Physical Therapy for Knee OA: What is the Evidence?

Department of Physical TherapyDepartment of Orthopaedics

Whitney A Meier, PT, DPT, OCS, COMT

3rd Annual Sports Medicine Symposium: The Weekend Warrior

Evidence Based Recommendations

• MOVE Consensus Statement (2005):Rheumatology 2005;44:67–73

– Strengthening and aerobic exercises• NICE Guidelines (2008 and 2014):National Institute for Health and Care

Excellence 2014 UK

– Exercise is the core treatment– Include strengthening, general aerobic fitness, and manual

therapy– Weight loss

• AAOS(American Academy of Orthopaedic Surgeons) Guidelines – Self management programs, strengthening, low-impact aerobic

exercises, and neuromuscular– education; and engage in physical activity– Weight loss >= 25 BMI

•

Evidence Based Recommendations

• ACR (America College of Rheumotology)Guidelines (2012):– Exercise is the core treatment– Include strengthening, general aerobic fitness, and manual

therapy– Weight loss

• OARSI (OA Research Society International)Guidelines (2014):– Land-based exercise– Weight management– Strength training– Water-based exercises– Self-management and education

Evidence Based Recommendations

OARSI: Land-Based-Level of Evidence: Systematic Review and Meta-Analysis-Quality of Evidence – GOOD

1. Aerobic Activity2. Active ROM3. Strength Training

Evidence Based Recommendations

OARSI: Land-Based1. Mixed physical therapy: (education, strengthening, balance)

1. Escape-knee pain program: 15-20 min discussion of coping strategies2. 30-45 minutes strengthening and balance training3. 2 x per week for 6 week4. Discharge to HEP

2. At 6 weeks1. Physical function (WOMAC) significantly better in exercise group vs usual

care control

3. At 30 months1. General decline in initial gains but better WOMAC compared to control

Hurley et al, 2012 Arthritis Care Res

Exercise Land-based

• 2008: Cochrane Review (Fransen M and McConnell S)

• 2009: Meta-analysis of RCT (Fransen and McConnells S)

– 32 RCT, 3800 individual– Land-based vs. no exercise– Self report benefit in knee pain (SMD 0.40, 95% CI 0.30 to 0.50)

and physical function

• 2012: Systematic Review (Roddy E etal)

– Aerobic walking(3) vs home-based quadriceps strengthening(9) and Combined(1)

– Both reduced pain vs Usual care– Neither is better than the other

Exercise Aerobic Programs

• 1997: FAST (The Fitness Arthritis and Senior Trial)– 365 Participant– Aerobic vs Resistance vs Control(health education)– 3 x/wk for 12 wks -> 15 month walking program– Aerobic Group better in:

• Less knee pain • Faster 6MW and the “Time Lift to Carry”• Faster Stair Climb Test and Car Transfer Time

Evidence

Strength Training

• OARSI Strength Training

– Good Evidence

– Decrease pain and improved function

• 2004 Meta-analysis RCT(Pelland et al)

• 2009 Cochrane Database SR of PRT(Latham and Liu)

– Decrease pain

– Improved function

– Improved quadriceps strength

• 2011 Meta-Analysis RCT and Systematic Review:

– Recommend LE strength, specifically quadriceps

– Both body weight and non body weight

– Group and individualized programs

Aquatherapy: The Evidence

• 2007: Cochrane Review (Bartels et al.)

– 6 studies: non very robust

– Knee and / or Hip Osteoarthritis (1 study for knee OA was included)

– Small to moderate effect on function and quality of life

• 2011: Systematic Review and Meta-Analysis (Batterham et al.)

– Aquatic a good alternative when people have difficulty with land based exercises(biking, walking, jumping, strengthening)

Exercise: Type

• Quadricep weakness -> function and disability– High intensity (>70%-1RM) more effective– High vs low speed(power) -> no difference– Dynamic vs isometric-> no difference– Vibration -> same as control– Weight bearing versus Non Weight bearing =Both

• Specific: – First priority on lower extremity exercises– Second stretching, ROM, balance

Exercise: Dosage

• 2007: American College of Sports Medicine and American Heart Association Guidelines (Nelson ME,

et. al.) and 2001 American Geriatrics Society– Aerobic

• 3-5 days/week; 50-60% HR max; 20-30 min

– Strength training• 8-10 exercises (major muscle groups)• 6-15 reps

– Flexibility• 3-5 days/ weeks

Manual Therapy and Exercise: The evidence

• 2000: Effectiveness of Manual Physical Therapy and Exercise in Osteoarthritis of the Knee (Deyle et. al.) Annal of Internal Med.

– 83 individual; 42 MT + Exercise, 41 Placebo– Significant improvement in MTE group in WOMAC, 6MW at 8 wk– Significantly few surgeries in MTE at 1 yr (5% vs. 20%)

Manual Therapy and Exercise:

The Evidence

• 2005: Physical Therapy treatment Effectiveness for

Osteoarthritis of the knee: A Randomized comparison of

Supervised Clinic Exercises and Manual therapy

Procedures Versus a Home Exercise Program. (Deyle, et al)

Physical Therapy

– 120 individuals (60 MTE, 60 HEP)

– Significant improvement in both groups WOMAC at 4 weeks

• (52% MTE vs. 26% HEP)

– Significant improvement in both groups 6MW at 4 weeks

– Improved over baseline with exercise program at 1 yr

Manual Therapy and Exercise:

The Evidence

• 2013: MOA(Management of Osteoarthritis) Trial, RCT

Osteoarthritis and Cartilage (Abbot, et al)

– Manual Therapy vs. Exercise Therapy vs. Combination vs. Usual Care

– Take Home Message:

• All Physical Therapy groups superior to Usual Care, effects lasted

to 1 yr.

• Manual Therapy superior to Ex or Combo for knee OA

• 2015: The Incremental Effects of Manual Therapy or

Booster Sessions in Additions to Exercise Therapy for

Knee OA, RCT JOSPT(Abott, et al)

– Booster sessions over a year better; then 12 in a row

– Addition of MT + exercise better than just exercise for knee OA

Manual Therapy: The evidence

• 2008: RCT Manual Therapy(Pollard H, et al)– 43 subjects– 3 x /wk for 2 wks– Decrease in pain and improved subjective function after 2 wks of

treatment• 2018: Systematic Review and Meta-analysis (Anwer S, Etal)

– Knee OA only– 11 RCT, 494 subjects– MT vs Exercise significantly better in VAS, WOMAC Pain,

WOMAC function– Significantly better in negotiating stairs

Weight Loss: The evidence

Strongly Recommended

OARSI:– Level of Evidence Systematic Review

– Quality : good

1. Improved disability with >5.1% weight reduction

2. Most effective combine calorie restriction, increase physical

activity, behavior reinforcement, support from groups and

physician

Evidence Based Maybe Recommended

OARSI:-Level of Evidence: Systematic Review of RCT-Quality of Evidence – FAIR

1. Knee braces/sleeves or foot orthoses2. Cane (walking stick)

Evidence BasedNot recommended

OARSI:Level of Evidence: SR and Meta-analysisQuality of Evidence –Fair to low to very low

1. Electrotherapy/NMES Maybe evidence weak2. Transcutaneous electrical nerve stimulation (TENS)short term???[3. Ultrasound Maybe short term??4. Low Level Laser Therapy -> decrease pain compared to controls 1 study5. Short Wave Diathermy6. Heat/cold

Physical Therapy:Conclusion

• Exercise (aerobic and strengthening) are the KEYS in the management of Knee OA

• Exercise adherence is important to success

• > 12 supervised visits may improve success

• Aqua therapy may be beneficial for those who can not exercise on land

• Manual Therapy techniques may augment exercise therapy

• Weight Loss if possible

References:• E. Roddy, W. Zhang, M. Doherty, N. K. Arden1, J. Barlow2, F. Birrell3, A. Carr, K. Chakravarty4, J. Dickson5, E. Hay6, G. Hosie7, M. Hurley8, K. M. Jordan1, C.

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