RELATED: 10 Minutes of Walking a Day Can Be a Game-Changer for People With OA These findings suggest that providers are focusing primarily on symptom control to relieve the pain and discomfort of knee osteoarthritis, says the lead author, Samannaaz Khoja, PhD, a physical therapist and a research assistant professor at the School of Health and Rehabilitation Sciences at the University of Pittsburgh. “We need to shift our thinking from taking care of the immediate pain and more toward preventing further disability or decline in physical health,” says Dr. Khoja.
Research Suggests That Knee OA Will Continue to Be a Public Health Issue
Since 2005, the number of people with knee OA has grown from around 9 million cases to 15 million, according to the earlier research designed to estimate the prevalence of knee osteoarthritis. “Both the actual data and the projections that we have about obesity and body mass index (BMI) combined with the aging population indicate there will be a continued increase in knee OA prevalence,” says Kelli Allen, PhD, a professor of medicine in the division of rheumatology, allergy and immunology at the UNC School of Medicine in Chapel Hill, North Carolina. RELATED: 6 Strategies to Help Prevent Mood Problems When You Have Knee Osteoarthritis
Knee OA Prescriptions Are Up, Lifestyle Counseling and Physical Therapy Are Down, According to Review
The study used information from a national survey that’s conducted by the Centers for Disease Control and Prevention (CDC). Researchers examined a total of 2,297 visits, which were weighted to represent 67 million physician visits, or about 8 million per year. The data was broken out into three 3-year blocks, 2007–2009, 2010–2012, and 2013–2015. About two-thirds of the visits were to orthopedic surgeons, 21 percent to primary care physicians, and the rest to other types of specialists. Key findings about knee OA included:
The rate of referral to PT by orthopedic specialists dropped from 158 per 1,000 visits in 2007–2009 to 86 per 1,000 visits in 2013–2015.Lifestyle counseling, which would include things like exercise recommendations and weight management strategies, provided by orthopedists fell by more than half, from 184 per 1,000 visits in 2007–2009 to 88 per 1,000 in 2015.During those same periods, the number of prescriptions written by orthopedic specialists for nonsteroidal anti-inflammatory drugs (NSAIDs) more than doubled, from 132 per 1,000 visits to 278 per 1,000, and tripled for narcotics, going from 77 per 1,000 to 236 per 1,000.Counseling and referrals for PT from primary care doctors was low throughout the study period, with fewer than 1 in 20 people getting a PT referral, and about 1 in 5 people receiving lifestyle counseling.Although there was no significant increase in the use of narcotic prescriptions for knee OA from primary care doctors (233 to 316 per 1,000 visits), the use of NSAID prescriptions nearly doubled, from 221 per 1,000 visits in 2007–2009 to 498 per 1,000 visits in 2013–2015.
“This may be one of the first studies that’s looked at this on a national level using an objective data source,” says Dr. Allen. “The increase over time of medication use is somewhat surprising, though the overall low use of PT and lifestyle counseling is what I would expect to see; that’s been shown in other studies,” says Allen. RELATED: 12 Natural Pain Relief Tips for Knee Osteoarthritis
Trend Shows Decrease in Exercise-Based Interventions, Despite Recommendations, Even From Specialists
PT referrals in primary care tend to be low because many patients who are going to primary care are seeing their doctor for a variety of health issues, many of which wouldn’t be helped by physical therapy, says Khoja. “In the case orthopedic specialists, however, we would expect the rate of PT and lifestyle recommendations to follow the same trend as medication practices because the use of exercise-based intervention is one of the frontline treatments suggested by various clinical practical guidelines,” says Khoja. “Exercise along with NSAIDs is the most widely recommended frontline treatment for knee OA, which is why we expected similar trends, but not a decline in lifestyle counseling or PT,” she adds.
Prescribing Diet, Lifestyle Counseling, or Physical Therapy Is Getting Less Common, Study Suggests
Both exercise and the use of NSAIDs and tramadol, a narcotic, in the treatment of knee OA are considered “strong” recommendations in the clinical practice guidelines set forth by the American Academy of Orthopaedic Surgeons (AAOS), which means “the benefits of the recommended approach clearly exceed the potential harm and/or [the] quality of the supporting evidence is high. Practitioners should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present,” state the guidelines.
When It Comes to Treating Knee Osteoarthritis, Doctors Aren’t Following Expert Guidelines
Weight loss for patients with a body mass index (BMI) of 25 or higher is a moderate recommendation, meaning that the benefits exceed potential harm, but the quality of evidence is not as strong. The research on the use of acetaminophen, opioids, or pain patches is inconclusive, meaning that there is not sufficient evidence for or against, and individual providers should use their own clinical judgment, with patient preference having “a substantial influencing role.”
Are People With Knee Osteoarthritis Getting Good Care?
Because this was an observational and cross-sectional study, the findings aren’t intended to prove causation, but they are important in that they tell us what’s being done in clinics to treat knee OA, says Khoja. “These findings suggest that patients are not receiving the optimal care. They’re not receiving guideline-based care,” she says. It’s important to note that treating knee OA with tramadol is consistent with the guidelines, says Khoja. Tramadol is a controlled substance, and it acts similarly to an opioid; it has potential for abuse and addiction. A study published in JAMA in March 2019 found that there was a significantly higher mortality rate for people with knee OA who took tramadol compared with people who took NSAIDs, although researchers weren’t able to prove causality. From the survey data collected for this research, investigators weren’t able to determine if the prescribed narcotic was tramadol or another drug such as an opioid, says Khoja. “This is a limitation to our study,” she says. RELATED: 6 Smart Ways to Lose Weight When You Have Knee Osteoarthritis
Treatment With Opioids Should Be a Last Resort
“Narcotics in general are the second and third line of intervention for knee OA. If everything else fails and you can’t do surgery, and their pain is really bad, then you can prescribe opioids,” she says. The guidelines have been very instructive in informing clinicians that narcotics are not frontline treatment for quite a while, adds Khoja. “Given the recent opioid epidemic and the increased awareness it has brought, I would hope that if we repeated the study next year that the level of narcotics prescribed would drop,” she says.
Long-Term Consequences Need More Consideration in Knee OA Treatment
Rather than focusing treatment on current symptoms, both specialists and primary care doctors need to start thinking more about long-term consequences, because knee OA is a lifelong chronic condition, says Khoja. “There is no known cure except replacement surgery. People need to know that the best way to improve the condition is to improve your strength and improve your fitness level,” she says.
Isn’t Exercise Medicine for Osteoarthritis?
These findings suggest we need to do more qualitative research on the barriers for prescribing exercise and start looking at ways for improving uptake of exercise-based interventions in the clinic, says Khoja. “Physicians have a full schedule; they are overwhelmed with the number of things they need to accomplish in a patient visit, and exercise not on their radar,” she says. “We need to find ways, even if it’s by utilizing other providers in the clinic, that can address some of these non-medication-related interventions that are effective,” she adds.
Treatment Models in Other Countries May Offer Help
“This should be a wake-up call, or a continued wake-up call, for us in the healthcare system to see what we can do to improve this trend,” says Allen. There are treatment models that are more systematic about getting people into lifestyle-related therapies for knee OA that are being tested in other countries, which could help guide future efforts stateside, she adds.
