Healio
Healio
December 19, 2011
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Nonpharmacologic Treatment Options for Knee Pain

A 66-year-old woman presents to her physiatrist with a chief complaint of right knee pain that limits her ability to climb stairs and walk her dog during obedience and skill training. Her pain has consequently tempered her enthusiasm for meeting a group of friends for lunch who also bring their dogs for training every week.

The patient describes her pain as a constant dull ache with intermittent periods of excruciating pain. She takes acetaminophen 1,000 mg 3 times a day, which results in a minor improvement in pain. Both the constant dull ache and excruciating types of pain occur within the patellofemoral and medial joint line regions of her right knee. She rates her constant pain as a 4/10 and the excruciating pain, when it occurs, as 8/10. Her pain is exacerbated by stair climbing, squatting, rising from a chair after sitting for a while, and getting in and out of a car.

Her knee pain started 2 years ago when she was working part time as a hospital aide. She attributed the pain to aging and ignored it for the most part, treating it with acetaminophen as needed. About a year ago, she noticed pain more frequently and retired from her job. Her primary care physician prescribed tramadol, and following 3 months of treatment with no pain relief, she was referred to orthopedic surgery. X-rays revealed moderate joint space narrowing of the medial tibiofemoral joint and the presence of osteophytes, and so she was diagnosed with radiographic knee osteoarthritis. However, she was not a surgical candidate for a total knee replacement given her diagnosis of severe congestive heart failure. Hence, she was referred back to her primary care physician, who then consulted physical medicine and rehabilitation.

On exam, the patient has a body mass index of 34, blood pressure of 130/75 mm Hg and heart rate of 70 bpm. In standing, the patient has genu valgum of her right knee. During a 10-meter hallway walk at a usual pace, she walks 1.1 meters per second, and her gait is somewhat antalgic for the first few steps before her cadence becomes symmetrical. After the walk, she transitions to sitting, shifting weight to her left lower extremity, extending her right knee and falling into the chair. Her right knee range of motion is 0 to 100 with a painful end-feel. Her right ankle and hip have normal range of motion. A patellar grind test is positive for pain, and she reports less pain with tibiofemoral joint distraction. Medial and lateral knee ligaments are stable. Her right knee strength is 5/5 with a manual muscle test.

Clinical Questions

  • Given that the patient has radiographic knee osteoarthritis with mild functional limitation and is not a surgical candidate, what treatment options are available?
  • What conservative, nonpharmacologic approaches can be recommended for this patient’s care that could decrease her pain and functional limitation?

Treatment Options

The latest Osteoarthritis Research Society International (OARSI) treatment recommendations for hip and knee OA support weight reduction and exercise for pain relief.1 A recent systematic review of physical therapy interventions support this recommendation as well.2 Certainly diet and exercise are not unfamiliar to the treatment of knee OA; however, these interventions are commonly overlooked clinically despite their effectiveness.3 In particular, supervised walking programs have been shown to improve function and decrease pain among people with painful knee OA,4,5 which is contrary to the clinical hesitation to ask people with knee pain to walk for exercise.

Other types of exercise effective for knee OA include lower body strengthening and stationary cycling,6,7 and tai chi has shown promise in decreasing pain and increasing function in people with knee OA.8 Given the multiple effective exercise interventions, attention should be paid to patient preference. Long-term adherence to any conservative, nonpharmacologic intervention is perhaps the most challenging aspect of exercise prescription. The good news is that a recent Cochrane review found a medium effect for reduction in pain regardless of whether exercise was delivered in an individual or group clinic setting or in a home setting.9 Because of this patient’s comorbid heart condition, exercise clearance from her primary care physician or cardiologist should be considered. Type and duration of activity should be closely tailored to protect the patient from cardiac complications.

From a physical medicine and rehabilitation perspective, this patient could be prescribed weight management from either a referral to a nutrition counselor or self-management (e.g., Weight Watchers). Exercise prescription, regardless of modality, should start with low, achievable goals and progress in duration and intensity.

An ideal goal would be to achieve physical activity guidelines for exercise: participating in 150 minutes of moderate-intensity activity per week. For instance, the patient states likes to take walks in her neighborhood. Exploiting this preference, she could be prescribed a walking program using a pedometer to help monitor her progress. Ideally, the patient should build up to walking at least 3,000 steps in 30 minutes with breaks as needed,10 though initially shorter bouts of walking 1,000 steps in 10 minutes, with breaks, may be more amenable to managing her knee pain while walking, with the expectation that pain would decrease as she stays with the program. Should her pain continue to be exacerbated with walking, alternative exercises, such as tai chi, biking or swimming, could certainly be considered.

References

  1. Zhang W, Nuki G, Moskowitz RW, Abramson S, Altman RD, Arden NK, et al. OARSI recommendations for the management of hip and knee osteoarthritis: part III: Changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis Cartilage.18(4):476-499.
  2. Jamtvedt G, Dahm KT, Christie A, Moe RH, Haavardsholm E, Holm I, et al. Physical therapy interventions for patients with osteoarthritis of the knee: an overview of systematic reviews. Phys Ther. 2008;88(1):123-136.
  3. Hunter DJ, Neogi T, Hochberg MC. Quality of osteoarthritis management and the need for reform in the US. Arthritis Care Res (Hoboken).63(1):31-38.
  4. Messier SP, Loeser RF, Miller GD, Morgan TM, Rejeski WJ, Sevick MA, et al. Exercise and dietary weight loss in overweight and obese older adults with knee osteoarthritis: the Arthritis, Diet, and Activity Promotion Trial. Arthritis Rheum. 2004;50(5):1501-1510.
  5. Ettinger WH, Jr., Burns R, Messier SP, Applegate W, Rejeski WJ, Morgan T, et al. A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis. The Fitness Arthritis and Seniors Trial (FAST). JAMA. 1997;277(1):25-31.
  6. Baker KR, Nelson ME, Felson DT, Layne JE, Sarno R, Roubenoff R. The efficacy of home based progressive strength training in older adults with knee osteoarthritis: a randomized controlled trial. J Rheumatol. 2001;28(7):1655-1665.
  7. Mangione KK, McCully K, Gloviak A, Lefebvre I, Hofmann M, Craik R. The effects of high-intensity and low-intensity cycle ergometry in older adults with knee osteoarthritis. J Gerontol A Biol Sci Med Sci. 1999;54(4):M184-190.
  8. Wang C, Schmid CH, Hibberd PL, Kalish R, Roubenoff R, Rones R, et al. Tai Chi is effective in treating knee osteoarthritis: a randomized controlled trial. Arthritis Rheum. 2009;61(11):1545-1553.
  9. Fransen M, McConnell S. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev. 2008(4):CD004376.
  10. Marshall SJ, Levy SS, Tudor-Locke CE, Kolkhorst FW, Wooten KM, Ji M, et al. Translating physical activity recommendations into a pedometer-based step goal: 3000 steps in 30 minutes. Am J Prev Med. 2009;36(5):410-415.