Stepped exercise program shows benefits for knee OA

A stepped exercise program for symptomatic knee osteoarthritis (KOA) can produce “modest improvements” in symptoms at nine months, according to a new study in US veterans.

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NEW YORK (Reuters Health) – “STEP-KOA could be an efficient way to deliver exercise and physical therapy based services for people with knee osteoarthritis, since it reserves the more resource intensive ‘steps’ for people who do not make improvements earlier,” Dr. Kelli D. Allen of the Center of Innovation to Accelerate Discovery and Practice Transformation at the Durham VA Health Care System in North Carolina told Reuters Health in an email. “This could be important in health systems that are trying to maximize resources or when there is limited access to physical therapy.”

While exercise-based therapies such as PT are effective for knee OA, “the vast majority of patients with knee osteoarthritis are physically inactive, and PT is substantially underused,” Dr. Allen and her team note. “Reasons for low use of PT include limited access (related to health insurance coverage or lack of physical therapists in some settings) and the absence of evidence to determine which patients may benefit the most from PT.”

The authors randomly assigned 345 patients with symptomatic knee OA 2:1 to the STEP-KOA intervention or an arthritis education (AE) control. Patients’ mean age was 60, 15% were female and 67% were people of color.

Step one of the program consists of three months of internet-based exercise. Patients who don’t respond are moved up to step 2, which includes three months of physical activity coaching calls every other week. Non-responders went on to three to seven in-person physical therapy (PT) visits.

In the AE group, patients received educational mailings about arthritis every two weeks for nine months.

Step 1 included seven levels, with stretching and strengthening exercises and recommendations for aerobic exercise. Patients were instructed to do the exercises three times a week at minimum, and could move up a level on request if their Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score had not declined.

Sixty-five percent of patients in the STEP-KOA group moved on to step 2, and 35% advanced to step 3. At baseline, estimated mean WOMAC score was 47.5 for the entire group. It was 6.8 points lower at nine months in the STEP-KOA group compared to the controls.

As with any intervention, additional trials are needed to further evaluate in different settings and groups of patients. In addition, work is needed to evaluate how to best implement STEP-KOA in real-world health care settings,” Dr. Allen said.

She and her colleagues have received funding from the Department of Veterans Affairs Office of Rural Health to do a pilot trial of a version of STEP-KOA administered entirely by telehealth to rural veterans.

“Exercise and physical therapy are key, recommended treatments for knee osteoarthritis, but they are under-utilized,” Dr. Lee said. “STEP-KOA could be a method for health systems to efficiently deliver these services to people with knee osteoarthritis.”

Source Medscape


Stepped Exercise Program for Patients With Knee Osteoarthritis : A Randomized Controlled Trial, Allen KD, Woolson S, Hoenig HM, Bongiorni D, Byrd J, Caves K, Hall KS, Heiderscheit B, Hodges NJ, Huffman KM, Morey MC, Ramasunder S, Severson H, Van Houtven C, Abbate LM, Coffman CJ. Ann Intern Med. 2020 Dec 29. doi: 10.7326/M20-4447. Epub ahead of print.

  Further reading

Stepped exercise program for patients with knee OsteoArthritis (STEP-KOA): protocol for a randomized controlled trial, Allen KD, Bongiorni D, Caves K, Coffman CJ, Floegel TA, Greysen HM, Hall KS, Heiderscheit B, Hoenig HM, Huffman KM, Morey MC, Ramasunder S, Severson H, Smith B, Van Houtven C, Woolson S. BMC Musculoskelet Disord. 2019 May 28;20(1):254. doi: 10.1186/s12891-019-2627-8. Full text

Level of participation in physical therapy or an internet-based exercise training program: associations with outcomes for patients with knee osteoarthritis, Pignato M, Arbeeva L, Schwartz TA, Callahan LF, Cooke J, Golightly YM, Goode AP, Heiderscheit BC, Hill C, Huffman KM, Severson HH, Allen KD. BMC Musculoskelet Disord. 2018 Jul 19;19(1):238. doi: 10.1186/s12891-018-2139-y. Full text

Physical therapy vs internet-based exercise training for patients with knee osteoarthritis: results of a randomized controlled trial, Allen KD, Arbeeva L, Callahan LF, Golightly YM, Goode AP, Heiderscheit BC, Huffman KM, Severson HH, Schwartz TA. Osteoarthritis Cartilage. 2018 Mar;26(3):383-396. doi: 10.1016/j.joca.2017.12.008. Epub 2018 Jan 5. Full text

Physical therapy vs. internet-based exercise training (PATH-IN) for patients with knee osteoarthritis: study protocol of a randomized controlled trial, Williams QI, Gunn AH, Beaulieu JE, Benas BC, Buley B, Callahan LF, Cantrell J, Genova AP, Golightly YM, Goode AP, Gridley CI, Gross MT, Heiderscheit BC, Hill CH, Huffman KM, Kline A, Schwartz TA, Allen KD. BMC Musculoskelet Disord. 2015 Sep 28;16:264. doi: 10.1186/s12891-015-0725-9. Full text

Changes in body weight and knee pain in adults with knee osteoarthritis 3.5 years after completing diet and exercise interventions, Messier SP, Newman JJ, Scarlett MJ, Mihalko SL, Miller GD, Nicklas BJ, DeVita P, Hunter DJ, Lyles MF, Eckstein F, Guermazi A, Loeser RF, Beavers DP. Arthritis Care Res (Hoboken). 2021 Aug 9. doi: 10.1002/acr.24765. Epub ahead of print.

The Success of ‘e-knee school’ for Knee Osteoarthritis During COVID 19; a Game- Changing Modality for the Future, Sharma M, Dhillon MS, Singh A, Adhya B, Chalana A, Negi S. Indian J Orthop. 2020 Oct 27:1-3. doi: 10.1007/s43465-020-00237-w. Epub ahead of print. Full text

Home-based management of knee osteoarthritis during COVID-19 pandemic: literature review and evidence-based recommendations, Karasavvidis T, Hirschmann MT, Kort NP, Terzidis I, Totlis T. J Exp Orthop. 2020 Jul 19;7(1):52. doi: 10.1186/s40634-020-00271-5. Full text

Changes in physical inactivity during supervised educational and exercise therapy in patients with knee osteoarthritis: A prospective cohort study, Bartholdy C, Skou ST, Bliddal H, Henriksen M. Knee. 2020 Dec;27(6):1848-1856. doi: 10.1016/j.knee.2020.09.007. Epub 2020 Nov 13.

Structured Education and Neuromuscular Exercise Program for Hip and/or Knee Osteoarthritis: A Health Technology Assessment, Health Quality Ontario. Amanda Manoharan, Xuanqian Xie, Olga Gajic-Veljanoski, David Wells, Corinne Holubowich. Ont Health Technol Assess Ser. 2018 Nov 2;18(8):1-110. Full text

Also see
Sustainable pain control: How a knee brace helps live a pain free life OA Knee Pain UK
‘Stepped’ approach to exercise may help with arthritic knees UPI Health News
Diet, exercise in older adults with knee OA have long-term payoff MDedge

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