The Orthotist’s Role in Successful Knee OA Management

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She is over 50. She is overweight. She is feeling depressed because she realizes that the everyday activities she enjoyed and did effortlessly have now become slower, harder, and more painful to perform. Who is she? She is the patient with osteoarthritis (OA) of the knee who has been referred to you for orthotic care.

Of course, not all persons with knee OA fit this profile—but many do. According to the U.S. Centers for Disease Control and Prevention (CDC) National Health Interview Survey (NHIS) 2003-2005, 28.3 million women and 18.1 million men reported doctor-diagnosed arthritis. Several other sources note that arthritis affects about one-third more women than men, and, after age 50, women strongly take the lead in knee OA. For instance, Christofer Mowrer, CPO, Scheck & Siress Orthotic & Prosthetic Inc., Oakbrook Terrace, Illinois, says that about 70 percent of the company's knee OA patients are women.

An estimated 21 million adults suffer from OA, and OA of the knee is one of the five leading causes of disability among older persons, according to the American Academy of Orthopaedic Surgeons (AAOS). In OA, the knee is the most commonly affected joint, and medial compartment involvement is much more prevalent than is lateral compartment disease, according to Julie E. Adams, MD, and Diane L. Dahm, MD, of the Mayo Clinic, Rochester, Minnesota ( Women's Health in Primary Care , May 2005).

When treating postmenopausal women with OA, conservative management is a first-line approach that can prevent or delay surgery. Conservative measures include patient education and social support, physical therapy, exercise, weight loss, unloader braces, shoe inserts, gait aids, and pharmacologic interventions such as acetaminophen, oral or topical NSAIDS, glucosamine, chondroitin, hyaluronic acid, and intra-articular injections, note Adams and Dahm. "Overall treatment should be tailored to the needs of the individual woman...[and] include educating the patient about her disease, reducing pain and disability, and minimizing the progression of disease."

"The approach to early arthritis is to maintain range of motion—to keep the joint moving and prevent contractures around the joint, to strengthen the muscles surrounding the joint, quadriceps and hamstrings in particular for the knee—and to protect the joint by avoiding activities or positions that may increase cartilage wear and tear," says Andrea Boon, MD, of the Mayo Clinic.

Lifestyle: What Patients Can Do

Christofer Mowrer, CPO
Christofer Mowrer, CPO

It has often been noted that the most important person in the healthcare team is the patient, and this is certainly true in achieving good outcomes in knee OA management. Lifestyle changes on the part of the patient may be essential in alleviating pain, restoring function, and slowing the progression of the disease. Often, what the patient can do to help herself the most can be summed up in four words: Lose weight, exercise more.

Being overweight or obese is frequently cited as a large risk factor for developing OA of the knee and exacerbating the symptoms after its onset. And Boon notes that women patients with knee OA tend to be overweight more often than men. "If they could lose some of the weight, sometimes the symptoms decrease significantly," she says.

"Even mild to moderate weight reduction may be beneficial. In women, loss of approximately ten pounds over a period of ten years may cut symptoms by half," Adams and Dahm point out. The CDC agrees with this, stating that weight loss of as little as 11 pounds reduces by 50 percent the risk of developing knee OA among women.

"I'd like to get education out to everyone" that losing a small number of pounds hugely decreases chances of developing OA of the knee, says Rhonda Turner, PhD, MBA, JD, CFM, BOCPO, The Prosthetic Center, Houston, Texas.

The combination of weight loss and exercise is significantly better than either intervention alone or healthy lifestyle counseling in reducing pain and improving function in patients with knee OA, according to the results of a randomized controlled trial published in the May 2004 issue of Arthritis & Rheumatism (cited on Medscape from WebMD, www.medscape.com ). "Considering that side effects often limit the use of drug therapy, and surgical intervention is often ineffective for mild or moderate knee osteoarthritis, our results give strong support to the combination of exercise and weight loss as a cornerstone for the treatment of overweight osteoarthritis patients," lead author Stephen P. Messier, PhD, Wake Forest University in Winston-Salem, North Carolina, says on the website.

Exercise: Beating the Pain Barrier

Andrea Boon, MD
Andrea Boon, MD

Overweight women patients often find themselves in a Catch-22 situation: pain keeps them from exercising as much as they would like and thus hurts weight-loss efforts; in turn, they may gain weight that exacerbates the OA. However, the recommended types of exercise may give the patient an end-run around the pain/weight gain impasse.

"Low-impact aerobic exercise is good. Walking is excellent. Stationary bike riding, if non-provocative, is fine too," says Boon. "Aquatic exercise is excellent if land-based exercise is too painful. Strengthening of the quadriceps is very important, as patients often have atrophy of that muscle, and this can lead to the sensation that the knee is weak or going to give out on them."

Turner recommends water exercise, noting that the buoyancy of the water enables patients to lose weight and use muscles without continued pounding. She also is a strong proponent of stretching. "You can get a lot of benefit by just plain stretching," Turner says. "Some of the exercises have hamstring stretches, ankle stretches—exercises that help reshape the muscles and give them strength without continuing the damage."

Adams and Dahm observe: "Exercise has been demonstrated to be an effective treatment for knee OA in a number of randomized, controlled clinical trials. Joint-specific conditioning exercises, such as those for quadriceps strengthening, as well as generalized aerobic fitness programs, appear to be beneficial, producing subjective decreases in pain and disability. Better coordination, mobility, and capacity to perform activities of daily living likewise make an exercise program an important part of therapy." According to these experts, however, women with OA should not participate in high-impact activities, which may exacerbate symptoms and hasten disease progression.

Among older adults with knee OA, engaging in moderate physical activity at least three times per week can reduce the risk of arthritis-related disability by 47 percent, according to the CDC.

What Orthotists Can Do

Osteoarthritis of the knees, medial and lateral cartilage degenerations (radiographs). ©1972–2004 American College of Rheumatology clinical slide collection. Used with permission.
Osteoarthritis of the knees, medial and lateral cartilage degenerations (radiographs). ©1972–2004 American College of Rheumatology clinical slide collection. Used with permission.

If the physician has prescribed a program of diet and exercise therapy, the orthotist can help motivate the patient to stick with it. If the physician has not done so, the orthotist can encourage the patient to ask her doctor about a self-management program incorporating weight loss and exercise. The orthotist also can provide relevant educational materials. The Prosthetic Center provides fact sheets on orthotics, exercise, and weight loss, notes Turner. "We also offer a generalized training session in Spanish as well as English, which includes patients' families."

The importance of education, along with social support, is underscored by Adams and Dahm. "Several studies have demonstrated that patient education improved pain control although functional outcome appeared unchanged. Patients may benefit from learning which activities are likely to worsen symptoms... Education about symptom management for acute flares may be helpful.& Regular telephone contacts from the clinician may reduce subjective pain and disability, [and]... social support networks and familial education seem to improve symptoms."

Starting Point: Keep It Simple

Conservative measures generally start with the least costly and complex and move on up the continuum if needed. Often physicians will look to orthotists for recommendations on orthotic management. "Generally, the physicians leave the type of device up to us," says Mowrer. "They will just prescribe medial to lateral offloading."

Turner says it's about a 50-50 split in her practice as to whether or not physicians tend to be highly specific in orthotic prescriptions or rely more on orthotists' recommendations. Turner generally starts with the simpler, less expensive devices and moves up if necessary. She says she often starts with orthotic insoles and uses shoe inserts with a brace for maximum results.

Mowrer agrees. "We begin conservatively with foot orthoses with wedging and/or posting," he says. "Most patients begin with a custom foot orthosis with a medial or lateral wedge from hindfoot to the forefoot. Then we move to a soft knee orthosis, and then to an OA knee orthosis. If all conservative treatment fails, they are then seen by the orthopedic surgeon for surgical intervention."

Adams and Dahm point out that a conservative approach involving the use of shoe inserts or insoles "seeks to mimic the beneficial effects of osteotomy, which has long been an effective treatment for unicompartmental OA of the knee," and may be helpful in relieving symptoms. "Placement of a wedge insert into the shoe is a conservative alternative, as it alters the mechanics of the leg, shifting pressure to the less arthritic compartment."

Mowrer notes that the vast number of Scheck & Siress' knee OA patients have unicompartmental involvement. "We generally use a single upright KO for unicompartmental OA and a double upright KO for multicompartmental involvement."

Unloader braces may help shift weight bearing away from the involved compartment. "Use of an unloader brace in order to apply a valgus moment to the knee joint may also help to shift weight bearing from the medial to the lateral compartment&resulting in symptomatic relief in patients with unicompartmental arthritis," Adams and Dahm explain. Likewise, varus moments may be applied by braces to unload the lateral compartment when lateral compartment arthritis exists. Adams and Dahm add that elastic joint sleeves and gait aids may aid stability and help provide symptomatic relief.

"The critical role of the orthotist is to know the full arsenal of OA knee orthoses and orthotic treatment available and apply the most appropriate orthotic management to each patient individually," says Mowrer.

Shoes: Part of the OA Arsenal

Appropriate shoes are highly important. "If the patient is in a brace but not supported in the foot, there will still be deterioration," says Turner. "We try to make sure that the patient is in a supportive shoe, not, for instance, flip-flops. I try to get them not to wear high heels. Wearing a brace with four-inch heels can really cause a lot of trouble."

Note Adams and Dahm: "When women wear high-heeled shoes, the forces across the medial knee and the patellofemoral joint are increased, resulting in a greater degree of pain."

Multidisciplinary Approach Achieves Best Outcomes

Adams and Dahm urge a multidisciplinary approach to knee OA. Health professionals involved in such an approach can include primary care physicians, rheumatologists, orthopedists, physiatrists, physical therapists, nurse educators, dieticians, psychologists, and social workers. Scheck & Siress takes a multidisciplinary approach. According to Mowrer, the Scheck & Siress OA healthcare team includes an orthopedic surgeon, an internist, a physical therapist, and an orthotist. "Typically, the patient is seen first by an internist who has completed a sports medicine fellowship," he explains.

Boon says that communication is the key to physicians and orthotists working together successfully as part of the healthcare team. "My main advice [to orthotists] is to be available for questions and to feel free to call the physician and discuss the case if there are any questions that arise. They should listen to the patient to evaluate what their needs and goals for bracing are, and to get an idea of the level of likely compliance with brace use before determining the best brace choice."

"[Physicians should] be open to orthotic design," Mowrer says. "Prescribe biomechanical objectives and let the orthotist work with the patient to find the best design for that patient to reach those objectives."

Miki Fairley is contributing editor for The O&P EDGE and a freelance writer based in southwest Colorado. She can be contacted via e-mail at  miki.fairley@gmail.com

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