Best Care for patients with Knee pain 2016 Evidence shows that a supervised programme of physiotherapy should be the first line of treatment for patients with degenerative meniscal tears of the knee Kay Stevenson, Tina Hadley- Barrows, Nina White, Panos Sarigiovannis & Helen Duffy December 2016
Aim of this paper To highlight to commissioners and key stakeholders that a recent review of latest evidence shows that a comprehensive physiotherapy rehabilitation programme should be offered as a first line of management for patients with degenerative meniscal tears of the knee. Which patient group are we referring to? Adults with no history of mechanical locking of the knee, with or without early/mild osteoarthritis Questions for commissioners and stakeholders 1. Are we assured that patients are having good quality, evidence based conservative/physiotherapy input prior to being referred for a surgical opinion? 2. Are we making the most of stepped care to ensure only those in need of surgery actually receive it? 3. Do we have appropriate physiotherapy provision in our area to ensure these patients achieve the best health outcomes? 4. Are orthopeadic surgeons confident that patients presenting to them have had sufficient physiotherapy rehabilitation before their consultation (pre-habilitation)? Summary of the evidence Local Physiotherapists* recently asked: In adults with degenerative meniscal tears in the knee, is physiotherapy as clinically and cost effective as surgery? The answer was: There is good quality evidence to suggest there is little benefit of arthroscopic surgery for degenerative meniscal tears over a physiotherapy programme for older adults (1) There is no difference in the pain, functional outcome or satisfaction between those having surgery compared with a physiotherapy programme including strengthening exercises (1) 1 *As part of the Musculoskeletal Research Facilitation Group
What did good quality Physiotherapy look like in the trials? Evidence from four clinical trials explored this issue (2-5). Conservative treatment included: Group exercise programmes of up to 8 weeks Individualised, supervised and progressed exercises Strengthening, proprioception and stretching exercises Endurance and flexibility work Additional home exercises programmes See appendix 1 for summary of physiotherapy provided in the trials. See appendix 2 for an example of how one health care provider incorporates this evidence into a physiotherapy class. Procedures of low clinical value Commissioning frameworks already exists across local Health Economies. They consistently state: Knee Washout and Debridement will only be routinely commissioned where the patient has mechanical features of locking that are associated with patient reported severe pain. Not routinely commissioned for symptoms of 'giving way' or x-ray evidence of loose bodies without true locking (6) This is consistent across Stafford and Wolverhampton, Shropshire and Telford, Sandwell, North Staffordshire and Stoke. The empirical evidence clearly shows this group of patients should be receiving a sufficient amount of physiotherapy focusing on strengthening, proprioception, flexibility and endurance. Audit data Evidence based Physiotherapy is currently being offered in Wolverhampton, where this patient population receive 6 appointments in a group class over a 6 week period. The design of this programme was based on NICE Guidance. The pre and post class outcomes show demonstrable improvement in key clinical outcomes such as functional measures and the Oxford Knee Score. Audit data from a large secondary care organisation within the West Midlands suggests that a proportion of patients with degenerative meniscal tears are being seen in orthopaedics and are listed for arthroscopic surgery. These patients have not had an evidence based rehabilitation programme prior to referral. 2 *As part of the Musculoskeletal Research Facilitation Group
Potential benefits of implementing an updated evidence based care pathway for patients with degenerative meniscal tears of the knee Improved care pathway for patients with degenerative meniscal tears. Greater potential for pre-habilitation for those who are referred on for a surgical opinion Potentially reduce number of patients needing consultation with orthopaedic surgeons Those who do require surgical opinion will have received high quality evidence based physiotherapeutic rehabilitation. Orthopaedic surgeons can be reassured by this as they will know exactly what the patient had received Potential to decrease consultant waiting time Potential to decrease arthroscopic procedures and associated PbR costs Cost Implications Arthroscopic surgery is subject to a payment by results tariff of 870-1654pp with patient requiring up to 6 outpatient physiotherapy appointments as part of their rehabilitation programme post-operatively. National benchmarking data suggests that physiotherapy costs 35-49 per patient per appointment (Department of Health 2011). Assuming a 10% increase in price over the last 4 years this would suggest a maximum cost of 71 pp. These figures would suggest that for every arthroscopic procedure (at tariff of 870) up to 12 physiotherapy appointments could be offered. For most physiotherapy programmes a maximum of 8 weeks would be offered as part of a group programme (reduced costs pp), suggesting savings a minimum 300 per patient per arthroscopic procedure avoided. Locally, patients receiving physiotherapy for a variety of acute and long term conditions have an average three treatments. The national average is currently four treatments. Evidence recommends 8 sessions over a 12 week period for this population of patients to allow supervised and progressed exercises to achieve good pain reduction and improved function. 3 *As part of the Musculoskeletal Research Facilitation Group
Recommendations 1. Review existing pathways to: Ensure appropriate access to evidence based physiotherapy for this population of patients (up to 8 sessions over a 12 week period) Ensure appropriate pathway for those who fail to improve with conservative treatment Ensure agreement between Physiotherapy and orthopaedic leads to allow appropriate referral Ensure training for physiotherapy staff is evidence based practice References 1.http://www.keele.ac.uk/media/keeleuniversity/group/evidencebasedpractice/catbank/C AT%20Deg%20men%20tears%20Final%20July%202014.pdf 2.Herrlin SV, Wange PO, Lapidus G, Hallander M, Werner S, Weidenheilm (2013). Is arthroscopic surgery beneficial in treating non traumatic degenerative medial meniscal tears? A five year follow up. Knee Surgery, Sports Traumatology, Arthroscopy 21, 358-364 3..Katz JN, Brohy RH, Chaisson CE, de Chaves L, Cole BJ, Dahm DL et al (2013). Surgery versus Physical Therapy for a meniscal tear and osteoarthritis. The New England Journal of Medicine 368, 1675-1684 4.Yim JH, Seon JK, Song EK, Choi JI, Kim MC, Lee KB, Seo HY (2013). A comparative study of menisectomy and non operative treatments for degenerative horizontal tears of the medial meniscus. The American Journal of Sports Medicine 41(7), 1565-1570 5.Khan m Evaniew N Bedi A Ayeni OR Bhandari M Arthroscopic surgery for degenerative tears of the meniscu s:a systematic review and meta analysis 2014 Canadian Medical Association Journal October 7 186 (14))2014 6.Commissioning Policy, Excluded and Restricted Procedures, Version 4.5, April 2015. North Staffordshire CCG Commissioning, Finance and Performance Committee Stoke on Trent CCG Planning and Prioritisation Group 4 *As part of the Musculoskeletal Research Facilitation Group
Appendix 1- Physiotherapy provide as part of the four clinical trials Author Khan et al 2014 ( all papers below included in this SR) Herrlin 2013 Type of study Systematic review Surgery plus exs v exs alone RCT Age 45-64 Daily medial knee pain 2-6 months of clinical suspicion of medial meniscus tear, MRI tear,without trauma, Excl Xray showing OA Non operative intervention From study Clinical context 7 rcts n=805 Examines efficacy of arthroscopic medial meniscal debridement in patient with knee pain in the setting of mild or no OA Standardise exercise programme for 8 weeks Week Exercise Dose 0-8 Stationary cycling Grad increase to 7-15 min 0-4 calf raises 3x10 reps 5-8 Calf raises on one leg 3x10 reps 1-4 Leg press sitting position 3x10 reps 5-8 lunges 3x10 reps 0-4 Knee flexions 3x10 reps 5-8 Knee flexions with one leg against a 3x10 reps machine 0-4 Knee extensions against a machine 3x10 reps 5-8 Knee extensions 1 leg against a 3x10 reps machine 0-8 Stair walking and balance on 3 mins wobble board 0-8 Jogging, jumping, landing on 5 mins rebounder 0-8 Stretching knee flexors and extensors 1 min per m/s group Moderate evidence to suggests there is no benefit to arthroscopic meniscal debridement for degenerative meniscal tears for middle aged patients with mild or no OA In addition a home exercise programme was carried out twice a week. One leg standing during 60s and a step down exs comprising 3x10 reps With limited evidence to support surgical intervention, non operative intervention should play a large part for middle aged adults with mild or no oa Both groups improved. At 24 and 60 months scope plus exs was not better than exs alone
Author Katz 2013 Type of study USA RCT 45 and older, meniscal tear and OA on MRI, also normal findings, symptoms of torn meniscus, pop catch, giving way, episodic Non operative intervention From study Clinical context Land based individualised physical therapy with progressive home exs programme. 3 staged structured programme designed to address inflammation, ROM, concentric and eccentric muscle strength, m/s length restrictions, aerobic conditioning)bike, elliptical machine, treadmill) functional mobility proprioception and balance Attended PT once or twice a week and perform exs at home Programme generally lasted 6 weeks See handout No significant differences between study groups in functional improvement at 6 months. 30% of those randomised to physio did have surgery within 6 months Yim 2013 102 patients Deg tear on MRI scan RCT Daily medial knee pain, mechanical symptoms Marked deg change on xray excluded (grade 2>) Supervised physical exercises followed by 8 week home exs programme Aimed to improve muscle strength, endurance, and flexibility 60 mins per session, three times a week for 3 weeks under supervision of a physio Then home exs programme without supervision for 8 weeks: daily isometric and isotonic exs Time Exercise Frequency per week 0-8 Stretching knee flexors and extensors 1 min per muscle group 0-8 Knee ext in sit 3x10 reps 0-8 Knee flex in sit 3x10 reps 0-8 Stationary cycling Gradual increase every 15 mins 5-8 Half squats 3x10 reps 5-8 Squats with full flex with weights Meniscectomy did not provide better clinical outcome that non operative treatment at 2 years in relation to pain, improved knee function or patient satisfaction VAS, pain relief and patient satisfaction were no different between the groups Supervised followed by a longer home exercise
Appendix 2 Royal Wolverhampton NHS Trust Patient centred OA knee group 1 *As part of the Musculoskeletal Research Facilitation Group