Does one exercise a day make the knee stronger and keep surgery away? A randomized dose-response trial of home-based knee-extensor exercise in patients eligible for knee replacement (the QUADX-1 trial)

Abstract

AbstractObjectivesTo firstly investigate the efficacy of three different dosages of home-based, knee-extensor strength exercise on isometric knee-extensor strength in patients eligible for knee replacement due to severe knee osteoarthritis, and secondly, the influence of exercise on symptoms, physical function and decision on surgery.DesignRandomized dose-response trial.SettingPrimary and secondary care.ParticipantsOne-hundred and forty patients eligible for knee replacement were included. Eligibility for surgery was assessed by an orthopedic surgeon specialized in knee arthroplasty.InterventionsPatients were randomized to three groups; 2, 4 or 6 home-based knee-extensor exercise-sessions per week (group 2, 4 and 6 respectively) for 12 weeks (N=47/group). Exercise instruction was given by a trained physiotherapist.Main outcome measuresThe primary outcome was isometric knee-extensor strength. Secondary outcomes were Oxford Knee Score, Knee Osteoarthritis Outcome Score, average knee pain last week (0-10 numeric rating scale), 6-minute walk test, stair climbing test, exercise adherence and “need for surgery”. The primary endpoint was after 12 weeks of exercise (before surgery) and the secondary after surgery. Outcome assessors and patients were blinded to allocation.ResultsAfter 12 weeks of exercise, data were available for 117 patients (N=39/group). Isometric knee-extensor strength increased in all groups but intention-to-treat analysis showed no difference between the three groups in change from baseline to after 12 weeks of exercise in isometric knee-extensor muscle strength: Group 2 vs. 4 (0.009 Nm/kg [95% CI -0.15 to 0.17], P=0.913), group 2 vs. 6 (-0.03 Nm/kg [95% CI -0.18 to 0.13], P=0.725) and group 4 vs. 6 (-0.04 Nm/kg [95% CI -0.20 to 0.13], P=0.668). For the secondary outcomes a significant difference before surgery was found between group 2 and group 6 for Oxford Knee Score (4.2 [95% CI 0.6 to 7.8], P=0.02) and average knee pain last week (NRS 0-10) (-1.1 [95% -2.2 to -0.1], P=0.03) in favour of group 2. No other differences were observed before and after surgery. After the 12- week exercise intervention, 38 (32.5%) patients wanted surgery and 79 (67.5%) postponed surgery. This was independent of exercise dosage.ConclusionKnee-extensor strength increased with both 2, 4 and 6 exercise sessions per week but none of the prescribed exercise dosages were superior to the others for the primary outcome isometric knee-extensor strength after 12 weeks. Two home-based knee-extensor exercise sessions a week seems superior to six for patient-reported outcomes, and across exercise dosages, only one in three patients decided to have surgery after the coordinated home-based exercise intervention.Trial registrationClinicalTrials.gov identifier: NCT02931058, pre-registered October 10th, 2016. Protocol PubMed (PMID: 29347947).What is already known on this topicClinical guidelines recommend exercise therapy targeting the knee-extensor muscles in patients eligible for knee replacement before surgery is considered.Exercise therapy may reduce knee osteoarthritis symptoms and impact the decision on surgery, but the dose-response relationship is not described.Exercise therapy is typically delivered as supervised programs requiring physical attendance at fixed times and often require self-payment, which may be a barrier for some patients.What this study addsKnee-extensor strength increased with 2, 4 and 6 exercise sessions per week, but none of the prescribed exercise dosages were superior to the others after 12 weeks – indicating no dose-response relationship.Two in three patients eligible for knee replacement decided to postpone knee replacement surgery after 12 weeks of home-based exercise with one simple exercise.This study successfully employed a model of coordinated care where the patients’ decision on surgical treatment was re-evaluated based on symptom changes following simple home-based exercise therapy. These findings suggest using a model of coordinated non-surgical and surgical care to improve the decision on surgery for patients eligible for knee replacement.