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Physical Therapy Interventions for Knee Pain Secondary to Osteoarthritis
Comparative Effectiveness Reviews, No. 77
Investigators: Tatyana A Shamliyan, MD, MS, Shi-Yi Wang, MD, PhD, Becky Olson-Kellogg, PT, DPT, GCS, and Robert L Kane, MD.
Author Information and AffiliationsStructured Abstract
Objectives:
To assess the association between intermediate and patient-centered outcomes and harms with physical therapy interventions in community-dwelling adults with chronic knee pain secondary to osteoarthritis and to examine validity and minimum clinically important differences of the tools for outcome measurement.
Data sources:
We searched major electronic bibliographic databases including MEDLINE, the Cochrane Library, the Physiotherapy Evidence Database, and Allied and Complementary Medicine and trial registries up to February 29, 2012.
Review methods:
We performed a systematic review of randomized and nonrandomized studies published in English to synthesize rates or means of measured pain, function, and quality of life with physical therapy interventions. Observational studies provided evidence of the association between changes in knee joint functional tests and patient-centered outcomes and minimum clinically important differences in validated tools for outcome measures. We performed meta-analyses of standardized mean differences using random effects models to synthesize the evidence.
Results:
Of 4,266 retrieved references, 154 eligible references examined the association between patient-centered and intermediate outcomes and 422 eligible references examined physical therapy interventions. Of these, 193 randomized controlled trials (RCTs) reported on knee pain, disability, quality of life, and functional outcomes after physical therapy interventions. Pooling criteria were met by 84 RCTs that provided evidence for 12 physical therapy interventions on pain (n = 58), physical function (n = 36), and disability (n = 29). Most studies reported physical therapy effects at followups of 3 months or less. Evidence on longer-term physical therapy effects was available for seven intervention-outcome pairs. Meta-analyses at the longest time of followup provided low-strength evidence that aerobic (n = 11) and aquatic exercise (n = 3) improved disability; aerobic exercise (n = 19), strengthening exercise (n = 17), and ultrasound (n = 6) reduced pain and improved function. Six of 11 individual RCTs demonstrated clinically important improvements in pain and disability with aerobic exercise. Pain relief was consistent in RCTs that reported physical therapist supervision of aerobic exercise. Diathermy, orthotics, and magnetic stimulation demonstrated no benefit. Limited direct comparative effectiveness evidence demonstrated similar benefits in disability measures with aerobic, aquatic, and strengthening exercise. Evidence from individual RCTs did not permit robust conclusions about which physical therapy interventions are most effective or whether differences in effect could be attributed to patient characteristics. Patients with high compliance to exercise tended to have better treatment responses. We found no association between the duration of examined interventions and better intermediate or patient-centered outcomes. Adverse events were uncommon and not severe enough to deter participants from continuing treatment. Gait, mobility restrictions, muscle strength, and range-of-motion measures were associated with disability measures in individual studies. Minimum clinically important differences in scales were determined for 26 tools but have not been used in RCTs to examine the clinical importance of improvements. The definition of the Patient Acceptable Symptom State that accounts for patient satisfaction was available for the Western Ontario McMaster Universities Osteoarthritis Index, the Visual Analog Scale for Pain, and the Patient Global Assessment Scale.
Conclusions:
Low-strength evidence suggested that core physical therapy interventions, including aerobic, aquatic, strengthening, and proprioception exercise, improved patient outcomes. Risk of bias in studies and heterogeneity in populations and physical therapy interventions downgraded the strength of evidence to low or moderate in most cases. Studies focused on a single modality of physical therapy rather than the combinations typically used in practice. Benefits with physical therapy interventions were not consistently evaluated according to the clinical importance of improvement in scales and tests. Adverse events were uncommon and not severe enough to deter participants from continuing treatment. Evidence about long-term adherence to and benefits of available physical therapy interventions is lacking.
Contents
- Preface
- Acknowledgments
- Key Informants
- Technical Expert Panel
- Executive Summary
- Introduction
- Methods
- Results
- Key Question 1 What are the effectiveness and comparative effectiveness of available physical therapy interventions (without drug treatment) for adult patients with chronic knee pain due to OA on intermediate and patient-centered outcomes when compared to no active treatment or another active physical therapy modality?
- Key Question 1a Role of Patient Characteristics on Outcomes
- Key Question 1b Association between the dose/intensity/frequency of examined interventions and intermediate/patient-centered outcomes
- Key Question 1c Association between the duration of examined interventions and intermediate/patient-centered outcomes
- Key Question 2 What is the association between changes in intermediate outcomes with changes in patient-centered outcomes after physical therapy interventions?
- Key Question 2a What is the validity of the tests and measures used to determine intermediate outcomes of physical therapy on OA in association with patient-centered outcomes?
- Key Question 2b Which intermediate outcomes meet the criteria of surrogates for patient-centered outcomes?
- Key Question 2c What are minimum clinically important differences of the tests and measures used to determine intermediate outcomes?
- Key Question 3 What are the harms from physical therapy interventions for adult patients with chronic knee pain due to osteoarthritis, when compared to no active treatment or active controls?
- Summary and Discussion
- References
- Abbreviations
- Appendix A Literature Search Strings
- Appendix B Excluded Studies
- Appendix C Ongoing Studies of Physical Therapy Interventions
- Appendix D Review Questions According to Population, Intervention, Comparator, Outcomes, Timing, and Settings (PICOTS) Framework
- Appendix E Data Abstraction Forms
- Appendix F Evidence Tables and Figures
Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. 290-2007-10064-I, Prepared by: Minnesota Evidence-based Practice Center, Minneapolis, MN
Suggested citation:
Shamliyan TA, Wang S-Y, Olson-Kellogg B, Kane RL. Physical Therapy Interventions for Knee Pain Secondary to Osteoarthritis. Comparative Effectiveness Review No. 77. (Prepared by the Minnesota Evidence-based Practice Center under Contract No. 290-2007-10064-I.) AHRQ Publication No. 12(13)-EHC115-EF. Rockville, MD: Agency for Healthcare Research and Quality; November 2012. www.effectivehealthcare.ahrq.gov/reports/final.cfm.
This report is based on research conducted by the Minnesota Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2007-10064-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.
This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.
None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.
- 1
540 Gaither Road, Rockville, MD 20850; www
.ahrq.gov
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