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

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 www.orthoinfo.org.

"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."

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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.

Exercise Therapy Best for Knee Pain

For patients with severe knee pain, supervised exercise therapy is more effective at reducing pain and improving function than usual care, finds a study published on bmj.com.

Patellofemoral pain syndrome is a condition in which pain occurs at the front of the knee during or after exercise and is a common reason to visit the doctor. Women are more likely to be affected than men, and symptoms usually start during adolescence when participation in sporting activities is high.

General advice is to rest during periods of pain and to avoid pain provoking activities. This "wait and see" approach is considered usual care.

A recent study reported only limited evidence for the effectiveness of exercise therapy with respect to pain reduction, while there is conflicting evidence with respect to functional improvement.

So researchers based in the Netherlands investigated the effectiveness of supervised exercise therapy compared with usual care in 131 patients aged between 14 and 40 years with patellofemoral pain syndrome.

A total of 131 participants were included in the study, 65 to a supervised exercise program (intervention group) and 66 to usual care (control group). Both groups received similar written information about the syndrome and similar instructions for home exercises, as well as advice to refrain from painful activities.

Patients rated their recovery, pain at rest, pain on activity, and function scores at the start of the study and again at three and 12 months.

After three months, the intervention group reported significantly less pain and better function than the control group. At 12 months, the intervention group continued to show better outcomes than the control group with regard to pain at rest and pain on activity, but not function.

A higher proportion of patients in the exercise group than in the control group reported recovery (42% v 35% at three months and 62% v 51% at 12 months), but these results were not significantly different between the two groups.

This study provides evidence that supervised exercise therapy for patellofemoral pain syndrome in general practice is more effective than usual care for pain at rest, pain on activity, and function at three and 12 months, say the authors. However, supervised exercise therapy had no effect on perceived recovery.

Further research is needed to understand how exercise therapy results in better outcome, they conclude.

Causes of ‘Runner’s Knee’

From professional athletes to weekend warriors, the condition known as “runner’s knee” is a painful and potentially debilitating injury suffered by millions of people – although until now, it has been unclear just what causes it.
But new research from the University of North Carolina at Chapel Hill has zeroed in on what appear to be the main culprits of the condition, formally known as patellofemoral pain syndrome.
The study is believed to be the first large, long-term project to track athletes from before they developed runner’s knee, said study co-author Darin Padua, Ph.D., associate professor of exercise and sport science in the UNC College of Arts and Sciences.
“Earlier studies have usually looked at people after the problem sets in,” Padua said. “That means that while previous research has identified possible risk factors related to strength and biomechanics, it’s been unclear whether those caused the injury, or whether people’s muscles and the way they moved changed in response to their injury.”
The research appears in the November issue of the American Journal of Sports Medicine.
Runner’s knee – the bane of many types of exercise, from running to basketball to dance – affects one in four physically active people. If unchecked, it can lead to more serious problems such as patellofemoral osteoarthristis.
“Patellofemoral pain syndrome can be devastating,” said Padua. “The pain can severely curtail a person’s ability to exercise and the symptoms commonly reoccur. That said, athletes often have a high pain threshold and may ignore it. But if they do, their cartilage may break down – and if that gets to the point of bone on bone contact, nothing can be done to replace the damaged cartilage.”
Padua and his colleagues studied almost 1,600 midshipmen from the United States Naval Academy. Researchers analyzed participants’ biomechanics when they first enrolled at the academy, then followed them for several years to see if they developed patellofemoral pain syndrome.
A total of 40 participants (24 women and 16 men) developed the syndrome during the follow-up period. The study found:
• Participants with weaker hamstring muscles were 2.9 times more likely to develop the syndrome that those with the strongest hamstrings
• Those with weaker quadriceps muscles were 5.5 times more likely
• Those with a larger navicular drop (a measure of arch flattening when bearing weight) were 3.4 times more likely
• Participants with smaller knee flexion angle (those whose knees bent less on landing during a jump test) were 3.1 times more likely
Padua said the pain associated with the condition could be explained by those different factors coming together to create a focal point of pressure between the kneecap and the underlying bone.
“Overall, these people generally have weaker quads and hamstrings. As a result, they don’t bend their knees as much when doing task, such as running or jumping. That means the contact area between the kneecap and the femur is smaller, so pressure is focused and pinpointed on a smaller area.
“Also, the more a person’s arch falls when bearing weight, the more their whole leg may rotate inwards. That will mean their kneecap won’t track properly, leading to yet more pressure and more potential pain.”
Padua said the good news is that the study appears to confirm that if people can change the way they move and improve their leg strength, they can prevent or correct the problem.
Everyday athletes can also spot for themselves whether they are at risk: if their knee crosses over the big toe when squatting; the arches of their feet collapse when landing from a jump; and if they do not bend their knees much when they land, they stand a greater chance of developing the syndrome, Padua said.
The researchers are now looking into which exercises are best for improving the biomechanics involved. They have also developed a simple screening tool, called LESS (Landing Error Scoring System), for identifying people most at risk of runner’s knee and similar conditions, and of suffering ACL (anterior cruciate ligament) injuries.

SMALLER ACLs = MORE SUSCEPTIBLE TO INJURY

A study comparing images of the knees in people who did and didn’t have previous injuries to the anterior cruciate ligament suggests that people who tore their ACLs are more likely to have a smaller ligament than do similarly sized people who have never injured a knee.

Researchers calculated the total volume of the ligaments based on magnetic resonance images of human knees. The ACLs among those with previous injuries were, on average, about 10 percent smaller than were ACLs among those without an injury.

In those with previous injuries, the uninjured ACL in the opposite knee was measured for the study. Their ligaments were compared to the ACLs in uninjured people of similar height and weight.

Those who had torn their ACLs had experienced noncontact injuries, meaning the injury occurred during some sort of movement of the body rather than because of a blow to the knee.

Researchers caution that the retrospective study does not mean that a smaller ACL will necessarily result in injury. Instead, they say the research offers more clues about the variety of factors – such as activity level, neuromuscular coordination, gender and muscle strength – that appear to be contributors to ACL injury.

In this group of participants, weight was the strongest predictor of ACL volume.

“If you compared two people of the same weight, based on our data set, we would expect the injured person had the smaller ACL,” said Ajit Chaudhari, assistant professor of orthopedics at Ohio State University and lead author of the study.

Knowing that the knee’s anatomy can influence susceptibility should help researchers who are trying to figure out why ACL injuries occur and who is most likely to experience these injuries, Chaudhari said. Most study results guide the assignment of a percentage of risk to one or more factors associated with torn ACLs, but to date no research had looked solely at the size of the ligament in injured and non-injured knees.

The research is published in a recent issue of the American Journal of Sports Medicine.


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“If you have a weaker ACL, it’s more likely to tear if all other factors are equal,” he said. “If being larger in size means the ACL has more fibers, then that would make it stronger. If the individual building blocks are of similar strength, then it comes down to how much total tissue there is.”

The anterior cruciate ligament, responsible for rotational stability in the knee, is located behind the kneecap and is one of four ligaments that join the thigh and shin bones. Noncontact tears of the ACL tend to occur in athletes when they pivot, stop quickly or land from a jump. Previous research suggests that college-age women athletes are at three- to 10-times higher risk of tearing their ACLs than their male counterparts, depending on the activity, but scientists have not determined why this is.

“Comparisons of the volumes of ACLs between men and women have been done, which have suggested that ACL volume may matter. Studies have also found that female ACLs had fewer fibers than male ACLs that were tested. But even with those findings, any differences between males and females could be a coincidence. There are so many variables that interact that you can’t really tell what’s causative unless you compare people who have had an injury to those who haven’t had an injury,” said Chaudhari, also director of Ohio State’s Sports Biomechanics Laboratory.

He and colleagues took MR images of the knees of 54 participants, who were divided into two groups. Volunteers with previous injuries were matched with uninjured participants of the same age, gender, height and weight.

The previously injured participants’ healthy knees were imaged for the study. Chaudhari said the fibers of a torn ACL tend to fray like a rope, meaning the volume of injured ACLs could not be measured in a meaningful way. Chaudhari recently presented related research that indicated that there is no significant difference in the size of two ACLs in the same body.

Researchers used the MR images to determine the outline of each ACL under the guidance of an orthopedic surgeon experienced in operating on injured knees. They validated this method of determining ACL volume by practicing the measurement technique on five pig knees obtained from a butcher.

Of the 27 injured participants, 16 had smaller ACLs than their matched controls. Overall, the injured group had an average ACL volume of 1,921 cubic millimeters, while the control group had an average volume of 2,151 cubic millimeters.

In this group of participants, weight and height were strongly correlated as potential variables affecting the size of the ligament.

Chaudhari said that based on what is currently known about the fibrous makeup of the ligament, it’s no surprise that a smaller ACL is more susceptible to injury.

“If you have a weaker ACL, it’s more likely to tear if all other factors are equal,” he said. “If being larger in size means the ACL has more fibers, then that would make it stronger. If the individual building blocks are of similar strength, then it comes down to how much total tissue there is.”

It’s too soon to consider knee imaging as a way to screen potential athletes, Chaudhari said, because of the high expense and the fact that knowing the size of the ACL still doesn’t tell the whole story of how the knee will react to activity.

“I would certainly not say in any way, shape or form that people should start using ACL size as a determinant of whether they should play any sport,” he said.

But what it does tell researchers is that there might be more than one way to go about trying to prevent knee ligament injuries. While many prevention efforts focus on the strength of muscles surrounding the knee, Chaudhari and other researchers hope to study whether the ACL itself can be made stronger, or larger, or both, while a child is still growing and developing.