Case Study on Aerobic Training in a Subject with Knee Pain

Abstract

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 logic model of classification of risk, who would benefit from specific physiotherapy intervention. After three weeks of matched, evidence-based intervention, Ms. X demonstrated a clear positive response with abolition of pain on the visual analogus scale (VAS).

Introduction

Ms. X 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”, there is still a situation in India where daughter-in-laws are expected to serve their in-laws until they themselves are dead tired and the daughter-in-laws themselves consider this amount of work to be their 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 outpatient department to dedicate a moment for her own self. 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 physiotherpist was saying. 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.

Case Presentation

Client characteristics

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.

Examination Findings

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 of patients. She did not have hypercholesterolemia. She could not be considered in the sedentary lifestyle category because of the household chores she performed. However, because since she was suffering from knee pain and her pace was slow, she could not be considered in the active group; her heart rate was barely elevated during her activities nor did the activities she performed be of sufficient intensity to lead to any kind of training response.

Physical Examination

During dynamic testing there was no temporal or spatial gait deviations noted. Knee flexion and extension were found to be full and pain-free. No impairment was seen in hip muscle flexion, extension, abduction or adduction. 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 VAS score 7 (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 balance and coordination.

Other tests which were conducted were blood calcium levels, thyroid function tests and parathyroid hormone, which were all 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.

Clinical Hypothesis

Ms. X presented with pain in both knees and was unable to do household chores.3 X-rays showed only age-related degenerative changes. Pain on palpation of the medial joint line of the knee could be due to loss in muscle power around hip and knee, altered joint proprioception and further muscle spasm. All this needed to be addressed to limit future disability.

Management and Outcomes

Intervention

Patient Education

• 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 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 mins 4-5 times per week ( ACSM FITT principle) was advised 6. This was brought to 30 minutes with slow progression starting from 10 minutes on day one to 30 minutes at the time of writing.
• She was observed for her Heart Rate and BP before and after the exercise. The Peak Heart Rate was taken 15 sec 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. 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 e.g. 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%. Her Resting heart rate has improved in the 3rd week now. It has come down slightly.

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.