PHYS THER
Vol. 88, No. 10, October 2008, p. 1123
DOI: 10.2522/ptj.20080077.ar
Author Response
Nadine E Foster
We thank Lund1 for his comments on our article2 and for his insights into the challenges within the field of exercise for patients with knee osteoarthritis (OA). Physical therapists in the United Kingdom have an important role in the management of patients with knee OA through designing and supervising exercise programs, and our article, based on a national random sample, describes patterns in current practice. Our first aim was to describe current use of exercise therapy for patients with clinical knee OA within the United Kingdom, and our second aim was to explore whether these patterns of practice appear to be in line with recent exercise recommendations.3 Given the lack of robust data from previous high-quality randomized controlled trials (RCTs) to guide clinical decision making about the type, dose, intensity, and progression of exercise for this patient population, a multidisciplinary group developed these recommendations by incorporating available research-based evidence with expert opinion (also "evidence" but of a different sort), a recognized approach to the development of best practice recommendations used by guideline development groups (eg, Zhang et al4) when there is a paucity of data from meta-analyses and RCTs.
The choice of a patient vignette upon which to base questions about practice met our aim of providing a prototypic case presentation that would permit comparison of therapists’ responses. The development and testing of the vignette was rigorous and followed available recommendations, including basing the vignette on a real patient case, testing the vignette for face validity, and careful pre-pilot and pilot testing. The responses from therapists in relation to the management of the patient described in the vignette allowed us to provide reasonably representative descriptions of practice in the United Kingdom and gave us the opportunity to compare the responses with the most recent recommendations for practice. We did not attempt to categorize responses as "correct" or "incorrect," as suggested by Lund in his commentary.
There are many individual RCTs of exercise for knee OA now available, including the one by Zhang et al4 described in the commentary by Lund. Many RCTs are based on small sample sizes and provide standardized exercise programs despite individual patient differences. We have contributed several RCTs that show individualized, physical therapist-led therapeutic exercise is effective and that adding other interventions, such as acupuncture, does not provide much additional benefit.5,6 The overall message, however, from systematic reviews of available trials is that effect sizes from exercise interventions are small, or at best moderate, and decline over time. At least one of the clear implications for those conducting RCTs is that future trials must be adequately powered to detect these small to moderate effects between treatment groups.
The commentary raises many issues with which we wholeheartedly agree. For example, key priorities for future research include the need to more carefully test impairment-directed exercise interventions through, for example, subgrouping patients into different categories based on priority impairments in strength, movement, or balance and targeting exercise to those specific impairments. A further key priority, particularly given the lack of robust data that any one type of exercise is superior to another and the evidence that general physical activity is of benefit, is to study how we can support patients to adhere to exercise in the longer term in ways that fit in with their everyday lives. Our current program of research7,8 aims to address both of these priorities, and we encourage other research groups to provide good-quality evidence that can be used in future best practice recommendations about exercise for patients with knee OA.
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References
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- Lund H. Commentary on: Physical therapists’ use of exercise therapy for patients with clinical knee osteoarthritis in the United Kingdom: in line with current recommendations? Phys Ther. 2008;88:1121–1122.[Free Full Text]
- Holden MA, Nicholls EE, Hay EM, Foster NE. Physical therapists’ use of exercise therapy for patients with clinical knee osteoarthritis in the United Kingdom: in line with current recommendations? Phys Ther. 2008;88:1109–1121.[Abstract/Free Full Text]
- Roddy E, Zhang W, Doherty M, et al. Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or knee: the MOVE consensus. Rheumatology(Oxford). 2005;44:67–73.[CrossRef]
- Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage. 2008;16:137–162.[CrossRef][Web of Science][Medline]
- Foster NE, Thomas E, Barlas P, et al. Acupuncture as an adjunct to exercise based physiotherapy for osteoarthritis of the knee: randomised controlled trial. BMJ. 2007;335:436.[Abstract/Free Full Text]
- Hay EM, Foster NE, Thomas E, et al. Effectiveness of community physiotherapy and enhanced pharmacy review for knee pain in people aged over 55 presenting to primary care: pragmatic randomised trial. BMJ. 2006;333:995.[Abstract/Free Full Text]
- Jordan JL, Foster NE, Holden MA, Mason EJ. Interventions to improve adherence to exercise for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev. 2006;2:CD005956.
- Wood L, Peat G, Thomas E, et al. Associations between physical examination and self-reported physical function in older community-dwelling adults with knee pain. Phys Ther. 2008;88:33–42.[Abstract/Free Full Text]
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Copyright © 2008 by the American Physical Therapy Association.
