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knee question
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knee question - October 27, 2004 8:19:00 AM
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tf8560
Posts: 47
Joined: October 21, 2004
From: miami
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Hi everybody, I need your help/experience. As a 44 yr old PT, who had his lateral meniscus removed 26 years ago ( just factor in 26 years of minor league baseball, A PT career and now roughing it up with a 13 y/o son and chasing a 3 yr old daughter) my knee is pretty shot. On a good day I have about 95 degrees of flexion and probably lack 5 or so degrees of extension. When ever I try to stretch it, my knee gets swollen and inflammed. What are your thoughts about trying to get more motion out of the joint. I am considering synvisc as well. Thank you all...Tom
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Re: knee question - October 27, 2004 9:00:00 AM
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Shill
Posts: 1107
Joined: February 13, 2003
From: Madison WI USA
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Tom,
How bad are your plain films? If severe, you could try an unloader brace, provided your DJD is unicompartmental. Synvisc might buy you some time, but probably not much. As bad as your ROM sounds, looks like you are looking at arthroplasty fairly soon, if the pain is equally as limiting. Look into unicompartmental replacement, if possible, and if you have skilled orthopods in your area. When you cant stand the pain, go for replacement, otherwise try to get as much life out of the original parts as you can.
If your films show only mild or moderate DJD, then it is conceivable that you could gain some ROM and function. If severe DJD exists, its just not likely. You will then have to manage as well as you can, with activity modification, and learning how to avoid over doing it, while maximizing available strength to help decrease stress on the joint through improving shock absorbing abilities of the muscles.
Good Luck
Who did you play for?
Steve PT/baseball fan
_____________________________
Steve Hill PT
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Re: knee question - October 27, 2004 12:08:00 PM
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FLAOrthoPT
Posts: 1011
Joined: May 8, 2004
From: West Palm Beach
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i pretty much agree except don't go too long on it without surgery, all of the hobbling around usually leads to a bad back, bad hips and a second knee that needs replacing, but at your age go partial replacement if necessary if possible/appropriate-
Ben
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Re: knee question - October 27, 2004 10:43:00 PM
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Alex Brenner PT MPT OCS
Posts: 1057
Joined: February 29, 2004
From: Kentucky
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I would have to disagree with the "quick to surgery" remarks. There was an excellent article that was well accepted in the both the field of medicine and in physical therapy that was published a few years ago in the Annals of Internal Medicine.
"Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee. A randomized, controlled trial."
Deyle GD, Henderson NE, Matekel RL, Ryder MG, Garber MB, Allison SC. Ann Intern Med 2000; 132(3): 173-181.
This article should be in the front of your research drawer for all physical therapist who treat knee OA (most of us). The article basically demonstrates how exercise and manual therapy was able to prevent a statistically significant group of people from having to have a total knee replacement. It was a well written and well designed study which won several research awards if I remember correctly.
I wouldn't be quick to have a surgery. Bracing could be a great option as an adjunct to therapy, but come on guys, lets put our hands on these types of patients. In my opinion, as PTs, this should be the first thing we think of.
Ben, read this article and let me know what you think.
ArmyPT, OCS
_____________________________
Alex Brenner, PT, MPT, OCS
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Re: knee question - October 28, 2004 4:33:00 AM
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tf8560
Posts: 47
Joined: October 21, 2004
From: miami
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First of all, thank you for your replies and help, I am new but this is a nice group of fellow PT's. To the point, My djd is probably mild to moderate...I normally don't have that much pain, it swells and locks if I overdo my exercise I dont think Im anywhere near a replacement surgery yet, I have avoided an unloading brace because I thought it might create an instability with prolonged use (I dont have alot of experience with them however). I usually get by with maintaining a healthy weight, ongoing exercise (with activity modification like avoiding certain plyometric exercises...dont forget, I still have to kick my 13 y/o son's butt for a couple of years)
I was wondering if synvisc could be used regularly like an oil change and/or would an arthroscopic cleaning up of the joint followed by appropriate rehab help avoid future degenerative problems
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Re: knee question - October 28, 2004 5:15:00 AM
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Alex Brenner PT MPT OCS
Posts: 1057
Joined: February 29, 2004
From: Kentucky
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Tom,
Right on. I think you would benefit from some manual therapy along with an impairment based strengthening and flexibility program. I would avoid the synvisc and defintely any surgery at this point and give the conservative route a try. I see some serious 13 year old butt kicking in your future.
Good luck. As always, just my opinions.
Army
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Alex Brenner, PT, MPT, OCS
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Re: knee question - October 28, 2004 8:09:00 AM
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Shill
Posts: 1107
Joined: February 13, 2003
From: Madison WI USA
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Army,
Thanks for the study reference. I read it, and it is good...
However, I would like to see a comparison of the improvement for those folks with severe DJD, and those with mild/moderate. Other studies show that by the time they get to this point, not much can be done. When I get someone with mild to moderate, I love to tell them "that research shows that just having mild to moderate OA does not mean you have to have significant problems, etc, etc,. " But, when I get the patients with severe OA, I am honest with them that the odds are not in their favor. Yet still, some do well, although this is a small number. One flaw in the manual therapy and exercise study, is that exercise was combined with something, making it difficult to know if it was the manual therapy, or the exercise that made the difference. Another group receiving just exercise therapy, or just manual therapy could clarify that when done again. Although one could argue that this may not be consistent with practice patterns. But then again, our practice patterns arent consistent, unfortunately. Though they should be... but thats another issue.
Tom,
Id still recommend you get films, if you have a contracture at 95 degrees flexion.
But, this also depends on your end-feel.
For some specific manual therapy, see if one of your colleagues can apply some femoral/tibial distraction during prone knee flexion stretching, to see if this would allow you to gain ROM without pain. It takes a lot of strength on the part of the PT applying the distraction, but works well in many cases, at increasing what would normally be limited by pain due to compression.
Good Luck
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Steve Hill PT
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Re: knee question - October 28, 2004 12:53:00 PM
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tr6454
Posts: 60
Joined: March 6, 2004
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I recently read a report by Miyaguchi, presented at the Orthopaedic Research Society's 2001 mtng. All subjects had Grd II-III OA and an effusion. with intervention they were able to see a change in the joint fluid. The molecular wt. of Hyaluronan was decreased. "we propose that HA metabolism and other biochemical change in joint fluid were directly caused by the mechanical stimulation of isometric muscle exercise.." They simply had them do 100 SLR's qd. Combine this with Deyle's excellent study and we may be able to have more of an effect on OA than we give ourselves credit for.
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Terry
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Re: knee question - October 29, 2004 4:39:00 AM
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eam
Posts: 293
Joined: February 5, 2004
From: New York, NY 10028
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Army-
Thanks for reference. Very compelling, I must admit. Tom-if one of your colleagues knows the Mulligan knee techniques-prone with belt-they may work-you need 90 degrees to start with this one and you just make it. Just my 2 cents,
Erica
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Re: knee question - October 29, 2004 7:45:00 AM
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tf8560
Posts: 47
Joined: October 21, 2004
From: miami
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Thanks everyone, I look forward to more exchange of all ideas and appreciate your expertise. By the way Army, my younger brother became a PT through the Army. I think he was a PT Tech in the Army then went on to PT school at Upstate Medical Center while he was in the reserves.He was at Ft Sam Houston and Ft Bragg, now a graduate of Ola Grimsby's residency program.
I still like the synvisc idea as an adjunct to the manual therapy, flexibility and strengthening. What are the reasons you advise against it?(for my own clinical knowledge)
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Re: knee question - October 30, 2004 6:55:00 AM
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hmgross
Posts: 292
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From: Minnesota
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I would like to second what Shill and Erica said about the prone techniques. I have good results performing the Mulligan because I don't have alot of upper body strength. The belt works very well. I follow it with high reps of SLR prone sidelying and supine. I had a women with pretty severe DJD who could not have surgery due to medical problems, and could only tolerate isometrics. She reported a significant decrease in the amt. of pain -- sometimes simple things work.
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Holly Gross PT
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Re: knee question - October 30, 2004 8:13:00 AM
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Alex Brenner PT MPT OCS
Posts: 1057
Joined: February 29, 2004
From: Kentucky
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Tom,
There is nothing wrong with getting the synvisc in conjunction with the therapy. I think personally I would wait and see if I could get the knee better without having to resort to that. I have seen several people get these injections with mixed results. I would think physical therapy care would be a cheaper and possibly a more effective approach.
Manual therapy: I like to perform PA mobs to the knee where you basically position the patient as if you were going to perform an anterior drawer test. You then simply just move the knee in a posterior to anterior direction in grades of II or III. This is almost always pain-less and will give you some good results. I like to follow that by placing the knee at end range extension and then externally rotate tibia on the femur in different grades as tolerated.
In many patients with knee DJD the medial compartment is narrowed. If you grab the knee and provide a small valgus force to gap the medial compartment you can passively move the knee into flexion and extension while maintaining this valgus force. Feels great for the patient and will get you some decent results. After performing these mobs, have the patient get up and walk down the hall. Watch the look on their face----money.
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Alex Brenner, PT, MPT, OCS
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Re: knee question - November 12, 2004 6:00:00 AM
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muffmama
Posts: 1
Joined: September 13, 2004
From: Yorkshire, UK
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For anyone interested in the article mentioned by Army on PT & exercise for knee OA, it is available online at: http://www.annals.org/cgi/reprint/132/3/173.pdf
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Re: knee question - November 14, 2004 4:11:00 AM
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PTupdate.com
Posts: 1490
Joined: October 8, 2001
From: Pittsburgh, PA USA
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Thanks for the article link muffmama. BUT, this article does what so many other PT articles do: Tell you something has beneficial results, but then doesn't tell you how to do it.
This is so typical and all too common in the PT world. Physicians that I know really enjoy sharing techniques, with surgeons from competing practices often doing a procedure together just to learn. PT's, for some reason, love to hoard information, as if showing it to someone else will end up with a loss of business and a new home of a box under a bridge.
This article concludes that manual therapy can have short and medium term positive results. Great, but they dont' tell you WHAT manual techniques, so it really does us no good. I am surprised there isn't a little blurb somewhere that you can learn all these, but have to attend coursea A-B for a nice hefty sum.
Were so many different techniques performed that we can imply that ANY manual technique will have the same effects? Is some simple efflurage going to have the same effect as something aggressive? Why couldn't these authors let their "secret" out and tell us what they did and how? Without the information, the study is useless to all of us, and patient loses out (as does our profession)
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: knee question - November 14, 2004 6:39:00 AM
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Augustine5I
Posts: 28
Joined: April 11, 2004
From: NJ
Status: offline
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Good point John.
Physical Therapists should share more.....I wish there were more websites like your own (of which I am a member). Even if you walk away with just one or two new treatment ideas, it is of great value to you and your patients.
We should always be learning and trying new things or just enhancing techniques we already know.
I have searched the internet for other sites like your own and have found little success (if you know of any please post it).
Tom,
I am assuming insidious onset since you did not mention a traumatic event or sudden symptom exacerbation.
You are too young to undergo any sort of knee replacement.......please try every avenue of approach first. Starting with a good physical therapist to help restore problem number one, ROM. Manage edema accordingly.
And, remember surgery is no guarantee either! This should be your last resort.
Obviously, you are dealing with a chronic knee condition. So this will factor in on overall prognosis and the amount of time it will take to achieve reasonable goals. Buy you should see some improvements........shoot for 110 degrees of flexion. This will restore many functional activities and improve quality of life.
Why have you waited so long for any sort of serious intervention?
I can only imagine what your knee must feel like at the end of the day considering the amount of mobility you lack combined with the activity level you sustain.
I personally have not seen long lasting relief from patients who were administered synvisc injections (it is only a bandaid). After they are done, the physician can then turn to you and say, "see.....we did all we could for you. Are you convinced you need surgery now?"
I have seen good results with dynasplints used on post op TKR that are responding poorly. May work for you too.
Good luck,
Tom
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[URL=http://www.colonialpt.com]www.colonialpt.com[/URL]
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Re: knee question - November 14, 2004 7:05:00 AM
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Alex Brenner PT MPT OCS
Posts: 1057
Joined: February 29, 2004
From: Kentucky
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John and all,
The study linked above was conducted and written by Army physical therapists. I was able to attend a course a few years ago where some of the authors showed us some of the techniques used in the study. I described some of them in my post above (30 Oct). I dont think there is any specific mobilization that was used in the study that most of us were not taught in PT school. Each person was treated differently in the study. For example, if the patient lacked ext and had pain with extension, then a mobilzation aimed at regaining extension was used. The "valgus" mobilization that I described above was used with many of the patients. The bottom line is that no "cook book" manual therapy was utilized; each person was treated independently with different manual therapy techniques, many of which we were all taught to us in physical therapy school. To my knowledge, there were no "cutting edge" techniques used in this study.
The below quote was taken directly from the research article.
[QUOTE] Manual therapy: A clinical approach involving skilled,specific hands-on techniques, including but not limited to mobilization, that are used by the physical therapist to diagnose and treat soft tissues and joint structures for the purpose of modulating pain; increasing range of motion; reducing or eliminating soft tissue inflammation; inducing relaxation; improving repair, extensibility, or stability of
contractile and noncontractile tissue; facilitating movement; and improving function.
Mobilization: Skilled passive movement applied a joint or the related soft tissues at varying speeds and intensities. Physiological movement: Movements that can be performed actively under voluntary muscle control.[/QUOTE]Isn't this what we were all taught in PT school? There were no new top secret techniques used.
Army
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Alex Brenner, PT, MPT, OCS
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Re: knee question - November 14, 2004 12:59:00 PM
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PTupdate.com
Posts: 1490
Joined: October 8, 2001
From: Pittsburgh, PA USA
Status: offline
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Tom,
Many thanks for the kinds words. There have been a few other sites that popped up over the past year or two, but didn't last long....it takes a ton of time and keep one chugging. Between my long job hours and working the website, I cannot figure out why my wife hasn't left me....perhaps she found some young stud on the side :o
Army,
I am sure many people read this article 4 years ago and did not have a clue what kind of manual therapy was performed. You easily pointed out a few beneficial tips above, and the same could have been listed in the article....after all, they did a good job of describing all the exercises, down to the number of reps and times. The same could have been done for the manual therapy.
If we are going to say a wide range of manual therapeutic techniques are beneficial for the knee with OA, a multi-center trial should be performed, with a wide range of PT's performing various non-related manual techniques. Then it is safe to say "manual therapy (in a general sense) improves knee function.
Also, the placebo group only had sham US, and no exercise. Because the treatment group had both exercise and manual therapy, we still cannot conclude that one facilitated the gains made.
The variability of manual therapy is so wide, that even if one specific technique was used, having more than one PT perform the task challenges the purity of the study. How many of us who practice in a multi-therapist environment have had patients tell us of significant improvement with the touch of one staff member compared to the others, even though the same technique is performed?
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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