The non-surgery patient

At the Knee Care Institute, the goal is to "optimize individual performance by restoring knee function." In many cases, this can be achieved with conservative, non-surgical treatment. For example, for Iliotibial Band Syndrome and Osgood-Schlatter disease, the most effective treatment includes stopping the offending exercise, performing recommended stretching and strengthening exercises, and applying ice. Conservative treatment is also the first-line approach for many mild-to-moderate cases of other knee conditions, such as chondrosis, ligament injuries, tendinitis, and bursitis.

In other cases, Dr. Kolisek or Dr. Farr will recommend conservative treatment first, recognizing that surgery may be needed later if the less invasive approach proves inadequate. In either situation, the Knee Wellness Center offers the non-surgery patient access to all the resources needed to ensure the best possible success with conservative treatment, including:

• Individualized exercise prescription
• Physical therapy
• Splinting/bracing/orthotics
• Workplace and home modifications
• Medication
• Orthotripsy®
• Other support services

Individualized exercise prescription
Although you may not feel like subjecting your painful knee to any non-essential movement, in many cases an individualized exercise program will result in a reduction in pain over time. In fact, painful knees often worsen as a direct result of reduced activity.

At the Knee Wellness Center, patients have access to a range of knee health professionals who specialize in conservative treatment, including physical therapists and Physical Medicine and Rehabilitation physicians. Physical Medicine and Rehabilitation, also called physiatry, is a medical specialty area that focuses on the restoration of function through non-surgical means.

By working with these professionals, Knee Wellness Center patients will receive an individualized exercise program designed to treat their particular condition. For example, patients may be given a set of functional exercises designed to allow the muscles around the knee to be exercised while easing stress on the ligaments.

Balance and proprioception exercises may also be prescribed. Depending on the type of knee injury, the nerves that send information to the brain about the position of the joint may be damaged and unable to transmit the proper information. Balance and proprioception exercises help restore this sense of position by retraining the nerves as they heal. Examples of these types of exercises include walking on uneven surfaces and balancing exercises.

While it may take some time for these programs to have the desired effect—and patients may do well to keep the old adage "no pain, no gain" in mind—responsible patients who perform the exercises as prescribed can look forward to less knee pain and greater knee strength, flexibility, range of motion, and function.

Physical therapy
Physical therapists (PT) are concerned with restoring patients’ independence through treatment such as therapeutic exercise, cardiovascular endurance training, ice massage or deep heat, nerve stimulation, and training in the activities of daily living. The physical therapist’s goals may include limiting pain, increasing range of motion, increasing strength, and providing joint protection.

For patients with appropriate conditions, the physical therapist may also prescribe the use of certain assistive devices, such as a cane or walker, or a brace, splint, or shoe orthotics. Workplace and home modifications may also be recommended to eliminate repetitive microtrauma, simplify the activities of daily living, and reduce the likelihood of injury or re-injury.

As with any prescribed exercise program, physical therapy often involves activities for the patient to perform independently at home over many weeks or months. For optimal results, patients must be willing to commit to the time and effort needed to make these activities effective.

Splinting or bracing
Splinting or bracing can have a number of favorable results—when performed by a professional. Bracing can improve knee alignment, reducing pressure and pain; replace some of the stability of the knee that may be lost due to certain knee injuries; and prevent the knee from giving way during strenuous activity. Most of these braces must be fitted by a physical therapist, physician, or certified orthotist—they are not the type you can buy at the local drugstore.

Medication—a proven prescription for improving knee health

COPY Medication can be a very important element in the knee healing process. Many people are understandably reluctant to begin any course of medication, but many medicines prescribed to relieve knee pain have been proven safe and effective over many years of use, while some newer agents are providing exciting alternatives.

Antiinflammatory agents
One of the most commonly-prescribed drugs that can be taken long-term to reduce both the pain and swelling caused by arthritis is nonsteroidal anti-inflammatory agents, or NSAIDs. There are many prescription NSAIDs that have been proven safe and effective over years of use.

A relatively new class of anti-inflammatory drugs called COX-2 inhibitors may provide significant benefits in the treatment of osteoarthritis. COX-2 is a protein in the body that assists in the production of substances that cause acute or chronic discomfort in the joints. COX-2 inhibitors block the creation of this protein, thus reducing inflammation in the joints.

However, traditional NSAIDs and COX-2 inhibitors have been associated with severe side effects. In rare cases, serious stomach problems, such as bleeding, can occur without warning.

Glucosamine and Chondroitin
Glucosamine and chondroitin sulfate are chondroprotective agents that occur naturally in the body. Glucosamine stimulates the formation and repair of articular cartilage, while chondroitin sulfate prevents other body enzymes from breaking down the building blocks of joint cartilage. The type sold in health food stores and pharmacies is derived from animal products.

While glucosamine and chondroitin are being heralded in the media as a virtual cure-all for osteoarthritis, Dr. Kolisek and Dr. Farr offer a more realistic view when recommending these substances for their patients. Based on their own experience, as well as mounting evidence from worldwide use, it appears that glucosamine and chondroitin have anti-inflammatory effects that help relieve the pain of osteoarthritis—with few side effects.

However, whether these agents actually slow the degenerative process or restore cartilage in arthritic joints has not been determined. A long-term study, sponsored by 2 highly reputable health-related organizations, is just beginning.

At the Knee Wellness Center, glucosamine and chondroitin sulfate are considered welcome allies in the battle to improve knee health for patients with osteoarthritis. And taking these substances while under a doctor’s care is the best approach as there are concerns about their use in people with diabetes and in pregnant women; certain brands are more reputable than others; and, if side effects should occur, your doctor can quickly provide intervention.

Viscosupplementation
Viscosupplementation, a new treatment for arthritis of the knee, is based on the premise that a stiff hinge joint—like any mechanical hinge—can benefit from a little lubrication.

Research shows that joints affected by osteoarthritis have a lower-than-normal concentration of hyaluronic acid, a naturally occurring substance found in the synovial fluid that acts as a lubricant and enables bones to glide over one another. Viscosupplementation involves injecting a preparation of hyaluronic acid into the arthritic knee joint. Two preparations are available—a natural product made from rooster combs and an artificial one manufactured from bacterial cultures. Depending on the product used, 3 to 5 shots will be given over several weeks.

The pain-relieving effect of viscosupplementation occurs slowly over the full course of the injections and may last several months. However, it is not effective in all cases, and it has not been proven to reverse or delay the progress of osteoarthritis.

Corticosteroids
Corticosteroids, given as an injection or in pill form, offer very powerful anti-inflammatory effects—but they can also have powerful side effects that limit their usefulness as a long-term treatment. Multiple injections of cortisone may actually speed up the process of degeneration in the joint, and can cause other potentially serious side effects. When used sparingly, under a physician’s supervision, corticosteroids can provide significant pain relief.

Orthotripsy: the "wave" of the future

Orthotripsy® is a non-invasive extracorporeal shock wave therapy (ESWT) that offers significant promise for long-term relief of knee pain caused by tendinitis. While still under investigation for its use in this area, the U.S. Food and Drug Administration (FDA) has recommended Orthotripsy for the treatment of chronic heel pain—a procedure that has been utilized for years in Europe, and is also available in Canada.

The FDA based its recommendation on the findings of a well-controlled clinical study of approximately 300 patients with plantar fasciitis. Nearly 60% of these patients were considered a success according to investigator assessment and patient self-assessement after a single Orthotripsy treatment. These results were statistically significant.

Orthotripsy technology is based on the principle that high-energy pressure waves may reduce inflammation and stimulate healing by increasing oxygen and blood supply to injured or diseased tissue and bone.

Other support services

While the pain in your knee is a direct result of a physiologic problem, it is important to realize that a chronic knee condition can also affect you psychologically. Many patients report feeling discouraged, inadequate, and fearful of the future as a result of the pain and loss of function caused by a severe knee problem. While exercise, physical therapy, and pain medication can help alleviate the physical aspects of your condition, some patients also find it useful to treat the non-physical aspects of dealing with a serious knee condition.

By providing access to a range of support professionals, the Knee Wellness Center can help patients benefit from such stress-reducers as relaxation training and behavioral management techniques. Supportive health counselors can assist patients and their families in adapting to life with a disability. Patient and family education resources are also available for those who want to understand more about their condition.

The post-surgery patient

COPY Like the non-surgery knee patient, the post-surgery knee patient can benefit greatly from care at the Knee Wellness Center. While surgery may correct an underlying knee problem, complete healing and restoration of knee health is dependent upon adequate and individualized post-surgical rehabilitation. At the Knee Wellness Center, post-surgery patients have access to a range of rehabilitation specialists who will tailor exercise, therapy, and return-to-activity guidelines for each patient.

In fact, many of the services described above for the non-surgery patient apply equally to the post-surgery patient—with certain modifications, given the post-op patient’s unique rehabilitative needs. If you are a post-surgery patient who will be receiving post-op care through the Knee Wellness Center, be sure to read the detailed description provided above of these services:
• Individualized exercise prescription—a rehabilitative exercise plan individualized for the patient recovering from a particular knee surgery
• Physical therapy—a complete and progressive multi-month program designed by a licensed physical therapy to aid in post-surgery rehabilitation. May include therapeutic exercises, physical endurance training, re-training in the activities of daily living, bracing, and workplace and home modifications; if needed, patients may also be referred to an occupational therapist for additional training in returning to the activities of daily living
• Medication—a progressive medication plan for pain management may be prescribed to help minimize discomfort during rehabilitation
• Other support services—access to professionals who can help the post-surgery patient deal not only physically, but also psychologically, with the lifestyle changes resulting from a severe knee condition and months of rehabilitation; services include relaxation training, behavior modification, patient and family education and training, and supportive counseling