In this issue of The Journal of Rheumatology, the article by King et al describes a registry-based cohort study of the Good Life With Osteoarthritis in Denmark (GLA:D) 8-week education and exercise program.1 Rather than focusing on knee pain, the authors examined change in self-reported difficulty walking, a primary reason people with knee osteoarthritis (OA) seek care, and assessed patient factors associated with improvement in difficulty walking after the program. Among over 2000 patients with baseline moderate/severe difficulty walking, 51% and 58% of the participants later reported only no difficulty to slight difficulty walking at 3- and 12-month follow-ups, respectively. Even though this is an observational study, this is an impressive finding highlighting the benefits of the GLA:D program.

This study1 is particularly salient since the articles comparing an intraarticular placebo to the GLA:D program raised questions about the utility of the GLA:D program.2,3 In the original study, at 9 and 12 weeks, the 2 treatments were equivalent.3 Since there is evidence that an intraarticular placebo has benefit over an oral placebo,4 these findings suggest a benefit to GLA:D as well. There was no difference seen between the 2 interventions at 1-year follow-up,2 which raised some questions about whether exercise and education are beneficial. However, those who were in the GLA:D arm less frequently required additional therapies for OA and were more likely to exercise on their own. Additionally, in a follow-up analysis of this study, those who self-identified as regularly using analgesics (paracetamol and nonsteroidal antiinflammatory drugs) were more likely to experience greater benefit from the GLA:D program.5 Collectively, these GLA:D studies should remind us that exercise and education programs have an important role in treatment guidelines, and taking a narrow perspective, with a focus only on pain, may cause us to overlook the other benefits of these programs (eg, decreased difficulty walking, requiring fewer additional therapies).

King et al also found that people with greater self-efficacy, lower BMI, less intense knee pain, and better function were more likely to improve.1 Conversely, severe difficulty walking at baseline was associated with a decreased chance of improvement. These results provide support for treatment guidelines that advocate for implementing programs like GLA:D as a first-line treatment. We should still view GLA:D as promising therapy for every patient but acknowledge that it may be more likely to benefit people if implemented earlier in the disease course.

The authors should be commended for this well-written manuscript that explores an important outcome among people with knee OA.1 This registry study offers real-world evidence that the GLA:D program is a nonpharmacologic intervention with the potential to improve outcomes in knee OA. It also reminds us that we need to adopt a more comprehensive approach when considering how exercise and education may improve patient well-being.

GHL’s salary is supported in part by the Biology of Inflammation Center at Baylor College of Medicine. This work is supported in part with resources at the Veterans Affairs Health Systems Research and Development Center for Innovations in Quality, Effectiveness and Safety (#CIN 13-413), at the Michael E. DeBakey VA Medical Center, Houston, Texas. The perspectives detailed in this editorial do not reflect the views of Baylor College of Medicine or the Department of Veterans Affairs.

The authors declare no conflicts of interest relevant to this article.

See Walking difficulty with OA, page 1033