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Deyle GD, Allen CS, Allison SC, et al. Physical Therapy versus Glucocorticoid Injection for Osteoarthritis of the Knee. N Engl J Med. 2020 Apr 9;382(15):1420-1429. doi: 10.1056/NEJMoa1905877. (Original study)
Abstract

BACKGROUND: Both physical therapy and intraarticular injections of glucocorticoids have been shown to confer clinical benefit with respect to osteoarthritis of the knee. Whether the short-term and long-term effectiveness for relieving pain and improving physical function differ between these two therapies is uncertain.

METHODS: We conducted a randomized trial to compare physical therapy with glucocorticoid injection in the primary care setting in the U.S. Military Health System. Patients with osteoarthritis in one or both knees were randomly assigned in a 1:1 ratio to receive a glucocorticoid injection or to undergo physical therapy. The primary outcome was the total score on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at 1 year (scores range from 0 to 240, with higher scores indicating worse pain, function, and stiffness). The secondary outcomes were the time needed to complete the Alternate Step Test, the time needed to complete the Timed Up and Go test, and the score on the Global Rating of Change scale, all assessed at 1 year.

RESULTS: We enrolled 156 patients with a mean age of 56 years; 78 patients were assigned to each group. Baseline characteristics, including severity of pain and level of disability, were similar in the two groups. The mean (±SD) baseline WOMAC scores were 108.8±47.1 in the glucocorticoid injection group and 107.1±42.4 in the physical therapy group. At 1 year, the mean scores were 55.8±53.8 and 37.0±30.7, respectively (mean between-group difference, 18.8 points; 95% confidence interval, 5.0 to 32.6), a finding favoring physical therapy. Changes in secondary outcomes were in the same direction as those of the primary outcome. One patient fainted while receiving a glucocorticoid injection.

CONCLUSIONS: Patients with osteoarthritis of the knee who underwent physical therapy had less pain and functional disability at 1 year than patients who received an intraarticular glucocorticoid injection. (ClinicalTrials.gov number, NCT01427153.).

Ratings
Discipline Area Score
Family Medicine (FM)/General Practice (GP) 7 / 7
General Internal Medicine-Primary Care(US) 7 / 7
Physical Medicine and Rehabilitation 6 / 7
Rheumatology 6 / 7
Internal Medicine 6 / 7
Comments from MORE raters

Family Medicine (FM)/General Practice (GP) rater

The evidence is slowly moving us away from routine intra-articular corticosteroid injection for knee osteoarthritis, but note the short-term improvement in WOMAC scoring for knee injections, which is attractive to many of our patients. In a perfect world, physical therapy would be inexpensive and easy to access. For many of our patients, this is not the case. In the post-COVID-19 world, will "hands on" physical therapy be acceptable still? Finally, this study evaluated these interventions as separate, rather than complementary. Nonetheless, this is a study worthy of our attention.

General Internal Medicine-Primary Care(US) rater

This trial is relatively small, the patients were not blinded and there was no sham injection, so patient expectation of benefit may have affected their perceived benefit from the intervention.

General Internal Medicine-Primary Care(US) rater

This is very relevant for primary care and determines where someone with knee pain is referred.

Internal Medicine rater

I don`t think most people think steroids have a long-term effect.

Internal Medicine rater

Insurance companies pay for injections, but they are often extremely stingy with physical therapy. This limits the number of sessions and large co-payments are requested. This study provides compelling reason to pay for PT and avoid the complications of injections. I suspect that PT may be more enduring than injections if patients continue the exercises. It would have been interesting to have a group that received both injections and PT.

Internal Medicine rater

This is right up a primary care physician`s alley and is a top 10 common complaint encountered. Getting patients to comply with an active therapy as opposed to a passive therapy is the challenge.

Physical Medicine and Rehabilitation rater

Physical therapy demonstrated greater improvement in the WOMAC and functional tasks over one year than intra-articular steroid injections in patients with symptomatic and radiologically demonstrated knee osteoarthritis.
Comments from EvidenceAlerts subscribers

Dr. Martin Kuersten (5/1/2020 12:44 PM)

Several individuals demonstrate an outdated understanding of PT. PT doesn't require continuous sessions with a physical therapist. Management for most chronic conditions should consist of one session for evaluation and development of a home exercise program, and then 1-2 follow-up sessions at 1-3 month intervals to re-assess and modify as needed. Not only is this more cost-effective than knee injections in the long-term, it also empowers patient autonomy. Unfortunately, there are still many patients who request injections because of the perceived immediate benefit, and many clinicians who are willing to provide injections (probably for economic reasons) even though evidence doesn't support long-term benefits.

Miss. Kim Heckmann (5/1/2020 9:05 AM)

How about a third arm in the study - physical therapy and cortisone injections? I think limiting conservative treatment of degenerative arthritis to one or the other is a disservice to our patients. How about considering topical NSAID's, and bracing options as well?

Dr. Tracy Kish (4/18/2020 7:18 AM)

It would be excellent if the authors clearly described in the abstract the type of therapy, frequency, and duration of the physical therapy.