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Physiotherapy & Braces
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Physiotherapy & Braces

Depending on where a patient is on the spectrum of cartilage injury, or how far ‘down the curve’ they are, conservative management such as physiotherapy or braces may be an option. As it is non-invasive, it may be suitable for people who are perhaps not ready to have a more invasive procedure, such as surgery, or perhaps may be too young to consider a total or partial joint replacement.

Even if a patient will end up having a more invasive procedure, it is good to consider conservative management options before their surgical intervention, so that they are familiar and compliant with the exercises. If they have any questions about the intervention or what to expect after surgery in terms of the rehab process, the physiotherapist can serve as a wonderful resource and educator.

More specifically, physiotherapists can identify if there are any pre-existing weaknesses, known as ‘biomechanical deficiency’, before an operation and determine if the patient can be successfully treated in a conservative way. For a patient in their 50s, 60s or 70s with pain in one part of their knee (uni-compartmental knee pain), physiotherapists can look for muscle imbalances, overall weakness, altered loading patterns and deficits in flexibility. Physiotherapists can explain these concepts, and can formulate a home exercise program that is safe for their current state, so they do not damage the remaining articular cartilage surfaces. They can also be offered treatments that they can use at home if they have edema (swelling) or any kind of swelling after a long walk or increased activity.

This educational process can have an empowering effect on patients, because it provides them with some autonomy, and the ability to be proactive and involved in their care.

The main goals of the physiotherapist are:

  • To be educators.
  • To salvage and preserve the articular cartilage patients still have.
  • Identify the true source (‘etiology’) of the degeneration and intervene appropriately.

For example, at times the physiotherapist will identify profound lateral hip and gluteal muscle weaknesses, and those are very easy things to build into a thorough home exercise or clinical-based program. Significant results can be achieved just by increasing strength in weaker muscle groups.

Intended audience

This article is intended for anyone suffering from damage to their articular cartilage and their families who would like to find out about physiotherapy, as well as anyone interested in cartilage problems.

What is Physiotherapy & Braces?

If a patient has a bone and cartilage injury (‘osteochondral’ defect), or the early signs of osteoarthritis, non-operative management is a reasonable option that may delay or prevent the need for surgical intervention.

The use of viscosupplementation can be complementary to the work that a physiotherapist will do. Its use has the potential to recreate balance (homeostasis), within the joint and this has the potential to help the physiotherapist in terms of the biomechanical interventions that they can offer you. In other words, if the pain and inflammation can be controlled, more therapeutic interventions can be introduced that can lead to a restoration of the patient’s function.

In older patients, the causes of articular (joint) cartilage defects are multifactorial. The aging process, which leads to changes in the articular cartilage’s ability to withstand the forces experienced by our joints, combined with muscular imbalances is thought to play a role in the actual articular cartilage defects seen in this age group. Comparatively, in the younger population, articular cartilage defects tend to be more focal and are typically the result of an injury (trauma).

A holistic approach is used in the evaluation of each patient. The patient’s movement and gait pattern are generally assessed very early during their evaluation by the physiotherapist. If they are able to run, then this is also examined. Anything that can be addressed through muscular changes, either through strengthening, stretching or the unravelling of an imbalance, is assessed. Furthermore, if the patient has a history of an anterior cruciate ligament tear (ACL), a lesion in their meniscus, or a bone bruise, they would be closely followed to ensure that further damage to the articular cartilage surfaces does not occur. Patients presenting with joint pain are examined to see if that is related to the history of the actual trauma or whether it is an area that they have been loading excessively for many years, resulting in slow degeneration.

A physiotherapist’s job is to make sure that the forces are distributed equally across the entire joint surface. The transmission of forces through the foot, knee and hip are examined, and the problem is looked at holistically, including assessment of the patient’s core and trunk strength. Even in very high-level athletes, the problems may not necessarily be displayed, as physical weakness, but the imbalance can be just as troublesome. If you think of the joints as a pulley system, particularly in the knee, the force at either end of the pulley needs to be similar. You have to be able to execute forces equally on both sides.

People need to be able to produce that force in order to maintain the homeostasis of the joint. Often times, that is not seen. There are muscle imbalances that are created by virtue of playing just one specific sport. For example, football or soccer places a lot of strain on the muscles of the thigh, including the quadriceps and adductors, which has ramifications for the knee, not only from an injury perspective but also in terms of wear and tear to the articular cartilage. Homeostasis and balance should always be the focus, whether that is terms of articular cartilage, muscle strength or force production, etc.

Bracing can be very helpful in patients with lesions in one compartment of the knee or in those with some malalignment of the lower extremity. Some physiotherapists use unloader braces, depending on whether the lesion is on the medial (inside) or lateral (outside) side of the joint. More specifically, in terms of the knee, if the patient has an injury to the medial femoral condyle or medial tibia plateau then the use of an unloader brace to unload the medial side of the knee may be beneficial. The knee is normally assessed from a biomechanical and muscular strength perspective, looking not only at weakness but also imbalances. There are also a variety of different braces that are able to provide added stability and increased proprioceptive function to different body parts and can be incorporated within the treatment approach to addressing the specific joint complaint. The use of braces in patients with knee arthritis and mild to moderate varus or valgus malalignment was recommended by the OARSI expert panel, because studies have shown that patients do receive some benefits from wearing braces for these conditions.

What are the disadvantages of physiotherapy and braces?

There are very few downsides, unless you are doing something that is out of the scope of recommended practice, or it is not evidence based. Perhaps the only downside is that, if the patient is too far down the degeneration curve, there is not a lot that can be offered to them in terms of an exercise based program. Although the improvements in their cardiovascular fitness as a result of low impact exercise will still be very beneficial.

At a bare minimum, patients can be provided with education, which in itself can be an extremely valuable piece in the overall treatment approach. The nature of the profession affords physical therapists a fair amount of time to spend with their patients and it is reasonable for some of this time to be utilised for providing on-going educational support.

Frequently Asked Questions (FAQs)

Some commonly asked questions patients have about braces are:

  • Are they effective?
  • Are they cumbersome?
  • How often do I need to wear this brace?
  • What are my options?
  • Are there different manufacturers?

Please refer to their physiotherapists as they are a great resource for discussing braces and will be able to discuss the recent literature on the efficacy of pre- or postoperative bracing.

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