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  • Study: Prevalence of Knee OA Today Twice What It Was 75 Years Ago

    Knee osteoarthritis (OA) has more than doubled among Americans since 1940, say researchers, and the increase can't be explained by longer lifespans or a higher prevalence of obesity and overweight in recent decades. Instead, the real culprit could be physical inactivity, which authors describe as "epidemic in the postindustrial era."

    The study, appearing in the Proceedings of the National Academy of Sciences, compared knee joints of 2,756 skeletons from 3 groups of individuals: those who lived in the 1800s and early 1900s ("early industrial," N=1,581), those who lived during the late 1900s through the early 2000s ("postindustrial," N=819), and prehistoric hunter-gatherers who lived between 6,000 and 300 BCE (“prehistoric,” N=176). Researchers were looking for knee joint eburnation—the ivory-like result of bone-on-bone contact that occurs after cartilage erodes—as the indicator for moderate to severe OA.

    Here's what they found:

    • The prevalence of knee OA in the postindustrial skeletons was about 16%, a rate 2.6 times higher than the early industrial group, which had a 6% incidence rate. Knee OA prevalence among the prehistoric sample was 8%.
    • After controlling for body mass index (BMI) and age when that information was available (1,859 of the 2,756 skeletons), researchers were unable to establish a correlation between these factors and prevalence of knee OA—instead, rates remained 2 times higher for the postindustrial group even when compared with early industrial skeletons with similar ages and BMIs. BMI for the prehistoric sample could not be estimated.
    • In the postindustrial individuals with knee OA, 42% had the disease in both knees. Bilateral occurrence was 30% among the early industrial samples with knee OA, and 17% among the prehistoric group.

    "Although knee OA prevalence has increased over time, today's high level of the disease is not, as commonly assumed, simply an inevitable consequence of people living longer and more often having a high BMI," authors write. "Instead, our analyses indicate the presence of additional independent risk factors that seem to be either unique to or amplified in the postindustrial era."

    The researchers believe that risk factor could have to do with "environmental changes"—namely, the reduced levels of physical activity associated with the postindustrial era, despite the human body's need for regular exercise. It's a phenomenon known as a "mismatch disease," when the human body can't easily or rapidly adapt to changes in the lived environment.

    "Although altered loads generated by walking more frequently on hard pavement … or with certain forms of footwear … might be factors, another possibility that merits more study is physical inactivity, which has become epidemic during the postindustrial era," authors write. "Less physically active individuals who load their joints less develop thinner cartilage with lower proteoglycan content … as well as weaker muscles responsible for protecting joints by stabilizing them and limiting joint reaction forces."

    The good news, according to the researchers, is that their findings point to the possibility that knee OA is a largely preventable condition—providing there's a widespread "reappraisal of potential risk factors that have emerged or intensified only very recently."

    "As with other mismatch diseases, it is likely that any effective prevention strategy will involve adjusting physical activity patterns and diets to approximate more closely the lifestyle conditions under which our species evolved," authors write.

    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.

    Technological Possibilities, Practical Challenges: Report Looks at Assistive Technologies in the Workplace

    Assistive technologies to help individuals in the workplace are developing at a rapid rate, but if the promise of these technologies is to be fully realized then thinking around access, user training, reimbursement, and other barriers needs to catch up. That conclusion echoes throughout a new report from the National Academies of Science, Medicine, and Engineering.  Authors of the study include Physical Therapy (PTJ) Editor-in-Chief Alan Jette, PT, PhD, MPH, FAPTA, and Linda Resnik, PT, PhD, FAPTA, and executive director of the Center on Health Services Training and Research (CoHSTAR).

    "The Promise of Assistive Technology to Enhance Activity and Work Participation" is the result of an extensive review of the literature pertaining to assistive products and technologies, a series of public meetings on the topic, and a public teleconference that invited expert comment. The purpose: to develop an analysis of the adult use of assistive technologies including wheeled mobility devices, upper-extremity prostheses, and technologies designed to assist with hearing, speech, and communication.

    The report, available to download for free, isn't just an account of what's out there and how far assistive technology has come—it's also an examination of the challenges of putting these technologies to their most widespread and effective use.

    "The committee's review of the literature and the expert opinions of its members and others who provided input for this study made clear that appropriate-quality assistive products and technologies … may mitigate the impact of impairments sufficiently to allow people with disabilities to work," authors write. "In some cases, however, environmental and personal factors create barriers to employment despite the impairment-mitigating effects of these products and technologies. In addition, maximal user performance requires that individuals receive the appropriate devices for their needs, proper fitting of and training in the use of the devices, and appropriate follow-up care."

    That concept of barriers and training needs colored most the committee's conclusions, which include recommendations that point to the importance of proper fit, ongoing follow-up, better training for providers, and an understanding among employers and others that a device that may be useful to an employee today may become less useful over time.

    Authors also addressed the lag-time that can exist between effective technologies and a payer's willingness to provide reimbursement for those technologies.

    "The provision of assistive products and technologies … is contingent largely on reimbursement policy rather than patient need," authors write. "In some cases, the products and technologies that are covered by Medicare and other insurers as medically necessary are not those that would best meet the needs of users to enhance their participation in life roles."

    Funded by the Foundation for Physical Therapy , CoHSTAR is a multi-institutional, multi-disciplinary center dedicated to advancing health services and health policy research capacity in physical therapy.

    Study Says Cost Savings of Physical Therapy for LBP Are Significant

    When it comes to physical therapy for treatment of low back pain (LBP), Medicare is getting a bargain, according to authors of a new study. Researchers say that not only is physical therapy cheaper than injections or surgery in the short-term, it's an approach that is likely to save on treatment costs for at least a year after initial diagnosis, with average savings of 18% over treatments that begin with injections and 50% over treatments that begin with surgery.

    The study, commissioned by the Alliance for Physical Therapy Quality and Innovation (APTQI), focused on Medicare A and B claims data from 472,000 beneficiaries who received a diagnosis of LBP and began treatment between February and October of 2014. Researchers from the Moran Company tracked 3 treatment paths—physical therapy, injections, and surgery—and compared total costs of initial treatment as well as total costs for 12 months after diagnosis. The study also included an analysis of cost differences associated with how soon physical therapy was initiated after diagnosis, the physical therapist interventions used, and relationships between the use of physical therapy and the referring health care provider.

    "We felt it was important to look at claims data to demonstrate how a physical therapy-first approach can improve outcomes and reduce overall medical expenditures," said APTQI Executive Director Troy Bage, PT, DPT. "We've known this to be true from our experiences as physical therapists, but we wanted to investigate the hard data that bear this out."

    Here's what they found:

    From an intervention cost perspective, physical therapy wins out.
    As an initial intervention, the average total medical cost when physical therapy was used first was $3,992—19% lower than total average costs when injections were used first ($4,905) and 75% lower than the total average costs for the surgery-first group ($16,195).

    Physical therapy also is associated with savings over time.
    Researchers found that during the 12-month period after initial diagnosis, individuals who received physical therapy as an initial intervention tended to rack up fewer additional costs than the injection and surgery groups. Average 12-month spending for the physical therapy group was $11,151, compared with $13,606 for the injection group and $36,772 for the surgery group. That's an 18% and 54% savings, respectively.

    Starting physical therapy sooner correlates with lower costs.
    Beneficiaries who received physical therapy within the first 15 days of diagnosis incurred lower average treatment costs than those whose physical therapy began later, and those savings continued through the 12-month study period.

    Active physical therapist services were the most common type of services delivered.
    Active physical therapist services accounted for 82.1% of the services delivered to the physical therapy group, with 5.7% recorded as passive and the remaining 11.2% designated as other interventions.

    Primary care physicians account for the most LBP diagnoses, but orthopedic physicians are most likely to refer patients for physical therapy.
    Overall, 37% of the LBP diagnoses in the study group were made by primary care physicians, with the next highest referrer being "all other" (32%). While orthopedic physicians accounted for only 8% of the diagnoses, they referred the largest portion of their patients—about 21%—to physical therapy. Primary care physicians referred 13% of their patients to physical therapy, while pain management physicians preferred injection referrals, sending about 36% of their patients to that treatment path.

    Most patients receive no physical therapy, injections, or surgery.
    Of the 472,000 cases studied, almost 13% received physical therapy, with 11.3% receiving injections and 1.6% receiving surgery. The remaining 74.4% of patients didn't receive any of the studied treatments during the yearlong study window.

    As for the makeup of the groups studied, the group receiving physical therapy tended to be slightly older, with an average age of 68.1 compared with averages ranging from 64.1 to 66.7 for the other groups (including those who received none of the 3 services). Beneficiaries who received physical therapy were also more often women (65.5%, compared with 50.5%-61.9%) and were not as often designated as disabled, with a 29.6% rate compared with 37.9% in the injection group and 44.3% in the surgery group.

    "The results of the study highlight the importance of initiating physical therapy prior to other more expensive and invasive interventions," Bage said. "The savings identified in the study are not insignificant and clearly correlate with better outcomes."

    Authors of the study assert that the timing is right for the study, and they say the results are promising.

    "In a Medicare policy environment focused on value-based payment reform and care management strategies aimed in part at cost reduction, understanding potential cost implications of first line treatment utilization is relevant," authors write. "The findings from this report signal possible advantages of [physical] therapy as a potential cost saver relative to other treatment interventions for low back pain. These results lend promising support for the role of [physical] therapy early in the care continuum from a cost perspective."

    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.

    Study: Chemical 'Marker' Sheds Light on Cognitive Benefits of Aerobic Exercise Among Older Adults

    In brief:

    • Researchers attempted to identify changes in the brain among cognitively healthy adults 65 and older who engaged in a 12-week aerobic exercise program
    • 53 participants were divided into exercise and non-exercise groups; chemical markers, proteins, cognitive function, and gray matter were evaluated at baseline and after 12 weeks
    • At the end of the 12 weeks, the only measurable difference between the groups was related to levels of total choline (tCho), a chemical associated with membrane degeneration and inflammation—exercise group's tCho levels remained stable while the non-exercise group's tCho levels rose
    • Researchers believe tCho levels could prove to be a useful marker to measure the effects of aerobic exercise on brain function of adults who are elderly

    The connection between physical activity (PA) and the slowing or prevention of cognitive decline in the elderly has been widely recognized, but an explanation of just how PA works on the brain's chemistry has been more elusive. Now researchers in Germany believe they've isolated a chemical marker that helps identify PA's neuroprotective effects.

    The research project itself was fairly straightforward: split 53 cognitively healthy individuals 65 and older into 2 groups—the first of which received 3 half-hour supervised cycle training sessions per week for 12 weeks, and the second of which did not increase their PA—and then measure a host of factors associated with cognitive decline at the beginning and end of the 12-week training program. Researchers didn't limit their investigation to chemical markers but also included evaluations of gray matter volume and cognitive performance tests. Results were published in Translational Psychiatry.

    At the end of the 12 weeks, only 1 major difference between the 2 groups was found: the amount of total choline (tCho) present in the brains of participants. A combination of 2 types of choline, tChol is associated with pathological membrane turnover and inflammation, and is often present along with elevated creatine levels in the brains of individuals with Alzheimer's disease and dementia. The tCho levels of individuals who participated in the exercise program remained stable, while the non-exercise group's tCho levels rose over the 12-week timeframe.

    Researchers were unable to identify significant differences in any other areas, including markers associated with neuronal energy reserve or brain-derived neurotrophic factor (BNF), a protein associated with brain plasticity. The study also found no changes to gray matter volume, a change other studies have noted. Authors noted, however, that those studies tended to take place over a longer time period—measurements at 12 weeks simply may be too soon to pick up those.

    As for what it is about PA that helps to tamp down the increase in tCho, researchers were unable to pin it to aerobic capacity, which did not increase significantly for the exercise group compared with the non-exercise group. Instead, they believe the effect could be due to an increase in cardiac efficiency among the exercise group.

    "Changes in fitness level … were positively associated with changes in metabolite concentrations … in the training group, thus suggesting that fitness is closely linked to cerebral brain metabolism," authors write. "Overall, the currently available data indicate that aerobic training interventions with moderate intensity may improve both brain metabolism and cardiopulmonary function."

    Authors acknowledge that their study is limited by its sample size and short timeframe, and call for additional studies with larger groups and longer study periods.

    Still, they assert, the notable difference in tCho levels could be a window into the chemistry behind the beneficial effects of PA.

    "As choline is a marker of neurodegeneration, this finding suggests a neuroprotective effect of aerobic exercise," authors write. "Overall, our findings indicate that cerebral tCho might constitute a valid marker for an effect of aerobic exercise on the brain in healthy aging."

    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.

    From PTJ: For Patients With Nontraumatic Knee Pain, Early Rehabilitation Lowers Odds of Later Use of Opioids, Injections, Knee Surgery

    In brief:

    • Retrospective cohort study analyzed Medicare claims data for 52,504 beneficiaries with nontraumatic knee pain (NTKP) to analyze effects of early rehabilitation on later use of drugs, nonsurgical invasive procedures, and surgery
    • Patients receiving rehabilitation were divided into 3 groups: early rehabilitation (within 15 days of diagnosis), intermediate rehabilitation (16-120 days after diagnosis), and late rehabilitation (120 or more days after diagnosis); data were tracked for 1 year after diagnosis
    • Early rehabilitation patients were 33% less likely than nonrehabilitation control to engage in later use of drugs, 50% less likely to receive nonsurgical invasive procedures, and 42% less like to undergo surgery; similar differences were not found in intermediate and late-rehabilitation groups
    • Only 11% of NTKP patients received any rehabilitation at any time; of those who did receive rehabilitation, 52% were in the early group, 27% were classified in the intermediate group, and 21% received late rehabilitation
    • Authors believe results, while preliminary, support the trend toward more widespread use of early rehabilitation as a first-line treatment for NTKP

    When it comes to rehabilitation of individuals with nontraumatic knee pain (NTKP), authors of a new study concluded that it really is a case of "the sooner the better"—at least when it comes to reducing use of drugs, injection therapies, and surgeries later on.

    In a retrospective cohort study that analyzed records of 52,504 Medicare beneficiaries, researchers from the University of Pittsburgh found that patients with NTKP who received rehabilitation within the first 15 days after diagnosis were 33% less likely to use narcotic analgesics over the following year than patients who received delayed or no rehabilitation. Additionally, the early rehabilitation group was 50% less likely to move to nonsurgical invasive procedures such as corticosteroid injections, and 42% less likely to undergo later knee surgery. Results were published in Physical Therapy(PTJ) APTA's scientific journal.

    The study defined rehabilitation as "exercise or other nonpharmacological services or procedures that are recommended as early stage management options for patients with NTKP." This definition included exercise, nutritional counseling, functional training, physical agents, manipulation, and manual therapy, and was not linked to a particular service provider or setting.

    Besides the utilization patterns of early rehabilitation patients, authors of the study were also interested in overall usage of rehabilitation and whether delayed rehabilitation—defined as "intermediate rehabilitation" that occurred 16-120 days after the diagnosis or "late rehabilitation" that took place more than 6 months after the diagnosis—would make a difference in whether or not patients went on to the other interventions.

    The findings about rehabilitation prevalence were not surprising: of the 52,504 patients with NTKP, only 11% received early, intermediate, or late rehabilitation—a number consistent with other studies, authors write. Of the 5,852 patients who received rehabilitation, 52% received early rehabilitation, with 27% receiving rehabilitation 16-120 days later, and the remaining 21% having late exposure to rehabilitation.

    When it comes to later use of drugs, nonsurgical invasive procedures, and surgery, early rehabilitation seems to make all the difference compared with intermediate or late rehabilitation. Authors found that in the intermediate and late groups, the adjusted odds for receiving any of the interventions were actually higher than for patients who received no rehabilitation. While these data may seem to indicate that no rehabilitation is preferable to delayed rehabilitation, authors believe the difference may be driven by the likelihood that patients in the intermediate and later rehabilitation groups were experiencing higher levels of pain and disability for a longer time than were the early rehabilitation or control groups. Still, they explain, it's hard to say for certain, because during the years of claims data studied, data on pain and function were not included—a gap that "points to the importance of ongoing efforts to link clinical measures with health care service utilization from claims data."

    "Our findings would seem to support the recent recommendations that nonpharmacological treatment options, including those delivered by physical therapists, should be considered prior to treatment with narcotic prescription," authors write. "Developing strategies to encourage the use of rehabilitation as a first-line treatment for NTKP, as recommended by current guidelines, has the potential to positively impact a large segment of this clinical population."

    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.

    Oncology Section Introduces New Guideline on Diagnosis of Upper Quadrant Lymphedema in Patients With Cancer

    While early recognition of upper quadrant lymphedema secondary to cancer can play a crucial role in maintaining quality of life for patients, few clinical practice guidelines (CPGs) exist to help clinicians diagnose the condition. The APTA Oncology Section set out to change that with the publication of “Diagnosis of Upper Quadrant Lymphedema Secondary to Cancer: Clinical Practice Guideline From the Oncology Section of the American Physical Therapy Association” in Physical Therapy (PTJ), APTA's science journal. An executive summary of the CPG will be published in Rehabilitation Oncology’s July issue.

    Authors Kimberly Levenhagen, PT, DPT; Claire Davies, PT, PhD; Marisa Perdomo, PT, DPT; Kathryn Ryans, PT, DPT; and Laura Gilchrist, PT, PhD, evaluated research on current diagnostic and assessment methods, including bioimpedence analysis, circumferential measurement, water displacement, perometry, and ultrasound imaging.

    In a podcast summarizing the work group’s recommendations, coauthor Claire Davies reminds clinicians, “We need to be aware that none of the diagnostic criteria are perfect in their diagnostic accuracy, especially [in] patients that fall just under or over a cut point. These [patients] have the potential to be misclassified. Also, the clinical presentation of lymphedema should influence the selection of diagnostic tool, as some measures … are more accurate in the early stage.”

    Physical therapists need to tailor the diagnostic approach to each patient. For example, Davies told PT in Motion News, “in some groups with early or subclinical lymphedema, volume measures may not be sensitive enough to diagnose and/or assess extracellular fluid. As tissue changes occur with later stage lymphedema, volume may be increased, yet measures of extracellular tissue fluid may not be as accurate due to fibrotic changes.”

    Authors of the CPG “encourage clinicians to cluster findings from their examination,” using the most appropriate tests recommended for each of the clinical presentations, to draw a conclusion on diagnosis.

    In her podcast, Davies ends “with a call for research.” Among their recommendations, authors of the CPG urge “further psychometric testing of the tools currently being used to assess and diagnose [secondary upper quadrant lymphedema].” They point out the need for research that examines diagnostic criteria at different stages of this condition. Further research should examine what “combination of history, symptoms, and other measurements” is “most accurate” for diagnosis, they state.

    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.

    News at NEXT: Foundation Receives Single $3 Million Donation, Largest Ever

    The Foundation for Physical Therapy (Foundation) recently received the largest single donation in its 38-year history—a $3 million gift that will be used to create an endowment for clinical research funding. The donation was announced at the Foundation's PT Party event held June 22 in conjunction with APTA's NEXT Conference and Exhibition.

    The remarkable donation comes from a family known for doing remarkable things for the Foundation—Stanley Paris, PT, PhD, and his wife Catherine Patla, PT, DHSc, MS. In past years, Paris has attempted to sail around the world and swim the English Channel, and he successfully bicycled across the United States, all in an effort to raise money for the organization, which is focused on strengthening physical therapy research.

    "This generous gift will transform the Foundation's ability to fund clinical research at a higher level, providing significant and ongoing support for research that forms the basis of physical therapist practice," said Foundation President, Edelle Field-Fote, PT, PhD, in a Foundation press release. "We are honored by the confidence that Dr Paris and Dr Patla have placed in us by recognizing and rewarding the exceptional work we do to support investigators in the field of physical therapy."

    "We support physical therapy research because it is critical to our profession's ongoing health." Patla said. "We want to sustain the Foundation's work for generations to come." In a video interview, Paris described the donation as a wise investment in physical therapy research. "We know that the money will be used carefully and spent effectively," Paris said.

    Paris and Field-Fote are Catherine Worthingham Fellows of the American Physical Therapy Association.

    News at NEXT: 2016-2017 VCU-Marquette Challenge Raises Over $340,000 for the Foundation

    Students from across the country were recognized June 22 during the Foundation for Physical Therapy's (Foundation) first annual PT Party, formerly known as the Foundation's Annual Gala, for their participation in the 2016-2017 VCU-Marquette Challenge—which for 2017-2018 will be called the Mercer-Marquette Challenge. Mercer University pulled ahead of its competitors this year after a second place finish in last year's competition to win the title, literally, as the challenge now takes on Mercer's name along with Marquette University as part of the contest's tradition. Mercer raised $45,220.

    Earning second place was last year's winner Virginia Commonwealth University ($37,834), and coming in third was the University of Pittsburgh ($24,449). The Foundation also recognized Marquette University students for their financial commitment to the challenge in raising over $20,000.

    The annual challenge is a grassroots fundraising effort coordinated and carried out by student physical therapists and physical therapist assistants across the country.

    This year, 146 schools nationwide participated in creative efforts to support the Foundation, raising a total of $340,986. A record number of schools returned to participate this year, yielding a 70% retention rate. Since its inception, 269 schools have contributed to the challenge, raising over $3.7 million for physical therapy research.

    The Foundation annually awards a research grant and a Promotion of Doctoral Studies Scholarship (PODS) in the name of the challenge to deserving researchers. Since 2002, the challenge has specifically funded more than 23 research grants and scholarships and also partially funded the $300,000 Clagett Family Research Grant in 2010.

    To view the complete list of participating schools visit Foundation4PT.org.

    News at NEXT: Foundation Service Awardees Recognized at NEXT

    Friends and donors of the Foundation for Physical Therapy (Foundation) recognized the achievements of several people and groups at the Foundation's inaugural awards luncheon on June 22. The event honored annual service award recipients and celebrated the efforts of students in the 2016-2017 VCU-Marquette Challenge.

    "Foundation Service Awards are presented to individuals and groups who have demonstrated their commitment to supporting the Foundation and advancing our mission to fund physical therapy research," said Foundation Board of Trustees Vice President Michael J. Mueller, PT, PhD, FAPTA, at the luncheon. "We are certain that the future of the Foundation, and more important our profession, lay bright, so long as there remains support to fund evidence-based practice."

    The 2017 service awards were presented to 4 deserving contributors.

    The 2017 Robert C. Bartlett Trustee Recognition Service Award was presented to past trustee and current honorary trustee Barbara Connolly, PT, DPT, EdD, FAPTA. This award is presented to trustees whose personal service and commitment has helped develop and sustain activities that promote the funding of physical therapy research and education programs.

    Section President William H. Staples, PT, DPT, DHSc, accepted the 2017 Premier Partner in Research Award on behalf of the Academy of Geriatric Physical Therapy. Over the years, the Foundation has presented this award to a select few who have made generous and longstanding contributions, which are critical to the success of the Foundation and its mission.

    The 2017 Charles M. Magistro Distinguished Service Award was presented to Nancy E. Byl, PT, MPH, PhD, FAPTA. This award, named for the first president and chair of the Foundation, is presented annually to individuals for outstanding service and steadfast commitment toward promoting the Foundation's goals.

    The 2017 Spirit of Philanthropy Award was presented to Patricia A. Traynor, PT. Since 2005, this award has been presented annually to donors who exhibit enthusiastic support and dedication to the growth of the Foundation and its mission.

    Later that evening, the Foundation held the Boston PT Party, a nontraditional twist on the former annual gala. During the event, further tribute was paid to the Foundation's service award recipients, and the winners of this year's VCU-Marquette Challenge were announced. Mercer University took top honors and will succeed VCU in being co-eponym of the challenge with Marquette University for 2017-2018.

    Special thanks go to this year's event sponsors: HPSO/CNA, the Boston PT Party title sponsor for the 17th consecutive year; NuStep, producer sponsor; Tri W-G, dessert sponsor; and Performance Health, awards luncheon sponsor.

    Study: Delaying ACL Surgery in Favor of Exercise Therapy May Produce Better Outcomes in Patients With 'Prognostic Factors'

    In brief:

    • Researchers analyzed Knee Injury and Osteoarthritis Scores (KOOS) of 118 young adults who experienced an ACL tear, comparing baseline with 5-year KOOS
    • Some participants received early ACL reconstruction surgery followed by exercise therapy; others received delayed surgery with a period of exercise therapy prior to the surgery; a third group received exercise therapy only
    • Researchers matched baseline and 5-year KOOS with "prognostic factors" associated with worse outcomes—cartilage and meniscus damage, osteochondral lesions, and knee extension deficits
    • Overall findings: early surgery was more often associated with worse outcomes, compared with delayed surgery or no surgery
    • In the early-surgery group, participants with meniscus damage at baseline reported worse KOOS at 5 years than did participants without meniscus damage at baseline; the delayed surgery group reported the opposite, with the meniscus-damage subgroup reporting KOOS gains over those without meniscus damage

    Researchers analyzing a study of patients with anterior cruciate ligament (ACL) tears have begun to connect the dots between early indicators of long-term outcomes and the kinds of treatments patients receive. They reached the conclusion that, for at least some, putting off ACL reconstruction surgery in favor of exercise therapy could be the way to go.

    In what authors call a "post-hoc exploratory, hypothesis-generating analysis of outcomes," researchers used data from the Knee Anterior Cruciate Ligament Nonsurgical versus Surgical Treatment (KANON) clinical trial conducted in Sweden to analyze how Knee Injury and Osteoarthritis Outcome Scores (KOOS) 5 years after injury compared with the presence of various baseline "prognostic factors" known to correlate to worse long-term outcomes. The trial focused on relatively active young adults (18-35 years) with no prior knee injuries who suffered an acute ACL rupture and began treatment within 4 weeks after injury.

    The researchers knew that the 4 prognostic factors—baseline cartilage and meniscus damage, osteochondral lesions, and knee extension deficits—increased the chances of worse outcomes at 5 years. What they wanted to find out was whether early ACL reconstruction surgery actually made those chances worse, compared with surgery delayed in favor of exercise therapy, or exercise therapy alone was responsible. Results were published in theBritish Journal of Sports Medicine (BJSM).

    A total of 118 participants were studied, with 59 receiving early (within 4-6 weeks) ACL surgery followed by exercise therapy, 30 receiving exercise therapy followed by surgery 2 to 56 months later, and 29 receiving exercise therapy only. All patients participated in the same "goal-oriented, physiotherapist supervised neuromuscular program at 9 outpatient clinics," according to authors. Functional measures were collected at baseline, 3 months, 6 months, 12 months, 24 months, and 5 years, with results adjusted for sex, age, body mass index, preinjury activity, education, and smoking.

    Among the findings:

    • For participants with baseline meniscus damage, early surgery followed by exercise therapy resulted in a KOOS that averaged 14 points worse than scores reported by participants with no baseline meniscus damage. But in what authors call a "surprising" result, when participants with baseline meniscus damage participated in exercise therapy and delayed surgery, their KOOS wound up being, on average, 14 points higher than those with no baseline meniscal injury.
    • Similar, albeit lower, effects were recorded for patients with baseline osteochondral lesions (average 5.4 points worse for the early-surgery group; average 6.2 points better for the delayed-surgery group in KOOS for pain). Participants in both categories (early vs delayed exercise) who reported baseline knee extension deficits reported small decreases for most KOOS categories.
    • Overall, participants whose ACL injury was managed with exercise therapy alone reported an estimated 10-point better KOOS at 5 years compared with the early surgery group.
    • Participants who received exercise therapy alone but later received " non-ACL surgery"—a knee surgery that was not ACL reconstructive—reported an estimated 14-point worse KOOS at 5 years compared with participants who received exercise therapy alone and no other surgeries.

    Authors of the study acknowledge that the findings related to meniscus damage were particularly unexpected, but not exactly beyond reason.

    "The mechanisms behind this surprising finding are not clear, but sustaining a second knee insult in the form of an early ACL reconstruction shortly after a previous knee trauma may increase the likelihood of experiencing persistent postoperative difficulties," authors write. They also speculate that the delayed-surgery group may have experienced more pain than their counterparts without meniscus injuries, and, as a result, "reconstructive surgery may have been more successful in relieving pain … compared with those electing to undergo surgery for a range of other reasons, including a desire to gain preinjury status, a pre-existing preference for surgery, and finding exercise therapy boring and time-consuming."

    Researchers also found that the baseline KOOS scores themselves functioned as prognostic factors for worse 5-year outcomes, with early-surgery participants who reported lower KOOS at baseline in turn reporting lower KOOS at 5-year follow-up compared with their delayed-surgery counterparts who also reported lower-baseline KOOS.

    "Low baseline KOOS scores also reflect more physical impairment and this may predispose an individual to worse postoperative outcomes," authors write. "Individuals who report worse KOOS scores prior to reconstruction may benefit from postponing surgery and commencing exercise therapy before considering surgical reconstruction."

    Authors acknowledge that the "exploratory nature" of their research included several limitations, including low sample size, lack of adjustment for multiple comparisons, and confidence intervals "suggesting uncertainty in some of the estimates." Still, they argue, this initial work is worth further exploration and, at the very least, could help to reinforce the concept that clinicians must approach treatment of ACL injuries at the individual patient level.

    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.