Journal of Bodywork & Movement Therapies: Søren T. Skou, Jonas B. Thorlund
Journal of Bodywork & Movement Therapies: Søren T. Skou, Jonas B. Thorlund
Journal of Bodywork & Movement Therapies: Søren T. Skou, Jonas B. Thorlund
a b s t r a c t
Keywords: Objective: To describe the development and feasibility of an exercise therapy program for treatment of
Menisci young adults (18e40 years of age) with a meniscal tear.
Tibial
Methods: Researchers and experienced physical therapists developed a 12-week supervised neuro-
Knee injuries
Exercise therapy
muscular and strengthening exercise therapy program based on clinical expertise and available evidence.
Six patients (age range 22e39 years) considered eligible for meniscal surgery by an orthopedic surgeon
underwent the program. Patients completed the Knee Injury and Osteoarthritis Outcome Score (KOOS)
and evaluated the program during a semi-structured qualitative interview. Feedback from patients was
included to finalize the exercise therapy program.
Results: Median improvements (Range) in KOOS subscales were 15 (0e33) for Pain, 11 (11 to 50) for
Symptoms, 16 (3e37) for Function in daily living, 23 (10e45) for Function in sport and recreation, and 9
(6 to 31) for Quality of life. The patients found the program relevant and effective with only a few short-
lasting adverse events and important clinical improvements after four to ten weeks. Physical therapist
supervision was considered important. No patients wanted surgery up to 6 month after the exercise
therapy program.
Conclusion: A neuromuscular and strengthening exercise therapy program was feasible and showed
important improvement in a small group of young adults with meniscal tears.
© 2017 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jbmt.2017.07.010
1360-8592/© 2017 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Skou, S.T., Thorlund, J.B., A 12-week supervised exercise therapy program for young adults with a meniscal
tear: Program development and feasibility study, Journal of Bodywork & Movement Therapies (2017), http://dx.doi.org/10.1016/
j.jbmt.2017.07.010
2 S.T. Skou, J.B. Thorlund / Journal of Bodywork & Movement Therapies xxx (2017) 1e6
Please cite this article in press as: Skou, S.T., Thorlund, J.B., A 12-week supervised exercise therapy program for young adults with a meniscal
tear: Program development and feasibility study, Journal of Bodywork & Movement Therapies (2017), http://dx.doi.org/10.1016/
j.jbmt.2017.07.010
S.T. Skou, J.B. Thorlund / Journal of Bodywork & Movement Therapies xxx (2017) 1e6 3
having treatment?” with six response options ranging from “less 2.6. Statistical analysis
than 2 weeks” to “more than 24 months”, “How did the knee pain/
problems for which you are now having treatment develop?” with Due to the small sample size of this feasibility study, the change
three response options “The pain/problems have slowly developed in mechanical symptoms and KOOS subscale scores was analyzed
over time”, “As a result of a less severe incident (i.e. kneeling, using non-parametric statistics. As the distribution of differences
sliding, and/or twisting of the knee or the like)”, and “As a result of a between baseline and 3 months scores was not symmetrical for any
severe incident (i.e. during sports, a crash, or a collision or the like)”. of the variables paired-samples sign test was used to assess for
change in the outcome.
2.4.2. Mechanical symptoms The significance level was set at p < 0.05 and all analyses were
At baseline and follow-up, the patients reported the presence carried out in IBM SPSS Statistics 24 (IBM, Armonk, NY, USA).
and frequency of mechanical knee symptoms (i.e. the sensation of
catching and locking): “How often have you experienced catching 3. Results
or locking of the knee that is about to undergo treatment?” with
five response options ranging from “never” to “daily”. 3.1. Outcomes
2.4.3. Knee injury and osteoarthritis outcome score (KOOS) Baseline characteristics and the number of exercise sessions that
At baseline and follow-up, patients completed the Knee injury the patients participated in are presented in Table 1.
and Osteoarthritis Outcome Score (KOOS) with scores ranging from
0 (worst) to 100 (best) for each subscale. KOOS contains the sub- 3.1.1. Mechanical symptoms
scales Pain, Symptoms, Function in daily living (ADL), Function in At baseline, three patients (50%, patient 1e3) reported having
sport and recreation (Sport/Rec) and Quality of life (QOL) (Roos mechanical symptoms (i.e. the sensation of catching or locking of
et al., 1998). KOOS is a valid, reliable and responsive patient- the knee), while only one (17%, patient 5) had self-reported me-
reported outcome measure in young and old adults with knee in- chanical symptoms at the 3 months follow-up (Table 2).
juries and/or OA (Collins et al., 2016).
3.1.2. Knee injury and osteoarthritis outcome score (KOOS)
Significant improvements from baseline to 3 months were
2.4.4. Knee-related adverse events
found for the KOOS subscales ADL (21% improvement) and Sport/
After the 12-week program, the patients were emailed and
Rec (43% improvement) (Table 2 and Fig. 1).
asked about worsening of symptoms or new symptoms during the
12-week exercise program. If they reported worsening or new
3.1.3. Knee-related adverse events
symptoms, they were asked to state which symptom and whether
During the exercise therapy program, patient 2 started running
it occurred during a specific exercise.
and playing soccer. At one point he had to reduce the number of
repetitions and weight applied in the individual exercises for a
2.4.5. Number of exercise sessions couple of sessions and to take a short break from running and
After the 12-week program, the patients were emailed and soccer. Before starting the exercise program, patient 3 performed
asked how many of the 24 exercise therapy sessions they partici- the exercises to improve range of motion at home as instructed by
pated in. the physical therapists. During the exercise to improve knee flexion
he felt that his knee locked, which resulted in that he had to
2.4.6. Surgery of the knee perform the exercise with caution in the following weeks. Patient 4
Six months after the last patient was enrolled in the feasibility had joint line pain during knee flexion in the exercise machine, but
study an email was sent to all patients asking them to report the pain decreased after reducing the resistance and number of
whether they had undergone surgery of their knee or if they were repetitions for a couple of exercise sessions. Patient 6 experienced
on a waiting list for knee surgery. soreness in his knee after playing beach volley after approx. eight
weeks in the exercise therapy program. The symptoms decreased
2.5. Patient interviews after one week.
Due to the short-lasting nature, neither of the adverse events
The semi-structured interviews with patients were conducted was considered severe enough to require medical attention.
online at the end of the 12-week exercise program using Adobe
Connect (Adobe Systems, San Jose, CA, USA) including both video 3.1.4. Surgery of the knee
and audio of the patient and interviewer. Six months after the last patient was enrolled none of the pa-
Each interview lasted between 30 and 60 min and was con- tients had undergone surgery in the study knee or were on waiting
ducted by the first author. An interview topic guide with open- list for knee surgery.
ended questions was developed in collaboration with experi-
enced qualitative researchers. Examples of questions were: ”Tell me 3.2. Semi-structured interviews
about your knee problem?” You have now exercised for 12 weeks, can
you please tell me what you have experienced?” “How were the 3.2.1. The exercise therapy program
physical therapists?” ”What did the physical therapist tell you about 12 weeks of exercise therapy two times a week were considered
your knee problem?” Themes that the patient brought up during the appropriate by most of the patients. One of the patients felt that
interview were followed by probing questions and, if needed, the three sessions per week would have been too much, while another
interviewer made the open-ended question more focused, e.g. patient stated that he would like to have had a couple of weeks
“How did the exercise affect your symptoms?” and “How was the level more with supervised exercise. The duration of the individual
of difficulty of the exercises?” Finally, they were asked whether they sessions were between one and two hours with most patients
would like to undergo surgery now, after participating in the ex- exercising for one to one and a half hour per session. One patient
ercise therapy program. All interviews were conducted in Danish felt that the first couple of exercise sessions were a bit too long.
and recorded in Adobe Connect. Some of the patients expressed that the timing of the individual
Please cite this article in press as: Skou, S.T., Thorlund, J.B., A 12-week supervised exercise therapy program for young adults with a meniscal
tear: Program development and feasibility study, Journal of Bodywork & Movement Therapies (2017), http://dx.doi.org/10.1016/
j.jbmt.2017.07.010
4 S.T. Skou, J.B. Thorlund / Journal of Bodywork & Movement Therapies xxx (2017) 1e6
Table 1
Baseline characteristics and treatment compliance of the patients (n ¼ 6)a.
Table 2
Improvements in outcomes from baseline to 3 months (n ¼ 6)a.
Fig. 1. Change in Knee injury and Osteoarthritis Outcome Score (KOOS) from baseline to three months for each of the six patients. KOOS has five subscales all with scores
ranging from 0 (worst) to 100 (best): Pain (A), Symptoms (B) Function in daily living (C; ADL), Function in sport and recreation (D; Sport/Rec) and Quality of life (E; QOL).
exercise sessions in relation to their daily life was important to effective by the patients. Some patients highlighted the neuro-
ensure that they were able to participate. muscular exercises, especially the sideways slide exercise, as
The individual exercises were considered feasible, relevant and particularly effective for their knee problem. One patient had joint
Please cite this article in press as: Skou, S.T., Thorlund, J.B., A 12-week supervised exercise therapy program for young adults with a meniscal
tear: Program development and feasibility study, Journal of Bodywork & Movement Therapies (2017), http://dx.doi.org/10.1016/
j.jbmt.2017.07.010
S.T. Skou, J.B. Thorlund / Journal of Bodywork & Movement Therapies xxx (2017) 1e6 5
line pain during knee flexion in the exercise machine, but was able function in sport and recreation were all larger than the clinically
to decrease the pain by reducing the resistance and number of relevant differences found in an RCT comparing surgery and exer-
repetitions for a couple of exercise sessions. cise therapy for patients with degenerative meniscal tears, while
As the program was considered feasible, relevant and effective the improvement in quality of life was not (Kise et al., 2016). In the
by the patients, no changes were made to the program tested in the present study, patients had a median improvement of 23 points
feasibility study. (mean improvement of 27 points) in KOOS Sport/Rec and 16 points
(mean improvement of 18 points) in KOOS ADL at 3 months while
3.2.2. The physical therapists the mean improvement in the same subscales was approx. 20 and
The patients described, that the physical therapists were sup- 10 points at 3 months in the exercise therapy group and 17 and 9
portive and ensured that the exercise therapy program was pro- points in the arthroscopic partial meniscectomy (APM) of the trial
and regressed to adapt to individual patient symptoms and were in degenerative meniscal tears (Kise et al., 2016). This suggests that
available for questions and feedback when needed. It was impor- exercise therapy is a viable treatment option also for younger in-
tant for patients, that the physical therapists gave a thorough dividuals with a meniscal tear, as the median age of our study was
introduction and instruction on how to perform the exercises. 23. The described exercise therapy program only requires equip-
Furthermore, the supervision was found important to ensure that ment that is available in most physical therapy clinics. Furthermore,
physical therapists were available to adjust the exercises if per- a relatively short training period is needed for physical therapists.
formed incorrectly. This suggests that implementation of the program in a clinical
setting is realistic, if the program proves to be effective in larger
3.2.3. Symptom flares and improvements in symptoms clinical trials.
In the first two to four weeks, some of the patients experienced Three patients had mechanical symptoms at baseline before
minor symptom flares during and after exercise and physical ac- starting the exercise therapy program. Only one patient reported
tivity, which decreased and disappeared as the exercise therapy mechanical symptoms at the 12-week follow-up after finishing the
program progressed. Improvements in symptoms were gradual, but program and with a low frequency of symptoms (i.e. monthly).
important improvements were experienced after four weeks in Presence of mechanical symptoms (i.e. the sensation of catching an
some patients and eight to ten weeks in others. All patients stated locking) is typically considered an important indication for
that they did not want to undergo surgery of their knee after fin- meniscal surgery (Mezhov et al., 2014). However, a recent sec-
ishing the exercise therapy program. ondary analysis from a RCT comparing APM to sham surgery in
patients aged 35e65 years with degenerative meniscal tears did
3.2.4. Exercising with others not find a larger effect of APM for improving mechanical symptoms
Some of the patients experienced that there were too many than sham surgery (Sihvonen et al., 2016). Based on before-and-
patients at some of the exercise sessions (10e15), which reduced after studies, APM in non-degenerative meniscal tears seems
the ability of the physical therapist to give feedback and supervise more effective in relieving mechanical symptoms than APM in
the individual patient and waiting time for some of the individual degenerative tears (Sihvonen et al., 2016). Therefore, future high-
exercises. However, exercising with others was considered benefi- quality comparisons of the effect of exercise therapy to that of
cial by some of the patients as it gave the possibility to interact with meniscal surgery for patients with a non-degenerative meniscal
other people with similar knee problems and get help with tear with or without mechanical symptoms are warranted to sup-
improving the performance of specific exercises. port clinical decision-making.
Albeit the qualitative interviews did not result in any specific
4. Discussion changes to the exercise therapy program, they contributed with
important information about the patients’ perspective on the
This study provided a detailed description of a 12-week exercise program and the feasibility of exercise in this population in gen-
therapy program designed for young adults with a meniscal tear. eral. Firstly, individual exercises were found feasible, relevant and
The program was found to be feasible in patients eligible for effective. Secondly, the supervision from physical therapists was
meniscal surgery with important improvements in symptoms. considered important. From RCTs of exercise therapy as treatment
Neither of the patients wanted surgery after completing the pro- for patients with knee osteoarthritis it has been shown that su-
gram and there were only a few short-lasting knee-related adverse pervised exercise sessions improves the efficacy of exercise ther-
events. apy (Juhl et al., 2014). It is unknown whether this is also true for
The median baseline KOOS Sport/Rec (53 points, mean: 53 young adults with a meniscal tear, but our study provides quali-
points) and KOOS Pain (68 points, mean: 70 points) scores from our tative support that patients consider ongoing supervision impor-
study are relatively similar to the mean scores in patients of 36e60 tant to help adapt and adjust exercises during the program.
years of age with a degenerative meniscal tear randomized to Furthermore, the interviews highlighted that symptom flares are
surgery or exercise therapy (44e48 and 63e68 points, respectively) frequent, but decrease during the first four weeks, and that pa-
(Kise et al., 2016). However, it is considerable better than baseline tients can expect gradual improvement over time with clinically
values of patients with anterior cruciate ligament injury random- relevant improvements after two to three months. These findings
ized to surgery or exercise therapy (14e15 and 57 points, respec- are similar to recent data from adults aged 35 years or older with
tively) (Frobell et al., 2010). This is consistent with the general knee or hip pain demonstrating pain flares to decrease with
perception that an anterior cruciate ligament injury has larger increasing number of exercise therapy sessions performed (Sandal
patient impact than meniscal injury. et al., 2016). This is important information for young adults with a
The median improvement for the five subscales of KOOS ranged meniscal tear that consult their physician or physical therapist.
from 9 to 23 points (mean improvements of 12e27 points) with the Patients should not abandon exercise therapy until after two to
largest effect for the subscale Sport/Rec with questions on running, three months of supervised exercise even though they have pain
jumping and twisting of the injured knee etc. and the smallest ef- flares in the beginning.
fect for the subscale QOL with questions on awareness of knee The study has some limitations. First of all, this study was a
problem, modification of activities and lack of knee confidence etc. feasibility study with a small sample size and the uncontrolled
The improvements in pain, symptoms, function in daily living and design precludes any conclusions on the effect from the exercise
Please cite this article in press as: Skou, S.T., Thorlund, J.B., A 12-week supervised exercise therapy program for young adults with a meniscal
tear: Program development and feasibility study, Journal of Bodywork & Movement Therapies (2017), http://dx.doi.org/10.1016/
j.jbmt.2017.07.010
6 S.T. Skou, J.B. Thorlund / Journal of Bodywork & Movement Therapies xxx (2017) 1e6
therapy program on self-reported outcomes. Secondly, only men the exercise therapy program.
were included in the feasibility study. Men and women might
respond differently to a specific treatment, and as such it is
important to include both men and women when assessing the Appendix A. Supplementary data
effectiveness of exercise. Lastly, information on number of exercise
sessions attended were collected through self-report and not by Supplementary data related to this article can be found at http://
the physical therapist potentially affecting the validity of this dx.doi.org/10.1016/j.jbmt.2017.07.010.
measure. However to the authors’ knowledge, this is the first
study thoroughly describing the development and application of a
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Acknowledgements Sihvonen, R., Englund, M., Turkiewicz, A., Jarvinen, T.L., 2016. Mechanical symptoms
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therapists Trine Brix, Annemette Bech and Elisa Gottschalck Stor- Jordan, K.P., 2015. Current evidence on risk factors for knee osteoarthritis in
mark from Arkadens Fysioterapi in Aalborg for helping with older adults: a systematic review and meta-analysis. Osteoarthr. Cartil. 23,
development and feasibility testing of the exercise therapy pro- 507e515.
Skou, S.T., Rasmussen, S., Laursen, M.B., Rathleff, M.S., Arendt-Nielsen, L.,
gram and senior surgeon Hans Peter Jensen from the Department Simonsen, O., Roos, E.M., 2015a. The efficacy of 12 weeks non-surgical treat-
of Orthopedic Surgery, Aalborg University Hospital for helping ment for patients not eligible for total knee replacement: a randomized
with inclusion of patients. Furthermore, the funders and the pa- controlled trial with 1-year follow-up. Osteoarthr. Cartil. 23, 1465e1475.
Skou, S.T., Roos, E.M., Laursen, M.B., Rathleff, M.S., Arendt-Nielsen, L., Simonsen, O.,
tients involved in the study should be acknowledged for partici- Rasmussen, S., 2015b. A randomized, controlled trial of total knee replacement.
pating and contributing to the development of the exercise N. Engl. J. Med. 373, 1597e1606.
therapy program. Photographers Lene Pedersen and Lasse Høj Slade, S.C., Dionne, C.E., Underwood, M., Buchbinder, R., 2016. Consensus on exer-
cise reporting template (CERT): explanation and elaboration statement. Br. J.
Nielsen should be acknowledged for taking the photos and layout
Sports Med. 50, 1428e1337.
of the exercise program. Finally, the authors would like to thank Thorlund, J.B., Damgaard, J., Roos, E.M., Aagaard, P., 2012. Neuromuscular function
professor Erik Elgaard Sørensen and research assistant Kathrine during a forward lunge in meniscectomized patients. Med. Sci. Sports Exerc 44,
Hoffmann Kusk from Aalborg University Hospital for helping with 1358e1365.
Thorlund, J.B., Juhl, C.B., Roos, E.M., Lohmander, L.S., 2015. Arthroscopic surgery for
the development of the interview guide and professor Ewa M. degenerative knee: systematic review and meta-analysis of benefits and harms.
Roos from University of Southern Denmark for providing input on BMJ 350, h2747.
Please cite this article in press as: Skou, S.T., Thorlund, J.B., A 12-week supervised exercise therapy program for young adults with a meniscal
tear: Program development and feasibility study, Journal of Bodywork & Movement Therapies (2017), http://dx.doi.org/10.1016/
j.jbmt.2017.07.010