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, GD, Allison SC, Matekel RL, Ryder MG, Stang M, Gohdes DD, Hutton JP, Henderson NE, Garber MB. Physical Therapy. 2005;12:1301-1317.

This is the editor's interpretation of a paper published in the orthopaedic literature in 2005 - our attempt to make relevant medical articles accessible to lay readers. If you wish to read the original it is easy to ask your librarian to obtain a reprint for you from any medical library.


This multi-author paper published the outcomes of a study to determine whether exercise helps the patient with knee osteoarthritis with respect to pain, stiffness and functional ability. The researchers also sought to determine whether there is any difference between a home-based regime and a fully supervised exercise and manual therapy programme in a clinical setting.

For inclusion in the study, patients needed to fulfil one of these groups:

  • knee pain and crepitus (crackles) with active motion, and morning stiffness of 30 minutes or less, in a person 38 years or older
  • knee pain and crepitus with active motion, and morning stiffness of 30 minutes or more, and bony enlargement of the knee
  • knee pain with no crepitus, and with bony enlargement

These criteria had been found in a previous study to be 89% sensitive and 88% specific (ie. anyone with one of these three sets of criteria has a good chance of having OA of the knee).

134 patients with osteoarthritis of the knee (OA) and who fulfilled certain criteria for OA (see box) were entered into the study. They were randomly assigned to the clinical treatment group (66 patients) or the home exercise group (68 patients).

X-rays were also taken to assess the OA - sunrise views, and weight-bearing AP and lateral views - and the degree of OA was given a radiological severity score from 0 (least severe) to 4 (most severe). Then finally, all the patients entering the study were examined using a standardised examination procedure that included - manual examination of lower spine, hip, knee and ankle manual muscle testing simple functional tests (eg squats, step-ups) active and passive ROM.

 

The exercise programme

The clinical treatment patients each had eight sessions. A physiotherapist supervised the exercise regime. Their treatment programme consisted of two elements:

  • individualised manual treatment - including stretches, soft tissue mobilisations and passive movements
  • standardised exercise programme - including range of motion (ROM) exercises, musicle strengthening, muscle stretching and the stationary bike.

The programme was adjusted up or down depending on the patient's clinical tolerance.

The home treatment group were instructed in the exercise regime and also received handouts. They did not attend the manual therapy sessions. Their exercise logs were examined and their programmes adjusted up or down according to their tolerance, as for the other group.

Both groups also took daily walks, gradually building up pace and distance.

 

Assessment

The main assessment tool was the scoring system known as WOMAC. This scoring system has 24 questions designed to check the patient's own assessment of pain, stiffness and dysfunction (difficulty doing ordinary things one normally can do). This scoring system is one that is widely used for assessing OA as it was specifically designed for this purpose and is deemed to be reliable.

The secondary assessment tool was a timed 6-minute walk, testing how far patients could walk in 6 minutes.

The WOMAC and 6-minute walk were measured in both groups at four weeks, after they had each been doing one or other exercise programme. After this both groups adhered to the same home programme, and they were assessed again at the eight week stage. The study was now basically complete. The researchers found that by the eight week stage 9% of those who had been in the original supervised programme had dropped out, and 12% had dropped out who had only done the home programme. This had left 60 in each group who had reached the eiight week mark.

Of this 120, only 94 were still availlable after one year when the patients were requested to come back and do a final WOMAC and 6-minute walk.

For readers who are interested the paper publishes full details of the supervised treatment programme.

 

Results

Both groups showed subjective and objective improvements at four weeks. The WOMAC score in the supervised treatment group had improved by 52% and the home exercise group had improved by 26%. The 6-minute walk improved by 10% in both groups.

At eight weeks and one year both groups still showed substantial improvement over their baseline results, but at the one year mark there was no difference between the two groups. Overall the clinical treatment group had taken less medication and were more satisfied with their improvement.

 

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