A Review of Non-Exercise Interventions for Knee OA
Annemarie Erich, SPT
My motivation for this project was sparked during my first clinical at the VA Hospital in Salisbury, NC. I worked in an outpatient rehabilitation facility affiliated with the hospital there for two months. Our patient population was mostly comprised of men over 50 who typically had extensive problem lists with many concomitant musculoskeletal issues. These patients were among the first on which I practiced PT evaluation skills with my main reference point being young, healthy classmates. Day after day I examined osteoarthritic knees that were stiff, painful, and frankly, loud. The disease process was having a major impact on the patients ability to exercise and preform activities of daily living. Each patient had a one of three different stories to tell regarding their treatment plan for knee osteoarthritis (OA). Some were going to receive an injection (usually steroid or hyaluronic acid) in the near future and in hopes their problems were going to be resolved. Or, they had already received and injection 2 weeks ago that worked wonders on their pain and stiffness allowing them to be more active than they had in quite some time. Then, there were those who were not so lucky. These patients had received multiple injections over several years with no noticeable benefit.
At times the results of our exercise-based interventions were less than desirable, leaving patients asking my CI and myself; what’s next? I didn’t know the answer. I was puzzled by what seemed a multitude of different treatment options (Synvisc, PRP, corticosteroids, etc.). Why did some patients get results when others did not? I decided to look deeper into this issue for my capstone project.
OA is a disease process causing the breakdown of articular cartilage and eventually the underlying bone. The knee joint is among the most common joints to develop the typical symptoms of pain, swelling, stiffness, decreased motion, and/or clicking or cracking sound during movement (1). People of all ages can have OA, but it occurs most often in people over 65 (1-2). When conservative treatments fail, there are many other interventions available for treating OA in the knee.
A large majority of care for OA occurs in a primary care setting (2). Though physical therapists are not necessarily primary care providers, patients often look to us for answers about treatment options related to joint pain. While we respond with a referral to an MD, we can also provide generalized education on treatment options without making concrete recommendations. Arthritis is one of the leading causes of disability in the US with osteoarthritis being the most common form affecting approximately half of the adult population. Managing this chronic condition is highly important given its significant impact on the ability and function of those affected (2).
There is a wealth of information published about non-exercise treatment for knee OA. These publications include five treatment options on which I’ve chosen to focus this project. Three interventions are delivered through intra-articular injection. Viscosupplementation is the attempt to restore the degenerated cartilage via injection of hyaluronic acid (HA) into the joint (3). In similar fashion, corticosteroid injections, a widely used procedure, are administered in hopes to decrease pain and inflammation of the joint (4). A third injection option is platelet rich plasma (PRP), a fairly new treatment in the orthopedic world, involving injection of concentrated blood components into the joint space in hopes to accelerate the healing process (5).
The other two interventions are surgical procedures to restore the physical structure to the joint. First is the osteochondral autologous transplant (OATS) procedure, which replaces defective joint surfaces with cartilage/bone plugs from non-weight bearing joint surfaces (6). Finally, autologous chondrocyte implantation (ACI) involves filling the cartilage defect with chondrocytes and placing a biomembrane patch to hold the cells in place (7).
The purpose of this project was to provide an update of the available literature on these five non-exercise treatment options for practicing therapists. Additional, products will provide clinicians with a patient education handout to deliver information about OA, explain treatment options, and provide resources for more information.
Gathering the Evidence
During EBP II, I completed a critically appraised topic on a related question. I asked which treatment option, exercise interventions or intra-articular treatment, was better at decreasing disability in those with OA. This was a step towards finding the body of literature that would prove helpful for my capstone. In the spring, I researched more focused questions about the five treatment options above and found that many researchers have been interested in these topics for over three decades.
I chose to create an evidence-based Voicethread presentation describing and summarizing the current evidence on the five non-exercise interventions for knee OA for clinicians in the outpatient physical therapy group at UNC. I chose this audience because busy clinicians often have limited time to do in depth research on the newest treatments available.
In preparation for the Voicethread, I created an evidence table with 3-5 articles per intervention including some that compare between interventions. As my CI at the VA experienced, clinicians are often questioned by patients about available treatments beyond the exercise interventions they receive in physical therapy. I decided that a patient handout with brief, simple explanations of each procedure would be a nice way to thank clinicians for viewing and evaluating my work.
Lastly, Jon Hacke,PT, DPT, MA, OCS and professor of MSK 2 has agreed to add the Voicethread presentation to the resource section on Sakai for students to view this coming fall semester.
I sought feedback from Mike Gross, PT, PhD, FAPTA, Jenn Cooke, PT, DPT, and Yvonne Golightly, PhD via email, in-person meetings, and phone calls. The outpatient physical therapy group at UNC will be evaluating the Voicethread presentation soon via online survey. A summary of the evaluations can be found here.
This process has taught me a lot about looking into the pros and cons of any intervention. Research articles typically have a limited scope and we must be careful not to generalize results that cannot be applied to our patient population. We must look at factors as: how does the treatment work, who has it been tested on, do the risks outweigh the potential benefits?
I have learned a few things about myself during this project as well. I set deadlines, and then life got in the way. I let other academic pursuits have priority and struggled to stay accountable to myself to chip away at this project throughout the semester. Working in pairs or with a group of my peers may have been a better choice for added accountability partnerships. Though the last stretch of project completion has been challenging, I was able to stay calm and work towards the finished product.
I am indebted to my committee members, Jenn Cooke PT, DPT and Yvonne Golightly, PhD for their input and provision of resources in the beginning stages as well as their communication throughout the project timeline. I left every meeting/phone call feeling much more optimistic than I was prior to speaking with them. I also want to thank my capstone advisor, Mike Gross, PT, PhD, FAPTA for helping me lay the groundwork for and providing quick, helpful feedback when I needed it most.
- Lai L, Stitik T, Foye P, Georgy J, Patibanda V, Chen B. Use of Platelet-Rich Plasma in Intra-Articular Knee Injections for Osteoarthritis: A Systematic Review. PM&R. 2015;7(6):637-648. doi:10.1016/j.pmrj.2015.02.003.
- Nelson A, Allen K, Golightly Y, Goode A, Jordan J. A systematic review of recommendations and guidelines for the management of osteoarthritis: The Chronic Osteoarthritis Management Initiative of the U.S. Bone and Joint Initiative. Seminars in Arthritis and Rheumatism. 2014;43(6):701-712. doi:10.1016/j.semarthrit.2013.11.012.
- Evanich J, Evanich C, Wright M, Rydlewicz J. Efficacy of Intraarticular Hyaluronic Acid Injections in Knee Osteoarthritis. Clinical Orthopaedics and Related Research. 2001;390:173-181. doi:10.1097/00003086-200109000-00020.
- Bellamy N, Campbell J, Robinson V, Gee T, Bourne R, Wells G. Intraarticular corticosteroid for treatment of osteoarthritis of the knee. The Cochrane Database of Systematic Reviews. 2005. doi:10.1002/14651858.cd005328.
- Khoshbin A, Leroux T, Wasserstein D et al. The Efficacy of Platelet-Rich Plasma in the Treatment of Symptomatic Knee Osteoarthritis: A Systematic Review With Quantitative Synthesis. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2013;29(12):2037-2048. doi:10.1016/j.arthro.2013.09.006.
- Chow J, Hantes M, Houle J, Zalavras C. Arthroscopic autogenous osteochondral transplantation for treating knee cartilage defects: A 2- to 5-year follow-up study. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2004;20(7):681-690. doi:10.1016/j.arthro.2004.06.005.
- Harris J, Siston R, Pan X, Flanigan D. The Journal of Bone and Joint Surgery (American). 2010;92(12). doi:10.2106/jbjs.j.00049.