Friday, January 29, 2010

Most patients gain weight after getting a new knee,

You'd think folks who've had knee replacement surgery -- finally able to walk and exercise without pain -- would lose weight instead of put on pounds, but surprisingly that's not the case, according to a University of Delaware study.

Researchers Joseph Zeni and Lynn Snyder-Mackler in the Department of Physical Therapy in UD's College of Health Sciences found that patients typically drop weight in the first few weeks after total knee arthroplasty (TKA), but then the number on the scale starts creeping upward, with an average weight gain of 14 pounds in two years.

The study, which was sponsored by the National Institutes of Health, is reported in the Jan. 15 online edition of Osteoarthritis and Cartilage, the official journal of the Osteoarthritis Research Society International.

The research involved 106 individuals with end-stage osteoarthritis who had knee replacement surgery, and an age-matched, healthy control group of 31 subjects who did not have surgery. Height, weight, quadriceps strength, and self-perceived functional ability were measured during an initial visit to UD's Physical Therapy Clinic, and at a follow-up visit two years later.

“We saw a significant increase in body mass index (BMI) over two years for the surgical group, but not the control group,” says Zeni, a research assistant professor at UD. “Sixty-six percent of the people in the surgical group gained weight over the two years -- the average weight gain was 14 pounds.”

Those who had the knee replacement surgery started out heavier and ended heavier than the control group. The weaker the surgery patients were, as measured by the strength of the quadriceps, the more weight they gained, Zeni notes.

“These findings are making us re-think the component after total knee surgery and of patients not being in a routine of moving around,” says Snyder-Mackler, Alumni Distinguished Professor of Physical Therapy at UD.

She notes that it's critical that people not wait too long to have a knee replaced because their functional level going into surgery typically dictates their functional level after surgery.

Gaining weight after one knee replacement is worrisome because it could jeopardize the patient's other knee. Between 35-50 percent will have surgery on the other side within 10 years, Snyder-Mackler says.

The researchers note that weight gain after a knee replacement needs to be treated as a separate concern and integrated into post-operative care through a combination of approaches, including nutritional counseling to help patients with portion control, and more emphasis on retraining patients with new knees to walk normally.

“For physical therapists and surgeons, the common thinking is that after a patient's knee has been replaced, that patient will be more active,” says Snyder-Mackler. “But the practices and habits these patients developed to get around in the years prior to surgery are hard to break, and often they don't take advantage of the functional gain once they get a new knee,” she notes.

“We need to re-train patients with new knees to walk more normally and more systematically. And we need to encourage more community participation,” Snyder-Mackler adds. “If you're not getting out of the house, you won't gain the benefit. We need people with new knees to get out there -- with the help of their family, their friends, and the community at large.”

Tuesday, January 12, 2010

NFL players with Achilles tendon injuries

More than a third of National Football League (NFL) players who sustained an Achilles tendon injury were never able to return to professional play according to research in the current issue of Foot & Ankle Specialist (published by SAGE). The injured players who did return to active play averaged a 50% reduction in their power ratings.

The aim of the study was to document the epidemiology of Achilles tendon ruptures in the NFL and to quantify the impact of these injuries on player performance. Previous studies have looked at the occurrence of Achilles tendon ruptures in elite athletes in general, but very little was known about how often that type of injury occurred specifically in the NFL or how it affected the athlete's future ability to play.

Researchers looked at publicly available NFL data including websites that summarized games, statistics and injuries, to identify players who sustained complete Achilles tendon rupture. Also noted were such variables as the player's position, age, and number of years in the league prior to the injury. In addition, yearly performance statistics were collected for the players for the years before and after the injuries.

The study found that Achilles tendon ruptures can be career-altering injuries. Nearly 36% of players who sustained this injury never returned to play in the NFL and the ones who were able to return were never able to return to their pre-injury levels of play.

"This article provides a novel approach to shed light on valuable epidemiologic data for Achilles tendon ruptures among NFL players and the functional outcome of the injury," write authors Selene G. Parekh, Walter H. Wray, III, Olubusola Brimmo, Brian J. Sennett and Keith L. Wapner. "Future studies with the cooperation of the NFL and their official injury database are needed to fully evaluate the impact of Achilles injuries in this at-risk population."

Injection of platelet-rich plasma doesn't help

Newer treatment for Achilles tendon disorder does not appear to be effective

An apparently increasingly used treatment method for a type of Achilles tendon disorder that includes injection of platelet-rich plasma into the tendon does not appear to result in greater improvement in pain or activity compared to placebo, according to results of a preliminary study published in the January 13 issue of JAMA.

"Overuse injury of the Achilles tendon is a frequent problem that often affects sport participants but also inactive middle-aged individuals. An estimated 30 percent to 50 percent of all sports-related injuries are tendon disorders," the authors write. Approximately 25 percent to 45 percent of patients eventually require surgery following ineffective conservative treatment. "There is a clear need for improved conservative therapy."

Chronic Achilles tendinopathy is a degenerative condition characterized by pain, swelling and decreased activity. Platelet-rich plasma (PRP) injections is a treatment method recently introduced to improve tendon regeneration. Several recent reports indicated promising results with this treatment method, although these conclusions were based on laboratory studies and on clinical studies with important limitations, according to background information in the article.

Robert J. de Vos, M.D., of Erasmus University Medical Center, Rotterdam, the Netherlands, and colleagues conducted a study to compare the effects on pain and functional outcome of a PRP injection with a placebo injection for patients with chronic Achilles tendinopathy. The trial included 54 patients ages 18 to 70 years and was conducted between Aug. 2008 and Jan. 2009, with follow-up until July 16, 2009. Patients were randomized to eccentric exercises (usual care; exercises involved stretching the Achilles tendon while contracting the calf muscle) with either a PRP injection (PRP group) or saline injection (placebo group). A questionnaire (Victorian Institute of Sports Assessment-Achilles [VISA-A]), used to gauge pain and activity level, was completed at the beginning of the study and at 6, 12, and 24 weeks.

The researchers found that the average VISA-A score improved significantly after 24 weeks within the PRP group and within the placebo group. After adjustment for different variables, including the duration of symptoms, there was no significant difference in improvement on the VISA-A scores at the different follow-up times between these two treatment groups.

There was also no significant difference in secondary outcome measures, which included subjective patient satisfaction and the number of patients returning to their desired sport.

"Among patients with chronic midportion Achilles tendinopathy treated with an eccentric exercise program, a PRP injection compared with a saline injection did not result in greater improvement in pain and activity. Therefore, we do not recommend this treatment for chronic midportion Achilles tendinopathy," the authors write.

"These findings are important and clinically relevant as PRP is thought to be growing in popularity and recent reviews supported its use for chronic tendon disorders."

Monday, January 11, 2010

Program may prevent knee injuries

A soccer-specific exercise program that includes individual instruction of athletes appears to reduce the risk of knee injuries in young female players, according to a report in the January 11 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.

Soccer is a dominant cause of sports-related injuries in part because of its increasing popularity, according to background information in the article. Between 2000 and 2006, the number of female soccer players around the world increased by 19 percent, to 26 million. "The most frequent and severe type of injury among soccer players is to the legs, especially the knees. The anterior cruciate ligament (ACL) injury incidence is highest among young athletes," the authors write. "Knee injuries, and especially ACL ruptures, may have long-term consequences, including a long absence from soccer, incomplete recovery and secondary osteoarthritis of the knee."

Ashkan Kiani, M.D., of Uppsala Primary Care, Uppsala County Council, Sweden, and colleagues assessed an intervention program specifically designed to reduce the risk of soccer-related knee injuries among 1,506 13- to 19-year-old Swedish female players. The program featured strengthening exercises designed to achieve an improved motion pattern, reducing strain on the knee joint. The training sessions were integrated into the regular soccer practices and required no additional equipment. In addition, players, parents and team leaders attended a seminar to raise awareness of injury risk.

During 2007, 777 girls on 48 teams participated in the program and 729 players on 49 teams served as controls. Three knee injuries, including one non-contact injury (not involving another player), occurred among players participating in the program, compared with 13 knee injuries and 10 non-contact injuries among girls in the control group. Therefore, the program was associated with a 77 percent reduction in the incidence of knee injuries and a 90 percent reduction in the incidence of non-contact knee injuries.

"The rate of injury was not only lower among teams participating in the preventive program but the injuries that did occur were also less severe," the authors write. All three injuries in the intervention group were categorized as major, but all three players regained full activity within six months. Among the control participants, most injuries were severe, and only four of the 13 regained full activity within six months.

Coaches reported their teams' adherence to the program at two time periods, after the preseason training period and after the competitive season. Of the 48 teams participating in the intervention, 45 (94 percent) reported a high adherence of at least 75 percent. "The high compliance rate in this study suggests that the program is easy to implement and incorporate into regular soccer practice," the authors conclude.

Tuesday, January 5, 2010

Strength training, self-management help knees

Researchers participating in the Multidimensional Intervention for Early Osteoarthritis of the Knee (Knee Study) determined that physically inactive, middle-aged people with symptomatic osteoarthritis benefitted equally from strength training regimens, self-management programs, or a combination of the two. Details of this study are available in the January 2010 issue of Arthritis Care & Research, a journal published by Wiley-Blackwell on behalf of the American College of Rheumatology.

Osteoarthritis (OA) is the most common form of arthritis and the second leading cause of disability in the United States. Currently OA is the most prevalent chronic condition among women, afflicting 35-45% of women by the age of 65. A number of studies have compared strength training protocols with self-management programs in older patient populations, but few have examined the potential benefit of using both approaches in conjunction. "We hypothesized that combining the 2 treatments might enhance the outcomes," said Patrick McKnight, lead author of the Knee Study.

The Knee Study, conducted at the University of Arizona Arthritis Center in Tucson, AZ, was a 24-month unblinded, randomized intervention trial to compare the effects of strength training programs, self-management programs, and a combination of both. The 273 study participants were between the ages of 35 and 65 years, reported pain and disability due to knee pain on most days in one or both knees for a period of no more than 5 years, and had Kellgren/Lawrence classification grade 2 radiographic evidence of knee OA in one or both knees.

Study participants were randomly assigned to 1 of 3 treatment groups. The strength training group engaged in a 9-month initial phase designed to improve the core areas of stretching and balance, range of motion and flexibility, and isotonic muscle strength. The second, 15-month phase of this group concentrated on developing independent, long-term exercise habits. The second study group participated in a 2-phase self-management program designed to educate participants and provide one-on-one treatment advice. The combined group participated in both the complete strength training and self-management programs. A total of 201 out of 273 participants completed the 2-year trial, with the self-management group achieving the highest compliance rates.

The study team set out to demonstrate that a combination of OA treatment programs would prove most effective, however, the study failed to uncover significant differences in results among the 3 study participant groups. All 3 groups demonstrated improvements in physical function tests and decreased self-reported pain and disability. "The logic behind the combined treatment was that the different factors addressed in physical and psychological treatments might produce an additive effect if administered together," said Dr. McKnight. "These results suggest otherwise. Instead, the comparison of the 3 treatment arms showed no difference, suggesting similar benefits for all 3 over a 2-year period."

Given the higher rate of compliance in the self-management group, the Knee Study researchers suggest that self-management may be a less intrusive and equally effective early treatment for knee OA. The CDC also recommends self-management activities to decrease pain, improve function, stay productive, and lower health care costs, including self-management education programs such as the Arthritis Foundation Self Help Program (AFSHP), or the Chronic Disease Self Management Program (CDSMP) to manage arthritis on a day-to-day basis.

Article: "A Comparison of Strength Training, Self-Management, and the Combination for Early Osteoarthritis of the Knee." Patrick E McKnight, Shelley Kasle, Scott Going, Isidro Villanueva, Michelle Cornett, Josh Farr, Jill Wright, Clara Streeter, and Alex Zautra. Arthritis Care and Research; Published Online: December 28, 2009 (DOI: 10.1002/acr20013); Print Issue Date: January 2010

Monday, January 4, 2010

Knee Replacement - I Probably Won't Die

New study finds low mortality risk following knee and hip replacement

Risks lower 26 days after surgery

Total hip and total knee replacement surgeries are highly successful and very common procedures for people experiencing pain associated with degenerative joints. With a new hip or knee, and postoperative care prescribed by their doctors, most patients are able to regain a more active lifestyle with considerably less pain.

According to a new study published in the January 2010 issue of the Journal of Bone and Joint Surgery (JBJS), the risk of early postoperative mortality – or death following surgery -- was slightly increased for the first 26 days after the elective surgery. The risk of mortality was estimated to be 0.1 percent. The size of the study and the precise statistical tools used show the increase in early postoperative mortality was highest immediately after the operation. Then, 26 days after the surgery, the increased risk of death was negligible.

"Previous studies suggesting that increased mortality exists for as long as 60 or 90 days post hip or knee replacement surgery may be wrong," said lead author of the study, Stein Atle Lie, PhD, MSc and professor in the Department of Surgical Sciences at the University of Bergen, Norway who led the study with colleagues from the Department of Orthopaedic Surgery, and the Norwegian Arthroplasty Register at the Haukeland University Hospital in Bergen, Norway. "We believe the risk is tied to a much shorter duration."

The study included data on 81,856 patients with a total knee replacement and 106,254 patients with a total hip replacement from the Australian Orthopaedic Joint Replacement Registry and the Norwegian Arthroplasty Register. Only patients between 50 and 80 years of age with osteoarthritis were included.

The study found the most important risk factors for increased early postoperative mortality were:

Male gender; and
Age, older than 70 years old.
"This very low postoperative mortality after hip and knee replacements should be reassuring for patients considering these surgeries," explains study co-author Lars B. Engesaeter, MD, PhD and Head of Norwegian Arthroplasty Register, Haukeland University Hospital in Bergen, Norway.

People considering hip or knee replacement should talk to their orthopaedic surgeon about any added risk in relation to their age and follow recovery guidelines closely. Other questions to consider prior to surgery can be found at

"We conducted this study to help people contemplating hip or knee replacement," continues Dr. Lie. "As with all surgeries, there is some increased risk of postoperative mortality. However, we were pleased to find the mortality rate is so minimal -- less than one percent -- following hip and knee replacements."


Friday, January 1, 2010

Don’t Let Arthritis Put the Kibosh on All Exercise

Achy knees and joints caused by arthritis are not reasons to stop exercising.

Regular, modest exercise improves joint stability and strengthens muscles, according to the December issue of Mayo Clinic Women’s HealthSource. Exercise also improves mood, sleep, energy levels and day-to-day functioning. Best of all, people with arthritis who exercise regularly report less pain.

When a person avoids exercise, joints become less mobile and the surrounding muscles shrink, causing increased fatigue and pain.

A physical therapist or personal trainer can tailor exercise programs to health conditions and fitness levels. The key is to choose safe, appropriate activities and to take it slowly at first. A variety of activities can be safe and helpful for people with arthritis, including:

-- Range-of-motion and flexibility exercises: Activities such as yoga and tai chi increase joint mobility. Doing range-of-motion exercises in the evening can reduce joint stiffness the next morning.
-- Low-impact aerobics: Aerobic exercise improves overall fitness and endurance as well as muscle function and joint stability. Low-impact options include water aerobics, swimming, bicycling, walking or using equipment such as treadmills and elliptical trainers.
-- Strengthening: Strength training builds the muscles around the joints to provide better support. These exercises may be done with one’s own body weight for resistance, with hand-held weights, resistance bands or weight machines.
-- Lifestyle: Many everyday activities -- gardening and housework -- provide the health benefits of moderate physical activities.

For those with joint damage, some high-impact activities can make arthritis pain worse. It’s wise to consult with a physician before starting a new exercise regimen. Exercising should be stopped when it increases pain or swelling; causes joint popping, locking or giving way; leads to abdominal, groin or chest pain; or results in moderate-to-intense shortness of breath.

Psoriasis: Effects Don’t Always Stop With the Skin

RPsoriasis, a chronic disease that causes red, raised patches of skin, is increasingly seen as a systemic disease with links to arthritis and cardiovascular disease. The December issue of Mayo Clinic Women’s HealthSource provides an overview of this sometimes embarrassing condition, what’s known about it and how it’s treated. Highlights of the overview include:

-- Symptoms: Patches of thick, red skin covered with silvery, flaky scales commonly appear on the elbows and knees, but can appear anywhere on the body. They result from skin cells on overdrive, reproducing much faster than normal. Doctors aren’t sure why this overproduction occurs, although genetic and environmental factors likely play roles. Psoriasis symptoms come and go and flare in response to triggers that can include infections, some medications, alcohol, smoking, stress, sunburn, skin irritation or injury.

-- A systemic illness: Doctors are finding that psoriasis is more than a skin disorder. About one in four people with psoriasis develop a form of arthritis called psoriatic arthritis that can cause pain, stiffness and swelling in the joints. Studies have shown that people with psoriasis face a higher risk of heart attack, stroke and other cardiovascular problems. The underlying link may be chronic inflammation, which plays a role in psoriasis and heart disease.

-- Treatment: While psoriasis can’t be cured, a variety of topical and systemic treatment options can help control the condition. For mild-to-moderate psoriasis, topical treatments often are effective. Options include corticosteroids or retinoids to reduce inflammation; vitamin D analogs to slow skin growth; and tar, to reduce scaling, itching and inflammation. Calcineurin inhibitors (tacrolimus and pimecrolimus) can help reduce inflammation and skin cell buildup.

In addition, ultraviolet light slows the rapid growth of skin cells. Ultraviolet light therapy may be used alone or in combination with other treatments. Several systemic medications are used for severe forms of psoriasis, though these options pose the risk of serious side effects.

-- Self-help measures: Home-care measures can help prevent or manage symptoms. A daily bath removes scales and calms inflamed skin. Adding bath oil, colloidal oatmeal, Epsom salts or Dead Sea salts can offer additional relief. After bathing, applying a thick moisturizing cream or ointment, such as petroleum jelly, can be helpful. During cold, dry weather, it’s beneficial to apply moisturizer several times a day. Short sessions in sunlight three or more times a week can improve psoriasis, as can avoiding known triggers.