Studies Evaluate the Anatomy and Stability of ACL Reconstruction with Different Techniques
An improved understanding of the anatomy of the anterior cruciate ligament (ACL) in recent years has generated a renewed interest in the evaluation of surgical techniques to repair the knee ligament. In a study to be presented at the 2009 American Orthopaedic Society of Sports Medicine Specialty Day in Las Vegas, researchers analyzed various aspects of two of the most common ACL reconstruction techniques.
“Studies have demonstrated improved movement and stability with restoration of the native anatomy of the knee. However, the surgical technique to achieve the best movement and stability outcomes remains controversial”, says lead author Asheesh Bedi, MD of the Hospital for Special Surgery in New York City.
Bedi worked with senior mentors Dr. David W. Altchek and Dr. Riley J. Williams on studying the anatomy and stability of ACL reconstructions using transtibial versus anteromedial portal drilling techniques on 19 cadaveric knees. Femoral socket position was characterized using high-resolution 3D-fluoroscopy with transtibial and anteromedial portal drilling. “While anteromedial portal drilling allows for excellent access and restoration of the femoral ACL footprint, there is a significant learning curve. There can be an increased risk of shorter femoral tunnels and wall blow-out intraoperatively” says Dr. Riley Williams, the senior author and Associate Attending Surgeon at the Hospital for Special Surgery.
Follow-up studies have evaluated the biomechanical stability of ACL reconstructions completed with transtibial and anteromedial portal techniques. “The anteromedial portal drilling technique allowed for better restoration of native ACL anatomy and knee stability compared to conventional transtibial techniques. We also found that re-reaming of the tibial tunnel is a bigger issue than has been previously recognized with transtibial drilling” says Dr. David Altchek, senior author and Co-Chief of the Sports Medicine Service at the Hospital for Special Surgery.
Bedi and Altchek will be presenting the second part of their study at the 2009 AOSSM Annual Meeting in Keystone, CO. “Continued research into the best techniques for ACL stabilization are ongoing and a vital part of getting athlete’s back into play at a quicker rate. We are working to define these techniques in the lab and have them translated into the operating room” says Altchek.
Saturday, February 28, 2009
Tuesday, February 10, 2009
Exercises To Prevent ACL Injuries
The nation’s first – and only – program aimed at taking a wide-scale community prevention approach to decrease non-contact anterior cruciate ligament (ACL) tears among female high school athletes is working, and as a result, is being expanded in Rochester, New York. The program, called PEP (Prevent injury, Enhance Performance), targets the prevention of one of the most serious knee injuries that can sideline athletic careers among females, who are at six to nine times greater risk than males to sustain an ACL tear.
Organized by University Sports Medicine (USM), the PEP program is being rolled out to 119 high schools in Section V, an area that covers all Monroe, Ontario, Seneca, Livingston, Allegany, Steuben and Wayne counties in upstate New York. The expansion, made possible by a $161,000 grant from the Greater Rochester Health Foundation (GRHF), will cover junior varsity and varsity female athletes playing soccer, volleyball and basketball – the three main sports with high incidences of ACL tears. USM officials expect to train about 11,180 athletes on nearly 700 teams during the two-year program.
GRHF provided the seed money for USM to introduce the program to Monroe County high school athletes in January 2007. Since that time, USM athletic trainers have worked with 1,137 female athletes on 71 teams, and preliminary results are promising.
“We would typically expect to see about two ACL tears per 100 participants, or about 58 non-contact ACL tears for the 2,900 athletes we have been working with,” Michael Maloney, M.D., director of USM, said. “To date, we’ve seen only 10 non-contact ACL tears, so this data is very promising. I’m grateful that with additional funding from the Greater Rochester Health Foundation, we are able to significantly expand the reach of our program, and help even more female athletes stay in the game and attain their goals, whatever they may be.”
The program has steadily been gaining national attention. In 2008, the NCAA posted an interactive segment on ACL injuries to its website, which included a feature on USM’s PEP program.
Mystery Surrounds Female ACL Tears
The numbers on female ACL tears are astounding. Over 1.4 million women have been afflicted in the past 10 years alone — twice the rate of the previous decade. It is estimated that more than 30,000 high school and college age females will rupture their ACL every year. In the last 15 years, ankle sprains have decreased by 86 percent while knee ligament injuries have increased by 172 percent.
Much speculation exists on the cause of the higher non-contact ACL injury rate in females, with hormones, biomechanics and environment some of the common culprits named. While researchers have been unable to definitively pinpoint the exact cause for the increased incidence in females, they have been able to develop a series of specific stretching, strengthening, flexibility and balance exercises that have been shown to significantly reduce injury rates.
“PEP works by retraining the nervous and muscle system in female athletes to be more efficient, and as a result, reduce the potential for non-contact ACL tears,” said Andy Duncan, P.T., A.T.C., director of sports rehabilitation at USM.
It consists of a specialized warm-up program that must be completed two to three times a week, and includes exercises and training to increase muscle strength, plyometrics (active strengthening like jumps), agility, balance and flexibility. The program takes about 20-25 minutes to complete.
“We stress quality versus quantity with the girls. These exercises are so precise that they must be done properly or they will not receive any benefit at all,” Duncan said. “In effect, we are re-teaching the muscles how to fire and respond to signals from the nervous system. At the end of six weeks, if the program is done correctly and consistently, these athletes will have a much better chance at preventing an ACL tear.”
Beginning in the summer of 2009 USM athletic trainers will use a “train-the-trainer” approach to educate team coaches/representatives on the benefits and components of the PEP program. The sessions will be interactive, including demonstration and participation. Videos detailing each exercise will be given to each team to help guide the athletes through the program.
Sample PEP Exercises
• Warm-ups: Jog, slides, backpedals
• Strengthening: Lunge walk, ball bridge, calf raise
• Plyometrics: Lateral, front/back and single leg hops, rebound jumps, scissor jumps
• Agility: Shuttle and pivot runs
• Stretching Hamstrings, quads, calves, groin and hip flexors
Organized by University Sports Medicine (USM), the PEP program is being rolled out to 119 high schools in Section V, an area that covers all Monroe, Ontario, Seneca, Livingston, Allegany, Steuben and Wayne counties in upstate New York. The expansion, made possible by a $161,000 grant from the Greater Rochester Health Foundation (GRHF), will cover junior varsity and varsity female athletes playing soccer, volleyball and basketball – the three main sports with high incidences of ACL tears. USM officials expect to train about 11,180 athletes on nearly 700 teams during the two-year program.
GRHF provided the seed money for USM to introduce the program to Monroe County high school athletes in January 2007. Since that time, USM athletic trainers have worked with 1,137 female athletes on 71 teams, and preliminary results are promising.
“We would typically expect to see about two ACL tears per 100 participants, or about 58 non-contact ACL tears for the 2,900 athletes we have been working with,” Michael Maloney, M.D., director of USM, said. “To date, we’ve seen only 10 non-contact ACL tears, so this data is very promising. I’m grateful that with additional funding from the Greater Rochester Health Foundation, we are able to significantly expand the reach of our program, and help even more female athletes stay in the game and attain their goals, whatever they may be.”
The program has steadily been gaining national attention. In 2008, the NCAA posted an interactive segment on ACL injuries to its website, which included a feature on USM’s PEP program.
Mystery Surrounds Female ACL Tears
The numbers on female ACL tears are astounding. Over 1.4 million women have been afflicted in the past 10 years alone — twice the rate of the previous decade. It is estimated that more than 30,000 high school and college age females will rupture their ACL every year. In the last 15 years, ankle sprains have decreased by 86 percent while knee ligament injuries have increased by 172 percent.
Much speculation exists on the cause of the higher non-contact ACL injury rate in females, with hormones, biomechanics and environment some of the common culprits named. While researchers have been unable to definitively pinpoint the exact cause for the increased incidence in females, they have been able to develop a series of specific stretching, strengthening, flexibility and balance exercises that have been shown to significantly reduce injury rates.
“PEP works by retraining the nervous and muscle system in female athletes to be more efficient, and as a result, reduce the potential for non-contact ACL tears,” said Andy Duncan, P.T., A.T.C., director of sports rehabilitation at USM.
It consists of a specialized warm-up program that must be completed two to three times a week, and includes exercises and training to increase muscle strength, plyometrics (active strengthening like jumps), agility, balance and flexibility. The program takes about 20-25 minutes to complete.
“We stress quality versus quantity with the girls. These exercises are so precise that they must be done properly or they will not receive any benefit at all,” Duncan said. “In effect, we are re-teaching the muscles how to fire and respond to signals from the nervous system. At the end of six weeks, if the program is done correctly and consistently, these athletes will have a much better chance at preventing an ACL tear.”
Beginning in the summer of 2009 USM athletic trainers will use a “train-the-trainer” approach to educate team coaches/representatives on the benefits and components of the PEP program. The sessions will be interactive, including demonstration and participation. Videos detailing each exercise will be given to each team to help guide the athletes through the program.
Sample PEP Exercises
• Warm-ups: Jog, slides, backpedals
• Strengthening: Lunge walk, ball bridge, calf raise
• Plyometrics: Lateral, front/back and single leg hops, rebound jumps, scissor jumps
• Agility: Shuttle and pivot runs
• Stretching Hamstrings, quads, calves, groin and hip flexors
Tuesday, February 3, 2009
Exercises to strengthen your quadriceps
It may be uncomfortable at first, but doing exercises to strengthen your quadriceps after you’ve had knee replacement surgery due to osteoarthritis is critical to your recovery. In fact, it can boost the function of your new knee to nearly that of a healthy adult your age.
That’s the finding of a University of Delaware study published in the February issue of Arthritis Care & Research.
The authors include Lynn Snyder-Mackler, Alumni Distinguished Professor of Physical Therapy at the University of Delaware, Stephanie Petterson, clinical faculty at Columbia University, Ryan Mizner, an assistant professor at Eastern Washington University, Jennifer Stevens, an assistant professor at the University of Colorado at Denver, and Drs. Leo Raisis, Alex Bodenstab, and William Newcomb of First State Orthopaedics in Newark, Delaware.
“It sounds logical that exercises to strengthen your knee should be a component of your post-operative physical therapy after a total knee replacement, but it’s not the convention at all,” says Snyder-Mackler.
“There are all of these old wives’ tales that strength training is a detriment to the patient and that the new knee should be treated delicately,” Snyder-Mackler notes. “Our study demonstrates that intensive strength exercise as outpatient therapy is critical to begin three to four weeks after surgery.”
Nearly 500,000 knee replacements, also known as total knee arthroplasties, are performed every year in the United States to treat severe knee osteoarthritis, the loss of the cushiony cartilage padding the knee. The joint disease leaves its sufferers with persistent pain and limited function, resulting in an overall diminished quality of life.
While knee replacement alleviates the pain of osteoarthritis and improves function, patients exhibit impaired quadriceps strength and function for such activities as walking and climbing stairs, and the levels remain below those of healthy people of the same age.
In a randomized controlled trial at the University of Delaware’s Physical Therapy Clinic conducted between 2000 and 2005, 200 patients who had undergone knee replacements were given six weeks of progressive strength training two or three times a week starting four weeks after surgery. Half of the group also received neuromuscular electrical stimulation (NMES).
Their function was compared to that of 41 patients who received conventional rehabilitation and home physical therapy. Quadriceps strength, knee range of motion, and gait were measured in such tests as timed up and go, stair climbing and a six-minute walk.
The group in the progressive strength-training program showed significant improvement in quadriceps strength and functional performance. They also demonstrated substantially greater quadriceps strength and functional performance after 12 months than the group that underwent conventional rehabilitation.
“This study clearly demonstrates the importance of surgeons encouraging their patients to be compliant with progressive quadriceps strengthening during their rehabilitation to enhance their clinical improvement and function post-total knee replacement,” notes Dr. Leo Raisis, a total joint surgeon and adjunct associate professor at the University of Delaware.
“Why undergo a $25,000 elective surgery and then not do as much as you can to get the most out of it and improve your quality of life?” Snyder-Mackler says. “Older people are incredibly motivated—they hurt after the surgery and they want to be better. They need to do this.”
That’s the finding of a University of Delaware study published in the February issue of Arthritis Care & Research.
The authors include Lynn Snyder-Mackler, Alumni Distinguished Professor of Physical Therapy at the University of Delaware, Stephanie Petterson, clinical faculty at Columbia University, Ryan Mizner, an assistant professor at Eastern Washington University, Jennifer Stevens, an assistant professor at the University of Colorado at Denver, and Drs. Leo Raisis, Alex Bodenstab, and William Newcomb of First State Orthopaedics in Newark, Delaware.
“It sounds logical that exercises to strengthen your knee should be a component of your post-operative physical therapy after a total knee replacement, but it’s not the convention at all,” says Snyder-Mackler.
“There are all of these old wives’ tales that strength training is a detriment to the patient and that the new knee should be treated delicately,” Snyder-Mackler notes. “Our study demonstrates that intensive strength exercise as outpatient therapy is critical to begin three to four weeks after surgery.”
Nearly 500,000 knee replacements, also known as total knee arthroplasties, are performed every year in the United States to treat severe knee osteoarthritis, the loss of the cushiony cartilage padding the knee. The joint disease leaves its sufferers with persistent pain and limited function, resulting in an overall diminished quality of life.
While knee replacement alleviates the pain of osteoarthritis and improves function, patients exhibit impaired quadriceps strength and function for such activities as walking and climbing stairs, and the levels remain below those of healthy people of the same age.
In a randomized controlled trial at the University of Delaware’s Physical Therapy Clinic conducted between 2000 and 2005, 200 patients who had undergone knee replacements were given six weeks of progressive strength training two or three times a week starting four weeks after surgery. Half of the group also received neuromuscular electrical stimulation (NMES).
Their function was compared to that of 41 patients who received conventional rehabilitation and home physical therapy. Quadriceps strength, knee range of motion, and gait were measured in such tests as timed up and go, stair climbing and a six-minute walk.
The group in the progressive strength-training program showed significant improvement in quadriceps strength and functional performance. They also demonstrated substantially greater quadriceps strength and functional performance after 12 months than the group that underwent conventional rehabilitation.
“This study clearly demonstrates the importance of surgeons encouraging their patients to be compliant with progressive quadriceps strengthening during their rehabilitation to enhance their clinical improvement and function post-total knee replacement,” notes Dr. Leo Raisis, a total joint surgeon and adjunct associate professor at the University of Delaware.
“Why undergo a $25,000 elective surgery and then not do as much as you can to get the most out of it and improve your quality of life?” Snyder-Mackler says. “Older people are incredibly motivated—they hurt after the surgery and they want to be better. They need to do this.”
Saturday, January 31, 2009
Supplements no better than placebo
Supplements no better than placebo in slowing cartilage loss in knees of osteoarthritis patients
In a two-year multicenter study led by University of Utah doctors, the dietary supplements glucosamine and chondroitin sulfate performed no better than placebo in slowing the rate of cartilage loss in the knees of osteoarthritis patients.
This was an ancillary study concurrently conducted on a subset of the patients who were enrolled in the prospective, randomized GAIT (Glucosamine/chondroitin Arthritis Intervention Trial). The primary objective of this ancillary study was to investigate whether these dietary supplements could diminish the structural damage of osteoarthritis. The results, published in the October issue of Arthritis & Rheumatism, show none of the agents had a clinically significant effect on slowing the rate of joint space width loss —the distance between the ends of joint bones as shown by X-ray.
However, in line with other recent studies, the researchers observed that all the study's participants had a slower rate of joint space width loss than expected, making it more difficult to detect the effects of the dietary supplements and other agents used in the study.
Rheumatologist Allen D. Sawitzke, M.D., associate professor of internal medicine at the University of Utah School of Medicine, was lead investigator. "At two years, no treatment achieved what was predefined to be a clinically important reduction in joint space width loss," Sawitzke said. "While we found a trend toward improvement among those with moderate osteoarthritis of the knee in those taking glucosamine, we were not able to draw any definitive conclusions."
More than 21 million Americans have osteoarthritis, with many taking glucosamine and chondroitin sulfate, separately or in combination, to relieve pain. The original GAIT, led by University of Utah rheumatologist Daniel O. Clegg, M.D., professor of internal medicine, was a multicenter, randomized, national clinical trial that studied whether these dietary supplements provided significant pain relief to people with osteoarthritis in the knees. GAIT found that the supplements produced no more pain relief than placebo (New England Journal of Medicine, February 2006), although a subset of the original GAIT participants with moderate to severe osteoarthritis knee pain appeared to receive significant pain relief when they took a combination of glucosamine and chondroitin sulfate.
In this ancillary study, GAIT patients were offered the opportunity to continue their original study treatment for an additional 18 months, for a total of two years. Participants remained on their originally assigned GAIT treatment: 500 mg of glucosamine three times a day; or 400 mg of chondroitin sulfate three times a day; or a combination of the two supplements; or 200 mg of celecoxib daily; or a placebo.
X-rays were obtained at study entry and again at one and two years. Joint space width was measured on 581 knees from 357 patients. None of the trial groups showed significant improvement. The group taking glucosamine had the least change in joint space width, followed by the groups taking chondroitin sulfate, celecoxib, placebo and the combination of both dietary supplements.
The total joint space width loss over two years for each group was:
0. 0.013mm (glucosamine)
0. 0.107mm (chondroitin sulfate)
0. 0.111mm (celecoxib)
0. 0.166mm (placebo)
0. 0.194mm (glucosamine and chondroitin sulfate)
The interpretation of the results was problematic because the placebo group's joint space width loss was much less at two years than the 0.4mm the researchers' expected. Based on other large studies published in scientific journals, the researchers hypothesized that a loss of 0.2mm or less at two years would mean a slowed rate of cartilage loss. However, because the reduction in rate of joint space loss for all the groups was under the 0.2mm threshold, the researchers concluded none of the agents significantly slowed the loss of joint space width.
Josephine P. Briggs, M.D., director of the National Center for Complementary and Alternative Medicine, one of the study's funders, said although no definitive conclusions can be drawn about the two dietary supplements yet, "the results of the study provide important insights for future research."
Clegg said the trial shed light on osteoarthritis progression, techniques that can more reliably measure joint space width loss, possible effects of glucosamine and chondroitin sulfate, and on identifying patients who may respond best as further studies are pursued.
In a two-year multicenter study led by University of Utah doctors, the dietary supplements glucosamine and chondroitin sulfate performed no better than placebo in slowing the rate of cartilage loss in the knees of osteoarthritis patients.
This was an ancillary study concurrently conducted on a subset of the patients who were enrolled in the prospective, randomized GAIT (Glucosamine/chondroitin Arthritis Intervention Trial). The primary objective of this ancillary study was to investigate whether these dietary supplements could diminish the structural damage of osteoarthritis. The results, published in the October issue of Arthritis & Rheumatism, show none of the agents had a clinically significant effect on slowing the rate of joint space width loss —the distance between the ends of joint bones as shown by X-ray.
However, in line with other recent studies, the researchers observed that all the study's participants had a slower rate of joint space width loss than expected, making it more difficult to detect the effects of the dietary supplements and other agents used in the study.
Rheumatologist Allen D. Sawitzke, M.D., associate professor of internal medicine at the University of Utah School of Medicine, was lead investigator. "At two years, no treatment achieved what was predefined to be a clinically important reduction in joint space width loss," Sawitzke said. "While we found a trend toward improvement among those with moderate osteoarthritis of the knee in those taking glucosamine, we were not able to draw any definitive conclusions."
More than 21 million Americans have osteoarthritis, with many taking glucosamine and chondroitin sulfate, separately or in combination, to relieve pain. The original GAIT, led by University of Utah rheumatologist Daniel O. Clegg, M.D., professor of internal medicine, was a multicenter, randomized, national clinical trial that studied whether these dietary supplements provided significant pain relief to people with osteoarthritis in the knees. GAIT found that the supplements produced no more pain relief than placebo (New England Journal of Medicine, February 2006), although a subset of the original GAIT participants with moderate to severe osteoarthritis knee pain appeared to receive significant pain relief when they took a combination of glucosamine and chondroitin sulfate.
In this ancillary study, GAIT patients were offered the opportunity to continue their original study treatment for an additional 18 months, for a total of two years. Participants remained on their originally assigned GAIT treatment: 500 mg of glucosamine three times a day; or 400 mg of chondroitin sulfate three times a day; or a combination of the two supplements; or 200 mg of celecoxib daily; or a placebo.
X-rays were obtained at study entry and again at one and two years. Joint space width was measured on 581 knees from 357 patients. None of the trial groups showed significant improvement. The group taking glucosamine had the least change in joint space width, followed by the groups taking chondroitin sulfate, celecoxib, placebo and the combination of both dietary supplements.
The total joint space width loss over two years for each group was:
0. 0.013mm (glucosamine)
0. 0.107mm (chondroitin sulfate)
0. 0.111mm (celecoxib)
0. 0.166mm (placebo)
0. 0.194mm (glucosamine and chondroitin sulfate)
The interpretation of the results was problematic because the placebo group's joint space width loss was much less at two years than the 0.4mm the researchers' expected. Based on other large studies published in scientific journals, the researchers hypothesized that a loss of 0.2mm or less at two years would mean a slowed rate of cartilage loss. However, because the reduction in rate of joint space loss for all the groups was under the 0.2mm threshold, the researchers concluded none of the agents significantly slowed the loss of joint space width.
Josephine P. Briggs, M.D., director of the National Center for Complementary and Alternative Medicine, one of the study's funders, said although no definitive conclusions can be drawn about the two dietary supplements yet, "the results of the study provide important insights for future research."
Clegg said the trial shed light on osteoarthritis progression, techniques that can more reliably measure joint space width loss, possible effects of glucosamine and chondroitin sulfate, and on identifying patients who may respond best as further studies are pursued.
Thursday, January 29, 2009
Exercise Good For Bad Knees
Exercise Plays Large Role in Recovery from Knee Replacement and the Occurrence of Osteoarthritis
Two new studies found that exercise may be a factor in recovering from a total knee replacement (total knee arthroplasty or TKA) and knee osteoarthritis (OA). One study involving a progressive quadriceps strengthening program after total knee replacement found that it enhanced clinical improvement almost to the level of healthy older adults. The other study, the first to examine the relationship between four components of physical activity and the incidence of knee OA in older adults, found that certain types of activities were linked to an increased risk of the disease. The studies were published in the February issue of Arthritis Care & Research (http://www3.interscience.wiley.com/journal/77005015/home).
Nearly half a million total knee replacements are performed each year in the U.S. to treat severe knee OA, which is on the rise due to an increase in the elderly and overweight populations. Although knee replacement improves function, patients continue to have impaired quadriceps strength and function for activities such as walking and climbing stairs, which remain below those of healthy people of the same age. Rehabilitation targeting these areas has not been studied well and is not routinely prescribed.
A randomized controlled trial led by Lynn Snyder-Mackler of the University of Delaware and funded by the National Institutes of Health involved 200 patients who had undergone a knee replacement and 41 patients who received conventional standard of care (inpatient rehabilitation and home physical therapy). The 200 patients received six weeks of progressive strength training two or three times a week that targeted knee extension, range of motion, kneecap mobility, quadriceps strength, pain control and gait. Half of this group also received neuromuscular electrical stimulation (NMES).
The results showed that those who did the strength training program had significant improvements in quadriceps strength and muscle activation, functional performance and self-reported function and that they also demonstrated substantially greater quadriceps strength and functional performance after 12 months than the standard of care group. There were no significant differences between the group that just did exercise and the group that did exercise plus NMES.
“Our data suggest that individuals who do not undertake an intensive rehabilitation program following TKA are clearly at a disadvantage,” the authors state. They point out that quadriceps strength is related to functional performance and was the single greatest predictor of function for activities such as rising from a chair or climbing stairs. Functional performance typically peaks about three years following surgery and slowly declines in the following 10 years. “Failing to obtain adequate functional recovery may accelerate functional decline and predispose these individuals to an early loss of functional independence as they age,” the authors conclude.
Another study published in the same issue and led by Led by Marjolein Visser of VU University Medical Center in Amsterdam involved almost 1,700 men and women ages 55 to 85 years old of the LASA study that were assessed over a 12-year period for knee OA. Their physical activity was evaluated with a questionnaire that included information on frequency and duration of physical activity over a two-week period. Intensity, mechanical strain, turning action and muscle strength scores were created for each activity.
During the follow-up period, 28 percent of participants developed knee OA. Activities with low muscle strength (such as light household work) or high mechanical strain (such as dancing or tennis) were associated with an increased risk of knee OA, even after adjusting for demographics, health, and early life/current physical activity, as well as the other components of physical activity.
The study did not find an association between the level of overweight and mechanical strain in the incidence of knee OA. “This finding could indicate that the higher risk of knee OA in obese persons may be explained by factors other than increased mechanical strain, and higher levels of physical activity may not negatively affect knee health in heavier respondents,” the authors state.
The authors caution that before these results can be translated into advice for health professionals on daily activities for older adults, further studies need to be conducted to clarify the optimal amount of daily activity necessary for healthy joints for each component of physical activity.
Articles: “Improved Functioning From Progressive Strengthening Interventions After Total Knee Arthroplasty: A Randomized Clinical Trial With an Imbedded Prospective Cohort,” Stephanie C. Petterson, Ryan L. Mizner, Jennifer E. Stevens, Leo Raisis, Alex Bodenstar, William Newcomb, Lynn Snyder-Mackler, Arthritis & Rheumatism (Arthritis Care & Research), February 2009.
“Physical Activity and Incident Clinical Knee Osteoarthritis in Older Adults,” Lisanne M. Verweij, Natasja M. Van Schoor, Dorly J.H. Deeg, Joost Dekker, Marjolein Visser, Arthritis & Rheumatism (Arthritis Care & Research), February 2009.
Two new studies found that exercise may be a factor in recovering from a total knee replacement (total knee arthroplasty or TKA) and knee osteoarthritis (OA). One study involving a progressive quadriceps strengthening program after total knee replacement found that it enhanced clinical improvement almost to the level of healthy older adults. The other study, the first to examine the relationship between four components of physical activity and the incidence of knee OA in older adults, found that certain types of activities were linked to an increased risk of the disease. The studies were published in the February issue of Arthritis Care & Research (http://www3.interscience.wiley.com/journal/77005015/home).
Nearly half a million total knee replacements are performed each year in the U.S. to treat severe knee OA, which is on the rise due to an increase in the elderly and overweight populations. Although knee replacement improves function, patients continue to have impaired quadriceps strength and function for activities such as walking and climbing stairs, which remain below those of healthy people of the same age. Rehabilitation targeting these areas has not been studied well and is not routinely prescribed.
A randomized controlled trial led by Lynn Snyder-Mackler of the University of Delaware and funded by the National Institutes of Health involved 200 patients who had undergone a knee replacement and 41 patients who received conventional standard of care (inpatient rehabilitation and home physical therapy). The 200 patients received six weeks of progressive strength training two or three times a week that targeted knee extension, range of motion, kneecap mobility, quadriceps strength, pain control and gait. Half of this group also received neuromuscular electrical stimulation (NMES).
The results showed that those who did the strength training program had significant improvements in quadriceps strength and muscle activation, functional performance and self-reported function and that they also demonstrated substantially greater quadriceps strength and functional performance after 12 months than the standard of care group. There were no significant differences between the group that just did exercise and the group that did exercise plus NMES.
“Our data suggest that individuals who do not undertake an intensive rehabilitation program following TKA are clearly at a disadvantage,” the authors state. They point out that quadriceps strength is related to functional performance and was the single greatest predictor of function for activities such as rising from a chair or climbing stairs. Functional performance typically peaks about three years following surgery and slowly declines in the following 10 years. “Failing to obtain adequate functional recovery may accelerate functional decline and predispose these individuals to an early loss of functional independence as they age,” the authors conclude.
Another study published in the same issue and led by Led by Marjolein Visser of VU University Medical Center in Amsterdam involved almost 1,700 men and women ages 55 to 85 years old of the LASA study that were assessed over a 12-year period for knee OA. Their physical activity was evaluated with a questionnaire that included information on frequency and duration of physical activity over a two-week period. Intensity, mechanical strain, turning action and muscle strength scores were created for each activity.
During the follow-up period, 28 percent of participants developed knee OA. Activities with low muscle strength (such as light household work) or high mechanical strain (such as dancing or tennis) were associated with an increased risk of knee OA, even after adjusting for demographics, health, and early life/current physical activity, as well as the other components of physical activity.
The study did not find an association between the level of overweight and mechanical strain in the incidence of knee OA. “This finding could indicate that the higher risk of knee OA in obese persons may be explained by factors other than increased mechanical strain, and higher levels of physical activity may not negatively affect knee health in heavier respondents,” the authors state.
The authors caution that before these results can be translated into advice for health professionals on daily activities for older adults, further studies need to be conducted to clarify the optimal amount of daily activity necessary for healthy joints for each component of physical activity.
Articles: “Improved Functioning From Progressive Strengthening Interventions After Total Knee Arthroplasty: A Randomized Clinical Trial With an Imbedded Prospective Cohort,” Stephanie C. Petterson, Ryan L. Mizner, Jennifer E. Stevens, Leo Raisis, Alex Bodenstar, William Newcomb, Lynn Snyder-Mackler, Arthritis & Rheumatism (Arthritis Care & Research), February 2009.
“Physical Activity and Incident Clinical Knee Osteoarthritis in Older Adults,” Lisanne M. Verweij, Natasja M. Van Schoor, Dorly J.H. Deeg, Joost Dekker, Marjolein Visser, Arthritis & Rheumatism (Arthritis Care & Research), February 2009.
No Joint Benefit From Glucosamine Or Chondroitin
September 29, 2008
No Joint Benefit From Glucosamine Or Chondroitin
If glucosamine and chondroitin provide any relief from osteoarthritis 572 study participants weren't enough to prove it.
The dietary supplements glucosamine and chondroitin sulfate, together or alone, appeared to fare no better than placebo in slowing loss of cartilage in osteoarthritis of the knee, researchers from the Glucosamine/chondroitin Arthritis Intervention Trial (GAIT) team report in the October issue of Arthritis & Rheumatism.[1] Interpreting the study results is complicated, however, because participants taking placebo had a smaller loss of cartilage, or joint space width, than predicted. Loss of cartilage, the slippery material that cushions the joints, is a hallmark of osteoarthritis and its loss is typically measured as a reduction in joint space width—the distance between the ends of bones in a joint as seen on an X-ray.
Rather than slowing down the decay we really need ways to stop and reverse it. Some sort of stem cell therapy is the best bet. Gene therapy might end up helping but I expect benefits from stem cells sooner. Further out nanobots will do joint repair. I hope at least one of these becomes available before any of my joints start to ache.
Glucosamine might provide a small benefit. But if glucosamine does provide a benefit it is not so large that it shouts out.
Rheumatologist Allen D. Sawitzke, M.D., associate professor of internal medicine at the University of Utah School of Medicine, was lead investigator. "At two years, no treatment achieved what was predefined to be a clinically important reduction in joint space width loss," Sawitzke said. "While we found a trend toward improvement among those with moderate osteoarthritis of the knee in those taking glucosamine, we were not able to draw any definitive conclusions."
A whole lot of people suffer pain from osteoarthritis. How many do you know that live with constant osteoarthritic pain?
No Joint Benefit From Glucosamine Or Chondroitin
If glucosamine and chondroitin provide any relief from osteoarthritis 572 study participants weren't enough to prove it.
The dietary supplements glucosamine and chondroitin sulfate, together or alone, appeared to fare no better than placebo in slowing loss of cartilage in osteoarthritis of the knee, researchers from the Glucosamine/chondroitin Arthritis Intervention Trial (GAIT) team report in the October issue of Arthritis & Rheumatism.[1] Interpreting the study results is complicated, however, because participants taking placebo had a smaller loss of cartilage, or joint space width, than predicted. Loss of cartilage, the slippery material that cushions the joints, is a hallmark of osteoarthritis and its loss is typically measured as a reduction in joint space width—the distance between the ends of bones in a joint as seen on an X-ray.
Rather than slowing down the decay we really need ways to stop and reverse it. Some sort of stem cell therapy is the best bet. Gene therapy might end up helping but I expect benefits from stem cells sooner. Further out nanobots will do joint repair. I hope at least one of these becomes available before any of my joints start to ache.
Glucosamine might provide a small benefit. But if glucosamine does provide a benefit it is not so large that it shouts out.
Rheumatologist Allen D. Sawitzke, M.D., associate professor of internal medicine at the University of Utah School of Medicine, was lead investigator. "At two years, no treatment achieved what was predefined to be a clinically important reduction in joint space width loss," Sawitzke said. "While we found a trend toward improvement among those with moderate osteoarthritis of the knee in those taking glucosamine, we were not able to draw any definitive conclusions."
A whole lot of people suffer pain from osteoarthritis. How many do you know that live with constant osteoarthritic pain?
Chondroitin
Chondroitin is a molecule that occurs naturally in the body. It is a major component of cartilage -- the tough, connective tissue that cushions the joints. Chondroitin helps to keep cartilage healthy by absorbing fluid (particularly water) into the connective tissue. It may also block enzymes that break down cartilage, and it provides the building blocks for the body to produce new cartilage.
A number of scientific studies suggest that chondroitin may be an effective treatment for osteoarthritis (OA). OA is a type of arthritis characterized by the breakdown and eventual loss of cartilage, either due to injury or to normal wear and tear, and commonly occurs as people age. Chondroitin supplements have been shown to decrease the pain of OA. Some researchers think it may actually slow progression of the disease, unlike other current medical treatments for OA. (Many people take either acetaminophen or nonsteroidal anti-inflammatory drugs, such as ibuprofen and naproxen, for OA pain). However, so far studies have not shown conclusively that chondroitin helps repair or grow new cartilage, or stops cartilage from being further damaged. Chondroitin is often taken with glucosamine, another supplement thought to be effective in treating OA.
Therapeutic Uses
Treatment
Osteoarthritis
Results from several well-designed scientific studies indicate that chondroitin supplements may be an effective treatment for OA, particularly OA of the knee or hip. In general, findings from these studies suggest that chondroitin:
Reduces OA pain
Improves functional status of people with hip or knee OA
Reduces joint swelling and stiffness
Provides relief from OA symptoms for up to 3 months after treatment is stopped
However, the largest clinical trial so far, the 2006 Glucosamine/Chondroitin Arthritis Intervention Trial (GAIT), sponsored by the National Institutes of Health, showed conflicting and somewhat confusing results. The study of about 1,600 people with OA of the knee found that glucosamine and chondroitin did not reduce pain in the overall group, although it did appear to lessen pain among those with moderate-to-severe OA of the knee. The study has raised questions for further research. Since glucosamine and chondroitin were combined in this study, it is not possible to determine the effect of chondroitin alone. In addition, researchers are now studying whether the glucosamine-chondroitin combination may in fact help those with more severe OA.
Most studies have shown that chondroitin needs to be taken for 2 - 4 months before it shows effectiveness, although some improvement may be experienced sooner. Glucosamine and chondroitin can be used along with NSAIDs to treat OA.
Other
Other conditions for which chondroitin has been suggested include preterm labor, Alzheimer's disease, heart disease, and osteoporosis. However, no studies have yet evaluated these claims.
Dietary Sources
There are no significant dietary sources of chondroitin, so people who want to take it must take supplements.
Dosage and Administration
Chondroitin is commonly sold as chondroitin sulfate in capsule or tablet form. It is often combined with glucosamine and sometimes manganese as well. Manganese is a trace element necessary for normal bone health. While the total amount of manganese from foods and supplements should not exceed 11 mg per day, several combination supplements for arthritis (containing glucosamine, chondroitin, and manganese) contain more than that. Read labels carefully, and consider choosing a supplement without manganese.
A number of scientific studies suggest that chondroitin may be an effective treatment for osteoarthritis (OA). OA is a type of arthritis characterized by the breakdown and eventual loss of cartilage, either due to injury or to normal wear and tear, and commonly occurs as people age. Chondroitin supplements have been shown to decrease the pain of OA. Some researchers think it may actually slow progression of the disease, unlike other current medical treatments for OA. (Many people take either acetaminophen or nonsteroidal anti-inflammatory drugs, such as ibuprofen and naproxen, for OA pain). However, so far studies have not shown conclusively that chondroitin helps repair or grow new cartilage, or stops cartilage from being further damaged. Chondroitin is often taken with glucosamine, another supplement thought to be effective in treating OA.
Therapeutic Uses
Treatment
Osteoarthritis
Results from several well-designed scientific studies indicate that chondroitin supplements may be an effective treatment for OA, particularly OA of the knee or hip. In general, findings from these studies suggest that chondroitin:
Reduces OA pain
Improves functional status of people with hip or knee OA
Reduces joint swelling and stiffness
Provides relief from OA symptoms for up to 3 months after treatment is stopped
However, the largest clinical trial so far, the 2006 Glucosamine/Chondroitin Arthritis Intervention Trial (GAIT), sponsored by the National Institutes of Health, showed conflicting and somewhat confusing results. The study of about 1,600 people with OA of the knee found that glucosamine and chondroitin did not reduce pain in the overall group, although it did appear to lessen pain among those with moderate-to-severe OA of the knee. The study has raised questions for further research. Since glucosamine and chondroitin were combined in this study, it is not possible to determine the effect of chondroitin alone. In addition, researchers are now studying whether the glucosamine-chondroitin combination may in fact help those with more severe OA.
Most studies have shown that chondroitin needs to be taken for 2 - 4 months before it shows effectiveness, although some improvement may be experienced sooner. Glucosamine and chondroitin can be used along with NSAIDs to treat OA.
Other
Other conditions for which chondroitin has been suggested include preterm labor, Alzheimer's disease, heart disease, and osteoporosis. However, no studies have yet evaluated these claims.
Dietary Sources
There are no significant dietary sources of chondroitin, so people who want to take it must take supplements.
Dosage and Administration
Chondroitin is commonly sold as chondroitin sulfate in capsule or tablet form. It is often combined with glucosamine and sometimes manganese as well. Manganese is a trace element necessary for normal bone health. While the total amount of manganese from foods and supplements should not exceed 11 mg per day, several combination supplements for arthritis (containing glucosamine, chondroitin, and manganese) contain more than that. Read labels carefully, and consider choosing a supplement without manganese.
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