Special thanks to star physical therapist Antara Quiñones of Alpine Physical Therapy for providing this write up on a recent article from the Journal of American Academy of Orthopedic Surgery.
Every 5 years or so the American Academy of Orthopedic Surgeons (AAOS), along with a cohort of other professions (like physicians and physical therapists) publish a guideline to treat certain conditions based on the latest and greatest evidence. These guidelines offer a quick look into what’s proven to work, what does not work, and what still needs to be further investigated. Below are the items that the AAOS recommends for the most up to date treatment of knee arthritis.
People with knee arthritis should:
1. Routinely take part in a strengthening program, neuromuscular education (or using techniques to restore balance, improve coordination and fine tune awareness of where your leg is in space), perform low-impact aerobic exercises, and keep physically fit to national standards in regards to heart health and body weight.
2. Maintain a body mass index (BMI) of less than 25.
3. Use nonsteroidal anti-inflammatory drugs (oral or topical) or tramadol to help with symptom management.
The following are NOT recommended for treatment of knee arthritis:
2.Lateral wedge insoles are not supported in the literature. This being said, however the recommendation is moderate and patient preference should be kept in mind.
3. The use of glucosamine and chondroitin.
4. The injection of hyaluronic acid into the knee joint.
5. Performing an arthroscopy with lavage and/or debridement in which the fluid of the knee joint is removed, the joint is washed, and any loose bodies or debris are removed.
6. The use of needle lavage where saline is injected into the joint and then removed in attempts to wash the joint and remove inflammatory factors and debris.
7. The use of free-floating (not cemented or screwed into place) interpositional devices in the inner knee compartment to alleviate pain and mimic meniscus function. (This was a general consensus recommendation due to the lack of research available for these devices.)
Evidence is inconclusive for the following due to either lack of available evidence or inconsistencies in the studies that have occurred. Practitioners should be on the lookout for future evidence, but in the meantime decisions regarding their use should be influenced by their clinical judgment and patient preference.
1. The use of physical agents, such as electrical stimulation and ultrasound.
2. Manual therapy.
3. Valgus knee brace (to unload the inner knee compartment).
4. The use of acetaminophen, opioids, or pain patches.
5. The use of injections into the knee joint of corticosteroid.
6. The use of growth factor injections and/or platelet rich plasma.
7. A valgus-producing proximal tibial osteotomy, or bone shaving that changes the direction of forces across the knee joint to relieve pressure at the inner knee.
As the evidence changes and our knowledge evolves, it is good to keep the AAOA standards in mind and to be on the look out for future recommendations.
David S. Jevsevar, M.D., MBA. Treatment of Osteoarthritis of the Knee: Evidence-Based Guideline, 2nd Edition. Journal of American Academy of Orthopedic Surgery. September 2013. Vol 21, No 9. Pp 571-576.
For more information, visit our topic module on Knee Osteoarthritis by clicking here.
Morgan York-Singer, DPT has joined Alpine Physical Therapy. The “Her Health” program at Alpine PT has steadily grown over the past six years, and Morgan’s arrival will allow Alpine to serve more women’s health patients.
Morgan’s specialty areas include Women’s Health (incontinence, pelvic pain, pre-natal/postpartum care) and sacroiliac joint dysfunction. She earned her Doctor of Physical Therapy degree from the University of Montana in 2009, and after practicing in Bozeman for several years, returns to her home town of Missoula with her family.
Morgan enjoys hiking, biking, skiing, and spending time with her family.
Ana Soulia, DPT, has joined Alpine Physical Therapy. Soulia earned her doctorate in physical therapy from Pacific University in 2005. Her clinical interests include general orthopedics, Pilates-based rehabilitation, movement impairment evaluation and treatment, hip and pelvic girdle dysfunction, and working with ballet and modern dancers.
When asked: “How did you find your way to Alpine Physical Therapy?” Here’s Ana’s reply:
With the decision to move back to my hometown, I set about researching orthopedic clinics in Missoula, and Alpine immediately stood out with its philosophy of care, promotion of continuing education, and integration of Pilates-based exercises into the rehabilitation process. After meeting with Sam and Angela, I knew that Alpine was a perfect fit for me and am grateful for the opportunity to join this team of skilled and passionate therapists.
Ana, welcome back to Missoula, and welcome to Alpine Physical Therapy. We’re delighted you’re here and know that many people will benefit with your excellent care as a physical therapist.
Special thanks to star physical therapist Leah Versteegen, DPT, of Alpine Physical Therapy for providing this write up on a recent article from the Journal of Bone and Joint Surgery.
ACL rupture affects an estimated 35 people per 100,000 and can increase based on gender and activity. Female athletes face a two to eight times increase in risk of ACL rupture compared to their male counterparts. With numbers like this, it is not wonder that the annual estimated health care cost for ACL repair is three billion dollars just in the United States. The most common treatment for ACL rupture is surgical reconstruction, though nonsurgical rehabilitation is also an option. The decision to reconstruct a ruptured ACL depends on many factors, including age, desired level of activity, episodes of instability and general health.
Before reviewing the surgical options for ACL reconstruction, it is important to understand the basic anatomy of the ACL, or anterior cruciate ligament. It is composed of two functional bundles of ligaments, the anteromedial and posterolateral bundle, which are so named due to their insertion sites on the tibia. Both bundles work together to stabilize the knee into flexion. The anteromedial bundle length remains constant throughout flexion and extension of the knee but is most taut at 45-60 degrees flexion. The posterolateral bundle is tight with extension but loosens with flexion in order to allow some rotation to take place at the knee joint.
Once the the decision to have surgery has been made, there are several factors to consider including timing of the surgery, technique used by the surgeon, and the graft site from which to build the new ACL. When making these decisions one must look at preoperative range of motion, swelling and strength as well as individual anatomy, post-operative activities and goals.
Timing of the knee surgery is one of the first factors to consider. There is evidence supporting early surgery, as it may lead to improved functional outcomes and decreased rate of future meniscal damage. However, delayed surgery can allow for potential avoidance of surgery all together if the individual is satisfied with their knee function. Allowing more time before surgery can definitely help an individual improve preoperative strength and range of motion.
Preoperative strength of at least 90per cent of the quadriceps, is correlated with improved long term functional outcomes. Preoperative swelling and limitations in range of motion are correlated with increased arthrofibrosis after surgery. Thus, a preoperative rehabilitation program focusing on decreased swelling, improved range of motion and quadriceps strength is beneficial.
There are two main surgical techniques utilized in ACL reconstruction, single or double bundle. Though the single bundle technique is far more common, with the double bundle technique being used primarily in Europe and Asia, the rupture pattern of the ACL in that individual and their unique anatomy should be considered by the surgeon when making the ultimate decision on which technique to use. Variations in the tibial notch, arthritic changes, multiligament injuries and bone bruising are all taken into consideration by the surgeon with the aid of a detailed flow chart. Outcomes measures detect no difference in long term functional outcomes between the two techniques, with the exception of fewer reported meniscal injuries with double bundle repair. Regarless, it is important that the surgery match anatomical placement of the ligament in order to help restore optimal biomechanics.
After the technique has been selected, the graft site is the next major decision. Typical graft options include bone-patellar-bone autograft, hamstring tendon autograft, quadriceps tendon autograft, and allograft. If a double bundle repair has been selected the bone-patellar-bone graft cannot be utilized. MRI scans can be helpful in allowing the surgeon to determine which tendon may be most useful based on graft size. The long term goals of the patient are also important in selecting the graft site. For example, an athlete that relies heavily on hamstring strength will not want to use the hamstring autograft. Similarly an individual who has to do a lot of kneeling will not want to choose the bone-patellar-bone autograft.
Once the surgery has been performed, several questions arise, including when one can return to sport, what is the chance of reinjury and/or developing osteoarthritis in the future. Return to sport is dependent on many factors including the healing of the graft, the individuals anatomy and the desired sporting level. For those who do not return to high level of sport, fear of reinjury is a common reason. Graft failure rate is about 11 percent and does not seem to be dependent of the choice of graft site. Several authors have actually reported a higher rate of ACL injury in the opposite leg compared to a reinjury of the repaired ACL. In general, those who do reinjury a repaired ACL are younger and returning to a higher level of activity. Arthritic changes and the development of osteoarthritis after ACL rupture is more common in those who have sustained some meniscal damage or lose range of motion in the knee joint.
Christopher D. Morawski, et al. Operative Treatment of Primary Anterior Cruciate Ligament Rupture in Adults. In the Journal of Bone and Joint Surgery. April 2014. Vol 96A. No. 8. pp 685-694.
For more information, visit our topic module on ACL injuries by clicking here.
The ‘C-Leaguered’ Alpine PT team has finished their final game for the season with mixed emotions. We had a strong season, then capitulated early in the tournament with a few unlucky kicks in the final moments of our last game. We ended the season with a balanced tally of 4 wins, 3 ties and 4 losses… and many awesome evenings of grass-kickin’ good times on the field.
This year we had many returning players from years past that nicely balanced out our new handful of Alpine staff and friends to the Missoula Parks and Recreation C League. Their were no injuries, no yellow or red cards, no field brawls, but a lot of semi-competitive/fully-recreational soccer games. We thank Alpine Physical Therapy for another fantastic year of sponsoring our soccer team and commend this business for supporting after-work, team-building, as well as health and fitness endeavors.
We have a lot to work on for the years to come and look forward to a cooler fall season of upcoming soccer.
Here’s this year’s team picture!
Special thanks to star physical therapist Leah Versteegen, DPT, of Alpine Physical Therapy for providing this write up on a recent article from the Journal of Bone and Joint Surgery.
Anterior cruciate ligament injuries are one of the more common injuries impacting young athletes. The impacts are not only physical in nature but have psychological components and add financial stress as well. As the prevalence of youth participating in sports has increased, ACL injuries have also increased. Some research estimates that return to sport after ACL rupture and repair is as low as fifty percent in young athletes, while epidemiological studies estimate that females are four to six times more likely to suffer an ACL injury compared to their male counterparts. For these reasons, a considerable amount of attention has been given to programs aimed to decrease ACL injury rate, particularly in the female athlete.
Research supports the effectiveness of many ACL injury prevention programs that have been developed in the past decade. These programs typically involve an altered warm up and inclusion of certain fitness drills in practice that include core work, stretches, plyometrics, strengthening and sport-specific agility drills. The end goal is to optimize muscle balance and improve the athletes biomechanics, particularly with jumping and cutting type movements that typically stress the ACL.
Aside from these ACL injury prevention programs, more recently certain researchers have recommended screening programs to identify the young athletes that may be at higher risk for ACL injury. Medical screening tools ideally are desigend to be sensitive enough to identify only the high risk individuals so that interventions can target this population rather than those who do not need the intervention, thus saving money. With an effective ACL injury screening tool, the athletes that are at highest risk can then participate in an injury prevention program, rather than having all of the athletes in the program, again with a goal of saving time and money.
As finances for youth and college sports can be limited and injury rates continue to rise with increased sport participation, it is important to find the most cost-effective program to implement that also provides the best results. It necessary to take into consideration the cost and accuracy of a screening tool, as the purpose of the screen is to identify those at risk. Similarly it is important to make sure that the intervention is targeting the correct population and is effective in making the modifications desired. Though research supports the sensitivity of screening tools as being effective in predicting ACL injury risk, these screening tests require extensive set-up, expensive motion analysis video equipment, and a skilled tester. Typically the athlete will run through a battery of jump and landing tests to determine the knee abduction moment. Even if a coach is educated on what to look for with a screening test and is able to use a simple camera, the time and cost required to conduct the testing exceeds the benefit.
The incidence of ACL injuries in youth is high enough that a screening tool is just not warranted. The high incidence rate equates to the fact that most athletes will benefit from an ACL injury prevention program, which are very inexpensive and highly effective as supported by research. On average, such programs decrease the incidence of ACL injury from three per cent to one pecent in a single season, saving on average $100 pre player per season in expenses related to such injuries. Universal ACL injury prevention programs for young athletes, male and female, are a cost effective strategy for reducing the physical, psychological and financial burden of ACL pathology.
Eric Swart MD, et al. Prevention and Screening Programs for Anterior Cruciate Ligament Injuries in Young Athletes. In the Journal of Bone and Joint Surgery. May 7, 2014. Volume 96A. Number 9. Pp 705 -711.
For more information on ACL injuries, visit our clinic resource page by clicking here.
8/6/2014 0 Comments
Special thanks to star physical therapist Brace Hayden, DPT, CSCS of Alpine Physical Therapy for providing this write up on a recent article from Spine.
It is widely accepted that low back pain is one of the most common orthopedic pains we will experience in a given year. It is also a highly scrutinized and researched health condition, as it is a very costly public health problem that affects a third of all adults.
Treatments for low back pain range from medication, to surgery, to therapist-delivered care. Recently, Dipesh Mistry and a team of health scientists from the UK’s Warwick Medical School, performed a systematic review of the research on the quality and effectiveness of low back pain treatments performed by therapists. Acceptable therapies for low back pain included a lot of treatments from psychological interventions to intensive rehabilitation programs, from laser acupuncture in Australia to high velocity thrust manipulation in Sweden.
The targeted types of low back pain were classified as ‘nonspecific’, meaning they do not come from a likely cause such as a fracture, tumor, infection or inflammatory disease. Nonspecific back pain is generally known as the common back ache or strain.
Mistry’s team combed through the research to select only high-quality, randomized controlled trial-based articles on subjects older than 18 with a history of nonspecific low back pain. Their results largely followed the prior literature reviews consensus small, rather than the conventionally-accepted moderate positive effective gains from therapeutic treatments. They were able to use a total of 39 articles from various search engines (ie. Medline and Cochrane Controlled Trial Register) completed between the years of 1948 to 2013.
They divided the articles into two sub-classifications as either a confirmatory finding or an exploratory finding. Confirmatory are more rigorous, follow-up research that strides to confirm or test the hypothesis. Exploratory are more preliminary research that aims to generate future hypotheses or build a base for future research.
Of the accepted, high-quality studies, only 3 studies (8%) tested hypotheses and were classified as confirmatory. Eighteen studies (46%) were classified as exploratory findings. The remaining 18 (46%), fell short of a substantive conclusion and were given the ‘insufficient findings’ status.
The researchers further tweezed each articles’ respective study methods for appropriate statistical testing for each interaction between studied variables. Fortunately, appropriate stats were employed in 27 of the 39 of the articles. The remaining articles had sub-classification reporting deficiencies or other areas deemed too weak to qualify for this paper’s systematic review.
They concluded that the sub-classified (either the confirmatory or exploratory findings) therapies for treating nonspecific low back pain have been ‘severely underpowered’ in their analysis. In other words, over the past 65 years, the 39 acceptable high-quality articles were only able to provide exploratory class research with insufficient evidence to boot. Moreover, they had poor quality data in their reported findings.
Mistry’s team also generalized that if we hope to better identify which form of low back pain treatment will be the most economical and effective, then we need to better classify which subgroup of persons with back pain are appropriate for each treatment.
Future research was suggested here to develop new methods to effectively identify subgroups in back pain research. Furthermore, they recommended that the low back pain research community needs to collectively revise their current approach to subgrouping the back pain studies. Continued perpetuations of exploratory class research won’t help improve the care for our substantial population of persons with back aches looking for effective therapies.
Dipesh Mistry, MSc, et al. Evaluating the Quality of Subgroup Analyses in Randomized Controlled Trials of Therapist-Delivered Interventions for Nonspecific Low Back Pain. A Systematic Review. In Spine. 2014, Volume 39, Number 7, pp 618 – 629.
For more information on the specialties and services provided by Alpine Physical Therapy, please visit our clinic website by clicking here.
When you come to visit us at Alpine Physical Therapy for an evaluation or reevaluation, you might wonder why you have to fill out a form answering questions about what you can and cannot do when your therapist will be asking you about it anyway. There are several reasons that we ask you to fill out these “outcome measures.” (These forms are available on our website. Simply click here.)
First, they offer a nice sounding board for questioning during our evaluation. Physical therapy is about getting back to the things you love or functioning in your daily life with ease. We are better able to get you back to these things if we know what they are, and we can get to the heart of the problem more efficiently with a heads up of your areas of difficulty.
Second, in our changing healthcare industry, insurance companies and Medicare are becoming more focused on objective measurements to track progress. They want a hard fast number that shows improvement. By filling out an outcome measure initially, then again after a month or so of therapy, they have a more concrete idea of how far along you are in your healing process, which in turn legitimizes further therapy appointments.
Finally, outcome measures help the physical therapy profession as a whole better monitor effectiveness and timeliness of treatment techniques. Each outcome measure that Alpine uses is carefully selected based on evidence of its effectiveness at accurately reporting physical deficits and gains. We want to provide you with the best care possible, and outcome measures are another tool available to us to ensure that we are doing so.
Fore more information to help you get started at Alpine Physical Therapy, click here for our new patient web page.
Brent Dodge is the founding owner of Alpine Physical Therapy and is a board certified orthopedic specialist. He holds additional certifications in Functional Dry Needling, Manual Physical Therapy, and Strength and Conditioning.
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