Transcript Exercise therapy in knee OA

Exercise therapy in Knee
Osteoarthritis
Marike van der Leeden PT PhD
Amsterdam Rehabilitation Research Center | Reade
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Osteoarthritis
Prevalence symptomatic OA in among adults aged ≥45
years
• Knee 16.7%
• Hip 9.2%
Jordan et al, 2007
Top 10 of most disabling diseases in European region
Most important cause of pain and disability in the elderly
WHO, 2008
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Conaghan et al, 2008
Total joint failure
Bijlsma et al, Lancet, 2011
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Osteoarthritis – multiple levels
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Impairments of cartilage and bone
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Findings on X-rays, MRI
Physical impairments
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Sensory impairments
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Pain, stiffness
Limitations in activity and functioning
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Muscle weakness, instability
Walking, rising
Problems in participation
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Work
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Exercise therapy in knee OA
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Exercise is dominant intervention
• Pain relieve
• Improved performance of activities
Franssen, 2008, 2009
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Exercise recommended in all major guidelines
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Definition and types of exercise
Definition: ‘a planned, structured and repetitively movement
designed to improve or maintain one or more components of
physical fitness’
Types of exercises:
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Muscle strenghtening:
• strength: maximum amount of force a muscle can generate
• endurance: ability of muscles to sutain muscle action
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Aerobic: improvement of aerobic capacity, eg walking, cycling
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Flexibility: stretching exercises to increase ROM
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Functional exercises: train problematic activities
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Evidence?
Cochrane Review
“Exercise for Osteoarthritis of the Knee”
Fransen M et al., January 2015
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Objectives
Update of Cochrane review of 2008
‘To determine whether land-based therapeutic exercise is
beneficial for people with knee OA in terms of reduced joint pain
or improved physical function and quality of life’
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Data collection and analysis
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A systematic review and meta-analysis was conducted
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Five databases were searched from their inception until May
2013
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Inclusion of all randomised controlled trials (RCTs) recruiting
people with knee OA and comparing some form of land-based
therapeutic exercise (as opposed to exercises conducted in the
water) with a non-exercise or non-treatment (or waiting list)
intervention were included (n =54)
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Main results on pain
High-quality evidence from 44 trials (3537 participants) indicates
that exercise reduced pain (SMD -0.49, 95% CI -0.39 to -0.59)
immediately after treatment
Pain was estimated at 44 points on a
0 to 100-point scale (0 indicated no pain)
in the control group;
exercise reduced pain by an equivalent
of 12 points (95% CI 10 to 15 points).
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Main results on physical function
Moderate-quality evidence from 44 trials (3913 participants)
showed that exercise improved physical function (SMD -0.52, 95%
CI -0.39 to -.064) immediately after treatment
Physical function was estimated at 38 points
on a 0 to 100-point scale (0 indicated no loss
of physical function) in the control group;
exercise improved physical function
by an equivalent of 10 points (95% CI 8 to 13 points)
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Treatment content
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Conclusion Cochrane review
High-quality evidence indicates that land-based therapeutic
exercise provides short-term benefit in terms of reduced knee
pain, and moderate-quality evidence shows improvement in
physical function among people with knee OA.
The magnitude of the treatment effect would be considered
moderate (immediate) to small (two to six months) but
comparable with estimates reported for non-steroidal antiinflammatory drugs.
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Optimization of effectiveness
• Effects are small to moderate
• Optimization of effects through targeted exercise
programs for specific subgroups
Targeted exercise therapy
Pain
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van Tunen et al, submitted
Pain medication and exercise
Muscle weakness
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de Zwart et al, accepted
Vitamin D, strength training
Comorbidity
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Exercise adapted to comorbidity
Depressive mood and avoidance
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Veenhof et al, Arthritis Care Res, 2006
Exercise plus graded increase of physical activity level
Instability of the knee joint
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de Rooij et al, in progress
Knoop et al, Osteoarthritis Cartilage, 2013
Proprioceptive exercise, strength training
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Stability trial
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Muscle weakness
Instability of knee joint:
 >60% of knee OA patients1,2
 associated with activity limitations1,2
1 van
der Esch et al, ’12; 2 Fitzgerald et al, ‘04
Laxity
(In)stability
knee
Poor proprioception
Varus-valgus knee motion
during walking
van der Esch et al,’06/’07
Activity
limitations
Exercise programs
Week 1-4
Experimental program
Week 5-8
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Week 9-12
Week 1-4
Week 5-8
Week 9-12
Focus on knee stabilization
Focus on muscle strengthening
Focus on performance
daily activities
Knee stabilization training +
education
Muscle endurance
Functional training + maximal strength +
aerobic training
Minimal intensity/loading
Increasing intensity and loading
Week 1-4
Control program
Week 5-8
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Week 9-12
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Minimal muscle training +
education
Minimal intensity/loading
Week 1-8
Week 9-12
Focus on muscle
strengthening
Focus on performance
daily activities
Muscle endurance
Increasing intensity and loading
Functional training + maximal strength +
aerobic training
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159 knee OA with knee
joint instability:
randomized
12 weeks with 2
sessions + home
exercises;
6-8 patients per group,
supervised by two pt’s;
gradual increase in
intensity and knee
loading;
exercises linked to daily
activities;
patients encouraged to
remain physically active
after treatment
Knee joint stabilization training
- feedback by PT’s
- use of mirrors
- specific exercises
Study design
•Randomized controlled trial (single-blinded)
• two exercise programs.
•Inclusion criteria:
• diagnosis of knee OA (ACR)
• knee instability
• age 40-75 years.
•Outcome measures:
• WOMAC, physical function (primary)
• NRS pain, GUG- test, global perceived effect, self-reported knee
instability, muscle strength, proprioception
• measurements at baseline, 6-week (mid-treatment), 12-week (posttreatment) and 38-week follow-up (6 months post-treatment)
• assessor blinded for treatment allocation.
Amsterdam Rehabilitation Research Center | Reade
Flow chart
61% female
age: 62 ± 7 yr
69% K/L ≥ 2
Amsterdam Rehabilitation Research Center | Reade
Results (1)
Primary outcome: WOMAC,
physical function (0-68)
Mean difference: B (95% CI) = -0.01 (-2.58-2.57)
Secundary outcome:
NRS knee pain (0-10)
Mean difference: B (95% CI) = -0.26 (-0.76-0.23)
• No difference in effectiveness between programs
Result on muscle strength
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Result on knee stability
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Results (2)
• Both exercise programs are highly effective and safe:
• effect size: 0.9 for pain and 0.7-0.8 for function
• effects unharmed after 6 months
• no adverse events
Conclusion Stability trial (1)
• No added value of additional knee joint stabilization
treatment, which is consistent with literature:
No differences between:
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strength only vs. proprioceptive/balance + strength training (Diracoglu, ‘05)
strength only vs. agility/perturbation + strength training (Fitzgerald, ‘11)
strength only vs. neuromuscular + strength training (Bennell, ‘14)
Conclusion Stability trial (2)
 Important role of muscle strength in knee
stabilization:
a)
b)
Most important mechanoreceptors for proprioception located inside
muscles: muscle spindles.
Self-reported knee instability associated with muscle weakness,
while not with poor proprioception or high laxity (Knoop et al. Arthritis
Care Res, 2012 Jan; 64(1)-38-45).
Implications for exercises
Exercising knee OA patients starts with muscle
strengtening exercises (focus on quadriceps strength)
and additional attention on knee joint stability
It seems that specific attention for knee stability is
neccessarry in case of sufficient muscle strength or
high laxity AND knee joint instability
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Is the severity of knee OA on
MRI associated with outcome
of exercise therapy?
Knoop et al, 2014
Background
• Effectiveness and safety of exercise therapy for OA patients with
severe joint damage have been questioned
• Randomized clinical trial to compare two exercise programs
(Knoop et al, Osteoarthritis Cartilage 2013)
• The two 12-week, supervised exercise programs (with/without
knee stabilization training) were equally effective
• From the total group of (ranging from K/L grade 0-4), baseline MRIs
were obtained in a random subsample (n=95)
Aim of study
To explore whether the severity of knee OA on MRI is
associated with treatment outcome in knee OA
patients treated with exercise therapy
Study sample (n=95)
MRI features*
MRI features*
Cartilage loss:
Effusion:
MRI protocol:
grade 0
7%
grade 0
34%
grade 1
8%
grade 1
30%
grade 2
31%
grade 2
23%
grade 3
54%
grade 3
13%
Synovitis:
Bone marrow lesions:
grade 0
17%
absent
66%
grade 1
25%
present
34%
grade 2
27%
Meniscal lesions:
grade 3
31%
grade 0
7%
grade 1
13%
Osteophytes:
grade 0
15%
grade 2
22%
grade 1
38%
grade 3
58%
grade 2
33%
*highest
grade 3
15%
regional grade per knee
•3.0 Tesla MRI (GEMS)
•5 sequences
•one index knee
•Boston Leeds Osteoarthritis
Scoring (BLOKS) system, in
which knee is subdivided
into multiple regions; each
region scored for severity of
MRI-feature (Hunter et al, 2008).
Results (1/3)
• Outcome of exercise therapy independent of severity
of knee OA in any MRI-feature
Example:
• With two exceptions
Results (2/3)
PF cartilage loss
p=0.01 for WOMAC physical function
p=0.04 for upper leg muscle strength
Results (3/3)
PF osteophyte formation
p<0.01 for upper leg muscle strength
Conclusions
• First study to explore the role of OA severity on MRI in
the effectiveness of exercise therapy
• Outcome of exercise therapy is independent of OA
severity
• Only exception seems to be advanced PF OA, in which
effects might be reduced; this needs replication for
validation
Implications
• Referral to exercise therapy needs to be considered
prior to total knee arthroplasty in patients with ‘endstage’ knee OA
• Also in patients with severe knee OA, weightbearing
intense exercises can be provided, if gradually
increased and professionally supervised
Future research
Effects on inflammation
Exercise more effective in inflammatory phenotype of
OA?
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Summary
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Exercise therapy is effective to reduce pain and
improve function
Targeting exercise therapy to specific groups seems
promising for patients with severe pain,
comorbidities, and probably inflammation
No added value of additional knee joint stabilization
treatment in patients with knee instability
Exercise therapy can be effective in all grades of OA
severity
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Questions:
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