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  • Study: Knee OA Treatment That Doesn't Follow Guidelines Comes at a Price

    Editor's note: the following story was modified to clarify terminology in the study, specifically around the authors' use of "modality."

    In brief:

    • Current orthopedic surgeon guidelines recommend use of physical therapy, tramadol, and NSAIDs for nonsurgical treatment of knee OA, and against use of injections and opioids other than tramadol.
    • Analysis of claims utilization data found that the top 3 interventions were corticosteroid injections (46.0%), hyaluronic acid injections (18.0%), and opioids other than tramadol (15.5%), none of which are recommended in the guidelines.
    • Physical therapy was prescribed for only 13.6% patients.
    • Adhering to AAOS treatment guidelines for knee OA could decrease cost of care by 45%.

    If health care providers treated patients with knee osteoarthritis (OA) according to established guidelines that include physical therapy, researchers say costs of treatment could drop by as much as 45%. Yet too many physicians are prescribing interventions that are not supported by evidence and may even carry extra risk.

    An award-winning study published in The Journal of Arthroplasty (abstract only available for free) queried the Humana claims database to determine the prevalence of 8 nonsurgical treatment modalities—hyaluronic acid (HA) injections, corticosteroid (CS) injections, physical therapy, knee brace, wedge insole, opioids, NSAIDs, and tramadol—used to treat 86,081 patients with knee OA. The patients were receiving conservative treatment in the year prior to total knee arthroplasty (TKA).

    Of all 8 treatments, only physical therapy, NSAIDs, and tramadol are strongly recommended by the American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines for nonsurgical management of knee OA. However, authors found the 3 most frequent interventions to be CS injections (46.0%), HA injections (18.0%), and opioids (15.5%). Physical therapy was utilized by only 13.6% of patients.

    More than half of the total cost of knee OA treatment was for noninpatient care, with 29.2% accounted for by HA injections, which AAOS classifies as “Cannot recommend – strong.” The per-patient cost for physical therapy was half that of HA injections. Researchers found that the AAOS-recommended interventions represented only 12.2% of the cost of noninpatient care: physical therapy at 10.9%, NSAIDs at 1.2%, and tramadol at 0.1%.

    The study shines a bright light on the “high prevalence of low-value interventions in the management of knee OA symptoms in the year prior to TKA,” say authors, who also express concern about risk of infection associated with injections. Preoperative use of opioids, they note, has a higher risk for complications and “a more painful recovery” after TKA.

    While experts acknowledge they have no data on the interventions’ effectiveness, “given that all patients in this study underwent TKA within a year or less … it seems likely that the treatments were not overly successful in alleviating symptoms.”

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.


    • Since I have adverse reactions to all the pharmaceutical treatments I have been told to just ice. How do you get the doctor to prescribe physical therapy?

      Posted by Lynn on 2/24/2017 6:38 PM

    • Great info and highly encouraging to share with patients. Wondering if they ever studied the PT intervention at early onset of OA. To find out the effectiveness in reducing symptoms early physical therapy intervention is key.

      Posted by Dimple Singh on 2/24/2017 9:33 PM

    • thanks for posting and sharing this article, but you guys need to specify that Physical Therapy is NOT a modality! Aaron

      Posted by Aaron LeBauer -> @HP^@O on 2/25/2017 7:55 AM

    • Lynn, many states now have Direct Access, meaning you can see a PT without a physicians referral. If your state does not permit, or your insurance does not participate, contact the physician and tell him what you want. If unsuccessful, ask your primary care physician, again if no luck (besides looking for new doctors) many states permit a nurse practitioner to write a script, and in that instance you can go to a Walgreens type health clinic.

      Posted by John Duffy, PT OCS on 2/25/2017 7:55 AM

    • Explain to the physician that you have experienced decline in function largely due to the pain, and need PT intervention to improve your strength and flexibility, and to learn proper techniques to improve activities of daily living.

      Posted by Barbara on 2/25/2017 1:38 PM

    • Lynn, Just ask. Although they should be recommending it on their own, any doctor worth seeing would definitely prescribe PT if you asked to go. If they say it won't help, find a new doctor.

      Posted by Christina on 2/25/2017 4:16 PM

    • Lynn, Most MDs I've worked with will refer you to PT if you just ask! Direct Access to PT is available in some states (meaning you don't need an MD's referral to legally receive PT services), but some (most) insurances will not cover PT without MD orders. If you have the means to pay out of pocket, it is an option to go directly to your PT of choice, if your state's practice laws allow. Otherwise, ask your MD to refer you. It's always a good idea to check out any copays and make your insurance and financial situation known to the PT office so they can strategically map your plan of care to best fit your needs/optimize results while being mindful of finances. Good luck!

      Posted by Joanna on 2/26/2017 10:45 AM

    • When I look at the study demographics it appears that these are all advanced knee OA patients. This is based on the notion that they are all within 1 year of surgery. As a PT I find this a more difficult population to achieve both short and long term pain relief. Perhaps this is reflected in the low rate of PT referral and overuse of "kitchen sink" interventions.

      Posted by Brian on 2/26/2017 5:14 PM

    • I suspect the injections (CS and HA) are to buy time which can be beneficial for a number of reasons such as : waiting through winter weather to make rehab easier, getting medical status as stable as possible, arranging for family member to take time off to help, or PT for other areas that need addressing and will improve outcome of the surgery.

      Posted by Sarah on 3/2/2017 8:45 AM

    • What about physicians who send patients to PT for OA and the patient weighs 350 lbs +. Had anyone counseled the patient on weight loss, aquatic therapy to decrease the stress & strain on the joints?

      Posted by Kim Tollefson, PT, DPT on 3/12/2017 5:51 PM

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