Knee Pain! Osteoarthritis!


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:

  1. Increased overall load through the weight bearing joint surfaces (e.g. obesity).
  2. Reduced load bearing surface area thereby increasing the pressure (same force through a smaller area) exerted through the joint (e.g. misaligned joint: bandy or bow-legged).
  3. Repetitive impulsive loading of the joint (e.g. trauma, doing moguls).

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!

  1. If you are overweight start a simple lifestyle change that entails weight loss (Call Joe Dibble, dietician at Sierra      Strength and Speed, for a consult.  He is really knowledgeable and practical.)
  2. Call Custom Physical Therapy so we can evaluate your      arthritic knees and set you up with appropriate treatment.
  3. Forward this post to someone you know who has sore      knees or you think may be interested in the information.

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.

Pain? What is it really?


The International Association for the Study of Pain defines pain as follows:

“Pain is an unpleasant sensory and emotional experience associated with actual or potential damage, or described in terms of such damage.”

So what does that mean anyway?

  1. Pain doesn’t feel good.
  2. Pain is influenced by our emotional status.
  3. There may or may not be any trauma to the body.

Put differently, per Dr. Lorimer Moseley, Ph.D., a world-renowned pain researcher and clinician at the Prince of Wales Medical Research Institute in Sydney, Australia:

“Pain is the conscious correlate of the implicit perception of threat to body tissue.”

Huh?!

This suggests that pain does not originate in the tissue due to injury or a degenerative process.  Instead, it is a very complex interaction between the peripheral tissues (e.g. torn muscle, knee arthritis, lumbar disc herniation, whiplash injury, broken bone) and the brain. The brain processes information as follows:

  1. From your experiences in life – how did your family deal with pain when you were growing up?
  2. Cultural factors – Italian men have been shown to be stimulated by a blue placebo pill and sedated by a red one while men of other cultures in the study experienced the opposite.
  3. Social and work environments – if you enjoy your job and like your boss then less pain may be experienced than if you don’t.
  4. Your expectations as to what might happen as a consequence of the pain – if you do not have an adequate understanding of a particular injury you have sustained you might be concerned as to how you will return to work or your hobby/sport and thus experience more pain.

So pain is an output from the brain after the brain has processed all the above information as well as the nerve impulses coming from the injured area, called sensory input.  Once it has synthesized the need for an output you will then “be told by your brain” if something is painful or not. Think about the person I spoke to a few years ago who had a motor cycle accident and felt minimal pain when she stopped skidding along the highway and noticed her leg 20 feet away from her!  Why no pain then? The brain had compiled an appropriate response at that time that suggested she had more important survival needs and thus did not feel pain. When she was loaded into the ambulance and the emergency personnel took over (they were in charge of survival now) she began to feel pain.

So what kind of output from the brain results once it has decided there needs to be a response to the “painful situation?”

  1. Pain is produced which makes us do something to address the “dangerous”  position we are in.
  2. The sympathetic nervous system causes the fight or flight reflex.  Increases in heart rate occur.  Energy systems are stimulated.  We sweat. We are ready to take evasive action!
  3. Muscles are reactive and are set to fight or run away as well as protect the damaged area. If you have torn a hamstring muscle you know you cannot move due to spasms – a physiological brace per se!
  4. The endocrine system is mobilized and in so doing hormones circulate in the blood stream to help mobilize energy for use by the muscles and reduce other nonessential body functions such as intestinal motility.

The most recent research into pain has changed the viewpoint from one of a noxious stimulus causing pain (i.e. a peripheral origin of pain) to one of the brain being the decision maker as to what is painful and what is not (i.e. a central origin of pain). How complicated is that! It is not as simple as treating the injured tissue to relieve the pain. Pain needs to be treated from multiple angles with a multi-disciplinary approach.

YOU CALL TO ACTION!

  1. Check out Dr. Lorimer Moseley’s blog at : http://bodyinmind.org/resources/journal-articles/full-text-articles/reconceptualising-pain-according-to-modern-pain-science/
  2. What do you think of this new concept of how pain is generated? Post your ideas on this blog for others to read.
  3. Invite a friend who is struggling with pain to read this.
  4. Call us at any of our three clinics if you have any questions:

Sparks location: 775-331-1199

South Reno location: 775-853-9966

Northwest location: 775-746-9222

It is Your Right to Choose Your Physical Therapy Clinic.


At Custom Physical Therapy, we come across many people who are not aware that it is their right to choose where they do their physical therapy. We also see patients who do not know that they can (and should) request their doctor to refer them to physical therapy if they think they need it.

Most people are referred to us by their physician, physician’s assistant, nurse practitioner, case manager or chiropractor. These providers partner with us in your recovery. We work together, as your “recovery team”, to provide the needed interventions for your speedy recovery.
 What about you? How should you be involved in the decision-making process?

1. You must be an informed consumer of healthcare.

Thus this blog! We want you to use this blog as an information source, a place to discuss (POST) your questions with other members of the Custom Physical Therapy community and our clinicians. Learn! Learn! Learn! Being informed takes effort on your part. We are here to answer any questions either by phone, in person or after you post them on the blog. Your choice. Obviously, we cannot give you concrete medical advice through the blog but we can give you access to information that may be in our head! We can direct you to appropriate resources if need be. This is an invitation to you whether you are a patient of ours, a prior patient or someone who has not visited our three clinics at all.

2. Actively participate in your healthcare.

To do this you need to be informed sufficiently to ask questions. Yes, you need to ask questions. Lots of them! Ask questions until you understand what interventions are being proposed by your doctor, nurse practitioner, physician’s assistant, case manager, physical therapist or chiropractor. This new understanding you have allows you to accept or reject what interventions we propose. You can also request other interventions – as long as you, the patient, are informed, i.e. you have done your homework! Educate yourself then actively participate in your care.

3. Make sure you know who you want to treat you.

Which clinic you attend and which provider (physical therapist) you want to be treated by is your choice. As long as they are on your insurance provider list (in-network) you will be covered by in-network benefits and typically pay less out-of-pocket than if you see someone who is out-of-network. You can, however, go out-of-network if your provider of choice hasn’t signed a contract with your health insurance company. You may then have a higher out-of-pocket expense.
At Custom Physical Therapy we try to match your out-of-network out-of-pocket cost to your in-network cost. So, never think you cannot see us if we are out-of-network. We will check your benefits and let you know what your out-of-pocket cost will be before you schedule your first appointment.

When should you request physical therapy if your doctor or other healthcare provider does not recommend it to you?

For any musculoskeletal issue there is a high likelihood physical therapy will benefit you.  Afterall, we specialize in the rehabilitation of musculoskeletal problems.  These include, but are not limited to, low back pain, neck pain, headaches, shoulder problems (weakness, pain, stiffness), arm and leg problems, ankle sprains, and numerous other conditions.  If you are unsure, call us at one of our clinics and we will be honest with you and tell you if we are an appropriate route to get you back to full function.

Regarding low back pain, research has documented the longterm benefits of physical therapy when started within 2 weeks of the onset of low back pain. Treatment with medications only (anti-inflammatories, muscle relaxers and/or pain killers) and no physical therapy resulted in an 85% reoccurrence within 1 year of resolution of the episode of low back pain, which took 3 months on average to resolve. Medical management combined with physical therapy (specific exercises and manual therapy interventions) only had a 35% reoccurrence!  That’s a huge difference!  Worthwhile I would say! It is totally appropriate for you to request physical therapy at the initial visit to your doctor for your low back pain.

Another condition where you should specifically request physical therapy immediately is for an ankle sprain, even if it is a slight one. Chronic ankle sprains may occur if early rehabilitation is not pursued.  There is a greater likelihood of arthritis in the ankle joint each time you traumatize the joint by spraining it. Research on ankle sprains shows that one sprain leads to another and then another if the brain’s ability to control the ankle in unstable situations (known as proprioception) is not retrained.  This involves being instructed in specific exercises to enable the brain to “adjust” to the faulty information, due to the ankle sprain, arising from the muscles, ligaments and tendons which control the ankle joint.

IN SUMMARY:

  1. Be proactive with your healthcare and learn as much as you can.
  2. Ask questions to gain understanding.
  3. You choose who you see for physical therapy.
  4. You can and should request physical therapy when you think it is needed.

 YOUR CALL TO ACTION!

  1.  Post a question concerning your health on this blog. If we do not know the answer, we will find it for you from another expert in the field.
  2. Check out the videos on the blog and rate them. Why do you think they are good?
  3. What topics would you like to see covered in this blog?
  4. Ask a friend to do action 1 through 3 above.  This will get our information out to many others with your help.

See you for the next post!  Plan on once a week visits to this blog for new information!