OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Chad Krueger, MD, in response to a recent study in the Annals of Internal Medicine.
Few disease processes are as prevalent within the United States as hip and knee osteoarthritis (OA). While OA is commonly thought to be a disease of older age, the reality is that over half of all individuals with knee arthritis are younger than 65. While some of those individuals will eventually go on to have a knee arthroplasty, before that, most OA patients try various other treatments in an effort to decrease pain and increase function. Medications such as NSAIDs and others are certainly a part of these treatment efforts, but nonpharmacologic treatments are also widely recommended.
However, as Bennell et al. clearly state in their Annals article, patients face multiple barriers to the implementation of these nonoperative, nonpharmacologic modalities, including cost and transportation to relevant clinical specialists. The authors used these barriers as the rationale for a randomized trial in which an intervention group of knee OA patients received Internet-based educational material, online pain-coping skills training, and videoconferencing with a physiotherapist who provided individualized exercises for each patient. A control group received only the educational material.
At 3 and 9 months, both groups showed improvements in pain and function, but the intervention group had significantly greater improvements than the control group. More importantly, the people in the intervention group largely adhered to all online programs on their own and were very satisfied with the prescribed treatments, especially the video-based physiotherapy component.
Internet-based health interventions are certainly not new. However, my suspicion is that 20 years from now we will look back and wonder why we did not use them more often. They are self-directed, cost-effective, reproducible, and available to any of the 87% of Americans over the age of 50 who, according to the Pew Research Center, use the Internet. These online interventions require no driving to an office, and patients can easily track their own progress by seeing how many modules they have completed.
While there are certainly limitations to the findings from Benell et al., as an accompanying editorial by Lisa Mandl, MD points out, the study serves as a very strong proof of concept that should be expanded upon. Dr. Mandl herself proclaims that “these results are encouraging and show that ‘telemedicine’ is clearly ready for prime time.”
With the number of ways we “stay connected” always increasing, it seems important for orthopaedists to learn how to use these technologies to benefit our patients. Doing so may require some adjustments, but the ultimate goal of improving the quality of life for our patients warrants whatever creativity and open-mindedness might be necessary.
Chad Krueger, MD is a military orthopaedic surgeon at Womack Army Medical Center in Fort Bragg, North Carolina.
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Chad Krueger, MD, in response to an Annals of Internal Medicine study investigating the effectiveness of tai chi for treating knee osteoarthritis (OA).
We have put men on the moon, but we still have no cure for the osteoarthritis that affects millions of Americans. We try a variety of injections and other conservative measures to help slow the progression of the disease, but at some point arthritis wins. Undaunted, we search for new modalities of easing the disability the disease brings to our patients in hopes of offering an effective treatment.
That is why I read with interest the recent study “Comparative Effectiveness of Tai Chi Versus Physical Therapy for Knee Osteoarthritis” in the Annals of Internal Medicine. I have many patients with debilitating knee arthritis who are not quite ready to embark on a joint replacement until they feel they have exhausted all other options. I have never referred a patient to tai chi, so would this provide another avenue for those patients to explore?
In this trial, 200 patients were randomized to either 24 total tai chi classes or standard physical therapy sessions (12 sessions at the PT office followed by six weeks of monitored home exercise). The primary outcome measure was the WOMAC score. After following the patients for a year, the researchers found that both groups had substantial improvements in their WOMAC scores, along with improvements in four secondary outcome measures: physical function, quality of life, depression, and medication usage. The one notable between-group difference was that the tai chi group had significantly greater improvements in depression and quality of life.
It’s clear that increasing physical activity, within reasonable bounds, helps patients with knee arthritis in many ways. Whether that extra activity comes from a tai chi class or a structured physical therapy program may not matter. However, it is possible that the tai chi classes (and other group-based physical activity programs) have social benefits that standard physical therapy does not—and that the patients in the tai chi classes may have benefited substantially from that social connection. Many studies, including those of the Lower Extremity Assessment Project (LEAP) cohort, have shown the power that social and psychological factors can have on a patient’s outcome. It’s not surprising that similarly positive social effects would be found in patients with knee osteoarthritis.
Still, not everyone with knee osteoarthritis will want or be able to attend a group class, so such a treatment option is not universally applicable. However, these findings should provoke orthopaedic surgeons and payers to consider seriously the social and emotional aspects of OA treatments. Tai chi is certainly not a “moonshot” solution to knee osteoarthritis, but then again, what is?
Chad Krueger, MD is a military orthopaedic surgeon at Womack Army Medical Center in Fort Bragg, NC.
We stumbled upon three recent studies of knee osteoarthritis (OA) that shed interesting new light on a condition that all orthopaedists deal with.
–A “network” meta-analysis in the Annals of Internal Medicine looked at 137 randomized trials of OA treatments comprising more than 33,000 participants. Treatments analyzed included acetaminophen, diclofenac, ibuprofen, naproxen, celecoxib, intra-articular (IA) steroids, IA hyaluronic acid, oral placebo, and IA placebo. For pain, all active treatments except acetaminophen yielded clinically significant improvement. IA hyaluronic acid came out on top for pain relief, although the authors postulated that an “integrated” placebo effect may explain that finding.
–A cost-modeling study in Arthritis Care & Research, co-authored by JBJS Deputy Editors for Methodology and Biostatistics Jeffrey Katz, MD and Elena Losina, PhD, revealed that the per-patient cost attributable to symptomatic knee OA over 28 years is $12,400. Any expanded indications for total knee arthroplasty (TKA) and a trend toward increased willingness among patients to undergo knee surgery will increase that cost. The researchers found that patients tried nonsurgical regimens for a mean of 13.3 years before opting for TKA, and they stress the need for more effective nonoperative therapies for knee OA.
–Wine drinkers, rejoice! A retrospective case-control study in Arthritis Research & Therapy found that people who drank four to six glasses of wine per week were less likely to develop knee OA than nondrinkers. Meanwhile, beer drinkers may want to switch to wine. The same study found that people who drank 8 to 19 half-pints of suds per week had an increased risk of developing knee OA. Researchers found no link between total alcohol consumption and risk of knee OA. The authors postulate that the resveratrol found in wine may be chondroprotective, and that the linkage between beer and increased blood levels of uric acid may explain the opposite finding. It’s wise to remember that studies investigating one or two dietary items can be less-than-definitive because they are usually retrospective, subject to recall bias, and do not account for complex interactions among many nutrients.
People with shoulder impingement syndrome (SIS) randomly assigned to six sessions of physical therapy (PT) experienced the same 50% improvement in average pain and disability scores as a similar group that received up to three corticosteroid injections over the course of a year. However, the injection group made more office visits and had more additional procedures during the 12-month follow-up period.
Editorialists commenting on this Annals of Internal Medicine study hypothesize that the lower resource utilization of the PT group may be attributed to patient-clinician interactions that “provide an opportunity for therapists to better address patients’ concerns about their conditions, provide reassurance, or educate patients in self-management.” They go on to say that if further research pinpoints specific inflammatory and non-inflammatory “diagnostic phenotypes” of SIS patients, clinicians could prescribe more targeted therapies.