With OA the most common thing people do is stop loading the knee when they feel pain:
OA is when cartilage starts to break down or we hear things like wear and tear of the joint space between your knee is next to nothing—what people need to realize is that OA exists in everybody as we age---we must be careful not to pathologize findings on MRI or asymmetries as pathological –ie: telling these finding are the drivers of your pain is nuanced and not always helpful:
Pain is far more complicated than that ---what we must consider is the patient in front of us –if a client is unable to flex their knee beyond 90 degrees this can make climbing a stair very difficult for example just from a lack of ROM point of view. If somebody has unrelenting pain and they have tried conservative measures and they are an older client it may be best to get a knee operation:
The following paragraph is from a fantastic physiotherapist called Greg Lehman who tries to come up with different alternative analogies to why people feel in pain with OA.
“However, OA can be described as the kindling in a fire --the kindling in this analogy is like your normal degeneration or tears. It is not enough for a fire alone and its not enough for pain. So how do we create that fire? We need a spark or some accelerant. We need the sensitizing agent to help contribute to pain. And this, again, is where pain becomes complicated and multidimensional. So, what in your life can make you more sensitive? We need to consider stress, too much physical stress, persisting into pain, avoiding meaningful activities, poor sleep, negative beliefs about pain, emotional health... almost everything. To get out of pain we have several options to make you less sensitive. You can either decrease the stressors/sensitizers in your life or build up your capacity to tolerate those stressors. But you don’t have to fix those degenerative changes or those normal things we find on scans:” –Greg Lehman”
This paragraph is by far the most useful analogy to tell people with OA ---OA is not a diagnosis of destiny. We can change the accelerant and we can alter certain components of our workout, sleep habits, reduce stress or like we said above we can build a bigger capacity towards our daily stressors so we can tolerate it more and habituate but to get told your pain is your OA and to live with it without any discussion around what can be done can be detrimental to many people. It is unfair to say that degenerative changes found on scans are irrelevant as some research and studies show that people who have tendinosis may go on to damage their Achilles tendon or people with degenerative disc disease tend to go on to have chronic lower back pain. However the main thing to note here is we can alter load and biomechanics and change beliefs and these can alter pain patterns. We are not changing the finding on the MRI but we are perhaps down regulating sensitivity by changing beliefs, encouraging movement or changing some inflammatory mediators in the spinal cord or brain. The truth is we are not really sure sometimes what mediates recovery. We do not always have to get stronger to get out of pain so we must be careful with these statements. Likewise we cannot blame someone's overweightness as the driving force of their OA, much of these theories are not holding up in the literature. OA nowadays appears to be driven much more by somebodies over all health status and comorbidities. So if we say your OA in your knees is due to your overweightness then you may be setting them up to fail as one, they might not be able to loose weight and two this might not be driving the sensitivity in the first place however exercise can help with reducing pain (analgesic effects), improves cardiovascular systems-- there by helping with comorbidities and other factor causing the sensitivity and finally more structurally load is actually needed to help increase bone density and muscle strength. My view of this is that medial knee compartment issues and compression fractures in the thoracic spine are all due to some extent underloading of the spine. People blame stooped postures or moving in incorrect positions as the reason we develop OA but if we think about it, sure gravity is acting down on us on a daily basis but this load is necessary to maintain bone density so here we have an issue, we get pain and degeneration which causes pain and this pain is driven somewhat by underloading not overloading of the joints. This is sticking just in the mechanical world of pain. The trick here is to continue to load the spine and knee progressively and gradually with no movements off limits. We can still perform very well with these finding on MRI and we can even expose, adapt and habituate. Most of the time pain happens when our stressors (mechanical and phycological )exceed our capacity to adapt.
There are of course times where the accelerant (pain sensitizing inputs) does become too much when completing daily tasks like walking and getting into and out of bed or getting dressed. In these cases we must consider surgeries after conservative treatments have failed and we must consider quality of life. Therefore, imaging can be helpful and unhelpful –a lot of structural changes that are found on imaging do not correlate to pain, structural changes do not equal damage and level of pain does not equal level of injury. In Lehmans terms, there are many findings on MRI and CT scans and X ray that may or may not be driving the pain response and these changes, more often than not, happen as we age or due to the work or sport we played in our lives. We can modify the load temporarily on these parts, but it does not mean we must stop doing what we love forever.
My job is to first discuss all options with my clients, we then formulate a plan discussing eliminating irritating factors temporarily, some people may be accidently sensitizing their joint, then we expose to the avoided behavior once our system has settled down. This is the simple formula for success.
A small case example –I once had a tennis player come to me in his mid 50’s. He has been diagnosed with B/L Knee OA medial compartment. His knees were very swollen on observation and pain was 7/10. I saw him in the peak of the summer here in Vancouver. He was playing tennis 5 times weekly at that time and loved tennis. He also has old knee injuries, and he was wearing a don-joy brace This is where the discussion on OA was very important. I told him it is okay to wear a brace (modifier) but he must reduce the number of times he is playing weekly as his knee is unable to keep up with the demand and due to the swelling and increased pain levels. Did I tell him to stop playing tennis, absolutely not, this man loved tennis, and this was meaningful for him, you take away tennis, you take away part of his life.
So, we modified what he was doing –to keep his brace on if he felt it worked and and to allow one day rest (metabolic breaks) between sessions. This is what I call modifying what he is doing but allowing him to keep doing the thing he loves. Other advice was we must try to keep swelling down completely as the joint is getting irritated and inflamed but pain of 4/10 on VAS is reasonable without swelling. Better to paly with some pain and get some exercise than to not paly at all and not get any exercises.
Pros to this approach: he sees his friends, he is playing what he wants to play, he is still building his bone density and muscle strength and over all physical and mental health status are thriving.
He may even be able to return to 5 days a week if he wishes but we must build up and tolerate the loads slower. Too much too quick is what this issue was here along with no rest periods and possible other factor in his life like poor sleep, stress etc.
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