Telehealth Case Study - Knee

Subjective:

  • 70-year-old women with complaints of right knee pain for about 1 year. She saw her GP and had X-ray showing moderate osteoarthritis. Has referral to surgeon – waiting to be seen.
  • Her right knee is aggravated by going downstairs (pain = 5/10) so she avoids this. She has some night pain (pain = 2/10). Tried cross-country skiing, was ++ sore. Also pain and difficulty getting up from floor.
  • Activities: walks regularly 30min daily on flat trails are okay. Also does water exercise 2x/week.
  • She is retired and volunteers on numerous committees (involves sitting at computer), she has 2 grandchildren under 2.
  • General health: good. Takes seizure medication.
  • BMI: 27

ANSWERS:

What is her sleep like?  Occasionally disrupted sleep due to night pain.

Does she live alone or with support? Lives with husband, however he has early signs of dementia.

What is her goal? She has recently moved to new apartment building with exercise room and would like to know what should and shouldn’t be doing.

Objective assessment:

  • Observation: right knee mild valgus and swollen compared to left.
  • Gait: mild trendelenburg with walking
  • Squat to chair: shifts left, poor knee control and ‘collapses’ into chair
  • Balance: single leg left: 10 sec; right <2 secs
  • Range of Motion: right knee cannot fully extend compared to left and decreased end range flexion right compared to left

ANSWERS:

Functional strength assessment: number of bridges (body weight only) –  15 repetitions; single leg bridge 8 on left, 1 on right; number of single leg heel raise (with balance support) – 8 on left, 2 on right

Self resisted strength testing: Patient can move through full available ROM against gravity. Flexion: with knee at  90 degrees push leg back into chair provokes mild pain. Extension: in terminal extension laying prone – mild pain.

ANSWERS:

  • Provide education on importance of exercise and loading in OA, pacing, how to manage pain related fear and catastrophising
  • Set goals – be able to play with grandchildren on floor and get up without pain, become independent in doing exercise program at apartment gym (3x week)
  • Exercise prescription: Chair stands exercise, bridging exercise on bed (videos) 3 sets of 10 each
  • Discuss tracking exercises and walking in log book or app as part of an aerobic exercise plan
  • Share “What is osteoarthritis” video 

Follow up appointment: 1 week later, she feels more confident with her walking and exercising. She would like more exercises. On objective examination she does 10 repetitions in a 30 sec chair stand test (but technique is poor).

ANSWERS:

  • Discuss “what is osteoarthritis” video and answer her questions. Also discuss the GLA:D program
  • Review all exercises, demonstrate and observe her. She has poor technique so encourage to go slow, focus on form. Add step up exercise using poles (2 sets of 5). Standing hip abduction (no band) and backward chaining exercise (to practice getting off floor).

Next follow up appointment: 10 days later, she is pleased with exercises but would like faster improvements. She is still struggling with poor technique and body awareness.

ANSWERS:

  • Discuss GLA:D program – she will be supervised, receive cueing, able to progress exercises, and should be able to do independently at end.
  • Review (demonstrate/observe) exercise technique.
  • Discuss walking program including routes, pacing, more varied terrain.

Patient completes GLA:D program via telehealth.

ANSWER: After program she is able to complete 14 chair stands. She feels confident to be able to continue on her own with exercises in an exercise room in her apartment. She would like to follow up for 1-on-1 physio in another 6 weeks to check in. Her average pain is 2/10 with mild soreness on stairs, but does not avoid them any longer. She has introduced some ‘rolling’ terrain into walks and sometimes walks up to 1 hour on weekends. Still has not seen surgeon. She would like to keep appointment, but is no longer considering surgery.