medwireNews: People with symptomatic knee osteoarthritis (OA) who undergo physical therapy have greater reductions in pain and functional disability over 1 year than those given intra-articular glucocorticoid injections, randomized trial results suggest.
As reported in The New England Journal of Medicine, the 78 participants from the US Military Health System who were randomly assigned to receive supervised physical therapy experienced an improvement in average total WOMAC score from 107.1 points at baseline to 37.0 points at the 1-year follow-up.
By comparison, their 78 counterparts who were instead given up to three injections of triamcinolone acetonide 40 mg over the 1-year period experienced an improvement from 108.8 to 55.8 points, giving a significant between-group difference of 18.8 points favoring physical therapy.
Gail Deyle (Brooke Army Medical Center, San Antonio, Texas, USA) and co-investigators explain that physical therapy comprised up to eight supervised treatment sessions over an initial 4–6 week period, with one to three possible additional sessions at the 4- and 9-month assessment visits, and “included instructions and images for exercises, joint mobilizations, and the clinical reasoning underlying the priorities, dosing, and progression of treatment.”
The team also found that patients in the physical therapy group were more likely to experience a minimal clinically important improvement in WOMAC score at the 1-year follow-up than those given glucocorticoid injections, with 10.3% and 25.6%, respectively, failing to meet the threshold of a 12% improvement.
Moreover, a number of secondary outcomes, including measures of functional tasks and patient-reported improvements, “also favored physical therapy,” say Deyle and colleagues.
They report that none of the participants experienced adverse events, with the exception of one individual who fainted during glucocorticoid injection administration.
Commenting on the trial results in an accompanying editorial, Kim Bennell (University of Melbourne, Victoria, Australia) and David Hunter (University of Sydney, New South Wales, Australia) say that “several issues” merit consideration, including participants in the physical therapy group having “considerably greater contact time with clinicians than patients in the glucocorticoid injection group.”
Furthermore, “because the trial was conducted in a U.S. military population, the generalizability of the conclusions may be limited,” they add.
Bennell and Hunter say that the trial findings “do not exclude a role for joint injection for treatment of a flare of acute pain, as acknowledged in guideline recommendations, but the implication could be that injections should not be used first, nor should they be used in place of a physical therapy program that includes exercise to manage symptoms of osteoarthritis of the knee.”
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N Engl J Med 2020; 382: 1420–1429
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