the rehabilitation of the osteoarthritic knee patient. In particular, I will discuss the physical therapy and whether or not it's effective for these patients with knee osteoarthritis. These are my faculty disclosures and it's certainly a pleasure to be presenting at the AOSSM ANA meeting in Nashville. Certainly this is an activity that we think is not advantageous for the OA patient, especially a 92 year old, but nevertheless, on the internet we see lots of examples of this going on. Knee osteoarthritis, as well as arthritis, is very common in the world, as well as in the United States. It's estimated around 14 to 17 million people in the United States suffer from knee osteoarthritis. Sometimes it's the aging athlete, sometimes it's the middle-aged athlete, and sometimes it can be a professional athlete after a traumatic knee injury of various sorts. This is an interesting study published in the New England Journal of Medicine in 2013 by CATS. They had 351 patients who were randomly assigned to surgery or non-operative standardized physical therapy. Both groups received physical therapy. Similar results occurred at six months, but in the physical therapy alone, the non-OPT group, 30% converted to a surgery group. In the surgery group, only 6% declined to have surgery. We know that the treatment for these particular problems are multifaceted, from cell-based therapies, injections, to physical therapy, supplements, diet, bracing, and orthotics. Many times it's an athlete like this, and it can be very devastating for them to have knee pain and swelling and problems. Cell-based therapy, such as PRP, stem cell, hyaluronic acid, was discussed previously with an excellent presentation, so I won't touch on that at all. But what about supplements? Certainly glucosamine with chondroitin sulfate has been advocated by some from a standpoint of reducing symptoms. There was one very large NIH-funded study in the New England Journal of Medicine in 2006 that basically showed no significant benefit from glucosamine with chondroitin sulfate or without compared to a placebo group. But if you look at the results carefully, all groups improved. Even the glucosamine group had somewhat of a 20 to 25% improvement. What about the glucosamine itself? Consumer reports have looked at this several times, identifying which one was the most cost-effective. And some of the cheaper brands may actually be more cost-effective than more expensive ones. But they did find, with the inexpensive as well as the higher price, the amount of drug in the capsule was very high. We need to educate these patients as far as problems, proper education as far as low to moderate impact loading, proper exercise prescription as far as sets and reps, but the exact exercise needs to be tailored to the person. Also coping skills, strategies that control pain, positive attitude. Patients do better if they do have a positive attitude. And that's been shown with RA patients as well as OA patients. If they think more positively, ignore the pain to some degree and stay active, they do much better. An active lifestyle is imperative. Significant short-term effects have been shown by doing weight training and flexibility exercises, particularly targeting the quadriceps, hip and core, as well as proprioception. Many times patients tell me, well, I can't exercise because it hurts too much. Well, and they say, I can't do that. We have to find some form of exercise that they can do to help control weight and also reduce body weight as well. Bicycling is 0.8 to one times body weight, so that's certainly a great way of going. Walking is three to three and a half times body weight. Running is six to seven times body weight. And the elliptical can also be used. So cycling may be a nice alternative for a lot of these patients. The pool. The pool is a great environment. Many times health clubs as well as rec centers and different types of facilities do have pool programs for the osteoarthritic patient. There are also unloading treadmills available. Water up to the waist is about 50% body weight on the individual. Water up to your axilla is about 25% body weight. The elliptical is another option. That's about two times body weight. So another low impact type of loading. So we tell patients when we see them, regardless of their age and their problem, we want to get your range of motion back, particularly get your extension and an adequate amount of flexion. We also want good hip range of motion and ankle as well. So we want that overpressure program, hamstring stretching, and we tell them to stretch at every opportunity. We don't want a stiff knee, particularly extension. We work on a moderate exercise program to start with, with core, hip, quads, and then progress to more functional exercises, walking. We want to reduce their body weight and to a healthy BMI. It's also been talked about as far as getting on an anti-inflammatory diet, rich in omega-3s, leafy green vegetables, nuts, fruits, those types of things, and avoid the sugary, rich carbs, salt, fried foods, white flour, omega-6. Unloader braces, interesting data out there. Probably the best study was done by Dr. Sandy Kirkley out of Canada and JBJS in 99, where they randomized people. And they documented that people in unloader brace did significantly better than in a neoprene sleeve or no brace at all. And there's other studies to document that as well. Orthotic can be beneficial, particularly lateral heel wedges for the genuverous knee to unload that medial compartment. And there's good evidence to support that. So perhaps an unloader brace during aggressive activities and symptomatic episodes can be beneficial. So what's my recommendation? Active lifestyle, healthy lifestyle, develop coping skills, reduce your body weight, perhaps orthotics, perhaps bracing, but yoga, Pilates, stretching, bicycle, multifaceted approach, injections when needed, and we wanna return them back to a physiologic level of function. In summary, it's a common problem. It can be debilitating, but I think with a proper program, it can be something that can be handled for a long period of time. Exercise is beneficial, and I think physical therapy can help. Getting old is tough, but we have to get through it, and we have to get through it together. Thank you very much for your kind attention. And. Yeah. Thanks, Kevin. I'm introducing David Flanagan, and just one comment on Kevin's talk. I think it's really important to pay attention to that multiple of body weight. So when you talk to patients about losing weight, if you tell them that it's six times their body weight going up and down stairs, you can say even losing 10 pounds is 60 pounds, and I think that makes a big difference to patients, because they don't think 10 pounds is even worth losing if they're significantly overweight. Go ahead.

rehabilitation

knee osteoarthritis

physical therapy

multifaceted approach

surgery vs non-operative therapy