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Physical therapy, lifestyle counseling underused in knee osteoarthritis
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Physical therapy and lifestyle counseling are underused as prescriptions for pain medications, including narcotics, continue to increase for patients with knee osteoarthritis, according to findings published in Arthritis Care & Research.
“In the United States, it is common practice for physicians to manage most patients with knee OA prior to referring them to physical therapists or other exercise and wellness specialists,” Samannaaz S. Khoja, PT, PhD, of the University of Pittsburgh, and colleagues wrote. “Since [physical therapy (PT)] and lifestyle-based approaches are not primarily physician-driven treatments, they may not be recommended as often as pharmacological agents (eg, [NSAIDS] or narcotic analgesics) for controlling symptoms such as pain.”
“It is important to acknowledge that pain medications alone are not sufficient to reverse or mitigate disability caused by OA,” they added. “Additionally, for some patients, PT and lifestyle modifications may be an important complement to or replacement for pain medication.”
To analyze and compare the rates of physical therapy recommendations, lifestyle counseling and pain medication for knee OA, as well as identify factors associated with each treatment, Khoja and colleagues conducted a cross-sectional study of 2007 to 2015 data from the National Ambulatory Medical Care Survey. Conducted annually by the CDC, the survey is a national probability sample of nonfederally employed office-based physicians who are engaged in direct patient care.
The researchers used the survey to identify 2,297 knee OA–related visits to orthopedists and primary care physicians. They analyzed each for physical therapy referrals, lifestyle counseling and prescriptions for NSAIDs or narcotics, and calculated triennial rates for each treatment. In addition, Khoja and colleagues assessed associations between patient, physician and practice factors and treatment using multivariate logistic regression, accounting for complex sampling design.
According to the researchers, recommendation rates from orthopedists for physical therapy and lifestyle counseling declined, from 158 per 1,000 visits to 88 per 1,000 visits, and from 184 per 1,000 visits to 86 per 1,000 visits, respectively. Prescriptions for NSAIDs and narcotics increased, from 132 per 1,000 visits to 278 per 1,000 visits, and from 77 to 1,000 visits to 236 per 1,000 visits, respectively (P < .05). Among primary care physicians, there were no significant changes, except for an increase in the rate of NSAID prescriptions, from 221 per 1,000 visits to 498 per 1,000 visits (P < .05).
“This contrasting trend suggests that knee OA is primarily managed from a perspective of symptom control and not from the perspective of improving physical function, fitness and overall well-being.,” Khoja and colleagues wrote. “Even though PT and lifestyle interventions for knee OA have been included as part of guideline-based care as early as 1995, the utilization of these recommendations as recent as 2013-15 by physicians continues to remain low.”
“If PT and lifestyle interventions were emphasized at a more optimal rate in clinical practice, reliance on pain medications (especially those that are not guideline concordant, i.e., narcotic analgesics) may reduce,” they added. – by Jason Laday
Disclosure: The researchers report a grant from the U.S. Department of Health and Human Services.
Perspective
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David A. McLain, MD, FACP, FACR
This is an interesting study that analyzed data from 2007 to 2015 from the National Ambulatory Care Survey to see what type of treatment was being recommended for osteoarthritis of the knee and the difference between primary care providers and orthopedic recommendations.
Over the study period, researchers found that recommendations for physical therapy and lifestyle modifications decreased and recommendations for medications —such as NSAIDs and opioids — increased. There was a 45% decrease in referrals to physical therapy over the period of the study by orthopedists and a 52% decrease in lifestyle counseling; on the other hand, there was a 110% increase in prescriptions for NSAIDs and a 206% increase in prescriptions for narcotics by orthopedists.
Physical therapy referral rates by PCPs were low and did not significantly change over the study; although lifestyle counseling by PCPs was higher than orthopedists, it also showed no change over the course of the study. However, NSAID prescribing by PCPs increased by 125% during the study while narcotic prescribing increased by 36%.
The researchers point out that there is low adherence to treatment guidelines for knee OA by both orthopedists and PCPs with no trend towards improvement over time. It is suggested that in-office knee OA management has been directed at symptom control rather than at improving fitness and physical function, challenging us to do better in this area.
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