Knee Osteoarthritis and Perceived Joint Instability

by Maureen Ambrose PT, DPT, OCS

A common report among patients suffering from knee osteoarthritis is the feeling that the knee is buckling or “giving way” during weight bearing activities. This could occur while walking or going down stairs and contributes to avoidance of activities due to the fear of falling.

True knee instability would indicate that the knee ligaments are damaged or over-stretched (laxity) and have lost the ability to stabilize the femur and tibia bones of the knee joint. A recent study set out to determine if the sensation of knee instability that osteoarthritis patients report is actually due to ligament laxity.

35 patients (24 female, 11 male) from age 52-68 years old were examined 1 month before undergoing total knee arthroplasty (total knee replacement). They measured

  •  Knee extensor strength
  • Knee pain (self-reported)
  • Perception of knee instability
    o Slight to none (15 patients)
    o Moderate to severe (20 patients)
  • Knee Ligament laxity in the operating room just prior to total knee replacement

Results showed that poor knee extensor strength and high pain rating were the most associated with perceived moderate to severe knee instability.

Knee ligament laxity was actually not associated with perceived instability.

As a result of these findings we can suggest that increasing knee extensor (quadriceps) strength and reducing knee pain would result in the knee feeling more stable. If you are suffering from knee osteoarthritis that leaves your knee feeling like it is “giving way”, contact us at Physical Therapy First where we can design a program to help you feel more stable and confident during activities.

Perceived Instability Is Associated With Strength and Pain, Not Frontal Knee Laxity, in Patients With Advanced Knee Osteoarthritis .
Journal of Orthopaedic & Sports Physical Therapy, 2019,
Volume:49 Issue:7 Pages:513-517

Increase your running distance without re-injury

by Maureen Ambrose PT, DPT, OCS

Are you a runner looking to increase your miles? Or, are you rehabilitating a running injury and ready to return to running? Is it possible to safely increase running mileage with the least risk for injury? The Journal of Orthopaedic Sports Physical Therapy has published several findings to consider.

Researchers followed over 800 new runners for 1 year, where the runners tracked their weekly mileage and weekly increase in mileage. The runners classified their increase in mileage in one week as less than 10%, 10-30%, and more than 30%. Over the course of the study, 202 runners reported a running-related injury. Analysis of the 2 week period prior to the onset of injury showed that:
– Runners who increased their mileage by 30% or more over 2 weeks had the highest rates of injury
– Runners who increased their mileage by less than 10% over 2 weeks had the lowest rate of injury
– Runners who increased running speed and distance were at higher risk for
o IT band syndrome
o Shin splints
o Trochanteric bursitis
o Patellofemoral pain
o Patellar tendinopathy

An interesting finding was that some runners sustained injuries that were not associated with an increase in running mileage. These include:
– Hip flexor strains
– Achilles tendinopathy
– Plantar fasciitis
– Hamstring and calf strains
– Tibial stress fractures

This may suggest that these injuries which seem to occur unexpectedly are due to other errors in training. Also, symptoms of an injury may not appear until up to 2 weeks after increasing running mileage.

It is recommended to avoid a sudden increase in running mileage by 30% or more. If possible, the safest strategy is to increase mileage by less than 10% over 2 weeks. This enables your tissues to adapt to a small increase in load that is manageable without strain. The therapists at Physical Therapy First can help you recover from any of the above injuries and develop a plan to get you back to running.

J Orthop Sports Phys Ther 2014;44(10):748.

Liars in Research … a quest for the truth in medicine.

by John A. Baur, PT, DPT, OCS, CSCS, FAAOMPT

A record number of retractions are occurring in research due to falsified or fake research.
One lie that many Americans have heard over the years is that resveratrol in red wine is heart healthy. Dipak Das, PhD, a researcher from University of Connecticut Health Center, studied and published articles suggesting that 2 glasses of red wine a night is needed to maintain heart health. In 2012, the University of Connecticut announced that a review board found Dr. Das was guilty of 145 counts of fabrication or falsification of data and at least twenty of his research papers have been retracted.

A parallel study performed at Harvard University found that one would actually need to consume 2000 glasses of red wine a day to ingest enough resveratrol to have a health benefit. Furthermore, scientists at the Johns Hopkins University School of Medicine studied 800 men and women ages 65 and older whose diets were natural high in resveratrol and the study found there was no link between resveratrol levels and the rates of heart disease, cancer, and death (JAMA Internal Medicine).

Another fake and fraudulent article published in 1998 in the Lancet Journal showed an association between Autism and vaccination. This article was eventually retracted, however, currently in some states approximately 4% of children are not vaccinated due to fear of autism.

Vioxx, an anti-inflammatory medication thought to replace the need of people suffering from osteoarthritis from taking large doses of Ibuprofen, is another example of research being falsified. Researchers in the study of Vioxx were well aware of the cardiac challenges associated with taking Vioxx. They decided to selectively remove individuals’ cardiac abnormalities from their data and selectively  hired FDA employees as consultants to prevent negative information from being released to the public.

Duke University’s pharmacokinetics and cancer researcher Anil Potti, MD published that he had found a connection between a person’s genes and a pharmacokinetics cocktail. He built research around his reported findings and received 4 grants (2 of them Federal grants) for his research. However, parallel research conducted at MD Anderson Cancer Center showed that Dr. Potti’s work was all falsified. In 2015 Dr. Potti was found guilty, by U.S. Health and Human Services Department investigators, of engaging in misconduct while researching treatments in human cancer patients. Ultimately Duke University reached a settlement agreement with the federal health agency, patients, and the estates of patients who participated in those medical trials. Dr. Potti was allowed to continue research work, under supervision, until 2020, and Duke University currently has to go through additional steps since being caught for falsifying research on this occasion, and with other researchers.

These research retractions, from falsified and fraudulent studies, are never fully reported to the public or the medical community, and the long-term impact on society is significant.
Most published research findings have little pertinence whatsoever to clinical practice. With over 3 million biomedical publications occurring every year we are now in a race to identify who has a grasp of the best research and who doesn’t.

At Physical Therapy First we work hard as a practice to keep pace with the greatest and latest research, including retracted falsified studies, in order to glide our patients to optimal health and physical therapy outcomes. We also work hard to disseminate the best available medical information to our patients, residents, fellows and students.

Optimal Sleep Position to Prevent Pain and Headaches

by Maureen Ambrose, PT, DPT, OCS, COMT

Optimal Sleep Position

  • What position is best for sleep?
  • What kind of pillow should I be using?
  • I wake up with neck/back/hip pain or headaches.

These are questions and concerns that a physical therapist will discuss with nearly every type of patient. Although most common in spinal patients, sleep can be an issue with shoulder, hip, headache, and post-operative patients due to difficulty finding a position of comfort. When recovering from an injury, sleep is a crucial time of restoration and healing of injured tissues. If a patient is tossing and turning all night or waking up with pain, then they may be placing excessive strain on the affected body region during their sleep.

sleep position side


Most of the following information is related to optimal positioning in the side-lying position, as the majority of people are side sleepers (for at least a portion of the night).

Starting at the neck, it is crucial for side sleepers to have a pillow that is high enough to span the distance between the shoulder and head. This will maintain a neutral cervical spine curve and prevent excessive forward shoulder positioning. Often, for those with broad shoulders, 2 pillows will be necessary or you may use the higher side of a contour pillow (as shown above). The chin should be slightly tucked down to prevent strain at the base of the head.

In the trunk, consider adding a small towel roll or bolster pillow to prop up your waist. The bolster will fit just below the ribs and above the hip bone, creating a neutral lumbar curve. This is especially helpful if you wake with mid or low back pain or have pain when turning in bed.

The above photo also shows a pillow between the knees, which keeps the pelvis from rotating.

Consider this option if you have lateral hip pain that limits how long you can sleep on your side.


Back sleepers make up the next most common position. A very small pillow under the knees can be helpful in those with acute back pain. However, this is not recommended as a long term solution as it can lead to hamstring muscle tightness.

Stomach sleepers make up the smallest percentage, and it is a position to avoid especially in lumbar and cervical spine patients diagnosed with stenosis or spondylolisthesis. A pillow under the trunk from hips to ribs is necessary to achieve a neutral spine. To avoid extreme neck rotation when on your stomach, consider placing your temple region on the end of the pillow and having your face angled towards the bed.

If you struggle with pain while trying to sleep or pain upon waking, discuss your concerns with your physical therapist. At Physical Therapy First, our thorough examination and evaluation allow the therapist to develop a customized treatment plan to improve your quality of life – including when you’re asleep.

Dizziness and Exercise Based Vestibular Rehab

Dizziness and Exercise Based Vestibular Rehab
By Sean Phillips PT, DPT, OCS

Millions of people suffer from dizziness every year, making even the simplest daily tasks difficult to perform. However, the word “dizzy” can accompany many different symptoms that someone can suffer from. Dizziness is a non-specific term used for the sense of imbalance, disorientation, vertigo, or light headedness. As we grow older our risk for encountering dizziness increases, and affects women at a higher rate than men. This is especially true when taking 3 or more forms of daily medication, as it is one of the most common side effects of combining medicine.

Feeling dizzy can lead to an increased risk of falls, heightened anxiety and fear levels, depression, and decreased activity levels. Due to this significant impact on daily activities, it is not surprising to learn that dizziness is one of the leading symptoms that would lead someone to seek care. But what can be done to help treat dizziness, especially if it has been going on for long periods of time?

Vestibular rehab has been attempting to treat patients with these complaints dating back to 1946, and today physical therapy is a leading provider for these services. These techniques have concentrated on identifying the causes of dizziness and correcting or reducing the impairments through specific exercises. In this article, we will briefly discuss several categories of dizziness and types of vestibular rehab that can treat specific disorders.

Categories of Dizziness

• True vertigo is a sense of rotation movement. This can feel like the room is spinning around you, or you are spinning around the room. It would be very similar to the sensation you get from someone suddenly stopping you from spinning in a chair, or a getting off a spinning theme park ride.
• Generally provoked by head movements, such as rolling over in bed or quickly looking upwards.
• BPPV = Benign Paroxysmal Positional Vertigo
• Tends to last less than 1 minute.

• Sense of poor balance or unsteadiness.
• Worse balance in dark rooms or when closing eyes, such as when washing your face in the shower.

• The sensation that someone is about to faint or pass out.
• Typically accompanied by nausea or sweating

• Sensation like rocking on a boat, floating, or rocking

Vestibular Rehab

– VR exercises include eye, head, and body movements that stimulate the vestibular system with a goal of gradually returning a patient to their normal state.
– These exercises include habituation, adaptive strategies, or substitution techniques.
– Habituation exercises uses repetitive movements or provoking stimuli until patients no longer respond adversely to the stimuli.
• For example, if turning head increases dizziness, performing this motion in a controlled environment can gradually resolve the issue.
– Adaptation exercises focus on head movements while keeping eyes focused on a stationary target.
– Substitution exercises utilize the remaining sensory inputs your body has to aid postural control and decrease dizziness.


In a systematic review of over 300 PT research articles, Kundakci et al. was able to conclude that vestibular rehab was beneficial in treating patients with chronic dizziness. These benefits included improvement in vertigo symptoms, fall risk, balance, confidence, and emotional status. However, they determined that it was not possible to identify the most effective vestibular rehab protocol, frequency, or intensity of exercises, attributing these changes to the high variability between patients.

Therefore, if you may be suffering from chronic dizziness then physical therapy and vestibular rehab may be of benefit to you. Since every patient’s symptoms may be slightly different, your physical therapist should be able to create a unique rehab program to return you to where you would like to be.

Kundakci B, Sultana A, Taylor AJ and Alshehri MA. How to cite this article: The effectiveness of exercise based vestibular rehabilitation in 2018, :276 (doi: adult patients with chronic dizziness: A systematic review [version 1; referees: 2 approved] F1000Research 7 )10.12688/f1000research.14089.1