Physical therapy for patients with knee and hip osteoarthritis: supervised, active treatment is current best practice

Skou ST, Roos EM. Physical therapy for patients with knee and hip osteoarthritis: supervised, active treatment is current best practice. Clinical and Experimental Rheumatology. 2019;38(5):112-117. https://europepmc.org/article/MED/33034560.

Link to Original Article: https://pubmed.ncbi.nlm.nih.gov/31621559/

Key Points

- The main focus of this research paper is on non-surgical treatments for knee and hip osteoarthritis (OA).

- Exercise therapy is a universally recommended first-line treatment and provides effective pain relief without serious adverse effects. At least 12 supervised sessions are required initially for sufficient clinical benefit.

- Structured patient education is essential for motivation and adherence to an exercise program.

- If exercise therapy and patient education do not provide sufficient improvement, supplementary interventions such as knee orthoses and manual treatment may be considered.

- Weight loss is an important part of the treatment plan and even modest weight loss of 5% can have a significant impact on symptoms.

- The combination of exercise therapy, patient education, and other non-surgical treatments can effectively postpone surgery for many OA patients, and prior participation in an exercise program can lead to faster postoperative recovery.

Introduction

The research paper highlights that knee and hip osteoarthritis (OA) is a "whole person condition" influenced by various biopsychosocial factors. It challenges the notion that structural damage is the sole cause of symptoms in OA. Non-surgical approaches are emphasized as key in managing OA. Physical therapists play a significant role in delivering exercise therapy, patient education, and weight loss interventions. These interventions are recommended as first-line treatments for knee and hip OA according to treatment guidelines. If these approaches are unsuccessful, physical therapists may offer supplementary treatments such as knee orthoses and manual treatment. Acupuncture is mentioned as a potential pain-relieving treatment, but its effectiveness remains inconclusive.

Physical therapy as treatment of knee and hip OA

The first-line treatments include exercise, patient education, and weight loss. Supplemental treatments such as knee orthoses and manual treatment should be offered if the patient is unsuccessful with the first-line treatment. Supplemental pain-relieving treatment such as acupuncture can be recommended as an alternative to pain relief medications, but evidence and effectiveness of acupuncture are inconclusive. Notably, weight loss of even 5% has a significant impact on OA symptoms, making it an important part of the treatment plan, particularly for overweight and obese patients. Treatment paradigms for OA in other peripheral joints may evolve based on new evidence.

First-line treatment

Exercise therapy

Exercise therapy is considered the most important non-surgical treatment for knee and hip osteoarthritis (OA). It not only improves joint symptoms but also helps in preventing and managing various chronic conditions. Many patients with knee and hip OA have comorbidities, and exercise is crucial for their overall health and well-being. Numerous randomized controlled trials have confirmed the positive effects of exercise therapy in knee and hip OA patients, with significant improvements in pain and physical function. Exercise therapy seems to have a larger impact on pain and function in knee OA patients compared to hip OA patients. Water-based exercises may be an alternative option for those unable to perform land-based exercises due to reasons such as intolerable symptoms or severe obesity. Exercise therapy is a recommended first-line treatment for knee and hip OA, providing significant benefits for patients.

• Exercise therapy as a painkiller in OA irrespective of radiographic severity

The research paper explores the role of exercise therapy in the management of knee and hip osteoarthritis (OA). It highlights that exercise therapy is effective in reducing pain regardless of the severity of radiographic evidence of OA. Exercise therapy is found to be more effective and safer than traditional pharmacological pain relievers, such as NSAIDs and acetaminophen. However, for patients with severe pain, supplementary pharmacological pain relievers may be beneficial. Physical therapists should inform patients that pain flares are expected with weight bearing exercises. With increased number and intensity of sessions, patients report decrease in pain flares and some even report pain flares disappearing completely. The research paper also notes exercise therapy is safe to perform with pain intensity of less than or equal to 5 on a 0 to 10 scale.

• Individualisation and exercise doses are important to increase the clinical effect

The research paper states specific exercise programs are not detailed to be incorporated into the clinic practice, but also notes that all patients should not be given the same exercise program. Individualization of the exercise program and supervision of patients increase the treatment effect. The exercise program should also be progressed as needed to ensure the patient maximizes the muscle strength and function. Supervision of patients is needed to reassure patients who have pain flare as a result of exercise. The research paper states a minimum of 12 sessions is needed to make a meaningful impact. Further research is needed to develop an optimal and individualized exercise program.

• The combined effect of exercise therapy and other treatment modalities

The research paper states combining exercise therapy with patient education is more effective than exercise therapy or patient education alone. Prior studies found individualized treatment plans to be more effective than providing information and advice and another prior study showed a clinically meaningful improvement in pain and function when patients received a combination of exercise therapy and patient education. Furthermore, if a patient decides on total knee or hip replacement surgery, previous participation in exercise therapy leads to faster postoperative recovery.

Patient education

The research paper highlights the importance of patient education in the management of knee and hip osteoarthritis (OA). While the immediate effect of a supervised exercise program is positive, it tends to diminish over time due to low adherence to the exercise regime and lifestyle changes. Patient education alone has a limited impact on pain and function. However, when combined with exercise therapy, it can increase self-efficacy and maintain motivation and adherence to exercise. The authors recommend that patient education should include information about the causes, risk factors, and mechanisms of OA, as well as the importance of physical activity and the consequences of inactivity. Effective and ineffective treatments, coping strategies, and a self-help guide should also be provided to help patients successfully manage their disease. This comprehensive information not only supports patients in understanding how to manage pain and exercise-induced pain flares but also motivates them to engage in lifelong exercise and physical activity.

Supplementary treatment

The research paper discusses various supplementary treatments that can be used in addition to exercise therapy, patient education, and weight loss for patients with knee and hip osteoarthritis (OA). Manual treatment, including joint mobilization and manipulation, may provide moderate benefit for pain and function in knee OA patients but more research is needed. Unloader braces can lead to small-to-moderate improvements in pain and function for patients with medial knee OA, but proper fit and supervision are important to optimize outcomes. Lateral wedge insoles do not have a significant effect on pain in medial knee OA. Acupuncture's effectiveness in treating knee and hip OA is inconclusive with limited evidence. Other passive treatments such as massage, electrical stimulation, ultrasound, and laser are not recommended due to the lack of high-quality evidence. Further research is necessary to determine the efficacy of these supplementary treatments for OA patients.

Opportunities for Future Research

1. Further research is needed to explore the long-term effects of exercise therapy for knee and hip osteoarthritis (OA), particularly in terms of pain relief and functional improvement.

2. Future studies should investigate the optimal duration and frequency of supervised exercise sessions for knee and hip OA patients, in order to determine the minimum number of sessions required to achieve sufficient clinical benefits.

3. There is a need for research on the effectiveness of structured patient education programs in improving adherence to exercise therapy and long-term maintenance of treatment effects in knee and hip OA patients.

4. More research is warranted to assess the effectiveness of supplementary interventions, such as knee orthoses and manual treatment, when exercise therapy and patient education alone are insufficient to improve pain and function in knee and hip OA patients.

5. Further investigation is needed to determine the effects of weight loss, even modest weight loss of 5%, on symptoms of knee and hip OA, as well as the optimal inclusion of weight loss as part of the treatment plan.

6. Additional research is needed to evaluate the efficacy of alternative non-surgical treatments, such as acupuncture and passive treatment approaches, in managing pain and improving function in knee and hip OA patients.