Osteoarthritis and the Painful Knee: Part 2/2

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Ok, so we discussed some of the contributing mechanisms of knee pain in Part 1/2 and we have yet to look at diagnosis, prognosis and treatment.  Let’s see what this prospective article, my main reference for this post series, suggests!

We have postulated that knee pain from osteoarthritis (OA) has three contributing factors: knee pathology, psychological distress, and neurophysiology.  So when diagnosing individuals with knee OA who have pain we must see if these criterion are met.  The authors in the article propose a phenotypical diagnostic thought process since the OA population is heterogeneous and broad.

The patient could present with varying levels of each of the three domains noted above along with a reported pain rating.  Example: a patient may have minimal radiographic changes, high psychological distress and moderate pain neurophysiology (central sensitization, etc) and report a 7/10 on the pain scale.  Another phenotype could present with high radiographic damage, and low distress and neurophysiology and report a 3/10.  This form of diagnosing a patient may help lead to the next two important steps; prognosis and treatment.

The authors do not state how to determine some of the levels in the different domains.  My question: how do you differentiate a person with high radiographic OA evidence with appropriate nociceptive input vs a person with high radiographic OA evidence with central sensitization as well?  I am sure there are diagnostic methods that are appropriate for PTs to administer in this arena.  (post to comments if you have some good guidelines!).  Ok, we continue…

Osteoarthritis and the Painful knee: Part 1/2

Nocebo Confession: this image makes my knee hurt!

The recently published prospective (March 2014) Future directions in painful knee osteoarthritis: Harnessing complexity in a heterogeneous population really breaks-down some wonderful concepts about pathoanatomy and pain perception.

The article reports that 50% of individuals with osteoarthritis-like knee pain have positive radiographs for osteoarthritis (OA).  Interestingly enough, 50% of those with positive radiographs for OA have knee pain.  Citing the NIH they quote “it is important to separate conceptually the disease process of OA and the syndrome of musculoskeletal pain and disability.” They also refer to N. Hadler’s paper Knee Pain is the Malady, Not Osteoarthritis, which is a wonderful title indeed!

The authors propose a new conceptual model which is outstanding in breadth and scope.  They delineate the disease process into three contributing categories:  1) Knee pathology 2) Psychological distress 3) Pain neurophysiology.

Knee pathology involves the regular and commonly held positions about OA.  They include the radiographic (X-Ray) evidence, the chondral changes, osteophytes, the joint narrowing, the “bone-on-bone”, the “you have the knees of a 90 year old.” This part of the puzzle obviously contributes, but the relationship is NOT 1-to-1 for pain and dysfunction.  – Try explaining that to someone who has knee pain, has been told they have OA and been told they have the knees of a 90 yr old.  It will be a long discussion. Of course there are the biomechanical stresses on the knee including increased body mass and joint positioning that are implicated in the knee pathology puzzle piece.

The psychological distress part has to do with fear of movement (moving could cause pain!!) and catastrophizing (ruminating over the situation and winding it up into a hypersensitive syndrome) and other factors (don’t want to give it all away, read the article!) similar to other chronic pains.  It is shown that the better the coping mechanisms and the better the positive belief strategies that the patient can employ the better the outcomes.

The pain neurophysiology aspect is… well, please allow me to quote:

“You are the knob.”

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I walk up and sit down at the rower.

Women sits on the next rower: “Where is the intensity knob?”

The limits of Biologic Plausibility

Biologic plausibility is required for any thought process in medicine, whether it be for diagnosis or treatment or anywhere in between.  This is much like face validity in research.  It is requisite, but not sufficient for truth.  You can’t hang your hat on either face validity or biologic plausibility.

You are touch and movement

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Touch is an immensely important sensation and has been linked to many healing properties, so too has proprioception (the sense of body position in space).  If you will, allow me to try to link these senses to pain and the body’s self representation.

So touch and movement helps with pain perception?  How does all that happen?

Iliotibial Band? More like Lateral Knee Pain.

(Credits: This post is inspired by a recent Journal Club discussion)

 image credit from: http://saveyourself.ca/tutorials/iliotibial-band-syndrome.php

The Ilitotibial Band (ITB) pain that many people seek relief from and many of us will treat is a confusing phenomena. The ITB lies lateral to the thigh as a thickening in the compartmental fascia of the upper leg.  Proximally the tensor fascia lata and gluteus medius insert into the band and distally the fascia inserts onto the lateral femoral condyle and the proximal lateral tibia at Gerdy’s tubercle. The ITB also dives perpendicular to the fascial plane to meet and attach to the femur along the lateral linea aspera.  The muscle belly diectly under the ITB is primarily the vastus lateralis muscle and the cutaneous sensory innervation along the ITB is the lateral femoral cutaneous nerve.

Cognitive Dissonance? That doesn’t make sense.

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There is some talk and discussion about how to engage the DPT student in a way that encourages higher levels of thinking and not just memorizing and regurgitating info for the Boards.  See here and here, both at ForwardthinkingPT.com.  This line of thinking should be pushed from the very beginning of the PT education, perhaps right after that all intensive Anatomy course.

Plan Of Use

A significant goal of this blog format is to help in the reflective process of becoming a better clinical and critical thinker, thereby providing patients and clients with a better experience and better outcomes.

The exercise in containing and writing a thought succinctly and with brevity is a tool that, in our opinion, should be utilized.

Perhaps the process by which we formulate and chew our thought-food will aid the reader in challenging their own current ideas, or perhaps reinforce them.

I will not speak to the specific interests of this group, since they are varied and are subject to change. Our own passions can be found on the ‘about’ page.

We encourage discussion on the topics discussed.  Community interaction is certainly a goal as well.

Thanks for visiting.

– PTBT

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