Introduction
Osteoarthritis (OA) of the knee is a leading cause of disability in the United States. Treatment typically involves symptom management until late stages warrant a knee replacement surgery. Intraarticular glucocorticoid injections are commonly used as a primary treatment for OA but there are conflicting reports on the duration of symptom-relief. Physical therapy (PT) is also a standard treatment, however, referrals for treatment of knee OA have declined between 2007 and 2015, despite guideline recommendations. In the U.S. Military Health System, patients who were initially diagnosed with knee OA were more likely to be referred for glucocorticoid injection than for physical therapy (51% vs. 29%), and only 13% received both. The authors in the article, Physical Therapy versus Glucocorticoid Injection for Osteoarthritis of the Knee, performed a randomized control trial comparing the long-term functional outcomes of patients who receive either physical therapy or a glucocorticoid injection for the treatment of knee OA.
Methods
Patients were either beneficiaries of the Military Healthy System (active-duty or retired service members) or their family members. Patients were eligible for the study if they were clinically diagnosed with OA and radiographs showed Grade I-IV arthritis of the knee joint. Patients were randomly assigned to either the PT group or the glucocorticoid injection group.
The injection group received one ml of triamcinolone acetonide and seven ml of 1% lidocaine and could receive up to three total injections in the 1-year trial period, as needed. This group had re-assessments performed at 4-months and 9-months. Patients in the PT group underwent eight sessions of PT over the initial 4-6-week period which included patient education, a written home exercise program, manual therapy, stretching and exercise. PT group patients could also attend an additional 1-3 sessions at the 4-month and 9-month reassessments as needed. All five treating therapists were board certified in orthopedic PT and fellowship-trained in orthopedic manual therapy.
The researchers assessed outcome measures at baseline and at one-year post-intervention physical function using the WOMAC and GROC questionnaires, and two functional tests which included the Timed Up and Go test and the Alternate Step Test.
Results
A total of 156 patients were recruited for the study; 78 patients in each treatment group. The mean treatment-related costs for all knee-related medical care during the one-year trial period was similar in the two groups ($2,113 in the glucocorticoid injection group and $2,131 in the physical therapy group). The mean (±SD) WOMAC scores at 1 year were 55.8±53.8 in the glucocorticoid injection group and 37.0±30.7 in the PT group. At one year, the median score on the Global Rating of Change scale was +5 (“quite a bit better”) in the physical therapy group and +4 (“moderately better”) in the glucocorticoid injection group. Patients in the PT group performed better (lower mean times) on both functional tests than patients in the glucocorticoid injection group.
Conclusion
In conclusion, physical therapy for OA of the knee resulted in better absolute scores on the WOMAC and GROC scales and the Timed Up and Go and Alternate Step functional tests than glucocorticoid injection at one year.
Physical Therapy First Implications
The therapists at Physical Therapy First are board-certified orthopedic clinical specialists and are residency or fellowship-trained in manual therapy. If you are having knee pain and/or have been diagnosed with knee OA, PT treatment may improve your pain and long-term function.
Reference:
Deyle, G., Allen, C., Allison, S., Gill, N., Hando, B., Petersen, E…Rhon, D (2020). Physical Therapy versus Glucocorticoid Injection for Osteoarthritis of the Knee. The New England Journal of Medicine. 382,15, pages 1420-1429.