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Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE (October 2023) Reducing Knee Adduction Moment During Gait via PT Exercises: What does the newest evidence say? by Mike Napierala, PT, SCS, CSCS, FAFS Clinical Scenario...What would you do? A 59 yr old female with a 7 year h/o progressive L > R medial knee pain and swelling/stiffness, with no recent trauma episodes, comes in for evaluation and treatment recommendations. Plain films show IKDC Grade C (2-4mm jt space) degenerative changes in medial compartment and mild Grade B changes in lateral compartment. She has a 1+ jt effusion and AROM on L knee is 5-1250 vs R knee at 2-1400 with L PROM ext only to 20. Meniscus provocation maneuvers are (-). Single squat is L 350 limited by pain with palpable crepitus and R is 55° without pain. Her L knee shows mild varus asymmetry vs the R. The patient’s goals are avoiding TKA for as long as possible, resuming doubles pickle ball and bowling (R handed), playing with her 5 and 3 yr old grandchildren, and travelling with her husband including light hiking. My clinical thinking is: Begin NSAID’s, instruct regarding activity modification and FU in 4 wks. Prescribe PT - providing sheet of local providers for ease of proximity. Perform cortisone injection and FU in 4 wks. Prescribe customized PT including biomechanical assessment and exercises, manual therapy, and laser trial. Recommend viscosupplementation injection/series - initiate insurance authorization request if pt agrees. CURRENT EVIDENCE: Cottmeyer DF, Hoang BH et al. Can exercise interventions reduce external knee adduction moment during gait? A systematic review and meta-analysis. Clinical Biomechanics. (109) 2023. 1-8. https://www.clinbiomech.com/article/S0268-0033(23)00195-X/pdf (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) SUMMARY: Physicians frequently see patients with medial joint OA and associated varus deformity for evaluation and treatment recommendations. Aside from general OA clinical decision making surrounding early handling of which treatment approach makes sense research relevant to this population has considered whether knee adduction forces can be altered with physical therapy. To the extent varus forces are considered a precursor to medial degeneration and not simply a result, these studies become pertinent in this clinical decision making. Cottymeyer et al in the above systematic review and meta-analysis attempt to discern the body of literature on this topic. A first read of their findings easily leads physicians and therapists alike to the conclusion that knee adduction moment (KAM) during gait is not significantly altered by physical therapy exercise; however, in females there may be some effective KAM reduction possible. Only one of the nine final accepted studies showed a significant KAM reduction vs control groups and that one utilized ankle proprioceptive training compared to TENS/hot packs. These conclusions could easily mislead physicians and therapists to ignore more in-depth evaluation and biomechanical treatment approaches in favor of simple, generic “exercise” that fails to address those KAM forces contributing to ongoing pain and deterioration. Like many studies, systematic reviews, and meta-analyses, caution must be used in reading and accepting conclusions as a basis for directing clinical decision making. The authors here, I believe, have overgeneralized the term “exercise” and the included studies did not specifically utilize targeted/customized approaches aimed specifically at evaluation based findings for those patients. Exercises were generic in nature. They mainly focused on strengthening rather than efforts at restoring joint mobility through manual therapy and ROM/stretching of biomechanically relevant pathways that would promote knee abduction capacity (i.e., reversal of existing KAM forces). The hypothesis that generic strengthening, whether at the knee, locally or including hip/ankle muscles as well as a means to alter KAM fails to address the more obvious biomechanical influences directly impacting KAM. The knee cannot experience increased lateral joint loading (i.e. medial unloading) without the hip’s frontal plane adduction and transverse plane IR capacity being available. The same is true for subtalar joint eversion/foot pronation. These ranges of motion are necessary biomechanically for knee abduction directed forces to occur. Physical therapy for medial knee OA cases with and without visible KAM deformity, based on our experience in the clinic with these patients, is often far more successful when biomechanically authentic exercise focused on medial unloading is used. This must include restoration/improvement of hip and ankle frontal/transverse plane capacity that allows for potential knee abduction directed loading. Many failed cases we see that have not improved with more generic therapy approaches utilized in the studies examined above do, in fact, see significant progress when more customized biomechanical approaches are used. Therefore, in this case, I would urge caution in too quickly accepting the conclusions of Cottymeyer et al’s study, which failed to more carefully define that generic strengthening exercises are inadequate at improving KAM with gait, a subtle but critical distinction that can have important impacts on clinical treatment decisions for patients. Background: Knee adduction moment (KAM) is considered a contributing factor in medial knee OA progression and a potential focus of treatment interventions, especially physical therapy exercise intentions. Purpose: This systematic review and meta-analysis is aimed at determining if exercise interventions are effective at reducing KAM during gait. Methods: Nine RCT studies published up until May 2023 met inclusion criteria and yielded 24 effect sizes for exercise vs control groups utilizing numerous subgroups (sex, BMI, exercise type, muscle group targeting, training volume, PT supervision). Findings: The effect size of exercise interventions on KAM during gait was similar to controls (ES=0.004, P=0.946). Subgroup analysis showed studies with females only did show a positive effect size versus those with combined sexes. Author's Conclusion: Exercise may not be effective in altering KAM during gait. Clinicians should consider alternative treatment options for decreasing KAM in patients with medial knee OA and need to explore further the mechanisms for females having a more positive response. THE PEAK PERFORMANCE PERSPECTIVE Physicians frequently see patients with knee OA issues that require careful evaluation and assessment of the best course of treatment. Medial joint degenerative changes are most common and these are often associated with knee adduction deformity. Sharma et al found that knee varus was not only associated with development of incident knee OA compared to valgus deformity but that the risk of progressing medial joint degeneration was greater in the presence of knee varus or adduction. The question arises as to whether non-operative measures prior to TKA or HTO can have any significant influence on knee adduction forces. This study by Cottmeyer et al reviewed existing data on exercise interventions via physical therapy based care and its impact on measured knee adduction moment (KAM) during gait. While their efforts are admirable and valuable to the body of knowledge this study represents another example of how great care must be taken before making sweeping or generalized conclusions about a given modality such as “exercise” because it significantly influences the decision making of both referring physicians along with physical therapists themselves, possibly to the detriment of the patient. Studies up until May 2023 measuring KAM during level walking after exercise interventions were found, involving patients with diagnosed knee OA, and included control groups receiving passive care or no treatment. Out of an initial 1272 studies eventually 9 RCT studies met criteria for meta-analysis. Hedges g Effect Size was calculated. Moderator variables examined included sex, muscle groups targeted, type of exercise (strength vs neuromuscular) , PT presence (supervision) level, BMI, and training volume of intervention group. Hip and ankle targeted exercise approaches were too few to be included in ES assessment. Of the 15 “intervention groups” subsets of data developed there were 10 performing exercise supervised by a PT and 5 without a PT. Adherence/attendance varied from not reported up to 100%. Cottmeyer et al’s meta-analysis found only one of the nine studies showing significant reduction of KAM - found with 1st and 2nd peaks during gait for the ankle proprioception training group vs the TENS/hot packs control group. The subgroup analysis showed sex, specifically only females, had significant ES vs studies with males + females. No other moderator variables were found significant. The authors concluded that while exercise in general does not appear effective at reducing KAM during gait that it may reduce KAM for females specifically. While on the surface this study seems in line with prior published literature indicating KAM cannot be altered by exercise interventions (ie PT) these conclusions break the rules surrounding external validity in a significant way that can negatively impact physicians’ perspectives on the potential value of PT in OA cases and also may serve to hasten the tendency toward higher level medical interventions that also themselves have limited efficacy based on current research evidence and also carry with them greater costs and sometimes risk profiles. Careful reading leads us to pumping the brakes on their conclusions in the several important ways. The studied groups were not standardized regarding the amount of knee varus malalignment they began with for entry into the study. Varying levels of knee angulation certainly can impact the lever arm potentiation of greater varus/adduction moment that would increasingly be expected to have lesser potential for modification during or through exercise and resultantly with gait. Another very key factor is that exercise types were highly variable and generic in nature. They did not specifically target contributory or causative areas toward the knee adduction moment - specifically attempting to address optimizing hip adduction, hip internal rotation, and subtalar joint eversion capacities in order to reduce knee varus/adduction tendency. Without these adjacent limb/joint capacities a knee joint cannot be expected to shift loading toward the lateral compartment since the limb is biomechanically tending toward varus alignment without them. The only mediating factor then becomes proximal trunk lean in the frontal plane. The studies did not expressly involve added manual therapy to promote quicker or more effective restoration of those typically reduced ROM areas noted above, nor specific stretching/PROM exercises to that same effect. Knee varus deformity patients consistently, in the clinic based on our experience, demonstrate significant ROM loss in one and often all of those areas. Approaches that lack specific targeting, much like generic PT programs, may help some limited percent of patient cases but will likely miss another substantial subset who did have good rehab potential but were not addressed with customized and biomechanically based approaches. I would caution orthopedists and primary care physicians who may have read systematic reviews like this one or other RCT’s suggesting similar conclusions to be wary of falling into the trap of fully trusting the authors’ conclusions. Deeper questioning often reveals carelessness in overgeneralizing results that can negatively impact how you care for your patients and the outcomes achieved. I’d submit that a better conclusion would have been that “in knee OA cases where variable amounts of KAM in gait are treated with only generic knee exercises do not show clear evidence of significant KAM reduction in gait except potentially for females only - further study is needed for biomechanically based custom targeted approaches that include more clinical care consistent based hybrid/encompassing approaches such as manual therapy/PROM-stretching/strengthening/neuromuscular/functional exercise based care. We frequently find that even acutely during exercise portions, specifically for squat based WB quad strengthening drills, where OA based knee pain is most frequently problematic, that utilizing biomechanically sound movement principles can immediately alter symptoms and afford patients less or no symptoms during mini lunges, split squats, step ups, step downs, leg press, wall/hangback squat etc. type drills. For example, a medial knee OA case will typically have fewer symptoms when lateral loading can be increased and medial loading decreased. This is accomplished in numerous ways by trial and error but often involve trunk lean ipsilaterally, ER of the foot/leg, mild medial drifting of the knee, BUE support across midline, pelvic shifting contra laterally, lateral wedging heel among others. These frontal and transverse plane adjustments, while non-traditional, implement sound biomechanical principles toward the goal of unloading the painful and sensitive medial joint. We often find that in “failed cases” of non-operative OA knee care, these approaches are highly beneficial to the patient in optimizing function and reducing symptoms. The case below illustrates a recent example of this approach. The case below illustrates an example of the opposite issue; predominant lateral joint pain issues with radiographic OA findings plus MRI confirmed degenerative meniscus issues. The same biomechanical principles underlying KAM and preferred lateral joint loading efforts are mutually reversed in this patient’s case. They were found very effective at optimizing comfort during WB squat based strengthening drills and ultimately promoted a dramatic increase in her squat function and resulting ADL capacity. This case demonstrates the value of both a patient focused customized biomechanically authentic treatment, and especially exercise based, program along with ongoing supervised care versus premature transition to a simple HEP alone. THE PEAK PERFORMANCE EXPERIENCE Basilike said: “My pain has really decreased and now I can do stairs more easily and I walked 5 miles in NYC on a recent trip without any pain!!” HX: 78 yr old female with 2+ yrs of progressive (B) knee pain, slightly worse on L, had two prior bouts with physical therapy but only very limited benefit. Several cortisone injections provided up to 2 mo relief and recent gel injections provided only 10% reported net improvement. Subjective: L knee 8/10 and R 7/10 max sx with reported fxn of 25% L and 35% R. CC is desc>asc stairs, walking 1 lap @ Cobbs Hill Reservoir, getting up after sitting 5min. WOMAC 44%. Objective: (*=pain) Eval 6 mo ReEval Flexion AROM 1290 / 1250 1370/1350 Extension AROM 10 / 40 00/10 Isometric Quads 14.2*/16.9* kg 22.2/23.7 kg Ober TFL Mod R> L Very min Hip rot PROM IR>> ER NT Calcaneal Eversion WNL NT Squat 300/400 * (B) 700/600 * (R) SLB Static - R STJ control ↓ Rot’s: F+ control (B) Anterior Stepdowns NT 4” w 5# wts 20x/17x *(R) only Key Findings: R>L lateral joint line tenderness more so than medial jt line along with R knee ITB at LFC as well. Both knees lacked good flexion ROM but extension was mostly limited only on the R knee. Hip PROM rot’s showed IR > ER consistent with retroversion influence but ER was 120/200. TFL tightness was worse on R. Her squat fxn was painful/limited L > R but biomechanical testing for sx reduction showed L improved with frontal + transverse plane knee adduction stimulus via UE reaching/trunk positioning and R w transverse plane knee add stimulus (via opp cross reach) - both consistent with lateral joint unloading techniques. WB DF was slightly limited on R. Treatment: BIW early frequency included manual therapy joint mobilization for R TCJ DF, R knee extension, and prone hip ER. Stretching/ROM work included knee flexion (B), R knee ext, hip ER, functional TFL and R soleus/gastrocnemius. SLB rotational control work promoting pronation deceleration for general foot-ankle control was initiated, consistent also with desire to minimize knee abd forces due to predominant lateral knee sx. A key component in early strengthening was PWB - - - > FWB- - -> eventually externally loaded squat-based PRE. These were consistently found to be pain-free or pain-minimized by producing knee adduction or varus forces utilizing pelvic shift-trunk tipping and rotational pre-positioning of either the foot or opposite UE in order to promote medial joint WB. NWB quad PRE were also incorporated. Outcome: Pt was able to advance from BIW to q1-2wk FU visits and ratings of 80% L and 70% R knee function, including 5 mi walk in NYC w/o issues, improved stairs function, and reduced pain max to L 3/10 and R 3.5/10 at reduced frequencies. WOMAC reduced to 21%. Pt is being DC in the next few wks to her (I) HEP. 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

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

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE November 2022 Knee OA Injection Therapy: New Evidence on Best Options for Improving Pain & Function by Allison Pulvino, PT, MSPT, CMP, FAFS Clinical Scenario…What would you do? A 57 year old female with a 5 yr h/o L knee pain medially has noted progressive worsening over the past 6 months, especially with long walking and hikes with her friends. Plain films show moderate joint space narrowing medially and only slight changes in the lateral and patellofemoral compartments. She has mild genu varum asymmetric on the L knee noted with WB exam. She wishes to continue TIW fitness exercise (cardio, weights, classes) and has been controlling symptoms with OTC NSAID’s for the past several years. She was seen in PT 2.5 yrs ago for three visits in PT and taught a HEP, which she remained compliant with. She demonstrated common knee exercises as her main HEP activities (SLR’s, Hip Abd clamshells, bridging, static balance on foam pad, 8” step ups, band walks for abd’s - band at ankles, full range quad bench PRE). I would prescribe… Customized physical therapy with 6 wk FU to discuss corticosteroid injection option depending on symptom and function status. Corticosteroid injection with 2 wk FU to discuss physical therapy option. Customized physical therapy w 6 wk FU to discuss HA injection option. Customized physical therapy w 6 wk FU to discuss PRP injection option. Begin HA injection series and begin customized physical therapy one week following 1st injection. CURRENT EVIDENCE Singh et al. Relative Efficacy of Intra-articular Injections in the Treatment of Knee Osteoarthritis. The American Journal of Sports Medicine. 2022; 50 (11): 3140-3148. Summary: Knee OA is a commonly seen condition for physicians, surgeons and physical therapists. Among the treatment considerations physicians often consider is injection therapy. Singh et al did a systematic review examining pain and function status 6 months after steroid(CS), HA, PRP, plasma rich in growth factor (PRGF), or placebo injection therapy. PRP demonstrated the best outcomes compared to others for pain and function findings. All injections except CS showed statistically significant improvements vs placebo. Steroid and HA injections anecdotally appear to be the most frequently used injections here locally in Rochester for these cases. This evidence for PRP efficacy may provide compelling support for physicians/surgeons making recommendations to patients for optimal injection therapy options. PRP presents a unique challenge since it is not yet approved by third party payers. This is likely a key factor for physicians and patients when choosing CS or HA injections first. One risk physicians and patients must be aware of is the tendency for early symptom relief following injections to dissuade appropriate consideration of physical therapy. Addressing ROM and strength/balance needs will not only optimize function but lessen the likelihood of symptom reactivity to ADL and recreational activities. Another factor in knee OA treatment prescribing may be physician or patient based past experiences with “failed PT.” We often find this is due to a lack of biomechanical considerations applied to especially key WB strengthening. Careful consideration should allow physical therapists to most often intentionally unload symptomatic knee compartments. While not part of traditional approaches, this biomechanical technique can be an effective means of promoting pain-minimized or pain-free strength gains, leading to more successful squat ADL and stairs or recreational participation. Expectations are that IA injection combined with excellent physical therapy should produce optimal outcomes not only acutely but for many months or even years to come in most cases. (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) Background: Intra-articular (IA) knee injections for knee OA has been a topic of increasing interest, as well as which type of injections most benefit patients long term in regards to pain and function. Methods: A systematic review and meta-analysis utilizing 23 RCT’s meeting the inclusion/exclusion criteria was performed to obtain information regarding pain and function at a 6-month follow-up after either Corticosteroid (CS), Hyaluronic acid (HA), platelet-rich plasma (PRP), or a plasma rich in growth factor (PRGF) injection, or a placebo. Findings: All IA treatments except CS were found to have statistically significant outcome improvements when compared to a placebo. PRP demonstrated the greatest results in function-related gains. In regards to pain, function and both combined, PRP was found to possess the highest probability of efficacy and CS as the last followed by the placebo. Author’s Conclusion: When comparing various IA injections, PRP had the most significant outcomes, followed by PRGF, HA, CS and then placebo for treatment of knee OA at a 6-month follow-up. Other non-operative treatments were not included in this study, including NSAIDS and physical therapy. THE PEAK PERFORMANCE PERSPECTIVE As a physician/surgeon, knee OA is likely a common diagnosis seen in the clinic. Conservative measures are key options for early treatment, including NSAIDs and physical therapy. Another frequent consideration is injection therapy. Quality research forms a critical foundation helping physicians and surgeons determine treatment recommendations. While as providers we all appreciate the value and necessity of optimizing function, for patients their top-of-mind concern is typically symptom control. Many but not all patients with knee OA will respond positively to OTC or prescription medications, at least temporarily. A majority will see significant improvements in pain, ROM, strength, and function with quality physical therapy. Additionally, intra-articular (IA) injection therapy is a potentially helpful treatment option, for some used as a primary stand-alone treatment and for others as an important part of a multi-faceted approach to thorough OA care. The question remains: Which type of injection is most effective and indicated for this patient? The evidence on comparing outcomes for various injections has been limited. Practice standards and habits had traditionally utilized IA corticosteroid (CS) as the first-line injection type. Over the past decades “gel” injections using hyaluronic acid (HA) and biologics (PRP, stem cells…) have become more available and had variable increasing evidence, however, most are short term studies. Singh et al. discovered in their Systematic Review and Meta-analysis that PRP really produces the best results, with PRGF and HA outperforming CS injection therapy, when they looked at longer 6-month follow-ups for pain and function outcomes. One risk for patients and physicians alike regarding injection therapy is that when highly effective early on, the motivation to actively participate in physical therapy to restore ROM and strength may be diminished. Patients often take a “It’s feeling good now so I’m gonna see how things go like this” sort of mentality, being unintentionally lured into complacency by their immediate post-injection symptom relief (typically after CS injection). We remind patients it is important to “get beyond feeling better to being better” - i.e., restoring mobility, strength, balance etc. in order to optimize function. Regarding the Singh et al. findings, locally we do not see PRP used often for knee OA cases. Certainly a lack of comparative outcomes data to support treatment recommendations of PRP over other options may be a primary reason for this. PRP is also presently a cash-based treatment, making a trial with CS injection initially the potentially more logical option since it is typically covered by insurance. The findings of this Singh et al study will probably provide some convincing data to support future trials with PRP, despite the higher expense to the patient, as doctors and surgeons evaluate the best treatment suggestions for knee OA aside from oral drugs and physical therapy. Also, there remains some limit on the frequency/volume of CS that can be injected before potential negative effects are noted within the joint - making PRP additionally appealing as an option. While we clinically have seen variable outcomes from IA injections (both HA and CS) ranging from no relief to full relief, these results are often temporary in nature, sometimes lasting for weeks to months but then requiring further injections. Research has shown physical therapy to be effective at reducing symptoms and increasing function for knee OA. While it is often prescribed it remains underutilized, possibly in part due to a perception that therapy itself cannot alter the degenerative chondral changes themselves. When NSAID’s or injection therapies, especially CS, are successful that also, as mentioned above, tends to dissuade some patients from the work therapy entails. For patients with knee OA, the loss of motion and strength both negatively affect not only day to day function but clearly contribute to worsening symptoms. This also contributes to increasing compensation patterns and too often symptoms developing in adjacent body parts such as the hip or lower back. For example, we see patients unable to squat their knee effectively tending to bend over from their spine which is more than ideal. Flexion sensitive LBP sometimes then develops. Knee OA physical therapy too often is mistakenly perceived to have “failed” in the eyes of the patient and the physician as well. This scenario begs the question - is physical therapy itself an ineffective tool for this patient/case or was the specific therapy provided ineffective/inappropriate/limited in nature? Just as a poorly done procedure or non-compliance with recommended medication dosages/frequency may yield less than favorable outcomes, physical therapy must be biomechanically appropriate, problem solving based and most often include manual therapy to optimize outcomes. While “cookie-cutter, simple” home programs may appear a great starting point for most patients, it presents the challenge that for too many patients (who have already waited too long to engage with health care professionals) that unimpressive results with early physical therapy risks being perceived as ineffective. These failures may be avoidable but require physical therapists to utilize deeper understandings of biomechanics rather than reliance on “keeping it simple” to such an extent that customized needs of each OA case are missed. From a physician’s standpoint it may help to prescribe something like “biomechanical adjustments prn with squat PRE.” The knee’s dominance as a primary sagittal plane functioning joint brings a double edged sword of sorts. Focused manual therapy and exercise efforts to gain full functional extension and/or flexion of an arthritic knee can greatly impact functional WB activities like ambulation and stairs; however, strengthening exercises dominating that same sagittal plane are most often the source of most patients’ chief complaints. Many knee OA situations involve one compartment being significantly worse than the other. Asymmetric loading of the arthritic chondral surfaces then occurs with traditional “closed chain” exercise attempts to strengthen. This is especially where deeper biomechanical understandings can significantly benefit patients attempting to regain quad strength for sit-stand function and stairs. Preferential loading and unloading of the medial or lateral compartment can be accomplished with a variety of different “tweaks” utilizing the frontal and/or transverse plane biomechanics of the knee and lower extremity. This involves in some way reversing the biomechanical patterns of how that degenerative compartment gets overloaded in the frontal and/or transverse plane to begin with. An overpronated foot elicits tibial IR or an anteverted hip likewise femoral IR, either being contributors to dynamic knee valgus and increased lateral compartment stresses (likewise reducing medial compartment compressive loading). Conversely a supinated foot, retroversion, a tight ITB, or even lacking pronation or femoral IR can all lead to a dynamic varus knee alignment which increases medial and decreases lateral compartment stresses. Thoughtful PT exercise plans work toward optimizing symptom-minimized knee status to promote more optimal exercise intensity and eventual strength gains. Utilizing various body “drivers” or movement stimuli meant to promote a given movement pattern or body positioning in order to reverse those damaging stresses. Thus, a hand reach or body tip/lean or altered foot position affecting the frontal and/or transverse plane can work to increase loading on the healthier or asymptomatic side during otherwise typically painful squat based WB strengthening exercises. This Applied Functional Science (AFS ®) based approach is a critical means of helping the majority of “previously ‘failed PT’ “cases and otherwise deemed “low rehab potential” cases to do well. Singh et al admit that physical therapy wasn’t addressed in this study. Injection therapy can be an important component to OA treatment especially because many patients struggle with pain limiting exercises. We would suggest that a comprehensive approach includes targeted, customized physical therapy using biomechanical approaches. The case below illustrates an example of effective conservative knee OA care with successful outcomes. THE PEAK PERFORMANCE EXPERIENCE Alice said: “I had the last shot 7 days ago and I feel improvement!” History: Alice has had moderate pain in her L knee for over 2 years, off and on. Has previously had a series of 3 cortisone injections without relief > a few months. Recent HA injections have provided improved ability to tolerate WB as well as PT ex’s to gain more extension ROM and functional strength. Objective: Initial Exam Re-evaluation Knee extension -10deg (flexion contracture) -2deg Knee flexion 120deg 130deg FABER test Pos Pos Ober’s test Pos Neg Thomas test Pos Neg Anterior step down L unable/fear of buckling 2” step down w 8# DB Pivoting for directional change L fear of instability No fear/no issue Sit-stand UE assist/stiffness 10x w/o UE assist Key Findings: L knee flexion contracture, lack of full knee flexion with pain as compared to opp knee, limited with all WB transfers, inability to descend any height step, valgus deformity, very limited hamstring length, lack of ankle DF and lack of hip extension Treatment: Manual joint mobs for ankle DF, knee extension with distraction and distal femoral ER to realign, hip extension mobs in WB, patellar mobs, hip ER mobs in WB. Stretching knee extension in prone, ankle DF WB stretching, hamstring and hip flexor stretching in WB, NWB hip ER stretching. Strengthening consisted of SLRs, quad control in L WB knee extended opp LE toe reaches, knee flexed DF loading toe reaches, progressing to 2 inch step downs with ipsilat pelvic rot for femoral ER control, SLB with ipsilateral rotation R crossover touches for valgus correction, assisted squats with L toeing in for alignment correction. Outcome: Pt was able to gain almost full knee extension, was able to ascend/descend steps without pain with UE assist, sit to stand transfers pain free without increased time needed, and ambulating short distances without AD. 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