What Can I Do To Reduce The Progression Of Knee Arthritis
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Knee arthritis is a common condition among older adults and remains one of the greatest causes of disability in our country. Consistent with many musculoskeletal conditions there remains a disconnect between imaging findings and a patient’s clinical presentation. Studies have shown many patients without knee pain can have signs of arthritis on their x rays. In addition, many older adults with knee pain can have negative x rays for arthritis. This lack of association is likely due to many patient factors including activity level, functional demands, strength, flexibility, and overall health. For example, a stronger patient is less likely to experience pain during a given activity compared to their weaker peers. Strength training as part of an individually tailored Physical Therapy program remains the gold standard for conservative treatment of this condition. A new research article highlights other modifiable factors which may influence the progression of knee arthritis.

A longitudinal, observational study was conducted to determine the factors associated with knee arthritis progression in older adults (Halilaj et al. Osteoarthritis and Cartilage. 2018). Authors recruited subjects based on presence (N = 3285) of the condition. Patient history, demongraphic, functional outcomes and x findings were taken upon the first visit. Patient’s were then categorized by risk of progression of arthritis. High risk patients included histories of knee pain, aching or stiffness, previous total knee replacement, family history of arthritis, high body mass index, or previous knee injury. Patient disease progression was based on follow up x rays at 1 and 2 year follow up. In addition, patient’s completed functional outcomes at these time points.

Authors then calculated predictive variables which may have contributed to the radiographic findings. Consistent with previous research, x ray findings of arthritis including joint space narrowing did not predict patient symptoms. Authors prediction models found a slower gait speed, poor sleep, and higher meat intake were associated with knee arthritis disease progression. This supports previous research on the importance of a patient’s overall health in managing their knee arthritis. Smoking history, body mass intake, sleep, diet, and exercise remain some of the most powerful modifiable factors to reduce the progression and symptoms associated with knee arthritis.

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How Heavy Should I Load My Achilles Tendon After An Overuse Injury?
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In the achilles tendinopathy (artist formally known as tendonitis) research two main themes have emerged. First, there is little to no evidence to support the use of injections of any kind into an injured tendon. Authors have advocated against steroid injections due to the risk of tendon rupture outweighing any potential benefits. Studies have also been limited in the use of PRP (platelet rich plasma) injections for tendon pain. Significant methodological concerns have impacted this area of research including the lack of large human trials, lack of placebo or alternative treatment (exercise) comparison, and small sample sizes. Without improvements in this line of research, PRP remains an expensive, experimental treatment compared to other proven treatment strategies.

Strengthening exercises remain the gold standard of care, both in the research and our Boulder Physical Therapy practice, for these tendon injuries. Although eccentric exercise was first published in the late 1990s as an effective treatment for tendinopathy, many other forms of strength training including isometric and isotonic exercise have also been shown to be effective. The key take home message from these trials remains the same, injured tendons must be progressively loaded based on their clinical presentation to recover. Initially improvements in a patient’s symptoms and function are secondary to improved strength of the surrounding muscles while long term improvements are attributed to structural healing of the tendon (remodeling).

A recent review of the evidence highlights the importance of intensity or resistance during achilles strength training exercises for patients with mid portion achilles tendinopathy (Murphy et al. Br J Sp Med. 2019). Authors reviewed the available literature on the use of heavy eccentric training for this patient population compared to a wait and see or traditional Physical Therapy approach (modalities, massage). They reviewed the data from 7 studies and reported heavy eccentric training may be superior to a wait and see approach and traditional Physical Therapy. Authors also found a trend showing these heavy eccentric exercises may be less effective than other forms of exercise (isometric, isotonic).

This review is consistent with our current understanding on tendon management. Tendons should be progressively loaded based on the tendon’s tissue tolerance and irritability. Although eccentric exercise has become popular, other forms of exercise and loading strategies should also be considered as part of the tendon loading plan of care. When it comes to tendons, one size does not fit all.

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Eccentric Quad Strengthening Shown To Improve Strength And Flexibility Of Muscle
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Mobility exercises designed to improve range of motion within an affected joint or tissue are a valuable part of any rehabilitation program. Previously clinicians prescribed various bouts (3 x 30 seconds) of static stretching in an attempt to lengthen short muscles. Current research has shown these prescriptions are ineffective at changing muscle length and instead alter the stretch tolerance of the muscle. Thus individuals who stretch more frequently, have an increased tolerance to stretch, and therefore greater range of motion. Conversely, eccentric exercise has been shown to not only develop muscle strength and size, but also change the structure of the muscle improving its’ true length. Further, in randomized, controlled trials eccentric exercise produces greater gains in hamstring flexibility than static stretching alone. A recent study suggests this may also be true for the quadriceps.

Alonso-Fernandez and colleagues studied the effects of 8 weeks of eccentric quadricep training on muscle strength, cross sectional area, and flexibility (J Sports Med Phys Fitness. 2011). Authors placed 26 participants underwent pre and post training testing, as well as, a 4 week detraining period to determine the lasting effects of this exercise program. As expected, eccentric quadriceps training led to gains in quadriceps strength and muscle size. Consistent with prior research on the hamstrings, this eccentric training also improved muscle length and flexibility measurements. Reinforcing a commonly held belief “strengthen to lengthen”. in addition, all measures of muscle performance decreased following the 4 week detraining period. This study further supports our understanding of muscle architecture and the forces required to make a significant change in muscle tissue.

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Higher Amounts Of Exercise Correlated With Greater Reductions In Neck Pain
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With the hypervigilance in abstaining from opioid prescriptions due to the opioid crisis, there has been an effort in determining alternate ways of providing analgesic effects for those in chronic pain. One of the most consistent modalities to help benefit with treatment is exercise. There has been many studies exploring the analgesic effect of exercise on pain and dysfunction as compared to pharmacological treatment. However, there has not been any literature supporting the appropriate dosage and intensity of exercise.

A recent study (Polaski, AM et al. PLoS One. 2019) performed a meta-analysis of many studies using exercise to help treat and manage chronic pain. The studies ranged from many different durations and intensities with different populations, all experiencing chronic pain. The researchers found a positive correlation between duration of exercise and decrease in neck pain. Duration could be constituted for amount of time during exercise, and/or number times exercising throughout the week.

If you are experiencing chronic pain, please seek counsel with your health provider to help guide you in designing a exercises program with the appropriate duration.

3 Week Immobilization Shown Equivocal To 6 Week For Some Ankle Fractures
Photo Credit: wikipedia.org

Photo Credit: wikipedia.org

Ankle fractures are a relatively common traumatic orthopedic injury involving the two lower leg bones and ankle joint.  Among these fractures, the most common type involves a break of the outer lower leg bone (weber B).  These fibular fractures are commonly allowed to weight bear early than tibia fractures because they are less important for lower body weight bearing.  Common medical practice provides immobilization to avoid excessive weight bearing or forces for 6 weeks following fracture, but smaller studies have not demonstrated a significant increased risk of adverse events if fractures are immobilized for less than the standard 6 weeks.

A large randomized, controlled trial was published in the British Medical Journal documenting the effects of two types of non surgical management strategies for Weber B ankle fractures (Haapasalo et al. 2019).  Authors randomized 247 fibular Weber B, stable, ankle fractures to either a 3 week or 6 week immobilization period in an orthosis.  Patients were assessed on ankle function, pain, quality of life, ankle motion, and adverse events at 6, 12, and 52 weeks after the fracture.  Authors reported no difference in outcomes between the 3 or 6 week management groups except a slight improvement in ankle range of motion and deep vein clot risk in the 3 week group.  Patients are encouraged to speak with their orthopedist regarding the best course of action for their individual fracture management. 

Study Shows Cost Effectiveness Of Out Of Network Physical Therapy Practices
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When we opened MEND we wanted a Physical Therapy practice focused on excellent patient outcomes, in fewer visits, delivered by experts in their field. Our practice will not employ anyone other than board certified Physical Therapy orthopedic specialists and the care would be one on one in nature. To maintain our clinical principles we decided to become an out of network provider of Physical Therapy services and have seen our practice thrive as patients seek out an alternative to the standard quo.

Consumers often mistakenly believe out of network is more expensive than in network care. When you compare the number of visits utilized by MEND, on average 3-4, it is significantly less expensive than an in network model seeing a patient 2-3 times per week for 6-8 weeks. In addition, services provided in Physical Therapy clinics owned by physicians (POPTS) often bill under “incident to” allowing them to charge a more expensive rate than in or out of network Physical Therapy practices. Incident to billing, increased visits, and a higher utilization of technicians and aides contributes to the increased Physical Therapy costs seen with POPTS. A recent study highlights these trends and documents the cost effectiveness of the out of network Physical Therapy model.

Pulford and colleagues examined the cost effectiveness of Physical Therapy services provided by an out of network (cash based) provider (Health Care Manag. 2019). They analyzed the charts of 48 randomly selected patients over a 3 year period. Authors reported patients were seen a median of 5 visits at an average cost of $98 per visit for a total cost of $780. Conversely, in network care averaged $936. This is the first study to examine the practice patterns and health care costs associated with out of network or cash based practices. In the presence of higher deductibles and co pays, patients are advised to consider both in and out of network models of care to see which model is most appropriate for their clinical and financial needs.

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