CLINICIAN’S CORNER

Osteoarthritis Patients

By: Liza Peressini, PT, DPT Physical Therapist at PTSMC Danbury

Since I began treating, I have seen many patients enter the clinic complaining of joint pain. Arthropathy and other joint-related pain generators signi cantly impact an individual’s health, function, and quality of life. Many of our patients seek out pain relief from their primary care physician (PCP) or orthopedic doctors with the hope they can provide a cure or referral avenue. Osteoarthritis (OA) is a common diagnosis seen in our clinics, most commonly at the knee and hip joints.1 It is the most common form of arthritis and a ects over 32.5 million US adults, females greater than males. Comorbidities include age greater than 50, obesity, overuse, previous injury, trauma, and/or genetics.2 The limitations are signi cant and can lead to years of pain and decreased function. Imaging has been found to increase awareness of these patients’ degenerative changes and may accelerate the surgical process, especially when the term “bone-on-bone” is used. Injections do not provide patients with long-term symptom relief and do not change the integrity of the joint.

In early stages of the disease, physical therapy can be used to assist with improving function, reducing pain, and allowing the patient to perform their daily tasks without needing surgery. This becomes more complicated when treating patients in later stages of OA. Insurance contracts and policies are other factors to consider as they vary patient to patient. They essentially determine the number of visits patients can receive, making it di cult to treat patients with OA e ectively. Fitzgerald et al. de ned ‘booster’ sessions as, “a periodic follow-up appointment occurring several weeks/months following a course of supervised therapy.”3 This concept has now been studied with several attempts to demonstrate the bene ts of conservative medicine for OA. When looking at several studies, research varies amongst treatment approaches and results, however, ‘booster’ sessions do show some promise in our practice.

Pisters et al. investigated behavioral graded activity (BGA) and whether the treatment had longer e ects than usual exercise therapy (UC, for “usual care”) in patients with OA – knee or hip. BGA is a treatment that integrates the concepts of conditioning with exercise in ‘booster’ sessions. The UC group was treated according to the Dutch PT guidelines for hip and/or knee OA. The BGA group consisted of an individualized program of the patient’s most problematic activities that were increased in a timely manner along the treatment timeline and based on progress. The UC recommended general guidelines, advice, exercise therapy, and coping mechanism for complaints. The long-term follow-up of ve years was a single-blind cluster randomized trial comparing the two groups. There was a maximum of 18 sessions within a 12-week period, then an additional seven sessions for the BGA group, or ‘booster’ sessions, for re-examination, motivation, and repetition and understanding of treatment. After the 18 sessions, patients were advised on a home exercise program to adhere to. The primary outcome measures were the (Western Ontario and McMaster osteoarthritis index) WOMAC and patient global assessment (PGA) with a secondary of MACTAR questionnaire. These measurements were obtained at baseline, 3, 9, 15, and 60 months. The results found that both groups improved long-term outcomes without any signi cant di erences between treatment groups for patients with OA at the knee or hip. The BGA hip group was found to required less joint replacement surgeries than the UC group in the long-term. When looking deeper into the study, the BGA group demonstrates superiority favoring all outcome measures for short-term (three months) and mid-long-term (nine months) outcomes, however, the lack of power led to the results being statistically insigni cant. The study demonstrates within-group di erences but no di erences between groups in any outcome measures at the long-term outcomes (60 months).1

In New Zealand, Abbott et al. evaluated the clinical e ectiveness of manual therapy and/or exercise along with routine care for patients with OA of the hip or knee using a 2x2 factorial RCT. The 206 participants were allocated into four groups, with the primary outcome being change in WOMAC after one year and secondary being physical performance tests. Each participant in the three intervention groups attended seven treatment sessions within nine weeks that lasted about 50 minutes with an additional two “booster” sessions at week 16. The manual therapy group targeted joint and soft tissue impairments tailored to each patient individually; the exercise group underwent a multi-modal approach including stretching, aerobic, strength, and neuromuscular control training; the manual therapy and exercise group had a combination of both treatments; and the usual care group received routine care from the general practitioner. The groups were assessed at baseline, nine weeks, six months, and one year. The results found that manual therapy had greater bene ts than exercise, however, both provided a greater bene t than usual care. The combination of manual therapy and exercise did not result in superior outcomes. Although there was a lack of statistical signi cance in this study, the CI scores for the WOMAC surpassed the MCID, leading researchers and other clinicians to believe there are clinical di erences in manual therapy and exercise over usual care alone.4

Both studies demonstrate improvements in pain and function in all groups, however, some groups demonstrated better progress. Pisters et al.1 found bene t for both the BGA and the UC groups, but no di erence when comparing the groups. The bene ts in the short-term and short-long-term outcomes found in the BGA group may lead to reduction in long-term pain and functional outcomes, prolonging the need for surgical intervention in patients with knee or hip OA. The study also found that 35% of UC and 28% of BGA groups adhered to their home exercise program, which could also lead to increase pain and need for surgical intervention. Abbott et al.4 found no statistically signi cant di erences between groups at any assessment, however, the results found clinical important di erences in baseline to end scores on the WOMAC. Clinicians can then infer manual therapy and exercise can provide better treatment than usual care alone in the long-term e ect.

The take-aways from this “corner” are: https://doi.org/10.1016/j.joca.2010.05.008

1. The idea of ‘booster’ sessions can allow patients to come for hands-on treatment for a bout of time before sending them to perform the treatments at home.

2. These results demonstrate the bene t of ‘booster’ sessions as a possible treatment approach for your patients complaining of OA-related symptoms.

3. Manual therapy and exercise are both better than usual care in providing patients pain relief and functional improvements with knee or hip OA.

4. Patient education on adhering to their home exercise program can prolong the need for surgical interventions.

2. Osteoarthritis (Oa) | arthritis | cdc. (2020, August 4). https://www.cdc.gov/arthritis/basics/osteoarthritis.htm

3. Fitzgerald, G. K., Fritz, J. M., Childs, J. D., Brennan, G. P., Talisa, V., Gil, A. B., Neilson, B. D., & Abbott, J. H. (2016). Exercise, manual therapy, and use of booster sessions in physical therapy for knee osteoarthritis: A multi-center, factorial randomized clinical trial. Osteoarthritis and Cartilage, 24(8), 1340–1349. https://doi.org/10.1016/j.joca.2016.03.001

4. Abbott JH, Robertson MC, Chapple C, et al. Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee: a randomized controlled trial. 1: clinical e ectiveness. Osteoarthritis Cartilage 2013;21(4):525-34.