Thursday, May 26, 2016 From PTJ: Group-Based Physical Therapy No More Effective Than 1-on-1 Care for Knee OA In a recent clinical trial published in the May issue of Physical Therapy (PTJ), APTA's science journal, group physical therapy for individuals with knee osteoarthritis (OA) was found to be no more effective in reducing pain and improving functional outcomes than 1-on-1 sessions—contrary to researchers' expectations. Researchers randomly assigned 320 patients with pain, aching, stiffness, or swelling associated with knee OA at a Veterans Administration (VA) medical center to either group or individual physical therapy. Most (88%) were male. Authors hypothesized that group-based physical therapy would lead to superior outcomes, citing several advantages of this setting, including the potential for more visits per patient, better ways to deliver education and support for chronic conditions, and stronger peer support that could lead to greater adherence to exercise-based interventions. Most aspects of care were the same for both groups. All patients were instructed in a home exercise program, educated on joint protection and activity pacing, and screened to determine if they required braces, assistive devices, or shoe lifts. To start, they all were instructed to perform the same 4 stretching exercises daily and 6 strengthening exercises 3 times a week. As they progressed, they were given opportunities to increase the difficulty of their exercises. The physical therapists (PTs) gave all participants written and illustrated instructions, exercise logs, and therapy bands, as well as reminder calls before each therapy session. The only difference between the groups was the greater number of sessions for patients in the group-based program compared with patients in the individual program. Because of this, the PTs in the group setting were able to follow up more on educational components and exercise progression. Patients in the group setting also had more time to ask questions and experienced greater peer support. Here is what researchers found: WOMAC scores were no different for each group. At the 12-week and 24-week follow-up assessments, Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores were slightly lower for patients who received group-based sessions, but with no meaningful difference. On average, patients in both groups improved from baseline, even at 24 weeks. Satisfaction with physical function didn’t improve much for either group. Both groups self-reported similar levels of satisfaction with physical function on the SPPB at 12 weeks. There was also no significant change over time for either group. Frequency and duration of exercise increased for both groups. There was no significant difference between the groups at any point, as measured by the Community Health Activities Model Program for Seniors. At 12 weeks, patients in both settings had improved frequency of exercise by 24% and duration by 12%. But while the overall frequency of moderate or greater intensity exercise improved by 31%, there was no noticeable difference in duration of moderate or greater intensity exercise. 6-Minute Walk Test distances improved for patients in groups, decreased for individual settings. The only significant difference was change from baseline for the 6-Minute Walk Test at 12 weeks. Group physical therapy participants improved by 14.3 meters, while the individual program patients actually had a mean decrease of 3.2 meters. Staffing costs may or may not be optimal. When staff costs per patient were estimated based on the expected number of patients, it was more cost-effective to deliver group care. However, when cost was calculated based on the actual number of patients who showed up, 1-on-1 care turned out to be cheaper. While these outcomes contradicted researchers’ expectations, authors note that “the results suggest that there may have been different advantages of each approach that ultimately resulted in similar changes for most outcomes. Although the group physical therapy approach allowed more contact and group support, the individual physical therapy visits allowed greater one-on-one time with a physical therapist.” Authors noted several limitations of the study. For example, all outcome measures were self-reported, and actual strength and range of motion were not objectively measured. And, while the researchers “assessed adherence” to physical therapy sessions, they did not measure performance of home exercises. Even though results of both approaches were nearly equivalent, authors of the study believe that group-based treatment for knee OA may be worth a closer look. "Given the expected rise in prevalence of knee OA and the general need to provide efficient health care,” authors note, “a physical therapist–led, group-based approach to delivering nonpharmacological treatment of knee OA could be a useful approach in many health care settings.” 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.