PT vs. Steroid Injections

Contributors: Deyle GD, Allen CS, Allison SC, et al. Physical therapy versus glucocorticoid injection for osteoarthritis of the knee.  New England Journal of Medicine 2020;382:1420-9.  

Physical Therapy versus Glucocorticoid Injection for Osteoarthritis of the Knee

Summary:

Osteoarthritis of the knee continues to be a leading cause of disability in the United States and worldwide.  Intra-articular glucocorticoid steroid injections are used as a primary treatment for arthritis of the knee.  Although there are conflicting reports regarding the extent and duration of symptom relief achieved with steroid injections, current clinical practice guidelines continue to endorse injections for the treatment of knee osteoarthritis.  In fact, upwards of 50% of patients who received a total knee replacement had previously received intra-articular steroid injections. 

Current clinical practice guidelines also recommends physical therapy for short and long term relief of symptoms, functional improvement, and need for pain medication in people with knee OA.  However, in contrast to steroid injections the use of physical therapy for knee OA has decreased over the last decade, with patients four times more likely to receive a steroid injection then physical therapy. 

A recent study published in the New England Journal of Medicine compared physical therapy treatment consisting of manual therapy, exercise, and education to intraarticular steroid injections at 1 month, 2-month, 6 month, and 1 year time intervals.  Patients receiving injection could receive up to 3 injections during that period.  Those receiving physical therapy received up to 8 treatment sessions within 8 weeks.  Additionally, the physical therapy group had follow up visits scheduled at the 6 and 9 months. 

The results of this study indicated that multimodal physical therapy with intermittent wellness visits at 6 and 9 months had less knee pain and disability at 1 year then those receiving intra-articular corticosteroid injections.  The effect size of the physical therapy in this trial was greater then previous trials at the 1-year mark, in part due to the emphasis on patient education and wellness visits at 6 and 9 months.  The results of this study indicate that increasing the use of physical therapy interventions in patients with moderate or advanced knee osteoarthritis would be beneficial in improving pain, disability, and medication usage.