‘Stepped’ Approach to Exercise Can Help With Arthritic Knees

‘Stepped’ Approach to Exercise Can Help With Arthritic Knees

Millions of Americans suffer from the pain of arthritic knees. But an innovative exercise regimen may help relieve discomfort and improve knee function, a new study finds.

The program is called STEP-KOA (short for stepped exercise program for patients with knee osteoarthritis). It starts with gentle exercises at home and, if needed, moves to phone consultation and in-person physical therapy.

“STEP-KOA could be an efficient way to deliver exercise and physical therapy services for people with knee osteoarthritis, since it reserves the more resource-intensive steps for people who do not make improvements earlier,” said lead author Kelli Allen. She’s a research health scientist at the Durham VA Medical Center in North Carolina.

“This could be important in health systems that are trying to maximize resources or when there is limited access to physical therapy,” Allen said.

For the study, researchers from the Veterans Affairs Health Care System randomly assigned more than 300 patients with painful knee osteoarthritis to either STEP-KOA or arthritis education. Osteoarthritis is the most common form of arthritis in the knee. It is a degenerative, “wear-and-tear” type of arthritis.

STEP-KOA starts with an internet-based exercise program. If it is not effective, the patient moves to step two, which included twice-monthly coaching phone calls for three months.

If pain still does not improve, the patient moves to step three, which included in-person physical therapy.

Participants in the arthritis education group were mailed educational materials every two weeks.

After nine months, 65% of patients in STEP-KOA progressed to step two, and 35% went on to step three.

Compared to participants who received education only, the stepped-care group had greater improvement in pain and function, the researchers reported.

This strategy could lower health care costs and tailor programs to patients’ needs, the study authors said.

However, a prominent orthopedic surgeon called this approach backwards.

It should start instead with physical therapy and move on to patients doing exercises on their own, said Dr. Jeffrey Schildhorn of Lenox Hill Hospital in New York City.

“It seemed like this study was designed for a style of medicine that I think very few of us would appreciate,” Schildhorn said. “It was almost like you’re preparing for a future where there are limited resources, and you try to do everything remotely, and you put the responsibility on the patient,” he added.

Schildhorn noted that 90 patients dropped out of the program, and only 10% remained at step one throughout the study.

Because each patient’s knee damage and perception of pain is unique, an effective program must be individually designed, he said.

“I think that it’s imperative that people who have mild to moderate disease try to do whatever they can on their own, with or without in-person physical therapy,” Schildhorn said.

The key is to keep the joint moving with gentle exercise. A multimodal approach that includes periodic check-ins with a therapist, being shown in person how to do the movements with follow-up by phone or video chat is a viable approach, he said.

But patients need to do their exercises at home every day, Schildhorn emphasized.

“Someone who goes to physical therapy three times a week probably doesn’t do as well as someone who goes three times a week and practices on their own. The majority of the value comes with daily in-home, stretching exercises,” Schildhorn said. “If you go to physical therapy two times a week, then do nothing the other five days, there’s zero value there.”

The report was published online Dec. 29 in the Annals of Internal Medicine.

More information

Learn more about knee osteoarthritis from the American Academy of Orthopaedic Surgeons.

SOURCES: Kelli Allen, PhD, research health scientist, Durham VA Medical Center, Durham, N.C., and associate director, Durham Center of Innovation to Accelerate Discovery and Practice Transformation; Jeffrey Schildhorn, MD, orthopedic surgeon, Lenox Hill Hospital, New York City; Annals of Internal Medicine, Dec. 29, 2020, online

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Which Exercise Regimen Works Best to Ease Lower Back Pain?

Which Exercise Regimen Works Best to Ease Lower Back Pain?

Chronic lower back pain can make the most routine tasks difficult. But a new study suggests patients can learn new, practical and less painful ways to move through individualized “motor skills training,” or MST.

A two-year study of nearly 150 patients found that MST appears to better relieve disability from lower back pain than a more common but less-tailored exercise regimen broadly focused on improving strength and flexibility.

“Our findings suggest that motor skill training in functional activities is an effective and efficient treatment that results in important short-term and long-term improvement in function in people with chronic low back pain,” said study lead author Linda Van Dillen. She’s a professor of physical therapy at Washington University in St. Louis School of Medicine.

Lower back pain is incredibly common, and the No. 1 cause of disability, according to Van Dillen. It is the most frequent cause of chronic pain among American adults.

Van Dillen notes that at least 60% to 80% of adults will experience lower back pain, and “almost half of them will have had a major episode by age 30.”

Yet there is no accepted standard of care for chronic lower back pain patients, nor a clear sense of what type of exercise intervention might work best, researchers said.

To get a better handle on the issue, Van Dillen’s team focused on a pool of patients diagnosed with what is known as “non-specific” lower back pain. That means they have tension, stiffness and/or soreness in the lower back area for which there is no clear cause.

Before the study began in December 2013, all participants had struggled with lower back pain for at least a year.

Participants, who ranged in age from 18 to 60, were randomly divided into two groups. One group received “strength and flexibility treatment for the trunk and lower limbs” — a common exercise intervention, according to Van Dillen.

The other group took part in MST, which teaches patients new ways to carry out everyday tasks rendered difficult by back pain.

MST aims to zero in on each patient’s personal posture and movements throughout an entire day, and then to tailor pain-free movement strategies to their specific routines.

Both groups received six weeks of training for one hour per week. Half of each group also received three “booster” treatment sessions six months later. Disability questionnaires were completed at the outset, and at six months and one year out.

While both groups’ ability to perform daily functions without pain improved, the MST group achieved “significantly” better gains (meaning lower disability scores) over the study period.

MST patients were more satisfied with their care and less likely to use drugs for back pain. They were also less fearful of addressing work-related needs, and less likely to avoid normal daily activities, the study found.

Six months out, MST patients had fewer acute back pain flare-ups and were more likely to keep up with their exercises. And after a year, when their back pain flared up, it was less severe, researchers said.

Dr. Daniel Park, an associate professor of orthopedic surgery at Oakland University William Beaumont School of Medicine in Rochester, Mich., reviewed the findings.

He said it remains to be seen just how much better MST is compared to more common interventions.

While Park said the findings appear to be statistically significant and support the benefit of therapy on back pain, he stopped short of saying the researchers had shown “meaningful improvement.”

“I think any structured therapy can be beneficial, because you want the muscles moving and working to help with back pain,” Park said. “We used to think rest and relaxation was better. But studies show only short-term rest is beneficial, and actually if you rest too long, you can have worse outcomes.”

As a result, he added, many doctors advise patients to rest for the short term and then to begin exercising to help the muscles.

The findings were published Dec. 28 online in JAMA Neurology.

More information

Learn more about lower back pain at the U.S. National Institute of Neurological Disorders and Stroke.

SOURCES: Linda Van Dillen, PT, PhD, professor, physical therapy and orthopedic surgery, Washington University School of Medicine in St. Louis, Mo.; Daniel Park, MD, associate professor, orthopedic spine surgery, Oakland University William Beaumont School of Medicine, Rochester, Mich., director, minimally invasive orthopedic spine surgery, William Beaumont Hospital-Royal Oak, Rochester, Mich.; JAMA Neurology, Dec. 28, 2020, online

Copyright ©2020 HealthDay. All rights reserved.

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