Case Study on Aerobic Training in a Subject with Knee Pain

Abstract

The patient comes onto the OPD limping and just psychologically distresses about her heath condition and that she is unable to continue to help her kids and husband with their day to day chores. She was found to fall within the Moderate risk stratification group according to logic model of classification of risk, who would benefit from specific Physiotherapy intervention1. After three weeks of matched, evidence based intervention, the patient has demonstrated a clear positive response with abolition of pain on VAS SCORE.

Introduction

This client of mine came in with a very distressed mood and a dejected feeling with her husband. Where the entire nation is pledging the slogan “ Beti Bachao Beti Padhao”, we still have this plight in India where the daughter in laws are expected to serve the in laws till they themselves are dead tired and the daughter in laws also keep on taking all these atrocities considering it to be her duty. This particular lady was hailing from such a family but with just one support acting as her saviour, her Husband, who forced her to walk into the OPD to dedicate some moments for her own self. She explained her chief complaints with hardly any interest in the entire treatment. As she came to know about our charges, which are just minimal, that was the first thing which made her overcome her resistance and to step forward for the treatment or to listen to atleast what I was talking. To initiate the “Motivation to Move” and to take a move for her ownself was my major task with this patient along with devising an exercise protocol. This would be the situation for most of the therapists and the households in here.

Case Presentation

Client characteristics

The patient is a 56 year old functionally independent female with a History of diabetes ( controlled on meds), She has osteoarthritis and had anxiety about engaging in social activities due to her limp. Her X rays show only some osteophytes and age related degenerative changes.

Examination Findings

Subjective findings and History

Patient gave no history of trauma and came with a chief complain of pain in the knees bilaterally diabling her to do her house hold chores. She could not sit cross legged or use Indian toilet , her pain used to aggravate at the end of the day.

While reviewing the medical history of the patient for known diseases or signs and symptoms or CVD risk factors, it was seen that it was a not a known case of Metabolic disease. The patient also had no signs and symptoms of Cardio vascular involvement but had a BMI > 25 kg/m2 and hypertension and was prediabetic. So according to Logic Model of Classification of risk she could be considered in Moderate risk Category of patients1. She did not have hypercholesterolemia. She could not be considered in sedentary lifestyle category due to her working for the household chores but as she was suffering from knee pain and her pace was slow she can not even be considered as in the active group as her heart rate hardly rose during her activities and nor did the activities be gauged to be of a particular intensity which could have led to any kind of training response.

Physical Examination

In Dynamic testing there was no temporal or spatial gait deviations noted. On assessing the knee for ROM in flexion, extension it was found to have full painfree motion. No impairment was seen in hip muscle flexion, extension and abduction and adduction. However muscle power was slightly reduced in both hip and knee and was measured to be Grade 4. On palpation there was tenderness over medial joint line of bilateral knees was noted and there was no increase in temperature around knee joint. There was pain on medial joint line on palpation with an intensity of VAS score 7 (Presently 2). On Neurological Testing, all reflexes were normal and sensations intact.

Baseline Anthropometric Evaluation showed that the patient had a BMI of 35 kg/m2 Special Tests for Knee stability were done to rule out any instability which could affect the exercise protocol, especially the balance and coordination.

Other test which were conducted were Blood Calcium levels , Thyroid function tests, Parathyroid hormone and the levels were found to be normal. The test of 25-hydroxyvitamin D test was advised to determine whether the body has enough vitamin D. It was found to be slightly reduced. 2

Clinical Hypothesis

The patient presented with pain in knee bilaterally and unable to do household chores.3 X ray shows only age related degenerative changes. Pain on medial joint line could be due to loss in muscle power around hip and knee, joint proprioception affection and further muscle spasm. All this needed to be addressed at the earliest to limit future disability.

Management and Outcomes

Intervention

Patient Education

Diet plays an important role as we have learnt3, so the patient was also put on a specific diet program in which she had regulated high fibre diet.( to include oats and salads in her diet). She needed to reduce the loading on her knees to get into the routine and any muscle to train and show the effect would take atleast 3 weeks so she should not loose patience before that. Also importance of regular exercise stressed upon. Patient was taken into confidence by talking to her about her children, her health and how her health could affect the final outcome status of her family and children.

Advise on Knee Care: To avoid cross legged sitting and to avoid sitting at low levels. To use raised toilet seats.

Progressive aerobic and specific muscle training

Patient was aided with increasing muscle strength in affected muscle groups5. Warm up protocol including stretching for all joints was given. For improving the aerobic activity level- as knees are affected, cycle ergometer Sessions, followed by strengthening exercises for the muscles that lasted at least 30 mins 4-5 times per week ( ACSM FITT principle) was advised 6. This was brought to 30 mint with slow progression starting from 10 mint on day one to present day 30 mint.

She was observed for her Heart Rate and BP before and after the exercise. The Peak Heart Rate was taken 15 sec before the finish of exercise and she was also observed for her recovery heart rate for another 5 mint.6 Her Resting heart rate has improved in the 3rd week now. It has come down slightly.

A home program was also implemented. This, she could do independently and integrate it into her daily routine. Walking in the garden around her for 20 mint at a speed on which she could talk comfortably was advised. She was also advised to wear good quality shoes with air cushioning to avoid unavoidable jerks on her joint of lower limb. Various routines (specific to extremities and trunk strengthening, flexibility, balance and coordination) were also given to her with illustrations, along with number of sets and repetitions clearly stated for ease of replication. 5 We included the use of weights or resistance bands.

Also a family meeting with husband was arranged, and other activities eg. swimming, aqua aerobics was suggested.

Medical Management

Uprise D3 60 K for Vit D3. 2. She was asked to meet her physician on time, to continue with her medications for other problems and compliance to the schedule of medications was stressed upon.

Outcome

In 3 weeks the patient has lost almost 3 kg weight and is feeling very active and the VAS score of the pain in the knee has come down by 70%.

Discussion

The review of the literature relating cardio respiratory fitness, muscular strength, metabolic health and bone health to the rationale for relation and dose response patterns was based on an evaluation from the regional strategies for health and aging 7, the evidence reviews from Warburton et al & Paterson et al.8,9 The dose-response pattern related to depression and cognitive decline were reviewed from the CDC Literature review 2008. There is strong scientific evidence that regular physical activity produces major and extensive health benefits in both adults aged 18–64 and in older adults aged 65 and above. In some cases the evidence of health benefits is strongest in older adults because the outcomes related to inactivity are more common in older adults. This results in an increased ability of observational studies to detect the protective effect of physical activity in this age group. Overall, conclusive evidence shows that both moderate-intensity and vigorous-intensity activity provide similar health benefits in both adult age groups. 10,11

With this backdrop the above exercise protocol was suggested to the patient and significant improvement was seen in the patient over a 3 week time.

In summary, motivation plays an important role in spreading awareness about physical activity in any kind of society. Once the patient/ subject finds improvement in health status it further motivates him/her to continue and also sends the repercussions around the subject, to his family members. Simple compliance to schedule and prophylactic involvement in physical activity and improved diet habits, at early stages, leads to marked improvement in health status of individuals.