Knee OA: Which patients are unlikely to benefit from manual PT and exercise?

,

Original Research

Knee OA: Which patients are unlikely to benefit from manual PT and exercise?

J Fam Pract. 2012 January;61(1):E1-E8

By

Gail D. Deyle, PT, DSc

A preliminary clinical prediction rule uses 3 patient attributes to predict who will fare better with alternative treatments.

PDF Download

References

1. Deyle GD, Allison SC, Matekel RL, et al. 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. Phys Ther. 2005;85:1301-1317.

2. Deyle GD, Henderson NE, Matekel RL, et al. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee. A randomized, controlled trial. Ann Intern Med. 2000;132:173-181

3. Sandmark H, Hogstedt C, Vingard E. Primary osteoarthrosis of the knee in men and women as a result of lifelong physical load from work. Scand J Work Environ Health. 2000;26:20-25.

4. Felson DT, Zhang Y, Hannan MT, et al. Risk factors for incident radiographic knee osteoarthritis in the elderly: the Framingham Study. Arthritis Rheum. 1997;40:728-733.

5. Jarvholm B, From C, Lewold S, et al. Incidence of surgically treated osteoarthritis in the hip and knee in male construction workers. Occup Environ Med. 2008;65:275-278.

6. Messier SP, Loeser RF, Mitchell MN, et al. Exercise and weight loss in obese older adults with knee osteoarthritis: a preliminary study. J Am Geriatr Soc. 2000;48:1062-1072.

7. Felson DT, Zhang Y. An update on the epidemiology of knee and hip osteoarthritis with a view to prevention. Arthritis Rheum. 1998;41:1343-1355.

8. Sandmark H, Vingard E. Sports and risk for severe osteoarthrosis of the knee. Scand J Med Sci Sports. 1999;9:279-284.

9. Gelber AC, Hochberg MC, Mead LA, et al. Joint injury in young adults and risk for subsequent knee and hip osteoarthritis. Ann Intern Med. 2000;133:321-328.

10. Cerejo R, Dunlop DD, Cahue S, et al. The influence of alignment on risk of knee osteoarthritis progression according to baseline stage of disease. Arthritis Rheum. 2002;46:2632-2636.

11. Wolfe F, Lane NE. The longterm outcome of osteoarthritis: rates and predictors of joint space narrowing in symptomatic patients with knee osteoarthritis. J Rheumatol. 2002;29:139-146.

12. Lewek MD, Rudolph KS, Snyder-Mackler L. Quadriceps femoris muscle weakness and activation failure in patients with symptomatic knee osteoarthritis. J Orthop Res. 2004;22:110-115.

13. Fitzgerald GK, Piva SR, Irrgang JJ. Reports of joint instability in knee osteoarthritis: its prevalence and relationship to physical function. Arthritis Rheum. 2004;51:941-946.

14. Fitzgerald GK, Piva SR, Irrgang JJ, et al. Quadriceps activation failure as a moderator of the relationship between quadriceps strength and physical function in individuals with knee osteoarthritis. Arthritis Rheum. 2004;51:40-48.

15. Scott DL, Berry H, Capell H, et al. The long-term effects of non-steroidal anti-inflammatory drugs in osteoarthritis of the knee: a randomized placebo-controlled trial. Rheumatology (Oxford). 2000;39:1095-1101.

16. Towheed TE, Maxwell L, Judd MG, et al. Acetaminophen for osteoarthritis. Cochrane Database Syst Rev. 2006;(1):CD004257.-

17. Kivitz A, Fairfax M, Sheldon EA, et al. Comparison of the effectiveness and tolerability of lidocaine patch 5% versus celecoxib for osteoarthritis-related knee pain: post hoc analysis of a 12 week, prospective, randomized, active-controlled, open-label, parallel-group trial in adults. Clin Ther. 2008;30:2366-2377.

18. Nussmeier NA, Whelton AA, Brown MT, et al. Complications of the COX-2 inhibitors parecoxib and valdecoxib after cardiac surgery. N Engl J Med. 2005;352:1081-1091.

19. Psaty BM, Furberg CD. COX-2 inhibitors—lessons in drug safety. N Engl J Med. 2005;352:1133-1135.

20. Solomon SD, McMurray JJ, Pfeffer MA, et al. Cardiovascular risk associated with celecoxib in a clinical trial for colorectal adenoma prevention. N Engl J Med. 2005;352:1071-1080.

21. Wittenberg RH, Schell E, Krehan G, et al. First-dose analgesic effect of the cyclo-oxygenase-2 selective inhibitor lumiracoxib in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled comparison with celecoxib [NCT00267215]. Arthritis Res Ther. 2006;8:R35.-

22. Bradley JD, Heilman DK, Katz BP, et al. Tidal irrigation as treatment for knee osteoarthritis: a sham-controlled, randomized, double-blinded evaluation. Arthritis Rheum. 2002;46:100-108.

23. Chang RW, Falconer J, Stulberg SD, et al. A randomized, controlled trial of arthroscopic surgery versus closed-needle joint lavage for patients with osteoarthritis of the knee. Arthritis Rheum. 1993;36:289-296.

24. Moseley JB, O’Malley K, Petersen NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002;347:81-88.

25. Laupattarakasem W, Laopaiboon M, Laupattarakasem P, et al. Arthroscopic debridement for knee osteoarthritis. Cochrane Database Syst Rev. 2008;(1):CD005118.-

26. Hawker GA, Badley EM, Croxford R, et al. A population-based nested case-control study of the costs of hip and knee replacement surgery. Med Care. 2009;47:732-741.

27. Losina E, Walensky RP, Kessler CL, et al. Cost-effectiveness of total knee arthroplasty in the United States: patient risk and hospital volume. Arch Intern Med. 2009;169:1113-1121.

28. Hamel MB, Toth M, Legedza A, et al. Joint replacement surgery in elderly patients with severe osteoarthritis of the hip or knee: decision making, postoperative recovery, and clinical outcomes. Arch Intern Med. 2008;168:1430-1440.

29. Robertsson O, Stefansdottir A, Lidgren L, et al. Increased long-term mortality in patients less than 55 years old who have undergone knee replacement for osteoarthritis: results from the Swedish Knee Arthroplasty Register. J Bone Joint Surg Br. 2007;89:599-603.

30. SooHoo NF, Lieberman JR, Ko CY, et al. Factors predicting complication rates following total knee replacement. J Bone Joint Surg Am. 2006;88:480-485.

31. Solomon DH, Chibnik LB, Losina E, et al. Development of a preliminary index that predicts adverse events after total knee replacement. Arthritis Rheum. 2006;54:1536-1542.

32. Abularrage CJ, Weiswasser JM, Dezee KJ, et al. Predictors of lower extremity arterial injury after total knee or total hip arthroplasty. J Vasc Surg. 2008;47:803-807.

33. Parvizi J, Han SB, Tarity TD, et al. Postoperative ileus after total joint arthroplasty. J Arthroplasty. 2008;23:360-365.

34. Pinaroli A, Piedade SR, Servien E, et al. Intraoperative fractures and ligament tears during total knee arthroplasty. A 1795 posterostabilized TKA continuous series. Orthop Traumatol Surg Res. 2009;95:183-189

35. Bellamy N, Campbell J, Robinson V, et al. Viscosupplementation for the treatment of osteoarthritis of the knee. Cochrane Database Syst Rev. 2006;(2):CD005321.-

36. Baker K, McAlindon T. Exercise for knee osteoarthritis. Curr Opin Rheumatol. 2000;12:456-463.

37. Baker KR, Nelson ME, Felson DT, et al. The efficacy of home based progressive strength training in older adults with knee osteoarthritis: a randomized controlled trial. J Rheumatol. 2001;28:1655-1665.

38. O’Reilly SC, Muir KR, Doherty M. Effectiveness of home exercise on pain and disability from osteoarthritis of the knee: a randomised controlled trial. Ann Rheum Dis. 1999;58:15-19.

39. Petrella RJ, Bartha C. Home based exercise therapy for older patients with knee osteoarthritis: a randomized clinical trial. J Rheumatol. 2000;27:2215-2221.

40. van Baar ME, Dekker J, Oostendorp RA, et al. Effectiveness of exercise in patients with osteoarthritis of hip or knee: nine months’ follow up. Ann Rheum Dis. 2001;60:1123-1130.

41. Silva LE, Valim V, Pessanha AP, et al. Hydrotherapy versus conventional land-based exercise for the management of patients with osteoarthritis of the knee: a randomized clinical trial. Phys Ther. 2008;88:12-21.

42. Hinman RS, Heywood SE, Day AR. Aquatic physical therapy for hip and knee osteoarthritis: results of a single-blind randomized controlled trial. Phys Ther. 2007;87:32-43.

43. Bellamy N. WOMAC: a 20-year experiential review of a patient-centered self-reported health status questionnaire. J Rheumatol. 2002;29:2473-2476.

44. Fritz JM. Clinical prediction rules in physical therapy: coming of age? J Orthop Sports Phys Ther. 2009;39:159-161

45. Angst F, Aeschlimann A, Stucki G. Smallest detectable and minimal clinically important differences of rehabilitation intervention with their implications for required sample sizes using WOMAC and SF-36 quality of life measurement instruments in patients with osteoarthritis of the lower extremities. Arthritis Rheum. 2001;45:384-391.

46. Youden WJ. Index for rating diagnostic tests. Cancer. 1950;3:32-35.

47. Fritz JM, Wainner RS. Examining diagnostic tests: an evidence-based perspective. Phys Ther. 2001;81:1546-1564.

48. van Walraven C, Hart RG, Wells GA, et al. A clinical prediction rule to identify patients with atrial fibrillation and a low risk for stroke while taking aspirin. Arch Intern Med. 2003;163:936-943.

49. Predictors of thromboembolism in atrial fibrillation: I. Clinical features of patients at risk. The Stroke Prevention in Atrial Fibrillation Investigators. Ann Intern Med. 1992;116:1-5

50. Aujesky D, Obrosky DS, Stone RA, et al. Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med. 2005;172:1041-1046.

51. Aujesky D, Obrosky DS, Stone RA, et al. A prediction rule to identify low-risk patients with pulmonary embolism. Arch Intern Med. 2006;166:169-175.

52. Espana PP, Capelastegui A, Gorordo I, et al. Development and validation of a clinical prediction rule for severe community-acquired pneumonia. Am J Respir Crit Care Med. 2006;174:1249-1256.

53. Kuijpers T, van der Heijden GJ, Vergouwe Y, et al. Good generalizability of a prediction rule for prediction of persistent shoulder pain in the short term. J Clin Epidemiol. 2007;60:947-953.

54. Ludica CA. Can a program of manual physical therapy and supervised exercise improve the symptoms of osteoarthritis of the knee? J Fam Pract. 2000;49:466-467

CORRESPONDENCE Gail D. Deyle, PT, DSc, Orthopaedic Manual Physical Therapy Fellowship, 3551 Roger Brooke Drive, Brooke Army Medical Center, Ft. Sam Houston, TX 78234; gail.deyle@amedd.army.mil

Abstract

Background The combination of manual physical therapy and exercise provides important benefit for more than 80% of patients with knee osteoarthritis (OA). Our objective was to determine predictor variables for patients unlikely to respond to these interventions.

Methods We used a retrospective combined cohort study design to develop a preliminary clinical prediction rule (CPR). To determine useful predictors of nonsuccess, we used an extensive set of 167 baseline variables. These variables were extracted from standardized examination forms used with 101 patients (64 women and 37 men with a mean age of 60.5±11.8 and 63.6±9.3 years, respectively) in 2 previously published clinical trials. We classified patients based on whether they achieved a clinically meaningful benefit of at least 12% improvement in Western Ontario MacMaster (WOMAC) scores after 4 weeks of treatment using the smallest and most efficient subset of predictors.

Results The variables of patellofemoral pain, anterior cruciate ligament laxity, and height >1.71 m (5’7’’) comprise the CPR. Patients with at least 2 positive tests yielded a posttest probability of 88% for nonsuccess with this treatment (positive likelihood ratio=36.7). The overall prognostic accuracy of the CPR was 96%.

Conclusion Most patients with knee OA will benefit from a low-risk, cost-effective program of manual physical therapy and supporting exercise.^1,2 The few patients who may not benefit from such a program are identifiable by a simple (preliminary) CPR. After validation, this rule could improve primary patient management, allowing more appropriate referrals and choices in intervention.

Although the exact cause of knee OA is unclear, its incidence increases with age and it is particularly prevalent among women and those who are obese and have occupations requiring heavy lifting and frequent kneeling or squatting.^3-6 Lifelong sport-specific activity^7,8 and joint injury⁹ also seem to increase the risk for knee OA. Knee malalignment also may predispose people to knee OA,¹⁰ and the presence of early degenerative changes predicts progression of the disease.¹¹ The disability and pain associated with knee OA correlate with a loss of quadriceps femoris muscle strength and limited joint range of motion.^12-14

Medications and surgery carry substantial risks. Pharmacologic interventions for knee OA include nonsteroidal anti-inflammatory drugs, acetaminophen, and cyclooxygenase-2-selective inhibitors.^15-17 While each of these drugs reduces pain and improves function, potential side effects include gastrointestinal, cardiovascular, renal, and hepatic complications.^16,18-21

Effective surgical options—most appropriate for advanced OA—include high-tibial osteotomy and total knee arthroplasty (TKA). There is good evidence that arthroscopic surgery is not an effective intervention for knee OA, yielding results for pain and function equivalent to those seen with knee capsule injections of saline, tidal irrigation, and placebo surgery.^22-25 TKA reduces pain, improves function, and decreases arthritis-related costs in older individuals with advanced knee OA.^26,27 However, this procedure is not without risk.²⁸ Total knee replacement in patients younger than 55 years is associated with increased mortality.²⁹ Reported adverse outcomes of TKA include death, deep vein thrombosis, pulmonary embolus, deep wound infections,^30,31 arterial lacerations, amputations,³² postoperative ileus,³³ fractures, joint stiffness, and ligamentous instability.³⁴ Viscosupplementation reduces pain and improves function, most evident at 5 to 13 weeks posttreatment, with few reported serious complications and moderate rates of local complications.³⁵

Physical therapy is beneficial for mild to moderate OA and confers very low risk. Both physical therapy and exercise programs for OA have demonstrated benefit in a variety of settings.^36-42 As shown in 2 independently conducted randomized controlled trials (RCTs) (one placebo controlled and one with an alternate treatment comparison), manual physical therapy applied during a small number of clinical sessions and supplemented by home exercise yields large reductions in pain and stiffness and improvements in functional ability persisting to 1 year as measured on the WOMAC Osteoarthritis Index,^1,2 a validated self-report outcome instrument for OA of the hip and knee.⁴³ In these studies, 60% of subjects receiving manual physical therapy and exercise achieved more than 50% improvement in WOMAC scores (pain, stiffness, and function) postintervention. Additionally, 83% achieved more than the minimal clinically important difference (MCID) of 12% improvement.^1,2 Physical therapy and exercise combined also decreased the need for TKA and long-term medication use.^1,2

For an intervention that benefits most patients, there is clearly an interest in determining predictors of treatment failure⁴⁴ to expedite referral for alternative care. When the time or resources required to attend physical therapy appointments would create financial or personal hardships, more appropriate interventions may be home-based physical therapy exercise programs or medications and injections. Equally important, patients for whom knee OA rehabilitation is predicted to fail can be reprioritized for physical therapy aimed at coexisting conditions or injuries such as a functionally limiting impingement syndrome of the shoulder or chronic degenerative back or hip conditions.