Stepped Exercise Program Shows Benefits for Knee OA

By Anne Harding

December 30, 2020

NEW YORK (Reuters Health) - A stepped exercise program for symptomatic knee osteoarthritis (KOA) can produce "modest improvements" in symptoms at nine months, according to a new study in US veterans.

"STEP-KOA could be an efficient way to deliver exercise and physical therapy based services for people with knee osteoarthritis, since it reserves the more resource intensive 'steps' for people who do not make improvements earlier," Dr. Kelli D. Allen of the Center of Innovation to Accelerate Discovery and Practice Transformation at the Durham VA Health Care System in North Carolina told Reuters Health in an email. "This could be important in health systems that are trying to maximize resources or when there is limited access to physical therapy."

While exercise-based therapies such as PT are effective for knee OA, "the vast majority of patients with knee osteoarthritis are physically inactive, and PT is substantially underused," Dr. Allen and her team note. "Reasons for low use of PT include limited access (related to health insurance coverage or lack of physical therapists in some settings) and the absence of evidence to determine which patients may benefit the most from PT."

The authors randomly assigned 345 patients with symptomatic knee OA 2:1 to the STEP-KOA intervention or an arthritis education (AE) control. Patients' mean age was 60, 15% were female and 67% were people of color.

Step one of the program consists of three months of internet-based exercise. Patients who don't respond are moved up to step 2, which includes three months of physical activity coaching calls every other week. Non-responders went on to three to seven in-person physical therapy (PT) visits.

In the AE group, patients received educational mailings about arthritis every two weeks for nine months.

Step 1 included seven levels, with stretching and strengthening exercises and recommendations for aerobic exercise. Patients were instructed to do the exercises three times a week at minimum, and could move up a level on request if their Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score had not declined.

Sixty-five percent of patients in the STEP-KOA group moved on to step 2, and 35% advanced to step 3. At baseline, estimated mean WOMAC score was 47.5 for the entire group. It was 6.8 points lower at nine months in the STEP-KOA group compared to the controls.

"As with any intervention, additional trials are needed to further evaluate in different settings and groups of patients. In addition, work is needed to evaluate how to best implement STEP-KOA in real-world health care settings," Dr. Allen said.

She and her colleagues have received funding from the Department of Veterans Affairs Office of Rural Health to do a pilot trial of a version of STEP-KOA administered entirely by telehealth to rural veterans.

"Exercise and physical therapy are key, recommended treatments for knee osteoarthritis, but they are under-utilized," Dr. Lee said. "STEP-KOA could be a method for health systems to efficiently deliver these services to people with knee osteoarthritis."

SOURCE: https://bit.ly/3o9r6ot Annals of Internal Medicine, online December 28, 2020.

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