Case Study on Aerobic Training in a Subject with Knee Pain
- 1 Abstract
- 2 Introduction
- 3 Case Presentation
- 4 Clinical Hypothesis
- 5 Management and Outcomes
- 6 Discussion
- 7 References
Ms. X came into the outpatient department limping because of bilateral knee pain. She exhibited signs of psychological distress about her heath condition, reporting that she was unable 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 the Logic Model of Classification of Risk and would therefore benefit from specific physiotherapy intervention. After three weeks of matched evidence-based intervention, Ms. X demonstrated a clear positive response with abolition of resting pain on the visual analogue scale (VAS).
Ms. X came in with her husband in a very distressed and dejected mood. Whereas the entire nation is pledging the slogan “Beti Bachao Beti Padhao”, there is still a situation in India where daughter-in-laws are expected to serve their in-laws until they are dead tired and the daughter-in-laws themselves consider this amount of work to be their duty. Ms. X hailed from such a family with only one support acting as her saviour, her husband, who forced her to walk into the outpatient department to dedicate a moment for her own health. She explained about her chief complaints but with little interest in the entire treatment process. Learning about the (minimal) charges for treatment was the first thing which helped her overcome her resistance and to at least listen to what the physiotherapist said. To initiate the “Motivation to Move” and to help the patient make a move for her own self by devising an exercise protocol were the therapist's major tasks. This is the same situation for most of the therapists and patients/households in the outpatient department in question.
The patient was a 56 year old functionally independent female with a history of diabetes which was controlled on medication. She had osteoarthritis and was anxious about engaging in social activities due to her limp. Her x-rays showed only some osteophytes and age-related degenerative changes.
Subjective findings and History
Ms. X gave no history of trauma and came with a chief complaint of pain in both knees, disabling her from doing her household chores. She could not sit cross-legged or use an Indian toilet. Her pain was more aggravated at the end of the day.
While reviewing the medical history of this patient for known diseases or signs and symptoms or CVD risk factors, it was determined that it was a not a known case of metabolic disease. Ms. X also had no signs and symptoms of cardiovascular involvement but had a BMI > 25kg/m2 and hypertension and was prediabetic. Based on the Logic Model of Classification of Risk, she was considered in the Moderate Risk Category. She did not have hypercholesterolemia. She could not be considered in the sedentary lifestyle category because of the household chores she performed. However, since she was suffering from knee pain and her walking pace was slow, she could not be considered in the active group either; her heart rate was barely elevated during her activities nor were the activities she performed of sufficient intensity to lead to any kind of training response.
During dynamic testing there was no temporal or spatial gait deviations noted. Knee flexion and extension range of motion were found to be full and pain-free. No impairment was seen in hip flexion, extension, abduction or adduction range of motion. However muscle power was slightly reduced in both hip and knee and was measured to be Grade 4. On palpation there was no increase in temperature around knee joint but there was pain on medial joint line with an intensity of 7/10 on the VAS (Presently 2). On neurological testing, all reflexes were normal and sensations were intact.
Baseline anthropometric evaluation showed that Ms. X 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 components.
Other tests that had been conducted were blood calcium levels, thyroid function tests and parathyroid hormone which were all found to be normal. The test of 25-hydroxy vitamin D test was advised to determine whether the body has enough vitamin D. It was found to be slightly reduced.
Ms. X presented with pain in both knees and was unable to do household chores. X-rays showed only age-related degenerative changes. Pain on palpation of the medial joint line of the knee could have been due to the loss in muscle power around the hip and knee, altered joint proprioception and further muscle spasm. All this needed to be addressed to limit future disability.
Management and Outcomes
- Diet plays an important role so Ms. X was also put on a specific program in which she had a regulated high fibre diet (including oats and salads) 
- She needed to reduce the loading on her knees to decrease her pain in the short-term to avoid her losing her patience with treatment before longer-term training effects could be seen on the target muscles (at least three weeks)
- The importance of regular exercise was stressed
- Ms. X was educated about how her health could affect the final outcome status of her family and children
- Advice on avoiding cross-legged sitting, avoiding sitting on low surfaces and to use raised toilet seats
Progressive aerobic and specific muscle training
- A warm-up protocol including stretching for all joints was given.
- Because her knees were affected, a cycle ergometer was used to improve her aerobic activity level.
- Aerobic exercise was followed by strengthening exercises for the affected muscle groups.
for the muscles that lasted at least 30 minutes 4-5 times per week ( ACSM FITT principle) was advised. This was gradually increased to 30 minutes with slow progression from 10 minutes on day one to 30 minutes at the time of writing.
- Ms. X was observed for her heart rate and BP before and after the exercise. The Peak Heart Rate was taken 15 seconds before the end of exercise and she was also observed for her recovery heart rate for another five minutes.
- A home program was also implemented. She could do this independently by integrating it into her daily routine. Walking in the garden for 20 minutes at a comfortable speed was advised. She was also advised to wear good quality shoes with air cushioning to improve shock absorption in her lower limb joints. 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. The use of weights and resistance bands were included.
- A meeting with Ms. X's husband was arranged during which other activities such as swimming and aqua aerobics were suggested.
Uprise D3 60 K for Vit D3. Ms. X was asked to follow up with her physician to continue appropriate medication prescription for her other problems. Compliance to the schedule of medications was stressed.
In three weeks Ms. X lost almost 3kg weight and was feeling very active. The VAS score of the knee pain during palpation had decreased from 7/10 to 2/10. Her resting heart rate had improved slightly by the third week of treatment.
The review of the literature relating to cardiorespiratory 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, the evidence reviews from Warburton et al and Paterson et al.   The dose-response pattern related to depression and cognitive decline were reviewed from the CDC Literature review 2008. There is strong scientific evidence showing 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 negative 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.  
With this backdrop the above exercise protocol was suggested to Ms. X and significant improvement was seen in the her status over a three week period.
In summary, motivation plays an important role in spreading awareness about physical activity in any kind of society. Once a patient finds improvement in his/her health status it further motivates him/her to continue. It also creates other positive repercussions (for example, to 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.
- Pescatello LS. and American College of Sports Medicine. (2014). ACSM's guidelines for exercise testing and prescription. Philadelphia: Wolters Kluwer/Lippincott Williams and Wilkins Health. Page 26.
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- Paterson DH, Jones GR, Rice CL. Ageing and physical activity: evidence to develop exercise recommendations for older adults, Applied Physiology, Nutrition, and Metabolism. 2007 Nov 14;32(S2E):S69-108.
- Buckley JP. Exercise physiology in special populations: advances in sport and exercise science. Elsevier Health Sciences; 2008 Aug 14
- Atkinson K, Lowe S, Moore S. Human development, occupational structure and physical inactivity among 47 low and middle income countries. Preventive medicine reports. 2016 Jun 30;3:40-5