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Table of Contents
Year : 2022  |  Volume : 4  |  Issue : 1  |  Page : 4-7

Considerations in the advancement of physical therapy services in the management of osteoarthritis

4068 Health Science Center, PT,UW-La Crosse, La Crosse, WI 54601, USA

Date of Submission04-Jun-2022
Date of Decision10-Jun-2022
Date of Acceptance08-Jul-2022
Date of Web Publication30-Jul-2022

Correspondence Address:
Dr. Steni Sackiriyas
PT,UW-La Crosse, 1725 State Street, 4068 Health Science Center, La Crosse, WI 54601
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijptr.ijptr_95_22

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How to cite this article:
Sackiriyas S. Considerations in the advancement of physical therapy services in the management of osteoarthritis. Indian J Phys Ther Res 2022;4:4-7

How to cite this URL:
Sackiriyas S. Considerations in the advancement of physical therapy services in the management of osteoarthritis. Indian J Phys Ther Res [serial online] 2022 [cited 2023 Feb 1];4:4-7. Available from: https://www.ijptr.org/text.asp?2022/4/1/4/353024

  Introduction Top

Osteoarthritis (OA) is the most common form of arthritis[1] that primarily affects weight-bearing joints such as the knee,[2] often resulting in pain and disability. Currently, the exact etiology of OA is poorly understood even though it is associated with multiple factors that have been classified into genetic (i.e., altered cartilage and subchondral gene expressions) and nongenetic factors (i.e., example, sedentary lifestyle, age, gender, obesity, mechanical stress, and trauma to joints).[3] However, articular cartilage damage is considered the hallmark sign of OA.[3],[4] In addition, approximately 60% of people with OA are likely to have other comorbidities such as cardiovascular diseases, type 2 diabetes, and dementia.[2] As the world population ages, the prevalence and incidence of OA are expected to rise in India[5] as well as worldwide.[2] The rapid rise of OA may pose significant challenges such as the financial burden for the patients and increased health-care costs. Currently, the treatment regimen available for OA is limited, which includes therapeutic drugs, nonpharmacological interventions, and surgeries.

Nevertheless, the available drug therapies used for treating OA are only partially effective and do not provide a cure.[6] When considering their use, clinicians must carefully weigh the benefits vs. risks of these drugs to manage OA. Surgeries such as joint replacements are typically recommended once conservative treatments (pharmacological d nonpharmacological) produce no desirable effects,[7] but they may carry risks such as deep-vein thrombosis. Consequently, nonpharmacological treatment techniques such as exercise have been advocated as a preferred treatment to manage OA.[8] Exercise programs are more effective under the supervision of a physical therapist (PT) in the management of OA.[1] When navigating through this challenging diagnosis of OA, the treating clinicians need to keep abreast of OA-related literature where they consider other factors such as age, gender, comorbidities, scope of practice, and patient's preference and values when tailoring a specific treatment program related to OA management. In addition, PTs are expected to educate their patients, other health-care professionals, and legislators clearly and adequately about the benefits of physical therapy services in managing OA.

  Exercise and Clinical Practice Guidelines in Osteoarthritis Top

Exercises have been shown to have numerous benefits for OA.[2],[9],[10],[11] The latest Clinical Practice Guidelines (CPGs)[9],[10],[11] and clinical commentary research evidence[2] support the beneficial effects of exercise and strongly suggest incorporating exercise in the management of OA. Skou et al.[2] reported on the importance of exercise in the management of OA symptoms and impairments:

  1. Exercise therapy may be as effective as nonsteroidal anti-inflammatory drugs
  2. Exercise therapy maybe two to three times more effective than acetaminophen (paracetamol)
  3. Different types of exercises (aerobic, resistance, and performance) may have similar effects.

When further examining these recommendations, one might think that there is no difference between the type of exercises in OA management. Although the different types of exercises may have similar benefits (effect sizes for aerobic [0.56–0.67], resistance [0.60–0.62], and performance [0.48–0.56]), the current recommendations advise when to utilize one type of exercise over the other when treating the different subgroups of OA. When considering exercise interventions, the PT is expected to optimize the exercise interventions by lowering or increasing, or changing the type of exercise program when necessary based on the patient's pain tolerance. For example, neuromuscular exercises (standing and weight-bearing exercises) have been suggested over isolated quadriceps-strengthening exercises for individuals with visible varus knee alignment associated with knee OA. At the same time, isolated quadriceps-strengthening exercises have been recommended for individuals with obesity and varus knee alignment. In addition, these hip and knee strengthening exercises have been suggested to be performed for two sessions per week, 2 to 4 sets of 8–12 repetitions at an intensity of 60%–80% of 1-repetition maximum under supervision for >12 weeks have shown to be beneficial in the management of hip and knee OA.[2]

Evidence also supports other critical nonpharmacological treatment procedures that include using assistive devices (i.e., cane), weight loss interventions, self-management programs, knee braces for knee OA, promotion of physical activity, and patient education programs[1],[10] to manage OA. Interestingly, the current CPGs have reported only limited evidence[10] and have strongly recommended against[1] the use of some of the traditionally used modalities, such as Transcutaneous Electrical Nerve Stimulation (TENS), in the management of knee OA. Furthermore, the CPGs have strongly recommended not to use the lateral wedge insoles for patients with knee OA.[1],[10] Due to the extensive information contained in these resources, this editorial may not be able to cover all such information. Therefore, clinicians, especially PT clinicians, are encouraged to consult these excellent resources for more detailed information regarding pharmacological, nonpharmacological, and surgical interventions available for OA management.

  Precision-Based Management of Osteoarthritis Top

Although exercise has shown to be beneficial in OA management, the PT clinician needs to be aware of different biomechanical factors that may affect different areas of a single joint or multiple joints that may need to be tailored for a more precise and effective exercise program to the management of OA. For example, the knee has been generally classified as having three compartments (medial and lateral tibiofemoral and patellofemoral), where the medial compartment is the most often affected by OA. This may be due to increased exposure of the medial compartment to ground reaction forces (GRFs) during weight-bearing activities such as walking. GRFs, when altered due to malalignment of the knee (for example, a 4%–6% increase in varus alignment), can increase abnormal joint compressive forces (knee loading) on the medial compartment during walking.[12] This increased medial compartment loading is often associated with the structural progression of knee OA.[13] Furthermore, atypical joint kinematic and kinetic changes have been reported to change the typical contact areas within the joints that may increase the potential for cartilage degradation.[14] Therefore, a thorough understanding of the factors associated with articular cartilage destruction in distinct locations of specific joints, other joints, and other body parts (for example, contralateral lower extremity) may play a crucial role in knee OA management.

Similarly, understanding and modification of these loading forces may provide more in-depth information for clinicians when managing OA. In fact, to modify these knee loading forces, various forms of feedback have been used to produce gait modifications (for example, using toe-in gait, increased step width, or increased medial knee thrust) during gait retraining for walking.[15] However, these approaches might seem only possible in an expensive laboratory environment with sophisticated equipment (force-plate embedded treadmill, 3-D motion analysis, and Inertial Measurement Unit (IMU) sensors) that may not be available in developing countries or in all clinical settings. However, Willy et al.[16] have shown that using a mirror on a treadmill can be utilized to achieve positive results in training and retention associated with hip mechanics where the hip abduction moment, hip adduction, and contralateral pelvic drop were improved in runners with chronic patellofemoral pain. Adopting such an approach when sophisticated equipment may not be available may provide similar results in the management of knee OA.

  Education Top

Specific exercises that are tailored to OA treatment may be beneficial. However, when providing PT services, clinicians should also consider educating their patients when they may benefit from well-designed PT intervention as well as abandoning exercises when they are not producing the desired results. This flexible approach to treatment may improve patient adherence to PT services. The clinical commentary article on OA[2] highly recommends patient education in the delivery of PT services. For example, the patient should be educated that, like analgesic medications used to treat OA, the effects of exercise depend on the correct dosage, duration, and frequency, and the beneficial effects may disappear when exercises are prematurely discontinued. Because, sometimes, patients may prematurely abandon exercise due to what they perceive as no effect or harmful effects. Therefore, to reduce premature discontinuation of exercise, clinicians need to educate their patients on the alternative exercise types available for them and highlight the beneficial effects of exercise in the management of their OA.

Educating and allowing the patient to choose an alternative exercise type can also be analogous to trying one analgesic medication over another to improve patient adherence. The American College of Rheumatology / Arthritis Foundation guidelines[1] also emphasize the importance of sharing the decision-making process with the patient. However, this information needs to be delivered in a language that a patient can understand to improve adherence to PT services. As an ethically trained PT, all should follow this recommendation and diligently delegate care to other eligible PT clinicians when warranted. I believe that quality care is the patient's right, and it is our privilege to treat patients.

In addition to patient education, the PT also needs to actively promote the PT profession and educate other health-care team members, society, and legislators regarding how services are advancing worldwide and can benefit not only the patients but also the society. For example, direct access[17] to physical therapy services allows patients to access quality physical therapy services from a skilled physical therapy clinician without a referral from other health-care professionals such as a physician. This approach may reduce patients' costs for necessary PT care without delay. However, a qualified PT with direct access needs to work collaboratively with and to refer patients to other health-care team members when necessary. Therefore, the PT clinician needs to be educated in the use of direct access and the benefits in collaborating with other health-care team members. They also must inform legislators as well as society to obtain or maintain direct access and in their state or country.

  Conclusion Top

Considering the challenges associated with OA, such as multifactorial causes, conditions involving comorbidities, limited treatment options, patient preference, scope of practice, and local- and national-level regulations, one must carefully design their PT treatment to manage OA precisely and effectively. Furthermore, treating clinician needs to refer the patient to appropriate health-care professionals when the symptoms require further evaluation. The PT can also play an important role in patient education on the beneficial effects of PT intervention that may improve short-term and long-term adherence to exercise. Furthermore, PT clinicians should consider educating other health-care members and legislators to understand what PT services can offer in OA management that may improve patients' function and quality of life to be productive citizens in society. I anticipate that the physical therapy profession can support early and affordable rehabilitation for individuals with OA. Utilizing evidence-based resources, the clinician can precisely provide interventions that can modify loading forces to a joint and support effective exercise programs to reduce pain and improve function associated with this debilitating disease.

  References Top

Kolasinski SL, Neogi T, Hochberg MC, Oatis C, Guyatt G, Block J, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Care Res (Hoboken) 2020;72:149-62.  Back to cited text no. 1
Skou ST, Pedersen BK, Abbott JH, Patterson B, Barton C. Physical activity and exercise therapy benefit more than just symptoms and impairments in people with hip and knee osteoarthritis. J Orthop Sports Phys Ther 2018;48:439-47.  Back to cited text no. 2
Cucchiarini M, de Girolamo L, Filardo G, Oliveira JM, Orth P, Pape D, et al. Basic science of osteoarthritis. J Exp Orthop 2016;3:22.  Back to cited text no. 3
Malemud CJ, Martel-Pelletier J, Pelletier JP. Degradation of extracellular matrix in osteoarthritis: 4 fundamental questions. J Rheumatol 1987;14:20-2.  Back to cited text no. 4
Pal CP, Singh P, Chaturvedi S, Pruthi KK, Vij A. Epidemiology of knee osteoarthritis in India and related factors. Indian J Orthop 2016;50:518-22.  Back to cited text no. 5
[PUBMED]  [Full text]  
Oo WM, Yu SP, Daniel MS, Hunter DJ. Disease-modifying drugs in osteoarthritis: Current understanding and future therapeutics. Expert Opin Emerg Drugs 2018;23:331-47.  Back to cited text no. 6
Rönn K, Reischl N, Gautier E, Jacobi M. Current surgical treatment of knee osteoarthritis. Arthritis 2011;2011:454873.  Back to cited text no. 7
Beckwée D, Vaes P, Cnudde M, Swinnen E, Bautmans I. Osteoarthritis of the knee: Why does exercise work? A qualitative study of the literature. Ageing Res Rev 2013;12:226-36.  Back to cited text no. 8
Bannuru RR, Osani MC, Vaysbrot EE, Arden NK, Bennell K, Bierma-Zeinstra SMA, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage 2019;27:1578-89.  Back to cited text no. 9
Osteoarthritis of the Knee-Clinical Practice Guideline (CPG) | American Academy of Orthopaedic Surgeons. Available from: https://www.aaos.org/quality/quality-programs/lower-extremity-programs/osteoarthritis-of-the-knee/. [Last accessed on 2022 May 24].  Back to cited text no. 10
Clinical Practice Guidelines Osteoarthritis. Available from: https://www.rheumatology.org/Practice-Quality/Clinical-Support/Clinical-Practice-Guidelines/Osteoarthritis. [Last accessed on 2022 May 23].  Back to cited text no. 11
Tanamas S, Hanna FS, Cicuttini FM, Wluka AE, Berry P, Urquhart DM. Does knee malalignment increase the risk of development and progression of knee osteoarthritis? A systematic review. Arthritis Rheum 2009;61:459-67.  Back to cited text no. 12
Hodges PW, van den Hoorn W, Wrigley TV, Hinman RS, Bowles KA, Cicuttini F, et al. Increased duration of co-contraction of medial knee muscles is associated with greater progression of knee osteoarthritis. Man Ther 2016;21:151-8.  Back to cited text no. 13
Vincent KR, Conrad BP, Fregly BJ, Vincent HK. The pathophysiology of osteoarthritis: A Mechanical perspective on the knee joint. PM R 2012;4:S3-9.  Back to cited text no. 14
Simic M, Hinman RS, Wrigley TV, Bennell KL, Hunt MA. Gait modification strategies for altering medial knee joint load: A systematic review. Arthritis Care Res (Hoboken) 2011;63:405-26.  Back to cited text no. 15
Willy RW, Scholz JP, Davis IS. Mirror gait retraining for the treatment of patellofemoral pain in female runners. Clin Biomech (Bristol, Avon) 2012;27:1045-51.  Back to cited text no. 16
Direct Access Advocacy. APTA. Available from: https://www.apta.org/advocacy/issues/direct-access-advocacy. [Last accessed on 2022 May 24].  Back to cited text no. 17


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