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Are Steroids Really the Answer for Arthritic Knees?
  • Posted April 8, 2020

Are Steroids Really the Answer for Arthritic Knees?

Folks with knee arthritis will get more out of physical therapy than a cortisone shot, a new clinical trial argues.

People with osteoarthritis of the knee had less pain and disability after one year of physical therapy than others who received as many as three injections during that same period, according to study results.

"We found that the steroid injection did not have any advantages over physical therapy," said lead researcher Gail Deyle, a physical therapist and professor at the Brooke Army Medical Center in San Antonio, Texas.

Deyle hopes these findings will spark a change in the way knee arthritis is treated.

Only about 10% of patients with knee arthritis are offered physical therapy prior to requiring a total knee replacement, Deyle said. By comparison, studies have shown as many as half will receive a steroid injection.

This occurs even though steroid injections carry greater risks, including accelerated aging of the joints, greater cartilage loss, possible infection, and even potentially increasing the risk of bone fractures, he said.

"If providers are open-minded, I think this will change their practice," Deyle said. "If I were a patient, I would not be tempted to have a steroid injection. I don't want that risk."

For this clinical trial, 156 patients, with an average age of 56, were randomly assigned to undergo either physical therapy or receive up to three cortisone shots in a year.

"The physical therapy strategy used in this study consisted of manual physical therapy with reinforcing exercise, including ongoing guidance to help patients find appropriate types and amounts of physical activity," Deyle said. The hands-on manual treatment helped people perform reinforcing exercises with little or no pain, which enabled them to do daily activities and home exercises with less pain.

The physical therapy involved here was arguably better than what average folks receive, noted Dr. Etan Sugarman, an orthopedic surgeon with Lenox Hill Hospital in New York City.

"What they're talking about here in terms of physical therapy is something very specific, which is guided supervised physical therapy by a certified, qualified physical therapist who is doing person-to-person specific manual therapy in conjunction with their treatment," said Sugarman, who wasn't part of the study.

Researchers checked in regularly with the patients over the course of the year to see how they were benefiting from treatment.

The difference in results became apparent as early as the first round of treatment, Deyle said.

"Most patients who got a steroid injection had to go home and rest for 72 hours and were given options like icing their knee or pain medications to recover from it," Deyle said. "Most patients left their initial physical therapy visit feeling quite good."

By the end of the year, patients in the physical therapy group reported much better outcomes than those in the steroid injection group, Deyle said.

"Patients receiving physical therapy had overall less pain and stiffness and performed better on functional tests," he said.

All patients who needed to proceed to surgery during the year -- one arthroscopic surgery and three total knee replacements -- belonged to the injection group, even though patients in the physical therapy group had more severe arthritis at enrollment, Deyle noted.

Total health care costs for both groups over the one-year period were equivalent, Deyle added.

The study was published April 8 in the New England Journal of Medicine.

While these results show the potential benefits of physical therapy, Sugarman noted that many or most patients don't have access to physical therapy at all, let alone intensive therapy conducted by a qualified expert.

"It calls to issue one of the major problems we have in the public health care system, which is for many people, their insurance may not approve all that many physical therapy sessions," Sugarman said. "Their access to a good certified physical therapist may be significantly limited."

He noted that many times patients come to him describing physical therapy sessions where they worked out in a corner, unsupervised, then had electrical stimulations slapped on for a bit.

"I say that's great -- that wasn't physical therapy," Sugarman said.

People with knee arthritis often proceed to a total knee replacement, but Sugarman said that decision is very individual.

Total knee replacement should be performed in a "patient with a diagnosis for arthritis stating they have failed nonsurgical treatment and are unhappy with their quality of life, and that first part is just as important as the second part," Sugarman said.

The amount of pain a person is in should drive the decision more than what their X-rays say, Sugarman asserted.

More information

The American Academy of Orthopaedic Surgeons has more about knee arthritis.

SOURCES: Gail Deyle, D.Sc., professor, Brooke Army Medical Center, San Antonio, Texas; Etan Sugarman, M.D., orthopedic surgeon, Lenox Hill Hospital in New York City; New England Journal of Medicine, April 8, 2020
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