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Exercise and Education vs. Saline Injection - Which is Better for Knee OA?

Physical therapy is largely built on the combination of exercise and education. For treating knee OA, exercise and lifestyle modifications first-line interventions, and they are heavily supported in research. The question is how durable are treatment outcomes? Are the improvements achieved through exercise and education long-lasting? This is important as short-term improvements in pain and function can be achieved more easily.

The GLAD program (Good Life with osteoArthritis in Denmark) includes 8 weeks of exercise and education for participants with knee OA. While participants experienced significant improvements in pain and function, recent studies showed equivalent improvements with inert intra-articular saline injections at 9- and 12-week follow-ups. Perhaps more time was needed to demonstrate improvements from sustained lifestyle changes resulting from education and adopting a new exercise routine. This study (PMID: 36657659) looked at the same groups (GLAD vs. injection) at 1-year follow-up.

This was an open-label trial, meaning all participants received information on both interventions prior to random allocation. The neutral descriptions were accompanied by positive messages which ensured the investigators had no treatment preference and expected beneficial effects from both groups. The injection group received four saline injections at weeks 1, 3, 5, and 7. The GLAD program included 8 weeks of patient education and supervised exercise. Two 90-minute group-based educational sessions were provided in weeks 1 and 2, followed by two weekly group-based exercise sessions for the following 6 weeks. Participants were encouraged to continue the exercises after completing the study.

The participants found no difference in outcomes, and both groups' improvements were small. The priori analysis indicated that patients who preferred the GLAD program may benefit from it more (same with the saline group). One major issue is only 29.4% of the GLAD group continued to exercise after the intervention. Twelve exercise sessions over 6 weeks is too low of a dose to make meaningful changes and without follow-up exercise, any improvements made are likely to be lost. My takeaway from these studies is that the GLAD program is insufficiently dosed for short or long-term physiologic or behavior changes.


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