RMT Options for Treating Osteoarthritis (OA)

“Therapy for arthritic knees often as effective as surgery” (CBC news)

Researchers at the University of Western of Ontario recently published a landmark study “A Randomized Trial of Arthroscopic Surgery for Osteoarthritis (OA) of the Knee” in The New England Journal of Medicine.

How does this new research affect your practice and patients?

Lets first start by looking at why is OA of the knee important to RMT’s?
In the EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis, we find out that osteoarthritis (OA) is the most common form of arthritis in Western populations. It is characterized pathologically by both focal loss of articular cartilage and marginal and central new bone formation. Knee OA is likely to become the fourth most important global cause of disability in women and the eighth most important in men. The annual costs attributable to knee OA are immense. There is therefore a burden on health from both morbidity and cost. Knee OA is associated with symptoms of pain and functional disability. Physical disability arising from pain and loss of functional capacity reduces quality of life and increases the risk of further morbidity and mortality.

What did the study “A Randomized Trial of Arthroscopic Surgery for Osteoarthritis (OA) of the Knee” tell us about OA management?
This study dealt only with arthroscopic surgery and physical therapy/medical management of knee OA. The main conclusion tells us that the long-term effects of arthroscopic surgery is the same as for patients that only have conservative therapy consisting of exercises and patient education. This study confirms the conclusions of an earlier 2002 study by Moseley et al called A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee.
It is most imperative that manual therapists are made aware of this trial given its implications on patient management within medical and orthopedic practices. If accepted as part of evidence-based practice, this study will likely result in an influx of patients to conservative therapy clinics seeking treatment for OA of the knee. In addition, it is important for clinicians to demonstrate leadership and educate each other on trials such as this.

What other therapy options are there?

The EULAR report has 10 recommendations on knee OA management.

OARSI published guidelines on management of knee and OA that recommend directing treatments towards:
_ Reducing joint pain and stiffness
_ Maintaining and improving joint mobility
_ Reducing physical disability and handicap
_ Improving health-related quality of life
_ Limiting the progression of joint damage
_ Educating patients about the nature of the      disorder and its management.
OARSI lists 25 recommendations for the treatment of hip and knee OA. These are summarized in Table I together with the level of evidence (LoE) supporting them.
(OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines)

Exercises and Manual therapy for knee OA

In their study “Massage therapy for osteoarthritis of the knee: A randomized controlled trial” Perlman AI et al. provide preliminary evidence that a course of Swedish (classical) massage can have a positive influence on symptoms and functional deficits associated with osteoarthritis of the knee. These benefits seem to last, at least for the additional 8 week follow-up period used in this study.
There is a reat potential for massage as an adjunct treatment for OA. Pharmaceutical treatments for OA (the COX-2 inhibitors specifically) have recently been correlated with higher adverse event rates than previously thought.

In the randomized, controlled trial “Effectiveness of Manual Physical Therapy and Exercise in Osteoarthritis of the Knee”
Deyle et al report that manual therapy, applied to the knee as well as to the lumbar spine, hip, and ankle as required, and performed a standardized knee exercise program in the clinic and at home yields functional benefits for patients with osteoarthritis of the knee and may delay or prevent the need for surgical intervention.

In their second study “Physical Therapy Treatment Effectiveness for Osteoarthritis of the Knee: A Randomized Comparison of Supervised Clinical Exercise and Manual Therapy Procedures Versus a Home Exercise Program” Deyle et al conclude that the results indicate that a home exercise program for patients with OA of the knee provides important benefit. Adding a small number of additional clinical visits for the application of manual therapy and supervised exercise adds greater symptomatic relief.

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Therapeutic Exercises and Manual Therapy in the Management of Osteoarthritis reports on 26 randomized controlled trials and controlled clinical trials. This review of the literature recommends the use of therapeutic exercises alone, or combined with manual therapy, for managing patients with OA

Investigation of Clinical Effects of High- and Low-Resistance Training for Patients With Knee Osteoarthritis:
A Randomized Controlled Trial, Mei-Hwa Jan et all
This study compared the effects of high- and low-resistance strength training in elderly subjects with knee OA. Both high- and low-resistance strength training significantly improved clinical effects in this study. The effects of high-resistance strength training appear to be larger than those of low-resistance strength training for people with mild to moderate knee OA, although the differences between the HR and LR groups were not statistically significant.

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Further resources

Cochrane Systematic reviews on knee and OA
(in the OVID databases select: EBM Reviews – Cochrane Database of Systematic Reviews)

•    Braces and orthoses for treating osteoarthritis of the knee
•    Aquatic exercise for the treatment of knee and hip osteoarthritis
•    Exercise for osteoarthritis of the hip or knee
•    Thermotherapy for treatment of osteoarthritis
•    Low level laser therapy (Classes III) for treating osteoarthritis
•    Intensity of exercise for the treatment of osteoarthritis.
•    Balneotherapy for osteoarthritis

Massage Therapists Asociation of British Columbia – OA literature review

• An evidence-informed educational material on the Assessment and Management of Osteoarthritis for Registered Massage Therapists

Filed under: Topic review

Physical Therapy Treatment Effectiveness for Osteoarthritis of the Knee: A Randomized Comparison of Supervised Clinical Exercise and Manual Therapy Procedures Versus a Home Exercise Program

Deyle, Allison, Matekel, Ryder et al

Background and Purpose. Manual therapy and exercise have not previously been compared with a home exercise program for patients with osteo-arthritis (OA) of the knee. The purpose of this study was to compare outcomes between a home-based physical therapy program and a clinically based physical therapy program.

Subjects. One hundred thirty-four subjects with OA of the knee were randomly assigned to a clinic treatment group (n=66; 61% female, 39% male; mean age [±SD]=64±10 years) or a home exercise group (n=68, 71% female, 29% male; mean age [±SD]=62±9 years).

Methods. Subjects in the clinic treatment group received supervised exercise, individualized manual therapy, and a home exercise program over a 4-week period. Subjects in the home exercise group received the same home exercise program initially, reinforced at a clinic visit 2 weeks later. Measured outcomes were the distance walked in 6 minutes and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).

Results. Both groups showed clinically and statistically significant improvements in 6-minute walk distances and WOMAC scores at 4 weeks; improvements were still evident in both groups at 8 weeks. By 4 weeks, WOMAC scores had improved by 52% in the clinic treatment group and by 26% in the home exercise group. Average 6-minute walk distances had improved about 10% in both groups. At 1 year, both groups were substantially and about equally improved over baseline measurements. Subjects in the clinic treatment group were less likely to be taking medications for their arthritis and were more satisfied with the overall outcome of their rehabilitative treatment compared with subjects in the home exercise group.

Discussion and Conclusion. Although both groups improved by 1 month, subjects in the clinic treatment group achieved about twice as much improvement in WOMAC scores than subjects who performed similar unsupervised exercises at home. Equivalent maintenance of improvements at 1 year was presumably due to both groups continuing the identical home exercise program. The results indicate that a home exercise program for patients with OA of the knee provides important benefit. Adding a small number of additional clinical visits for the application of manual therapy and supervised exercise adds greater symptomatic relief.

Physical Therapy, Vol. 85, No. 12, December 2005, pp. 1301-1317

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Filed under: Exercise therapy, Knee, Manual therapy, Osteoarthritis

Massage Therapy for Osteoarthritis of the Knee

Perlman, Sabina, Williams, Njike, Katz

Background Massage therapy is an attractive treatment option for osteoarthritis (OA), but its efficacy is uncertain. We conducted a randomized, controlled trial of massage therapy for OA of the knee.

Methods Sixty-eight adults with radiographically confirmed OA of the knee were assigned either to treatment (twice-weekly sessions of standard Swedish massage in weeks 1-4 and once-weekly sessions in weeks 5-8) or to control (delayed intervention). Primary outcomes were changes in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and functional scores and the visual analog scale of pain assessment. The sample provided 80% statistical power to detect a 20-point difference between groups in the change from baseline on the WOMAC and visual analog scale, with a 2-tailed of .05.

Results The group receiving massage therapy demonstrated significant improvements in the mean (SD) WOMAC global scores (–17.44 [23.61] mm; P<.001), pain (–18.36 [23.28]; P<.001), stiffness (–16.63 [28.82] mm; P<.001), and physical function domains (–17.27 [24.36] mm; P <.001) and in the visual analog scale of pain assessment (–19.38 [28.16] mm; P<.001), range of motion in degrees (3.57 [13.61]; P = .03), and time to walk 50 ft (15 m) in seconds (–1.77 [2.73]; P<.01). Findings were unchanged in multivariable models controlling for demographic factors.

Conclusions Massage therapy seems to be efficacious in the treatment of OA of the knee. Further study of cost effectiveness and duration of treatment effect is clearly warranted.

Archives of Internal Medicine. 2006;166:2533-2538

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Filed under: Knee, Massage, Osteoarthritis

Effectiveness of Manual Physical Therapy and Exercise in Osteoarthritis of the Knee

Deyle, Henderson, Matekel, Ryder et al

Background: Few investigations include both subjective and objective measurements of the effectiveness of treatments for osteoarthritis of the knee. Beneficial interventions may decrease the disability associated with osteoarthritis and the need for more invasive treatments.

Objective: To evaluate the effectiveness of physical therapy for osteoarthritis of the knee, applied by experienced physical therapists with formal training in manual therapy.

Design: Randomized, controlled clinical trial.

Setting: Outpatient physical therapy department of a large military medical center.

Patients: 83 patients with osteoarthritis of the knee who were randomly assigned to receive treatment (n = 42; 15 men and 27 women [mean age, 60 ± 11 years]) or placebo (n = 41; 19 men and 22 women [mean age, 62 ± 10 years]).

Intervention: The treatment group received manual therapy, applied to the knee as well as to the lumbar spine, hip, and ankle as required, and performed a standardized knee exercise program in the clinic and at home. The placebo group had subtherapeutic ultrasound to the knee at an intensity of 0.1 W/cm² with a 10% pulsed mode. Both groups were treated at the clinic twice weekly for 4 weeks.

Measurements: Distance walked in 6 minutes and sum of the function, pain, and stiffness subscores of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). A tester who was blinded to group assignment made group comparisons at the initial visit (before initiation of treatment), 4 weeks, 8 weeks, and 1 year.

Results: Clinically and statistically significant improvements in 6-minute walk distance and WOMAC score at 4 weeks and 8 weeks were seen in the treatment group but not the placebo group. By 8 weeks, average 6-minute walk distances had improved by 13.1% and WOMAC scores had improved by 55.8% over baseline values in the treatment group (P < 0.05). After controlling for potential confounding variables, the average distance walked in 6 minutes at 8 weeks among patients in the treatment group was 170 m (95% CI, 71 to 270 m) more than that in the placebo group and the average WOMAC scores were 599 mm higher (95% CI, 197 to 1002 mm). At 1 year, patients in the treatment group had clinically and statistically significant gains over baseline WOMAC scores and walking distance; 20% of patients in the placebo group and 5% of patients in the treatment group had undergone knee arthroplasty.

Conclusions: A combination of manual physical therapy and supervised exercise yields functional benefits for patients with osteoarthritis of the knee and may delay or prevent the need for surgical intervention.

Annals of Internal Medicine, 1 Feb 2000, Vol 132 Issue 3, 173-181

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Filed under: Exercise therapy, Knee, Manual therapy, Osteoarthritis

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Therapeutic Exercises and Manual Therapy in the Management of Osteoarthritis

Ottawa Methods Group: Brosseau, Wells, Tugwell, Egan et al

BACKGROUND AND PURPOSE: Osteoarthritis (OA) affects a large and growing proportion of the population. The purpose of this project was to create guidelines for the use of therapeutic exercises and manual therapy in the management of adult patients (>18 years of age) with a diagnosis of OA. All stages of the disease were included in the analysis, and studies of patients who had recent surgery or other rheumatologic, musculoskeletal, or spinal problems or of subjects without known pathology or impairments were excluded.

METHODS: The Ottawa Methods Group used Cochrane Collaboration methods to find and synthesize evidence from comparative controlled trials and then asked stakeholder groups to nominate representatives to serve on a panel of experts. The Ottawa Panel agreed on criteria for grading the strength of the recommendations and their supporting evidence. Of the 609 potential articles on therapeutic exercises for OA that were identified, 113 were considered potentially relevant, and 26 randomized controlled trials and controlled clinical trials were ultimately used.

RESULTS: Sixteen positive recommendations of clinical benefit were developed for therapeutic exercises, especially strengthening exercises and general physical activity, particularly for the management of pain and improvement of functional status. Manual therapy combined with exercises also is recommended in the management of patients with OA.

DISCUSSION AND CONCLUSION: The Ottawa Panel recommends the use of therapeutic exercises alone, or combined with manual therapy, for managing patients with OA. There were a total of 16 positive recommendations: 13 grade A and 3 grade C+. The Ottawa Panel recommends the use of therapeutic exercises because of the strong evidence (grades A, B, and C+) in the literature.

Physical Therapy, Vol. 85, No. 9, September 2005, pp. 907-971

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Filed under: Exercise therapy, Manual therapy, Osteoarthritis, Treatment guidelines

Investigation of Clinical Effects of High- and Low-Resistance Training for Patients With Knee Osteoarthritis: A Randomized Controlled Trial

Mei-Hwa Jan et al

Background and Purpose: Muscle strength training is important for people with knee osteoarthritis (OA). High-resistance exercise has been demonstrated to be more beneficial than low-resistance exercise for young subjects. The purpose of this study was to compare the effects of high- and low-resistance strength training in elderly subjects with knee OA.

Subjects and Methods: One hundred two subjects were randomly assigned to groups that received 8 weeks of high-resistance exercise (HR group), 8 weeks of low-resistance exercise (LR group), or no exercise (control group). Pain, function, walking time, and muscle torque were examined before and after intervention.

Results: Significant improvement for all measures was observed in both exercise groups. There was no significant difference in any measures between HR and LR groups. However, based on effect size between exercise and control groups, the HR group improved more than the LR group.

Discussion and Conclusion: Both high- and low-resistance strength training significantly improved clinical effects in this study. The effects of high-resistance strength training appear to be larger than those of low-resistance strength training for people with mild to moderate knee OA, although the differences between the HR and LR groups were not statistically significant.

Physical Thrapy, Vol. 88, No. 4, April 2008, pp. 427-436
DOI: 10.2522/ptj.20060300

Full text available in through MTABC member only website

Filed under: Exercise therapy, Knee, Osteoarthritis

OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines

Zhang, Moskowitz, Nuki, Abramson et al

PURPOSE: To develop concise, patient-focussed, up to date, evidence-based, expert consensus recommendations for the management of hip and knee osteoarthritis (OA), which are adaptable and designed to assist physicians and allied health care professionals in general and specialist practise throughout the world.

METHODS: Sixteen experts from four medical disciplines (primary care, rheumatology, orthopaedics and evidence-based medicine), two continents and six countries (USA, UK, France, Netherlands, Sweden and Canada) formed the guidelines development team. A systematic review of existing guidelines for the management of hip and knee OA published between 1945 and January 2006 was undertaken using the validated appraisal of guidelines research and evaluation (AGREE) instrument. A core set of management modalities was generated based on the agreement between guidelines. Evidence before 2002 was based on a systematic review conducted by European League Against Rheumatism and evidence after 2002 was updated using MEDLINE, EMBASE, CINAHL, AMED, the Cochrane Library and HTA reports. The quality of evidence was evaluated, and where possible, effect size (ES), number needed to treat, relative risk or odds ratio and cost per quality-adjusted life years gained were estimated. Consensus recommendations were produced following a Delphi exercise and the strength of recommendation (SOR) for propositions relating to each modality was determined using a visual analogue scale.

RESULTS: Twenty-three treatment guidelines for the management of hip and knee OA were identified from the literature search, including six opinion-based, five evidence-based and 12 based on both expert opinion and research evidence. Twenty out of 51 treatment modalities addressed by these guidelines were universally recommended. ES for pain relief varied from treatment to treatment. Overall there was no statistically significant difference between non-pharmacological therapies [0.25, 95% confidence interval (CI) 0.16, 0.34] and pharmacological therapies (ES=0.39, 95% CI 0.31, 0.47). Following feedback from Osteoarthritis Research International members on the draft guidelines and six Delphi rounds consensus was reached on 25 carefully worded recommendations. Optimal management of patients with OA hip or knee requires a combination of non-pharmacological and pharmacological modalities of therapy. Recommendations cover the use of 12 non-pharmacological modalities: education and self-management, regular telephone contact, referral to a physical therapist, aerobic, muscle strengthening and water-based exercises, weight reduction, walking aids, knee braces, footwear and insoles, thermal modalities, transcutaneous electrical nerve stimulation and acupuncture. Eight recommendations cover pharmacological modalities of treatment including acetaminophen, cyclooxygenase-2 (COX-2) non-selective and selective oral non-steroidal anti-inflammatory drugs (NSAIDs), topical NSAIDs and capsaicin, intra-articular injections of corticosteroids and hyaluronates, glucosamine and/or chondroitin sulphate for symptom relief; glucosamine sulphate, chondroitin sulphate and diacerein for possible structure-modifying effects and the use of opioid analgesics for the treatment of refractory pain. There are recommendations covering five surgical modalities: total joint replacements, unicompartmental knee replacement, osteotomy and joint preserving surgical procedures; joint lavage and arthroscopic debridement in knee OA, and joint fusion as a salvage procedure when joint replacement had failed. Strengths of recommendation and 95% CIs are provided.

CONCLUSION: Twenty-five carefully worded recommendations have been generated based on a critical appraisal of existing guidelines, a systematic review of research evidence and the consensus opinions of an international, multidisciplinary group of experts. The recommendations may be adapted for use in different countries or regions according to the availability of treatment modalities and SOR for each modality of therapy. These recommendations will be revised regularly following systematic review of new research evidence as this becomes available.

Osteoarthritis and Cartilage, Volume 16, Issue 2, February 2008, Pages 137-162

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Filed under: Exercise therapy, Hip, Knee, Osteoarthritis, Patient education, Treatment guidelines