Docs Prefer Pills for OA
Ouch! This was the title of a post that was shared to me regarding a trend over the last decade by orthopedists and family practice physicians. This post, from MedPage, reviews a research article published in Arthritis Care and Research by the American College of Rheumatology. Osteoarthritis of the knee (KOA) has risen over the years in our country.
“The prevalence of knee OA in the U.S. has risen dramatically in recent years, from 9 million in 2005 to 15 million in 2012, and costs have increased accordingly.” Nancy Walsh, MedPage
Could this be related to our increased desire for activity as well as the trend for longer lifespans? Either way, finding ways to address this problem and improve our patient’s function and lifestyles is not only the goal of the individual but should be our goal as practitioners.
"Physicians seem more focused on helping their patients manage their pain with medications, which includes both NSAIDs and narcotic medications," Khoja told MedPage Today. "However, it is important to consider the long-term benefits of lifestyle interventions, such as weight management, exercise, and PT, for mitigating declines in physical health and reducing dependence on medications."
One of the biggest concerns related to this article and study was the increased narcotic prescription for knee osteoarthritis. Being aware that this is a trend may help practitioners watch out for a potential trend in their practice.
Interesting to note that most of the reviewed visits were by orthopedic surgeons. Primary care made up 21% of the surveys conducted from the National Ambulatory Medical Care Survey
The referrals for physical therapy dropped by half while narcotic use has doubled during this period. This is not a trend that we want to continue.
Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee: a randomized, controlled trial.
This is a great article showing not only a placebo or control group but also a long term follow-up. It was interesting to note that the physical therapy/exercise group were four times less likely to have knee surgery than the placebo group.
Patients treated with manual physical therapy and exercise were four times less likely to have joint replacement surgery after one year.
The conclusions of this study?
“A combination of manual physical therapy and supervised exercise yields functional benefits for patients with osteoarthritis of the knee and may delay or prevent the need for surgical intervention.”
Four Tips when assessing a patient with knee pain and osteoarthritis
Is there a loss of knee motion?
Look at the mechanics. Does the joint move fully? It has been our perspective that a loss of mobility is present to the knee with KOA affecting the patient’s gait. Even a loss of 5 degrees of knee extension will prevent the ‘screw home mechanism’ of the knee causing constant knee muscle use during all standing activities. This will also change the person’s gait increasing overall workload but also abnormal stresses to the lower kinetic chain.
Assess knee mobility passively.
Loss of motion has a negative effect
on gait and knee mechanics.
Is there fluid on the knee?
Swelling on the knee inhibits quadriceps activation. This will cause increased soleus firing and the development of calf trigger points are common. The test we use at Cornerstone is the patellar tap test.
When this test is positive the use of diagnostic ultrasound to confirm fluid on the knee is a great diagnostic tool and does not need radiation such as a skyline x-ray view of the patella. It will also pick up fluid more readily as you can squeeze the knee making it easier to see. Cornerstone Physical Therapy routinely uses diagnostic ultrasound to screen the knee. Bone spurs and osteoarthrosis can also be observed with this diagnostic tool.
Fluid on the knee?
Weak quad/Tight calf
Is there a hip or ankle problem?
A sacroiliac joint problem creates a muscle firing imbalance around the hip. This will cause increased tensor fascia latae firing and iliotibial band tension. This will put more lateral tension on the knee and can damage the lateral facet of the patella. The problem with abnormal knee joint mechanics causing inflammation and swelling is that hyaline cartilage does not have a nerve supply. Significant articular damage can be done before there is significant pain.
Tight ITB? There is a Sacroiliac Joint Dysfunction.
Loss of ankle dorsiflexion changes a person’s gait causing increased external rotation of the leg. This will have a negative effect on knee mechanics and is quite easy to ‘fix’ through specific ankle joint mobilization techniques or manual physical therapy.
Loss of ankle dorsiflexion motion?
Foot is turned out with walking.
Abnormal stresses on the knee!
What lifestyle changes can be recommended?
Manual Physical Therapy
Lower impact exercise programs
A great treatment option to reduce swelling and knee pain is dry needling. Dry needling combined with manual therapy and exercise can be a great approach in reducing pain and improving function with knee osteoarthritis.
Injections of the knee
- Steroid Injections
- Stem cells