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
Departm ent of Physical Therapy • Dosage • Manual Therapy • Motor Learning
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
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)
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.
Departm ent of Physical Therapy Alternative to Repetition Maxim um for Dosing Borg Perceived Exertion Scale • Modified Borg 0 Nothing at all Perceived Exertion 1 Very light 2 Fairly light Scale 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
Departm ent of Physical Therapy Alternative to Repetition Maxim um for Dosing Borg Perceived Exertion Scale • Emphasize gains in 0 Nothing at all muscle force output 1 Very light • Increase resistance as 2 Fairly light 3 Moderate patient progresses and 4 Somewhat Hard RPE falls below 5 Hard desired level. 6 7 Very Hard 8 9 10 Very very hard
Departm ent of Physical Therapy Alternative to Repetition Maxim um for Dosing • Emphasize gains in Borg Perceived Exertion Scale endurance 0 Nothing at all 1 Very light • Increase resistance as 2 Fairly light patient progresses and 3 Moderate RPE falls below 4 Somewhat Hard 5 Hard desired level. 6 7 Very Hard 8 9 10 Very very hard
Departm ent of Physical Therapy Alternative to Repetition Maxim um for Dosing • Potential Advantages • Potential of RPE Disadvantages of RPE – Can dose without need – Not yet known if it will for major testing produce the same equipment strength outcomes as %RM approach – Easy to teach patient for independent exercise and activity programs
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
Departm ent of Physical Therapy Manual Therapy • Techniques include accessory and physiologic motion techniques, manual stretching techniques, and soft tissue manipulation techniques
Departm ent of Physical Therapy Exam ples of Manual Therapy Techniques Manually applied stretch to the P-A glide of tibia on femur with hamstrings and posterior medial tibial rotation: Target capsule anterior-lateral capsule
Departm ent of Physical Therapy Exam ples of Manual Therapy Techniques Accessory Motion: Soft tissue manipulation Patellofemoral inferior glides with manual stretching
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
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
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.
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.
Departm ent of Physical Therapy Abbott JH, et al. Osteoarthritis Cartilage. 20 13;21:525-534 Usual Care (UC) UC + Manual Therapy (MT) N =54 N = 51 UC + Exercise (Ex) UC+MT+Ex N = 51 N = 50 • Included subjects with knee or hip OA • 9 sessions (7 in first 9weeks +2 boosters at 16 weeks)
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 -41.4 -29.3 -27.4 (51.8) (55.5) (50.4) (41.1) 30s sit to .02 .67 1.6 1.59 (-.79;.84) (-.12;1.45) (.80;2.40) (.60;2.59) stand (# stands) 40m walk (sec) .78 -.50 -3.18 -.61 (-1.40;2.95) (-3.70;2.70) (-4.41; -1.99) (-2.22; 1.00) NNT* 5 6 8 * Number needed to treat for achieving responder to treatment status based on OMERACT-OARSI responder criteria
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)
Summary of Experimental Design Baseline Testing R Exercise MT +Exercise Exercise MT+ Exercise +Booster +Booster 12 Rx Sessions 12 Rx Sessions 8 Rx Sessions 8 Rx Sessions 9 Wk 9 Wk 9 Wk 9 Wk F/U F/U F/U 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
Departm ent of Physical Therapy Motor Learning Approaches • Biomechanical unloading • Task Specific Training
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.
Departm ent of Physical Therapy Gait Retraining Approaches • Goal to reduce knee adduction moment • Foot progression angle (toe out) • Trunk sway (lateral)
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
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
Departm ent of Physical Therapy Shull PB, et al. J Orthop Res. 2013;31:1020-1025
Departm ent of Physical Therapy
Departm ent of Physical Therapy
Departm ent of Physical Therapy
Departm ent of Physical Therapy Task-Specific Training
Departm ent of Physical Therapy Traditional Prem ise ↓ Physical Function + Performance
Departm ent of Physical Therapy Traditional Prem ise ↑ Physical Function + Performance
Departm ent of Physical Therapy • Changes in impairments (muscle strength, flexibility, joint mobility) not associated with clinical outcome of pain and function in subjects with knee OA. 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
Departm ent of Physical Therapy • Impairment-based rehabilitation approach yielded only modest self- reported improvements in functional task performance ability 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 osteoarthritis. Phys Ther. 20 11;91:1752-1765
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