A New England Journal of Medicine (NEJM) study showing that physical therapy is just as effective as surgery in patients with meniscal tears and arthritis of the knee should encourage many health care providers to reconsider their practices in the management of this common injury, according to the American Physical Therapy Association (APTA).
The study, published March 19, showed no significant differences in functional improvement after 6 months between patients who underwent surgery with postoperative physical therapy and those who received standardized physical therapy alone.
“This study demonstrates what physical therapists have long known,” explained APTA President Paul A. Rockar Jr, PT, DPT, MS. “Surgery may not always be the best first course of action. A physical therapist, in many cases, can help patients avoid the often unnecessary risks and expenses of surgery. This study should help change practice in the management of symptomatic meniscal tears in patients with knee osteoarthritis.”
According to lead physical therapist for the trial and American Physical Therapy Association (APTA) member Clare Safran-Norton, PT, PhD, OCS, “our findings suggest that a course of physical therapy in this patient population may be a good first choice since there were no group differences at 6 months and 12 months in this trial. These findings should help surgeons, physicians, physical therapists, and patients in decision-making regarding their treatment options.”
Researchers at 7 major universities and orthopedic surgery centers around the country studied 351 patients aged 45 years or older who had a meniscal tear and mild-to-moderate osteoarthritis of the knee. Patients were randomly assigned to groups who received either surgery and postoperative physical therapy or standardized physical therapy. Within 6-12 months, patients who had physical therapy alone showed similar improvement in functional status and pain as those who had undergone arthroscopic partial meniscectomy surgery.
Patients who were given standardized physical therapy — individualized treatment and a progressive home exercise program — had the option of “crossing over” to surgery if substantial improvements were not achieved. Thirty percent of patients crossed over to surgery during the first 6 months. At 12 months these patients reported similar outcomes as those who initially had surgery. Seventy percent of patients remained with standardized physical therapy.
According to an accompanying editorial in NEJM,”millions of people are being exposed to potential risks associated with a treatment [surgery] that may or may not offer specific benefit, and the costs are substantial.” Physical therapist and APTA member Mary Ann Wilmarth, PT, DPT, MS, OCS, MTC, Cert MDT, chief of physical therapy at Harvard University, said, “Physical therapists are experts in improving mobility and restoring motion. The individualized treatment approach is very important in the early phases of rehabilitation in order to achieve desired functional outcomes and avoid setbacks or complications.”
Jeffrey N. Katz, Robert H. Brophy, Christine E. Chaisson, Leigh de Chaves, Brian J. Cole, Diane L. Dahm, Laurel A. Donnell-Fink, Ali Guermazi, Amanda K. Haas, Morgan H. Jones, Bruce A. Levy, Lisa A. Mandl, Scott D. Martin, Robert G. Marx, Anthony Miniaci, Matthew J. Matava, Joseph Palmisano, Emily K. Reinke, Brian E. Richardson, Benjamin N. Rome, Clare E. Safran-Norton, Debra J. Skoniecki, Daniel H. Solomon, Matthew V. Smith, Kurt P. Spindler, Michael J. Stuart, John Wright, Rick W. Wright, Elena Losina. Surgery versus Physical Therapy for a Meniscal Tear and Osteoarthritis. New England Journal of Medicine, 2013; 130318220107009 DOI: 10.1056/NEJMoa1301408
HIP AND KNEE PAIN
Spacing exercise-based physical therapy sessions over a 12-month period while using three additional “booster” sessions periodically has been shown to be more cost effective than alternative physical therapy strategies in the treatment of knee osteoarthritis, according to research presented this week at the American College of Rheumatology Annual Meeting in San Francisco.
Osteoarthritis, sometimes called degenerative joint disease, is a slowly progressive disease in which joint cartilage breaks down. Normally, cartilage on the ends of bones allows smooth, pain-free joint movements. In OA, cartilage becomes thin and irregular, resulting in symptoms of joint pain and stiffness. Grinding or cracking sensations may occur. Joints that are under high stress due to repeated activity or weight bearing are most susceptible to OA. The hips, knees, hands and spine are commonly affected. OA becomes more common with aging.
Common pharmacologic treatments for OA include nonsteroidal anti-inflammatory drugs (called NSAIDs) and analgesics (e.g., acetaminophen and ibuprofen), and exercise is considered an excellent first line, conservative, treatment for the disease. Researchers recently compared the cost-effectiveness of four different physical therapy strategies among 300 people with knee OA participating in a two-year study across several different institutions.
Strategy one included 12 visits of exercise therapy alone over a nine-week period; strategy two included eight initial visits of exercise therapy within a nine-week period plus four booster sessions at 3 time points (two boosters at month five and one at months eight and 11) spaced across a 12-month period; strategy three included 12 visits of exercise therapy plus manual therapy; and strategy four included eight initial visits of exercise therapy plus manual therapy and four booster sessions. Total health care costs were estimated using patient-reported outcomes as well as data from the Healthcare Utilization Project and the Medicare physician fee schedule.
“We believed there was a need to improve both the magnitude and sustainability of treatment effects of exercise therapy for improving pain and function in people with knee OA,” explains G. Kelley Fitzgerald, PT, PhD, FAPTA; professor and associate dean of graduate studies, University of Pittsburgh School of Health and Rehabilitation Sciences and the principal investigator in the study.
“Previous research indicated that using manual therapy might be a way of improving the magnitude of treatment effects, and booster sessions might be a way of ensuring sustainability of treatment effects. We also believed it would be important to determine the impact on health care costs to inform best-practice approaches with regard to using manual therapy and/or booster sessions, should they prove to be clinically effective.”
The researchers noted that the booster strategies (strategies two and four) significantly lowered health care costs and showed greater effectiveness in the treatment of knee OA. Between those two strategies, strategy two cost $1,061 more, but gained .082 more quality-adjusted life years, which looks at the burden of the disease in comparison with the quality and quantity of life.
Overall, the study showed that, while exercise therapy remains effective in treating people with knee OA, it might be more effective to supplement exercise with manual therapy and space physical therapy visits over a longer period of time to maximize long-term benefits.
“These results indicate that supplementing exercise with manual therapy and spacing physical therapy sessions across a longer period of time may provide greater benefit to individuals with knee osteoarthritis, while simultaneously reducing downstream health care utilization,” explains lead investigator in the study, Allyn Bove, PT, DPT; assistant professor, Department of Physical Therapy, University of Pittsburgh School of Health and Rehabilitation Sciences.
Based on these findings, Dr. Bove believes patients should consider consulting a physical therapist to treat the pain and disability caused by knee OA and notes they should be willing to potentially commit to re-visiting their physical therapist every few months to reinforce the benefits. Additionally, Dr. Bove says these findings may encourage physical therapists to add more manual therapy techniques, as well as booster sessions to their plans of care for these patients.
Materials provided by American College of Rheumatology (ACR).