Comparing Physical Therapy, Internet-Based Exercise Training, and No Therapy for Knee Osteoarthritis

This project has results

Results Summary and Professional Abstract

Results Summary

Download this abstract: English (pdf) | Español (pdf) | Audio Recording (mp3)

What was the research about?

Knee osteoarthritis is a chronic health problem that causes pain and stiffness in the knee joints. Appropriate exercise may help with these symptoms. One common treatment is physical therapy. But physical therapy services aren’t available everywhere. These services may also be costly.

In this study, the research team wanted to help patients get support and instruction for appropriate exercise for knee osteoarthritis. The team assigned patients to one of three groups. Patients in the first group received physical therapy. Patients in the second group could access a website that guided them through knee exercises. It also helped patients track their exercise progress. In the third group, patients didn’t receive either treatment.

What were the results?

After one year, patients in all three groups had better function and less pain and stiffness than they did at the start of the study. All three groups improved by a similar amount.

Compared with the group that didn’t receive treatment, the physical therapy group

  • Reported more physical activity and stretching
  • Performed better on a physical ability test
  • Had higher satisfaction with their physical function, fewer sleep problems, and less fatigue
  • Had a higher overall rating of knee symptom improvement

Compared with the group that didn’t receive treatment, the website group

  • Reported more minutes of weekly stretching
  • Had a higher overall rating of knee symptom improvement

Who was in the study?

The study included 350 patients in North Carolina who had knee osteoarthritis. Of these, 72 percent were white, and 20 percent were black. In addition, 3 percent were Asian, 3 percent were more than one race or didn’t report a race, and 1 percent were American Indian or Alaska Native. The average age of patients was 65, and 71 percent were female. All patients had internet access. They weren’t receiving physical therapy before the study.

What did the research team do?

Patients who received physical therapy had as many as eight sessions with trained therapists over four months. Therapists tailored the sessions to meet patients’ specific needs. For patients who could access the website, the research team encouraged them to do the exercises on the website at least three times a week and to do aerobic exercise daily. Patients who didn’t receive treatment during the study received two physical therapy sessions and access to the website after the study.

At the start of the study and again one year later, the research team gave a survey to patients. The survey asked patients about their knee pain, stiffness, and function. The survey also asked about physical activity, mental health, social support, and satisfaction with physical function. The team also tested patients’ physical ability at one year.

A group of patients with knee osteoarthritis, doctors, physical therapists, an exercise scientist, and two members of arthritis advocacy organizations worked with the research team. The group helped recruit patients and decide what information to collect.

What were the limits of the study?

In this study, 20 percent of patients in the website group never logged on to the website. Results may have been different if more patients had used the website.

Future research could look at how to increase patients’ use of the website, such as by sending text message reminders.

How can people use the results?

Doctors, patients, and clinic managers can use these results when considering ways to improve function and lessen pain for patients with knee osteoarthritis.

Professional Abstract

Objective

To compare the effectiveness of physical therapy, internet-based exercise training (IBET), and no intervention on patient-reported pain, stiffness, and function among individuals with knee osteoarthritis

Study Design

Design Elements Description
Design Randomized controlled trial
Population 350 patients with knee osteoarthritis
Interventions/
Comparators
  • Physical therapy
  • IBET
  • No intervention (control)
Outcomes

Primary: patient-reported lower extremity pain, stiffness, and function measured through a validated osteoarthritis index

Secondary: patient-reported physical activity, weekly minutes of exercise, satisfaction with physical function, sleep disturbance, fatigue, global assessment of knee symptom change, depressive symptoms, social support for exercise, self-efficacy for exercise, fear of movement, physical ability tests (unilateral stand time, chair stand, 2-minute march, standing up, and sitting down)
Timeframe 1-year follow-up for primary outcome

This randomized controlled trial compared the effectiveness of physical therapy and IBET against no intervention in improving outcomes for patients with knee osteoarthritis. Researchers randomly assigned patients to one of three groups: physical therapy, IBET, or no intervention. In the first group, patients received up to eight physical therapy sessions within four months. Therapy was tailored to their needs and functional limitations. In the second group, patients received access to IBET, which included a website with tailored exercise routines, video displays of exercises, and automated reminders. Researchers encouraged patients to do strengthening and stretching exercises from the website at least three times a week and aerobic exercises daily. Patients in the control group did not receive an intervention. After the study ended, patients in this group received two physical therapy visits and access to IBET.

The study included 350 patients in North Carolina who had a diagnosis of knee osteoarthritis. Of these, 72% were white, 20% were black, 3% were Asian, 1% were American Indian or Alaska Native, and 3% were from more than one race or did not indicate a race. The average age was 65, and 71% were female. All patients reported pain or stiffness in their knee, were not receiving physical therapy, and had internet access.

Researchers surveyed patients regarding pain and function and conducted physical ability tests at baseline and again 4 and 12 months later.

A group of patients with knee osteoarthritis, physicians, physical therapists, an exercise physiologist, and members of arthritis advocacy organizations helped researchers decide on study outcomes and recruitment procedures.

Results

Scores for pain, stiffness, and function improved for patients in all three groups. At 4 and 12 months, there was no significant difference in the change in scores for pain, stiffness, and function for patients in the physical therapy or IBET group compared with patients in the control group.

Compared with patients in the control group, patients in the physical therapy group

  • Reported more minutes of weekly stretching at 4 and 12 months (p<0.05)
  • Reported better scores for global assessment of change of knee symptoms at 4 and 12 months (p<0.05)
  • Performed better on the two-minute march test at 12 months (p<0.05), but not at 4 months
  • Reported more physical activity at 12 months (p<0.05), but not at 4 months

Patients in the physical therapy group also reported greater satisfaction with physical function and fewer sleep problems and less fatigue at 4 months (all p<0.05), but not at 12 months, compared with patients in the control group.

Compared with patients in the control group, patients in the IBET group reported

  • More minutes of weekly stretching at 4 and 12 months (p<0.05)
  • A better global assessment of change at 12 months (p<0.05), but not at 4 months

Researchers found no differences in other secondary outcomes when comparing patients in the physical therapy or IBET groups with those in the control group at 4 or 12 months.

Limitations

Of the patients in the IBET group, 20% never logged on to the website; among those who did, the number of days they logged on was low. Results may be different if more patients used IBET at all or more often.

Conclusions and Relevance

Physical therapy and IBET did not improve the primary outcome of patient-reported pain, stiffness, and function more than no intervention. However, both physical therapy and IBET were associated with improvement in some aspects of function.

Future Research Needs

Future research could explore other methods to increase patient use of IBET, such as using text message reminders.

Journal Articles

Article Highlight: This project reported in BMC Musculoskeletal Disorders that more physical therapy visits was associated with more improvement in various areas such as pain levels and knee function, for people with knee osteoarthritis. The study, which included 259 participants, also found more-frequent use of online exercise training was not associated with greater improvement in the same areas.

Results of This Project

Osteoarthritis and Cartilage

Physical therapy vs internet-based exercise training for patients with knee osteoarthritis: results of a randomized controlled trial

Related Articles

Arthritis Care & Research

Racial differences in performance-based function and potential explanatory factors among individuals with knee osteoarthritis

Journal of Geriatric Physical Therapy

Fall Risk and Utilization of Balance Training for Adults With Symptomatic Knee Osteoarthritis: Secondary Analysis From a Randomized Clinical Trial

Physical Therapy

Sociodemographic and Clinical Correlates of Physical Therapy Utilization in Adults With Symptomatic Knee Osteoarthritis

BMC Musculoskeletal Disorders

Level of participation in physical therapy or an internet-based exercise training program: associations with outcomes for patients with knee osteoarthritis

Arthritis Care & Research

Demographic and Clinical Factors Associated with Non-Surgical Osteoarthritis Treatment Use Among Patients in Outpatient Clinics

Arthritis Care & Research

Fear of Movement and Associated Factors among Adults with Symptomatic Knee Osteoarthritis

BMC Musculoskeletal Disorders

Physical therapy vs. internet-based exercise training (PATH-IN) for patients with knee osteoarthritis: study protocol of a randomized controlled trial

The Rheumatologist

Physical therapy, exercise advances for knee osteoarthritis

More on this Project  

This project's final research report is expected to be available by June 2019.

Peer-Review Summary

Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.

The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments. 

Peer reviewers commented, and the researchers made changes or provided responses. Those comments and responses included the following:

  • The reviewers noted that the draft report emphasized within-group improvements on outcomes, showing that patients in both treatment groups improved, rather than the differences between the two treatments and the wait-list control. The researchers acknowledged this and revised the report to emphasize the between-group differences instead, since this was the focus of the study.
  • The reviewers asked the researchers to clarify whether the study had sufficient power to detect a true clinically significant difference given that the patient attrition rate was higher than expected. The researchers added a study limitation related to the attrition rate.

Conflict of Interest Disclosures

View the COI disclosure form.

Project Details

Principal Investigator
Kelli D. Allen, PhD
Project Status
Completed; PCORI Public and Professional Abstracts Posted
Project Title
Physical Therapy vs. Internet-Based Exercise Training for Patients with Knee Osteoarthritis
Board Approval Date
December 2013
Project End Date
December 2018
Organization
University of North Carolina Chapel Hill^
Year Awarded
2013
State
North Carolina
Year Completed
2018
Project Type
Research Project
Health Conditions  
Muscular and Skeletal Disorders
Arthritis
Functional Limitations and Disabilities
Intervention Strategies
Behavioral Interventions
Other Clinical Interventions
Other Health Services Interventions
Technology Interventions
Training and Education Interventions
Populations
Racial/Ethnic Minorities
Low Income
Older Adults
Rural
Individuals with Multiple Chronic/co-morbid Conditions
Veterans
Urban
Funding Announcement
Assessment of Prevention, Diagnosis, and Treatment Options
Project Budget
$1,949,199
Study Registration Information
HSRP20143542
NCT02312713

^Kelli D. Allen, PhD was affiliated with Duke University when this project was initially awarded.

Page Last Updated: 
July 22, 2019