Search the Community

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE November 2022 Knee OA Injection Therapy: New Evidence on Best Options for Improving Pain & Function by Allison Pulvino, PT, MSPT, CMP, FAFS Clinical Scenario…What would you do? A 57 year old female with a 5 yr h/o L knee pain medially has noted progressive worsening over the past 6 months, especially with long walking and hikes with her friends. Plain films show moderate joint space narrowing medially and only slight changes in the lateral and patellofemoral compartments. She has mild genu varum asymmetric on the L knee noted with WB exam. She wishes to continue TIW fitness exercise (cardio, weights, classes) and has been controlling symptoms with OTC NSAID’s for the past several years. She was seen in PT 2.5 yrs ago for three visits in PT and taught a HEP, which she remained compliant with. She demonstrated common knee exercises as her main HEP activities (SLR’s, Hip Abd clamshells, bridging, static balance on foam pad, 8” step ups, band walks for abd’s - band at ankles, full range quad bench PRE). I would prescribe… Customized physical therapy with 6 wk FU to discuss corticosteroid injection option depending on symptom and function status. Corticosteroid injection with 2 wk FU to discuss physical therapy option. Customized physical therapy w 6 wk FU to discuss HA injection option. Customized physical therapy w 6 wk FU to discuss PRP injection option. Begin HA injection series and begin customized physical therapy one week following 1st injection. CURRENT EVIDENCE Singh et al. Relative Efficacy of Intra-articular Injections in the Treatment of Knee Osteoarthritis. The American Journal of Sports Medicine. 2022; 50 (11): 3140-3148. Summary: Knee OA is a commonly seen condition for physicians, surgeons and physical therapists. Among the treatment considerations physicians often consider is injection therapy. Singh et al did a systematic review examining pain and function status 6 months after steroid(CS), HA, PRP, plasma rich in growth factor (PRGF), or placebo injection therapy. PRP demonstrated the best outcomes compared to others for pain and function findings. All injections except CS showed statistically significant improvements vs placebo. Steroid and HA injections anecdotally appear to be the most frequently used injections here locally in Rochester for these cases. This evidence for PRP efficacy may provide compelling support for physicians/surgeons making recommendations to patients for optimal injection therapy options. PRP presents a unique challenge since it is not yet approved by third party payers. This is likely a key factor for physicians and patients when choosing CS or HA injections first. One risk physicians and patients must be aware of is the tendency for early symptom relief following injections to dissuade appropriate consideration of physical therapy. Addressing ROM and strength/balance needs will not only optimize function but lessen the likelihood of symptom reactivity to ADL and recreational activities. Another factor in knee OA treatment prescribing may be physician or patient based past experiences with “failed PT.” We often find this is due to a lack of biomechanical considerations applied to especially key WB strengthening. Careful consideration should allow physical therapists to most often intentionally unload symptomatic knee compartments. While not part of traditional approaches, this biomechanical technique can be an effective means of promoting pain-minimized or pain-free strength gains, leading to more successful squat ADL and stairs or recreational participation. Expectations are that IA injection combined with excellent physical therapy should produce optimal outcomes not only acutely but for many months or even years to come in most cases. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) Background: Intra-articular (IA) knee injections for knee OA has been a topic of increasing interest, as well as which type of injections most benefit patients long term in regards to pain and function. Methods: A systematic review and meta-analysis utilizing 23 RCT’s meeting the inclusion/exclusion criteria was performed to obtain information regarding pain and function at a 6-month follow-up after either Corticosteroid (CS), Hyaluronic acid (HA), platelet-rich plasma (PRP), or a plasma rich in growth factor (PRGF) injection, or a placebo. Findings: All IA treatments except CS were found to have statistically significant outcome improvements when compared to a placebo. PRP demonstrated the greatest results in function-related gains. In regards to pain, function and both combined, PRP was found to possess the highest probability of efficacy and CS as the last followed by the placebo. Author’s Conclusion: When comparing various IA injections, PRP had the most significant outcomes, followed by PRGF, HA, CS and then placebo for treatment of knee OA at a 6-month follow-up. Other non-operative treatments were not included in this study, including NSAIDS and physical therapy. THE PEAK PERFORMANCE PERSPECTIVE As a physician/surgeon, knee OA is likely a common diagnosis seen in the clinic. Conservative measures are key options for early treatment, including NSAIDs and physical therapy. Another frequent consideration is injection therapy. Quality research forms a critical foundation helping physicians and surgeons determine treatment recommendations. While as providers we all appreciate the value and necessity of optimizing function, for patients their top-of-mind concern is typically symptom control. Many but not all patients with knee OA will respond positively to OTC or prescription medications, at least temporarily. A majority will see significant improvements in pain, ROM, strength, and function with quality physical therapy. Additionally, intra-articular (IA) injection therapy is a potentially helpful treatment option, for some used as a primary stand-alone treatment and for others as an important part of a multi-faceted approach to thorough OA care. The question remains: Which type of injection is most effective and indicated for this patient? The evidence on comparing outcomes for various injections has been limited. Practice standards and habits had traditionally utilized IA corticosteroid (CS) as the first-line injection type. Over the past decades “gel” injections using hyaluronic acid (HA) and biologics (PRP, stem cells…) have become more available and had variable increasing evidence, however, most are short term studies. Singh et al. discovered in their Systematic Review and Meta-analysis that PRP really produces the best results, with PRGF and HA outperforming CS injection therapy, when they looked at longer 6-month follow-ups for pain and function outcomes. One risk for patients and physicians alike regarding injection therapy is that when highly effective early on, the motivation to actively participate in physical therapy to restore ROM and strength may be diminished. Patients often take a “It’s feeling good now so I’m gonna see how things go like this” sort of mentality, being unintentionally lured into complacency by their immediate post-injection symptom relief (typically after CS injection). We remind patients it is important to “get beyond feeling better to being better” - i.e., restoring mobility, strength, balance etc. in order to optimize function. Regarding the Singh et al. findings, locally we do not see PRP used often for knee OA cases. Certainly a lack of comparative outcomes data to support treatment recommendations of PRP over other options may be a primary reason for this. PRP is also presently a cash-based treatment, making a trial with CS injection initially the potentially more logical option since it is typically covered by insurance. The findings of this Singh et al study will probably provide some convincing data to support future trials with PRP, despite the higher expense to the patient, as doctors and surgeons evaluate the best treatment suggestions for knee OA aside from oral drugs and physical therapy. Also, there remains some limit on the frequency/volume of CS that can be injected before potential negative effects are noted within the joint - making PRP additionally appealing as an option. While we clinically have seen variable outcomes from IA injections (both HA and CS) ranging from no relief to full relief, these results are often temporary in nature, sometimes lasting for weeks to months but then requiring further injections. Research has shown physical therapy to be effective at reducing symptoms and increasing function for knee OA. While it is often prescribed it remains underutilized, possibly in part due to a perception that therapy itself cannot alter the degenerative chondral changes themselves. When NSAID’s or injection therapies, especially CS, are successful that also, as mentioned above, tends to dissuade some patients from the work therapy entails. For patients with knee OA, the loss of motion and strength both negatively affect not only day to day function but clearly contribute to worsening symptoms. This also contributes to increasing compensation patterns and too often symptoms developing in adjacent body parts such as the hip or lower back. For example, we see patients unable to squat their knee effectively tending to bend over from their spine which is more than ideal. Flexion sensitive LBP sometimes then develops. Knee OA physical therapy too often is mistakenly perceived to have “failed” in the eyes of the patient and the physician as well. This scenario begs the question - is physical therapy itself an ineffective tool for this patient/case or was the specific therapy provided ineffective/inappropriate/limited in nature? Just as a poorly done procedure or non-compliance with recommended medication dosages/frequency may yield less than favorable outcomes, physical therapy must be biomechanically appropriate, problem solving based and most often include manual therapy to optimize outcomes. While “cookie-cutter, simple” home programs may appear a great starting point for most patients, it presents the challenge that for too many patients (who have already waited too long to engage with health care professionals) that unimpressive results with early physical therapy risks being perceived as ineffective. These failures may be avoidable but require physical therapists to utilize deeper understandings of biomechanics rather than reliance on “keeping it simple” to such an extent that customized needs of each OA case are missed. From a physician’s standpoint it may help to prescribe something like “biomechanical adjustments prn with squat PRE.” The knee’s dominance as a primary sagittal plane functioning joint brings a double edged sword of sorts. Focused manual therapy and exercise efforts to gain full functional extension and/or flexion of an arthritic knee can greatly impact functional WB activities like ambulation and stairs; however, strengthening exercises dominating that same sagittal plane are most often the source of most patients’ chief complaints. Many knee OA situations involve one compartment being significantly worse than the other. Asymmetric loading of the arthritic chondral surfaces then occurs with traditional “closed chain” exercise attempts to strengthen. This is especially where deeper biomechanical understandings can significantly benefit patients attempting to regain quad strength for sit-stand function and stairs. Preferential loading and unloading of the medial or lateral compartment can be accomplished with a variety of different “tweaks” utilizing the frontal and/or transverse plane biomechanics of the knee and lower extremity. This involves in some way reversing the biomechanical patterns of how that degenerative compartment gets overloaded in the frontal and/or transverse plane to begin with. An overpronated foot elicits tibial IR or an anteverted hip likewise femoral IR, either being contributors to dynamic knee valgus and increased lateral compartment stresses (likewise reducing medial compartment compressive loading). Conversely a supinated foot, retroversion, a tight ITB, or even lacking pronation or femoral IR can all lead to a dynamic varus knee alignment which increases medial and decreases lateral compartment stresses. Thoughtful PT exercise plans work toward optimizing symptom-minimized knee status to promote more optimal exercise intensity and eventual strength gains. Utilizing various body “drivers” or movement stimuli meant to promote a given movement pattern or body positioning in order to reverse those damaging stresses. Thus, a hand reach or body tip/lean or altered foot position affecting the frontal and/or transverse plane can work to increase loading on the healthier or asymptomatic side during otherwise typically painful squat based WB strengthening exercises. This Applied Functional Science (AFS ®) based approach is a critical means of helping the majority of “previously ‘failed PT’ “cases and otherwise deemed “low rehab potential” cases to do well. Singh et al admit that physical therapy wasn’t addressed in this study. Injection therapy can be an important component to OA treatment especially because many patients struggle with pain limiting exercises. We would suggest that a comprehensive approach includes targeted, customized physical therapy using biomechanical approaches. The case below illustrates an example of effective conservative knee OA care with successful outcomes. THE PEAK PERFORMANCE EXPERIENCE Alice said: “I had the last shot 7 days ago and I feel improvement!” History: Alice has had moderate pain in her L knee for over 2 years, off and on. Has previously had a series of 3 cortisone injections without relief > a few months. Recent HA injections have provided improved ability to tolerate WB as well as PT ex’s to gain more extension ROM and functional strength. Objective: Initial Exam Re-evaluation Knee extension -10deg (flexion contracture) -2deg Knee flexion 120deg 130deg FABER test Pos Pos Ober’s test Pos Neg Thomas test Pos Neg Anterior step down L unable/fear of buckling 2” step down w 8# DB Pivoting for directional change L fear of instability No fear/no issue Sit-stand UE assist/stiffness 10x w/o UE assist Key Findings: L knee flexion contracture, lack of full knee flexion with pain as compared to opp knee, limited with all WB transfers, inability to descend any height step, valgus deformity, very limited hamstring length, lack of ankle DF and lack of hip extension Treatment: Manual joint mobs for ankle DF, knee extension with distraction and distal femoral ER to realign, hip extension mobs in WB, patellar mobs, hip ER mobs in WB. Stretching knee extension in prone, ankle DF WB stretching, hamstring and hip flexor stretching in WB, NWB hip ER stretching. Strengthening consisted of SLRs, quad control in L WB knee extended opp LE toe reaches, knee flexed DF loading toe reaches, progressing to 2 inch step downs with ipsilat pelvic rot for femoral ER control, SLB with ipsilateral rotation R crossover touches for valgus correction, assisted squats with L toeing in for alignment correction. Outcome: Pt was able to gain almost full knee extension, was able to ascend/descend steps without pain with UE assist, sit to stand transfers pain free without increased time needed, and ambulating short distances without AD. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com