Physical Therapy Management Of Knee Osteoarthritis

Description

Knee osteoarthritis is a degenerative process involving a gradual breakdown of the articular cartilage within the knee. Most commonly, degeneration occurs due to excessive loading on the knee joint over time causing normal degrees of shock absorption to become significantly reduced. This can produce significant pain, inflammation, stiffness, muscle weakness, and joint instability.

The Guide to Physical Therapy Practice identifies the following as the primary patterns associated with knee osteoarthritis:1

Pattern 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Localized Inflammation
Pattern 4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Connective Tissue Dysfunction

According to Pattern 4E, which is most appropriate for symptomatic osteoarthritis, patients on average use 6-24 visits per episode of care. "The Guide to Physical Therapy Practice" provides a broad approach to possible interventions to expect in the management of knee OA.1

Therapeutic exercise may include the following:1
-Aerobic Capacity/Endurance Training

  • aquatic programs
  • gait training
  • increased workload over time
  • walking and wheelchair propulsion programs

-Balance, coordination, and agility training

  • developmental activities training
  • motor function (motor control and motor learning) training or retraining
  • neuromuscular education or reeducation
  • perceptual training
  • posture awareness training
  • standardized, programmatic, complementary exercise approaches
  • task-specific performance training

-Body Mechanics and Postural Stabilization

  • body mechanics training
  • posture awareness training
  • postural control training
  • postural stabilization activities

-Flexibility

  • muscle lengthening
  • range of motion
  • stretching

-Gait and Locomotion Training

  • developmental activities training
  • gait training
  • implement and device training
  • perceptual training
  • standardized, programmatic, complementary exercise approaches
  • wheelchair training

-Relaxation

  • breathing strategies
  • movement strategies
  • relaxation techniques
  • standardized, programmatic, complementary exercise approaches

-Strength Training

  • active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, eccentric, isokinetic, isometric, and plyometric)
  • aquatic programs
  • standardized, programmatic, complementary exercise approaches
  • task-specific performance training

-Anticipated Goals

  • Joint swelling, inflammation, or restriction is reduced.
  • Nutrient delivery to tissue is increased.
  • Osteogenic effects of exercise are maximized.
  • Pain is decreased.
  • Physiological response to increased oxygen demand is improved.
  • Soft tissue swelling, inflammation, or restriction is reduced.
  • Tissue perfusion and oxygenation are enhanced.

Manual Therapy Techniques may include:1

  • Manual traction
  • Massage
  • Mobilization/manipulation

(Soft Tissue, Spinal/Peripheral Joints)

  • Passive range of motion

-Anticipated Goals

  • Edema, lymphedema, or effusion is reduced.
  • Joint swelling, inflammation, or restriction is reduced.
  • Neural compression is decreased.
  • Pain is decreased.
  • Soft tissue swelling, inflammation, or restriction is reduced.

Devices/Equipment:1

  • -Assistive devices

(Cane, Crutches, Long-Handled Reachers, Power Devices, Static/Dynamic Splints, Walkers, Wheelchairs)

  • Orthotic devices

(Braces, Casts, Shoe Inserts, Splints)

  • Protective/Supportive devices

(Braces, Cushions, Protective Taping)

-Anticipated Goals

  • Edema, lymphedema, or effusion is reduced.
  • Joint swelling, inflammation, or restriction is reduced.
  • Pain is decreased.
  • Soft tissue swelling, inflammation, or restriction is reduced.

Modalities:1

  • Electrotherapeutic delivery of medications

(Iontophoresis)

  • Electrical stimulation

(Electrical Muscle Stim (EMS), Functional Electrical Stim (FES), High Voltage Pulsed Current (HVPC),
Neuromuscular Electrical Stim (NMES), Transcutaneous Electrical Nerve Stim (TENS))

  • Cryotherapy

(Cold packs, Ice massage, Vapocoolant Spray)

  • Hydrotherapy

(Whirlpool, Contrast Bath, Pools)

  • Light agents

(Infrared, Laser)

  • Sound agents

(Phonophoresis, Ultrasound)

  • Thermotherapy

(Hot packs, Paraffin Bath)

  • Compression therapies

(Taping)

-Anticipated Goals

  • Edema, lymphedema, or effusion is reduced.
  • Joint swelling, inflammation, or restriction is reduced.
  • Nutrient delivery to tissue is increased.
  • Osteogenic effects are enhanced.
  • Pain is decreased.
  • Soft tissue swelling, inflammation, or restriction is reduced.
  • Tissue perfusion and oxygenation are enhanced.

Conservative Management

Conservative management is based on improving functional status as well as reducing pain and inflammation. Clinical research indicates the greatest improvements are made with lifestyle modifications and exercise over the aggressive use of modalities. This involves both weight loss (individuals with BMI >25 should obtain a minimum of 5% reduction of their total weight), as well as choosing low-impact aerobic activity (walking/aquatic) over higher impact activities such as running. Strengthening of the quadriceps has also shown significant improvements in knee OA patients. This commonly includes exercises such as quad sets, straight leg raise, squats, and long-arc quad with appropriate resistance applied. Strengthening the leg can increase muscle mass and decrease the workload of the knee joint in performing activities. Patellar taping has also been shown to decrease pain in the short term as well as enhance function. There is some evidence that ROM/flexibility exercises can improve function and pain as well. In a study looking at various conservative treatments, Ringdahl et al. 2011, shows that engaging in aquatic or land-based exercise, aerobic walking, quadriceps strengthening, resistance exercise, and tai chi are most effective for pain reduction and decreasing disability from knee osteoarthritis.3 NSAIDS are effective for short term pain relief. The National Institute for Health and Clinical Excellence suggests that nonpharmacologic agents such as thermal, manipulation, TENS, bracing, and assistive devices as possible adjunct therapy to exercise.4 Cryotherapy using ice for between 10-15 minutes can result in pain control up to 2 hours post application and reduced inflammation.5 Modalities like E-Stim, TENS, ultrasound, bracing, and massage have shown inconclusive evidence in terms of their effectiveness of reducing the symptoms of knee OA and some evidence even recommends decreasing their use.2,6 The best clinical evidence shows either inconclusive or insignificant effectiveness of modalities on knee OA management. Therefore, physical therapy management should focus on low-impact aerobic fitness exercises, ROM/flexibility exercises, quad strengthening, and patellar taping for short-term pain relief.7,8,9,10

Surgical Management

Surgical procedures for osteoarthritis of the knee include an arthroscopy, osteotomy, or arthroplasty. Arthroplasty is typically viewed as a last resort following conservative treatment other surgical procedures. Modalities may be slightly more effective post surgery than managing symptomatic OA through conservative treatment. However, results are likely due to improved joint structure from surgery, and not as much from the modality itself. Once swelling and pain have decreased appropriately following arthroplasty, management should focus on joint ROM/stretching and strengthening. Modalities may be chosen to be used in combination with ROM/stretching and strengthening. The following are procedure-specific protocols designed by Galland and Kirby for post-surgical rehabilitation:11

KNEE ARTHROSCOPY: (GALLAND/KIRBY)

POST-OP DAYS 1 – 7

  • TED Hose – Continue until swelling resolved
  • Crutches – weight bearing as tolerate (WBAT)
  • (DC when gait is normal – generally at 3-5 days)
  • Patellar mobilization as needed (teach patient)
  • Calf pumping
  • AAROM, AROM, heel slides as tolerated
  • Quad sets – Electrical stimulation as needed
  • Short Arc Quads
  • Straight leg raise (SLR) x 4 directions
  • Mini squats 0-45 degrees in parallel bars
  • Hamstring curls – Standing, without resistance
  • Double leg heel raises
  • Stationary bike for range of motion – Complete cycle as able
  • Stretches – HS, Hip Flexors, ITB
  • Ice Pack with knee elevated and in extension after exercise

GOALS

  • Pain and swelling controlled
  • ROM 0-90 degrees

Weeks 1 - 3

  • TED Hose – Continue until swelling resolved
  • Continue appropriate previous exercises
  • AAROM, AROM through full range
  • SLR x 4 on mat – Add ankle weights when quad control is maintained

– Progress to standing with light Theraband bilaterally

  • Wall squats 0-60 degrees
  • Leg press 0-60 degrees with light resistance
  • Hamstring curls on weight machine with light resistance
  • Forward, lateral and retro step downs in parallel bars (small step)
  • Single leg heel raises
  • Stationary bike – Progressive resistance and time

GOALS

  • Full ROM
  • Normal gait

WEEKS 3 - 6

  • Continue appropriate previous exercises with increased range and resistance
  • Forward, lateral and retro step downs (medium to large step)
  • Hip weight machine x 4 bilaterally
  • Knee extension weight machine
  • Proprioceptive training – Single leg BAPS, ball toss and body blade
  • Fitter
  • Slide board
  • Treadmill – Walking progression program
  • Elliptical trainer
  • Pool therapy

GOALS

  • Walk 2 miles at 15 min/mile pace
  • Stair ambulation without pain or sensation of giving way

WEEKS 6 - 10

  • Continue appropriate previous exercises
  • Agility drills / Plyometrics
  • Stairmaster
  • Treadmill – Running progression program
  • Transition to home / gym program

GOAL

  • Return to all activities

KNEE OSTEOTOMY: (GALLAND/KIRBY)

POST-OP DAYS 1 – 14
Dressing:
– POD 1: Debulk dressing, TED Hose in place
– POD 2: Change dressing, keep wound covered, continue TED Hose
– POD 7-10: Sutures out, D/C TED Hose when effusion is resolved

  • Brace – 0-90 degrees
  • Crutches – Non weight bearing (NWB) x 6 weeks
  • CPM in hospital – 0-90 degrees
  • AROM, AAROM 0-90 degrees
  • Patellar mobilization (teach patient)
  • Calf pumping
  • Passive extension with heel on bolster or prone hangs
  • Electrical stimulation with quad sets and SLR
  • Quad sets, Co-contractions quads/hams
  • Straight leg raise (SLR) x 4 on mat, in brace (parallel bars if poor quad control)
  • Stretches – Hamstring, Hip flexors, ITB
  • Ice pack with knee in full extension after exercise

GOALS

  • Pain / effusion control
  • ROM – 0-90 degrees

Weeks 2 - 4

  • Brace – Open to available range
  • Crutches – NWB
  • AROM, AAROM 0-120 degrees
  • Scar mobilization when incision healed
  • Co-contractions quads/hamstring at 0, 30, 60, 90 degrees
  • SLR x 4 on mat, no brace – Add weight above knee if good quad control
  • Stationary bike for ROM

GOALS

  • ROM 0-120 degrees
  • No extensor lag

WEEKS 4 - 8

  • Brace – Open to available range
  • Crutches – NWB x 6wks then Partial weight bearing (PWB)
  • Continue appropriate previous exercises
  • PROM, AAROM, AROM to regain full motion
  • SLR x 4 on mat, no brace – Light weight below the knee
  • Weight shifts, Mini squats – In parallel bars
  • Leg press with light resistance
  • Hamstring curls – Carpet drags or rolling stool (closed chain)
  • Double leg heel raises
  • Stationary bike – Progressive resistance and time
  • Pool therapy – Chest deep exercises in sagittal plane only

GOAL

  • Full ROM

WEEKS 8 - 12

  • Brace – Continue until 12 weeks post-op
  • Crutches – Weight bearing as tolerated (WBAT) (D/C when gait is normal)
  • Continue appropriate previous exercises
  • Forward, lateral and retro step downs – No flexion > 45 degrees (small step)
  • SLR x 4 with Theraband bilaterally
  • Wall squats – No knee flexion past 45 degrees
  • Single leg heel raises
  • Proprioceptive training – Single leg standing in parallel bars

– Double leg BAPS for weight shift
– Progress to single leg BAPS, ball toss and body blade

  • Treadmill – Forwards and backwards walking

– Walking progression program

  • Elliptical trainer
  • Pool therapy – Walk in waist deep water

GOALS

  • Normal gait
  • Walk 2 miles at 15 min/mile pace

MONTHS 3 - 4

  • D/C crutches and brace
  • Continue appropriate previous exercises with progressive resistance
  • Forward, lateral and retro step downs – Medium to large step
  • Hamstring curl weight machine
  • Knee extension weight machine
  • Hip weight machine x 4 bilaterally
  • Fitter
  • Slide board
  • Stairmaster
  • Swimming
  • Treadmill – Running progression program

GOAL

  • Jog/Brisk Walk 2 miles at easy pace

MONTHS 4 - 6

  • Continue appropriate previous exercises
  • Agility drills / Plyometrics
  • Sit-up progression
  • Progressive weight training program
  • Running progression to track
  • Transition to home / gym program

RETURN TO ALL ACTIVITIES. NO CONTACT SPORTS UNTIL 6 MONTHS POST-OP

KNEE ARTHROPLASTY: (GALLAND/KIRBY)

POST-OP DAYS 1 – 7

  • TED Hose x 6 weeks
  • Walker or crutches:

– Primary – Weight bearing as tolerated (WBAT)
– Revision – 50% Weight bearing x 6 weeks

  • Bed mobility and transfers
  • Heel slides, AROM, AAROM, PROM as tolerated
  • Straight leg raise (SLR) x 4 in standing
  • Short arc quads
  • Calf pumping
  • Quad sets, Co-contractions quads/hams
  • Passive extension with heel on bolster or prone hangs
  • Ice and elevation – Pillow under ankle NOT knee

GOALS

  • Independent with bed mobility and transfers
  • Independent ambulation 100 feet
  • AROM 5 - 90

Weeks 1 - 3

  • Walker or crutches:

– Primary – WBAT, progress to cane and D/C when gait is normal
– Revision – 50% Weight bearing until 6 weeks post-op

  • Continue TED Hose and appropriate previous exercises
  • AROM, AAROM, PROM through full range as tolerated
  • Stationary bike for ROM
  • Patellar mobilization (teach patient)
  • Scar massage when incision healed (teach patient)
  • Electrical stimulation in full extension with quad sets and SLR
  • SLR x 4 on mat
  • Weight shifts and Mini-squats in parallel bars (0-45 degrees)
  • Stretches – Hamstring, Hip Flexors, ITB
  • Primary Only:

– Wall squats (0-45 degrees)
– Forward, retro and lateral walking in parallel bars
– Double leg heel raises
GOALS

  • ROM 0-110 degrees
  • No extensor lag

WEEKS 3 - 6

  • Primary – Cane as needed, D/C when gait is normal
  • Revision – Walker or crutches, 50% Weight bearing
  • Continue TED Hose and appropriate previous exercises
  • SLR x 4 on mat, add ankle weights as tolerated
  • Leg press (double leg) up to ½ body weight
  • Hamstring curl weight machine (double leg) with light weight as tolerated
  • Sitting knee extension (chair or mat) 90-0 degrees
  • Stationary bike for progressive resistance and time
  • Primary Only:

– Forward, retro and lateral step downs (small to med step)
– Single leg heel raises
GOALS

  • ROM 0-120 degrees
  • Primary – Normal gait

WEEKS 6 - 9

  • D/C TED Hose
  • Revision:

– Walker or crutches, Weight bearing as tolerated (WBAT)
– Progress to cane as tolerated, D/C when gait is normal

  • Continue appropriate previous exercises
  • Revision – Begin:

– Wall squats (0-45 degrees)
– Forward, retro and lateral walking in parallel bars
– Forward, retro and lateral step downs (small to med step)
– Double leg heel raises

  • Primary and Revision:

– Standing SLR x 4 with Theraband bilaterally
– Isometric knee extension at 0 and 60 degrees
– Proprioception exercises – Single leg (stork) standing in parallel bars
– Treadmill – Walking progression program
– Elliptical trainer
GOALS

  • ROM WNL and equal bilaterally
  • Revision – Normal gait

WEEKS 9 – 12

  • Continue appropriate previous exercises
  • Leg press – Single leg
  • Hamstring curl weight machine – Single leg
  • Leg extension weight machine – Double leg, progress to single leg as tolerated
  • Hip weight machine x 4 bilaterally
  • Single leg heel raises
  • Practice sit-to-stand without using hands
  • Stair training
  • Proprioception exercises – Double to single leg BAPS
  • Cone drills – Side step, cariocas, elevated walking
  • Pool therapy
  • Quad stretches

GOALS

  • Walk x 20 minutes
  • Independent with stairs

MONTHS 3 – 4

  • Discontinue supervised PT
  • Resume all recreational activities as tolerated
  • Encourage non-impact activities

RETURN TO PREVIOUS
LEVEL OF ACTIVITY
Swimming- 1 year (Pool aquatic therapy at 6 wks)
Bowling- 6 months
Golfing- Chipping and putting at 3 months
Driving – 6 months
Tennis Doubles 6 months, Singles 1 year
Snow Skiing- Greens/Blues 6 months-1 year
Horseback Riding 3-6 months if experienced 1 year
Bicycling- Stationary 2 months, outdoor 3 months

SPORTS / ACTIVITIES NOT RECOMMENDED
Jogging / Running / Jumping
Basketball / Football / Baseball / Soccer / Volleyball
Waterskiing

Bibliography
1. American Physical Therapy Association. Guide to physical therapist practice. Second edition. American physical therapy association. Phys Ther. 2001;81(1).
2. American Academy of Orthopaedic Surgeons. Treatment of osteoarthritis of the knee: Full guideline. http://www.aaos.org/Research/guidelines/OAKguideline.pdf. Revised Dec 2008. Accessed March 2012.
3. Ringdahl E, Pandit S. Treatment of knee osteoarthritis. Am Fam Physician. 2011 Jun 1;83(11):1287-1292.
4. National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults. London: Royal College of Physicians; 2008.
5. Cameron M. Physical agents in rehabilitation. from research to practice. 3rd ed. Philadelphia: Saunders Elsevier; 2009:457.
6. Ottawa Panel evidence-based clinical practice guidelines for therapeutic exercises and manual therapy in the management of osteoarthritis. Phys Ther 2005;85:907-71.
7. American Academy of Orthopaedic Surgeons. Treatment of osteoarthritis of the knee (non-arthroplasty). Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008.
8. Richmond J, Hunter D, Irrgang J, et al. American Academy of Orthopaedic Surgeons clinical practice guideline on the treatment of osteoarthritis (OA) of the knee. J Bone Joint Surg Am 2010;92:990-3.
9. Zhang W, Nuki G, Moskowitz RW, et al. OARSI recommendations for the management of hip and knee osteoarthritis: Part III: changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis Cartilage 2010;18:476-99.
10. Iwamoto J, Yoshihiro S, Tsuyoshi T, et al. Effectiveness of exercise for osteoarthritis of the knee: A review of the literature. World J Orthop. 2011 May 18; 2(5):37–42.
11. Galland M, Kirby K. Physical therapy post-operative rehabilitation protocols. Orthopaedic Specialists of North Carolina. http://www.orthonc.com/physical-therapy/physical-therapy-postoperative-rehabilitation-protocols. Revised 2012. Accessed Feb 2012.
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