Posts tagged knee replacement
The Benefit Of Physical Therapy Before Knee Replacement Surgery
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Knee arthritis is most effectively treated in its’ early stages with Physical Therapy including manual therapy and exercise interventions. These interventions have been shown to reduce pain and disability, as well as, prevent or post pone the need for future knee surgery. In later stages of disease progression, knee arthritis is most effectively treated with a total knee replacement. This major surgery involving the replacement of joint surfaces in the knee was first performed in the 1960s. Since this time it has become one of the most successful orthopedic surgeries due to its’ ability to improve pain and function among this end stage patient population. In our Boulder physical therapy practice, we often find patients who enter their orthopedic surgery with optimal range of motion, strength, and function have the best outcomes after surgery. A recent review article supports our clinical findings.

Authors in the journal Physical Therapy reviewed the available evidence on the use of pre operate Physical Therapy among patients electing for total knee replacement (Devasenapathy et al. 2019). They were interested in finding the importance of pre operative treatments on post operative function including gait speed, stair climbing, and function. Authors reviewed 12 studies and found an association between pre operative quadricep strength and post operative function. They noted pooling of information was limited in this meta analysis due to the different methodologies used in the available studies. They called for additional studies of higher methodological quality to improve predictor analysis.

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High vs. Low Intensity Physical Therapy after Total Knee Replacement
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Knee replacements are a common and effective solution for end state knee osteoarthritis.  Post operative Physical Therapy helps accelerate the recovery from this surgery by reducing pain, improving range of motion and leg strength after this surgical procedure.  Research questions remain regarding the optimal frequency and intensity of post operative Physical Therapy visits.  A recent randomized controlled trial completed by authors in Colorado examined the impact of these variables on a patient's recovery from a total knee replacement.

Over 160 patients were randomized to either receive a high or low intensity post operative Physical Therapy plan of care (Bade et al. Arthritis Care and Research. 2016).  Both groups attended Physical Therapy 2-3 times per week for 11 weeks but varied based on the intensity of the prescribed exercises.  The authors found no significant differences in post operative groups with either high or low intensity programs at either 3 or 12 month follow up.   It appears the early post operative recovery's high pain, swelling, and impairments may prevent individuals from getting the full benefits of exercise in the first few months.  

Does Physical Activity Improve after a Total Knee or Hip Replacement?

Total knee and hip replacements are among the fastest growing surgeries in our country.  Physical Therapy remains the first line treatment for patients with knee and hip arthritis, but in patients with severe osteoarthritic pain and loss of function joint replacement remains a good surgical option.  In prior research among patients undergoing these procedures there is often a disconnect between subjective reporting of pain and function and the objective testing of a patient's function.  For example, a patient may report great outcomes and an ability to walk long distances without fatigue or pain, but objective testing in Physical Therapy often reveals residual endurance, strength, and balance impairments.  

In addition to severe pain, one of the most important indications for a total joint procedure is loss of function.   After the surgery patients are expected to increase their activity levels due to reduced pain, but new research is questioning this assumption.  A recent review article in the Journal of Orthopedic and Sports Physical Therapy examined if physical activity levels increased after these procedures (Arnold et al. 2016).  Authors reviewed the available data and found 8 studies of 373 patients who underwent a total joint replacement.  

These studies objectively tracked a patients physical activity levels up to 1 year after the procedure to see if levels had increased compared to pre operative levels.  The authors reported negligible improvements at 6 months and limited evidence to support increases in activity levels at 1 year.  At one year, patients with total joint replacements were significantly less active than their peers.  This study indicates the importance of post operative Physical Therapy to effectively improve strength, endurance, and balance allowing patients to resume an active lifestyle.  

Total Knee Replacement compared to Physical Therapy for Knee Arthritis

Knee osteoarthritis (OA) is a common condition in middle to older age and is a leading cause of pain and disability among this population.  Our prior posts detailed improvements in cartilage thickness occurring in individuals with mild knee OA after a lower body exercise program.  In advanced stages of knee OA or with a progressive worsening of symptoms and loss of function patients may opt for total knee replacement surgery.  This is a relatively common and effective surgery for knee OA.   Authors reported 670,000 patients in the U.S. underwent a total knee replacement (TKA) in 2012 alone.   These surgeries amounted to a total cost of $36 billion dollars and this cost is estimated to rise with our aging population (Kurtz et al. 2007).

A recent well designed study in the New England Journal of Medicine examined the short and long term outcomes associated with either a 12 week pre operative Physical Therapy and TKA compared with a similar Physical Therapy program and other conservative treatments (Skou et al. 2015).  100 patients with moderate to severe OA participated in the study and were randomly assigned to 1 of 2 groups listed above.  The authors noted significant improvements in function in both groups over the following 12 months.  In the Physical Therapy group, 74% of the patients reported enough improvements to not opt for any surgical intervention over the course of the study.  As a group, the TKA group did report higher outcomes at 12 months compared to the Physical Therapy and conservative group.  Pre operative Physical Therapy has been shown to accelerate recovery and lead to greater improvements in surgical outcomes compared to groups offered surgery alone (Villadsen et al. 2014)  Due to the invasive nature of the surgery, surgical patients had a 4 times greater risk of adverse events compared to the conservative group.   

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In short, Conservative treatment of knee OA  has been shown to delay or prevent the need for TKA surgery but some patients may require the procedure.   Patients considering this surgery should opt for pre operative Physical Therapy to accelerate outcomes and improve functional outcomes at short and long term follow ups. 

Physical Therapy Exercise and Knee Osteoarthritis

Previously we wrote about the positive impacts of exercise on the body's tissues.  The benefits of exercise is based on the ability of your rehabilitation program to properly load and unload an injured tissue allowing it to remodel and heal.  The optimal amount of load is key with both ends of spectrum, over doing it and too much rest, causing equal amounts of harm and lost time.  Knee osteoarthritis is a common condition among older adults resulting in a substantial amount of disability and health care costs.  Many of these patients may seek out the services of an orthopedic surgeon for a total knee replacement, but conservative Physical Therapy treatments have been shown to delay or prevent the need for this costly, invasive replacement surgery.  

Physical Therapy interventions are designed to reduce pain, improve mobility and function by using hands on manual Physical Therapy interventions and exercise.  Exercise is a powerful component of any conservative treatment plan and should be tailored to meet the individual needs of the patient and their symptoms.  As we add strengthening into a patient's home exercise program we are impacting many of the bodies tissues and systems including bone, muscle, tendon, nerves, and the cartilage on top of the ends of long bones (femur, tibia) in the knee.

A recent article by Koli et al (Am J Sp Med. 2015) examined the impact of exercise on patients' with knee osteoarthritis (OA).  Specifically, the authors were interested in documenting the impact of exercise on cartilage growth and healing.  80 women with mild knee OA were placed in a progressive exercise program 3 times per week for 12 months.  Exercises included multi directional step and aerobic step exercises.  The women were assessed for baseline and 1 year knee function, aerobic and strength capabilities, and patellar cartilage.  

The authors noted progressive, high impact exercise programs provides stimulation to remodel and improve patellar cartilage in patients with mild knee OA.  At the 1 year follow up, thickness of the patellar cartilage had improved within the exercise group compared to controls.  This study adds to the available evidence on the positive effects of exercise on the ability of the body to heal injured tissues.  As we look for further solutions for injured cartilage, exercise remains an important component of any rehabilitation program.  To learn more about how exercise may improve your cartilage health contact the experts at Mend Physical Therapy.  

Knee Arthritis and Physical Therapy Interventions
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Knee Arthritis Background Information

Osteoarthritis (OA) costs have risen to 13.2 billion dollars per year and are the leading cause of disability in adults(1).

Knee OA is the most common area and leads to mild to moderate disability in >10% of adults over age 552. Up to 70% of older adults have OA changes on imaging but remain asymptomatic(3).

The clinical examination has also been shown to help in the ruling out (sensitivity .91) and ruling in (specificity of .86) using the following findings(4). 

Physical Therapy Treatments for Knee Arthritis 

knee manual physical therapy, knee pain, knee arthritis

A multimodal approach is utilized in the management of OA including activity modification, weight reduction, education, manual therapy including joint mobilization/ manipulation and soft tissue treatments, and exercise(7,8).

Grade A Oxford Level of Evidence is found with a manual therapy and exercise approach to knee OA(9).

Exercise is recommended by all clinical guidelines for management of knee OA(5,6). 

Evidence for Physical Therapy Management of Knee OA

knee arthritis, function, pain, boulder physical therapy treatment

Deyle et al. demonstrated improvements in pain, disability, and function following PT including manual therapy and exercise interventions. Some patients reported a 20-40% improvement in 2-3 visits. This program also delayed or prevented a total knee replace- ment in some participants9. See figures at the right.

Authors have reported manual therapy to be more clinically and cost effective compared to usual medical care for the treatment of knee OA with improvements noted up to 1 year(11,12).

In addition, manual therapy and exercise was twice as successful as a home program for the short term improvement of pain and function1(3).

Cochrane Reviews support the utilization of exercise to alleviate symptoms of OA, as well as, improve strength and physical fitness(10). 

knee replacements, knee pain, physical therapy treatments

When to seek Physical Therapy care 

Most patients (>80%) will benefit from a low risk, cost effective program of manual therapy and exercise.

Patients with primary complaints of knee pain/stiffness, difficulty and/or pain with gait, stairs, and ADLs are appropriate for referral to a manual physical therapist. 

References

1. Leigh, J. et al. Estimating the costs of job related arthritis. J Rheumatol. 2001. 28(7):1647-54.

2. Peat, G. et al. Knee pain and osteoarthritis in older adults: a review of community burden and current use of primary health care. Ann Rheum Dis. 2001. 60(2):91-7.

3. Guermazi, A. et al. Prevalence of abnormalities in knees detected by MRI in adults without knee osteoarthritis: population based observational study. BMJ. 2012.

4. Altman, R. et al. Development of criteria for the classifica- tion and reporting of osteoarthritis. Classification of OA of the knee. Arthritis Rheum. 1986. 29(8):1039-49.

5. Fernandes L, Hagen KB, Bijlsma JW, Andreassen O, Christensen P, Conaghan PG, et al. EULAR recommenda- tions for the non- pharmacological core management of hip and knee osteoar- thritis. Ann Rheum Dis 2013;72:1125–35.

6. Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N, et al. OARSI recommendations for the management of hip and knee osteoarthritis. Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthri- tis Cartilage 2008;16: 137– 62.

7. Larmer, P. et al. Systematic Review of Guidelines for the Physical Management of Osteoarthritis. Arch Phys Med Rehab. 2014. 95:375-389

8. Jamtvedt, G. et al. PT interventions for patients with osteoarthritis of the knee: An overview of systematic reviews. PT. 2008. 88(1).

9. Deyle, G et al. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee. A RCT. Ann Int Med. 2000. 132(3):173-81.

10. McConnell, F. et al. Exercise for osteoarthritis of the knee. Cochrane Review. 2015.

11. Abbott, J. Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee: a RCT. Osteoarthritis Cartilage. 2013. 21:525-534.

12. Pinto, D. Manual therapy, exercise therapy, or both in addition to usual care, for OA of the hip or knee. Economic evaluation alongside a RCT. Osteoarthritis and Cartilage. 2013. 21:1504-1513.

13. Deyle, G. 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;85:1301–1317.