To my fellow Boomers out there ….. How are your knees doing? We are an active sector of the population and we want to remain that way for the health benefits (and the fun!) thereof. Knee pain due to osteoarthritis, whether one or both knees, has a dramatic impact on a person’s ability to continue with their chosen active lifestyle and, if it gets painful enough, may impact activities of daily living such as getting into and out of a car or a chair, cooking a meal or simply walking.
WHY KNEE OSTEOARTHRITIS?
Osteoarthritis affects 25 million North Americans and is symptomatic in 13% of people aged 55 years and older. It has been shown to be the most frequent cause of functional disability including being dependent on alternative forms of mobility due to the tremendous pain with walking. Ouch! The prevalence of osteoarthritis is rapidly increasing due to two main factors. Firstly, the aging of the American population (that includes us!) is increasing the share numbers of people older than 55 years. Secondly, the rapidly increasing obesity in our population is increasing the rate of joint degeneration. One study reported 83% of males who had knee osteoarthritis were obese compared to 42% of males without it. Wow! Now there is a statistic that says a lot and leaves nothing to the imagination as to what we need to do to address the issue.
WHAT IS IT?
Osteoarthritis is the joints response to structural damage caused by mechanical problems. It is the body’s attempt to repair a joint under unusual stress and often leads to a stable, pain free joint. If this process fails (is insufficient for the magnitude of mechanical stress placed on the joint) the knee becomes symptomatic and hence functionally debilitating.
MECHANICAL STRESS YOU SAY?
Pathological mechanical stress of the knee joint may be due to:
Obesity increases the overall load through the joint and overwhelms the joint tissues resulting in osteoarthritis. Being bandy or bow-legged reduces the weight bearing surface area in the knee joints (shifts it from throughout the knee to one side or the other of the joint) and results in excessive wear and tear of the joint on the outer or inner surfaces respectively. Sustaining a serious injury to the knee in which ligaments are torn and the joint surfaces are banged together in the injury may initiate the osteoarthritic “repair” process as well. Thus, when stress on the joint tissues exceeds their physiological tolerance breakdown ensues and osteoarthritis begins.
HOW CAN WE ADDRESS THE CAUSATIVE FACTORS?
Weight loss in an effort to attain a normal body weight for your frame is paramount in reducing the forces through the knees. Walking results in a force through the knee equal to 3 – 4 times your body weight each step. If you lose 20 – 50 pounds in an effort to attain your normal weight, you reduce the forces through your knees by 80 – 200 pounds each step you take! Talk about happier knees! An 11.2 pound weight loss over a 10 year period has been shown to reduce the likelihood of developing knee osteoarthritis by 50%.
For misaligned knee joints (those of you who are bandy or bow-legged) there are unloading braces to modify (increase) the load bearing surface and hence reduce stress to the one side of the affected knee.
In all osteoarthritic knee joints muscle weakness, joint stiffness and poor balance are factors. Muscles around the knee joint serve to cause movement in bending and straightening the knee, can reduce mechanical stresses to the joint by absorbing loads applied to the limb (e.g. cushioning during landing a jump or when skiing) and stabilize the knee joint during daily tasks of walking, running, lifting and carrying to name a few. Patients with knee osteoarthritis are 20% to 40% weaker in their quadriceps than people without the condition. As the disease worsens the knee muscle activation patterns become less efficient and less specific and joint proprioception (the brain’s ability to know what is happening at the joint and react accordingly) is suppressed. A well constructed, evidence-based physical therapy program will improve strength, range of motion and proprioception and result in improvements in physical function, pain and quality of life. Modifying the mechanical problems causing the osteoarthritis together with addressing the inflammatory and pain aspects of the disease process through pharmacological intervention from your physician can result in an 86% success rate in improving your function. Who would not like that!?
All our physical therapists at Custom Physical Therapy have undergone specialized training for treating osteoarthritis. The therapists work as part of a team comprised of you the patient, your physician and the physical therapist. Using physical therapy interventions to modify the mechanical factors impacting the progression of osteoarthritis together with the physician addressing the pharmacological aspects and the patient being compliant with an exercise and stretching program (see our very first post on this blog) as well as brace use, if prescribed, the team of patient-physical therapist-doctor minimizes the effect of the disease process on your function.
YOUR CALL TO ACTION!
You are encouraged to call Custom Physical Therapy to talk to one of our accredited physical therapists about your knee pain. You may be a candidate for this customized evidence-based program specifically developed to improve your function which deteriorated due to knee osteoarthritis.
The goal of a pre-offer or post-offer pre-employment screen (PWS) is to mitigate risk in an effort to minimize workers compensation claims. In high risk jobs, those which cost your business the most in workers compensation claims due to higher injury rates, there are essential and critical job functions which can be tested prior to placing an employee in a position which may result in an injury.
Matching the right worker to the job is not a new concept, but has grown with the advent of companies concerned with providing an “Industrial Athlete” approach to the workplace – essentially ensuring that their employees are “game ready” and able to meet all challenges ahead of them. So, how should you proceed?
The first thing to do is decide if the pre-offer or post-offer screen should be used. The pre-offer pre-employment screen identifies the applicants who are physically able to safely complete the essential job functions of the position for which they are applying. It also will give you a baseline assessment of their physical abilities. If they do sustain an injury at work, this is the baseline physical ability to which they will be rehabilitated too. A post-offer pre-employment screen performs the same function but you can include a medical examination too. The advantage of a post-offer over the pre-offer screen is that you can ascertain if the applicant you have offered the job to contingent on passing the PWS has any disability (e.g. are they under physical limitations by a physician due to a prior injury). The functional test has a significant advantage over just doing a medical screen, as an employee may not choose to report a pre-existing condition. The functional test will uncover and thus document this unreported inability to perform tasks if their pre-existing condition is deemed a hindrance to performing the job demands.
Now your company must identify the high risk jobs within your business. High risk jobs are those which are simply physically difficult to perform. They are not easily modifiable to the employee nor are they easily changed to improve safety. Hence, the employee must be fitted to the demands of the job. These jobs historically may include heavy lifting, highly repetitive functions or aerobic activities. Is there a manufacturing or laborer position which results in a larger proportion of your workers compensation costs? Do you have musculoskeletal injuries occurring in a particular type of worker in a production line? Is there a high turnover rate for a particular position at your business? Are there employees who are physically taxed during the work day (sweating, out of breath, unusually fatigued) and hence avoid doing the more challenging aspects of their job by giving it to the newer, younger employees? If you have a “Yes” to the above questions, your business should be performing pre/post-offer pre-employment screens on these specific high risk employees as part of the selection process.
The next step is to develop a well-constructed, objective, accurately measured job demands analysis (JDA) for each high risk job you identified. This entails evaluating the job to ascertain the essential and nonessential tasks and objectively quantifying them. This process involves close teamwork between the employer, the physical therapist performing the JDA and worker representatives. Teamwork such as this produces a JDA that accurately reflects the high risk job functions and will comply with the American with Disabilities Act and the U.S. Equal Employment Opportunity Commission laws. Not only is the JDA used for PWS design, it is also used in rehabilitating any injured workers. The JDA should be used by the physical therapist treating your injured worker to design the rehabilitation program based on essential job functions listed in the JDA. In addition, the physical therapist will be able to clearly ascertain if the employee is ready for a safe and most importantly a sustained return to work. This same JDA becomes the foundation for any Fit for Duty testing, Job Transfer or post injury evaluation job placement.
Utilizing the JDA, the PWS is then developed by the physical therapist. It tests the essential job functions prior to placing the employee in the high risk position. The final PWS will involve combinations of lifting, pushing, pulling, carrying, ladder climbing, overhead arm use, cranking, kneeling, crawling and any other essential job functions specific to the job in which the employee will be placed on passing the test. All tasks will have a critical cadence which must also be assessed to place these tasks in a physical demands category: sedentary, light, medium, heavy or very heavy. Job specific weights will thus be lifted to job specific heights at job specific critical cadences. Job specific weights will be pulled or pushed for job specific distances. It is important that all tasks tested in the PWS are absolutely specific to the job. All tests in the protocol have to have a solid foundation of evidence supported by peer-reviewed and published papers to validate a proper extrapolation to a full eight hour workday.
Is this a cost-effective program for your business?
Consider the following savings reported by companies who utilize this approach:
Considering the average cost of industrial injuries ($13 to $15 billion annually for musculoskeletal disorders), setting up a program to limit injury rates and hence workers compensation premiums is a good idea for any company which has high risk jobs.
By matching physically suitable employees to the appropriate high risk jobs you are mitigating risk, reducing lost time and thereby improving productivity and yielding a better bottom line through a healthier workforce.
André Meintjes, M.P.T., C.F.E.,Ph.D. is a physical therapist and owner of Custom Physical Therapy in Sparks and Reno, Nevada. Contact him at 775-331-1199 or firstname.lastname@example.org.