Tag Archives: osteoarthritis

Foot Center of Pressure Reduces Kinetic Chain Dysfunction and Chronic Pain

If you read my blog before you are well aware that I am a big proponent of identifying human movement dysfunction and correcting functional imbalances to reduce chronic pain, such as knee osteoarthritis (OA), patellofemoral pain syndrome (PFPS), and low back disorders such as sacroiliac dysfunction, facet arthropathy, or generalized lumbago.

A few years ago I read about a new neuromuscular technique called AposTherapy.  For those unfamiliar, AposTherapy corrects gait abnormalities by retraining muscles to adopt an optimal gait mechanics. The primary goal of AposTherapy is to correct the foot center of pressure (COP) during gait. This is done by wearing a unique, foot-worn biomechanical device. At the time, I heard good results about the use of AposTherapy, but data was too young to consider valid just yet or share-able, just yet.

Recently, when looking at functional rehabilitation techniques for chronic knee pain I came across an interesting study in the Journal of Biomechanics the evaluates the benefits of AposTherapy, to correct kinetic chain dysfunction responsible for the development of knee OA (1). The results of the study were significant. Following the intervention patients demonstrated significant reduction in knee adduction (valgus) moment (KAM). Several authors have demonstrated KAM to be a primary cause of knee OA, including Miyazaki, who noted KAM correlates with the progression of knee OA (2). In addition, patients who participated in AposTherapy demonstrated increased walking velocity, reduced pain, and improvement of functional living (1).

The foot-worn biomechanical device alters foot COP, allowing for proper kinetic chain alignment neuromuscular efficiency. Clark and Lucett, noted that dysfunction at one joint precipitates altered movement patterns, at adjacent joints, both proximally and distally (3). This is the foundation of AposTherapy. By correcting  foot COP during gait, altered joint mechanics up the kinetic chain are nullified and neuromuscular efficiency is enhanced. Overtime, strength gains occur allowing for optimal gait patterns. Sharma, stressed the role of neuromuscular ineffciency, suggesting that secondary to elevated joint stress with higher impact loads and altered joint mechanics facilitate the pathogenesis of the chronic joint disease (4).

Biomechanical interventions focusing on foot COP, neuromuscular development and agility, enhance functional ability, reduce pain and increase spatiotemporal patterns of gait (1).  Working knowledge of human movement dysfunction and human movement compensation patterns are prudent to health practitioners.  Health practitioners should emphasize and correct human movement dysfunction when treating clients with chronic joint pain such as and certainly not limited to knee OA, PFPS, SI pain, and other  low back disorders like facet arthropathy.  Training to enhance neuromuscular recruitment, force-coupling, as well as the correction of altered length-tension relationships and poor joint arthrokinematics will go far in reduction of pain, prevention of chronic pain, and improved functional outcomes.

What techniques do you implement to train for optimal neuromuscular efficiency?

References:

1. Haim, A, et al. Reduction in knee adduction moment via non-invasive biomechanical training: A longitudinal gait analysis study. J of Biomechanics. 45 (2012) 41–45.

2. Miyazaki, T., Wada, M., Kawahara, H., et al. Dynamic load at baseline can predict radiographic disease progression in medial compartment knee osteoarthritis. Annals of the Rheumatic Diseases.  2002. 61, 617–622.

3. Clark, MA, and Lucett, SC. NASM Essentrials of Corrective Exercise Training. Lippincott, WIlliams and Wilkins. 2010.

4. Sharma, L., Dunlop, D.D., Cahue, S., et al. Quadriceps strength and osteoarthritis progression in malaligned and lax knees. Annals of Internal Medicine. 2003. 138, 613–619.

Arthritis: Causation, Symptomalogy, and Management

According to the CDC approximately 1 in 5 adults and 50% of older adults (> 65 yrs of age) have been diagnosed with some form of arthritis (1). The physical pain associated with arthritis is well documented, however, there is a large social impact on arthritis suffers. From an outsiders perspective, arthritis goes undetected. Outsiders do not see the pain or suffering that arthritic patients must suffer through. They are often labeled as weak, malingerer’s, or even lazy. Point is, many people with arthritis are having difficulty performing simple activities of daily living.

The purpose of this blog is to provide a high-level overview of the disease and share basic exercise and dietary guidelines that can provide a holistic approach to reducing symptoms, improve quality of life, and functional outcomes.

Disease Overview: 

There are more than 100 rheumatic diseases and conditions that affect joints, the tissues which surround the joint and other connective tissue (1). It is the most common chronic musculoskeletal condition in older adults. The two most common forms of arthritis include osteoarthritis (caused by damage or wear and tear) and rheumatoid arthritis (autoimmune causes).

Osteoarthritis:

Osteoarthritis (OA) is characterized by the gradual deterioration of cartilage within a joint (2). It is commonly developed in load-bearing or highly mobile joints, such as the knee, hips, fingers, lower back, and feet. Often, those who suffered a significant injury to a joint are at an increased risk of developing OA. For example, knee OA is very common following ACL tears and surgery. The internal joint damage caused by the injury compounded by incomplete rehabilitation (prolonged inflammation and muscle weakness) are the perfect ingredients for OA development.

The synovium of a joint produces the lubricating substance, synovial fluid. Healthy cartilage functions much like a sponge, it is receives nourishment by absorbing synovial fluid during joint movement. As we age, the synovium decreases its production of synovial fluid, we move less, and inflammation the articular cartilage increases resulting in dehydrated / malnourished cartilage). This creates a vicous inflammatory cycle.

Inflammation causes pain, loss of function, which eventually leads to muscle wasting and cartilage deterioration. Overtime, the poor cartilage condition can result in the formation of exotosis (bone spurs) that further damage the joint structures, increases pain, and creates a loss of function.

The most common symptoms of OA are pain, inflammation, reduced range of motion, and grinding sensations upon movement. As cartilage continues to detoriorate, pieces of cartilage my break free and float withing the joint (osteochondritis dissecans). The floating bodies will sometimes lock or catch the joint during movement. This locking or catching is very uncomfortable and sometimes painful.

There is no cure for osteoarthritis. Since pain is alleviated with rest, many of those afflicted tend to avoid regular exercise for fear of pain or flare-ups. Despite this, a recent study demonstrated that older adults who regularly participate in aerobic and resistance exercise are effectively able to relieve arthritic pain and improve joint function (4, 5). This creates a paradox for optimal treatment (movement vs. rest).

Rheumatoid arthritis:

Rheumatoid arthritis affects approximately 1% of Americans. It is an autoimmune disease where by the body’s own immune system attacks joint structures, including cartilage, synovial membrane, and ligaments. Rheumatoid arthritis is a systemic condition characterized by periods of activity and remission where affected joints are painful and swollen in addition to whole body symptoms of fever and malaise. Currently, there is no cure of rheumatoid arthritis, but there are medications designed to relieve symptoms.

Rheumatoid arthritis of the hands

 

Holistic Approach to Arthritis Treatment and Prevention:

Although I have great respect for western medicine and the research that pharmaceutical companies do to help cure chronic diseases, I have always been a believer in the holistic approach. The body is a self-healer – its own internal mechanic.

As I mentioned previously, cartilage gets nourishment through dynamic pressure gradients caused by movement and joint loading. Most people with arthritis can safely participate in physical activity programs to help the disease. Many studies have shown physical activity to have a positive effect on the reduction of arthritic pain. A 2010 agenda released by CDC lists physical activity as a priority intervention to improve arthritis symptoms and prevent arthritis-related limitations in activity (6). Unfortunately, there is a fine line; arthritis causes pain and subsequently, sufferers will not move due to pain. The perpetuates the disease and worsens symptoms. So movement is prudent, however we must be careful and be cognizant of exacerbating the issue. Below are some exercise guidelines.

Exercise Guidelines:

Things to avoid:

  • Rheumatoid arthritis results in early morning stiffness, so avoid early morning exercise.
  • Avoid end ranges of motion exercise as extreme cases may allow you to move in a small mid-range of motion only.
  • Be certain to distinguish between exertional pain in the muscles and pain in the joints.
  • If any movement causes moderate pain in a joint, stop immediately and modify or regress the exercise.
  • Always move joints through a slow and controlled range of motion.
  • Avoid fast or jerky movements.
  • Progress and increase exercise intensity very slowly.

Exercise tips and suggestions:

  • Exercise sessions should be relatively short and of low to moderate intensity.
    • Use circuit training (to give body parts a rest between exercises)
  • Aerobic exercise should be comprised of multiple sessions of using various cardio equipment (treadmill, to bike, to rower, etc)
  • Flexibility:
    • Self myofascial release (foam rolling) might be painful, but try it.
    • Static stretching as tolerated but avoid end range of motion for the joint
  • Resistance:
    • Low intensity
    • 1–3 sets of 10–12 repetitions 2–3 days per week
    • Work on core musculature
    • Use a circuit or peripheral heart action training system.
    • Avoid high reps or high loads.
  • Use thera-bands or cuffs when possible to avoid gripping if hand and grip strength is a problem.
  • In severe cases training sessions maybe have to be limited to short bouts (8-10 minutes at a time).
  • Emphasize the development of functional flexibility and eccentric control through simple reactive training exercises.
    • forward lunge with emphasis on lowering.
    • Eccentric training will improve soft tissue to absorb ground reaction forces and reduce the force transmission to damaged joint structures.
  • Water aerobics or swimming may be the best environment for clients with severe arthritis.

Dietary Considerations:

Arthritis is a chronic inflammation cycle, where inflammatory mediators remained elevated and a continued process of degradation ensues. Individuals with chronically elevated inflammatory markers are at high risk of chronic disease and now research shows that poor diet can also contribute to increased inflammatory markers. I wrote about this in a previous blog entry titled “Is Your Diet Making You Sick?”.

Excessive consumption of refined carbohydrates and low dietary fiber intake is strongly associated with the production of proinflammatory molecules (7). One large study compared a western diet, which contained more red meat, refined carbohydrates and saturated fat to a paleolithic diet (8). The Western diet group had greater levels of inflammatory markers, including C- reactive protein (CRP) and E-selectin when compated to those following a paleo-like diet (8).

Clinical studies in found frequent nut and seed consumption is associated with lower levels of CRP, Insulin-like growth factor (IL-6) and fibrinogen(9). Consuming an almond-enriched diet for four weeks significantly decreased serum E-selectin compared with the control diet in healthy men and women (9).

The rise of these inflammatory diseases over the past few decades may be linked to the Western diet of saturated fats, low antioxidants, and refined carbohydrates. A diet rich in omega-3 fatty acids such as fish and nuts as well as whole grains and high fiber have been shown to reduce chronic inflammation markers in the blood.

Summary:

Arthritis is a serious chronic inflammatory disease which has both physiological and psychological effects on overall health. Pharmaceutical companies continue to search for a magical cure for arthritic conditions, but to date nothing has been found. Thankfully, we can do something to help relieve the pain and symptoms of arthritis. Creating a safe and systematic physical activity program can help prevent cartilage deterioration and improve overall function. In addition, a dietary change can also help. By limiting intake of refined carbohydrates, excessive sugar, and foods high  in saturated fat we can lower chronically elevated inflammatory markers that are responsible for chronic diseases such as arthritis. I hope these tips help you or someone you know improve quality of life.

 References:

  1. http://www.cdc.gov/arthritis/data_statistics/arthritis_related_stats.htm. retrieved August, 23, 2012
  2. Ferrini AF, Ferrini RL. Health in the Later Years. 4th ed. New York, NY: McGraw-Hill; 2008.
  3. Hills, B. A., Ethell, M. T., and Hodgson, D. R. Release of Lubricating Synovial Surfactant By Intra-Articular Steroid.  Br J of Rheum. 1998;37:649–652.
  4. Petrella RJ. Is exercise an effective treatment of osteoarthritis of the knee? West J Emerg Med.2001; 174(3): 191-196.
  5. Ettinger WH, Burns R, Messier SP, et al. A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis. The Fitness Arthritis and Seniors Trial (FAST). JAMA. 1997: 277(1): 25-31
  6. Centers for Disease Control and Arthritis Foundation. A National Public Health Agenda for Osteoarthritis. 2010
  7. Neustadt J. Western Diet and Inflammation. IMCJ. Vol. 10: 2  Apr/May 2011.
  8. Lopez-Garcia E, Schulze MB, Fung TT, et al. Major dietary patterns are related to plasma concentrations of markers of inflammation and endothelial dysfunction. Am JClin Nutr.2004;80(4):1029-1035.
  9. Rajaram, S, Connell, KM, and Sabate´ J. Effect of almond-enriched high-monounsaturated fat diet on selected markers of inflammation: a randomised, controlled, crossover study. BR J of Nut.  2010: 103, 907–912.