Physician Led • Outcomes Centered • Patient Focused

Journal Club Review: Exercise Therapy for Anterior Knee Pain Provides Cost Savings

                Exercise Therapy for Patellofemoral Pain Syndrome Costs Society Less Than Usual Care. Tan SS et al. J Med Sci Sports. 2010;20:568-579.

This study, done in the Netherlands on patients with anterior knee pain, showed an overall cost-effectiveness of exercise therapy when compared with usual care of medication and observation.  131 subjects between the ages of 14 and 40 with symptoms between two months and two years were included.  None of the subjects had undergone prior exercise therapy, prior knee surgery or had other known knee problems.  Subjects were randomized to either a six week exercise protocol involving information on anterior knee pain and nine therapy visits or a control group given the information alone.  Total treatment costs, including therapy, physician visits, bracing, imaging studies, medication and work-related costs were monitored in the two groups over a one year observation period.

Although up-front costs in the therapy group were higher than the observation group, when productivity costs were factored in, total costs in the therapy group was less.  In addition, patients in the treatment group obtained better control of their symptoms.

I’ve included this study for one reason.  Personally, I am not that impressed with the cost savings reported in this study.  The total costs for the exercise group were estimated at $1348 versus $1555 for the group that was managed with usual care.  The observation period in this study was only one year, and we don’t have any idea what the long-term trends of both groups look like.  The up-front costs of the therapy group were greater than the usual care group, though outcomes were better in the former group.  I include this study because I think that it highlights our usual approach to anterior knee pain quite well.  At Stadia, when a patient is evaluated by a physician for anterior knee pain, the approach is a focus on effective but cost-conscious care.  Unless the patient is requesting them, x-rays are usually not obtained at the first visit unless arthritis is considered a risk or there are other reasons, (such as swelling in the knees) to obtain them.  Medications are rarely used.  Instead, each patient is offered a home exercise program tailored to their own unique exam.  This program is put onto paper and reviewed with the patient prior to discharge, and the patient is scheduled for a follow-up visit – usually at three weeks from the first appointment.  If, as expected, the patient is improving, their home exercise program is advanced and they are usually discharged with instructions to follow-up if symptoms are not completely resolved within 3-4 weeks.  If struggling at follow-up, x-rays are obtained and other treatment options can be discussed.  Braces are rarely required.  Although we do not deny patients the option of medication or supervised therapy for anterior knee pain (recognizing that patients come to us with different priorities, abilities to follow-through with home exercise or timelines that may require more rapid improvement), we have found that this approach results in significant improvement in the majority of our patients, without the need for physical therapy and without the necessity of imposing prolonged restriction from activity on patients who are seeing us in order to stay active.  It is a focused approach that avoids the common approach to patients of advice “strengthen your legs” without providing any direction to tell patients how to do that.  We feel that our approach results in outcomes that are similar to the intervention groups in studies like this, but with up-front costs to the patient which are significantly reduced – a major issue in today’s economy.  If your knees are consistently bothering you, don’t assume that there isn’t a simple fix for your pain.  Give us a call and let us show you how to effectively get rid of your pain on your own time and dollar, in a way that doesn’t sacrifice quality at all.

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