What is the recommended protocol for knee physiotherapy?

Recommended Protocol for Knee Physiotherapy

The optimal management of knee osteoarthritis requires a combination of pharmacological and non-pharmacological treatment modalities, with exercise being the cornerstone of effective physiotherapy for knee osteoarthritis. 1

Core Exercise Components

Aerobic Exercise

• Both land-based and aquatic aerobic exercises are strongly recommended for patients with knee osteoarthritis 1
• Options include walking, cycling, swimming, and low-impact aerobics 1
• Aquatic exercises are particularly beneficial for patients who are deconditioned or have significant pain with weight-bearing activities 1

Strength Training

• Focus on quadriceps strengthening exercises, which have shown significant improvement in pain and function 1
• Include both open and closed kinetic chain exercises 1
• Progressive resistance training should be incorporated to gradually increase muscle strength 1
• Examples of effective exercises:
  • Quad sets (lying with legs straight, tightening thigh muscles) 1
  • Short-arc quad sets (with pillow under knee) 1
  • Long-arc quad sets (seated knee extensions) 1
  • Closed-chain exercises (partial squats, step-ups) 1

Range of Motion Exercises

• Regular stretching to maintain or improve joint mobility 1
• Focus on both knee flexion and extension 1
• Perform exercises 5-7 times, 3-5 times daily 1

Adjunctive Modalities

Manual Therapy

• Conditionally recommended in combination with supervised exercise 1
• Includes joint mobilization techniques and soft tissue mobilization 2

Thermal Agents

• Heat and cold therapy can be used for pain management 1
• Apply before or after exercise sessions as needed 1

Assistive Devices

• Walking aids should be provided as needed to reduce joint loading 1
• Medially wedged insoles for lateral compartment OA 1
• Laterally wedged subtalar strapped insoles for medial compartment OA 1

Taping Techniques

• Medially directed patellar taping can help reduce pain 1
• Particularly useful for patients with patellofemoral pain 2

Implementation Considerations

Exercise Dosage

• Frequency: 3-5 times per week 1
• Duration: 20-60 minutes per session 1
• Intensity: Moderate (able to talk while exercising) 1
• Hold strengthening exercises for 6-7 seconds with 2-3 seconds rest between repetitions 1

Progression

• Begin with low-intensity exercises and gradually increase difficulty 1
• For deconditioned patients, start with aquatic exercises before progressing to land-based programs 1
• Increase resistance, repetitions, or duration as tolerated 1

Self-Management Education

• Include education on joint protection techniques 1
• Teach proper body mechanics during daily activities 1
• Emphasize the importance of weight management for overweight patients 1

Special Considerations

Post-Operative Rehabilitation

• After total knee replacement, early mobilization and progressive exercise are essential 3
• Home-based and outpatient physiotherapy have shown similar outcomes for post-surgical rehabilitation 3

Common Pitfalls to Avoid

• Overexertion leading to increased pain and reduced adherence 1
• Neglecting proper warm-up before exercise 1
• Holding breath during exercises (should maintain normal breathing) 1
• Focusing only on pain relief without addressing functional improvement 1, 2
• Discontinuing exercise program once pain improves 1

Evidence Quality and Limitations

• The strongest evidence supports aerobic, aquatic, and resistance exercises for knee OA (Grade quality: ⊕⊕⊕) 1
• Moderate evidence supports manual therapy in combination with exercise 1, 2
• Limited evidence exists for optimal exercise parameters (frequency, intensity, duration) 4
• Long-term benefits of physiotherapy interventions require further investigation 3, 5

By following this structured protocol, patients with knee osteoarthritis can experience significant improvements in pain, function, and quality of life through appropriate physiotherapy interventions.