Department of Physical Therapy

Knee Pain/OA Physical Therapy ApproachesG. Kelley Fitzgerald, PT, PhD, FAPTA

Professor, Department of Physical Therapy, School of Health and Rehabilitation SciencesDirector, Physical Therapy Clinical and Translational Research Center

Department of Physical Therapy

• Dosage

• Manual Therapy

• Motor Learning

Department of Physical Therapy

Strength Training Dosage

• % of a repetition maximum

• Perceived Exertion Scales

• For our patients with arthritis, these should be “pain-free” entities

Department of Physical Therapy

Strength Training Dosage• American College of Sports Medicine

Recommendations for Older Adults– 60-80% 1 RM, 8-12 reps, 1-3 sets, with 1-3

min rest between sets.

– Can also incorporate power programs of 30-60% 1 RM, 6-10 reps, 1-3 sets at higher repetition velocity.

– For endurance training, use lighter loads (50-60%) with higher reps (10-15 or more)

Department of Physical Therapy

Progression of Strength Training Intensity

• When patient can perform 1-2 reps over the target reps for 2 consecutive sessions, training load should be increased by 2 to 10%.

• Recommend re-establishing the 1 RM every 2 to 4 weeks to re-adjust training loads appropriately.

Department of Physical Therapy

Alternative to Repetition Maximum for Dosing

• Modified Borg Perceived Exertion Scale

Borg Perceived Exertion Scale0 Nothing at all

1 Very light

2 Fairly light

3 Moderate

4 Somewhat Hard

5 Hard

6

7 Very Hard

8

9

10 Very very hard

Borg, G. (1982) Psychophysical bases of perceived exertion. Medicine and Science in Sports and Exercise, 14 (5), p. 377-81

Department of Physical Therapy

Alternative to Repetition Maximum for Dosing

• Emphasize gains in muscle force output

• Increase resistance as patient progresses and RPE falls below desired level.

Borg Perceived Exertion Scale0 Nothing at all

1 Very light

2 Fairly light

3 Moderate

4 Somewhat Hard

5 Hard

6

7 Very Hard

8

9

10 Very very hard

Department of Physical Therapy

Alternative to Repetition Maximum for Dosing

• Emphasize gains in endurance

• Increase resistance as patient progresses and RPE falls below desired level.

Borg Perceived Exertion Scale0 Nothing at all

1 Very light

2 Fairly light

3 Moderate

4 Somewhat Hard

5 Hard

6

7 Very Hard

8

9

10 Very very hard

Department of Physical Therapy

• Potential Advantages of RPE– Can dose without need

for major testing equipment

– Easy to teach patient for independent exercise and activity programs

• Potential Disadvantages of RPE– Not yet known if it will

produce the same strength outcomes as %RM approach

Alternative to Repetition Maximum for Dosing

Department of Physical Therapy

Aerobic Training Dose• 30 to 60 minutes per week

• 50-70% of heart rate reserve (HRR)

• Target HR = 220- Age –(Resting HR x %HRR) + Resting HR

• Example: 60 y/o with resting HR of 80, exercise at 60% of HRR:

220 – 60 – (80 X .60) + 80 =128 beats/min

Department of Physical Therapy

Manual Therapy

• Techniques include accessory and physiologic motion techniques, manual stretching techniques, and soft tissue manipulation techniques

Department of Physical Therapy

Examples of Manual Therapy Techniques

P-A glide of tibia on femur with medial tibial rotation: Target

anterior-lateral capsule

Manually applied stretch to the hamstrings and posterior

capsule

Department of Physical Therapy

Examples of Manual Therapy Techniques

Accessory Motion: Patellofemoral inferior glides

Soft tissue manipulation with manual stretching

Department of Physical Therapy

Manual Therapy: Joint Mobilization • Can be used to induce relaxation and reduce

pain (grades 1 and 2)

• Can be used to improve joint mobility (grades 3-5)

• Objective of treatment is to manually reproduce joint accessory motions such as distractions and joint surface translations.

• Can also be used to apply more targeted stretching of joint capsule

Moss P, et al, Manual Therapy. 2007;12:109-118Deyle G, et al, Phys Ther. 2005;85:1301-1317

Department of Physical Therapy

Joint Mobilization: Indications

• Hypomobility on accessory motion testing (reproduction of joint translatory movements)

• Measureable reduction in joint motion even after de-emphasizing contribution from tight muscles

• Pain/stiffness in specific portions of the peri-articular soft tissue on joint motion

Department of Physical Therapy

Deyle, et al. Phys Ther. 2005; 85: 1301-1317.

• Compared group with knee OA receiving supervised manual therapy and exercise to group receiving home exercise.

• Manual therapy and exercise delivered to lumbo-pelvic, hip, knee, foot and ankle regions based on reduced motion or pain in these regions.

Department of Physical Therapy

Deyle, et al. Phys Ther. 2005; 85: 1301-1317.

• Both groups improved function scores.

• Group receiving supervised manual therapy and ex had greater improvements. (52% vs 26%)

• Larger effect compared with many other exercise studies.

Department of Physical Therapy

Abbott JH, et al. Osteoarthritis Cartilage. 2013;21:525-534

Usual Care (UC)

N = 51

UC + Manual Therapy (MT)N =54

UC + Exercise (Ex)N = 51

UC+MT+ExN = 50

• Included subjects with knee or hip OA• 9 sessions (7 in first 9weeks +2

boosters at 16 weeks)

Department of Physical Therapy

Abbott JH, et al. Osteoarthritis Cartilage. 2013;21:525-534

ONE YEAR FOLLOW-UP CHANGES

UC MT Ex MT + Ex

WOMAC -12.9 (51.8)

-41.4 (55.5)

-29.3 (50.4)

-27.4 (41.1)

30s sit to stand (# stands)

.02 (-.79;.84)

.67(-.12;1.45)

1.6(.80;2.40)

1.59(.60;2.59)

40m walk (sec) .78(-1.40;2.95)

-.50(-3.70;2.70)

-3.18(-4.41; -1.99)

-.61(-2.22; 1.00)

NNT* 5 6 8* Number needed to treat for achieving responder to treatment status based on OMERACT-OARSI responder criteria

Department of Physical Therapy

Enhancing the Effectiveness of Physical Therapy in People with Knee Osteoarthritis1 RO1 HS019624-01

University of Pittsburgh, Pittsburgh PA- Data Coordinating Center (PI: G. Kelley Fitzgerald)

Other Study Sites:

University of Utah/Intermountain Healthcare, Salt Lake City, UT (PI: Julie M. Fritz)

Army-Baylor University, San Antonio, TX (PI: John Childs)

University of Otago, Dunedin NZ (PI: Haxby Abbott)

Baseline TestingSummary of Experimental Design

R

Exercise MT +Exercise Exercise +Booster

MT+ Exercise +Booster

12 Rx Sessions 12 Rx Sessions 8 Rx Sessions 8 Rx Sessions

9 Wk F/U

9 Wk F/U

9 Wk F/U

9 Wk F/U

Home Program Home Program Home Program Home Program

5 mo Booster – 2Rx 5 mo Booster – 2Rx

8 mo Booster – 1Rx 8 mo Booster – 1Rx

11 mo Booster – 1Rx 11 mo Booster – 1Rx

1 YR F/U 1 YR F/U1 YR F/U 1 YR F/U

2 YR F/U 2 YR F/U2 YR F/U 2 YR F/U

Department of Physical Therapy

Motor Learning Approaches

• Biomechanical unloading

• Task Specific Training

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Contralateral Cane Use

• ↓ KAM by 7-10%• ↓ cumulative loading by:

– ↑ stride length

– ↓ cadence

• ↓ GRF by 25%-35% during gait

• Most effective if placed as far laterally as possible without inducing sx.

Department of Physical Therapy

Gait Retraining Approaches

• Goal to reduce knee adduction moment

• Foot progression angle (toe out)

• Trunk sway (lateral)

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• Motion capture and instrumented treadmill

• Patient tailored altered foot progression angle or lateral trunk to get 10% ↓ in KAM

• Vibration motors on tibia (foot angle) and scapula (trunk sway) for feedback during training

Shull PB, et al. J Orthop Res. 2013;31:1020-1025

Department of Physical Therapy

• 1x/week, 6 weeks

• 10 min practice daily

• Subject selected method of alteration– Foot progression angle

– Trunk sway

– Both

• Fading feedback training design

Shull PB, et al. J Orthop Res. 2013;31:1020-1025

Department of Physical Therapy

Shull PB, et al. J Orthop Res. 2013;31:1020-1025

Department of Physical Therapy

Department of Physical Therapy

Department of Physical Therapy

Department of Physical Therapy

Task-Specific Training

Department of Physical Therapy

Traditional Premise

↓Physical Function +

Performance

Department of Physical Therapy

Traditional Premise

↑Physical Function +

Performance

Department of Physical Therapy

Fitzgerald GK, White DK, Piva SR. Associations for change in physical and psychological factors and treatment response following exercise in knee osteoarthritis: An exploratory study. Arthritis Care Res. 2012;64:1673-1680

• Changes in impairments (muscle strength, flexibility, joint mobility) not associated with clinical outcome of pain and function in subjects with knee OA.

Department of Physical Therapy

Teixeira PEP, Piva SR, Fitzgerald GK. Effect of impairment-based exercise on performance of specific self-reported functional tasks in individuals with knee osteoarthritis. Phys Ther. 2011;91:1752-1765

• Impairment-based rehabilitation approach yielded only modest self-reported improvements in functional task performance ability

Department of Physical Therapy

Task-Specific Training

• Use the specific task that is problematic as the training tool

• Can work on strength and joint mobility in context of the task

• Provide opportunity to improve motor patterns in context of task

• May consider task modifications

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Chair Rise Task Step 1: Moving to Edge of Seat

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Chair Rise Task Step 2: Lift Off

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Chair Rise TaskStep 3: Terminal Stand

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Chair Rise TaskFull Task Practice

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Floor Transfers

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