Conference Coverage
BOSTON – Improvements in pain, stiffness, and physical function that occur with the addition of exercise therapy or manual therapy to usual care for patients at all stages of osteoarthritis extended out to 2 years in a randomized, controlled trial.
Although evidence already supports the use of exercise therapy or manual therapy for improving the symptoms and physical function of patients with osteoarthritis (OA), the trial is the first to show that either intervention provides benefits over and above that of usual care during the course of 2 years of follow-up.
Dr. Haxby Abbott
The investigators, led by Dr. Haxby Abbott of the University of Otago, Dunedin, New Zealand, randomized 206 patients who met American College of Rheumatology criteria for knee or hip OA to usual care alone, exercise therapy plus usual care, manual therapy plus usual care, or both interventions plus usual care.
Those who received one or both of the interventions underwent 10 treatment sessions, including 7 sessions within the first 9 weeks plus 3 booster sessions (2 at 4 months and 1 at 13 months). Between and after those sessions, participants carried out the interventions on their own.
Mean age of the patients was 66 years. The spectrum of OA ranged from mild to severe, with a mean Western Ontario and McMaster Universities (WOMAC) OA index score of 100.8. The patients had been recruited to the trial from primary care and orthopedic services, the investigators reported at the annual meeting of the American College of Rheumatology.
Exercise therapy consisted of strengthening, range-of-motion, neuromuscular coordination, and aerobics activities; manual therapy consisted of skilled passive movement to joints applied by external force. Physical therapists guided both interventions in one-on-one visits.
The 1-year results, which were published in 2013, showed significant decreases in pain and improvements in physical function in both single-intervention groups, but no significant improvement in the combined therapy group ( Osteoarthritis Cartilage 2013;21:525-34 ).
Among the 186 patients who still remained in the study at 2 years of follow-up, scores on the WOMAC – the trial’s primary outcome – improved by 31.7 points in those who received exercise therapy plus usual care, compared with usual care alone, while patients receiving manual therapy in addition to usual care showed a relative improvement of 30.1 points. While the difference in WOMAC improvement for participants receiving combined exercise therapy and manual therapy in addition to usual care did not meet the a priori threshold for clinical significance (28 points), there was a trend toward benefit, with this group improving 26.2 points more than usual care only.
In all three intervention groups, Dr. Abbott noted that those changes represented greater than 20% declines in WOMAC scores from baseline.
In a planned subanalysis that did not include the approximately 20% of patients in each group who had joint replacement surgery, there was still an improvement in scores from baseline to 2 years, whereas those who received usual care alone were 20% worse, he said.
The effect sizes in the exercise group (0.57), manual therapy group (0.55), and combined therapy group (0.55) were substantially better than were the effect sizes of 0.30-0.35 normally attributed to nonsteroidal anti-inflammatory drugs, Dr. Abbott said. When patients with joint surgery were dropped from the analysis, those effect sizes grew to as high as 0.70 in the manual therapy group.
On the second primary outcome of several physical performance tests (timed up-and-go, 40-meter fast-paced walk, and 30-second sit-to-stand), the participants in the exercise therapy group showed greater mean changes than did patients in the other groups.
The Health Research Council of New Zealand funded the trial. None of the investigators had disclosures.