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Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE February 2023 A “new” Low Cost Treatment for Knee/Hip OA Without NSAID and Tylenol Side Effect Risks and Downstream Medical Costs… by Karen Napierala MS, AT, PT, CAFS What would you do? A 67 yo female enters your office with pain in her L anterior thigh traveling up into her anterior hip/groin. She has pain on heel strike and late stance phase of gait, which is visibly shortened. She can stand 30 minutes maximum while leaning forward to prepare meals at the counter, but can only stand upright < 10 minutes socializing at a family gathering. Hip flexion for tying her shoe is painful and limited. Hip scouring is (+) for pain and limited motion. All hip AROM and PROM are limited, especially with loss of IR, Faber’s, and hip ext. Plain films confirm moderately severe L hip DJD. The Pt’s goals are to resume WNL ADL, watching grandchildren BIW for 5 hr each, fitness class BIW 45min and occasional doubles pickleball. I would prescribe… A. A normal course of NSAID’s along with continued usual activity until 6 wk FU B. A normal course of paracetamol along with continued usual activity until 6 wk FU C. Surgical consult for THR consideration D. Customized PT to include Class IV laser, manual therapy, biomechanical exercise with FU 6 wks E. Provide handout of simple HEP drills for ROM and light strengthening with FU 6-8 wks F. Intra-articular corticosteroid injection with FU 4 wks CURRENT EVIDENCE Weng Q, Goh SL et al. Comparative efficacy of exercise therapy and oral nonsteroidal antiinflammatory drugs and paracetamol for knee or hip osteoarthritis: a network meta-analysis of randomized controlled trials. BJSM, Jan 2, 2023(online). https://bjsm.bmj.com/content/early/2023/01/02/bjsports-2022-105898 SUMMARY: Osteoarthritis is one of the most common orthopedic conditions seen by physicians. Clinical decision making often initially includes pharmaceutical management for control of pain and inflammation along with other potential treatment options. NSAID’s and paracetamol are commonly prescribed medicines but their cost-benefit analysis regarding potential adverse effects and comorbidity profiles (Tuhina Neogi , Amer College of Rheumatology) may make these drugs inappropriate. Exercise is a recommended treatment for restoring ROM, strength, balance, and overall function but pain reduction is more so considered a secondary benefit. Weng et al performed a network meta-analysis that included 152 RCT studies with a total of 17,431 participants with hip or knee OA comparing the efficacy, directly or indirectly, of exercise vs oral NSAID’s and paracetamol for pain and function. The results showed that exercise was comparably effective vs NSAID’s and paracetamol in reducing pain and improving physical function at 4 weeks, 8 weeks, and 24 weeks comparisons. It was also superior to “usual care” (ie. continued daily activities). Exercise may present some challenges regarding the delayed benefit of symptom reduction, requiring compliance by patients, the challenge in slowing down “over-exercisers”, and that oftentimes we find (especially for “failed PT” cases we see) specific biomechanical adjustments and considerations are necessary beyond traditional PT approaches in order to produce successful outcomes. The use of medications, however, does not produce the same expected gains in needed ROM, strength/endurance, and balance these patients require to optimize function and quality of life. Patients relying mainly on continued dosing of NSAID’s and Tylenol also are habituating into a mindset reinforcing quick fixes to symptom control and return to activity that will not serve them long-term regarding their need to modify activity and actively participate in restorative/preventative exercise. Downstream costs for patients relying on these medications also have been shown to increase significantly over time, including due to adverse effects on numerous body systems. The other risk is that patients will contribute unknowingly to accelerated degenerative changes as they medicate their way “successfully” through impact activities that are deleterious to their joint health long term. Expert physical therapy should include specific customizing intended to off-load the compartment mainly effected via specific reaching/shifting maneuvers to allow pain-free/minimized functional strengthening work. Prescriptions should also order kinetic chain evaluation and exercise/manual therapy to address contributing factors (ie., lack of hip IR and ITB length both contributing to varus knee tendency and subsequent medial joint loading). Simple traditional therapy exercises for knee and hip OA do not take these biomechanical considerations into account. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) Purpose: Comparing analgesic benefits of exercise vs NSAID’s and paracetamol in hip and knee OA patients. Study Design: Network meta-analysis Methods: Studies included were: 1. RCT’s, 2. Participants with knee or hip OA, 3. Comparisons of exercise with oral NSAIDs , 4. Studies comparing exercise therapy with any common comparator that may be shared with NSAID’s (i.e. usual care/no treatment/waiting list control, glucosamine sulfate/chondroitin/intra-articular hyaluronic acid, topical NSAID’s, acupuncture), and 5. Studies reporting pain or function. Any study with less than 1 week follow up, use of a cross-over design, or postoperative pain were excluded. The full texts of 2738 potentially eligible articles were reviewed. There were 152 studies (17,431 participants) meeting the inclusion criteria. There were 49 studies with data available at or nearest to four weeks, two studies had data available at eight weeks and nine studies at 24 weeks. Most trials recruited participants with knee OA, while 12 studies investigated hip OA and 13 studies were both. Results: For pain relief there was no difference between oral NSAID’s and Tylenol at or nearest to 4, 8, and 24 weeks. Similar findings were noted for function as well. Authors Conclusion: Exercise has similar positive benefits to oral NSAID’s and Tylenol for pain relief and function. Since exercise has an excellent safety profile it should be given more prominence in clinical care, especially for older patients with comorbidity or higher adverse event risks related to NSAID or Tylenol use. THE PEAK PERFORMANCE PERSPECTIVE: Osteoarthritis is one of the most common orthopedic conditions seen by physicians. Clinical decision making often initially includes pharmaceutical management for control of pain and inflammation along with other potential treatment options. With pain relief ultimately comes the expectation that function will be improved significantly as well, optimizing quality of life. NSAID’s and paracetamol are among the most commonly prescribed medicines used for OA, however, the cost-benefit analysis for these medicines presents some challenges for physicians due to both potential adverse effects and comorbidity profiles (ie. Tuhina Neogi , Amer College of Rheumatology) that may make these drugs inappropriate long term or at all. Exercise is often considered a valuable treatment for restoring ROM, strength, balance, and overall function. Pain reduction is often more so thought of as a secondary benefit. Prescribed physical therapy to include formal supervised exercise is frequently delayed until more significant losses of function (i.e., ROM and strength deficits evident on clinical exam) are noted. Boston rheumatologist Jean Liew, MD noted that over 50% of patients receive NSAID’s and the same percent were given an opioid prescription when diagnosed with OA (American College of Rheumatology Convention 2021). Liew, updating their group’s findings looking at patterns of NSAID, opioid, and physical therapy (PT) use among more than 30,000 newly diagnosed patients with knee or hip OA found 9% had NSAID contraindications and 22% had NSAID precautions. This begs the question: Are NSAID’s and paracetamol being prescribed too frequently for hip and knee OA? Weng et al performed a network meta-analysis that included 152 RCT studies with a total of 17,431 participants comparing the efficacy, directly or indirectly, of exercise vs oral NSAID’s and paracetamol for pain and function knee or hip OA. The results not only showed that exercise was a clinically effective treatment (better than usual care) for reducing pain and improving physical function in people with knee or hip OA, but it was comparable in efficacy to NSAID’s and paracetamol at 4 weeks, 8 weeks, and 24 weeks comparisons. NSAID’s, for example, while effective for control of that knee/hip OA pain and inflammation, have been associated with gastrointestinal, renal, and cardiovascular complications, especially in older adults with comorbidities, There are also patients whose comorbidities deem NSAID’s as strictly contraindicated. Together these facts leave physicians and patients in a difficult position regarding ideal options if left to typical medications alone. Exercise, on the other hand, has the multi-faceted benefits of decreasing pain, increasing range of motion, increasing balance and strength - thus improving function, without the ongoing cost or risks associated with medications. Does exercise have some limitations also? There remains no absolute agreed protocols or best practices based on the evidence, however, this also should be viewed in the light that even heterogeneous “exercise” has been shown not only in this study but in numerous others to nevertheless be effective. Numerous orthopedic and rheumatology organizations have included exercise as strongly recommended based on review findings.. Three particular difficulties must be considered and addressed with prescribing exercise, especially if chosen over NSAID’s and paracetamol alone. One, the patient's desire to do the least and get the most results. We live in a society where people often “want results yesterday, not four weeks from now!” If I am told that I can take a pill today and do nothing, or I can go to PT and exercise, but it will probably take four to six weeks to work, what would I do? If I knew that I would get stronger, get off the ground easier, climb stairs better after exercise, and not just relieve the pain, patients would be more likely to follow those orders. Educating patients about these “long term” expectations and benefits fosters the compliance needed for good outcomes. Secondly, patients unaccustomed to exercise may struggle with commitment to an exercise program. There are patients who will flat out refuse to put the effort in. Third, is slowing down those who are avid exercisers. We have to be careful not to overdose, or allow exercise that will overload the joints. Many patients become their own “worst enemy” as they swing the exercise pendulum in the direction of excess, be it volume, frequency, or oftentimes intensity (especially for impact related activities). One study corroborated that the exercise for 8 weeks was very effective, but the effect of exercise gradually decreased when reassessed a year from the original study. We must approach such facts with caution, however, as the same would be true for medications taken for 6 weeks and not expecting patients to remain substantially better one year later. Exercise is a treatment that must be continued to have maximum results. Siew-LiGoh et al (Sports Medicine, 2019) compared a variety of exercises with “usual care” (i.e. continuing normal daily activity without other treatment). They found that aerobic, flow and pattern exercise, strength and coordination exercises all reduced the pain in knee and hip OA subjects. The question for physicians remains - if exercise, as shown in this and other studies, can be as effective at pain control as NSAID’s and paracetamol, have positive effects on increased function, strength, movement, coordination, and potential decrease risk in falls, and, lack the adverse effects and downstream medical costs associated with those side effects, then why would exercise not be used with every patient that presents with knee or hip OA in the office? The final but not least important points about exercise prescribing and treatment is that the RIGHT exercise will bring the BEST results. Careful attention to detail is necessary for many OA patients to succeed with exercise. Many patients will appear to succeed early on using simple NWB exercises. Unfortunately that often leaves a large “gap to bridge” to more authentic functional demands. For many of these cases, sometimes becoming “failed PT” cases, although finding effective pain-free/minimized PWB and WB functional strength methods can be a much more daunting task, it provides a more effective impact on day to day life. Expert Physical Therapy applies understanding of key biomechanics in order to both intentionally load healthier portions of articular surfaces and also in order to address key kinetic chain shortcomings that are contributing to joint overload. For example, in a common knee medial joint OA case, where the knee is in a varus presentation, PT exercise should focus on unloading the medial knee joint especially via the frontal plane but also the transverse plane. Specific reaching and shifting during otherwise typically painful exercises like split squats or step ups/downs etc can significantly reduce or abolish symptoms, allowing patients to more effectively strengthen. Key biomechanical shortcomings related to having caused the genu varum or that will perpetuate those forces such is poor hip IR, poor ITB length, poor STJ eversion all should be assessed and custom exercises done to treat. These are not approaches common to traditional physical therapy for knee/hip OA. The following case illustrates an example of simple/traditional exercises not working for his case of knee OA. THE PEAK PERFORMANCE EXPERIENCE: Mark said: “ I came to Peak after other physical therapy didn’t work for me. I was on the verge of needing surgery that I didn't want. I came to a Peak PT knee arthritis workshop. After starting PT I I know what to do, and I’m doing it. I can get through work and vacations now pain free!” History: Mark is a 64 year old male who had prior physical therapy and tried to exercise on his own, but was finding the things that he usually did created medial knee pain. He tried NSAIDs for a few months with some relief, but decided that he didn't see that as a long term solution. His job requires climbing ladders and stairs, squatting and carrying. By the end of the day his R > L medial knee is painful. He knows there is some OA on films, but he is not ready to think about a knee replacement yet. Subjective: He complained of knee pain and stiffness that limited walking, climbing ladders for work, and by the start of PT that his knees “hurt all the time.” Objective: (*=pain) Initial Eval Re-Eval Knee extension R knee 50 10 Single leg squat knee angle L 400/ R Unable ** L 650/R 500 Hip IR standing L 150/R 120 L 300 / R 250 2” quad dom step down (eccentric ) painful * 10 # front racked with ant lateral op toe reach ( inc valg at knee) L 24x / R 15x Step up 6” w 10# wts doing P-L opp foot reach ($ knee valgus for med jt unload) L 5x / R painful** L 16x / R 12x Sit stand to seat 15 sec 7x 12x Single leg balance rotation 15 sec painful ER L 15x R 13x WOMAC 41 % 16 % Key Findings: Poor knee ext and flex ROM, lacking hip IR (B) - slightly worse on R, poor tol of WB rotation, limited/painful squat function Treatment: Mark needed to regain as much knee extension as possible initially before moving into flexion exercises. This immediately decreased his pain with walking. He also worked on his limited hip IR NWB and then he progressed to functional WB methods to improve ADL and work applications. He began strengthening with PWB squats (using 0-300 and 60-950 pain-free depths) that were hip and ankle dominant to offload the knee. He used hands holding onto a stationary pole to unweight using arms also. A small yoga ball between his knees allowed Mark to maintain valgus alignment at the knees, thereby unloading his painful medial joint. All sagittal knee motions such as squats, split squats, step ups, and step downs were modified to decrease forces on the medial compartment of the knee. Frontal plane motion into valgus, and increased pronation or tibial IR were allowed as this relieved symptoms. When Mark was able to progress to impacting he began with crossover lunges focusing on valgus force from the foot up. Even once he progressed to lateral lunges, medial joint unloading was maintained by landing laterally on a wedge. Mark also received 6 sessions of Class IV Laser treatments on his R knee. The pain relief for him was immediate and lasting. This allowed faster progressions and improved his functional status quicker. After 6 weeks: Mark was ambulating at 3.0 mph pain free for 30 min, and could sit stand easily and was pain- free up and down ladders at work. He knows he has a limit for the total amount of weight bearing and work during each day, but has kept himself well under that. Outcome: Pt was DC’d to an (I) HEP, pain-free, able to remain at work full duty performing all tasks w/o troubles, walking and sitting were WNL, and he was able to go on vacation as well. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com

by Karen Napierala, PT, AT, MS, CAFS A week ago I had the great opportunity to assist my husband Mike at the High Peaks Elite Distance Camp in Lake Placid that Rick Guido puts on bi-annually. I was demoing the body weight agility section that Mike was orchestrating. I was actually surprised, when he asked me to demo 6 single leg regular pushups. Then six more! I was wondering inside if I really could do this, but on the outside I smiled and said, “Sure.” My voice in my head was talking a mile a minute, fighting with myself, as I “repped” these pushups out trying not to look like a glue horse put out to pasture! On one hand, I was flattered that Mike actually thought I could do this, but the other side screamed, “Hey, bud, you know I will be 57 in a few weeks....that’s kind of old! How strong do you think I am?” Later I started thinking: how strong should I be? Pen State just released an article on the benefits of strength as you get older. Apparently less than 10% of Americans over 65 exercise 2 times a week! The people in the study who didn't live actively or “work out” had more difficulty standing for more than 2 hours, bending, kneeling, and walking stairs, to name just a few activities. Did we really need a study to prove to us that our mother was right when she said, among other things, “If you don’t move it, you lose it!” The sad part is that the ones who buy into this are not the ones who really need the convincing! It’s you, yes YOU…the one sitting in that chair! You who are starting to realize that you do less and less each year! You who looks back on your couch or chair and sees a permanent indentation from where you sit daily! Remember when you took the stairs two at a time? Remember when a walk in the woods was a no brainer? Carrying a basket of wet clothes was a cinch? When you took control during those tennis or softball matches? And when carrying your grandchild didn't leave you winded? No one expects you to have the same strength at 80 as at 30, but the decline you have noticed (and ignored) CAN be slowed down!! When you first learned to walk, when you first tied your shoes, or learned to write, it was a slow, arduous process that developed over months! How long do you think this will take? That’s probably right... months. But don’t give up…it will be worth it. There is a whole beautiful and exciting world out there to see!!! Start small. Your first step may be a walk around your living room three times per day. You may sit and stand 5 times every time you get up. You may walk to the mailbox two times daily. If you are already active, start to increase either by steps (love those Fitbits), or by time, 2 to 5 minutes daily. Make sure you complete two successful days with no lasting muscle or joint soreness before increasing anything. If you really struggle with pain or weakness limiting you, come and see us! I would be honored to help you get back to living. Whether it is climbing a mountain, or climbing the stairs, medical studies all show that balance, strength, and flexibility CAN be improved no matter what the age!!! So join me…get up and move. Your life is waiting!

When dealing with rehabbing an injury the old saying, “No Pain, No Gain” often does not apply! This idea refers to exercising hard enough to feel the burn or a considerable amount of muscle fatigue and soreness. Pain, on the other hand, is our body’s natural indicator stating that something is wrong. In the Physical Therapy world our goal is to activate muscles while performing pain-free exercises guiding you to return back to your prior function. Often patients who have that old exercise cliché mentality believe they can go harder, stronger, and faster, which may lead to abnormal pain, soreness, re-injury, or even additional injury. Instead of a “No Pain, No Gain” mentality we at Peak Performance Physical Therapy promote a “Sing, Not Scream” attitude. This means that we are activating your muscles by performing pain-free comfortable exercise without causing further tissue damage or injury. This attitude towards exercise will enable you to return back to work, sport, and function as quick as possible.