Knee Pain/ OA Physical Therapy Approaches G. Kelley Fitzgerald, - - PowerPoint PPT Presentation

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Knee Pain/ OA Physical Therapy Approaches G. Kelley Fitzgerald, - - PowerPoint PPT Presentation

Dec 01, 2022 1.45k likes •1.91k views

Departm ent of Physical Therapy Knee Pain/ OA Physical Therapy Approaches G. Kelley Fitzgerald, PT, PhD, FAPTA Professor, Department of Physical Therapy, School of Health and Rehabilitation Sciences Director, Physical Therapy Clinical and

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Departm ent of Physical Therapy

Knee Pain/ OA Physical Therapy Approaches

  • G. Kelley Fitzgerald, PT, PhD, FAPTA

Professor, Department of Physical Therapy, School of Health and Rehabilitation Sciences Director, Physical Therapy Clinical and Translational Research Center

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Departm ent of Physical Therapy

  • Dosage
  • Manual Therapy
  • Motor Learning
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Departm ent of Physical Therapy

Strength Training Dosage

  • % of a repetition maximum
  • Perceived Exertion Scales
  • For our patients with arthritis, these

should be “pain-free” entities

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Departm ent of Physical Therapy

Strength Training Dosage

  • American College of Sports Medicine

Recommendations for Older Adults

– 60-80% 1 RM, 8-12 reps, 1-3 sets, with 1-3 min rest between sets. – Can also incorporate power programs of 30- 60% 1 RM, 6-10 reps, 1-3 sets at higher repetition velocity. – For endurance training, use lighter loads (50-60%) with higher reps (10-15 or more)

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Departm ent of Physical Therapy

Progression of Strength Training Intensity

  • When patient can perform 1-2 reps over

the target reps for 2 consecutive sessions, training load should be increased by 2 to 10%.

  • Recommend re-establishing the 1 RM

every 2 to 4 weeks to re-adjust training loads appropriately.

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Departm ent of Physical Therapy

Alternative to Repetition Maxim um for Dosing

  • Modified Borg

Perceived Exertion Scale

Borg Perceived Exertion Scale Nothing at all 1 Very light 2 Fairly light 3 Moderate 4 Somewhat Hard 5 Hard 6 7 Very Hard 8 9 10 Very very hard

Borg, G. (1982) Psychophysical bases of perceived exertion. Medicine and Science in Sports and Exercise, 14 (5), p. 377-81

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Departm ent of Physical Therapy

Alternative to Repetition Maxim um for Dosing

  • Emphasize gains in

muscle force output

  • Increase resistance as

patient progresses and RPE falls below desired level.

Borg Perceived Exertion Scale Nothing at all 1 Very light 2 Fairly light 3 Moderate 4 Somewhat Hard 5 Hard 6 7 Very Hard 8 9 10 Very very hard

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Departm ent of Physical Therapy

Alternative to Repetition Maxim um for Dosing

  • Emphasize gains in

endurance

  • Increase resistance as

patient progresses and RPE falls below desired level.

Borg Perceived Exertion Scale Nothing at all 1 Very light 2 Fairly light 3 Moderate 4 Somewhat Hard 5 Hard 6 7 Very Hard 8 9 10 Very very hard

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Departm ent of Physical Therapy

  • Potential Advantages
  • f RPE

– Can dose without need for major testing equipment – Easy to teach patient for independent exercise and activity programs

  • Potential

Disadvantages of RPE

– Not yet known if it will produce the same strength outcomes as %RM approach

Alternative to Repetition Maxim um for Dosing

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Departm ent of Physical Therapy

Aerobic Training Dose

  • 30 to 60 minutes per week
  • 50-70% of heart rate

reserve (HRR)

  • Target HR = 220- Age –

(Resting HR x %HRR) + Resting HR

  • Example: 60 y/ o with

resting HR of 80, exercise at 60% of HRR: 220 – 60 – (80 X .60) + 80 =128 beats/ min

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Departm ent of Physical Therapy

Manual Therapy

  • Techniques include accessory and physiologic

motion techniques, manual stretching techniques, and soft tissue manipulation techniques

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Departm ent of Physical Therapy

Exam ples of Manual Therapy Techniques

P-A glide of tibia on femur with medial tibial rotation: Target anterior-lateral capsule Manually applied stretch to the hamstrings and posterior capsule

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Departm ent of Physical Therapy

Exam ples of Manual Therapy Techniques

Accessory Motion: Patellofemoral inferior glides Soft tissue manipulation with manual stretching

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Departm ent of Physical Therapy

Manual Therapy: Joint Mobilization

  • Can be used to induce relaxation and reduce

pain (grades 1 and 2)

  • Can be used to improve joint mobility (grades

3-5)

  • Objective of treatment is to manually

reproduce joint accessory motions such as distractions and joint surface translations.

  • Can also be used to apply more targeted

stretching of joint capsule

Moss P, et al, Manual Therapy. 2007;12:109-118 Deyle G, et al, Phys Ther. 2005;85:1301-1317

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Departm ent of Physical Therapy

Joint Mobilization: Indications

  • Hypomobility on accessory motion

testing (reproduction of joint translatory movements)

  • Measureable reduction in joint motion

even after de-emphasizing contribution from tight muscles

  • Pain/ stiffness in specific portions of the

peri-articular soft tissue on joint motion

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Departm ent of Physical Therapy

Deyle, et al. Phys Ther. 20 0 5; 8 5: 130 1-1317.

  • Compared group with knee OA receiving

supervised manual therapy and exercise to group receiving home exercise.

  • Manual therapy and exercise delivered to

lumbo-pelvic, hip, knee, foot and ankle regions based on reduced motion or pain in these regions.

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Departm ent of Physical Therapy

Deyle, et al. Phys Ther. 20 0 5; 8 5: 130 1-1317.

  • Both groups improved

function scores.

  • Group receiving

supervised manual therapy and ex had greater improvements. (52% vs 26%)

  • Larger effect compared

with many other exercise studies.

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Departm ent of Physical Therapy

Abbott JH, et al. Osteoarthritis

  • Cartilage. 20 13;21:525-534

Usual Care (UC) N = 51 UC + Manual Therapy (MT) N =54 UC + Exercise (Ex) N = 51 UC+MT+Ex N = 50

  • Included subjects with knee or hip OA
  • 9 sessions (7 in first 9weeks +2

boosters at 16 weeks)

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Departm ent of Physical Therapy

Abbott JH, et al. Osteoarthritis

  • Cartilage. 20 13;21:525-534

ONE YEAR FOLLOW-UP CHANGES UC MT Ex MT + Ex WOMAC

  • 12.9

(51.8)

  • 41.4

(55.5)

  • 29.3

(50.4)

  • 27.4

(41.1)

30s sit to stand (# stands) .02

(-.79;.84)

.67

(-.12;1.45)

1.6

(.80;2.40)

1.59

(.60;2.59)

40m walk (sec) .78

(-1.40;2.95)

  • .50

(-3.70;2.70)

  • 3.18

(-4.41; -1.99)

  • .61

(-2.22; 1.00)

NNT* 5 6 8

* Number needed to treat for achieving responder to treatment status based

  • n OMERACT-OARSI responder criteria
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Departm ent of Physical Therapy

Enhancing the Effectiveness of Physical Therapy in People with Knee Osteoarthritis

1 RO1 HS0 19624-0 1

University of Pittsburgh, Pittsburgh PA- Data Coordinating Center (PI: G. Kelley Fitzgerald) Other Study Sites: University of Utah/ Intermountain Healthcare, Salt Lake City, UT (PI: Julie M. Fritz) Army-Baylor University, San Antonio, TX (PI: John Childs) University of Otago, Dunedin NZ (PI: Haxby Abbott)

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Baseline Testing Summary of Experimental Design R Exercise MT +Exercise Exercise +Booster MT+ Exercise +Booster

12 Rx Sessions 12 Rx Sessions 8 Rx Sessions 8 Rx Sessions

9 Wk F/U 9 Wk F/U 9 Wk F/U 9 Wk F/U

Home Program Home Program Home Program Home Program 5 mo Booster – 2Rx 5 mo Booster – 2Rx 8 mo Booster – 1Rx 8 mo Booster – 1Rx 11 mo Booster – 1Rx 11 mo Booster – 1Rx

1 YR F/U 1 YR F/U 1 YR F/U 1 YR F/U 2 YR F/U 2 YR F/U 2 YR F/U 2 YR F/U

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Departm ent of Physical Therapy

Motor Learning Approaches

  • Biomechanical unloading
  • Task Specific Training
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Departm ent of Physical Therapy

Contralateral Cane Use

  • ↓ KAM by 7-10%
  • ↓ cumulative loading by:

– ↑ stride length – ↓ cadence

  • ↓ GRF by 25%-35%

during gait

  • Most effective if placed as

far laterally as possible without inducing sx.

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Departm ent of Physical Therapy

Gait Retraining Approaches

  • Goal to reduce knee adduction moment
  • Foot progression angle (toe out)
  • Trunk sway (lateral)
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Departm ent of Physical Therapy

  • Motion capture and instrumented

treadmill

  • Patient tailored altered foot progression

angle or lateral trunk to get 10% ↓ in KAM

  • Vibration motors on tibia (foot angle) and

scapula (trunk sway) for feedback during training

Shull PB, et al. J Orthop Res. 2013;31:1020-1025

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Departm ent of Physical Therapy

  • 1x/ week, 6 weeks
  • 10 min practice daily
  • Subject selected

method of alteration

– Foot progression angle – Trunk sway – Both

  • Fading feedback

training design

Shull PB, et al. J Orthop Res. 2013;31:1020-1025

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Departm ent of Physical Therapy

Shull PB, et al. J Orthop Res. 2013;31:1020-1025

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Departm ent of Physical Therapy

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Departm ent of Physical Therapy

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Departm ent of Physical Therapy

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Departm ent of Physical Therapy

Task-Specific Training

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Departm ent of Physical Therapy

Traditional Prem ise

↓Physical Function + Performance

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Departm ent of Physical Therapy

Traditional Prem ise

↑Physical Function + Performance

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Departm ent of Physical Therapy

Fitzgerald GK, White DK, Piva SR. Associations for change in physical and psychological factors and treatm ent response following exercise in knee osteoarthritis: An exploratory study. Arthritis Ca re Res. 20 12;64:1673-168 0

  • Changes in impairments (muscle

strength, flexibility, joint mobility) not associated with clinical outcome of pain and function in subjects with knee OA.

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Departm ent of Physical Therapy

Teixeira PEP, Piva SR, Fitzgerald GK. Effect of im pairm ent-based exercise on perform ance of specific self- reported functional tasks in individuals with knee

  • steoarthritis. Phys Ther. 20 11;91:1752-1765
  • Impairment-based rehabilitation

approach yielded only modest self- reported improvements in functional task performance ability

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Departm ent of Physical Therapy

Task-Specific Training

  • Use the specific task that is problematic

as the training tool

  • Can work on strength and joint mobility

in context of the task

  • Provide opportunity to improve motor

patterns in context of task

  • May consider task modifications
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Departm ent of Physical Therapy

Chair Rise Task Step 1: Moving to Edge of Seat

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Departm ent of Physical Therapy

Chair Rise Task Step 2: Lift Off

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Departm ent of Physical Therapy

Chair Rise Task Step 3: Term inal Stand

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Departm ent of Physical Therapy

Chair Rise Task Full Task Practice

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Departm ent of Physical Therapy

Floor Transfers

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Departm ent of Physical Therapy

THANK YOU!!!