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Physical Therapy and Exercise for Osteoarthritis of the Knee



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Am Fam Physician. 2000 Jun 15;61(12):3727-3728.

Approximately one third of persons 63 to 94 years of age have osteoarthritis of the knee, a degenerative condition that typically limits ambulation and the ability to climb stairs and stand comfortably. Acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used therapies for osteoarthritis. Other treatments include physical therapy, exercise, cortisone injections and joint replacement surgery. Even though exercise plays an important role in osteoarthritis management, no one regimen has clearly been shown to reduce pain or improve function. Active and passive range-of-motion exercises traditionally have been an important component of physical therapy programs for osteoarthritis to improve joint mobility and function. Deyle and associates compared the effectiveness of a fixed therapeutic regimen for the knee, hip, ankle and lumbar spine with placebo in patients with osteoarthritis of the knee.

Eighty-three patients with confirmed osteoarthritis of the knee were randomized to receive treatment or placebo. The end points of the study were improved function, decreased pain and stiffness, and increased walking distance in six minutes. The treatment group received a combination of manual physical therapy and supervised exercise, while the placebo group received ultrasound therapy at a subtherapeutic intensity. For a detailed review of the patient exercise program used in the study, see the accompanying table. Both groups were treated twice weekly for four weeks, for a total of eight sessions. Patients in the treatment group also performed the same exercises at home. Neither group was aware of the treatment being given to the other group. Knee radiographs were obtained at baseline so that severity ratings could be assigned for each patient. Both groups returned one year after treatment for additional testing and to identify the patients who required knee surgery.

Exercise Program for Patients With Osteoarthritis of the Knee

Exercise Measures

Stretching exercises

Standing calf stretch

Three repetitions with 30-second hold

Supine hamstring stretch

Three repetitions with 30-second hold

Prone quadriceps stretch

Three repetitions with 30-second hold

Range-of-motion exercises

In long sitting position, knee mid-flexion to end-range extension

Two 30-second bouts with 3-second hold at end range.

In long sitting position, knee mid-flexion to end-range flexion

Two 30-second bouts with 3-second hold at end range.

Stationary bicycle

Five minutes; increase time as tolerated.

Strengthening exercises*

Static quadriceps sets in knee extension

One set of 10 repetitions with 6-second hold; 10-second rest between repetitions

Closed-chain progression†:

Standing terminal knee extension

One 30-second bout; increase resistance as tolerated

Seated leg press

One 30-second bout; increase resistance as tolerated

Dips weight-lessened

One 30-second bout; 1 second during concentric phase and 2 seconds during eccentric phase; progress from 2 legs to 1 leg as tolerated.

Step-ups

One 30-second bout; increase step height as tolerated


*—The number of exercise bouts was increased according to the patient's tolerance.

†—Patients performed closed-chain exercises B, C, or D, depending on which one they could perform pain-free.

Reprinted with permission from Deyle GD, Henderson NE, Matekel RL, Ryder MG, Garber MB, Allison SC. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee. A randomized, controlled trial. Ann Intern Med 2000; 132:180.

Exercise Program for Patients With Osteoarthritis of the Knee

View Table

Exercise Program for Patients With Osteoarthritis of the Knee

Exercise Measures

Stretching exercises

Standing calf stretch

Three repetitions with 30-second hold

Supine hamstring stretch

Three repetitions with 30-second hold

Prone quadriceps stretch

Three repetitions with 30-second hold

Range-of-motion exercises

In long sitting position, knee mid-flexion to end-range extension

Two 30-second bouts with 3-second hold at end range.

In long sitting position, knee mid-flexion to end-range flexion

Two 30-second bouts with 3-second hold at end range.

Stationary bicycle

Five minutes; increase time as tolerated.

Strengthening exercises*

Static quadriceps sets in knee extension

One set of 10 repetitions with 6-second hold; 10-second rest between repetitions

Closed-chain progression†:

Standing terminal knee extension

One 30-second bout; increase resistance as tolerated

Seated leg press

One 30-second bout; increase resistance as tolerated

Dips weight-lessened

One 30-second bout; 1 second during concentric phase and 2 seconds during eccentric phase; progress from 2 legs to 1 leg as tolerated.

Step-ups

One 30-second bout; increase step height as tolerated


*—The number of exercise bouts was increased according to the patient's tolerance.

†—Patients performed closed-chain exercises B, C, or D, depending on which one they could perform pain-free.

Reprinted with permission from Deyle GD, Henderson NE, Matekel RL, Ryder MG, Garber MB, Allison SC. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee. A randomized, controlled trial. Ann Intern Med 2000; 132:180.

Of the 69 patients who completed all treatment and testing, 33 were in the treatment group and 36 were in the placebo group. Patients in the treatment group had improved symptom scores and significantly increased average distances walked in six minutes compared with those in the placebo group. These improvements were maintained after one year. After one year, patients in the placebo group had significantly more knee surgeries than those in the treatment group.

The authors conclude that patients with osteoarthritis who are treated with a regimen that combines manual physical therapy with supervised exercise have improved function and less reported pain and stiffness than patients who are not treated with a physical therapy program. This type of treatment may decrease the need for knee surgery.

Deyle GD, et al. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee. A randomized, controlled trial. Ann Intern Med. February 1, 2000;132:173–81.



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