May 2022

Lifestyle and Integrative Medicine Strategies for Managing Knee Osteoarthritis

By Ziya “Z” Altug, PT, DPT, MS, OCS

Osteoarthritis (OA) is a slowly evolving articular disease that affects the underlying bone, soft tissue, and synovial fluid.1 Osteoarthritis typically affects the hands and large weight-bearing joints, such as the hips and knees. Some risk factors for OA include aging, obesity, overuse or abuse of joints, trauma, instability of joints, excessive mobility, and/or immobilization.2 Symptom descriptors may include dull ache, insidious onset, and slow progression. Weight-bearing activity is an aggravating factor, rest is an alleviating factor, night pain may be present and/or early morning stiffness.3 Finally, knee OA may be classified as medial, lateral, or patellofemoral compartments.4

The following are some intervention strategies that may be considered for individuals with knee OA.

Strategy #1: Include Sustainable and Fun Activities and Exercises

Patients with knee OA may benefit from low joint-loading activities such as calisthenics, stationary cycling, swimming, tai chi, or walking, or moderate joint-loading activities such as cross-country skiing, doubles tennis, hiking, or weight lifting to help manage knee pain.5 It is also important to encourage patients to engage in hip and leg strengthening and range of motion, flexibility, aerobic, and balance training exercises to help improve function in daily life and reduce knee pain.6-10

Research shows that short bout walking is an effective way of improving physical activity.11 For example, the short bout approach for knee OA may include a walking program that consists of 5 to 10 minutes of walking in the morning before starting work and another short bout walk after work as an easy way to increase activity. Then at lunch, an individual could walk for another 5 to 10 minutes. This approach could add 15 to 30 minutes of physical activity into an individual’s daily activities. Another therapeutic approach is to utilize aquatic exercises to help unload and reduce stress to the knees.12,13 Also, a person may try Ai Chi, where the elements of tai chi and qigong are performed in an aquatic setting.14

Finally, a person with OA may be advised to use motivational phrases such as “motion is lotion” or “movement is medicine.”15 This strategy may help empower individuals to move throughout their day and increase home program compliance.

Strategy #2: Try Mind Body Movements

Various studies show that yoga classes,16,17 tai chi,18 and qigong (Baduanjin)19 may help reduce pain and improve quality of life in individuals with knee OA.

Strategy #3: Improve Nutrition

A study by Xu and colleagues in 202020 concludes that “Adherence to a Western dietary pattern was associated with increased radiographic and symptomatic knee osteoarthritis (KOA) progression, while following a prudent pattern was associated with reduced progression. In general, for people already diagnosed with KOA, eating a diet rich in fruits, vegetables, fish, whole grains, and legumes may be related to decreased radiographic and symptomatic disease progression.” For this reason, a registered dietitian or nutritionist should be a part of the rehabilitation team.

Strategy #4: Reduce Weight

An article by Felson and colleagues in 200021 indicates that weight loss can affect joint forces in the knee. This could be a key fact to share with patients as a motivational tool. Felson and colleagues state that, “for each one-pound increase in weight, the overall force across the knee in a single-leg stance increases two to three pounds. This load effect probably explains most of the increased risk for osteoarthritis of the knee and hip among overweight persons.”

Strategy #5: Manage Mental Stress

A study by Lee and colleagues in 201722 concludes that, “Mindfulness is associated with depression, stress, self-efficacy, and quality of life among knee OA patients. Mindfulness also moderates the influence of pain on stress, which suggests that mindfulness may alter the way one copes with pain.” For example, suggested stress management strategies may include meditation, mindful walking, gardening, aromatherapy (such as lavender), and gentle exercises (such as walking, yoga, tai chi, or qigong). Moreover, providing individuals with phrases such as “my mind is quiet,” “my legs feel relaxed,” or “I feel comfortable” may prove to help a person relax and feel comfortable. The phrases may be given to individuals to repeat to themselves as a part of their home program.23

Finally, progressive muscle relaxation (PMR, see “Muscle Relaxation Routine” in gray box), originally developed by Edmund Jacobson,24 may help with relaxation and managing knee pain.25

Strategy #6: Optimize Sleep

A study by Gilbert and colleagues in 202126 finds that “Poor sleep quality is associated with less physical activity in persons with or at risk for knee osteoarthritis.” Patients may be provided sleep hygiene guidelines that include:27-29

  • Make sure the bedroom is quiet, dark, and cool.
  • Make sure the bed and pillow are comfortable.
  • Turn the alarm clock away from the bed.
  • Create a regular bedtime ritual (such as wash face, brush teeth, meditate, or light reading).
  • Use the bed for sleep and avoid using the bed for activities such as television, computer, or phone use.
  • Do not smoke as smoking is a stimulant that disturbs sleep and negatively affects many other functions.
  • Avoid caffeinated foods and beverages close to bedtime (preferably at least 3 to 5 hours before bedtime).
  • Avoid alcohol near bedtime as alcohol may fragment sleep.
  • Avoid heavy meals near bedtime.
  • Avoid spicy food near bedtime (at least 2 to 3 hours before bedtime).
  • Avoid intense exercise near bedtime as it may act as a stimulant.
  • Minimize stimulating mental activities before bedtime (such as emotional discussions, reading intense books, or watching intense movies or the news).

Strategy #7: Consider Various Integrative Therapies

Adapted Progressive Muscle Relaxation Routine

Start: lie down, close your eyes, and breathe in and out slowly 2 times with diaphragmatic breaths.

  1. Take a deep chest breath and breathe out. Then, relax with 2 diaphragmatic breaths.
  2. Wrinkle up your forehead for 5 seconds and then relax with 2 diaphragmatic breaths.
  3. Frown for 5 seconds and then relax with 2 diaphragmatic breaths.
  4. Press your lips together for 5 seconds and then relax with 2 diaphragmatic breaths.
  5. Shrug for 5 seconds and then relax with 2 diaphragmatic breaths.
  6. Tighten your arm muscles for 5 seconds and then relax with 2 diaphragmatic breaths.
  7. Make a fist for 5 seconds and then relax with 2 diaphragmatic breaths.
  8. Tighten your abdominal muscles for 5 seconds and then relax with 2 diaphragmatic breaths.
  9. Tighten your buttock muscles for 5 seconds and then relax with 2 diaphragmatic breaths.
  10. Tighten your thigh muscles for 5 seconds and then relax with 2 diaphragmatic breaths.
  11. Flex your toes toward you tightly for 5 seconds and then relax with 2 diaphragmatic breaths.

Point your toes away from you tightly for 5 seconds and then relax with 2 diaphragmatic breaths.

End: smile gently for 5 seconds, and then relax with 2 diaphragmatic breaths.

The following are some integrative strategies that may be used for managing knee OA:

  • Cupping is a form of instrument-assisted manual therapy.30
  • Tui Na is a traditional Chinese medicine massage.31
  • Self-acupressure is a form of traditional Chinese medicine based on a similar philosophy to acupuncture.32,33
  • Electroacupuncture is a modern version of acupuncture using electricity.34

Strategy #8: Consider Various Self-Help Strategies

Patients may be taught how to use self-massage35,36 and kinesiotaping37,38 as a self-management strategy before a walking or exercise program to improve home program compliance. Also, guiding patients to select appropriate footwear may help manage knee pain.39,40

Strategy #9: Consider Assistive Devices and Knee Braces

To improve quality of life and increase function in daily activities, patients may benefit from the use of a single point cane (or other assistive device),41 soft knee brace,42 or a knee unloader brace43 to manage knee pain.

Strategy #10: Include Psychosocial Support Strategies

Include psychosocial support for patients through group-based activities, peers, family, and spouse for pain management and improved quality of life.44-46

Conclusion

Interprofessional collaborations and shared decision-making47 with the patient can help establish a therapeutic alliance to help uncover strategies for short-term symptom relief and develop meaningful long-term goals to improve overall quality of life.

Ziya “Z” Altug, PT, DPT, MS, OCS is a board-certified doctor of physical therapy with over 30 years of clinical experience treating musculoskeletal injuries. He uses lifestyle and integrative medicine strategies as a part of his therapeutic interventions. His book, Integrative Healing: Developing Wellness in the Mind and Body is available on Amazon. He is a member of the American Physical Therapy Association and the American College of Lifestyle Medicine. He can be reached at https://www.linkedin.com/in/zaltug/

REFERENCES
  1. Goodman CC, Fuller KS. Pathology: Implications for the Physical Therapist, 4th ed. St. Louis, MO: Elsevier; 2015:1304.
  2. Venes D. (Ed.). Taber’s Cyclopedic Medical Dictionary, 23rd ed. Philadelphia, PA: FA Davis; 2017:1708.
  3. Boissonnault WG, VanWye WR. (2021). Primary Care for the Physical Therapist: Examination and Triage, 3rd ed. St. Louis, MO: Elsevier; 2021:76.
  4. Altman R, Asch E, Bloch D, et al. Development of criteria for the classification and reporting of osteoarthritis. Classification of osteoarthritis of the knee. Diagnostic and Therapeutic Criteria Committee of the American Rheumatism Association. Arthritis Rheum. 1986;29(8):1039-1049.
  5. Buckwalter JA. Sports, joint injury, and posttraumatic osteoarthritis. J Orthop Sports Phys Ther. 2003;33(10):578-588.
  6. Brosseau L, Taki J, Desjardins B, et al. The Ottawa panel clinical practice guidelines for the management of knee osteoarthritis. Part two: strengthening exercise programs. Clin Rehabil. 2017;31(5):596-611.
  7. Brosseau L, Taki J, Desjardins B, et al. The Ottawa panel clinical practice guidelines for the management of knee osteoarthritis. Part three: aerobic exercise programs. Clin Rehabil. 2017;31(5):612-624.
  8. DeVita P, Aaboe J, Bartholdy C, Leonardis JM, Bliddal H, Henriksen M. Quadriceps-strengthening exercise and quadriceps and knee biomechanics during walking in knee osteoarthritis: A two-centre randomized controlled trial. Clin Biomech (Bristol, Avon). 2018;59:199-206.
  9. Deyle GD, Allison SC, Matekel RL, et al. Physical therapy treatment effectiveness for osteoarthritis of the knee: a randomized comparison of supervised clinical exercise and manual therapy procedures versus a home exercise program. Phys Ther. 2005;85(12):1301-1317.
  10. Wang J, Xie Y, Wang L, et al. Hip abductor strength-based exercise therapy in treating women with moderate-to-severe knee osteoarthritis: a randomized controlled trial. Clin Rehabil. 2020;34(2):160-169.
  11. Jakicic JM, Kraus WE, Powell KE, et al. Association between Bout Duration of Physical Activity and Health: Systematic Review. Med Sci Sports Exerc. 2019;51(6):1213-1219.
  12. Bartels EM, Juhl CB, Christensen R, et al. Aquatic exercise for the treatment of knee and hip osteoarthritis. Cochrane Database Syst Rev. 2016;3:CD005523.
  13. Rewald S, Lenssen AFT, Emans PJ, de Bie RA, van Breukelen G, Mesters I. Aquatic cycling improves knee pain and physical functioning in patients with knee osteoarthritis: a randomized controlled trial. Arch Phys Med Rehabil. 2020;101(8):1288-1295.
  14. So BCL, Kong ISY, Lee RKL, et al. The effect of Ai Chi aquatic therapy on individuals with knee osteoarthritis: a pilot study. J Phys Ther Sci. 2017;29(5):884-890.
  15. Louw A, Puentedura E, Schmidt S, Zimney K. Pain Neuroscience Education: Teaching People About Pain, 2nd ed. Minneapolis, MN: OPTP; 2018.
  16. Brosseau L, Taki J, Desjardins B, et al. The Ottawa panel clinical practice guidelines for the management of knee osteoarthritis. Part one: introduction, and mind-body exercise programs. Clin Rehabil. 2017;31(5):582-595.
  17. Kuntz AB, Chopp-Hurley JN, Brenneman EC, et al. Efficacy of a biomechanically-based yoga exercise program in knee osteoarthritis: A randomized controlled trial. PLoS One. 2018;13(4):e0195653.
  18. Wang C, Schmid CH, Iversen MD, et al. Comparative effectiveness of tai chi versus physical therapy for knee osteoarthritis: a randomized trial. Ann Intern Med. 2016;165(2):77-86.
  19. An B, Dai K, Zhu Z, et al. Baduanjin alleviates the symptoms of knee osteoarthritis. J Altern Complement Med. 2008;14(2):167-174.
  20. Xu C, Marchand NE, Driban JB, McAlindon T, Eaton CB, Lu B. Dietary patterns and progression of knee osteoarthritis: data from the Osteoarthritis Initiative. Am J Clin Nutr. 2020;111(3):667-676.
  21. Felson DT, Lawrence RC, Hochberg MC, et al. Osteoarthritis: new insights. Part 2: treatment approaches. Ann Intern Med. 2000;133(9):726-737.
  22. Lee AC, Harvey WF, Price LL, Morgan LPK, Morgan NL, Wang C. Mindfulness is associated with psychological health and moderates pain in knee osteoarthritis. Osteoarthritis Cartilage. 2017;25(6):824-831.
  23. Turk DC, Gatchell RJ. Psychological Approaches to Pain Management: A Practitioner’s Handbook, 3rd ed. New York, NY: The Guilford Press; 2018.
  24. Jacobson E. You Must Relax, 5th ed. New York, NY: McGraw-Hill Book Company, Inc; 1976.
  25. Baird CL, Sands L. A pilot study of the effectiveness of guided imagery with progressive muscle relaxation to reduce chronic pain and mobility difficulties of osteoarthritis. Pain Manag Nurs. 2004;5(3):97-104.
  26. Gilbert AL, Lee J, Song J, et al. Relationship between self-reported restless sleep and objectively measured physical activity in adults with knee osteoarthritis. Arthritis Care Res (Hoboken). 2021;73(5):687-692.
  27. Altug Z. Integrative Healing: Developing Wellness in the Mind and Body. Springville, UT: Plain Sight Publishing; 2018.
  28. Siengsukon CF, Al-Dughmi M, Stevens S. Sleep health promotion: practical information for physical therapists. Phys Ther. 2017;97(8):826-836.
  29. Vitale KC, Owens R, Hopkins SR, Malhotra A. Sleep hygiene for optimizing recovery in athletes: review and recommendations. Int J Sports Med. 2019;40(8):535-543.
  30. Li JQ, Guo W, Sun ZG, et al. Cupping therapy for treating knee osteoarthritis: The evidence from systematic review and meta-analysis. Complement Ther Clin Pract. 2017;28:152-160.
  31. Zhu Q, Li J, Fang M, Gong L, Sun W, Zhou N. [Effect of Chinese massage (Tui Na) on isokinetic muscle strength in patients with knee osteoarthritis]. J Tradit Chin Med. 2016;36(3):314-320.
  32. Li LW, Harris RE, Tsodikov A, Struble L, Murphy SL. Self-acupressure for older adults with symptomatic knee osteoarthritis: a randomized controlled trial. Arthritis Care Res (Hoboken). 2018;70(2):221-229.
  33. Cheung DST, Yeung WF, Suen LK, et al. Self-administered acupressure for knee osteoarthritis in middle-aged and older adults: a pilot randomized controlled trial. Acupunct Med. 2020;38(2):75-85.
  34. Tu JF, Yang JW, Shi GX, et al. Efficacy of intensive acupuncture versus sham acupuncture in knee osteoarthritis: a randomized controlled trial. Arthritis Rheumatol. 2021;73(3):448-458.
  35. Tosun B, Unal N, Yigit D, Can N, Aslan O, Tunay S. Effects of self-knee massage with ginger oil in patients with osteoarthritis: an experimental study. Res Theory Nurs Pract. 2017;31(4):379-392.
  36. Atkins DV, Eichler DA. The effects of self-massage on osteoarthritis of the knee: a randomized, controlled trial. Int J Ther Massage Bodywork. 2013;6(1):4-14.
  37. Kaya Mutlu E, Mustafaoglu R, Birinci T, Razak Ozdincler A. Does kinesio taping of the knee improve pain and functionality in patients with knee osteoarthritis?: a randomized controlled clinical trial. Am J Phys Med Rehabil. 2017;96(1):25-33.
  38. Rahlf AL, Braumann KM, Zech A. Kinesio taping improves perceptions of pain and function of patients with knee osteoarthritis: a randomized, controlled trial. J Sport Rehabil. 2019;28(5):481-487.
  39. Chughtai M, Newman JM, Akil S, et al. Knee pain and the use of various types of footwear-a review [published correction appears in J Knee Surg. 2018 Nov;31(10):e1]. J Knee Surg. 2018;31(10):952-964.
  40. Paterson KL, Bennell KL, Campbell PK, et al. The Effect of flat flexible versus stable supportive shoes on knee osteoarthritis symptoms: a randomized trial. Ann Intern Med. 2021;174(4):462-471.
  41. Fang MA, Heiney C, Yentes JM, Harada ND, Masih S, Perell-Gerson KL. Effects of contralateral versus ipsilateral cane use on gait in people with knee osteoarthritis. PM R. 2015;7(4):400-406.
  42. Cudejko T, van der Esch M, van der Leeden M, et al. Effect of soft braces on pain and physical function in patients with knee osteoarthritis: systematic review with meta-analyses. Arch Phys Med Rehabil. 2018;99(1):153-163.
  43. Thoumie P, Marty M, Avouac B, et al. Effect of unloading brace treatment on pain and function in patients with symptomatic knee osteoarthritis: the ROTOR randomized clinical trial. Sci Rep. 2018;8(1):10519.
  44. Tan BY, Thach T, Munro YL, et al. Complex lifestyle and psychological intervention in knee osteoarthritis: scoping review of randomized controlled trials. Int J Environ Res Public Health. 2021;18(23):12757.
  45. Keefe FJ, Blumenthal J, Baucom D, et al. Effects of spouse-assisted coping skills training and exercise training in patients with osteoarthritic knee pain: a randomized controlled study. Pain. 2004;110(3):539-549.
  46. Briani RV, Ferreira AS, Pazzinatto MF, Pappas E, De Oliveira Silva D, Azevedo FM. What interventions can improve quality of life or psychosocial factors of individuals with knee osteoarthritis? A systematic review with meta-analysis of primary outcomes from randomised controlled trials. Br J Sports Med. 2018;52(16):1031-1038.
  47. Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken). 2020;72(2):149-162. [correction in Arthritis Care Res (Hoboken). 2021 May;73(5):764]

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