In Osteoarthritis of the Knee, Physical Therapy Reduced Pain and Functional Disability Compared with Glucocorticoid Injection at 1 Year

Question: In adults with osteoarthritis (OA) of the knee, how do physical therapy (PT) and intra-articular glucocorticoid injection compare for pain and functioning? Design: Randomized (allocation concealed), blinded (data collectors and data analysts), controlled trial with 1 year of follow-up. Setting: PT, orthopaedic, and rheumatology clinics in 2 large military hospitals in the U.S. Patients: 156 patients empty set38 years of age (mean age, 56 years; 52% men) who had radiographic evidence of OA and met American College of Rheumatology clinical classification criteria for OA of the knee. Exclusion criteria included glucocorticoid injection or physical therapy for knee pain in the past 12 months. 96% of patients completed follow-up. Intervention: Patients were allocated to PT (n = 78) or glucocorticoid injections (n = 78). PTwas delivered by boardcertified physical therapists with fellowship training in ortho-paedic manual PT and comprised instructions with images for exercises, joint mobilization, and information about the clinical reasoning underlying treatment. Clinical sessions typically included hands-on manual (passive movement) techniques by the therapist, followed immediately by patient-performed reinforcing exercises. The reinforcing exercises were also performed at home on days when patients did not have clinical treatment. Patients had up to 8 treatment sessions during the first 4 to 6 weeks, with up to 3 sessions at the time of the 4 and 9-month assessments. Glucocorticoid therapy comprised an intra-articular injection of 1 mL of triamcinolone acetonide (40 mg/mL) and 7mL of 1% lidocaine in 1 or both knees administered by orthopaedists or rheumatologists. Patients in the glucocorticoid group could receive additional injections at the 4 and 9-month assessments for a total of 3 injections in the year. Main outcome measures: The primary outcome was pain, function, and stiffness (total Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC] score) at 1 year. Secondary outcomes included functioning (TimedUp andGo test and Alternate Step Test), failure to achieve empty set12% improvement on theWOMAC, Global Rating of Change scale score, and adverse events at 1 year. Main results: The efficacy results are shown in Table I. 1 patient fainted while receiving a glucocorticoid injection; there were no other adverse events. Conclusion: In adults with OA of the knee, PT reduced pain, stiffness, and functional disability compared with intra-articular glucocorticoid injections at 1 year.