if people do their exercises.”
To Learn More…
This article presents only highlights of “Keeping Knee OA Patients Active,” a 2-hour, 2.25 CEU educational event. To hear all 3 presentations in full, visit lerEXPO.com; go to EVENTS in the top menu and scroll down to “Keeping Knee OA Patients Active.”
Keith Loria is a freelance writer in Washington, DC. Janice T. Radak is editor of Lower Extremity Review.