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Monica Maly


I am so very privileged to work with McMaster physiotherapy students in their first term. I thoroughly enjoy their unique perspectives, youthful energy, and most of all, their enthusiasm for the amazing profession they have chosen. However, I also bear witness to – and share in – their frustration when they discover that the evidence supporting physiotherapy practice is often thin. 

We are getting there, though…. The Optimal Aging Portal is helping us compile what we know for clinicians and patients alike.  (More on that in a bit.)

The Big Idea

My research team and I are working hard to shed some light on the best practices of exercise and osteoarthritis (OA). There is excellent evidence that exercise produces meaningful improvements in the lives of Canadians with OA. For example, a 2015 Cochrane Review of high quality evidence from over 50 randomized controlled trials related to exercise for knee OA emphasizes that land-based exercise programs improve pain, physical function, and quality of life. These benefits of exercise are equivalent in size to the benefits provided by pain medication! BAM! Any type of exercise works (individual physiotherapy, supervised classes, home program), so long as it is performed regularly, and monitored.

My Take on Things…

Our strength as physiotherapists is tailoring exercise to fit the person and the health condition(s) they are facing. For the person with knee OA, cornerstones of exercise are:

  • Functional, weight-bearing exercise that focuses on strengthening the quads++
  • Flexibility exercise that increases range of motion (hips, hips, hips, and ankles) to ensure the best possible lower limb alignment
  • Aerobic training to combat the number one risk factor for knee OA: obesity

Combine all of these, while respecting the damaged joint.

Here is where my research team aims to contribute. We are investigating how to strengthen the quads and improve flexibility, while protecting a damaged joint. Overloading a damaged OA joint has its costs.  Just like our highways in Canadian winter, the cartilage, bone, ligament and menisci in the knee can only withstand so much. Once OA settles into its destructive path, we can expect the potholes to deepen and multiply, even with normal traffic. (Forgive the analogy – yesterday a pothole ate my Mini Cooper :O ). Our exercise prescriptions must ensure adequate control over the magnitude and repetition of loads. Some basic science studies suggest that the best exercises for knee OA are low velocity, barefoot, with proper alignment of the lower limb (yoga or Tai Chi anyone?). You know better than most that this is a balancing act. It’s important to engage the patient to pick activities that they enjoy – so that they stick with them. However, we can nudge them toward exercises that will build strength in the muscles, without overloading their joints.

While we have come a long way, we still have hurdles. We lack information to provide proper dosing. We do not yet understand how the tissues inside an OA joint respond to exercise. To tackle these problems, we are using some innovative techniques.

Check out my knee in technicolour! This magnetic resonance imaging scan uses a pretty new approach called “T2 relaxation time.”  T2 measures water content allowing us to identify swollen tissues (in blue). We do not expect, nor want, the menisci and cartilage in the knee to be swollen – too much fluid means a limited ability to withstand large or repetitive forces. Instead, the meniscus (red “bow-tie” between the femur and tibia) and cartilage should be red, showing that water, and therefore OA, has not yet settled in. This scan shows that, for me, so far so good…. We are using T2 to explore how exercise (various types, durations, intensities) affects knees with and without OA. Stay tuned, the next few years are sure to be colourful! In the meantime, there is more than exercise that we can offer our patients. We can help them become information literate.

Education and Information Literacy

Exercise and all of its “side effects” (mobility, heart health, mood, weight control) need to be front-line treatment for the hundreds of thousands of Canadians who live with OA. To convince more people to try physiotherapy, education and information literacy are key. Baby boomers are information-gatherers and critical thinkers. But how on Earth is Dr. Oz still on TV? The media pick up and highlight health stories based on drama, rather than substance. As for therapists, the volume of research published increases daily, making it challenging to find and interpret quality evidence.

The Optimal Aging Portal addresses these issues. (You caught me, this is a McMaster initiative!) It’s well-worth checking out:  it’s free and it provides evidence-based information to support healthy aging. It provides summaries of research evidence (with different versions for citizensand therapists), ratings of web resources that patients may access, and commentaries on the latest research.

To convince more people to try physiotherapy, education and information literacy are key.

Take a look at the Portal resources related to OA. Under “Professional” and “Clinician” (drop-down menu bar), a search of “osteoarthritis” will enable you to access the abstracts (or full-text) of over 500 original research articles about OA, and nearly 200 reviews. To refine your search further, you can pick categories, disciplines, or article types just below the search bar. The quality rating gives some insight about whether the information is useful for making health decisions. That 2015 Cochrane review of exercise in knee OA is there – along with several other studies, reviews, and meta-analyses.

One of the most valuable parts of the Portal is the Citizen section. Here, patients can find summaries of research studies – giving them the information that they want and need without annoying jargon. Reviews of websites posting information about OA can guide patients to finding legitimate information. Blog posts can engage patients in making their own health decisions, with information from a reputable source.

We are building strong evidence to treat diseases like OA. We can access and share high quality evidence of these treatments with our patients. It is an exciting time for physiotherapy! It brings me back to the perspectives, energy, and enthusiasm that physios bring to their patients every day.


There’s a lot of information out there that our patients can access online, some good and some not so good. Which resources do you recommend to patients in your practice area to make sure they’re becoming information literate?

Chime in using the comments box below, or via the CPA Facebook page or on Twitter (hashtag #30Reps).

About Monica Mali and Anthony Gatti

Monica Maly is an Associate Professor and CIHR New Investigator at McMaster. Her research focuses on developing physical activity guidelines for knee OA. She loved that Mini.




Anthony Gatti is a Master’s student at McMaster and a triathlete. He is using T2 mapping to discover the responses of knee cartilage to different exercises. True to his last name, Tony’s greatest love is cats.




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