WEB EXCLUSIVE ❙ Supplemental content for: EXERCISE TO IMPROVE OUTCOMES IN KNEE OSTEOARTHRITIS >> BY MARIAN A. MINOR, PT, PHD Sample Home Exercise Program Exercises for flexibility and strength Perform each exercise five times a day for the first week and then increase gradually to 10 repetitions. 1. Knee bending Sit on the floor or firm surface. Keep your foot flat and bend your knee as far as you can until you feel a slight pull or tension. Hold this position for 10 to 30 seconds. Breathe normally and relax. Then straighten out your leg completely and rest in that position for 10 to 30 seconds before repeating. 2. Knee straightening Sit on a firm surface with a rolled towel under your knee. If you feel a pull behind your knee or it is difficult to straighten your knee, lean back slightly to lessen the tension at the back of your knee. Start by tightening up the muscles on the front of your thigh, pushing the back of your knee into the rolled towel and at the same time, raising you heel slightly up off the surface. Hold for a count of 10. Once you can do this 10 times comfortably, begin to lift your knee up off the towel, raising your straight leg up in the air. Hold for a count of five and relax. It is important to make sure you get your knee completely straight before you raise your leg. 3. Knee and hip strengthening Lean up against a wall with your feet shoulder width apart and heels about 12 to 14 inches from the wall. Place a sturdy chair close by or stand close to a counter or table for support. Slowly slide down the wall, bending your knees slightly. It is not necessary to bend your knees very much at first. Never bend them so far that you feel pain or more than 90 degrees. Hold this lowered position for 10 seconds and then slide back up the wall. Rest and repeat. Endurance activity Combine these three exercises done daily with a walking or stationary bicycle program on most days of the week. Start walking or cycling for five to 10 minutes at a moderate speed. Walk on flat, even ground and cycle without resistance at 50 to 70 rpm. Your goal can be three 10-minute sessions to accumulate 30 minutes of activity or to exercise continually for 30 minutes. As you get more endurance and strength, add some hills or resistance to your program. Walk or cycle at a speed that is no more than moderate intensity. (Moderate intensity means that you can carry on a conversation while exercising, your breathing is deeper and a bit faster, you start to feel warm, and you might begin to sweat after 10 minutes.). THE RHEUMATOLOGIST ❙❙❙ MAY 2008 Treating inflammation with PRICE - OA OF THE KNEE Promoting Health Through Exercise immediately after injury and for 3-5 days afterwards Tissue injury usually involves damage to small blood vessels that results in bleeding at the site of injury. This bleeding leads to the five main signs of inflammation: heat, redness, swelling, pain and loss of function. The inflammatory reaction is necessary as it is part of the natural healing process. However the body tends to overreact to sudden traumatic injury and as a result more inflammatory fluid accumulates than is necessary for healing. This fluid contains a protein that turns into replacement ‘scar’ tissue. Too much scar tissue may prevent the structure returning to normal function with reduced flexibility and increased risk of re-injury. The advice below should be followed for 3-5 days depending on severity. It can be remembered by the acronym PRICE. ● ● ● ● ● PROTECT - Protect the injured tissue from undue stress that may disrupt the healing process and/or cause further injury. Make sure the mode of protection can accommodate swelling. REST - This reduces the energy requirements of the area, avoids any unnecessary increase in blood flow, ensures protection of the area and optimises healing. For example using slings, crutches or static rest (ie. sitting or lying down). ICE - The ice helps constrict the blood vessels thereby limiting bleeding and reducing the accumulation of unnecessary scar tissue. Crushed ice wrapped in a damp towel (to prevent ice burn) is best (ice cubes can be wrapped in the cloth and smashed against a wall to crush the cubes). Ice should be applied immediately after injury for 20 minutes every 3-4 hours or no more than 5-10 minutes at a time on bony areas. COMPRESSION - Simple off-the-shelf compression bandages such as Tubigrip™ and adjustable neoprene supports are adequate. It is important to ensure the bandages are not too tight to cause pins and needles or any loss of feeling around the joint. ELEVATION - Lowers the blood pressure and helps limit bleeding and encourage drainage of fluid through the lymphatic system. When following PRICE it is also important to avoid HARM, hence the saying: ‘Give PRICE and avoid HARM’. AVOID H – Heat (eg. hot bath, sauna) A – Alcohol R – Running M - Massage } these are counterproductive to PRICE treatment WWW.SPORTEX.NET Exercises for osteoarthritis of the knee Femur Quadriceps muscle Joint capsule Patella tendon Synovium Healthy knee Patella Roughened back of patella Knee with OA Damaged cartilage Articular cartilage Lipping of bone (osteophyte or ‘spur’) Meniscus OSTEOARTHRITIS Osteoarthritis (OA) is a disease of the joint cartilage associated with secondary changes in the underlying bone which may cause pain and compromise the function of the affected joint. OA is the result of aging and general wear and tear. Exercise is important in order to maintain a full range of movement at the knee, improve strength and preserve joint function. Be careful not to over-exercise as this may cause increased pain. Controlled rehabilitation exercises have been proven to increase leg muscle strength and decrease disability without increasing pain in patients with OA of the knee. • • • • • USEFUL RESOURCES SportEX Medicine magazine www.sportex.net The Organisation of Chartered Physiotherapists in Private Practice - www.physiofirst.org.uk General Osteopathic Council www.osteopathy.org.uk The Sports Massage Association www.thesma.org The Osteopathic Sports Care Association www.osca.org.uk WWW.SPORTEX.NET PATIENT ADVICE Your rehabilitation programme This exercise programme has specific exercises to help maintain your range of joint movement, and strengthen the muscles around your knee. In order to achieve these goals it is important to ensure the exercises are performed with a good technique. The following leaflet includes some exercises to help in your rehabilitation. Warm up and warm down It is important that you warm up if possible with a gentle pain free walk for 3-4 minutes before you start your exercises. This increases your circulation and helps prepare your muscles for the activity to come. When you have finished your exercises it is also important to allow your heart rate to slow down gradually by ending the session with a gentle walk for a few minutes. General guidelines Exercises for osteoarthritis of the knee Early rehabilitation exercises 1 Quadriceps stretch – Lie on the floor (or bed if the floor is difficult) with your knee straight, slowly bend the affected knee as far as possible (moving your ankle as close to your bottom as possible). When you feel a stretch in the thigh muscle hold the position for 10 seconds then return to a straightened position and hold again for 10 seconds. Repeat 10 times. 2 Quadriceps tense – Remain lying on your back with your legs straight and place a rolled up towel under the knees. Tighten the front thigh muscle (quadriceps) by pushing the knee in to the towel. Hold for 10 seconds and then release for 20 seconds. Repeat this process 10 times. your knee with your hands but slowly lean forward until you feel a stretch at the back of the thigh. Hold the stretch for 20 seconds. Repeat 5 times. 4 Inside thigh muscles and gluteal muscles tense – Sit on a chair, place a towel or ball between the thighs, tighten buttocks and squeeze thigh muscles together. Hold for 10 seconds. Repeat 5 times. Later rehabilitation exercises 1 Straight leg raise – Lie on your back, lean on forearms with the knee of the affected leg straight and foot pulled up (bend the knee of the unaffected leg for balance). Lift During acute attacks, rest will help by decreasing inflammation but you’re likely also to experience increased stiffness and reduced muscle power. When attempting the following exercises there should be no pain but it is relevant to work the muscles as hard as feasible. If the exercises cause pain and swelling then you should allow a period of time, perhaps two days, for the irritation to settle. All exercises should be performed gently, slowly and ideally little and often. slowly to the sitting position again without using your arms. Repeat 10 times. 3 Quadriceps strengthening - step down – Place the affected leg on a shallow step about 3 inches high. Step down with the good leg (slowly), taking 3-4 seconds to complete the step. Repeat 7 times. You can hold on to a bannister for support. 4 Quadriceps strengthening minisquats - Using a chair, squat down bending both knees but keeping the back straight. The squat should be to approximately 45 degrees. Repeat 10 times. Additional exercises 3 Hamstring stretch (tight hamstrings are a common finding in OA) – Stand upright and place the foot of your affected leg on a stool or chair. Try not to push down on the straight leg about 4-6 inches off the ground and hold for 10 seconds. Repeat 10 times. Swimming and cycling may be appropriate for certain individuals as mobility, strength and aerobic capacity can be increased without too much stress to the joint. PRACTITIONER CONTACT DETAILS 2 Quadriceps strengthening – Sit on a chair with your arms folded, slowly stand up without using your arms. When upright, return The information contained in this leaflet is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. To the extent permissable by law, the publisher, editors and contributors accept no liability for any loss, injury or damage howsoever incurred (including negligence) as a consequence, whether directly or indirectly, of the use of any person of the contents of this leaflet. WWW.SPORTEX-MEDICINE.COM