Physical therapy superior to glucocorticoid injection for OA pain, functional disability
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Patients with knee osteoarthritis who participated in physical therapy demonstrated less pain and functional disability at 1 year compared with those who received glucocorticoid injection, according to data published in The New England Journal of Medicine.
“While osteoarthritis of the knee is primarily a chronic disorder associated with aching and stiffness, it can clinically present with acute episodes leading patients to visit primary care and emergency department physicians for timely relief,” Gail D. Deyle, DSc, of the Brooke Army Medical Center, in San Antonio, Texas, told Healio Rheumatology. “Providers commonly use glucocorticoid injections to help patients through this acute phase — this is an important point to guide patients to a physical therapist.”
“These injections may provide short-term relief, but they also increase the risk of infection and accelerated aging of the joint, including fractures of the joint surfaces,” Deyle added. “If the patient is also sent to see an orthopedic surgeon, they may receive an MRI and perhaps be told that they are ‘bone on bone,’ leading patients to believe that there is little hope with treatment options other than more injections and eventual total knee replacement.”
Unfortunately, Deyle noted that only 10% of patients with knee OA go on to receive treatment from a physical therapist. “Physical therapy is simply not offered as often as glucocorticoid injections despite study findings over the past 20 years that physical therapy treatment strategies reduce pain, improve function, reduce medication use including opioids, and reduce the incidence of surgery for patients with knee osteoarthritis,” he said.
To compare the short- and long-term effectiveness of physical therapy and intraarticular glucocorticoid injections, Deyle and colleagues conducted a randomized trial among patients with knee OA who presented at one of two large military hospitals from October 2012 through May 2017. Investigators assigned 156 participants aged 38 years or older to receive either glucocorticoid injection or physical therapy, with 78 in each group. Baseline characteristics, including severity of pain and level of disability, were similar between the groups.
The physical therapy intervention included instructions and images for exercises and joint movements, as well as the clinical reasoning for the priorities, dosing and progression of treatment. In a typical session, a physical therapist would use hands-on, manual techniques immediately before the patient performed them, to limit pain.
“Patients typically left the initial physical therapy treatment session feeling less pain and stiffness in their knee, while injection patients needed several days of rest and strategies for pain control from the injection,” Deyle noted.
The primary outcome was the total score on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at 1 year. Secondary outcomes included the time needed to complete the Alternate Step Test, the time needed to complete the Timed Up and Go test, and Global Rating of Change scale at 1 year.
The researchers reported the mean baseline WOMAC scores were 108.8±47.1 in the glucocorticoid group and 107.1±42.4 in the physical therapy group. After 1 year of treatment, the mean scores were 55.8±53.8 in the glucocorticoid group and 37±30.7 in the physical therapy group (mean between-group difference = 18.8; 95% CI, 5-32.6). Changes in secondary outcomes were similar. One patient fainted while receiving a glucocorticoid injection.
“When physical therapy offers better outcomes with less risk, it is comparable to an investment strategy that provides higher return with less risk,” Deyle said. “The question becomes ‘why not’ rather than ‘why.’ The results of this study should guide providers to offer the option of physical therapy to their patients with knee osteoarthritis until more invasive procedures like knee replacement surgery are required.” – by Jason Laday
Disclosures: The researchers report no relevant financial disclosures.
Perspective
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David A. McLain, MD, FACP, FACR
Osteoarthritis of the knee is a common condition that is seen frequently by rheumatologists, orthopedists and PCPs in the office. The standard of care is for symptomatic treatment until late stage disease when a total knee replacement is recommended. Practice guidelines have recommended intra-articular glucocorticoid injections as an accepted form of treatment.
In this study, Deyle and colleagues compared intra-articular glucocorticoid with physical therapy for management of OA of the knee, with patients randomized 1:1 to receive either injection or physical therapy, yet no placebo group for either intervention. The average age of participants was fairly young at 56 years; this was a military study and, most likely, older veterans are being cared for in the VA system and not at a military base.
According to the authors, the physical therapy group demonstrated superior results over the injection group. Over the one year of the study, the WOMAC score difference between groups widened as the physical therapy group continued to lower and the injection group leveled off after an initial drop at 4 weeks. There was no placebo control for hands-on care that was not physical therapy or injection.
The authors also noted that the physical therapy group had more visits with a health care provider than the injection group; we know that rapport with a patient and personal interest in a patient’s care will often improve results. Additionally, there was a crossover between the groups with some patients in the physical therapy group patients receiving glucocorticoid injections and some patients in the injection group receiving physical therapy.
Although there was no comparison of cost between the groups or the time required for the two interventions, this was, however, a clear “win” for physical therapy over intra-articular glucocorticoid injections in knee OA. It would be interesting to compare the two interventions with a third group receiving both interventions, as well as compare extended-release triamcinolone to physical therapy.
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