ARTHROSCOPY NOT RECOMMENDED FOR DEGENERATIVE KNEE DISEASE

A recent systematic review concluded that arthroscopic surgery for degenerative knee disease (including arthritis and meniscal tears) did not result in lasting pain relief or improved function. As a result, panelists strongly recommend against arthroscopy for patients with degenerative knee disease. 

The review (Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline- May 2017) was published in BMJ.

According to the review, about 25% of people older than 50 years of age experience pain from degenerative knee disease (the percentage rises with age), and costs for arthroscopies for this condition are in excess of $3 billion per year in the United States. Furthermore, only 15% of arthroscopy patients reported a small or very small improvement in pain or function at 3 months post surgery, and those benefits were not sustained at 1 year post surgery. 

In place of arthroscopy, panelists recommend effective alternatives including an individualized regimen combining rest, weight loss as needed, a variety of treatments provided by a physical therapist, exercise, and nonsteroidal anti-inflammatory drugs.

In an interview with the New York Times, Dr Reed A.C. Siemieniuk, a methodologist at McMaster University in Hamilton, Ontario, Canada, and chairman of the panel, said, “Arthroscopic surgery has a role, but not for arthritis and meniscal tears.” The procedure, he elaborated, “became popular before there were studies to show that it works, and we now have high-quality evidence showing that it doesn’t work.”

ARTHROSCOPY NOT RECOMMENDED FOR DEGENERATIVE KNEE DISEASE, PER NEW RESEARCH

A recent systematic review concluded that arthroscopic surgery for degenerative knee disease (including arthritis and meniscal tears) did not result in lasting pain relief or improved function. As a result, panelists strongly recommend against arthroscopy for patients with degenerative knee disease in most cases. 

The review (Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline- May 2017) was published in BMJ.

According to the review, about 25% of people older than 50 years of age experience pain from degenerative knee disease (the percentage rises with age), and costs for arthroscopies for this condition are in excess of $3 billion per year in the United States. Furthermore, only 15% of arthroscopy patients reported a small or very small improvement in pain or function at 3 months post surgery, and those benefits were not sustained at 1 year post surgery. 

In place of arthroscopy, panelists recommend effective alternatives including an individualized regimen combining rest, weight loss as needed, a variety of treatments provided by a physical therapist, exercise, and nonsteroidal anti-inflammatory drugs.

In an interview with the New York Times, Dr Reed A.C. Siemieniuk, a methodologist at McMaster University in Hamilton, Ontario, Canada, and chairman of the panel, said, "Arthroscopic surgery has a role, but not for arthritis and meniscal tears." The procedure, he elaborated, "became popular before there were studies to show that it works, and we now have high-quality evidence showing that it doesn't work."

PREVENTING OSTEOARTHRITIS IN THE KNEE

WHAT IS IT?

Osteoarthritis is the medical term for the more common "arthritis" and refers to the general deterioration of cartilage that leads to damage on articulating surfaces of joints. 

Osteoarthritis can occur in any joint, some as small as the bones in the hand/fingers, and as large as the hip and knee joints. 

Preventing osteoarthritis in the knee, or delaying onset, is a lifetime practice, as many of the causes that lead to deterioration of bone articulating cartilage are due to overuse during youth, adolescence, and early adulthood. Other increased risks come from lifestyles, and habits that are typically formed at a younger age. 

INCREASED LIFESTYLE RISK FACTORS INCLUDE, BUT ARE NOT LIMITED TO: 

• Extremely active lifestyle, where the joints take a beating
  • Participating in physical activity that heavily load the joint, such as running, put large loads onto the body that continuously put stress on the cartilage and articulations of joints, running the articulation cartilage thin.
• Extremely sedentary lifestyle, where the joints receive very little to no load
  • Sedentary lifestyles tend to lead to a decrease in bone density, and a decrease in bone density leads to an increase risk of osteoarthritis
• Ligament, tendon, or cartilage tears
  • Tearing your ACL, MCL, and PCL all show an increase risk for early onset osteoarthritis, as the joint lacks stability, and therefore overloads cartilage 
• Misalignments
  • Having leg length discrepancies, wearing shoes that lack arch/medial support, etc. lead to increased pressure on one side of the body compared to the contralateral side, and results in deterioration of cartilage
• Musculoskeletal discrepancies
  • Having weak muscles on one aspect of the leg compared to the other leads to decreased stabilization in the knee, which leads to increased load on one aspect of the joint. 
  • This is the highest, non-impact cause that is correlated with an increased risk of developing osteoarthritis in both adults and children

WHAT CAN YOU DO? 

Prevention is key. Having musculoskeletal evaluations, leg length, joint alignment measured by a physical therapist prior to your child starting physical activity is key to identifying potential problems early. Children are resilient, physically, but those same joints may not be so quick to heal at age 40, and like wearing sunscreen, it's extremely necessary to attempt prevention at a young age. 

Preventative physical therapists, including us here at CHAMPION, can take your children, or even you through preventative programs to help decrease risk, delay onset, or even delay surgical repair. 

OSTEOPENIA (LOW BONE MASS)

Osteopenia, now called low bone mass, is a term used to describe lower-than-normal bone density or thickness. Approximately 44 million adults in the United States have osteopenia.The condition is different than osteoporosis, which is a disease where normal bone structure becomes thinned out and porous.

Low bone mass can occur at any age, but noticeable and significant bone loss is most likely to occur in women during the 5 to 7 years following menopause. This group is also more likely to experience a bone fracture than someone with normal bone mass.

What is Osteopenia?

Low bone mass is a condition that develops when a person:

• May naturally have less-dense bones due to factors such as body size, genetics, or gender.
• Has gradually lost bone mass over time due to lack of exercise and poor diet.
• Has begun to experience perimenopause, symptoms that signal the onset of menopause or who is in menopause.
• Has rapidly lost bone mass due to an illness or use of medication.

How Is It Diagnosed?

Low bone mass is diagnosed through a quick and painless specialized scan ordered by aphysician. If you are seeing a physical therapist for rehabilitation, the therapist may confer with your physician when detecting a possible need for bone testing.

The results of the scan are reported using T- and Z-scores.

The T-score compares your score to that of healthy 30-year-old women. A T-score between -1 and -2.49 means that you have low bone mass. Those who have a T-score of -2.5 and lower have osteoporosis.

If you have a T score of -1 or less, you have a greater risk of experiencing a fracture. A person with a T-score of -2 has lower bone density than a person with -1.

The Z-score compares your bone mineral density to the average of peoplewho are of the same age, sex,weight,and race as you. A Z-score of -2 or lower might mean that something other than normal bone loss due to age is occurring. Your doctor will likely explore other health issues that might be causing the bone loss.

Other methods of screening bone density include x-ray, ultrasound, and CT scan.If you have risk factors that includecertain diseases, short- or long-term use of steroids, or a recent bone fracture, a DXA scan may be prescribed.

How Can a Physical Therapist Help?

A physical therapist can help you prevent and treat low bone massat any age by prescribing the specific amount and type of exercise that best builds and maintains strong bones.

When you see your physical therapist, the therapist will review your health history, including your medical, family, medication, exercise, dietary, and hormonal history. Your physical therapistwill also conduct a complete physical therapy examination and identify your risk factors for low bone density.

It is important to exercise throughout life, and especially when you have been diagnosed with low bone mass in order to build and maintain healthy bones. Exercise can help to build bone or slow the loss of bone.

Your physical therapist is likely to prescribe 2types of exercise that are best to build strong bones:

Weight-bearing Exercises

• Dancing
• Walking at a quick pace (122-160 steps per minute or 2.6 steps per second)
• Jumping, stomping, heel drops
• Running at least a 10-minute mile
• Racket sports

Resistance Exercises

• Weightlifting
• Use of resistance bands
• Gravity-resistance exercises (pushups, yoga, stair climbing, etc.)

Your physical therapist will design an individual exercise program for you based on your particular needs. Your physical therapist will test you to see how much resistance is needed and is safe for your specific bone density as well asother physical issues that you may have. Treatment starts at the level you can tolerate. Once you learn how to perform your program, your physical therapist may add more strenuous activity with physical effort to encourage your bones to grow stronger.

Your exercise prescription will include guidelines for weightbearing and resistance training for the hips, spine, shoulders, and wrists. The therapist will prescribe guidelines for the intensity, frequency, and progression of your exercises.

Exercise is only 1component of healthy bones. Your physical therapist will encourage you to pursue a healthy and varied diet, including foods rich in calcium, to reach the amount recommended according to your age and health status. Your physical therapist may recommend that you meet with a dietitian to learn about the many foods that contribute to bone health. Sometimes, medication or hormone replacement therapy may be recommended. Your physician will help guide you to find the best combination of exercise, diet, and medication to treat your condition.

Can this Injury or Condition be Prevented?

Risk factors that you can avoid in order to lower your chances of developing low bone mass include:

• Cigarette smoking
• Excessive alcohol intake (greater than 1 drink per day for women, 2 per day for men)
• Poor diet
• Low calcium and Vitamin D levels        
• Sedentary or low level activity—less than 5,000 steps per day

MANAGING ARTHRITIC PAIN WITH EXERCISE

According to the National Center for Health Statistics, more than 50 million adults have some form of arthritis. The most common type is osteoarthritis — also known as "wear and tear" arthritis — which most often affects the weight-bearing joints in the knees, hips, neck, and lower back.

In osteoarthritis, the smooth cartilage that cushions our joints begins to wear away. Cartilage does not heal or grow back, and over time it can become rough and frayed. Without healthy cartilage, our bones can no longer smoothly glide across one another, and movement begins to cause pain and stiffness.

When it is very severe and there is no remaining cartilage cushion, the joint becomes bone-on-bone.

How Exercise Helps Arthritis Pain

It is not uncommon for arthritis pain to limit activity and slow most down - the body's natural reaction is to avoid movements that increase pain. Not exercising, however, can result in more problems. Recent research shows that not only do the compensations naturally adapted to limit pain during required daily movements (limping while walking, shuffling as opposed to stride walking), but also that over time inactivity actually worsens osteoarthritis pain, and puts adults at greater risk for eventual total loss of mobility.

Because exercise is painful for so many adults with arthritis, it may be hard to understand how exercise helps to actually relieve pain. First, exercise increases blood flow to cartilage, bringing it the nutrients it needs to stay healthy.

In addition, specific exercises will strengthen the muscles that surround your joints. The stronger your muscles are, the more weight they can handle without pain. As a result, the bones in your joints carry less weight, and your damaged cartilage is better protected.

Having strong muscles to support your joints is even more important if you are overweight. And exercise, of course, can help you with weight loss. Losing just a few pounds can make a big difference in the amount of stress you place on your weight-bearing joints, such as hips and knees.

Studies have also found that people who exercise are less likely to be depressed or feel anxious. Plus, exercise can help you manage stress and improve your sleep patterns. Getting a full night's sleep is especially important because arthritis symptoms often worsen when you are tired. With hip and knee arthritis, it can be helpful to sleep with a pillow under your knees or between your legs for comfort. 

Starting an Exercise Program

Of course, understanding how exercise can help is just the beginning. Starting an exercise program is the next step and often the toughest. Be sure to talk to your doctor first, especially if activity is painful for you or you have been sedentary for a long period of time.

Your doctor will talk to you about the types of exercises that would be best for you, depending on the severity of your arthritis - and they'll likely recommend you to physical therapy so you have medical oversight while adjusting to the exercise programs and increasing skeletomuscular strength - this is where we at Champion Performance and Physical Therapy come into play. Our staff maintains the perfect mix between experience, studying under some of Kansas City's longest-practicing physical therapists, and practicing based off of the most up-to-date research and developments. 

The program we would create would likely include three types of exercise:

• Range-of-motion exercises to improve your flexibility and reduce stiffness in your joints
• Strengthening exercises to help build muscle mass and protect your joints
• Some aerobic exercise to strengthen your heart and lungs, and improve your overall fitness. Aerobic exercise is key to controlling your weight, as well.

Even if pain does not prevent you from exercising, it is a good idea to talk to your doctor about your fitness program.

Moderate Exercise

Typically, doctors recommend a moderate, balanced fitness program. If you regularly do high-impact aerobic exercises, such as running or competitive sports, your doctor may recommend that you switch to low-impact activities that place less stress on your weight-bearing joints. Walking, swimming, and cycling are good alternatives. A stationary exercise bike, even a recumbent one, can provide aerobic exercise for those who cannot walk well or have balance problems. 

To help with balance, strength, and flexibility, your doctor or therapist may suggest you try yoga or tai chi, a program of exercises, breathing, and movements based on ancient Chinese practices.

Start Slowly

If it has been awhile since you have exercised, slow and steady is the safest and most effective way to begin a fitness program. Your goal is 20 to 30 minutes of aerobic activity, 3 to 4 times a week. If this is challenging for you, you can break it up into shorter segments, such as a 10-minute walk in the morning and a 10-minute walk in the evening.  We will likely focus on the first two of the three key exercises focuses - then when your pain dissipates enough to add aerobic activity back into your lifestyle, we'll provide the keys to upkeep on your own.

Strength exercises can be done every other day, and you can work on your range of motion every day. Always begin with a warm up to prepare your body for all types of exercise.

As you get stronger, gradually increase the duration of your aerobic exercise and the number of strength exercise repetitions. Be sure not to overdo it. You should not feel serious pain after exercise. It is typical to feel some muscle soreness the day after you exercise, but if you feel so sore that it is difficult to move, then you have overdone your exercise. You can reduce muscle soreness with a heating pad or a warm bath or shower. 

Talk to you doctor or therapist if you have any pain or are unsure about your fitness program. Your therapist may recommend assistive devices, such as braces or shoe inserts, to help reduce stress on your joints.

Living with osteoarthritis can be very challenging. Remember that there are many things you can do to lessen the impact arthritis has on your life. Regular, moderate exercise can help.

Call us at Champion Performance and Physical Therapy at 913-291-2290 with any questions.

Source: National Center for Health Statistics (NCHS), National Health Interview Survey 2010.

DIAGNOSED WITH OSTEOARTHRITIS

Our last post, ARE YOU AT RISK FOR OSTEOARTHRITIS? focused on the "before" aspect of a diagnosis, and what risk factors increase your chances for a diagnosis. DIAGNOSED WITH OSTEOARTHRITIS is going to focus on the "after" aspect - what to do after you've been diagnosed. 

1. First and foremost: do not self diagnose.

See your primary care physician, or an orthopaedic specialist. A series of tests and health history questions will allow most medical practitioners to be positive about an osteoarthritis diagnosis, but for physical proof, you'll need either an X-ray or an MRI. 

Why an X-ray? More advanced cases of osteoarthritis will be visible in an X-ray.  Severe cartilage degeneration will be visible (or more realistically, will be nonexistent) by recognizing what's out of place in comparison to where they're anatomically in place.  Joints that are suffering from osteoarthritis will look noticeably different in an X-ray compared to that of a healthy joint. 

2. Talk to your doctor about your options.

Depending on the severity of your case, your doctor may present you with a multitude of paths to assess, or potentially just a fair few.

Non-surgical opportunities include but are not limited to: steroid injections to lessen inflammation and reduce pain, physical therapy to strengthen muscles and therefore lighten the load on the joint, or pain medications to allow you to continue functioning with minimal pain.

Surgical opportunities, or joint replacements, are extremely common. Depending on age or the severity of your case, you may be a prime candidate for a partial or total joint replacement. This will require physical therapy to aide your body in returning to full range of motion and strength, but most cases are completely successful and will allow you to return to the lifestyle you enjoy with less pain than in you have had in probably 5 or more years. 

3. In the meantime: less is not more.

While it may feel as though movement is going to aggravate and inflame that joint, lack of movement is consequentially worse. The lack of movement weakens the muscles, and therefore, adding more pressure on the joint when it's loaded. Lack of movement will essentially make it significantly more painful to move - and therefore, making the condition feel much worse. Movement, as well as strengthening, is key to maintaining a quality of life until the correct treatment option for you can be identified and agreed upon. 

4. Ice, and Anti-inflammatories

Icing the joints can lead to some stiffness, but it can also decrease the activity of inflammatory responses that lead to increased swelling from bone-on-bone activity and therefore, decreases the residual pain. Not only does it limit the inflammatory response by constricting the blood flow into that joint, but also allows you to feel relief temporarily until the numbness from the cold entirely wears off. An anti-inflammatory can help aide in minimizing your inflammatory (immune) response, but be sure to talk with your doctor about which anti-inflammatory works best for you and your specific medication protocol. 

ARE YOU AT RISK FOR OSTEOARTHRITIS?

What is osteoarthritis?

Osteoarthritis, also known as Degenerative Joint Disease (DJD) but more commonly known as "arthritis", is the degeneration of cartilage in a joint leading to bone-on-bone degradation. 

What causes osteoarthritis?

Osteoarthritis results in the deterioration of the cartilage that acts as a protective cushion between bones.  It is more common in the general population in partially weight-bearing joints, such as the hips and knees. As bones grind against one another, it can result in hardening of the joint, inflammation of the fluid-filled, protective bursa sacs, and possibly bone spurs and other problems that lead to pain. 

What risk factors increase my chances of getting osteoarthritis? 

Unfortunately, not qualifying for any risk factors does not guarantee you'll never have osteoarthritic symptoms, but it can help to decrease chances. Some risk factors are out of our control, but some definitely aren't!

1.  Old Age increases your risk significantly, as not only do the proteins in the body that recreate and make up cartilage become more sparse in the joints, but the fluid that protects the cartilage is produced less as you age, as well. 

2. Obesity puts added stress on weight-bearing joints, and adipose (fatty) tissue produce proteins that can lead to harmful, degrading inflammation in the joint cavities. 

3. Joint Injuries that stemmed from an accident or sports injury can increase your risk of osteoarthritis.

4. Bone Deformities or Protein Deficiencies can increase the amount of stress on a certain area of the joint that will later lead to a breakdown of cartilage, and life-long protein or hormonal deficiencies diagnosed at a young age can eventually cause an early onset of osteoarthritis. 

5. Genetics has also proven to be a major factor in developing osteoarthritis, not only because of gene function, but lifestyles. Some are more prone to the breakdown of cartilaginous proteins and fibers. As far as genetically inherited lifestyles, that's probably more accurate when described as a nuture versus a nature problem. More often than not, children are going to have similar lifestyles to that of their parents. Parents who developed osteoarthritis due to being extremely active in their youth and adulthood likely passed those same habits onto their child, which could, in turn, potentially lead to the same osteoarthritic developments. 

Does meeting these risk factors necessarily mean you'll develop osteoarthritis? No. Like every medical condition, qualifying for a risk factor is not a guarantee. Simply worry about the ones you can control. 

OUR NEXT BLOG POST: What to do when you already have osteoarthritis.