In this podcast, Gage sits down with Caitlin Scott (APA Sports and Exercise Physiotherapist/ Musculoskeletal Physiotherapist.), a Physiotherapist at Milton Physio and a close allied health colleague of ours.
Caitlin has had extesnsive experience in the physiotherapy world and discusses all things knee OA, specifically on physiotherapy principles and how and EP can integrate effectively into the care of the patient. A great multidisciplinary discussion!
o Knee OA is a progressive multifactorial degenerative joint disease involving the articular surface of the joint
§ progressive loss of articular cartilage
§ early, mild, moderate, severe
o 3 key areas in the knee
§ tibiofemoral medial compartment
§ patellofemoral compartment
o 653.1 million >40 y.o with knee OA worldwide (2020).
o 73% of those with OA >55 y.o, 60% female
o Knee most frequently affected, followed by hands and hip
o Previous trauma/Surgery
o Individualised subjective and objective assessment
§ Consideration of history, symptoms, other health conditions, physical assessment, functional levels
§ Persistent knee pain, limited morning stiffness and reduced function
§ Crepitus, restricted movement and bone enlargement
o When all 6 signs/symptoms present – 99% accuracy in diagnosis
o No imaging required – diagnosis can occur on assessment alone
o Imaging considered for other alternate diagnosis as clinically indicated
§ Considering insufficiency fracture, avascular necrosis, inflammatory
§ WOMAC, KOOS o Osteoarthritis Knee clinical care standard
- Treatment pathways for knee OA – Surakanti et al 2023
· Including pain management (Lesmond et al 2023)
§ Weight loss and exercise
· Research supports Exercise> NSAIDS
o However need to consider if patient having an acute painful flair – is medication required to maintain exercise levels Thorlund et al 2022
· Considering other comorbidities. Activity levels, goals
· Promoting restoration/maintaining movement
· Identification of contributing factors
o Adding hip strengthening to quads exercises improves patient reported pain and function: Ref: Hislop et al 2020
o Unilateral OA: hip add is lower affected side, hip strength is lower bilaterally, dynamic balance lower bilaterally, patient reported pain associated with knee ext strength but not hip strength/dynamic balance: Ref: Hislop et al 2022 § GLAD program - Good Life with OsteoArthritis: Denmark Ewa Roos
· 2-3 patient education sessions and 12 supervised exercise sessions over 8 weeks
o Improved pain and objective outcome measures
· Need to consider this is a group exercise program – it is better than nothing but we need to have individualised programs ideally
§ Cortisone, hyaluronic acid, platelet-rich plasma
· Need to consider limitations – chondrotoxicity resulting in increased cartilage damage, increased risk of infection if injection 3/12 prior to surgery (Wernecke et al 2015)
§ Total knee arthroplasty
§ Uni-compartmental: unicompartment knee arthroplasty, High tibial osteotomy · McCormack et al 2021
§ Less likely to see arthroscopy’s
- Criteria for Surgery – Hawker et al 2023
o Considers the need, readiness/willingness, expectations and health status.
§ Do not want to wait until extended period of being inactive with reduced quads and gluteal function.
§ Evidence of knee OA on clinical and radiographic examination
§ Reports knee OA symptoms impacting on quality of life
· WOMAC, KOOS, 4 item arthritis coping efficacy Scale
§ Adequate trial of non-surgical OA treatment
· Exercise, physiotherapy, weight loss, medications, injections
o Patient expectations – Quote Quentin.
- Realistic improvements – Quote Dr Quentin Scott – Specialist MSK Physiotherapist
o 3 months before you are starting to do well
o 6 months before you are pleased you did it
o 9-12 months before you have forgotten about it
o Key is individual – everyone will respond differently depending on reason for surgery, prehab
o Post operative response can be affected by prehab: ROM, quads fn, understanding of initial rehab process
- How long should we approach conservative treatment
§ Understanding comorbidities
o Surgical techniques and replacement technology has improved § 82% TKR last >25 years (Evans et al 2019) § 3.9% require revision within 10 years, 10.3 within 20 years (Bayliss et al 2017)
§ Age matter: >70 y.o 5% likely to require second replacement, 50 y.o men – 35% require second replacement (Bayliss et al 2017)
- What assessments should we do, measures, goals
o Baseline strengthening and loading
o Range of Movement o Consider regarding exercise – Lawford et al 2022
§ Develop by and for consumers
§ Different ways to deliver information
§ Different types of resources for self management
§ Resources on exercises and how to perform them/progress
§ Support motivation and track progress
§ Facilitate access to support
- What's a physio's and EPs role in rehab
§ Diagnosis, movement impairment identification, specific exercise prescription, manual therapy, education
§ Exercise prescription and modification, education, o Therapeutic exercise recommendations (Holden et al 2022)
§ Use evidence based approach
§ Consider exercise in context of living with OA and pain
§ Comprehensive baseline assessment with follow up
· Reported difficulties, physical limitations, functional restrictions, impact on participation, psychosocial factors
· Red flags, contraindication to exercise
· Overall health (comorbidities) and exercise precautions
· Baseline measurements and targets
§ Consider type of exercise, dose, modification and progression
§ Optimise delivery of exercise and adherence
§ Education OA and role of exercise
- Osteoarthritis is painful
o Not all osteoarthritis is painful – many show changes on imaging without pain or significant movement limitations
- Weights and running will make it worse
o Evidence indicates otherwise – positive outcome
§ Consideration regarding training into pain – exercises should not be painful and increase symptoms associated with OA
- I need an X-ray to confirm osteoarthritis
o Consider signs and symptoms as a diagnosis
Australian Commission on Safety and Quality in health Care 2017 – Osteoarthritis of the knee clinical care standard.
Cieza et al 2021, Global estimates of the need for rehabilitation based on the global burden of Disease study in 2019: a systematic analysis for the global burden of disease study 2019
Cui et al 2020, Global, regional prevalence, incidence and risk factors of knee osteoarthritis in population based studies
Dong et al 2023 Evidence on risk factor for knee osteoarthritis in middle-older aged: a systematic review and meta-analysis
Evans et al 2019 How long does a knee replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 15 years follow up
GLA:D Australia https://gladaustralia.com.au/
Hawker et al 2023 Patient appropriateness of total knee arthroplasty and predicted probability of a good outcome
Hislop et al 2020 Does adding hip exercises to quadriceps exercises result in superior outcomes in pain, function and quality of life for people with knee osteoarthritis: A Systematic review and meta-analysis
Hislop et al 2022 Hip strength, quadriceps strength, dynamic balance are lower in people with unilateral knee osteoarthritis compared to their non-affected limb and asymptomatic controls
Holden et al 2022 Recommendations for the delivery of therapeutic exercise for people with hip and/or knee OA. An international consensus stydy from OARSI Rehabilitation discussion group
Lanois et al 2024 Associations between anterior knee pain and 2-year patellofemoral cartilage worsening: the MOST study
Lawford et al 2022 What should a toolkit to aid the delivery of therapeutic exercise for hip and knee osteoarthritis look like? Qualitative analysis of an international survey of 318 researchers, clinicians and consumers by the OARSI Rehabilitation Discussion
Lesmond et al 2023 Neurophysiological pain education for patients with symptomatic knee osteoarthritis: a Systematic review and Meta-analysis
Roos et al 2021 Immediate outcomes following the GLA:D program in Denmark, Canada and Australia. A longitudinal analysis including 28370 patients with symptomatic knee or hip osteoarthritis
Surakanti et al 2023 Surgical vs Non-surgical treatments for the knee: Which is more effective?
Thorlund et al 2022 Similar effects of Exercise therapy, nonsteroidal Anti-inflammatory drugs and opiods of the management of osteoarthritis pain: A Systematic Review with Network Meta-analysis
Wernecke et al 2015 The effect of intra-articular corticosteroids on articular cartilage: A Systematic review
Zhang et al 2010 EULAR evidence-based recommendations for the diagnosis of knee osteoarthritis
