Is Acetaminophen Effective For Hip Or Knee Arthritis?
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Paracetamol, or acetaminophen, was initially introduced in the late 1800s and has become the most commonly prescribed medication for fever and pain in the United States. It is one class of medications recommended by the American College of Rheumatology for patients with arthritis who have not responded favorably to weight loss and Physical Therapy. Although a relatively inexpensive and commonly prescribed medication recent research has demonstrated the harmful effects of acetaminophen when combined with other pain medications which may also contain the same drug. A recent Cochrane Review of the evidence analyzed acetaminophen’s effects on patients with hip or knee arthritis.

Leopoldino and colleagues reviewed 10 randomized placebo controlled trials of 3541 patients with either hip or knee arthritis (Cochrane Review. 2019). Patients within these trials were followed for up to 24 weeks to determine the impact of the medication on pain, activity, and adverse events. Authors reported at 3 and 12 week follow there was high quality evidence that acetaminophen provided no clinically important improvements in pain and physical function. No increased risk of adverse events was found among the medication vs. placebo patients. Patients with knee or hip arthritis should follow up with their physician before making any medication decisions.

Which Muscles Should I Strengthen For Knee Arthritis
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Knee osteoarthritis is a common and increasing diagnosis that is contributing to an rapid rise in total knee arthroplasty surgery in the United States. Knee Osteoarthritis leads to disability in greater than 10% of those over 55 years, however manual therapy and exercise has shown to be twice as successful compared to a home exercise program in short term pain and function. More importantly, research has shown this Physical Therapy approach can postpone or prevent the need for knee replacement. One of most common complaints from patients with knee arthritis is pain with walking or ascending/descending stairs. Weakness of the quadriceps, hip adductors (inner thigh) and abductors (outer hip) are crucial to improving stair climbing and squatting ability.

A recent study (Hislop et al. 2019. Br J Sports Med) aimed to find the benefit of adding hip strengthening exercises to quad strengthening exercises among people with Knee Osteoarthritis. Authors randomized participants with knee arthritis into one of two groups: knee strengthening or knee and hip strengthening. Consistent with clinical practice, the authors found a decrease in patient related pain as well as improvements in patient function in patients who combined hip and knee strengthening exercises compared to knee strengthening exercises alone.

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Research Does Not Support Use Of Instrumented Assisted Soft Tissue Treatments
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The human body is an amazing system of interconnected tissues and organ systems designed to handle and thrive against the forces of life, work, and sport. Our body tissues such as bone, muscle, and tendons are extremely resilient to repetitive forces, but can be modified through progressive, consistent loading. Examples include improvements in bone density, skeletal or heart muscle with exercise, as well as, changes in your smile through braces. All of these examples demonstrate the consistent forces and stimuli required to cause a body’s tissue to adapt. Conversely, smaller less consistent forces are unlikely to cause a tissue to adapt. Despite these physiological constants some health practitioners continue to recommend rolling an IT band or using metal instruments to break up adhesions, scar tissue, or improve tissue health. A new review of the available medical evidence highlights the limitations of these interventions.

A review article in the Archives of Physical Medicine and Rehabilitation analyzed the available evidence on the use of instrument assisted soft tissue mobilization among healthy and injured participants (Nazari et al. 2019). Authors reviewed 9 available trials on the effectiveness of these interventions on outcomes including pain, range of motion, strength or function. In head to head trials, instrumented assisted soft tissue mobilization was not more effective than a control group or other interventions. Authors of the review found only one trial which found small effects of improved muscle performance in active individuals compared to no treatment. The authors of the review concluded “the current evidence does not support the use of instrumented assisted soft tissue mobilization to improve pain, function, or range of motion in healthy individuals or those with varied pathologies”.

Can push ups help determine future heart disease events?
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Heart disease remains the number one killer of both women and men in our country. Although the causes of heart disease are multifactorial in nature a significant percentage of known risk factors are modifiable. Abstaining from smoking, weight loss, nutrition, and exercise remain some of the most powerful ways to reduce your individual risk for heart disease including heart attack and stroke. Unfortunately, only a small percentage of Americans reach minimum national standards for weekly exercise. As our country becomes more sedentary and obese heart disease will continue to be a major health problem. Consistent with any disease, emphasis is often placed on prevention of heart disease as a more effective and less costly option for tackling heart disease. A recent study identified a functional test that can be used to help identify those at risk of future heart disease.

Researchers in the Journal of the American Medical Association reported on a retrospective analysis of heart disease events and push up ability (Yang et al. JAMA Network Open. 2019). Authors reviewed the cardiac history, anthrometric measurements, and functional testing of over 1100 participants. During the 10 year follow up 37 cardiovascular disease outcomes were reported. Authors reported a lower push up capacity was associated with an increased risk of cardiovascular disease events. Participants who could perform > 40 push ups were at a significantly lower risk of cardiovascular risk compared to those who were unable to perform 10 reps. Further studies are needed to confirm these findings and determine if this relationship is present in other patient populations.

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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