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  • 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.


    • A neat trick for knee pain is to do deep massage over the genu articularis muscle. This muscle seems to get fibrotic. A couple of minutes of somewhat painful massage will relieve quite a bit of "arthritis pain". Follow it up with gluteal retraining and some quad strengthening and you can "cure" knee pain.

      Posted by Brian Lamber, PT on 7/12/2017 3:23 PM

    • I liked it want to know more.

      Posted by Raymond E. Johnson on 9/15/2017 10:39 PM

    • I am interested in the massage of the “Geru articulatis muscle”. Also the “dry needle “ treatment. Can these be added to my current treatment plan ?

      Posted by Jack olmstead on 4/30/2018 12:38 PM

    • Can I self-refer and do you take Blue Cross Blue Shield? I have pain on inner edge of knee that is keeping me from running. Anything I can do to self-treat?

      Posted by roger medd on 4/4/2019 6:12 PM

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