Alex

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21st August 2017by Alex0

I see many patients suffering with osteoarthritis (OA) throughout different joints in the body and recently many more clients requiring physiotherapy for Knee OA. OA is the most common form of joint disease, and the knee is one of the most commonly affected joints. There are some excellent resources to give you advice and recommendations on all aspects of OA from cause, complications, management and treatment.  The arthritis research website is a great place to start and their free downloadable booklets give clear and simple explanations on this.  I won’t repeat all the information they display on there as I’m sure they will explain it better than I can, however, there are some questions I do often get asked that I will try and help shed some light on.


Do I need an operation?
Will physiotherapy actually help?
Are there any supplements I can take or dietary changes I can make?

Do I need an operation?
There has been some excellent research released recently answering just that.  The British Medical Journal (BMJ) is one of the largest medical journals covering a number of topics amongst their papers.  They are currently publishing ‘rapid recommendations’ on a number of topics – their May topic answers this very question.  They have strongly recommended against knee arthroscopy (keyhole operation) in almost all patients with knee OA.  Their reasons for this is that research has shown that there is no lasting benefit in pain or function.  This paper was from a systematic review which is classed as 1a level of evidence (the highest level).  The other main surgical alternative is from a knee replacement this however, is reserved for patients with ‘severe disease after nonoperative management has been unsuccessful’ (McGrory B et al., 2016).
Although there is still debate amongst orthopaedic surgeons as to when the ideal time for a knee replacement may be it is agreed that conservative management (i.e. exercises) is extremely important – in some cases completely resolving pain and functional problems and in others allowing the patient to self-manage more effectively. Some consultants believe that if a patient is struggling with pain and function then the best solution is to provide a knee replacement early therefore allowing a better quality of life, the negative aspect of this is that as people are living for longer there is a greater chance that the materials used will wear out and then need to be revised.  Having a big operation to revise a knee replacement into your 90s when you may have other health problems probably isn’t ideal either!  Alternatively encouraging self-management and exercises to delay any potential operation can be highly effective.
Ultimately decision making lies with the patient after being guided by knowledgeable consultants and health professionals such as physiotherapists.  Exercises are vital either way, whether it be to build up muscles to help with pain and function, or to delay the need for an operation or in the rehabilitation phase after an op.

Will physiotherapy actually help?
Yes – Physiotherapy for OA Knees will include exercises which have been proven to be effective. Other modalities may be used such as soft tissue work, mobilisations, acupuncture although these can aid in short-term benefits there is little evidence that this in isolation is beneficial long term.  National Institute for Clinical Excellence (NICE) in their osteoarthritis recommendations include:
  • advice and support to increase physical activity and exercise, including pacing strategies, that gives information about local services such as physiotherapy, or exercise classes, groups and facilities
  • advice and support for people who are overweight or obese to lose weight, which may include referral to local resources such as weight-loss and exercise programmes
  • referral to local services such as occupational therapy, orthotics and podiatry that can provide advice on suitable footwear, orthotic devices (such as insoles and braces) and assistive devices (such as walking sticks and tap turners)
  • pain management advice

Are there any supplements I can take or dietary changes I can make?

There are no specific dietary supplements that have been proved to be of benefit to arthritis sufferers, however, there is a subset of patients who have found different diets beneficial. Having said this, a healthy diet is essential for good general health.  One of the most important links between diet and arthritis is that of weight.  Being overweight puts extra stress on weight bearing joints.  Because of the way that some joints work, the effect of extra weight can be four to five times greater in important parts of the joint.If you were overweight and have arthritis, losing weight will be much more beneficial than any supplement.In general, there are 8 points to a healthy diet.
  1. Base your meals on a starchy food – starchy food should make up 1/3 of what we eat, they are a good source of energy and the main source of a range of nutrients on our diet. Also a good source of fibre. Where possible, try to choose wholegrain varieties of foods, these include wholegrain bread, pasta and breakfast cereals.
  2. Eat plenty of fruit and vegetables – Try to eat 5 portions of fruit and veg a day, you can choose from fresh, frozen, tinned or dried but remember potatoes count as starch not veg.
  3. Eat plenty of oily fish – aim to eat at least two portions of fish a week, including one oily portion, again you can choose fresh, frozen or canned but remember that tinned and smoky fish may be high in salt. Oily fish include salmon, mackerel, trout, herring, fresh tuna, sardines, pilchards and eel.
  4. Cut down on saturated fat and sugar – having too much saturated fat can increase the amount of cholesterol in the blood, which can increase the chances of developing heart disease.
  5. Eat less salt (<6g/day) – eating too much salt can raise your blood pressure and increase both the risk of heart disease and stroke by up to 3 times!
  6. Get active – Physical activity is good way of using extra calories and helps to control weight, this doesn’t mean you have to join a gym. Try and get exercise every day and try to build this up.
  7. Drink plenty of water – we should be drinking 1.2 litres of water or other fluids every day (increased during hot weather).
  8. Don’t skip breakfast – research shows that eating breakfast can actually help people to control their weight.

Supplements:

Glucosamine and chondroitin: both have been around for many years, with few reported side effects and both have been linked to some anti-inflammatory effect and also some pain relief.  Evidence into this area is still ongoing. An article released late last year suggests that an increased dietary intake of fibre can help reduce symptomatic OA of the knee.  However, although I have included a link to this article it is important to note, many articles have limitations. This article compares two studies which aren’t set up in exactly the same way, therefore makes comparing difficult; there is also the risk of bias as well as patient reported dietary intake being difficult to assess.
I hope you have enjoyed this slightly more lengthy blog post and if there are any topics you would like to discuss with me or comment on, please drop me a message.

Alex
McGrory B, Weber K, Lynott JA, et al. (2016) American Academy of Orthopaedic Surgeons. The American Academy of Orthopaedic Surgeons evidence based clinical practice guideline on surgical management of osteoarthritis of the knee. J Bone Joint Surg Am 2016;98:688-92.
*picture courtesy of Arthritis Research UK website.



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1st June 2017by Alex0

What better place to start for my first blog post than Wimbledon? As a tennis player myself, tennis injuries have always been an interest to me and possibly also sparked my interest in physiotherapy to start with.

This year’s Wimbledon has been dogged by injury from the first round right through to the final. Notable casualties saw Queens champ Feliciano Lopez crash out in the first round as did entertainer/madman Nic Kyrigos, Nishikori and Djokovic followed with GB favourite Andy Murray concluding his 5 setter but visibly struggling with his recent hip problem.  Cilic failed to beat the great Roger Federer in the final and despite an injury timeout for treatment on his foot could not overhaul the Swiss.
Sadly the most horrific injury of the tournament goes to Bethanie Mattek-Sands. The American was two sets down when she slipped and fell. Screaming in pain we later found out she had suffered a dislocated patella and ruptured patella tendon. She will require an operation to repair the tendon with an immediate period of rest and immobilisation and after weeks of a cast / brace she will slowly be allowed to increase the movement in her knee.  In the early stages swelling management and range of movement is key.  Progressive strengthening, proprioception and balance exercises will continue until she can move into dynamic training, It is unlikely she will be able to pick up a racket and get back to the court for the best part of a year.  Although when initially looking at tennis you may assume wrist and shoulder injuries would be the most prevalent, the huge amount of fast intense footwork, cutting and change of direction will mean Mattek-Sands will have to endure a range of intense single leg loading and change of direction activity until she could consider going back to the competitive environment.  It is not all doom and gloom though. Previously cited as the injury to end a sports star’s career – others have returned but it will certainly be a hard slog.
Interestingly two articles have reviewed the injuries over a 16 and 9 year period at both the US Open (Sell et al., 2014) and Wimbledon (McCurdie et al., 2014) respectively.  Although now a few years old these articles show how:
  • The majority of injuries presenting at this tennis Grand Slam competition were pre-existing or recurrent, that is, occurred prior to arrival at Wimbledon.
  • Muscle and ligament injuries are the predominant type of acute injury in professional grass court tennis and, despite annual variability, appear to have increased in female players during the study period
  • Ligament and articular surface injuries are less common and vary little from year to year.

(McCurdie et al., 2017)

The image below taken from the study shows the common distribution of injuries throughout the body during the period of study.

We also know that the grass is far firmer than it has been in years gone by, and with a particularly dry tournament this year we may find Wimbledon’s injuries are far more similar to those of the other slams.  Previously with more slipping on damp grass or moving from an area of wear to the fresh grass outside the court has created a problem that the other slams don’t have to contend with.  Although this will remain, the roof now on Centre and soon to be Court 1 will definitely change the dynamics of injuries moving forward.

References:

McCurdie, I., Smith, S., Bell, P.H. and Batt, M.E., 2017. Tennis injury data from The Championships, Wimbledon, from 2003 to 2012. Br J Sports Med51(7), pp.607-611.
Sell, K., Hainline, B., Yorio, M. and Kovacs, M., 2014. Injury trend analysis from the US Open Tennis Championships between 1994 and 2009. Br J Sports Med48(7), pp.546-551.