Knee Osteoarthritis Assessment Management Presentation Slides

Knee Osteoarthritis Assessment
and Management
An evidence-based guide for clinicians
Presented By
Anthony Teoli MScPT
Physiotherapist
Founder/President of
InfoPhysiotherapy
Twitter: @InfoPhysioPT Facebook: @infophysiotherapy

Instagram: @infophysiotherapy LinkedIn: @anthonyteoli
Presented by
Anthony Teoli MScPT

Anthony Teoli MScPT
◻ Physiotherapist in private practice in Laval,
Quebec (Canada)
◻ Graduated from McGill University with a
Master of Science degree in Physical
Therapy in 2016
◻ Returning to complete my PhD at McGill
University in September 2018 with a focus
on knee osteoarthritis research and
knowledge translation
◻ Founder and President of InfoPhysiotherapy
Anthony Teoli MScPT
❏ Conducted two
research studies
examining the
relationship between
knee osteoarthritis and
walking kinematics.
❏ This research was

presented at
provincial, national
and international
conferences.

Anthony Teoli MScPT
◻ Published first article
with two co-authors in
July 2016.
◻ Research interests:
knowledge translation,
promoting best
practice in the
conservative
management of knee
OA, walking
biomechanics

Course Objectives
1. Understand and appreciate the complex,
multifactorial nature of knee OA.
2. Identify important risk factors for disease

initiation and progression.
3. Apply evidence-based assessment tools

and strategies to inform clinical diagnosis
and treatment strategies.
Course Objectives
4. Understand the importance of identifying
psychosocial factors, and how they relate to
prognosis, outcomes, etc.
5. Understand the importance of listening,

reassurance and patient education.
6. Integrate and apply evidence-based

non-surgical management strategies for
patients with knee OA.
Outline
Part 1 - Understanding Part 2 - Assessment &
Knee OA Management
Introduction Assessment
Epidemiology Clinical Diagnosis
Etiology Non-surgical
Risk Factors Management
Surgical
Management

NOTE:
This presentation cites more
than 150 peer-reviewed
articles from the scientific
literature!
REFERENCES
Lesson 1:
What is knee OA?
The Burden of
Osteoarthritis
❏ Osteoarthritis (OA) is the most common
joint disorder worldwide (Litwic et al., 2013)
❏ Can occur in any joint, but often occurs

in the knees, hips, lower back, neck
and small joints of the fingers and toes
❏ Hip and knee OA is one of the leading

causes of global disability (Cross et al., 2014)
The Burden of OA
❏ OA affects over 250 million people or 4% of
the world’s population (Vos et al., 2010)
❏ According to the WHO: 9.6% of men and

18.0% of women older than 60 years of age
WORLDWIDE have symptomatic OA (Bone and
Joint Canada, 2014)
❏ No longer a disease of the elderly. OA is

ranked among the top 20 diseases in the
40–45 years age group (Institute for Health Metrics and
Evaluation, 2015)
What is Osteoarthritis?
Definition: “Osteoarthritis is a disorder involving
movable joints characterized by cell stress and
extracellular matrix degradation initiated by micro-
and macro-injury that activates maladaptive repair
responses including pro-inflammatory pathways
of innate immunity. The disease manifests first as a
molecular derangement (abnormal joint tissue
metabolism) followed by anatomic, and/or
physiologic derangements (characterized by
cartilage degradation, bone remodeling, osteophyte
formation, joint inflammation and loss of normal
joint function), that can culminate in illness.”
Osteoarthritis Research Society International (OARSI, 2015)

Knee Osteoarthritis
Characterized by:
❏ Progressive loss and destruction of
articular cartilage
❏ Thickening of the subchondral bone
❏ Formation of osteophytes
❏ Variable degrees of inflammation of the
synovium
❏ Degeneration of ligaments and menisci of
the knee
❏ Hypertrophy of the joint capsule.
Chen et al., 2017

Knee Osteoarthritis
Can be categorized as:
- Non-traumatic (idiopathic)
- Post-traumatic (i.e. post-ACL injury)
Sward et al., 2010

Vanwanseele et al.; 2010
Kellgren and Lawrence system for
classification of knee OA severity
Grade 0: no radiographic features of OA are present
Grade 1: doubtful joint space narrowing (JSN) and

possible osteophytic lipping
Grade 2: definite osteophytes and possible JSN on AP

weight-bearing radiograph
Grade 3: multiple osteophytes, definite JSN, sclerosis,

possible bony deformity
Grade 4: large osteophytes, marked JSN, severe sclerosis

and definite bony deformity
Kohn et al., 2016

The OA Systems Model
Cartilage health is dependent on the integrated
behavior of biological, mechanical and
structural components.
Healthy cartilage homeostasis is maintained

when each of the components is within normal
ranges during normal activity.
Figure 1 - Andriacchi et al., 2015

The OA Systems Model
Introducing a “risk factor” moves one or more
components (and the system) out of
homeostasis.
The latter can lead to the initiation of cartilage

degradation (pre-OA).
The time required to develop clinical OA is

dependent on on the state of the other
components.
Figure 1 - Andriacchi et al., 2015

What about symptomatic
knee OA?
Osteoarthritis is a disease
of the whole person!
Lesson 1:
What is knee OA?
Lesson 2:
Etiology, Risk Factors
& Prevention
Etiology of Knee
Osteoarthritis
Knee OA is a
complex and
multifactorial
disease!
Risk Factors For Knee OA
◻ Age (Silverwood et al., 2015)
◻ Obesity (Silverwood et al., 2015)
◻ Previous knee injury

(Silverwood et al., 2015)
◻ Gender (Silverwood et al., 2015)
◻ Excessive/abnormal knee
joint loading (Sharma et al., 2006)
◻ Knee extensor muscle

strength (Oiestad et al., 2015)
◻ Knee Mal-Alignment
(Tanama et al., 2009; Sharma et al., 2010)
◻ Genetics (Ryder et al., 2008)
◻ Occupational Risks (Ingham

et al., 2011; Zhang et al., 2011)
Age and Knee OA
Knee osteoarthritis is more
than just “wear and tear”!
Age and Knee OA
❏ The risk of developing knee OA increases
substantially above 45 yo (Felson et al., 1987)
❏ Approximately 50% of individuals above

the age range of 45 to 75 years DO NOT
develop clinical OA (Felson et al., 1987)
❏ The number of cycles of mechanical load

over time does not necessarily cause
cartilage to breakdown.
Andriacchi et al., 2015

Age and Knee OA
EXAMPLE
In the absence of joint trauma, who would
be at more risk for developing knee
osteoarthritis?
A. Healthy older, more active,

moderate-weight individuals
B. Healthy, older, more sedentary,
moderate-weight individuals

Age and Knee OA
One might initially be tempted to think that
more active individuals (i.e. individuals with
a greater number of loading cycles) would
have a higher incidence of knee OA than
their less active counterparts.
“However, it is difficult to find quantitative

evidence to suggest that more active
individuals have a greater incidence of
knee OA.”
Age and Knee OA
Knee osteoarthritis is more
than just “wear and tear”!
Obesity Is A Robust Risk
Factor For Knee
Osteoarthritis
Obesity & Knee OA
❏ Knee OA risk increased almost
exponentially according with the
increase of BMI (Zhou et al., 2014)
❏ Each 8 kg increase in weight as a young

adult (20-29 years) was associated with a
70% increase in risk of clinical knee OA
more than 30 years later (Gelber et al., 1999)
❏ Risk of knee OA increased up to 35% with a

5 kg/m2 increase in BMI (Zheng & Chen, 2015)
Obesity & Knee OA
❏ Lifetime risk of symptomatic radiographic
knee OA increased by 30.3% in individuals
who were obese compared with those who
had a normal BMI (Murphy et al., 2008)
❏ Large, population based prospective study

(n=823) with follow-up of 22 years
demonstrated that the risk for knee OA was
7 times greater for people with BMI > 30
kg/m2 compared to the control group with
a BMI < 25 (Toivanen et al., 2010)
Obesity & Knee OA
❏ Lohmander et al., 2009
➢ Large, Swedish prospective cohort
study (n = 27 960)
➢ BMI, waist circumference, waist-hip
ratio, body weight and body fat
percentage were monitored over 11
years.
➢ Being overweight was associated with
the incidence of knee osteoarthritis,
with BMI eliciting the strongest
association (relative risk ratio from
2.2-8.1).
Obesity and Knee OA
What’s the Link?
Increased Joint Loading
❏ Excessive and abnormal joint loading have
been suggested to be an important risk
factor for the development of knee
osteoarthritis (Andriacchi et al., 2015)
❏ Abnormal loads have been shown to alter

the composition, structure, and mechanical
properties of hyaline cartilage, leading to
erosion of the surface cartilage (Sowers &
Karvonen-Gutierrez, 2010)
CLINICAL RELEVANCE
It is possible that the additional body mass
can stress articular cartilage beyond the
biological regeneration capabilities,
potentially initiating degenerative changes
over time.
❏ It has been suggested that mechanical
activation of chondrocyte
mechanoreceptors may increase
expression of cytokines, growth factors and
metalloproteinases.
❏ These processes may lead to additional

oxidative stress, inflammation, and tissue
breakdown at the knee joint.
Teichtahl et al. 2008

Systemic Inflammation
❏ Obesity is thought to contribute to
systemic inflammation through secretion
of adipokines (Conde et al., 2011; Fain et al., 2010)
❏ May trigger the signaling pathways that

stimulate articular chondrocyte catabolic
processes and lead to extracellular
matrix degradation (Kapoor et al., 2011)
❏ C-reactive protein (CRP) is associated
with decreased cartilage volume and
disease progression of OA (Spector et al., 1997;
Sharif et al., 2000; Hanna et al., 2008)
❏ Interleukin-6 and Interleukin-1 (primary

regulators of CRP) are also positively
associated with knee joint space
narrowing (Stannus et al., 2010)
❏ Fat mass has also been shown to be a risk
factor for cartilage defects (Berry et al., 2010)
❏ Adipose tissue is an endocrine organ that can

secrete substances such as cytokines and
adipocytokines (Sowers and Karvonen-Gutierrez 2010)
❏ Elevated concentrations of adipocytokines

have been identified in the synovial fluid and
plasma of OA patients, potentially influencing
cartilage homeostasis (Lee & Kean, 2012)
CLINICAL RELEVANCE
Systemic inflammation caused by obesity
may play an important role in OA initiation
and progression. This could also potentially
explain the positive association between
obesity and hand OA, despite the hands not
being weight-bearing joints.
Carman et al., 1994; Oliveria et al., 1999

Previous Knee Injury
and Knee OA
Approximately 50% of
individuals diagnosed
with ligaments and/or
meniscal injuries will have
OA 10 to 20 years later,
with pain and functional
impairment (Lohmander et al., 2007)
❏ 9 studies included in systematic review,
6 studies were further included in
meta-analysis.
❏ 121 of 596 (20.3%) ACL-injured knees

had moderate or severe radiologic
changes vs. 23 of 465 (4.9%) un-injured
contralateral knees.
SR - Ajuied et al., 2013

Non-operative ACL Reconstructive
ACL Injury Surgery
Relative Risk (RR) of Relative Risk (RR) of
developing any grade developing any grade
of knee OA: 4.98 of knee OA: 3.96
ACL-reconstructed knees had a significantly higher

RR (RR, 4.71; P < .00001) of progressing to moderate
or severe OA after 10 years compared with
non-operative management (RR, 2.41; P = .54).
SR - Ajuied et al., 2013

❏ 4 retrospective studies included
❏ 140 surgical patients, 240 nonsurgical

patients
❏ Average length of follow-up was 11.8 years
Prevalence of knee OA:

Surgically treated patients: 32.6% to 51.2%
Non-surgical patients: 24.5% to 42.3%
SR - Harris et al., 2017
❏ 135 (82%) of 164 patients at a mean of
14 years after ACL reconstruction
randomized to a quadrupled
semitendinosus tendon or a
bone-patellar tendon-bone graft.
❏ Outcome measures: radiological

examination results, Tegner activity
levels, and KOOS values
RCT - Barenius et al. 2014

Increased prevalence of OA for
ACL injury treated with
reconstruction vs. contralateral
healthy knee
Initial meniscus resection was a strong risk

factor for OA. The time between injury and
reconstruction was not.
No significant difference between type of ACL

reconstruction (OA incidence & KOOS scores).
RCT - Barenius et al. 2014

❏ Cohort study
❏ 210 subjects, prospectively followed from

15 to 20 years after ACL reconstruction
Prevalence at 20-year follow-up:

❏ Tibiofemoral OA: 42% (↑ in subjects with
combined injuries vs. isolated ACL injury)
❏ Patellofemoral OA: 21%
Cohort - Risberg et al., 2016

❏ The majority of the subjects were stable
radiographically over the 5 years
between follow-ups.
❏ Significant deterioration in knee

symptoms and function was observed
on the KOOS subscales (P ≤ .01), but not
in QOL (P = .14).
Cohort - Risberg et al., 2016

Previous Knee Injury
and Knee OA
CLINICAL RELEVANCE
1. Sustaining a knee injury (i.e. ACL tear, meniscus
tear, etc.) increases the risk of developing knee
OA 10 to 20 years later.
2. ACL reconstructed knees have a higher relative

risk of developing knee OA after 10 years vs.
non-operatively managed knees.
3. Combined injuries further increase the risk of

developing knee OA vs. isolated injuries.
Does Sports Participation
Increase the Risk of Knee
OA?
❏ 31 of 46 studies demonstrated ↑ risk of OA
❏ 19 demonstrating an ↑ risk in elite athletes.
❏ ↑ risk after sports exposure
❏ Low-quality evidence to support an

increased relationship between sports
participation and OA in elite participants.
SR – Tran et al., 2016

Sports Participants Non-exposed controls
(n = 3759) (n = 4730)
7.7% prevalence of 7.3% prevalence of
knee OA knee OA
SR – Driban et al., 2015

Specific sports had a significantly higher
prevalence of knee OA
Elite-level
Soccer long-distance Weight
Elite + non-elite running Lifting Wrestling
OR = 3.5 OR = 3.8 OR = 6.9 OR = 3.8

Sports Participation and
Knee OA
CLINICAL RELEVANCE
1. Sport participation may increase the risk of
osteoarthritis.
2. Unclear whether this is due to the specific

sport, a sport-related injury, or some other
unknown factor.
3. Participation in certain sports may be

associated with knee osteoarthritis later in life.

Sports Participation and
Knee OA
CLINICAL RELEVANCE
4. Athletes who choose to participate in contact
and collision sports such as soccer and football
at elite levels may also have an increased
likelihood of developing osteoarthritis.
5. Strategies should be implemented to mitigate

other factors (i. e. preventing obesity and severe
joint injuries) associated with the development of
osteoarthritis.

Does Running Cause
Knee OA?
45 long distance runners, 53 controls
Prevalence of Knee OA
1984 2002
6.7% in runners 20% in runners
0% in controls 32% in controls
CONCLUSION
By the end of the study, runners did not have more prevalent
OA nor more cases of severe OA than did controls.
Chakravarty et al., 2008

METHODS
Retrospective cross-sectional study of 2637 Osteoarthritis Initiative
participants (2004 – 2014) with knee x-ray readings.
Participants were asked to identify all activities they performed at

least 20 minutes within a given day at least 10 times in their lives
during 4 age periods: ages 12 – 18, 19 – 34, 35 – 49 and > 50 years old.
Individuals indicating running or jogging as a top 3 activity were

defined as runners in those age periods. “Any history of running”
included people who were runners in at least one age period.
Lo et al. 2017
RESULTS
No increased risk of symptomatic knee OA among self-selected runners vs.
non-runners.
A history of leisure running was not associated with increased odds of

prevalent knee pain, radiographic knee OA, and symptomatic knee OA.
For knee pain, there was a dose-dependent inverse association with
running, where runners had less knee pain.
LIMITATIONS
Running was retrospectively ascertained. Therefore, assessment of running
status may have been influenced by recall bias. Methodological flaws with
study definition of a “runner”.
Lo et al. 2017
Systematic review, 22 studies, > 100 000 pooled participants
Overall prevalence of hip and knee OA
10% in controls 3.5% in recreational 13% in competitive

or non-runners runners runners
Alentorn-Geli et al. 2017.

Running Does Not Cause
Knee OA
Why might the joint
loads experienced with
running not lead to the
initiation of knee OA?
POTENTIAL MECHANISM #2
POTENTIAL MECHANISM #1
Running conditions the cartilage
Cumulative load vs. peak load
It is has been suggested that cartilage

Although peak knee joint loads health in vivo is regulated by the
are much greater in running vs. greatest stress the cartilage
walking, the average load per frequently sustains during activities of
unit distance traveled is daily living (Seedhom, 2006).
similar in walking and running
at self-selected speeds
Therefore, living cartilage in a healthy
because of shorter ground state may become conditioned to
contact time and longer withstand the frequent stresses of
stride length in running. running, given sufficient stimulus, rest,
and nutrition.
Miller, 2017
REMEMBER
The body can adapt as long
as the mechanical stresses
applied are not greater than
the body’s capacity to
adapt to it.
Should individuals with
pre-existing knee OA
continue to run?
Should individuals with
a total knee replacement
continue to run?
Excessive or Abnormal
Knee Joint Loading
Knee Adduction Moment
◻ Knee adduction
moment (KAM) = product
of ground reaction force
and moment arm.
◻ KAM is frequently used

as a proxy measure for
the amount of loading in
the medial knee
compartment.
Knee Adduction Moment
KAM is important to consider:
❏ Medial knee compartment is most
commonly involved in knee OA (Braga et al., 2009)
❏ Shown to predict the progression of medial

compartment knee OA (Miyazaki et al., 2002; Bennel et
al., 2011; Kean et al., 2012)
❏ KAM ↑ with OA severity and was directly

proportional to varus malalignment (SR –
Foroughi et al., 2009)
Is loading bad for
the knee?
The common narrative...
“Squats are bad for the knees”
“Running causes knee osteoarthritis”
“People with knee osteoarthritis shouldn’t

run. It’ll wear out their knees”
“Make sure you have no pain when you

exercise. You don’t want to make your knee
osteoarthritis worse!”
REMEMBER
The body can adapt as long
as the mechanical stresses
applied are not greater than
the body’s capacity to
adapt to it.
Clinical Relevance
Determining what activity or
exercise is best for your patient
will depend on their preferences,
their tolerance to physical effort,
as well as their capacity to adapt.
There is no “one-size-fits-all”
approach.
Gait Kinematics and
Knee OA
Overview of Gait Alterations Consistently
Reported With Medial Knee OA
Knee OA progression was

associated with:
- Larger heel-strike knee flexion angle
- Larger mid-stance KAM
- Larger knee flexion moment
Favre & Jolles, 2016

Gait Kinematics & Knee OA
◻ Age-related changes in kinematics can
influence the prospective cartilage changes.
◻ AP position of the femur relative to the tibia at

baseline was correlated with cartilage thinning
at a five year follow-up.
Favre et al., 2013

Gait Kinematics & Knee OA
CLINICAL RELEVANCE
Healthy cartilage adapts to individual kinematic
patterns during walking. Therefore, any condition
such as aging that causes chronic kinematic
changes at the knee can move contact during
walking to regions of the cartilage that have
different structural and biological properties, and
consequently, may not be adapted to withstand
the newly imposed mechanical stresses.
Neuromuscular Adaptations
In Patients With Knee OA
Research has demonstrated neuromuscular
alterations (co-activation of the knee joint
musculature) in patients with knee OA when
compared to asymptomatic individuals, as
well as between knee OA severity groups.
Childs et al., 2004; Astephen et al., 2008; Hubley-Kozey et al., 2009

◻ Increase in lateral knee joint muscular
co-activity found during gait in individuals
with moderate knee OA.
◻ Theory: increase in lateral knee joint

muscular co-activity to offload the medial
compartment of the knee → reduce loading
in the medial tibiofemoral compartment →
slow disease progression
◻ Overall increase in knee joint musculature
co-activity during gait in those with later
stage knee OA.
◻ Theory: This would theoretically increase

medial knee joint stability → protective
response to the significant medial joint
space narrowing and instability typically
found in those with severe knee OA.
CLINICAL RELEVANCE
1. Abnormal muscle force/coordination must
be considered as a potential influence on
disease progression (Winby et al., 2009)
2. Increased medial knee muscle

co-contraction was significantly related to a
faster progression of medial knee OA (Hodges
et al., 2016)
CLINICAL RELEVANCE
3. Increased duration of lateral muscle
co-contraction actually had a protective effect
against medial cartilage loss (Hodges et al., 2016)
Exercise and biomechanical interventions to

modify knee muscle activation patterns could
theoretically optimize knee joint biomechanics and
reduce dynamic knee joint loading, which could
potentially slow disease progression.
Prevention of Knee
Osteoarthritis
Prevention of Knee OA
❏ Primary prevention → prevention of knee
injuries.
❏ Typically achieved via risk reduction, by

altering behaviours or exposures that can
lead to disease, or by enhancing
resistance to the exposure to a disease.
❏ Example: preventing knee injuries and

obesity during adolescence
Roos & Arden, 2016

❏ Secondary prevention includes detection
and treatment of risk factors for
progression in individuals who are already
at risk.
❏ Example: optimizing exercise/physical

activity levels and diet in individuals who
are overweight or obese, have impaired
muscle function or prior joint injury.
Roos & Arden, 2016

❏ Tertiary prevention involves early
treatment of OA to prevent progression of
the disease.
❏ Example: encouraging individuals with

knee OA to be active and manage their
weight in order to optimize physical
function, quality of life, etc.
Roos & Arden, 2016

Lesson 2:
Etiology, Risk Factors
& Prevention
Lesson 3.1:
Clinical Assessment of Knee OA
Subjective Assessment
Clinical Assessment of
Knee Osteoarthritis
Subjective
Assessment
5 Types of Listening
Listening for the gist

↓
Intermittent listening that
is long enough to get the
gist of what the other side
is saying to see if it aligns
with our views.
“Did You Know There Are 5 Levels of Listening?” - Derek Gaunt

Listening to rebut
↓
Listening long enough to
understand the incoming
message until it hits a trigger.
Once heard, we just wait for
the other side to stop talking so
we can tell them how their
position is faulty and by
extension, how much smarter
we are.

Listening for logic

↓
Listening to identify why
what the other is saying
matters to them or gathering
understand of why they
share this view.

Listening for emotion

↓
Listening to identify the
emotions that may be
driving the person’s
argument. We recognize
their significance to the other
side as they talk about what
is important to them.

Listening for their point of view
↓
Listen for what their argument,
phrase, or statement says about
who they are in the world.
What does it symbolize or
mean to them? “Filter their
emotion and logic through a
prism of empathy”.

The Art of Listening
“If we do not understand their
world view, we do not really
understand them. If we do not
understand them, we will never
influence them.”
Derek Gaunt

Goals:
1. Take thorough history
2. Rule out yellow/red flags and differential
diagnoses
3. Determine triggers (i.e. what causes
flare-ups?)
4. Address concerns, beliefs and perceptions
5. Explore previous experiences (i.e. with other
healthcare professionals, with exercise, etc.)
6. Determine patient expectations and goals
Illness Perceptions
& Knee OA
Factors associated with disability
after 6 years in patients with OA
❏ ↑ number of symptoms attributed to OA
❏ ↓ perceived control (low self-efficacy)
❏ Stronger beliefs about the negative impact of
OA
❏ Perceived disease chronicity
❏ ↑ negative emotions experienced due to OA
“Illness perceptions do change over time, and

they are related to and, most importantly,
predictive of disability.”
Bijsterbosch et al., 2009

Why address perceptions
and beliefs?
❏ Illness perceptions are associated with, and
predict future disability
❏ Patients’ cognitive representations of their

illness determine their emotional responses
and guide coping strategies
❏ Crucial to help improve understanding of the

disease, benefits of exercise, importance of
exercise adherence, etc.
Bijsterbosch et al., 2009; Pouli et al., 2014

❏ Perceptions and beliefs regarding OA
➢ Nature of the illness and associated
symptoms
➢ Beliefs about the time course of the
illness
➢ Beliefs about what caused the illness
➢ Beliefs about the personal impact of
the illness
➢ Beliefs about whether illness can be
cured or controlled
❏ Previous and current physical activity
levels
❏ Facilitators and barriers to ADLs/physical

activity/exercise
❏ Past experiences and expectations
❏ Patient goals
10 Important Questions
To Ask During A
Activities & Belief Structure
1. What are the things you enjoy doing that
you no longer do?
2. List 3 things you would like to get back to

doing.
3. What is currently stopping you from

doing these things?
4. What do you think will happen if you did

them now?
Disease & Belief Structure
5. What do you believe is the cause of your
knee osteoarthritis?
6. What do you believe is the source of

your pain?
7. What have you been told thus far about

treatment options?
8. Do you believe exercise or physical

activity would help with your pain?
Expectations &
Previous Experiences
9. Is this your first time in physiotherapy? If
not, what were your previous experiences
like?
10. What are your expectations for today in

physiotherapy? What are your long term
expectations in physiotherapy?
Lesson 3.1:
Lesson 3.2:
Objective Assessment
Objective
Assessment
1. Inspection and palpation
2. Range of motion
3. Strength
4. Special tests (e.g., meniscus tests)
5. Ligament stress tests (note laxity)
6. Gait analysis
7. Functional testing
Michael et al., 2010

Functional Assessment
Dobson et al., 2013

Functional Assessment
Dobson et al., 2013

30s Chair Stand Test
Description
From the sitting position, the participant
stands up completely so their hips and knees
are fully extended, then completely back
down, so that the bottom fully touches the
seat. This is repeated for 30 seconds.
If the person cannot stand even once then

allow the hands to be placed on their legs or
use their regular mobility aid. This is then
scored as an adapted test score.
Dobson et al., 2013

30s Chair Stand Test
Normative scores (i.e. between the 25% and 75%
percentiles) for the 30-s CST in community
dwelling older people aged 60-94 years
Dobson et al., 2013

4x10m Fast-Paced
Walk Test
Description
Participants are asked to walk as quickly but
as safely as possible, without running, along a
10 m (33 ft) walkway. The participant then
turns around a cone, returns, and then repeats
again for a total distance of 40 m (132 ft) (3
turns).
Regular walking aid is allowed and recorded.
Dobson et al., 2013

4x10m Fast-Paced
Walk Test
Normative fast speed reference
values m/s (SD) for healthy adults
Dobson et al., 2013

Stair Climb Test
Description
The time (in seconds) it takes to ascend and
descend a flight of stairs.
The number of stairs will depend on individual

environmental situations.
Where possible, the 9-step stair test with

20cm (8 inch) step height and handrail is
recommended.
Dobson et al., 2013

Stair Climb Test
Normative scores available only for the
12-step Stair Test
Dobson et al., 2013

Timed Up-and-Go Test
Description
Time (seconds) taken to rise from a chair, walk
3 m (9 ft 10 inches), turn, walk back to the chair,
then sit down wearing regular footwear and
using a walking aid if required.
Dobson et al., 2013

6-Minute Walk Test
Description
A test of aerobic walking capacity over longer
distances. The maximal distance covered in a
6-minute period is recorded.
Dobson et al., 2013

3 Simple Tests Predict Physical
Function Difficulties in Patients
with Knee OA
5-Time Gait speed 400-m walk test
Sit-to-Stand < 1.13–1.26 m/s > 315-349 sec
> 11.4-14 sec
Not meeting these minimum performance thresholds on clinical

tests of physical function may indicate inadequate physical
ability to walk ≥6,000 steps/day for people with knee OA.
Master et al., 2017

Outcome Measures
◻ Knee Injury & Osteoarthritis Outcome
Score (KOOS)
◻ Knee Injury & Osteoarthritis Outcome
Score Physical Function Short Form
(KOOS-PS)
◻ Western Ontario & McMaster
Universities Osteoarthritis Index
(WOMAC)
Collins et al., 2011

Knee Injury & Osteoarthritis
Outcome Score (KOOS)
◻ Purpose: To measure patients’ opinions
about their knee and associated problems
over short- and long-term followup (1 week
to decades).
◻ 42 items across 5 subscales. All items are

rated on a 5-point Likert scale (0 – 4), specific
to each item. Takes 10 minutes to complete.
◻ Freely available to download

http://www.koos.nu in different languages.

Knee Injury & Osteoarthritis Outcome
Score Physical Function Short Form
(KOOS-PS)
◻ Purpose: Measures patients’ opinions about the
difficulties they experience with physical activity
due to their knee problems
◻ 7 items, all scored on a 5-point Likert scale

(none, mild, moderate, severe, extreme) scored
from 0–4. Takes 2 minutes to complete.
◻ Freely available to download

http://www.koos.nu in different languages.

Western Ontario & McMaster
Universities Osteoarthritis Index
(WOMAC)
◻ Purpose: To assess the course of disease or
response to treatment in patients with knee
or hip osteoarthritis (OA).
◻ 24 items, 3 subscales. In the Likert version,

each item offers 5 responses. . 5–10 minutes
to complete.
◻ Can be found online via simple Google

search.

Lesson 3.2:
Lesson 3.3:
Clinical Diagnosis
Clinical Diagnosis
of Knee OA
Clinical Presentation
❏ Pain (with movement, especially after
prolonged rest)
❏ Stiffness (morning or after prolonged rest)
❏ Decreased range of motion at the knee

joint
❏ Swelling/effusion
Michael et al., 2010; Sinusas, 2012

Clinical Presentation
❏ A feeling of instability at the knee joint
may be present
❏ Cracking and clicking may be present at

the knee joint
❏ Valgus or varus deformity
Michael et al., 2010; Sinusas, 2012

NICE Guidelines
The National Institute for Health and Care
Excellence (NICE) Guidelines for Osteoarthritis
(2014) state that a diagnosis of OA can be made
without investigations if a person:
1. Is 45 or over and
2. has activity-related joint pain and
3. has either no morning joint-related stiffness or
morning stiffness that lasts no longer than 30
minutes.
National Institute for Health and Care Excellence, 2014

NICE Guidelines
Atypical features that may indicate alternative or
additional diagnoses:
❏ History of trauma
❏ Prolonged morning joint-related stiffness
❏ Rapid worsening of symptoms
❏ Presence of a hot swollen joint
Differential diagnoses:
❏ Gout
❏ Other inflammatory arthritis (i.e.rheumatoid
arthritis)
❏ Septic arthritis
❏ Malignancy (bone pain).
National Institute for Health and Care Excellence, 2014

EULAR Guidelines
The European League Against Rheumatism (EULAR)
guidelines state that a confident diagnosis of knee OA
can be made without X-ray if an adult >40 years old
has:
1. Usage-related pain
2. Short-lived morning stiffness
3. Functional limitation
AND one or more of the following examination findings:

4. Crepitus
5. Restricted movement
6. Bony enlargement
Zhang et al., 2010
EULAR Guidelines
These guidelines apply even if x-rays have
been taken and appear normal.
Patients ≥45 years old presenting with all

6 signs and symptoms have a 99%
probability of having knee OA.
Zhang et al., 2010

ACR Guidelines
Using clinical findings alone, a patient with
symptomatic knee OA should have knee pain
AND at least three of the following 6 criteria:
1. Age >50 years
2. Morning stiffness <30 minutes
3. Crepitus on active movements
4. Tenderness of the bony margins of the
joint
5. Bony enlargement
6. No palpable warmth
Altman et al., 1986

Lesson 3.3:
Clinical Diagnosis
Lesson 3.4:
Imaging & Pain
Imaging
◻ Radiograph (X-ray):
primary imaging tool for
diagnosing knee OA
◻ May be accompanied by
CT scan or MRI
◻ Blood tests
Michael et al., 2010

Is knee OA severity
correlated with the intensity
of the pain experienced?
Radiographic Knee OA
vs. Pain Intensity
❏ 15–76% of patients with knee pain were
found to have radiographic osteoarthritis
❏ 15–81% of those with radiographic knee

osteoarthritis had pain
Wide variability of results regarding the

degree to which knee pain relates to
radiographic knee osteoarthritis.
Bedson & Croft, 2008

The discordance between
clinical and radiographic
knee osteoarthritis
Table 4 - Bedson & Croft, 2008

Radiographic Knee OA
vs. Pain Intensity
Potential Explanations
1. Insufficient x-ray numbers or views
used to estimate the association
2. Wide variation in pain definitions used
3. Varying nature of the study population
Bedson & Croft, 2008

Radiographic Knee
OA vs. Pain Intensity
◻ Weak correlation (Lawrence et al., 1966; Bedson &
Croft, 2008)
◻ Strong correlation (Duncan et al., 2007; Neogi et al.,

2009; Laxafoss et al., 2010; Murphy et al., 2011; Wang et al.,
2018)
◻ Discordance between knee OA severity

and pain intensity (Hannan et al., 2000, Bedson &
Croft, 2008; Finan et al., 2013)
Bone Marrow Lesions
vs. Pain Intensity
◻ A number of studies have linked bone
marrow lesions (BMLs) with knee pain
(SR - Yusuf et al., 2010).
◻ Significant correlation has also been

demonstrated between change in
BMLs and change in pain, both in
unselected community living (Dore et al.,
2010) and OA populations (Felson et al., 2007).
WHY does there seem
to be no consensus?
Participants with Varying definitions
Gender Differences varying KL grades of pain used
included in studies
Varying age ranges Varying levels of Different imaging

included in study psychosocial modalities used
factors present
Varying levels of central

sensitization present
Knee OA is a
complex and
multifactorial
disease!
Central sensitization
plays an important
role in the experience
of pain in patients
with knee OA!
Evidence for Central
Sensitization in OA
◻ Systematic review, 36 studies included
◻ Subgroup of subjects (around 30% of

OA patients) was identified with central
sensitization contributing to their
clinical picture.
◻ Occurs at different degrees over a

continuum.
SR - Lluch et al., 2014
Evidence for Central
Sensitization in OA
◻ Systematic review, 15 studies included
◻ Results suggest that pain sensitization

is present in people with knee OA and
may be associated with knee OA
symptom severity.
SR - Fingleton et al., 2015

Recognizing Central Sensitization
Table 2 – Lluch et al., 2017

Lesson 3.4:
Imaging & Pain
Lesson 4.1:
Non-Surgical Management
of Knee OA
Exercise
Non-Surgical
Management of
Knee Osteoarthritis
McAlindon et al., 2014
Evidence for
Exercise in Knee OA
“As of 2002, sufficient evidence had
accumulated to show significant benefit of
exercise over no exercise in patients with
osteoarthritis, and further trials are
unlikely to overturn this result.
An approach combining exercises to
increase strength, flexibility, and aerobic
capacity is likely to be most effective in the
management of lower limb osteoarthritis.”
Uthman et al., 2013

Evidence for
Exercise in Knee OA
◻ High-quality evidence indicates that
land-based therapeutic exercise provides
short-term benefit that is sustained for at
least two to six months after cessation of
formal treatment in terms of reduced knee
pain.
◻ Moderate-quality evidence shows

improvement in physical function among
people with knee OA.
SR - Fransen et al., 2015

Take-Home Message
Exercise is the ONLY intervention for patients
with painful knee OA whose efficacy is
supported by:
◻ More than 50 randomized, controlled trials

(Fransen et al., 2015)
AND
◻ Strongly recommended by several
best-practice guidelines
➢ ACR - Hochberg et al., 2012
➢ EULAR - Fernandes et al., 2013
➢ OARSI - McAlindon et al., 2014
➢ National Institute for Health & Care Excellence (NICE), 2014
➢ Ottawa Panel Clinical Practice Guidelines - Brosseau et al.,
2017
Evidence-Based Practice in
the Management of Painful
Knee OA Is SUB-OPTIMAL!
A recent systematic
review demonstrated
that only 36% of
patients with OA
received appropriate
non-pharmacological
care according to the
guidelines.
SR - Basedow & Esterman, 2015

What proportion of people with
hip and knee osteoarthritis meet
physical activity guidelines?
For knee OA → 21 studies, 3266 participants
❏ Participants averaged 50 min/week of moderate

to vigorous physical activity (MVPA) when
measured in bouts (≥10 mins).
❏ 13% completed ≥150 min per week of MVPA in

bouts of ≥10 min
❏ 19% completed ≥10,000 steps per day
❏ 48% completed ≥7000 steps per day
Wallis et al., 2013

Sedentary Behavior &
Physical Function
Sedentary behavior was objectively measured by
accelerometer on 1,168 participants from the
Osteoarthritis Initiative (49–83 years old) with
radiographic knee OA at the 48 month clinic visit.
❏ Adults with knee OA spent 2/3 of their daily

time in sedentary behavior.
❏ Being more active was related to better
physical function in adults with knee OA
independent of MVPA time.
Lee et al., 2015

What Type of Exercise
or Physical Activity?
Aquatic Exercise &
Knee OA
❏ Systematic review of 13 studies (n=1190)
❏ Moderate quality evidence for small,

short-term, and clinically relevant effects
on patient-reported pain, disability
(moderate quality evidence).
Bartels et al., 2016

Aquatic Exercise
Recommendations
Aquatic therapy is an appropriate
intervention for patients with knee OA,
and is recommended by several
international guidelines (OARSI & EULAR).
The prescription of aquatic therapy

should depend on patient goals,
preferences, tolerance to physical activity,
etc.
Fernandes et al., 2013; McAlindon et al., 2014

Aquatic Exercise
Recommendations
Session Frequency:
2-3x/week
Duration of Sessions:
30-60 mins
Duration of Intervention:
6-12+ weeks
Tai Chi & Knee OA
❏ Systematic review of 5 studies (n=242)
❏ Frequency: 2-3x/week
❏ Duration of Sessions: 20-60 mins
❏ Duration of intervention: 8-20 weeks
❏ Moderate evidence for short-term

improvement of pain, physical function and
stiffness.
Lauche et al., 2013

❏ 18 RCTs included (n=1260), 8 RCTs for OA
❏ Frequency: 2-3x/week
❏ Duration of Sessions: 20-90 mins
❏ Duration of intervention: 6-36 weeks
❏ Tai Chi improved chronic pain in patients

with OA compared to the control
interventions.
Kong et al., 2016

Tai Chi
Recommendations
Tai Chi is an appropriate intervention for
patients with knee OA, and is
recommended by the Ottawa panel
clinical practice guidelines.
The prescription of tai chi should depend

on patient goals, preferences, tolerance to
physical activity, etc.
Brosseau et al., 2017

Tai Chi
Recommendations
Tai Chi Qigong Sun Style Tai Chi
Session Frequency: Session Frequency:
2x/week 1-3x/week
Duration of Sessions: Duration of Sessions:

60 mins 20-60 mins
Duration of Intervention: Duration of Intervention:

8 weeks 12-20 weeks
The Ottawa panel clinical practice guidelines for the management of knee
osteoarthritis (Brosseau et al., 2017)
Yoga & Knee OA
❏ Included 6 studies (n=372)
❏ Frequency: highly variable

❏ Duration of session: 40-90 minutes/session
❏ Duration of intervention: at least 8 weeks
❏ Results demonstrated positive effects on

relieving pain and mobility in patients with
knee OA, but effects on quality of life (QOL)
are unclear. No adverse events reported.
Kan et al., 2016

Yoga
Recommendations
Yoga is an appropriate intervention for
clinical practice guideline (CPG).
The prescription of tai chi should depend

on patient goals, preferences, tolerance to
physical activity, etc.

Yoga
Recommendations
Hatha Yoga
Sessions:
Class - 60 mins, 1x/week
Home - 30 mins, 4x/week
8 weeks
The Ottawa panel clinical practice guidelines for the management of knee
osteoarthritis (Brosseau et al., 2017)
Walking & Knee OA
❏ Evidence from 7
high-quality studies.
❏ Programs ranged
from 2 to 9 months.
Some studies
combined walking
with flexibility and
strengthening
exercises.
Loew et al., 2012

Conclusion:
❏ Walking is effective for the
management of patients with OA to
improve stiffness, strength, mobility,
and endurance.
❏ Greatest improvements were found in

pain, QOL, and functional status.
Loew et al., 2012

Why Consider Walking?
❏ Commonly reported mode of PA
❏ Very few adverse events reported in

studies
❏ Previous research has shown no

association between daily walking and
structural changes over 2 years in the
knees of people at risk of or with mild knee
OA (Oiestad et al., 2015)
Each additional 1,000 steps/day associated
with a 16% and 18% ↓ in incident functional
limitation by performance-based and
self-report measures, respectively.
Walking approximately 6000 steps/day was

the best threshold to distinguish incident
functional limitation by performance-based
and self-report measures.
White et al., 2014

Older adults (≥65 years) were:
❏ 12% less likely to have a TKR for each
additional 1000 steps/day walked.
❏ 52% less likely to have a TKR if they

walked 6000 steps/day or more vs.
those who did not.
Master et al., 2018

Walking
Recommendations
Walking is an appropriate intervention for
patients with knee OA, and is recommended
by several best-practice guidelines (EULAR &
Ottawa panel CPGs).
The prescription of a walking program should

depend on patient goals, preferences,
tolerance to physical activity, etc., and it is
encouraged to combine walking with other
forms of exercise when possible.
Loew et al., 2012; Fernandes et al., 2013; Brosseau et al., 2017

Walking
Recommendations
Step Count:
Aim for ≥6000 steps/day (≤2500 steps/day →
increased risk of impaired physical function)
Duration & Intensity of Sessions:

Aim for frequent bouts of ≥10 mins of brisk walking
(moderate to vigorous intensity)
Frequency
At least 3-4x/week
Loew et al., 2012; White et al., 2014; Iijima et al., 2017; Master et al., 2018
Cycling & Knee OA
Cycling
Group cycling (n=19) demonstrated
significantly better improvements vs.
controls (n=18) after 12 weeks for:
❏ Preferred gait velocity

❏ Visual analog pain scale on the 6-minute
walk test
❏ The WOMAC pain and stiffness subscales
❏ The KOOS pain and ADL subscales
RCT - Salacinski et al., 2012

Cycling
❏ 30 subjects, randomized to two groups
(cycling or strength training), 2x/week for 12
weeks.
❏ Increase in quadriceps muscle strength

(strength training group: 12.3%, cycling group:
8.1%) and VO2max (strength training group:
4.1%, cycling group: 6.8%) in both groups.
❏ Clinical improvement was reported in about

two third of the included patients.
RCT - Lund et al., 2017

Cycling
Recommendations
Cycling is an appropriate intervention for
clinical practice guideline.
The prescription of a cycling program

should depend on patient goals,
preferences, tolerance to physical
activity, etc.

Cycling
Recommendations
Session Frequency:
2-6x/week
20-60 mins
12 weeks

Strength Training
& Knee OA
Strength Training
❏ Meta-analysis & systematic review
❏ Moderate effect sizes of strength training for

reducing pain and improving physical
function vs. controls.
❏ Primarily incorporated resistance-based

lower limb and quadriceps strengthening
exercises.
❏ Similar significant improvement with each

of these programs.
Jansen et al., 2011

Land-Based Exercise
❏ 4 meta-analyses → small, clinically relevant
short-term benefits for pain & physical
function.
❏ Duration and type of exercise programs

varied widely. Interventions included a
combination of strength training, active
range of motion exercises, and aerobic
activity.
❏ No specific exercise regimen was

demonstrated to be favorable.

Neuromuscular
Exercise
Figure 3 - Roos & Arden, 2016

Neuromuscular Exercise
❏ Goal is to improve sensorimotor control
and the functional stabilization of joints.
❏ Targets postural control, proprioception,

muscle activation, muscle strength and
coordination.
❏ Exercises involve multiple joints and

muscle groups, closed kinetic chains, and
lying, sitting and standing positions.
Roos & Arden, 2016

Neuromuscular Exercise
❏ Neuromuscular exercise therapy, like
aerobic exercise and strength training, has
been demonstrated to provide effective
pain relief in individuals with established
OA (Ageberg et al., 2013; Bennel et al., 2014; Villadsen et al.,
2014)
Good Life with osteoarthritis
in Denmark (GLA:D)
❏ Consists of education and supervised
neuromuscular exercise delivered by
trained physiotherapists.
❏ Data from 9,825 participants with knee

osteoarthritis from the GLA:D registry
included in analysis.
Skou et al., 2017

Good Life with osteoarthritis
in Denmark (GLA:D)
RESULTS
❏ Improved pain intensity and quality of life at
3 and 12 months
❏ Improved physical function and physical
activity (only at 3 months)
❏ Fewer patients took painkillers following the
treatment
❏ Fewer patients were on sick leave at 12
months post GLA:D program vs. the year
prior to GLA:D
Skou et al., 2017

General Exercise
Recommendations
Session Frequency:
at least 2x/week
20-65 mins
8-12 weeks (24 total sessions)
Young et al., 2018

Aerobic Exercise
Recommendations
❏ 150 minutes (2.5 hours) of moderate-intensity aerobic
activity per week.
❏ 75 minutes (1.25 hours) of vigorous-intensity aerobic

activity per week.
❏ Aerobic activity can be broken into short periods of 10

minutes or more during the day.
Centers for Disease Control and Prevention (CDC), 2008

Resistance Training
Recommendations
❏ Resistance training can include lifting weights,
working with resistance bands, and yoga. These can
be done at home, in an exercise class, or at a fitness
center.
❏ Resistance training should be performed at least 2

days/week, with enough resistance employed to
the muscle to result in muscle overload.

Flexibility & Balance
Recommendations
❏ Doing daily flexibility exercises like stretching and
yoga is recommended to help maintain range of
motion and ensure participation in activities of daily
living.
❏ Performing balance exercises 3x/week is also

recommended, especially for those who are at a risk
of falling or who have trouble walking.

Is exercise appropriate
for all patients with
knee OA?
YES!
Exercise is appropriate for all individuals
with knee OA. It is also feasible and
effective in patients at all severity levels
of OA, even in those with moderate to
severe OA eligible for total knee and total
hip replacement.
Ageberg et al., 2013; McAlindon et al., 2014 Juhl et al., 2014; Villadsen et al., 2014;
Skou et al., 2015
Will all patients with
knee OA respond or get
better with exercise?
NO!
Although exercise is strongly
recommended as part of the first-line
treatment for patients with knee OA, not
every patient will respond or get better with
exercise. Other interventions may need to
be considered to best manage the patient’s
pain and help improve physical function
and quality of life.
Pain and functional trajectories in
symptomatic knee OA
The authors identified four different trajectories in a cohort of 171
participants with symptomatic knee OA
Lower Pain Level-Early Higher Pain Level-Delayed

Improvement (43%) Improvement (15%)
❏ Lower initial WOMAC pain ❏ Higher initial levels of pain
score of 139.2 points ❏ Small improvement
❏ Decline in pain that through 4-5 weeks
plateaued after 5 weeks ❏ Large improvement after
5-11 weeks of intervention
Moderate Pain Level-Early Higher-No Improvement (10%)

Improvement (32%) ❏ Higher initial levels of pain
❏ Initial WOMAC pain scale (317.7 points on WOMAC
of 230.4 points pain scale)
❏ Decline in pain over 5 ❏ No improvement
weeks throughout intervention
Lee et al., 2018

symptomatic knee OA
Clinical Relevance
❏ Large amount of heterogeneity with
regards to pain and function change in
response to 12 weeks of exercise
interventions among adults with
symptomatic knee OA.
❏ Simply put, no two patients will respond

the same way to any one intervention,
including exercise.
Lee et al., 2018

symptomatic knee OA
Clinical Relevance
❏ 10% of patients did not improve with exercise.
Need to find out why. Was it due to:
➢ Exercise adherence?
➢ Psychosocial factors?
➢ Perceptions & beliefs?
❏ 15% of patients had delayed improvement

➢ Important for managing patient
expectations
➢ It can take time before an improvement is
seen. It does not occur overnight.
Lee et al., 2018

Lesson 4.1:
of Knee OA
Exercise
Lesson 4.2:
of Knee OA
Patient Education
Patient education is
crucial for exercise
adherence!
“But I Have Pain When I
Exercise or do Physical
Activity…”
“But I Have Pain When I Exercise
or do Physical Activity…”
❏ Listen to your body
❏ Pain and discomfort does not necessarily

equal tissue damage
❏ Pain/discomfort is acceptable as long as it

remains tolerable (2-5/10) (Ageberg et al.,, 2010)
❏ If pain does increase after exercise, it should

subside within 24 hours. Exercise should not
worsen morning stiffness or swelling.
REMEMBER
The body can adapt as
long as the mechanical
stress applied is not
greater than the body’s
capacity to adapt to it!
Facilitators and Barriers to
Exercise Adherence in
patients with Knee OA
REMEMBER
The best exercises are
those that get done!
Example
Poor exercise prescription
Important increase in pain/discomfort
Increased patient frustration
Decreased exercise adherence

Patient Characteristics &
Exercise Adherence
❏ Motivation
➢ High vs. low
➢ Motivation by enjoyment ＞ motivation by results
➢ Seek to increase enjoyment factor
❏ Internal locus of control → high

self-efficacy and active coping
❏ External locus of control → low

self-efficacy and more passive coping
Petursdottir et al., 2010

Patient Characteristics &
Exercise Adherence
❏ Previous exercise experience can affect
present attitude toward exercise.
❏ Attitude toward pain is a fundamental

factor to consider for exercise adherence
(i.e. belief that pain = tissue damage).
❏ Hope of less pain, or at least bearable pain,

was demonstrated to be a major facilitator
for many participants.

External Factors &
Exercise Adherence
❏ Attitude and support of the immediate
family are important.
❏ Communication and a sense of a positive

connection with the healthcare
professional were equally as important as
the physical results of the therapy!

External Factors &
Exercise Adherence
❏ Education regarding importance of
exercise to patients and their family
members.
❏ Weather can affect the general

wellbeing of people with OA.
❏ Accessibility and user-friendlieness of

nearby facilities.

Tips on How to Maximize
Exercise Adherence
Ensure that the exercise program:
❏ Is simple, personalized, and practical.
❏ Takes into account individual's prior exercise

experience.
❏ Utilizes clear written instructions, pictures,

etc.
❏ Is well tolerated and most importantly,

enjoyable for the patient.
Petursdottir et al., 2010; Marks et al., 2012

Exercise Adherence
❏ Provide personalized feedback,
encouragement, reassurance, advice,
careful explanations.
❏ Ensure setting of realistic goals.

❏ Stress the importance and benefits of
exercise.
❏ Boost motivation via education and

emphasizing expected results. Don’t forget
to highlight successes!

Exercise Adherence
Follow Up Sessions:
❏ Continue to stress the importance and
benefits of exercise.
❏ Provide clarification regarding the

treatment regimen to ensure that it is
clearly understood.
❏ Include ongoing support services,

reminders, and scheduled follow-ups.

Still having difficulty with
patient exercise adherence?
Patient education is crucial
in the management of
knee OA!
Patient Education
❏ What is knee OA?
❏ Identify and address perceptions of disease
and beliefs (i.e. fear avoidance)
❏ Discuss the importance of exercise, diet and
weight management
❏ Explain the quantification of mechanical
stress and proper dosing of physical
activity/exercise
❏ Reassure, reassure, reassure!
❏ Discuss expectations, goals, etc.
❏ Discuss treatment plan
Words Matter!
“Degenerative or “It’s a normal part of aging. “Bone on bone”
chronic disease” It’s just wear and tear” ↓
↓ ↓ Provides an inaccurate
Perceived to have no Dismissive in nature. Tend depiction of what is
treatment or to link getting older with occurring at the knee
prevention. inevitably poor prognosis. joint with movement.
Highly nocebic, may ↑
fear avoidance.
These words tend to decrease the patient’s perceived

control over their pain, as well as their self-efficacy. It also
provides a false representation of knee OA as a disease
that has no treatment, and a poor prognosis, in turn
creating a sense of helplessness.
Pouli et al., 2014

Shared Decision Making
1. Understand the patient’s experience and
expectations (including illness perceptions)
2. Build Partnerships
3. Provide Evidence, Including Uncertainties
4. Present Recommendations
5. Check for Understanding and Agreement
Epstein et al., 2004

Lesson 4.2:
of Knee OA
Patient Education
Lesson 4.3:
of Knee OA
Weight Management
Weight Management &
Knee OA
Weight Loss & Knee OA
❏ At the population level, approximately
30% of knee OA is avoidable with the
reduction of BMI (Zhang et al., 2010)
❏ A two-unit drop in BMI has been shown

to lower knee OA risk by 50% (Felson et al., 2004)
❏ Every 1 kg of weight loss, the peak knee

load was diminished by 2.2 kg at a given
walking speed (Aaboe et al., 2011)
The effect of weight loss on
pain and function in knee OA
❏ Moderate exercise and weight loss
significantly reduced OA associated pain
while improving performance (i.e. 6MWT
distance and stair-climb-time) and
self-reported physical function (Messer et al.,
2004)
❏ Weight reduction significantly improved

disability in obese patients with knee OA,
and also showed clinical efficacy on pain
reduction (SR & MA - Christensen et al., 2007)
The effect of weight loss on
pain and function in knee OA
❏ Results demonstrated that a 10% weight
loss led to a 50% reduction in knee pain
from OA.
❏ Participants in the diet + exercise and diet

groups had more weight loss and greater
reductions in IL-6 levels (inflammatory
mediator) than those in the exercise group
after 18 months.
Messier et al., 2013

A protective effect of weight
loss on cartilage loss?
❏ A recent study demonstrated that
participants who lost 5-10% body weight
over 48 months showed significantly lower
cartilage degeneration assessed via MRI
when compared to the stable weight group.
❏ Cartilage loss was even lower in the >10%

body weight loss when compared to the
stable weight group.
Gersing et al., 2017

Maintaining Weight Loss
❏ A number of interventions have been
shown to be effective to reduce weight
in the short and medium terms (Wluka et al.,
2013)
❏ Maintaining weight loss is the big

challenge!
❏ Up to 50% of individuals regain some of

their lost weight by 12 months from the
initiation of the strategy (Wing et al., 2005; Wluka et
al., 2013)
Modifiable factors associated with
maintenance of ≥10% weight loss for ≥1 year
❏ Low-calorie, low-fat diet

❏ High levels of physical activity (~1h per day of
brisk walking)
❏ Frequent self-monitoring of weight
❏ Eating breakfast
❏ Cognitive restraint
❏ Dietary consistency throughout the week
rather than just on weekdays
Wluka et al., 2013

maintenance of ≥5% weight loss for ≥5 years
❏ Smoking
❏ Increased moderate physical activity over the
5-year period in comparison with activity
before the weight-loss intervention
❏ Emotional support greater over the 5-year
period than before the intervention
❏ Lower consumption of sugar-sweetened soft
drinks reported at follow-up in comparison
with those who regained weight
Wluka et al., 2013

maintenance of ≥5% weight loss over 9 years
❏ Unmarried status (women)

❏ Low stress levels and health-promoting
behaviours (men)
❏ Lower levels of admitted previous alcohol use
❏ Lower sugar consumption, more frequent
intake of vegetables, and more frequent
leisure activity
Wluka et al., 2013

Modifiable factors associated with regain of
weight after >1 year successful weight loss
❏ Reduced dietary disinhibition (periodic loss of

control of eating)
❏ Depression
❏ Decrease in physical activity
❏ Increase in the percentage of calories from fat,
compared with period of maintenance of
weight loss
❏ Reduced dietary restraint
Wluka et al., 2013

Modifiable factors associated with regain of 5%
weight loss after 9 years
❏ Stressful life, with use of tranquilizers in the

year prior to weight loss (men)
❏ Low life satisfaction (self-reported, women)
❏ Social isolation (women)
❏ Poor sleep (women)
❏ Increased high-salt food intake compared with
those who maintained weight loss (women)
Wluka et al., 2013

Why Weight Loss?
❏ Modifiable risk factor for knee OA initiation
and progression
❏ Those who are obese tend to have total

knee arthroplasty at an earlier age, with
worse post-operative outcomes (Xu et al., 2018)
❏ Weight loss has the potential to reduce the

risk and progression of knee OA, improve
pain and function, and reduce certain
inflammatory mediators.
Recommendations
❏ Weight loss (if applicable) is an effective
intervention that should be considered as
first-line treatment for patients with knee
OA.
❏ Weight loss is indicated in any patient with

knee OA whose BMI exceeds 25 kg/m²:
➢ Normal: < 25 kg/m²
➢ Overweight: ≥25-29.9 kg/m²
➢ Obese: ≥ 30 kg/m²
Recommendations
❏ It is recommended that a weight loss of
>5% should be achieved within a
20-week period → 0.25% body weight
loss per week (Christensen et al., 2007)
❏ A weight loss program should include both

diet and exercise (Roos & Arden, 2016)
❏ Education should also be provided

regarding weight management
Lesson 4.3:
of Knee OA
Weight Management
Lesson 4.4:
of Knee OA
Adjunct Treatments
The Role of Manual
Therapy
❏ 4 studies included (3 on knee OA)
❏ Manual therapy (ex: manipulation, massage,

stretching) provided short-term benefit in
pain and function vs. no treatment.
❏ No evidence that manual therapy is better

than placebo or NSAID (Meloxicam) for pain
and function in knee OA.
❏ Limited research, most with high risk of bias
SR - French et al., 2011

❏ 12 trials included
The effect size on pain:

➢ Strength Training: 0.38
➢ Exercise: 0.34
➢ Exercise and manual mobilisation:
0.69
❏ Each intervention also improved physical

function significantly.
SR - Jansen et al., 2011

❏ 14 studies included comparing manual
therapy to placebo or another intervention
(n=841).
❏ Results demonstrated statistically significant

effects on relieving pain, stiffness, improving
physical function and total score.
❏ Methodological quality of most included

RCTs was poor. Results limited by potential
bias and heterogeneity between studies.
SR & MA - Xu et al., 2017

Recommendations
❏ Manual therapy may provide additional
benefit when combined with exercises
❏ As a result, it should be considered as an

adjunct to exercise and weight
management
❏ Potential Mechanisms:
➢ Likely pain modulation via
“neurophysiological effects”
➢ We are not “breaking down adhesions”
Hochberg et al., 2012; National Institute of Health and Care Excellence, 2014
Assistive Devices
and Braces
Recommendations
❏ A walking cane may be considered as an
adjunct to core treatments and could be
used to diminish pain and improve function
and some aspects of quality of life in
participants with knee OA (Jones et al., 2012;
McAlindon et al., 2014; National Institute for Health and Care
Excellence, 2014)
❏ Braces/joint supports may also be

considered as adjuncts to core treatments
(McAlindon et al., 2014; National Institute for Health and Care
Excellence, 2014)
Electrophysiological
Modalities
Recommendations
❏ TENS → non-conclusive
❏ Ultrasound → non-conclusive
❏ Electrotherapy and neuromuscular

stimulation → not appropriate
Note: These modalities may be just

as effective when left unplugged.

Lesson 4.4:
of Knee OA
Adjunct Treatments
Lesson 4.5:
of Knee OA
Injections & Supplements
Injection Therapies
Corticosteroid Injections
❏ Previous research has demonstrated
clinically significant short-term decreases
in pain (SR - Bellamy et al., 2006; SR - Bannuru et al., 2009)
Conclusion:
❏ Should be considered as an adjunct to
core treatments for short-term relief
❏ For a longer duration of pain relief,
clinicians should consider other treatment
options
Hochberg et al., 2012; National Institute of Health and Care Excellence, 2014;
McAlindon et al., 2014; McCrum et al., 2017
❏ 2 year, randomized, placebo-controlled,
double-blinded trial
❏ Intra-articular triamcinolone (n = 70) or

saline (n = 70) every 12 weeks for 2 years
❏ Annual knee MRI for quantitative

evaluation of cartilage volume
❏ WOMAC index collected every 3 months

❏ Over a 2 year period, intra-articular
triamcinolone resulted in significantly
greater cartilage volume loss than did
saline
❏ No significant difference in knee pain
❏ These findings do not support this

treatment for patients with symptomatic
knee osteoarthritis.

Intra-Articular Hyaluronic
Acid (IAHA) Injection
❏ Very few adverse events reported
❏ Inconsistent conclusions among the

meta-analyses (McAlindon et al., 2014)
❏ Recommendations provided by 10
CPGs for IAHA treatment for knee OA
are highly inconsistent as a result of the
variability in guideline methodology
(Altman et al., 2015)
ACR Guideline Recommendations (2012):
No recommendations regarding the use of
intra-articular hyaluronates.
NICE Guideline Recommendations (2014):
Do not offer intra-articular hyaluronan
injections for the management of OA.
OARSI Guideline Recommendations (2014):
Uncertain secondary to non-conclusive
evidence.
Hochberg et al., 2012; National Institute of Health and Care Excellence, 2014;
❏ Several recent reviews and meta-analyses
support the effectiveness of IAHA injection
for patients with knee OA.
❏ These findings may affect future
recommendations.
❏ IAHA was deemed a reasonable alternative
in patients with knee OA who did not
sufficiently respond to previous
pharmacologic treatments.
Bhandari et al., 2017; Cooper et al., 2017; SR - Altman et al., 2018; Ong et al., 2018;
MA - Ran et al., 2018
Platelet-rich-plasma
(PRP) Injections
❏ Platelet-rich plasma (PRP) is an
autologous derivative of whole blood
❏ Contains high concentrations of growth

factors and bioactive proteins that
influence the healing of tendon,
ligament, muscle, and bone
Kabiri et al., 2014

(PRP) Injections
Step #1: Collect blood
Step #2: Separate the platelets from the

rest of the blood components via
centrifugation.
Step #3: Extract platelet-rich plasma.
Step #4: Inject injured area with PRP.

(PRP) Injections
❏ PRP has been shown to have a positive
effect on chondrogenesis and
mesenchymal stem cell proliferation (Kabiri et
al., 2014)
❏ PRP has also been shown to increase

anti-inflammatory and decrease
pro-inflammatory mediators (Bendinelli et al.,
2010; van Buul et al., 2011; Kabiri et al., 2014)
❏ Six articles (739 patients, 817 knees,
average of 38 weeks follow-up)
In patients with symptomatic knee OA:

➢ PRP injection results in significant clinical
improvements up to 12 months
post-injection
➢ Clinical outcomes and WOMAC scores
were significantly better after PRP versus
HA at 3 to 12 months post-injection.
Meheux et al., 2016

❏ 10 systematic reviews eligible (4 with low
risk of bias, 6 with high risk of bias).
❏ Intra-articular PRP injection may be more

efficacious than HA in treating knee OA in
terms of pain relief and function
improvement over HA within 12 months.
❏ PRP is an effective intervention for knee

OA without increased risk of adverse event.
Xing et al., 2017

Chondroitin &
Glucosamine Supplements
Chondroitin & Glucosamine
OARSI Guidelines (2014):
❏ Effect on symptom relief:
non-conclusive
❏ Effect on disease modification: not

appropriate

In Summary
Corticosteroid Injections Chondroitin/Glucosamine
❏ Second-line treatment Supplements
❏ Recommended for ❏ Not recommended
short-term pain relief
Intra-Articular Hyaluronic Platelet Rich Plasma (PRP)

Acid (IAHA) Injections Injections
❏ Not recommended by ❏ Preliminary evidence
current guidelines available to suggest
❏ Recent research effectiveness.
demonstrating ❏ More research is needed
effectiveness may affect prior to making official
future recommendations. recommendations.
Lesson 4.5:
of Knee OA
Injections & Supplements
Lesson 5:
Surgical Management
of Knee OA
Surgical
Management
Knee Arthroscopy
❏ Most common orthopedic procedure
performed in the United States
❏ Approximately 700,000 arthroscopic

partial meniscectomies are performed
annually in the US alone
❏ Annual direct medical costs estimated

at $4 billion
Cullen et al., 2006

Knee Arthroscopy
❏ Arthroscopic partial meniscectomy
combined with PT provides no better
relief of symptoms vs. PT alone in
patients with meniscal tear & knee OA (Katz
et al., 2013)
❏ Arthroscopic partial meniscectomy was

not shown to be superior to sham
surgery, with regard to outcomes
assessed during a 12-month follow-up
period (Sihvonen, et al., 2013)
Siemieniuk et al., 2017
Total Knee Arthroplasty
When Is Surgery Recommended?
◻ Severe knee pain or stiffness that limits
ADLs/transfers (standing up, walking, stairs,
etc.)
◻ Moderate to severe knee pain at rest (day
and/or night)
◻ Knee deformity (varus or valgus)
◻ Chronic knee inflammation not responsive to
medical treatment
◻ Failure to respond to other medical treatments
(PT, NSAIDs, corticosteroids, lubricating
injections,etc.)
Foran et al., 2011

What proportion of patients
report long-term pain after total
hip or knee replacement for OA?
❏ Systematic review including eleven studies
(prospective)
❏ Total of 12 800 patients when pooled
❏ Post total knee replacement, an

unfavorable pain outcome was seen in
10-34% of patients (20% in the studies with
the highest methodological quality)
Beswick et al., 2012

Identifying Predictors
of Persistent Pain & Poor
Functional Recovery After A
Total Knee Replacement
❏ 32 studies, ~ 30 000 pooled participants
6 pre-operative factors were identified as
significant predictors of persistent pain after
a total knee replacement:
❏ Greater number of pain sites
❏ Higher levels of pre-operative pain
❏ Higher levels of catastrophizing
❏ Higher levels of depression and anxiety
❏ Poorer levels of pre-operative function.
Lewis et al., 2014

❏ Having had other pain sites prior to surgery &
pain catastrophizing = strongest independent
predictors of chronic, post-operative pain post
TKA.
❏ ↑ attention and awareness of pain exhibited in
patients demonstrating pain catastrophizing
could potentially magnify pain intensity.
❏ ↑ joint pain and/or having numerous pain sites

prior to surgery could indicate a more
sensitized nociceptive system.
Lewis et al., 2014

❏ Systematic review, 20 studies included
❏ Obese individuals are at a higher risk for

complications post total knee arthroplasty
such as :
➢ Infection
➢ Deep infection requiring surgical
debridement
➢ Revision of the original procedure
(exchange or removal of the
components for any reason)
Kerkhoffs et al., 2012

In Summary
❏ Arthroscopic partial meniscectomy is not
recommended. Further research is
unlikely to overturn this
recommendation.
❏ Unfavorable outcomes were seen in

approximately 20% of patients post total
knee replacement. Patients should be
made aware of this, as this is crucial to
addressing their expectations prior to the
surgery.
In Summary
❏ There are several pre-operative factors that
were shown to be associated with
persistent pain and poor functional recovery
after a total knee replacement.
❏ It is crucial to address these factors (i.e.

obesity, anxiety/depression, catastrophizing
poor physical function, etc.) prior to surgery
with the hopes of optimizing outcomes
post-surgery.
Lesson 5:
Surgical Management
of Knee OA
Lesson 6:
Take-Home Messages
Putting It All
Together
Take-Home Messages
❏ Knee OA is a complex, multi-factorial
disease.
❏ Knee OA is a disease of the whole person. it

is not just “wear and tear”, nor is it just a
simple consequence of aging.
❏ Not all patients with radiographic knee OA

experience knee pain, and many of them
will not progress to require surgery.
Take-Home Messages
❏ Obesity, excessive joint loading and
previous joint injury are important risk
factors for knee OA initiation and
progression.
❏ Educating patients about the importance

of addressing modifiable risk factors is
crucial for disease prevention.
Take-Home Messages
❏ Addressing knee OA perceptions and
beliefs, fear-avoidance behaviours, and
patient expectations is key to optimizing
rehabilitation.
❏ Words matter! Be mindful of the words

you choose to use when educating your
patients about their knee OA.
Take-Home Messages
❏ Exercise, weight management,
self-management and patient education are
first line treatment for patients with knee
OA.
❏ Exercise is feasible and effective in patients

at all severity levels of OA.
❏ Manual therapy, medications and/or

injections are considered second-line
treatment and are adjuncts to the core
treatments above.
Questions? Feedback?
Send us an email. We’d love to hear from

you!
Email: infophysiotherapy10@gmail.com
Follow InfoPhysiotherapy
on Social Media!
@infophysiotherapy Anthony Teoli
@infophysiotherapy @InfoPhysioPT

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Knee Osteoarthritis Assessment

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❏ This research was

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2. Identify important risk factors for disease

3. Apply evidence-based assessment tools

5. Understand the importance of listening,

6. Integrate and apply evidence-based

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❏ Can occur in any joint, but often occurs

❏ Hip and knee OA is one of the leading

❏ According to the WHO: 9.6% of men and

❏ No longer a disease of the elderly. OA is

Osteoarthritis Research Society International (OARSI, 2015)

Chen et al., 2017

Sward et al., 2010

Grade 1: doubtful joint space narrowing (JSN) and

Grade 2: definite osteophytes and possible JSN on AP

Grade 3: multiple osteophytes, definite JSN, sclerosis,

Grade 4: large osteophytes, marked JSN, severe sclerosis

Kohn et al., 2016

Healthy cartilage homeostasis is maintained

Figure 1 - Andriacchi et al., 2015

The latter can lead to the initiation of cartilage

The time required to develop clinical OA is

Figure 1 - Andriacchi et al., 2015

◻ Obesity (Silverwood et al., 2015)

◻ Previous knee injury

◻ Knee extensor muscle

◻ Genetics (Ryder et al., 2008)

◻ Occupational Risks (Ingham

❏ Approximately 50% of individuals above

❏ The number of cycles of mechanical load

Andriacchi et al., 2015

A. Healthy older, more active,

Andriacchi et al., 2015

“However, it is difficult to find quantitative

❏ Each 8 kg increase in weight as a young

❏ Risk of knee OA increased up to 35% with a

❏ Large, population based prospective study

❏ Abnormal loads have been shown to alter

❏ These processes may lead to additional

Teichtahl et al. 2008

❏ May trigger the signaling pathways that

❏ Interleukin-6 and Interleukin-1 (primary

❏ Adipose tissue is an endocrine organ that can

❏ Elevated concentrations of adipocytokines

Carman et al., 1994; Oliveria et al., 1999

❏ 121 of 596 (20.3%) ACL-injured knees

SR - Ajuied et al., 2013

ACL-reconstructed knees had a significantly higher

SR - Ajuied et al., 2013

❏ 140 surgical patients, 240 nonsurgical

❏ Average length of follow-up was 11.8 years

Prevalence of knee OA:

❏ Outcome measures: radiological

RCT - Barenius et al. 2014

Initial meniscus resection was a strong risk

No significant difference between type of ACL

RCT - Barenius et al. 2014

❏ 210 subjects, prospectively followed from