Exercise topped NSAIDs for knee osteoarthritis

After participating in an eight-week neuromuscular exercise therapy program, patients with mild to moderate knee osteoarthritis showed significantly greater symptomatic improvement at 12 months of follow up than if they had been instructed to treat with analgesics and anti-inflammatory agents in the randomized EXERPHARMA trial.

Neuromuscular exercise could be the superior choice for long-term relief for symptoms such as swelling, stiffness, and catching, while avoiding the potential side effects of analgesics and anti-inflammatory drugs as reported in the World Congress on Osteoarthritis.

Major guidelines recommend exercise, patient education, and weight loss as first-line treatment for osteoarthritis. Anti-inflammatory and analgesic drugs are reserved as second line therapy. Yet the pharmacologic approach is far more widely used in clinical practice.

The Danish single-blind, randomized EXERPHARMA study was designed to bring fresh evidence into play by comparing the long term efficacy of a structure exercise training program versus NSAIDs and acetaminophen as explained by doctors from the University of Southern Denmark in Odense.

Ninety-three patients with mild to moderate medial knee osteoarthritis – “a group we commonly see in primary care, has been noted – were randomized to the structured eight-week neuromuscular exercise therapy program or to eight weeks of instructions in the appropriate use of NSAIDs and acetaminophen. The exercise program entailed to our long physical therapist supervised sessions per week, which included functional proprioceptive, strength and endurance exercises of three or four progressive degrees of difficulty.

The initial results obtained at the conclusion of the eight-week intervention-change in knee joint load while walking – had been published; (Osteoarthritis Cartilage 2017, Apr. 25[4]470-80). There was no significant difference between the two study groups. But outcomes at the prespecified 12-month follow-up designed to capture any late improvement were a different story.

The neuromuscular exercise therapy group showed a significantly greater improvement on the knee injury and osteoarthritis outcome scores (KOOS) symptom subscale at 12 months. A mean 10.9 point improvement from baseline, compared with a 3.3 improvement with drug therapy.

Another key finding was the disparity between the exercise and medication arms in the proportion of patients achieving at least a minimal clinically important difference – that, at least a 10-point improvement in KOOS ratings – on the various KOOS subscales. Across the board, on the symptoms, activities of daily living, pain, sports and recreation, and quality of the life of subscales, the exercise therapy graduates did better.

That being said, the pre-specified primary end point at 12 months was change on the activities of daily living subscales – and this between – group difference didn’t reach statistical significance. So technically EXERPHARMA was a negative study, according to the investigator.

That comment caused audience member to rise in protest. It was further mentioned that it might have been forgotten to focused on values rather than looking at the whole picture. It was the opinion, that the hypothesis is more validated than it seemed they think according to Rush University in Chicago.