Exercise helps manage hip arthritis pain

Water- or land-based exercise should provide some short-term benefit in pain management for hip osteoarthritis, though there are few well-designed trials testing it, according to a new review.

Americans develop three million new cases of osteoarthritis each year. Most vulnerable are those who are older, obese, have previous joint injuries, overuse, weak muscles or genetic risk factors.

“It is nice to finally have some hip-specific data, as hip and knee osteoarthritis are often grouped together and it is almost certain that there are differences between these groups of patients, as well as differences in those with multiple joint osteoarthritis,” said Dr. Amanda E. Nelson of the Thurston Arthritis Research Center at the University of North Carolina Medical Center in Chapel Hill, who was not part of the new study.

“However, the studies are still small and heterogeneous, and larger, longer-term studies of more specific interventions are certainly needed to provide more specific recommendations,” she said.

The review only considered pain, not joint function, which may also improve with physical activity, Nelson told Reuters Health by email.

The researchers, lead by Kay M. Crossley of La Trobe University in Bundoora, Australia, reviewed 19 studies of water-based or land-based exercise therapy or manual therapy for hip pain, 10 of which were designed specifically for hip osteoarthritis.

Four studies found short-term benefits, up to three months later, with water-based exercise compared to minimal pain management. Six found similar benefit for land-based exercise therapy in the short term, but there was no evidence for benefit in the medium or long term, up to one year after therapy.

Manual therapy, which includes joint manipulation, active stretching and massage, did not appear to provide additional benefit on its own or in combination with exercise, the researchers reported in the British Journal of Sports Medicine.

That’s not encouraging, said Dr. Kim Bennell of The University of Melbourne in Australia, who was also not part of the review. “However, the number of studies is relatively small and there was a lot of variation in the methods of the studies, so further research is needed in this area to confirm the results.”

Most doctors do not recommend exercise therapy, relying instead on pain-relieving drugs for osteoarthritis, despite agreement across guidelines and organizations that non-drug approaches are worthwhile, Nelson said.

“There are numerous potential barriers to recommendation and treatment including access to care, financial concerns, and the burden of managing multiple medical conditions in a short visit with a provider, among others,” she said. “Therefore, although the guidelines are in agreement, it is likely that the majority of patients are not receiving this recommendation from their providers, and that even fewer actually follow through on the recommendation if given.”

The 19 studies in the review all tested different type, frequency and duration of exercise, so the best sort of exercise, how much and how often to do it, remains to be determined, she said.

It would appear that a 12-week program with exercises generally including strengthening and range of motion three times per week is beneficial, Bennell told Reuters Health by email.

“Based on the overall body of work in physical activity, though, any regular physical activity is likely to be beneficial to most patients,” Nelson said. “It is safe to say that most adults do not get enough physical activity, and that this is even more of an issue among those with osteoarthritis.” — Reuters

Knee replacement surgery works, but so can nonsurgical techniques

Total knee replacement can usually relieve pain and improve function, but a nonsurgical regimen can also be effective in some people without posing the complication risks that can plague people who choose surgery, according to a new study.

The test found that while 85 percent of patients who underwent surgery showed clinically-significant improvement after one year, so did 67 percent assigned to a combination of supervised exercise, use of insoles, pain medication, education and dietary advice.

"It won't do any harm trying the nonsurgical treatment," chief author, Dr. Soren Skou of the University of Southern Denmark in Odense, told Reuters Health. "I hope this will give a more balanced discussion of whether or not to have the surgery."

There's little debate that knee replacement helps many people, and the new test of 100 patients—the first randomized controlled trial ever done on the technique—confirms it. Surgery patients didn't show just some improvement. They registered far less pain and disability than those assigned to the non-surgery group.

Yet the study was needed because as many as 1 percent of surgery patients die within 90 days of their operation and about 1 in 5 have residual pain at least six months after the procedure, said Dr. Jeffrey Katz of Harvard Medical School in Cambridge, Massachusetts, in an accompanying editorial in the New England Journal of Medicine. "Until now, we have lacked rigorously controlled comparisons between total knee replacement and its alternatives."

"People need to understand and respect that knee replacement is not without complication. Knee replacement is a big surgical procedure and there are risks associated with it," Dr. Andrew Pollak, chairman of orthopedics at the University of Maryland School of Medicine in Baltimore, told Reuters Health.

The study "really emphasizes what we suspected all along—total knee replacement works. It will be obvious to many of us who take care of patients. But for patients with significant symptoms and evidence of arthritis, total knee replacement is a very effective way of improving quality of life," said Pollak, who was not associated with the research. "Therapy alone has a role. It does help certain patients. It can certainly prolong the time to when knee replacement is necessary."

More than 670,000 total knee replacements are done in the US each year at a cost of $36.1 billion.

All of the patients in the study had moderate-to-severe knee osteoarthritis. The team measured symptoms, pain and quality of life over a one year period.

Volunteers in the surgery group gained an average of 32.5 points versus 16.0 points for people who received nonsurgical therapy. All started off with a score of about 48 on a 101-point assessment scale.

Individual measures of pain, symptoms, activities of daily living, quality of life, and sports and recreation all showed significant improvement with surgery.

But while there were just six instances of serious adverse events in the 50 patients who didn't receive surgery, there were four times as many among the 50 assigned to have a knee replaced. One third of the problems involved the replaced knee, including three cases each of unacceptable stiffness and deep vein thrombosis requiring anticoagulation, and one case each of deep infection and leg fracture.

Thirteen of the 50 patients assigned to the no-surgery group ended up having their knee replaced anyway during the 12-month follow-up period.

"We've had some patients who had the surgery who did not improve in pain and, in some cases, had worse pain," Skou said. They may improve with longer followup, but, he said, "what struck me is, if you do not go through surgery, you could always have the surgery later." —Reuters