1 “It’s Arthritis” “What can PT do???” Carol A. Oatis, PT, PhDProfessor, Department of Physical Therapy, Arcadia University
2 Objectives Discuss the evidence for PT interventions with positive outcomes for patients with OA, RA or JIA. Discuss the prevalence of adverse events following PT for arthritis. Discuss strategies to enhance the benefits of PT in patients with arthritis.
3 Interventions Exercise Manual therapy Self-managementMechanical Interventions Electrotherapy Assistive devices
4 Measure of EffectivenessStandardized effect size (ES) 0.2 small; 0.5 moderate; 0.8 large Relative effect (RE) < 1.0 favors control; 1.0 no difference; >1.0 favors treatment
5 State of the Evidence Considerable in OA Less in RA Scarce in JIAEBCPGs from ACR, EULAR,AAOS, OARSI ACR update in process Less in RA National Clinical Guidelines (UK) Non-Pharma EBCPG in development at ACR Scarce in JIA Existing guidelines limited
6 Do you… …treat people with athritis (PWA)? …use exercise with PWA?…believe that exercise will decrease pain in PWA? …believe exercise will decrease pain in PW severe A? …believe PWA will do their exercises?
7 Exercise is Medicine!
8 Exercise is Medicine! In people with OA Decreases painSimilar to decreases with pain medication (oral analgesics) Improves function Patient reported outcomes Walk faster Walk farther Treatment Guidelines New data unlikely to change results Uthman OA, 2013
9 Exercise is Medicine! In people with RA Data are limitedDecreases pain and improves QoL Increases strength No sign of increased joint destruction or disease activity de Jong Z et al, 2003
10 Exercise is Medicine! In people with JIASparse evidence and poor quality Decreases pain and impairment Increases function, QoL Decreases number of active joints Data are conflicting Cavallo et al, 2017
11 Evidence for Exercise in PWOABenefits Adverse events
12 Benefits (McAllindon et al 2014)Pain relief Effect size 0.38 ( ) Improved function Effect size (0.41 (0.17 – 0.66) Comparable to oral analgesics
13 Adverse Events (Quicke JG et al 2015)Systematic review of therapeutic exercise 49 studies with varied exercise types and intensities No serious adverse events Moderate adverse events rare (0-6%) Falls, fracture, drop outs, inguinal hernia Mild adverse events few (0-22%) Muscle soreness, mild or temporary joint pain increase
14 Effectiveness Evidence in people with Severe KOA (Skou et al 2015)100 persons eligible for TKR 50 randomly selected for TKR + 12 weeks of non-surgical treatment 50 randomly selected for 12 weeks of non-surgical treatment
15 Non-surgical treatmentNeuromuscular exercise Education Dietary advice Insoles Pain medication
16 Neuromuscular Exercise
17 Results Of the 50 in non-surgical group Of the 50 in surgical group37 did not receive TKR in next 12 months Clinically important improvements in pain and function Of the 50 in surgical group Greater improvements in pain and function than in non-surgical group More serious adverse events
18 For PWOA Exercise is not a cureExercise can decrease pain and increase function Exercise has few side-effects (and none serious!) Exercise may delay or prevent TKR Exercise is included in all EBCPGs …but What? How much? How hard?
19 Evidence for Exercise in PWRABenefits Adverse events
20 RAPIT Study de Jong et al, 2003High-intensity, long duration exercise program Warm up and cool down Aerobic Circuit (strength, flexibility and ADL) 2 years Primary outcomes Functional ability (MACTAR and HAQ) Safety (Radiographic joint damage) Secondary outcomes Aerobic fitness and strength
21 Results (MACTAR)
22 Results (Fitness and Strength)
23 Safety No change in median radiographic damage CaveatPatients with more baseline damage showed slightly more damage progression
24 UK Clinical Guidelines (2009)Land or aquatic exercise beneficial for most PWRA Access to PT for tailored exercise with periodic reviews Consistent messages from whole team
25 2016 EULAR Recommendations in Early RA Combe et al, 2017; Daien CI et al 2017Exercise may decrease pain and increase function in lower extremities and hands Exercise considered adjuncts to pharmacologic intervention
26 Evidence for Exercise in PWJIABenefits Adverse events
27 Exercise and JIA (Kuntze G et al 2017; Cavallo S et al 2017)Aquatic aerobic Home exercise (strength, flexibility, functional) Strengthening Jumping Pilates Aerobic-martial arts
28 Limitations Varied interventions Intensity unclearPoor research methodology
29 Results Beneficial by many measures Function Pain StrengthQuality of life Range of Motion Swollen joint count Bone mineral density
30 Safety Well-tolerated High dropout rates due to pain with jumpingAdverse events not well reported
31 What We Know about Exercise and PWAExercise decreases pain Exercise improves function Exercise is safe Overall effect size: 0.2 – 2.0
32 Exercise is Medicine, but…What kind? How much?
33 Recommendations for Exercise for OA and RAAerobic 30-60 min cumulative at 50-85% max HR 2-3 days / week at least Strengthening 50-80% of maximal load and progressed 8-12 reps, 1-2 sets 2-3 days / week Minor M et al 2003
34 Do you meet the ACSM recommendations for PA?
35 What We Don’t Know Optimal dosage Optimal intensity Optimal typeRole of supervision Ways to optimize adherence
36 What We Suspect… 2-3 X weekly Moderately challengingBenefits appear slowly Benefits subside without continued exercise
37 Significant health benefits are gained in going from inactive to insufficiently active!
38 Physical Activity Minimum (Dunlop et al 2017)40% of PWOA are inactive (0 10-minute bouts of moderate PA) 45 minutes cumulative of moderate PA improve low function or sustain high function in PWOA
39 So Exercise Seems Beneficial in OA, RA and JIA
40 Role of Beliefs and Attitudes in Effectiveness of Exercise
41 Patients’ Beliefs about Exercise (Holden MA, et al 2012; Quicke et al 2017, Marszalek et al 2017)<50% agreed exercise would improve pain Greater self-efficacy and positive exercise outcome expectations are associated with current and future physical activity
42 PTs’ Attitudes and Beliefs about Exercise in PWA (KOA) (Holden MA, 2009)55 % “largely” or “totally” agreed that local strengthening improved knee problems <50% agreed for general exercise < 35% agreed that exercise was safe for every patient Majority agreed that exercises are effective for patients with mild or moderate KOA 30% agreed exercises are beneficial for severe KOA
43 PTs’ Attitudes and Beliefs about Exercise in PWA (KOA) (Holden MA, 2009)Strengthening exercise for function and stability (not for pain) OA is progressive Patients are responsible for adherence No role for PT in changing adherence
44 Ways to Improve Adherence (Nicolson PJA 2017a, 2017b)
45 Ways to Improve Adherence (Nicolson PJA 2017a, 2017b)Booster sessions or “post discharge” contact may help continued adherence PTs can help improve patient self-efficacy Behavior Change Technique (BCT) Education of exercise benefit most common Patients ranked BCT less effective than PTs did. Goal setting and supervision with follow-up exercise correction viewed positively by both PTs and patients.
46 PTs need to work to help patients benefit from this medicineExercise is Medicine PTs need to work to help patients benefit from this medicine
47 What Else Besides Exercise?
48 Self Management Included in most treatment guidelines Strong evidenceSmall positive effect On-line courses for patients available Can/should be included as part of PT program Hurley et al, 2007
49 Additional Treatments for OAMind-Body
50 Tai Chi ACR – Suggest Ottawa Panel – Recommends Level of evidence: II
51 Yoga Ottawa Panel – Recommends for pain relief Suggests for functionNo recommendation for QoL
52 Additional Treatments for OABiomechanical interventions Braces Shoe inserts Taping Modified shoes Weight loss Hand/wrist splints
53 Shoe Inserts OARSI - Appropriate Lateral wedges for medial KOAAAOS – Suggest ACR – Suggest (with subtalar strapping) ACR – no recommendation vs. neutral inserts Medial wedges for lateral KOA AAOS – no recommedation ACR – Suggest EULAR “should” use “insoles”
54 Shoe Inserts Level of Evidence: Ib RE: 0.7 – 3.0
55 Varus/Valgus OrthosesOARSI – Appropriate AAOS and ACR – no recommendation Level of Evidence: Ib RE: 1.1 – 2.2
56 Taping AAOS Suggest ACR Suggest for medial taping for PF painACR – no recommendation for lateral taping Level of Evidence: Ib RE: – 2.0
57 Weight Loss Recommend weight loss for those overweightOARSI EULAR AAOS ACR Cochrane Group Strength of the recommendation Recommend Level of Evidence I ES: RE: 1.2
58 Weight loss Cochrane group: weight loss plus PA most beneficial (17-20% change from baseline)
59 Hand Splints Evidence of improved function and pain at 12 months
60 Additional Treatments
61 Manual Therapy ACR – Suggested only in conjunction with exerciseLevel of evidence: II RE: 1.1 – 1.5
62 NMES OARSI – Not appropriate No additive effect
63 TENS ACR – suggest for KOA; no recommendation for HOAOARSI – Uncertain for KOA. Not appropriate for multi-joint OA Level of evidence: I ES: 0.76 RE: 2.6
64 Acupuncture AAOS – no recommendationACR – Suggest for knee; no recommendation for hip OARSI – Uncertain Level of evidence: Ib ES: – 1.75 RE: 1.1 – 1.6
65 US OARSI – Uncertain for KOA. Not appropriate for multi-joint OA
66 Assistive Devices OARSI – Appropriate ACR – suggestLevel of Evidence: IV ES: NA
67 Lots of Non-Pharmacological Treatments! And yet…Patients ≥ 65 yrs (Medicare) Non-traumatic knee pain ~ 11% received outpatient rehabilitation services. Stevans JM et al 2017
68 Additional Treatments for RA (Grossec L et al, 2006, Brosseau L et al 2014)Recommended consistently Patient education including joint protection Self management Conflicting recommendations Splints Shoe modifications Thermotherapy Electrotherapy
69 Additional Treatments for JIA (Dueckers G et al 2012)“Physical Therapy” “Occupational Therapy” Orthoses (hand, wrist and foot) Electrotherapy Cold
70 The PT Toolbox Offers many effective treatments for PWOAExercise is beneficial for people with RA and JIA PTs can offer wisdom to help implement and maintain an exercise program for PWA
71 Put this in perspective…40,000,000 PWA There are ~ 200,000 PTs in US There are ~ 30,000 orthopedic surgeons There are ~ 8000 rheumatologists in US Get to know a rheumatologist It can be a “win-win” for you, the rheumatologist …and the Patient!
72 …and Most PWA are treated by their PCPWe need to help PCPs recognize the PTs toolbox is pretty full!
73 Your Thoughts? Your Questions?
74 Thank you!
75 References Brosseau L et al. The Ottawa panel clincial practice guidelines for the management of knee osteoarthritis. Part one: introduction, and mind-body exercise programs. Clinical Rehabilitation 2017; 31: Brosseau L et al. The Ottawa panel clincial practice guidelines for the management of knee osteoarthritis. Part two:strengthening exercise programs. Clinical Rehabilitation 2017; 31: Brosseau L et al. The Ottawa panel clincial practice guidelines for the management of knee osteoarthritis. Part three:aerobic exercise programs. Clinical Rehabilitation 2017; 31: Brosseau L et al. A systematic critical appraisal of non-pharmacological management of rheumatoid arthritis with appraisal of guidelines for research and evaluation II. PLOS One 2014;9:e95369. Cavallo S et al Ottawa Panel Evidence-Based Clinical Practice Guidelines for Structured Physical Activity in the Management of Juvenile Idiopathic Arthritis. Arch Phys Med Rehabil 2017; 98(5): Combe B et al update of the EULAR recommendations for the management of early arthritis. Ann Rheum Dis 2016;0:1-12.
76 References (cont) Daien CI et al. Non-pharmacological and pharmacological interventions in patients with early arthritis: a systematic literature review informing the 2016 update of EULAR recommendatiosn for the management of early arthritis. RMD Open 2017;3:e De Jong et al Is a long-term high-intensity exercise program effective and safe in patients with rheumatoid arthritis? Results of a randomized controlled trial Arth & Rheum, 2003;48(9): Dueckers G et al. Evidence and consensus-based GKJR guidelines for the treatment of juvenile idiopathic arthritis. Clin Immunology 2012; 143: Hochberg MC, American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmcologic therapies in osteoarthritis of the hand, hip and knee. Arthritis Care Res. 2012 Apr;64(4): Holden MA et al. UK-based physical therapists' attitudes and beliefs regarding exercise and knee osteoarthritis: findings from a mixed-methods study. Arthritis and Rheumatism (Arthritis Care and Res) 2009;61(11): Hurkmans E et al. Dynamic exercise programs (aerobic capacity and/or muscle strength training) in patiens with rheumatoid arthritis. Cochrane Database of Sytematic Reviews 2009; 4: Art No CD
77 References (cont) Hurley et al Clinical effectiveness of a rehabilitation program integrating exercise, self-management, and active coping strategies for chronic knee pain: A cluster randomized trial. Arth Rheum 2007; 57: McAlindon TE et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis and Cartilage 2014; 22: Minor M et al. Work group recommendations:2002 exercise and physical activity conference, St. Louis, Missouri 2003; Arth Rheum 49(3): Munneke et al. Adherence and satisfaction of rheumatoid arthritis patients with a long-term intensive dynamic exercise program (RAPIT program). Arth Rheum 2003; 49(5): National Collaborating Centre for Chronic Conditions. Rheumatoid arthritis: national clinical guideline for management and treatment in adults. London: Royal College of Physicians, February 2009. Nicolson PJA et al. Improving adherence to exercise: Do people with knee osteoarthritis and physical therapists agree on the behavioral approaches likely to succeed? Arth Care Res 2017; doi: /acr
78 References (cont) Nicolson PJA. Interventions to increase adherence to therapeutic exercise in older adults with low back and/or hip/knee osteoarthrits: a systematic review and meta-analysis. Br J Sports Med 2017; 51: Peter WF et al. Healthcare quality indicators for physiotherapy management in hip and knee osteoarthritis and rheumatoid arthritis: A Delphi study. Musculoskeletal Care 2016;14(4): Quicke JG et al. Relationship Between Attitudes and Beliefs and Physical Activity in Older Adults With Knee Pain: Secondary Analysis of a Randomized Controlled Trial. Arthritis Care and Res 2017; 69(8): Skou et al A randomized, controlled trial of total knee replacement NEJM 2015;373: Stevans JM et al. Association of early outpatient rehabilitation with health service utilization in managing Medicare beneficiaries with nontraumatic knee pain: Retrospective cohort study. Phys Ther 2017;97: Uthman OA et al. Exercise for lower limb osteoarthritis: systematic review incorporating trial sequential analysis and network meta-analysis. BMJ 2013; 347:f5555 doi: /bmj.f5555.