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Preserving knee function following osteoarthritis diagnosis: A sustainability

theory and social ecology clinical commentary

Article in Physical Therapy in Sport · January 2014

DOI: 10.1016/j.ptsp.2014.07.003

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 Physical Therapy in Sport 16 (2015) 3e9

Contents lists available at ScienceDirect

Physical Therapy in Sport

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Masterclass

Preserving knee function following osteoarthritis diagnosis:

A sustainability theory and social ecology clinical commentary
J. Nyland a, *, J. Wera a, C. Henzman a, T. Miller b, R. Jakob c, D.N.M. Caborn a
a
Division of Sports Medicine, Department of Orthopaedic Surgery, University of Louisville, First Floor ACB, 550 S. Jackson St., Louisville, KY, 40202, USA
b
Department of Education, School and Counseling Psychology, University of Kentucky, Lexington, KY, 40506, USA
c
Orthopadie FMH, 1787 Motier (Vully), Switzerland

a r t i c l e i n f o a b s t r a c t

Article history: To sustain natural systems, there must be an ongoing balance between environmental, social, and
Received 2 January 2014 economic considerations. A key element of sustainability theory is to identify the most vulnerable sur-
Received in revised form roundings. The most vulnerable knee tissue is the articular cartilage as it is the last line of osteoarthritis
21 July 2014
(OA) defense. This tissue has a poor capacity for healing. Based on sustainability theory and social ecology
Accepted 23 July 2014
concepts we propose that several key factors contribute to knee function preservation. Factors include
health history, genetic predisposition, personal behaviors, and socio-environmental factors in addition to
Keywords:
local-regional-global physiological system function. Addressing only some of these factors or any one
Self-efficacy
Active learning
factor in isolation may lead to less than optimal treatment effectiveness. The purpose of this commentary
Sports is to introduce a medical, surgical and rehabilitation management approach for patients with knee OA
Arthroplasty that considers more than physical function improvement. This approach also considers social, emotional,
and environmental factors to better ensure patient satisfaction, fulfilled expectations and successful
outcomes. A clinical care pathway is presented for a 57-year-old patient with medial compartment knee
OA who is contemplating early arthroplasty versus a knee function preservation treatment approach.
Early arthroplasty refers to high revision likelihood based on a minimum 15 year prosthesis life-
expectancy.
© 2014 Elsevier Ltd. All rights reserved.

1. Introduction treatment of end stage knee OA is placing a considerable economic

burden on healthcare systems (Healy & Iorio, 2007; Weinstein
For humans, sustainability represents the capacity to endure et al., 2013). It has been predicted that first time (primary) total
and the potential for long-term maintenance of well-being. Sus- knee arthroplasty procedures in the USA will increase by 673% by
tainability theory has become increasingly used to develop 2030 (PRNewswire, AAOS. 2006). The purpose of this clinical
methods for mankind to better sustain natural ecosystems by commentary is to introduce a management approach for patients
making more judicious use of available resources (Soederbaum, with early knee OA based on sustainability theory and social ecol-
2008). Sustainability theory requires a healthy balance and inter- ogy principles. Early knee arthroplasty is operationally defined as a
active relationship between three essential factors or pillars: 1. surgical age where eventual revision is highly likely based on a
environmental, 2. social, and 3. economic (Adams & Jeanrenaud, minimum 15 year prosthesis life-expectancy. For example if a 60-
2008). Osteoarthritis (OA), the leading source of physical year-old patient undergoes early knee arthroplasty, with a life ex-
disability and impaired quality of life in industrialized nations, is pectancy of 85 years of age, they would be likely to undergo one
expected to increase with a growing population of older individuals primary and one revision surgery (Koh, Cho, Choi, Kim, & Kleos
(Madry, Luyten, & Facchini, 2012). The costs associated with an Korea Research Group, 2014; Yoo, Chang, Kang, Kim, Seong, &
increasing number of total knee arthroplasty procedures for Kim, 2011). Patient outcomes following revision knee arthroplasty
are generally poorer than those observed following a primary
procedure (Greidanus, Peterson, Masri, & Garbuz, 2011). In addition
to physical factors, the patient management approach we describe
* Corresponding author. Spalding University, Kosair Charities College of Health
considers social, emotional well-being and environmental factors
and Natural Sciences, 901 South Fourth St., Louisville, KY 40203-2188, USA. Tel.: þ1
502 874 4224; fax: þ1 502 585 7149. to better ensure patient satisfaction and fulfilled expectations
E-mail addresses: jnyland@spalding.edu, john.nyland@louisville.edu (J. Nyland). following knee OA diagnosis. A clinical care pathway example is

http://dx.doi.org/10.1016/j.ptsp.2014.07.003
1466-853X/© 2014 Elsevier Ltd. All rights reserved.
4 J. Nyland et al. / Physical Therapy in Sport 16 (2015) 3e9

presented for a 57-year-old patient with medial compartment knee physiological system function, healthy aging and knee function
OA who is contemplating early arthroplasty versus a knee function preservation (Enoka, 1997; Heikkinen, Vihriala, Vainionpaa,
preservation treatment approach. Korpelainen, & Jamsa, 2007; Huiskes, 2000; van Praag, 2009;
Vainionpaa, Korpelainen, Vaananen, Haapalahti, Jamsa, &
2. Sustainability theory and knee function preservation Leppaluoto, 2009; Winett, Williams, & Davy, 2009; Wondrasch,
Aroen, Rotterud, Hoysveen, Bolstad, & Risberg, 2013; Wright,
Sustainability theory suggests that the rate of available resource Zautra, & Going, 2008).
use should not exceed the rate at which it can be regenerated,
particularly in regards to the most poorly regenerated sources. An 3. Social ecology
analogy for the knee might be maintaining healthy articular carti-
lage. Since it has a poor healing capacity, articular cartilage repre- Health is influenced by the patient, their societal interactions,
sents a comparatively non-renewable resource compared to other and the environment in which they live. A basic social ecology
knee tissues (Buckwalter, Martin, & Brown, 2006; Gomoll et al., concept is that health and wellness is a multifaceted phenomenon
2012; Griffin & Guilak, 2005; Madry et al., 2012; Van Ginckel, encompassing physical health, emotional well-being, and social
Baelde, Almqvist, Roosen, McNair, & Witvrouw, 2010). In contrast, cohesion (Stokols, 1992). Social ecology is based on the belief that
the neuromuscular and musculoskeletal systems have a more most of humanity's current ecological problems originate from
renewable capacity with proper exercise training, a nutritional diet, dysfunctional social arrangements (Bookchin, 2007). Many public
and appropriate daily activities. Certainly a given patient's genetic health challenges such as knee OA are too complex to be under-
predisposition may increase their likelihood for developing con- stood adequately from single analysis levels, requiring more
nective tissue disorders or deficiencies that may be detrimental to comprehensive and holistic approaches that integrate psychologi-
capsuloligamentous knee stability (Beighton, 1988; Valdes & cal, organizational, cultural, community planning, and regulatory
Spector, 2010). Innovative technologies such as knee orthoses and perspectives (Sallis et al., 2006; Stokols, 1992, 1996). Based on this
foot orthotics that eliminate or largely reduce excessive potentially assumption there is value in approaching complex personal, com-
injurious knee loads or laxities during sport, recreational and munity and environmental problems from multiple analysis levels
vocational activities may also influence knee function preservation rather than from single disciplines or from solely theoretical per-
(Giotis, Zampeli, Pappas, Mitsionis, Papadopoulos, & Gerogoulis, spectives. Since patient compatibility with their surroundings is
2013; Hinman, Bowles, Metcalf, Wrigley, & Bennell, 2012; Ramsey important to general health, this expanded emphasis on societal
& Russell, 2009). Environmental sustainability benefits through and environmental relationships with sociocultural and institu-
the development of nature friendly cities, gardens, and parks (Sallis, tional components is important (Sallis et al., 2006; Stokols, 1992,
Cervero, Ascher, Henderson, Kraft, & Kerr, 2006). Knee function 1996).
preservation similarly benefits from healthy lifestyles, exercise and Another essential social ecology principle is that human-
activity habits, and daily living routines (Fransen & McConnell, eenvironmental interactions represent dynamic and active pro-
2009; Kon et al., 2012). Knee tissues and function are more likely cesses. This creates interdependencies between physical and social
to be preserved when both the environment and patient lifestyle conditions within specific environments in the structure of multi-
predispose them to well-controlled impact loads and ample op- ple settings and life domains (Sallis et al., 2006). From the
portunity for low-risk active mobility (Dye, 1996). This may be perspective of care for a patient with knee OA, it is important not to
particularly true for articular cartilage as well as for the menisci neglect links between the social and physical aspects of environ-
(Crema et al., 2009; Englund, Guermazi, & Lohmander, 2009; ments and their combined influence on knee function preservation
Hunter et al., 2006; Roos, Herzog, Block, & Bennell, 2011; (Sallis et al., 2006). From this perspective it is important for patients
Verdonk, Verstraete, Almqvist, De, Veys, & Verbruggen, 2006; with knee OA to link therapeutic exercise performance with self-
Wang et al., 2011). education as they attempt to achieve functionally relevant and
In addition to the escalating costs of knee OA surgical in- valued goals. In this manner, they develop a more valid and precise
terventions, economics as it applies to sustainability theory con- cognitive appraisal of their condition and functional capabilities.
siders the financial aspects of environmental and ecological This empowers them with diverse self-efficacy, coping and resil-
variables from a multidimensional perspective (Soederbaum, ience skills (Hurley, Mitchell, & Walsh, 2003). With this, they
2008). Sustainable businesses integrate ecological concerns with become more effective in managing their condition from a com-
social and economic concerns (Kinsley & Lovins, 1995). Growth that bined personal, societal, and environmental perspective (Binder,
simultaneously depletes an ecosystem is not only uneconomic, but Stokols, & Catalano, 1975). Use of social cognitive or learning the-
it also leads to a decline in quality of life (Daly, 2007, 1999). This ory concepts within a therapeutic exercise environment is essential
may be analogous to increasing body mass without a concomitant to improve self-efficacy, coping skills, resilience, and self-education
increase in lower extremity neuromuscular strength-power- (Bandura, 2001; Hallam & Petosa, 2004; Maly, Costigan, & Olney,
endurance or cardiopulmonary and vascular system functional 2006; Marks, 2001; Rawiworrakul, Sirapo-ngam, Tsang, Mala-
capacity, thereby compromising the economy of knee function thum, Kulthanan, & Vorapongsathron, 2007; Sallis et al., 2006;
preservation. Sustainability theory suggests that appropriate Smedley & Syme, 2000; Van den Akker-Scheek, Zijlstra, Groothoff,
resource management better ensures environmental adaptability, van Horn, Bulstra, & Stevens, 2007; Winett et al., 2009).
preventing irreversible long-term damage to ecosystems and hu- The environment and social group in which the patient dwells
man health, and greater acceptance of global management re- can be either a powerful enabler of healthy behaviors and attitudes
sponsibility. At the knee, maintenance of local factors such as lower or a constraint that negatively influences personal and collective
extremity strength and active joint mobility, and regional factors well-being (Stokols, 1992). Physicians, surgeons, rehabilitation cli-
such as maintaining appropriate walking stride length, forefoot nicians, and others (psychologists, public health educators, social
mediated propulsion, and eccentric lower extremity muscle func- scientists, and wellness professionals) must interact to develop
tional capability (Larose et al., 2013; LaStayo, Meir, Marcus, Mizner, more cohesive, better integrated and shared conceptual frame-
Dibble, & Peters, 2009; LaStayo, Woolf, Lewek, Snyder-Mackler, works drawing together specific theories, concepts, and approaches
Reich, & Lindstedt, 2003; Marcus, Yoshida, Meier, Peters, & Las- to better address environmental and societal issues associated with
tayo, 2011) contribute directly to more effective global patients who have knee OA. These frameworks can serve as
 J. Nyland et al. / Physical Therapy in Sport 16 (2015) 3e9 5

comprehensive organizing constructs for patient care as well as for program adherence is desired. Movement tasks that challenge
research that bridges discipline-specific theoretical and methodo- existing motor skills and that develop and refine new ones in an
logical orientations to better define and analyze knee OA as a active learning exercise environment are essential. In addition to
world-wide health problem (Bijlsma & Knahr, 2007; van Dijk, the specific movement tasks performed, the sensorimotor richness
Veenhof, Lankhorst, van den Ende, & Dekker, 2011; Hawker, of the exercise environment contributes directly to knee function
Mian, Bednis, & Stanaitis, 2011; Madry et al., 2012; Wright et al., preservation (Dye, 1996; Huiskes, 2000; Nyland, Kanouse, Krupp,
2008). This process can lead to more innovative, practical and Caborn, & Jakob, 2011; Rhodes, 2006; van Praag, 2009). Devel-
cost effective approaches to solving societal, environmental, and oping appropriate lower extremity neuromuscular responses to
personal problems related to knee OA. unexpected loads within relevant functional scenarios can improve
Bookchin (2005) suggested that most activities that consume dynamic knee stability and whole body postural control (Horita
energy and destroy the environment are senseless because they et al., 2002; Kamibayashi & Muro, 2006; Williams, Chmielewski,
contribute little to quality of life and well-being. This might be Rudolph, Buchanan, & Snyder-Mackler, 2001). Balanced hip, knee,
analogous to a person repeatedly placing their knee in potentially and ankle-foot region neuromuscular activation with appropriate
injurious situations at an early age through sport, recreational or trunk and lower extremity alignment during the performance of
vocational activities and expecting long-term function to be pre- functionally relevant movements helps facilitate safer knee loads
served. To optimize the positive benefits of sport, recreational and and more precise neuromuscular control pre-set, and co-activation
vocational activity participation, the context and environment in level adjustments (Williams et al., 2001). These functions are
which it occurs greatly matters. For example, overuse, overtraining, essential to knee injury prevention during sports, recreational or
under recovery and the progression from micro-to-macro trauma vocational activity performance (Barra, Bray, Sahni, Golding, &
can degenerate knee tissues (Dye, 1996; Mostafavifar, Best, & Myer, Gresty, 2006; Horita et al., 2002; Kamibayashi & Muro, 2006).
2013). The perceived societal roles and responsibilities that in- To increase the likelihood of treatment success, increase patient
dividuals begin to develop during childhood and the behaviors that satisfaction, and better fulfill expectations, medical, surgical and
drive the need to fulfill these roles across their lifespan directly rehabilitative planning for knee OA may need to change. The In-
influence knee function preservation and general health (Brewer, ternational Classification of Functioning, Disability, and Health (ICF)
2003; Brewer & Cornelius, 2010; Langford, Webster, & Feller, provides a standard language and conceptual basis for the defini-
2009). Lessons learned during early sport, recreational or voca- tion and measurement of disability, integrating medical and social
tional activity participation can set the stage for effectively coping models into a bio-psycho-social synthesis (World Health
with health-related challenges to knee function preservation and Organization, 2013). The ICF conceptualizes function as a dynamic
overall general health that occur later in life (Mostafavifar et al., interaction between personal health, environmental, and personal
2013). Developing diverse social roles, positive responses to peer factors. Within this multidimensional, integrated model, patients
pressure, resilient responses to early injury and sport, recreational are placed in a context where function and disability represents the
or vocational activity success or failure experiences, and diverse result of an interaction between their health condition and their
coping skills may be important to long-term knee function pres- physical, social and emotional environment. Biological, personal,
ervation, healthy aging, injury prevention and wellness (Brewer, and social perspectives that influence health across the entire life
2003; Brewer & Cornelius, 2010; Chan, Lonsdale, & Fung, 2012; span are also taken into consideration. In addition to improving
Langford et al., 2009; Mostafavifar et al., 2013). patient care, by looking beyond solely physical function, the ICF
framework can improve inter-professional education, collaboration
4. Managing a spectrum of knee function preservation and practice between experts with diverse expertise, and facilitate
factors communication across services, organizations and agencies.
With consideration for the pillars of sustainability (environ-
Diverse factors can influence knee function preservation among mental, social, economic) (Adams & Jeanrenaud, 2008) and the ICF
patients with knee OA. Multiple physiological systems are directly it can be surmised that social considerations may be the most
linked to general health (American College of Sports Medicine, important factors for knee function preservation. Embedded within
1998; Enoka, 1997; Koster et al., 2008; Krasnoff & Painter, 1999; social considerations are the psychobehavioral, psychosocial, and
Liu-Ambrose, Nagamatsu, Hsu, & Bolandzadeh, 2013; van Praag, cultural factors that facilitate societal roles. Numerous and diverse
2009). Knee function preservation is also directly related to general social considerations may influence knee function preservation.
health (Dobson et al., 2013; Hunt, Birmingham, Skarakis-Doyle, & These may include a patient's perceived pain and catastrophizing
Vandervoort, 2008; Larose et al., 2013; Rapp, Rejeski, & Miller, threshold and tolerance (Axford, Heron, Ross, & Victor, 2008;
2000; Shih, Hootman, Kruget, & Helmick, 2006; Wright et al., Bookwala, Harralson, & Parmelee, 2003; Keefe, Lefebvre, Egert,
2008). Maintaining knee and adjacent joint articular cartilage sur- Affleck, Sullivan, & Caldwell, 2000; Rapp et al., 2000; Sullivan,
face integrity and congruity (Van Ginckel et al., 2010), bone integ- 2008), basic life attitude (Christensen, Herskind, & Vaupel, 2006),
rity and density (Heikkinen et al., 2007; Huiskes, 2000; Vainionpaa self-efficacy (Harrison, 2004; McKnight, Afram, Kashdan, Kasle, &
et al., 2009), capsuloligamentous stability (Krogsgaard, 2007; Zautra, 2010; Silverman, Nutini, Musa, Schoenberg, & Albert,
Schmitt, Fitzgerald, Reisman, & Rudolph, 2008), neuromuscular 2009; Thomee, Wahrborg, Borjesson, Thomee, Eriksson, &
strength-power-endurance (Horita, Komi, Nicol, & Kyrolainen, Karlsson, 2008; van Dijk et al., 2011), health locus of control
2002; LaStayo et al., 2003), eccentric muscle function (LaStayo (Steptow & Wardle, 2001), spirituality (Jones, Kwoh, Groeneveld,
et al., 2003), static and dynamic postural control (Horita et al., Mor, Geng, & Ibrahim, 2008), movement fear-relative risk
2002; Kamibayashi & Muro, 2006), use of a propulsive gait appraisal (Brewer, 2003; Langford et al., 2009), proper balance
pattern with normal stride length (Maly et al., 2006), and efficient between life stressors and coping mechanisms (Hunt et al., 2008;
responses to sudden perturbations (Bijlsma & Knahr, 2007; Enoka, Lopez-Olivo et al., 2011), expectation-satisfaction requirements
1997; Hinman, Heywood, & Day, 2007; Horita et al., 2002; (French, Keogan, Gilsenan, Waldron, & O'Connell, 2010), lifestyle
Kamibayashi & Muro, 2006) sets the stage for better maintaining choices such as dietary habits, alcohol and cigarette consumption
general health. (Koster et al., 2008; World Health Organization, 2004), and resil-
The context and environment in which therapeutic exercises are ience when adapting to changes associated with aging, injury,
performed is a vital consideration when patient self-education and disease, surgery, rehabilitation, and perceived barriers (American
6 J. Nyland et al. / Physical Therapy in Sport 16 (2015) 3e9

College of Sports Medicine, 1998; Koster et al., 2008; McKnight procedures such as high tibial osteotomy, meniscal repair or
et al., 2010; Miller, Nyland, & Wormal, 2006; van Dijk et al., 2011). transplantation, or chondroplasty (Birmingham et al., 2009; Bonnin
Creating an active learning therapeutic exercise environment et al., 2013; Rueff, Nyland, Kocabey, Chang, & Caborn, 2006).
that facilitates local-regional-global system physiological system However, they will typically not recover their pre-pathology per-
adaptations that promote balanced, homeostatic regeneration of formance level and will continue to experience some pain during
healthy tissues and neuromuscular control is important (Bandura, strenuous sports performance (Bonnin, Laurent, Parratte, Zadegan,
2001; Hallam & Petosa, 2004; van Praag, 2009; Rawiworrakul Badet, & Bissery, 2010; Bonnin et al., 2013).
et al., 2007; Winett et al., 2009). Patients who train in this envi- The patient and surgeon often have divergent views of satis-
ronment more likely benefit from the self-education associated faction following knee OA surgery (Nelson et al., 2014). Satisfaction
with learned resourcefulness, goal setting, vicarious learning of a patient's preoperative expectations is the primary factor that
through peer observation, modeling, and proactive planning influences the subjective outcome following knee OA surgery and
(Bandura, 2001). Helping the patient establish well-defined links more motivated patients are better able to continue sport, recrea-
between the true necessity of many functional tasks and quality of tional or vocational activity participation (Bonnin et al., 2010, 2013;
life values is paramount to healthy aging, knee function preserva- Bullens, van Loon, de Waal Malefijt, Laan, & Veth, 2001; Iorio, Healy,
tion, and therapeutic exercise program planning. Pain-free walking & Applegate, 2006; Noble, Conditt, Cook, & Mathis, 2006; Yoo et al.,
and other less programmed free movements such as multi- 2011). Consideration for how the selected clinical care pathway will
directional hopping or skipping can facilitate general health match a patient's preoperative expectations thereby improving
throughout multiple body systems, but particularly through the their satisfaction level is essential.
neuromusculoskeletal and vestibular systems (Dobson et al., 2013; A case is presented of a 57-year-old man with medial
Shull et al., 2013). compartment knee OA and a 33% articular cartilage thickness
It is essential that patients with knee OA develop greater resil- deficit on standing radiograph compared to his opposite knee. He
ience, coping skills, and pain-tolerance. Concurrently they need to smokes one pack of cigarettes daily, has a BMI of 29, and scores his
become more self-efficacious, minimize catastrophizing and knee pain during level walking as 4e5 on a visual analog scale (end
depression, and maintain vigilance in identifying innovative range descriptors 0 ¼ no pain, 10 ¼ extreme pain). He currently
methods to continue or intentionally modify current sport, recre- requires only occasional pain medication and has a strong desire to
ational or vocational activities. Continued participation in these lose 10 kg and stop smoking. Should he desire to eliminate his knee
activities and their associated social roles suggests effective adap- pain, but be less agreeable to, or capable of making any substantive
tation to varying life stressors. The patient's problem-solving ability psychobehavioral and psychosocial changes, early arthroplasty may
as it relates to functional movement task dilemmas and possible be the preferred knee OA surgical approach for him. Another
solutions is important. Rational decisions are also needed for sport, important decision-making factor is the value he places on
recreational or vocational activity selection. Interest in lifelong returning to sport, recreational, or vocational activities that involve
learning to stay current with evidence-based knee function pres- impact (activities with intense, sudden and/or frequent weight-
ervation information, liberal use of social support systems, open- bearing loads such as recreational club soccer) and the social
ness to alternative and complementary care approaches such as relevance and values he attaches to those activities. Should he wish
nutritional supplementation, and activities such as yoga, and tai chi to participate in activities that involve higher impact he should be
are also important (Caborn, Rush, Lanzer, Parenti, Murray, & cautious of early arthroplasty risks including, but not limited to,
Synvisc 901 Study Group, 2004; Civinini et al., 2013; Hawker accelerated polyethylene deformation, deterioration, peri-
et al., 2011; Kraemer, 2006; Laslett et al. 2014; Lauche, Langhorst, prosthetic loosening and heightened fracture incidence (Hernigou,
Dobos, & Cramer, 2013; Miller et al., 2006; Roos & Dahlberg, 2013; Koh et al., 2014; Lavernia, Sierra, Hungerford, & Krackow,
2005; Sanghi et al., 2013; Turajane et al., 2013). With thoughtful 2001; Mackie, Muthumayandi Gerrand, & Deehan, 2013; Nyland
planning, behavioral and lifestyle changes can occur without et al., 2011; Peck, Childs, & McLauchlan, 2013). Since he desires to
compromising quality of life values following a knee OA diagnosis. continue to perform some higher impact activities, he currently
only requires occasional pain medication, and he plans on imple-
5. Knee preservation versus early arthroplasty clinical care menting the psychobehavioral and psychosocial changes needed to
pathway lose 10 kg and stop smoking, he might be a good candidate for
undergoing a knee function preservation and rehabilitation clinical
Relatively low impact sports such as bicycling, golfing, swim- care pathway rather than early arthroplasty (Table 1).
ming, or doubles tennis are generally recommended for patients
following TKA. However, many desire to participate in sports that
are characterized by more intense, sudden, and/or frequent
Table 1
weightbearing joint loads such as running, soccer, basketball and Characteristic differences between patients that likely fit best with either a knee
downhill skiing. The arthroplasty industry has been expanding its function preservation or early arthroplasty (avoiding revision within his lifetime
market to include younger, more active patients with greater ex- based on a minimum prosthesis life-expectancy of 15 years)clinical care pathway
pectations regarding sport, recreational or vocational activities (Koh et al., 2014; Nyland et al., 2011; Yoo et al., 2011).

than elderly patients (Meehan, Danielsen, Kim, Jamali, & White, Knee function preservation Early arthroplasty
2014; Ravi, Croxford, Reichmann, Losina, Katz, & Hawker, 2012). Strong desire to continue impact sport, Strong desire to eliminate
The possibility of successfully returning to sport, recreational or recreational or vocational activities knee pain
vocational activities is an important factor in the decision-making Willingness to implement significant Minimal or no desire to continue
process for many patients with knee OA (Bonnin, Laurent, behavioral change needs and impact sport, recreational or
develop support system vocational activities
Zadegan, Badet, Pooler Archbold, & Servien, 2013). The motivated
Willingness to tolerate minor-to- Desire to only make minor or
patient with knee OA needs to determine if undergoing an early moderate pain levels and learn to no changes to existing behaviors
arthroplasty procedure or a knee function preservation treatment increase pain tolerance
approach will better meet their expectations resulting in greater Understanding that this clinical care Understanding that this clinical
treatment satisfaction. Patients with knee OA can often resume pathway was designed primarily care pathway was designed
for young or middle-aged patients primarily for elderly patients
strenuous activities following knee function preservation surgical
 J. Nyland et al. / Physical Therapy in Sport 16 (2015) 3e9 7

One primary consideration for patients who desire to continue system that can assist the patient with achieving the necessary
impact activities following knee OA surgery and rehabilitation is psychobehavioral and psychosocial changes is essential. Complete
how they will successfully manage knee pain (Beswick, Wylde, pain relief is generally not a realistic option with either clinical care
Gooberman-Hill, Blom, & Dieppe, 2012; Bonnin et al., 2013; pathway, but it is considerably less so with the knee function
Nyland et al., 2011). Given the excellent success of procedures such preservation treatment approach. With this approach the patient
as high tibial osteotomy, with appropriate patient selection, it is must learn how to better tolerate knee pain and improve self-
reasonable to prefer a knee function preservation treatment efficacy, resilience, and coping skills. The patient with a sport,
approach when possible (Birmingham et al., 2009; Bonnin et al., recreational or vocational activity participation history who places
2013; Hernigou, 2013). Without actual psychobehavioral and psy- high value on their societal role as a participant may be the ideal
chosocial changes, however, this patient would likely be a poor candidate to forego early arthroplasty substituting a less invasive
candidate for achieving a successful outcome following a knee knee function preservation treatment approach.
function preservation treatment approach. He only becomes an
acceptable candidate after he commits to stop smoking, lose Conflict of interest
weight, and participate in a regular, progressive and individually The authors affirm that they have no involvement with any
prescribed therapeutic exercise program performed in an active commercial organization that has a direct financial interest in any
learning environment with functionally-relevant movements matter included in this manuscript.
selected based on existing impairments, functional limitations and
educational needs. It may be particularly helpful if the rehabilita-
Funding
tion clinician uses social cognitive theory learning principles
The authors affirm that they have no financial affiliation
(Bandura, 2001; Hallam & Petosa, 2004; Rawiworrakul et al., 2007;
(including research funding).
Winett et al., 2009).
Before selecting either clinical care pathway, the patient should
be provided detailed information regarding all possible surgical References
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