On group classes; much needed in public health. But generic classes aren't enough. They need to be individualised. Physiotherapy is much more than advice and exercise.

Patients suffering OA are too often coddled (like many other age related problems); advised to take it easy, with fear avoidance behaviours imposed upon them. This isn’t the way. Some will need TKR, but many can delay or avoid completely with comprehensive rehab. 14/

Too many OA patients are told they've failed rehab, when in fact rehab has failed them. They often don't improve because they weren't given permission or guidance to push themselves. Not all patients will, but all should be given the chance. 13/

Outcome:

- 6/52 sleep was undisturbed.
- 3/12 climbing stairs pain free.
- 12/12 full function restored, and working without restriction.
- 2 years he cycled Mt Ventoux!
- 8 years after he was 🚴‍♂️ regularly, in the gym x 2/week, and comes for a ‘loosen up’ as symptoms dictate. 12/

6. Strengthening: *Controversially* we used open chain resistance.🤯.an exercise demonised like few others. But they can be invaluable in patients with atrophied quads who struggle with WB load. Used sensibly they’re fine, and offer a step to heavier WB load. 11/

5. The physio sessions weren’t just ‘hands-on’. Also a combination of coaching and motivation. It’s important for patients to see incremental ‘wins’ to help sustain them through a long rehab. In the initial stages progress can be slow, so in person sessions are invaluable. 10/

4. Restore extension: poor extension = poor result. We used *manual therapy* to help. 😬. Twice/week. 😬🤯. For 6 weeks..FFD’s can be hard to change, so he was pushed pretty hard. Patient needs to stretch. A lot. Multiple times daily for at least 5 minutes per time. 9/

3. Cycling: He bought an exercise bike. 🚴‍♂️ for 20-30 minutes. Every. Single. Day. Good evidence that lubricant secreting cells in synovial joints respond well to cyclical movement. But also a great exercise for restoring belief in the legs, and modulating his knee pain. 8/

2. Medication: 1/12 course of Naproxen. Oddly, had not tried NSAID’s previously. Immediately helped his night pain. Sleep is important for many reasons, but it’s particularly important during intensive rehab, and can help break a pain cycle. 7/

What did we do? Five key pillars.

1. Educate. In detail. To succeed, patients with moderate/advanced knee OA need to embark on a fairly demanding rehab program. So they need to understand their condition and the reasoning behind everything they'll be doing. 6/

But...with established flexion contracture, night pain, substantial loss of range and function, and > 12/12 Hx of pain it can be challenging to get good conservative outcomes without complete patient commitment to a difficult rehab program. 5/

Impression: His arthritic knee was impacting quality of life and ability to work. Arthroplasty was a reasonable option, but to proceed before more comprehensive physio/rehab is questionable. Failure to improve from an OA class is not a failure of physio. 4/

Came for 2nd opinion. Examination: 120 degrees flexion. Fixed flexion deformity of 5-10 degrees. Quads atrophy++ Tender joint lines. Small effusion. Poor single leg balance. Unable to sit to stand without support..3/

Wait listed for arthroplasty and referred for physio in the interim. Physio included; one in person consult, a sheet of exercises, advice to 🚶more, and 6 group exercise classes. 3/12 later, no better and resigned to a TKR. 2/