90 minutes’ CPD: Learning by Oneself

OA Knee Rehabilitation with Dr Claire Minshull

Supporting Material

Here are Claire’s website and her current courses on offer. www.getbacktosport.com/ipt If you contact her and advise you are an APM member you may be given a discount on the course.

Further Q&A's from the broadcast

What is muscle adaptation in rehab?

A conditioning response elicited by the rehabilitation – for example an increase in muscle strength, power etc.

Would you agree that for a condition that is mulitfactoral, with factors interacting unpredicatbly, RCT isn’t always the best paradigm?

RCTs are the best way of scientifically evaluating an intervention / treatment, especially if double-blinded. Without evidence it’s just guess work and anecdotes

Have you noticed a correlation between OA knee sufferers who also have a history of back pain?

In my personal practice, sometimes, which is usually due to altered gait and walking/running mechanics

As practitioners we are all dealing with significant number of patients who are simply fobbed off by their GP with drugs. Do you think there is a way to tackle what seems to be a medicate-and-leave-alone policy by GP’s?

Yes, but it requires a hell of a lot of work, forward thinking and persuasion to change from all parties involved. I’m working on it – but the NHS is such a vast organisation it’s tremendously difficult (needlessly I might say)

Is there an age limit or minimum physical requirement for knee rehab to be appropriate?


According to a study published in the journal ‘Osteoarthritis & Cartilage’, mechanical distortion is detected by the living cells in cartilage which then blocks the action of inflammatory molecules associated with arthritis. The research shows that this anti- inflammatory effect is caused by the activation of a particular protein, called HDAC6, which triggers changes in the proteins that form primary cilia in cells.Changes in the length of the primary cilia, provide a biomarker of the level of inflammation. This study suggests that exercise that loads the joints causing the cartilage to be ‘squashed’, is the most beneficial in suppressing inflammatory cells. Would you agree with this?

This is one of the studies that I was referring to in the broadcast. We’re just starting to discover at the cellular level the effects of impact exercise

Its good to hear you guys chat about the benefits of exercise and also intensity… A previous MRI scan showed I have moderate/severe OA in the knee (and ankle) due to a head-on impact injury several years ago. Although I am sometimes aware of discomfort if i over do it.. I generally have very little pain. I squat, run, cycle and still play squash at a reasonable level, along with the occasional small triathlon. I have been a firm believer that keeping joints flexible and strong have a huge impact on maintaining and improving joint function. I do wonder if some joints rehab programmes are not intense enough or focus too much on stretching or quad strength.. thus missing hamstrings, glutes, proprioception, balance ect. Are we too soft or overcautious with rehab?

Agreed, there’s an inherent fear of ‘overloading’ patients, in case it does ‘damage’. Within the appropriate clinical boundaries (if any) we should encourage a more progressive loading approach!

Can I ask about knee OA and running?

Patients often ask, and I’ve read studies saying it’s

a) protective if your knees are healthy b) improves OA knees

but many are told by their orthopods to give up running to “save their knees”. What’s the latest thinking?

Yes – currently no evidence that show a causal relationship between running and OA. In the very elite, whose training and competition volume is super high (not your average club runner ), there’s the suggestion of a greater incidence of early OA, but again, that’s not a causal relationship. Do what makes you happy I say smile

I have always worked on optimal range of movement, before proprioception, strength and functional training….would you have a standard RoM recommendation to achieve before strength & functional training?

What’s optimal? No- strength (and balance) training at any range can be beneficial.

What does Claire feel about the use of corporeal radial shockwave as we are having great results for tendons and massively with swollen bursars on the elbow and knee.

Well done! Evidence is emerging.

What is Claire’s opinion of Pilates – obviously very different from heavy weights and low reps!

Answer is in the question here – it’s very different and will bring about changes in stability / endurance / posture (which may be needed), but any strengthening stimulus will be lost within the first couple of weeks. There’s a need to load up to develop strength.

Are there any disadvantages of using the gym? ie the argument about it not being functional exercise…

I think ‘functional exercise’ is over-hyped and potentially faddish if taken to the extreme. What’s not functional about having stronger quadriceps when needing to stand up, for example? Functional exercise could be used once the person has sufficiently built muscle strength, or as proprioception-type exercise.

Ref the nutrition.. the nightshade group of food is thought to be inflammatory if you eat too much… peppers, potatoes, tomatoes etc, and of course too much sugar.

I often advise to be cautious if a patient eats quite a bit of these types of food, and suggest more omega 3 (anti-inflammatory) How much it really works is unclear, but it does give the patient some focus on diet too. I’m afraid I’m yet to see any empirical evidence that this influences pain/symptoms of OA etc. If it helps with a conversation around diet then that’s good, of course.