CASM Research Grant Proposal

Title: The effectiveness of hip strengthening exercises compared to leg strengthening exercises on knee pain and quality of life in patients with knee osteoarthritis. Investigators: Dr. Victor Lun, MD (Principle Investigator, CASM Member), Andrew Marsh, BSC, Dr. Preston Wiley, MD, and Dr. Robert Bray, MD Principal Investigator Contact information: 2500 University Drive NW Calgary, AB T2N IN4 Telephone: 403-220-8518 E- mail: [email protected] Grant applied for: CASM Research Grant

1. Introduction and Background Knee osteoarthritis (KOA) is a very common medical problem with well-known impacts on patient quality of life and costs to the health care system.[1,

2]

The primary

aims of management of KOA are to educate the patient, control pain, improve function and alter the disease process.[3,

4]

One of the important components of conservative

treatment of KOA is exercise therapy. There is consistent evidence that physical exercise of various forms has a beneficial effect on improving pain, joint function and quality of life of KOA patients.[5-19] Improvements in pain and function have been demonstrated using strengthening[7-13] and aerobic [12, 14, 16] exercise programs.

Some form of regular

exercise is generally recommended to patients suffering from KOA, however the compone nts of the most effective exercise prescription for KOA patients have yet to be established.[20, 21] Traditionally, exercise therapy for KOA has focused on strength and flexibility training of the quadriceps, hamstring and calf muscles of the leg. However, it has been identified that strengthening the musculature of the pelvis and hips may also be an important component of an exercise prescription for KOA. Yamada et al (2001) found that patients with medial compartment KOA had stronger hip adductors compared to age matched controls suggesting that patients with medial compartment KOA had this increased hip strength in an attempt to decrease varus deformity and lower knee adduction moment.[22] Chang et al (2005) suggested that decreased hip abductor activity might lead to extra tensile stress on the lateral knee structure, like the iliotibial band, and increased load on the medial compartment of the knee[23] . Therefore it may also be possible that strengthening the hip abductors may also improve symptoms of medial

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osteoarthritis and possibly even reduce the rate of osteoarthritis progression. Sharma et al (2001) investigated the effects of hip-knee-ankle alignment on KOA over 18 months. The study found that in general varus alignment increased the risk of medial osteoarthritis progression while valgus alignment increased the risk of lateral osteoarthritis progression. The authors suggest that the results of the study indicate that there is a need to develop and test the effectiveness of interventions that reduce the stresses produced by varus and valgus alignment of the knee. [24] Although there have been few studies examining the effects of hip strengthening exercises on KOA, studies have shown beneficial effects in other common knee injuries. Patellofemoral pain syndrome (PFPS) can present with clinical symptoms that are similar to KOA, most notably the presence of knee pain and decreased knee function.

Hip

strengthening and flexibility exercises have been shown to decrease pain and improve function of patients suffering from patellofemoral knee pain.[25,

26]

Moreover,

Fredericson et al (2000) found that after 6 weeks of hip abductor strengthening, runners with iliotibial band syndrome had increased hip abductor muscle strength and returned to pain free running.[27] The exact mechanism by which these improvements in symptoms occur is still unknown, however it may be possible that the improvements in hip strength help provide a more stable pelvis and an improvement in dynamic lower extremity alignment. Although there is an abundance of evidence demonstrating the benefits of leg strengthening exercises for KOA patients, the utilization of hip strengthening exercise may provide further additive or even adjunctive benefits, particularly in those patients with valgus or varus deformity of the knee.

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2. Objective The objective of this study is to compare the effects of hip strengthening exercises to traditional leg muscle strengthening exercises on knee pain, function, and quality of life in patients with knee osteoarthritis. 3. Project Methodology 3.1 Subjects Seventy male and female subjects diagnosed with KOA will be recruited for the study from patients who are referred to sport medicine physicians and orthopedic surgeons at the University of Calgary Sport Medicine Center (UC SMC). A sample size of 30 subjects for each group was calculated based upon a change of 10 points in the Knee Injury and Osteoarthritis Outcome Score (KOOS) and assuming a standard deviation of 15 points[28], with the probability of a type I error set at 0.05 and a power of 0.80.

Assuming a possible 15% dropout rate, a total of 70 subjects (35 subjects per

group) will be recruited for this study Subjects will provide written consent to participate in the study and will continue to receive current medical care from their physician. Medical care and daily activity logs for each patient will be recorded for the duration of the study. Inclusion criteria 1. Patients between 40 and 65 years of age and meeting the diagnosis criteria outlined below. 2. Patients not currently participating in a regular strength training exercise program.

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3. Patients currently or previously treated with NSAIDs/analgesic medications, glucosamine sulphate, and/or knee sleeves will be included in the study as long as these treatments have been used for at least 3 months prior to enrollment into the study. 4. Patients previously treated with arthroscopic surgery will be included in the study as long as the surgery was performed over 2 years prior to the start of the study. 5. Patients will commit to attend all testing and exercise sessions (16 total sessions). Diagnosis Criteria History 1. Knee pain for at least 6 months with KOOS Pain score of 65 or less. 2. No prior history of any significant knee injury (including but not limited to patellar subluxations/dislocations/fractures or ligament injuries, etc.). 3. No previous treatment with physiotherapy or specific exercise instruction Radiological Investigation Subjects will have standing anterior posterior, lying lateral (or decubitus lateral), and supine skyline plain film x-rays taken of their affected knee(s). Patients with positive identification of grade 1 or higher radiographic evidence of osteoarthritis (KellgrenLawrence Scale, Table 1) will be included in this study.

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Exclusion criteria 1. Bilateral Knee Osteoarthritis 2. Bony abnormalities including bone fracture, osteochondritis dissecans, bi-paritite patella of affected knee 3. Osteoarthritis of other lower extremity weight bearing joints 4. Any physical or medical problems fo r which exercise would be contraindicated 5. Scheduled knee surgery within the time-frame of the study 6. Regular participation in an organized strength exercise program 7. Recent (within 3 months) or current treatment by a physiotherapist. 3.2 Research Procedure A flow chart of the research procedure can be seen in Figure 1. Potential subjects will be instructed to contact the study coordinator to review the historical eligibility criterion of the study. If subjects meet the historical criterion, they will be eva luated by one of two sport medicine physicians (autho rs VL and PW) at the UC SMC completing a physical examination and recording the presence or absence of knee effusion, joint line tenderness, palpable osteophytes and flexion contracture. Patients meeting the inclusion criterion will then have plain film rad iographs of the affected knee taken, as described previously. X-rays will not be repeated if taken within the previous 12 months. If the xrays meet the inclusion criterion, then informed consent will be obtained if the subject agrees to participate in the study. The study coordinator will then obtain background demographic data and measure subject height, weight, and knee flexion and extension range of motion, amount of varus/valgus deformity, and symptom duration. Baseline

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assessment of the study outcome measurements will then be performed by a research assistant. The outcome measurements will be: Primary Outcome Measures 1. Pain, Symptoms, Activities of Daily Living, Sport and Recreation Function and Quality of Life subscale scores from the Knee Osteoarthritis Outcome Score (KOOS) questionnaire (Appendix A). The KOOS questionnaire is a 42-item selfadministered questionnaire assessing pain (9), symptoms (7), activities of daily living (17), sport and recreation function (5), and knee related quality of life (5), and has previously been demonstrated to be a valid and reliable measurement of knee pain, function, and quality of life.[29-31] Each subscale is scored out of 100 points, 0 representing extreme knee problems and 100 representing no knee problems. A change of 10 in the KOOS questionnaire score is considered to be a clinically significant difference. [28] Secondary Outcome Measures 2. Pain and Physical Function subscale scores from the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). The WOMAC is a 24item self-administered questionnaire assessing pain (5), stiffness (2) and physical function (17) and has been previously reported reliable and valid.[32] The three subscales are summated to maximum scores of 20, 8 and 68 respectively. Higher scores on these subscales indicate higher degrees of joint pain, joint stiffness, and functional limitations.

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3. Six- minute walk test. The timed 6- minute walk test measures the distance a patient walks in 6 minutes and has been demonstrated to be a reliable measurement of functional exercise capacity. [33] 4. Knee and hip range of motion a. Knee flexion[34, 35] . While supine the subject will place the knee joint in maximal flexion, using a universal goniometer the angle of flexion will be measured. This measure has previously reported reliable and valid.[35] b. Knee extension[34, 35] . While supine the subject will place the knee joint in maximal extension, using a universal goniometer the angle of extension will be measured. This measure has previously reported reliable and valid.[35] c. Hip external rotation.[36, 37] . While supine on a bed with the hip in a neutral position (no extension) and the lower leg hanging off of the end of the bed and the other knee and hip in a flexed position the subject will maximally rotate the hip externally.

Using a universal goniometer the angle of

external rotation will be measured from the vertical position at the patella. This measure has previously reported reliable and valid.[37] Additionally, the FABER test will be completed. The subject will place the lateral malleolus of one ankle immediately superior to the opposite patella. The subject will be told to relax the completely (no pelvic tilt), the vertical distance (cm) from the lateral patella of the folded leg to the surface of the bed will be measured.

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d. Hip internal rotation.[36, 37] While supine on a bed with the hip in a neutral position (no extension) and the lower leg hanging off of the end of the bed and the other knee and hip in a flexed position the subject will maximally rotate the hip internally.

Using a universal goniometer the angle of

external rotation will be measured from the vertical position at the patella. This measure have previously been reported reliable and valid.[37] 5. Muscle Strength a. Biodex knee flexion and extensio n muscle torque [38, 39] b. Biodex hip external and internal rotation muscle torque [40] Biodex system 3 isokinetic dynamometer will be used for all tests. On each testing day the machine will be calibrated in accordance with the manufactures manual. All tests will be performed at 60°/s, and peak torque will be measured. Isokinetic dynamometers have previously been reported reliable for leg and hip strength measurements.[39-41]

Following baseline evaluation of the outcome measurements, the research coordinator will use a rando m number generator with gender block design to assign subjects to one of two treatment groups: Hip (H) group or Leg (L) group. The exercises for the H group will consist of dynamic resistance strengthening and stretching exercises for the hip primarily using Thera-Band elastic bands (Appendix B). The exercises for the L group will consist of dynamic resistance exercises using Thera-Band elastic bands for the lower extremities (quadriceps, hamstrings and calves) (Appendix C).

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strengthening exercise program has been used in a previous study and shown to be effective for improving symptoms of KOA. [7] Subjects in both treatment groups will be enrolled into a 12-week, 3 times per week, self-directed home exercise program. Subjects will be enrolled into the exercise groups on an ongoing basis in groups of 5-10 subjects for each treatment group until sufficient subjects have been recruited. Subjects in each treatment group will attend three supervised exercise sessions in the first three weeks of the study to ensure familiarization with their exercise program and to be given an appropriate resistance Thera-Band elastic tubing. Subjects will be given a detailed handout explaining their exercise program containing specific descriptions and photographs of the exercises (Appendices B & C) as well as a physical activity and medication log to be completed on a daily basis (Appendix D). Thereafter, subjects will be required to attend follow-up exercise sessions at 6 and 9 weeks of the study during which they will be observed to ensure that they are doing the exercises correctly and instructed on further progression of their exercise program. At 3, 6, and 9 weeks, subjects will submit their completed daily activity/medication logs for the prior three weeks and receive a new log for the following three weeks. Additionally, subjects will complete the KOOS and WOMAC questionna ires during these follow-up sessions. The initial three weeks of the programs will require the participants to complete 3 sets of 10 repetitions of each exercise. After the completion of the first 3 weeks subjects will progress to performing 3 sets of 20 repetitions of each the exercise. After the completion of 6 weeks, the participants will receive a heavier resistance Thera-Band elastic band and perform 3 sets of 10 repetitions of each exercise. After 9 weeks, subjects

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will progress to 3 sets of 20 repetitions of each exercise with the heavy-resistance band. Subjects will be encouraged to do their exercises at home at least 3 days a week. Subjects in both exercise groups will be encouraged to only follow the exercises assigned for their group and not make any significant life style or exercise regime changes for the duration of the study. Subjects in both groups will be asked to maintain an activity log to document their daily physical activity (type and duration) for the 12-week study period. All subjects will have the KOOS and WOMAC questionnaires reassessed at 3, 6, 9, and 12 weeks. The 6 minute walk test, range of motion and Biodex strength tests will be re-assessed at 12 weeks. The change from 0 to 12 weeks in the KOOS and WOMAC subscale scores, 6 minute walk test, flexibility tests and Biodex tests will be determined. The investigator completing the outcome measurements will be blinded as to which group the subjects are enrolled in. Subjects who withdraw from the study will be followed fo r intention to treat analysis. 3.3 Analysis Data will first be analyzed descriptively to assess homogeneity and normal distribution. Depending on the results of these tests, the appropriate statistical tests will be determined (parametric versus non-parametric) and performed with statistical significance set at p less than 0.05.

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4. Relevance/Significance Sport medicine physicians are often involved in the management of knee osteoarthritis patients. The results of this study will aid sport medicine physicians and physiotherapists

in

providing

appropriate

recommendations

regarding

exercise

prescription for patients with knee osteoarthritis.

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5. Budget

Item Equipment and Software

Office Supplies, Photocopies, Miscellaneous Parking Staff

Description Thera-Band 1. Hip group $5.00/ band x 2 bands/subject x 35 subjects = $350 2. Leg group $10.00/band x 2 x 35 subjects = $700 WOMAC questionnaire - License cost = $500 Includes storage of sensitive material and production and photocopying of required forms. Parking for all sessions Research Coordinator -Responsibilities include recruitment of subjects, study organization, allocation of treatment groups, instruction of exercises and analysis of data. - 6 month, salary position, approximately 200 total hours. Research Assistant - Responsibilities include data collection and entry. - 6 month, salary position, approximately 100 total hours.

Cost $1550

$500

$2400 $4500

$1800

Total Cost = $10,750 Funding from UC SMC Research Grant = $3,250 Funding requested from CASM Research Grant = $7,500

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References 1. 2.

3. 4. 5.

6. 7.

8. 9.

10.

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14. 15.

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17.

Arthritis prevalence and activity limitations--United States, 1990. MMWR Morb Mortal Wkly Rep, 1994. 43(24): p. 433-8. Badley, E.M. and P.P. Wang, Arthritis and the aging population: projections of arthritis prevalence in Canada 1991 to 2031. J Rheumatol, 1998. 25(1): p. 13844. Hunter, D.J. and D.T. Felson, Osteoarthritis. Bmj, 2006. 332(7542): p. 639-42. Haq, I., E. Murphy, and J. Dacre, Osteoarthritis. Postgrad Med J, 2003. 79(933): p. 377-83. Bautch, J.C., D.G. Malone, and A.C. Vailas, Effects of exercise on knee joints with osteoarthritis: a pilot study of biologic markers. Arthritis Care Res, 1997. 10(1): p. 48-55. Peterson, M.G., et al., Effect of a walking program on gait characteristics in patients with osteoarthritis. Arthritis Care Res, 1993. 6(1): p. 11-6. Topp, R., et al., The effect of dynamic versus isometric resistance training on pain and functioning among adults with osteoarthritis of the knee. Arch Phys Med Rehabil, 2002. 83(9): p. 1187-95. Borjesson, M., et al., Physiotherapy in knee osteoarthrosis: effect on pain and walking. Physiother Res Int, 1996. 1(2): p. 89-97. van Baar, M.E., et al., The effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a randomized clinical trial. J Rheumatol, 1998. 25(12): p. 2432-9. Fransen, M., J. Crosbie, and J. Edmonds, Physical therapy is effective for patients with osteoarthritis of the knee: a randomized controlled clinical trial. J Rheumatol, 2001. 28(1): p. 156-64. Gur, H., et al., Concentric versus combined concentric-eccentric isokinetic training: effects on functional capacity and symptoms in patients with osteoarthrosis of the knee. Arch Phys Med Rehabil, 2002. 83(3): p. 308-16. Evcik, D. and B. Sonel, Effectiveness of a home-based exercise therapy and walking program on osteoarthritis of the knee. Rheumatol Int, 2002. 22(3): p. 103-6. O'Reilly, S.C., K.R. Muir, and M. Doherty, Effectiveness of home exercise on pain and disability from osteoarthritis of the knee: a randomised controlled trial. Ann Rheum Dis, 1999. 58(1): p. 15-9. Kovar, P.A., et al., Supervised fitness walking in patients with osteoarthritis of the knee. A randomized, controlled trial. Ann Intern Med, 1992. 116(7): p. 529-34. Minor, M.A., et al., Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis. Arthritis Rheum, 1989. 32(11): p. 1396405. Mangione, K.K., et al., The effects of high-intensity and low-intensity cycle ergometry in older adults with knee osteoarthritis. J Gerontol A Biol Sci Med Sci, 1999. 54(4): p. M184-90. Bennell, K.L., et al., Efficacy of physiotherapy management of knee joint osteoarthritis: a randomised, double blind, placebo controlled trial. Ann Rheum Dis, 2005. 64(6): p. 906-12.

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18.

19.

20. 21. 22. 23. 24. 25.

26. 27. 28.

29. 30.

31.

32.

33. 34.

35.

Deyle, G.D., et al., Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee. A randomized, controlled trial. Ann Intern Med, 2000. 132(3): p. 173-81. Deyle, G.D., et al., Physical therapy treatment effectiveness for osteoarthritis of the knee: a randomized comparison of supervised clinical exercise and manual therapy procedures versus a home exercise program . Phys Ther, 2005. 85(12): p. 1301-17. Felson, D.T., et al., Osteoarthritis: new insights. Part 2: treatment approaches. Ann Intern Med, 2000. 133 (9): p. 726-37. Sisto, S.A. and G. Malanga, Osteoarthritis and Therapeutic Exercise. Am J Phys Med Rehabil, 2006. 85(11 Suppl): p. S69-S78. Yamada, H., et al., Hip adductor muscle strength in patients with varus deformed knee. Clin Orthop Relat Res, 2001(386): p. 179-85. Chang, A., et al., Hip abduction moment and protection against medial tibiofemoral osteoarthritis progression. Arthritis Rheum, 2005. 52(11): p. 3515-9. Sharma, L., et al., The role of knee alignment in disease progression and functional decline in knee osteoarthritis. Jama, 2001. 286(2): p. 188-95. Mascal, C.L., R. Landel, and C. Powers, Management of patellofemoral pain targeting hip, pelvis, and trunk muscle function: 2 case reports. J Orthop Sports Phys Ther, 2003. 33(11): p. 647-60. Tyler, T.F., et al., The role of hip muscle function in the treatment of patellofemoral pain syndrome. Am J Sports Med, 2006. 34(4): p. 630-6. Fredericson, M., et al., Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sport Med, 2000. 10(3): p. 169-75. Paradowski, P.T., et al., The effect of patient characteristics on variability in pain and function over two years in early knee osteoarthritis. Health Qual Life Outcomes, 2005. 3: p. 59. Roos, E.M., et al., Knee injury and Osteoarthritis Outcome Score (KOOS)-validation of a Swedish version. Scand J Med Sci Sports, 1998. 8(6): p. 439-48. Roos, E.M. and S. Toksvig- Larsen, Knee injury and Osteoarthritis Outcome Score (KOOS) - validation and comparison to the WOMAC in total knee replacement. Health Qual Life Outcomes, 2003. 1(1): p. 17. Roos, E.M., et al., Knee Injury and Osteoarthritis Outcome Score (KOOS)-development of a self -administered outcome measure. J Orthop Sports Phys Ther, 1998. 28(2): p. 88-96. Bellamy, N., et al., Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol, 1988. 15(12): p. 1833-40. Guyatt, G.H., et al., The 6-minute walk: a new measure of exercise capacity in patients with chronic heart failure. Can Med Assoc J, 1985. 132(8): p. 919-23. Gajdosik, R.L. and R.W. Bohannon, Clinical measurement of range of motion. Review of goniometry emphasizing reliability and validity. Phys Ther, 1987. 67(12): p. 1867-72. Brosseau, L., et al., Intra- and intertester reliability and criterion validity of the parallelogram and universal goniometers for measuring maximum active knee

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36. 37.

38. 39. 40.

41.

42.

flexion and extension of patients with knee restrictions. Arch Phys Med Rehabil, 2001. 82(3): p. 396-402. Bierma-Zeinstra, S.M., et al., Comparison between two devices for measuring hip joint motions. Clin Rehabil, 1998. 12(6): p. 497-505. Croft, P.R., et al., Interobserver reliability in measuring flexion, internal rotation, and external rotation of the hip using a plurimeter. Ann Rheum Dis, 1996. 55(5): p. 320-3. Emrani, A., et al., Isokinetic Strength and Functional Status in Knee Osteoarthritis. J. Phys Ther Sci, 2006. 18: p. 107-114. Feiring, D., T. Ellenbecker, and G. Derscheid, Test-retest reliability of Biodex isokinetic dynamometer. J Orthop Sports Phys Ther, 1990. 11: p. 298-300. Dugailly, P., et al., Isokinetic assessment of hip muscle concentric strength in normal subjects: a reproducability study. Isokinetics and Exercise Science, 2005. 13: p. 129-137. Carpenter, M., et al., Reliability of isokinetic and isometric leg strength measurements amoung individuals with symptoms of mild osteoarthritis. Med Sci Sports Exerc, 2001. 33(5 Suppliment s333). Kijowski, R., et al., Arthroscopic validation of radiographic grading scales of osteoarthritis of the tibiofemoral joint. AJR Am J Roentgenol, 2006. 187(3): p. 794-9.

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Tables and Figur es Table 1. Kellgren-Lawrence Radiographic Grading of Osteoarthritis Grade of Osteoarthritis

Description

0

No radiographic findings of osteoarthritis

1

Minute osteophytes of doubtful clinical significance

2

Definite osteophytes with unimpaired jo int space

3

Definite osteophytes with moderate joint space narrowing

4

Definite osteophytes with severe joint space narrowing and subchondral sclerosis

Recreated from Kijowski et al 2006.[42]

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Figure 1 Flow chart of research procedure Recruitment of subjects

Examination by SMC Physician

Eligible, consented subjects n= 70

Baseline assessments of outcome measurements (0 weeks)

Hip exercise group n = 35

Leg exercise group n = 35

3 weeks of supervised instruction, KOOS and WOMAC at 3 wks

3 weeks of supervised instruction, KOOS and WOMAC at 3 weeks

6 wk follow-up, KOOS and WOMAC reassessment

6 wk follow-up, KOOS and WOMAC reassessment

9 wk follow-up, KOOS and WOMAC reassessment

9 wk follow-up, KOOS and WOMAC reassessment

12 week postintervention assessment of outcome measurements

12 week postintervention assessment of outcome measurements

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Appendix A KOOS Questionnaire (English version LK1.0 1)

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KOOS KNEE SURVEY Todays date: _____/______/______ Date of birth: _____/______/______ Name: ____________________________________________________ INSTRUCTIONS: This survey asks for your view about your knee. This information will help us keep track of how you feel about your knee and how well you are able to do your usual activities. Answer every question by ticking the appropriate box, only one box for each question. If you are unsure about how to answer a question, please give the best answer you can. Symptoms These questions should be answered thinking of your knee symptoms during the last week. S1. Do you have swelling in your knee? Never Rarely Sometimes Often Always

o o o o o S2. Do you feel grinding, hear clicking or any other type of noise when your knee moves? Never Rarely Sometimes Often Always

o o o o o S3. Does your knee catch or hang up when moving? Never Rarely Sometimes Often Always

o o o o o S4. Can you straighten your knee fully? Always Often Sometimes Rarely Never

o o o o o S5. Can you bend your knee fully? Always Often Sometimes Rarely Never

o

o

o

o o

Stiffness The following questions concern the amount of joint stiffness you have experienced during the last week in your knee. Stiffness is a sensation of restriction or slowness in the ease with which you move your knee joint. S6. How severe is your knee joint stiffness after first wakening in the morning? None Mild Moderate Severe Ext reme

o o o o o S7. How severe is your knee stiffness after sitting, lying or resting later in the day? None Mild Moderate Severe Extreme

o

o

o

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o

o

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Pain P1. How often do you experience knee pain? Never Monthly Weekly Daily Always

o

o

o

o

o

What amount of knee pain have you experienced the last week during the following ativities? P2. Twisting/pivoting on your knee None Mild Moderate Severe Extreme

o o o o o P3. Straightening knee fully

None Mild Moderate Severe Extreme

o o o o P4. Bending knee fully

o

None Mild Moderate Severe Extreme

o o o o o P5. Walking on flat surface

None Mild Moderate Severe Extreme

o o o o o P6. Going up or down stairs

None Mild Moderate Severe Extreme

o o o o o P7. At night while in bed None Mild Moderate Severe Extreme

o o o o P8. Sitting or lying

o

None Mild Moderate Severe Extreme

o o o o P9. Standing upright

o

None Mild Moderate Severe Extreme

o

o

o

o

o

Function, daily living The following questions concern your physical function. By this we mean your ability to move around and to look after yourself. For each of the following activities please indicate the degree of difficulty you have experienced in the last week due to your knee. A1. Descending stairs None Mild Moderate Severe Extreme

o o

o

o

o

A2. Ascending stairs None Mild Moderate Severe Extreme

o

o

o

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o

o

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For each of the following activities please indicate the degree of difficulty you have experienced in the last week due to your knee. A3. Rising from sitting None Mild Moderate Severe Extreme

o o o A4. Standing

o

o

None Mild Moderate Severe Extreme

o o o o o A5. Bending to floor/pick up an object None Mild Moderate Severe Extreme

o o o o o A6. Walking on flat surface

None Mild Moderate Severe Extreme

o o o o o A7. Getting in/out of car

None Mild Moderate Severe Extreme

o o o o A8. Going shopping

o

None Mild Moderate Severe Extreme

o o o o o A9. Putting on socks/stockings

None Mild Moderate Severe Extreme

o o o o A10. Rising from bed

o

None Mild Moderate Severe Extreme

o o o o o A11. Taking off socks/stockings None Mild Moderate Severe Extreme

o o o o o A12. Lying in bed (turning over, maintaining knee position) None Mild Moderate Severe Extreme

o o o o o A13. Getting in/out of bath

None Mild Moderate Severe Extreme

o o o A14. Sitting

o

o

None Mild Moderate Severe Extreme

o o o o o A15. Getting on/off toilet

None Mild Moderate Severe Extreme

o

o

o

o

o

For each of the following activities please indicate the degree of difficulty you have experienced in the last week due to your knee. A16. Heavy domestic duties (moving heavy boxes, scrubbing floors, etc) None Mild Moderate Severe Extreme

o o o o o A17. Light domestic duties (cooking, dusting, etc) Lun/Knee OA

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None Mild Moderate Severe Extreme

o

o

o

o

o

Function, sports and recreational activities The following questions concern your physical function when being active on a higher level. The questions should be answered thinking of what degree of difficulty you have experienced during the last week due to your knee. SP1. Squatting None Mild Moderate Severe Extreme

o o o SP2. Running

o

o

None Mild Moderate Severe Extreme

o o o SP3. Jumping

o

o

None Mild Moderate Severe Extreme

o o o o o SP4. Twisting/pivoting on your injured knee None Mild Moderate Severe Extreme

o o o SP5. Kneeling

o

o

None Mild Moderate Severe Extreme

o

o

o

o

o

Quality of Life Q1. How often are you aware of your knee problem? Never Monthly Weekly Daily Constantly

o o o o o Q2. Have you modified your life style to avoid potentially damaging activities to your knee? Not at all Mildly Moderately Severely Totally

o o o o o Q3. How much are you troubled with lack of confidence in your knee? Not at all Mildly Moderately Severely Extremely

o o o o o Q4. In general, how much difficulty do you have with your knee? None Mild Moderate Severe Extreme

o

o

o

o

o

Thank you very much for completing all the questions in this questionnaire.

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Appendix B

Hip Exercise Program

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Hip Exercise Program (handout) The purpose of this program is to strengthen your hip muscles. It is possib le that by strengthening the musculature of your pelvis and hips you may improve the alignment of your knee, subsequently improving your pain and function and decreasing osteoarthritis progression.

This program requires you to complete three 45 minute

sessions per week for a total of twelve weeks. There are two stages to the hip program. This first stage is 6 weeks long and is performed with light resistance Thera-Bands, the second stage is the final 6 weeks and is performed with heavy resistance Thera-Bands.

Stage 1: This is the initial strengthening component of your exercise program, consisting of three sets of 10 repetitions of dynamic light-resistance Thera-Band exercises including hip external rotation, internal rotation, flexion, extension, abduction and adduction exercises (Figures 1-6). You will be required to perform these exercises, on both your affected and unaffected legs, three times a week for the first 6 weeks. Your sessions will include 5 minutes of warm-up, 30-35 minutes of dynamic exe rcise and 5 minutes of light stretching. Since technique is extremely important for gaining maximum benefit, you will be required to attend supervised sessions 3 times a week for the first 3 weeks. After the completion of the first 3 weeks you will gradually increase the number of repetitions to 20 (it is suggested that you start by trying to achieve 15 repetitions before progressing to 20 repetitions, alternatively you may like to increase the number of repetitions in increments of 2 for example first complete 12 repetitions, then 14, then 16 and then 18 repetitions until you are able to comfortably perform 20 repetitions). It is possible that you may initially have a painful response to these hip exercises. However, we encourage you to try and work through the pain unless it becomes too severe. It is recommended that you complete as many of the prescribed repetitions as possible as it is better for you to do some exercise than none at all. It is important that you record what exercises you were and were not able to complete in your Daily Activity Logs.

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Light stretc hing will be completed after you complete all the dynamic exercises. The 4 stretches you will perform target the hip flexor, lateral hip/piriformis, quadricep and hamstring muscles (Figures 7-10). You will perform 1-2 repetitions of each stretch each session, holding each stretch for approximately 15 seconds.

Stage 2: After the first 6 weeks of your program have been completed you will have a supervised check-up/progression session. During this session you will receive a heavier resistance Thera-Band. You will use this new band with the exercises that you have already been taught. For the next 3 weeks (weeks 6-9 of your program) you will perform 3 sets of 10 repetitions of each exercise. After the completion of the 9th week you will have another supervised check-up session after which you will gradually increase the number of repetitions from 10 to 20 repetitions (it is suggested that you start by trying to achieve 15 repetitions before progressing to 20 repetitions , alternatively you may like to increase the number of repetitions in increments of 2 for example first complete 12 repetitions, then 14, then 16 and then 18 repetitions until you are able to comfortably perform 20 repetitions). Just as in the initial 6 weeks of the program, your sessions will consist of 5 minutes of warm-up, 30-35 minutes of dynamic exercise and 5 minutes of light stretching. The same stretching exercises you used in the first 6 weeks of the program will be used for the second six weeks maintaining the repetitions and holding time for each stretch.

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Table 1 Exercise progression Exercise Internal Rotation External Rotation CLAM Adduction Extension Flexion Hip Flexor Stretch Outer Hip Stretch Quad Stretch Hamstring Stretch

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Weeks 1-3 sets repetitions 3 10

Weeks 4-6 Sets Repetitions 3 20

Weeks 7-9 sets repetitions 3 10

Weeks 10-12 sets repetitions 3 20

3 3 3 3 3

10 10 10 10 10

3 3 3 3 3

20 20 20 20 20

3 3 3 3 3

10 10 10 10 10

3 3 3 3 3

20 20 20 20 20

1

2

1

2

1

2

1

2

1 1

2 2

1 1

2 2

1 1

2 2

1 1

2 2

1

2

1

2

1

2

1

2

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HIP EXERCISES – pictures courtesy of David Lindsay, University of Calgary Sport Medicine Centre

Figure 1. HIP INTERNAL ROTATION Sitting well back on a table with your feet off the ground. Attach the elastic so it loops around your instep (outside of your foot). Place your hands on each side of your thigh. While keeping your lowerleg vertical and your ankle at 90 degrees, slowly move your foot OUT as far apart as possible and against the elastic resistance. Consciously tighten your buttock muscles as you move your foot against the elastic. Hold briefly at this position then allow your foot to return to the start position. Do 3 sets of 10 repetitions gradually progressing to 20 repetitions. Fatigue should be felt in the outer hip/buttock region.

Figure 2. HIP EXTERNAL ROTATION (GROIN): Sit on a table so your feet are off the ground. Attach the tubing around your foot as shown. With your hands on each side of your thigh, slowly rotate your foot IN as far apart as possible and against the elastic resistance. Hold briefly at this position then allow the foot to return to the start position. Do 3 sets of 10 repetitions gradually progressing to 20 repetitions. Fatigue should be felt in the inner thigh/groin region.

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Figure 3. SIDE LYING BUTTOCK (aka CLAM) : a) Lie on your side with your hips and knees bent such that your heels are inline with your buttocks. Your pelvis MUST be tilted forward slightly so that your belly-button is aimed at the ground in front of you. Place the elastic around both knees. While keeping your heels together, slowly rotate the top knee up towards the ceiling as far as possible and against the elastic resistance. Don’t let the pelvis or trunk move -- the only motion should be at the hip joint. Hold briefly at this position then allow your knees to come back together. Do 3 sets of 10 repetitions gradually progressing to 20 repetitions. Fatigue should be felt in the outer hip/buttock region. b) Alternatively this exercise can be performed supine (on your back). Sitting on the floor with your knees bent and the elastic around your knees slowly spread your knees apart against the band. Don’t let the pelvis or trunk move -- the only motion should be at the hip joint. Hold briefly at this position then allow your knees to come back together. Do 3 sets of 10 repetitions gradually progressing to 20 repetitions. Fatigue should be felt in the outer hip/buttock region.

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Start Position Figure 4. STANDING HIP ADDUCTION

End Position

a) Loop the elastic band around your ankle and attach the elastic so it loops around a stationary object near the floor (for example a table leg or railing pole). Stand with the band to the side closest to the exercising leg so that the band rests just above your ankle. Keep your hands to your sides and stand tall (chin up, abdominals tight and not letting your pelvis or trunk move). Keeping your back straight slowly move your leg (try to keep it as straight as possible) inwards towards your other leg against the resistance of the elastic. Try to avoid leaning or bending over while performing the exercise (hold onto something if you need to). Hold briefly at this position then allow your foot to return to the start position. Do 3 sets of 10 repetitions gradually progressing to 20 repetitions. Fatigue should be felt in the inner thigh/groin region. b) Alternatively this exercise can be performed lying on your side with your bottom leg straight and your top leg bent (knee close to your chest in a comfortable position. Keeping your bottom leg straight slowly raise your leg of off the ground bringing it towards your over leg. Hold briefly at this position then allow your leg to return to the start position. Do 3 sets of 10 repetitions gradually progressing to 20 repetitions. Fatigue should be felt in the anterior thigh region.

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Start Position

Figure 5. STANDING HIP EXTENSION:

End Position

Loop the elastic band around your ankle and attach the elastic so it loops around a stationary object near the floor (for example a table leg or railing pole). Stand facing the attachment of the band so that the band rests just above your ankle. Keep your hands to your sides and stand tall (chin up, abdominals tight and not letting your pelvis or trunk move). Keeping your back straight slowly move your leg (try to keep it as straight as possible) backwards against the resistance of the elastic. Try to avoid leaning or bending over while performing the exercise (hold onto something if you need to). Hold briefly at this position then allow the foot to return to the start position. Do 3 sets of 10 repetitions gradually progressing to 20 repetitions. Fatigue should be felt in the buttock region.

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Start Position

Figure 6. STANDING HIP FLEXION:

End Position

a) Loop the elastic band around your ankle and attach the elastic so it loops around a stationary object near the floor (for example a table leg or railing pole). Stand facing away from the attachment of the band so that the band rests just above your ankle. Keep your hands to your sides and stand tall (chin up, abdominals tight and not letting your pelvis or trunk move). Keeping your back straight slowly move your leg (try to keep it as straight as possible) forwards against the resistance of the elastic. Try to avoid leaning or bending over while performing the exercise (hold onto something if you need to). Hold briefly at this position then allow the foot to return to the start position. Do 3 sets of 10 repetitions gradually progressing to 20 repetitions. Fatigue should be felt in the anterior thigh region. b) Alternatively this exercise can be performed sitting. Sitting in a sturdy chair, loop the elastic around the top of the knee of the exercising leg and bring the ends of the band underneath the foot of the opposite leg to stabilize and create the resistance in the band. Keeping your back straight (not leaning forward) slowly flex the hip against the resistance of the band. Hold briefly at this position then allow the foot to return to the start position. Do 3 sets of 10 repetitions gradually progressing to 20 repetitions. Fatigue should be felt in the anterior thigh region.

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STRETCHING EXERCISES – pictures courtesy of David Lindsay, University of Calgary Sport Medicine Centre

Figure 7. HIP FLEXOR STRETCH: Stand about 2-3 feet away from a chair or desk and place your left foot on the front edge of the chair/desk. Both feet should be aimed straight ahead. Draw in your belly button using your abdominal muscles. Tighten your right buttock to push your right hip forward until you feel a stretch at the front of the right hip. Keep your back vertical the whole time. Maintain the stretch for 15 seconds. (Progress to having both feet on the floor)

Figure 8. OUTER HIP STRETCH: Sit on the front part of a chair and cross your legs by placing the outside of one ankle on top of the other knee. Slowly let the knee fall out to the side as far as comfortable. Bend forward at the waist slightly until you feel a stretch in the outside of this hip. Gently pushing the knee down further with your hand will increase the stretch. DO NOT FORCE - no pain should be experienced. Maintain the stretch for 15 seconds.

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Figure 9. QUADRICEP STRETCH: Steady yourself using a wall and bend your right knee and hold your right ankle with your hand. Keep your back straight and tighten your stomach by drawing in your belly button. Now position your right knee just behind and touching your straight left knee (your right knee cap will be pointing just behind your left heel). A stretch should be felt in the front of the right thigh. Hold for 15 seconds.

Figure 10. HAMSTRING STRETCH: Steady yourself using a wall and step forward with your right foot 2-3 feet. Keeping your right knee straight, pull your right foot and toes back then slowly bend forward at the waist until you feel a stretch in the back of your right thigh and knee. Pushing your backside out and letting the left knee bend slightly will increase the stretch. Hold for 15 seconds.

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Appendix C

Leg Strengthening Exercise Program

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Leg Exercise Program (handout) The purpose of this program is to strengthen the muscles of your legs. It has been shown that increasing the strength of the muscles of the legs helps to improve pain and function in knee osteoarthritis patients.[7-13] This exercise program is an extension to the leg strengthening program used by Topp et al (2002) using Thera-Band elastic band dynamic resistance exercises. This program requires you to complete three 45 minute sessions per week for a total of twelve weeks. There are two stages to the leg program. This first stage is 6 weeks long and is performed with light resistance Thera-Bands, the second stage is the final 6 weeks and is performed with heavier resistance Thera-Bands.

Stage 1: This is the initial strengthening component of your rehabilitation program, consisting of 3 sets of 10 repetitions of dynamic Thera-Band exercises including knee flexion, extension, leg press and calf raises (Figures 1-6).

You will perform these

exercises, on both your affected and unaffected knees, three times a week for the first 6 weeks. Your exercise sessions include 5 minutes of warm- up, 30-35 minutes of dynamic exercise and 5 minutes of light stretching. Since technique is extremely important for gaining maximum benefit, you will be required to attend supervised sessions 3 times a week for the first 3 weeks. After the completion of the first 3 weeks you will attend your first check- up session after which you will gradually increase the number of repetitions to 20, with the exception of calf raises which will progress to 3 sets of 12 repetitions (it is suggested that you start by trying to achieve 15 repetitions before progressing to 20 repetitions, alternatively you may like to increase the number of repetitions in increments of 2 for example first complete 12 repetitions, then 14, then 16 and then 18 repetitions until you are able to comfortably perform 20 repetitions ). It is possible that you may initially have a painful response to the leg exercises. However, we encourage you to try and work through the pain unless it becomes too severe. It is recommended that you complete as many of the prescribed repetitions as possible as it is better for you to do some exercise than none at all. It is important that

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you record what exercises you were and were not able to complete in your Daily Activity Logs. Light stretc hing will be completed after you complete all the dynamic exercises. The 4 stretches you will perform target the hip flexor, lateral hip/piriformis, quadricep and hamstring muscles (Figures 7-10). You will perform 1-2 repetitions of each stretch each session, holding each stretch for approximately 15 seconds.

Stage 2: After the first 6 weeks of the program have been completed you will have a supervised check-up/progression session (Stage2). During this session you will receive a heavier resistance Thera-Band. You will use this band with the exercises that you have already been taught. For the next 3 weeks (weeks 6-9 of your program) you will perform 3 sets of 10 repetitions of each exercise, with the exception of calf raises which will progress to 3 sets of 15 repetitions. After the completion of the 9th week you will have another supervised check-up session after which you will gradually increase the number of repetitions from 10 to 20 repetition (it is suggested that you start by trying to achieve 15 repetitions before progressing to 20 repetitions, alternatively you may like to increase the number of repetitions in increments of 2 for example first complete 12 repetitions, then 14, then 16 and then 18 repetitions until you are able to comfortably perform 20 repetitions). Just as in the initial 6 weeks of the program, your sessions will consist of 5 minutes of warm-up, 30-35 minutes of dynamic exercise and 5 minutes of light stretching. The same stretching exercises you used in the first 6 weeks of the program will be used for the second six weeks maintaining the repetitio ns and holding time for each stretch.

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Table 1 Exercise progression Exercise Extension Flexion Calf Raises Mini-squat Terminal Knee Extension Leg Press Hip Flexor Stretch Outer Hip Stretch Quad Stretch Hamstring Stretch

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Weeks 1-3 sets Repetitions 3 10 3 10 3 10 3 10

Weeks 4-6 sets Repetitions 3 20 3 20 3 12 3 20

Weeks 7-9 sets repetitions 3 10 3 10 3 15 3 10

Weeks 10-12 sets repetitions 3 20 3 20 3 20 3 20

3 3

10 10

3 3

20 20

3 3

10 10

3 3

20 20

1 1 1 1

2 2 2 2

1 1 1 1

2 2 2 2

1 1 1 1

2 2 2 2

1 1 1 1

2 2 2 2

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LEG EXERCISES

Start Position

End Position

Figure 1. KNEE EXTENSION: a) Secure one end of the elastic band behind the chair, attaching the other end of the band to your ankle. Sitting tall (chin up, abdominals tight and not letting your pelvis or trunk move ) in the chair, holding onto the side of the chair, slowly extend your leg against the resistance of the band until the leg is straight. Hold briefly at this position then allow your leg to return to the start position. Do 3 sets of 10 repetitions gradually progressing to 20 repetitions. Fatigue should be felt in the quadriceps muscle. b) Alternatively, wrap the middle of the band around your foot. Lay on your stomach (prone) holding the ends of the band in your hands. Begin with your knee bent and extend your leg against the resistance of the band until it reaches the floor. Hold briefly at this position then allow your leg to return to the start position. Do 3 sets of 10 repetitions gradually progressing to 20 repetitions. Fatigue should be felt in the quadriceps muscle.

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Start Position

End Position

Figure 2. KNEE FLEXION: a) Tie the ends of the band together creating a loop and securely attach one end of the loop close to the floor. Wrapping the other end of the loop around the heel of your foot, sitting tall (chin up, abdominals tight and not letting your pelvis or trunk move) in a chair, slowly bend your knee bringing your foot closer to the base of the chair. Hold briefly at this position then allow your leg to return to the start position. Do 3 sets of 10 repetitions gradually progressing to 20 repetitions. Fatigue should be felt in the hamstring muscle. b) Tie the ends of the band together creating a loop and securely attach one end of the loop close to the floor. Lay on your stomach (prone) place the other end of the loop around your ankle. Begin with your knee straight and bend your leg against the resistance of the band. Hold briefly at this position then allow your leg to return to the start position. Do 3 sets of 10 repetitions gradually progressing to 20 repetitions. Fatigue should be felt in the hamstring muscle.

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Start Position

Figure 3. CALF RAISES : (Not using Thera-Band) Standing tall (ideally on a stair), holding onto a chair or railing if needed, keeping your legs straight slowly raising your heels so that you are standing on your toes. Hold briefly at this position then allow your legs to return to the start position. Do 3 sets of 10 repetitions gradually progressing to 20 repetitions. Fatigue should be felt in the calf muscle.

End Position

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Start Position

Figure 4. MINISQUAT: Hold the ends of the band in your hands (at hip level) and stand on the middle of the band with both feet. Keeping your back and arms straight slowly bend both knees slightly to the minisquat position (DO NOT allow your knees to rotate either inward or outward). Hold briefly at this position then allow your leg to return to the start position. Do 3 sets of 10 repetitions gradually progressing to 20 repetitions. Fatigue should be felt in the quadriceps muscle.

End Position

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Start Position

Figure 5. Terminal Knee Extension: Make a loop in the band and securely attach one end at knee height. Place your knee inside the loop (keeping the band above the knee joint) and take up the slack. Slowly bend and straighten your knee stretching the band as you extend your knee. Do 3 sets of 10 repetitions gradually progressing to 20 repetitions. Fatigue should be felt in the hamstring muscle.

End Position

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Starting Position

Figure 6. Leg Press: a) Lay on your back (supine) with your knee slightly bent and the middle of the band looped around the bottom of your foot. Grasp the ends of the band and place close to your shoulders. Slowly extend your leg against the resistance of the band until your leg is straight. Hold briefly at this position then allow your leg to return to the start position. Do 3 sets of 10 repetitions gradually progressing to 20 repetitions. Fatigue should be felt in the quadriceps muscle.

End Position b) Sitting tall in a chair wrap the middle of the band around, grasp the ends of the bands around chest level. With your knee slightly bent slowly extend your leg against the resistance of the band until your leg is straight. Hold briefly at this position then allow your leg to return to the start position. Do 3 sets of 10 repetitions gradually progressing to 20 repetitions. Fatigue should be felt in the quadriceps muscle.

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STRETCHING EXERCISES – pictures courtesy of David Lindsay, University of Calgary Sport Medicine Centre

Figure 7. HIP FLEXOR STRETCH: Stand about 2-3 feet away from a chair or desk and place your left foot on the front edge of the chair/desk. Both feet should be aimed straight ahead. Draw in your belly button using your abdominal muscles. Tighten your right buttock to push your right hip forward until you feel a stretch at the front of the right hip. Keep your back vertical the whole time. Maintain the stretch for 15 seconds. (Progress to having both feet on the floor)

Figure 8. OUTER HIP STRETCH: Sit on the front part of a chair and cross your legs by placing the outside of one ankle on top of the other knee. Slowly let the knee fall out to the side as far as comfortable. Bend forward at the waist slightly until you feel a stretch in the outside of this hip. Gently pushing the knee down further with your hand will increase the stretch. DO NOT FORCE - no pain should be experienc ed. Maintain the stretch for 15 seconds.

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Figure 9. QUADRICEP STRETCH: Steady yourself using a wall and bend your right knee and hold your right ankle with your hand. Keep your back straight and tighten your stomach by drawing in your belly button. Now position your right knee just behind and touching your straight left knee (your right knee cap will be pointing just behind your left heel). A stretch should be felt in the front of the right thigh. Hold for 15 seconds.

Figure 10. HAMSTRING STRETCH: Steady yourself using a wall and step forward with your right foot 2-3 feet. Keeping your right knee straight, pull your right foot and toes back then slowly bend forward at the waist until you feel a stretch in the back of your right thigh and knee. Pushing your backside out and letting the left knee bend slightly will increase the stretch. Hold for 15 seconds.

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Appendix D Daily Activity and Medication Log

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Name: Date of Familiarization Session: Date

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Activity

Duration

Medication

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