J. Hawkeswood, MD, R. Reebye, MD, FRCPC

                                          Evidence-based guidelines
Evidence-based guidelines for the nonpharmacological treatment of osteoarthritis of the hip and knee

      of activiti...
Evidence-based guidelines for the nonpharmacological treatment of osteoarthritis of the hip and knee

the weight of the...
Evidence-based guidelines for the nonpharmacological treatment of osteoarthritis of the hip and knee

      for knee an...
Evidence-based guidelines for the nonpharmacological treatment of osteoarthritis of the hip and knee

    loss and stra...
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British Columbia Medical Journal, October 2010 issue: Evidence-based guidelines for the nonpharmacological treatment of osteoarthritis of the hip and knee


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British Columbia Medical Journal, October 2010 issue

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British Columbia Medical Journal, October 2010 issue: Evidence-based guidelines for the nonpharmacological treatment of osteoarthritis of the hip and knee

  1. 1. J. Hawkeswood, MD, R. Reebye, MD, FRCPC Evidence-based guidelines for the nonpharmacological treatment of osteoarthritis of the hip and knee Education about osteoarthritis, guidance regarding weight loss and exercise, and timely referrals should all be part of early intervention. n order to develop patient-focused The majority of evidence consid- I ABSTRACT: Osteoarthritis is the most common form of arthritis and evidence-based recommendations ered by the panel pertains to knee can lead to signigicant pain and dis- for the management of hip and osteoarthritis, as reflected in this nar- ability. Treatment of osteoarthritis knee osteoarthritis, the Osteoarth- rative review. The hip and knee joints of the knee and hip should aim to ritis Research Society International are very different in structure, load- reduce joint pain and stiffness, (OARSI) convened a panel of 16 ex- ing, and movement. Certainly the maintain or improve mobility, and perts from four medical disciplines: treatment effect of a modality des- optimize patient functioning and primary care, rheumatology, ortho- cribed for one joint may not be the quality of life while limiting the pro- paedics, and evidence-based medicine. same for the other joint. Clarification gression of joint damage. A recent Panel members reviewed existing regarding the nature of supporting expert review of the management of guidelines for the management of hip evidence has been made below when- osteoarthritis by the Osteoarthritis and knee osteoarthritis, a highly prev- ever possible. We also outline the Research Society International sup- alent cause of pain and disability,1 OARSI recommendations and pro- ports a combination of nonpharma- along with data published from 1945 vide additional practical suggestions cological and pharmacological stra- to January 2006.2 for implementing evidence-based, tegies. The review also indicates Treatments were evaluated for ef- conservative management of hip and that patient education is critical in ficacy, safety, and cost-effectiveness. knee OA. the early stages of care, and that Panel members also considered each weight loss and exercise are key to treatment in terms of patient tolerance, OARSI recommendations any nonpharmacological treatment. acceptability, likely adherence, and All patients with hip and knee OA The guidelines are expanded for prac- further logistic issues involved in its should be given information access tical implementation of evidence- administration.3 A subjective “strength and education about the objectives of based, conservative management of of recommendation” (SOR) overall treatment and the importance of hip and knee osteoarthritis. numeric rating (0 to 100 mm on a visu- changes in lifestyle, exercise, pacing al analog scale) was provided for each management strategy based on the Dr Hawkeswood is a fifth-year resident in individual scoring by each of the 16 physical medicine and rehabilitation at the panel members. Mean and standard University of British Columbia. Dr Reebye errors of the mean for each SOR were is a physical medicine and rehabilitation calculated and presented with confi- specialist, a staff physician at G.F. Strong dence intervals. Of the 25 treatments Rehabilitation Centre, and a member of the suggested, 20 involved nonsurgical Division of Physical Medicine and Rehabil- options.3 itation at UBC. www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 399
  2. 2. Evidence-based guidelines for the nonpharmacological treatment of osteoarthritis of the hip and knee of activities, weight reduction, and led to better scores for weight loss, crease patient activity levels. Physical other measures to unload the dam- physical activity, and pain after 4 medicine and rehabilitation special- aged joint(s). The initial focus should months.5 ists also play an essential role. They are be on self-help and patient-driven Patients with hip and knee OA, trained in all nonsurgical treatment treatments rather than on passive ther- who are overweight, should be en- options and can longitudinally sup- apies delivered by health professionals. couraged to lose weight and maintain port patients faced with complex dis- Subsequently emphasis should be their weight at a lower level. SOR: ease, pain, disability, and resource placed on encouraging adherence to 96% (95% CI 92–100)2 challenges. the regimen of non-pharmacological The entire OARSI panel recom- therapy. SOR: 97% (95% CI 95–99)2 mended encouraging patients to main- General exercise strategy There are two major barriers to the uptake of routine exercise in the osteo- arthritis population: (1) failure on the part of medical practitioners to prop- In patients with knee OA and erly recommend exercise to patients or make appropriate referrals to exer- mild/moderate varus or valgus cise professionals and (2) failure of instability, a knee brace can patients to comply with prescribed exercise programs.8 A survey of osteo- reduce pain, improve stability arthritis patients in Canada revealed and diminish the risk of falling. only one-third had been advised to exercise for their OA; however, 73% had tried exercising in the past.9 A dose-response relationship between compliance and exercise Patient education regarding osteo- tain a healthy body weight.2 Patients effects has been demonstrated in arthritis pathogenesis, clinical course, with knee OA who commenced a low- knee OA, indicating the importance and treatment is needed to promote energy diet reported improved pain, of patient adherence.10 Compliance behavioral modifications and improve stiffness, and functional status after 8 can be improved through professional symptoms. However, such complex weeks of intervention.2,6,7 For each disease education and exercise pres- interventions can be time-consuming kilogram of body weight lost, the knee entation. 11 Initial physiotherapist- and difficult to provide during a single experiences a 4 kg reduction in load supervised classes have been shown visit. Consequently, systematic con- per step and a 4800 kg reduction in to be beneficial as a supplement to servative OA management programs compressive load for each kilometre longer-term home exercises for both are not routinely offered to patients, as walked.7 pain and functioning.12 In general, less than half of those with obesity and Patients with symptomatic hip and physicians should encourage patients OA are advised to lose weight.4 knee OA may benefit from referral to to undertake exercises patients enjoy. In a recent study, patients with a physical therapist for evaluation mild to moderate OA received stan- and instruction in appropriate exer- Pool exercise dardized educational content over the cises to reduce pain and improve func- Patients with hip and knee OA should course of three encounters with a phy- tional capacity. This evaluation may be encouraged to undertake, and con- sician (days 0, 15, and 30) versus usual result in provision of assistive devices tinue to undertake, regular aerobic, care (also involving three encoun- such as canes and walkers, as appro- muscle strengthening and range of ters).5 In the treatment group, the first priate. SOR: 89% (95% CI 82–96)2 motion exercises. For patients with visit focused on informing the patient A global assessment of a patient’s symptomatic hip OA, exercises in water about the disease and outlining treat- medical and functional issues is nec- can be effective. SOR: 96% (95% CI ment. The second visit focused on essary when prescribing therapy for 93–99)2 standardized exercise, and the third osteoarthritis. Physiotherapists play Archimedes recognized that “any visit on weight loss instructions. Com- an essential role in managing hip and object, wholly or partly immersed in a pared with usual care, this program knee osteoarthritis by helping to in- fluid, is buoyed up by a force equal to 400 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org
  3. 3. Evidence-based guidelines for the nonpharmacological treatment of osteoarthritis of the hip and knee the weight of the fluid displaced by patients with hip and knee OA. Pa- bone-on-bone weight-bearing distri- the object.” The depth of water can tients should be given instruction in bution within the joint itself.15 be a useful gauge, and patients with the optimal use of a cane or crutch in Osteoarthritis of the knee often severe symptoms may progress to the contralateral hand. Frames or involves the medial compartment, a more shallow water. Additionally, pa- wheeled walkers are often preferable situation thought to be the result of the tients may find other aspects of the for those with bilateral disease. SOR: natural “bowing” or varus moment water therapeutic, such as the temper- 90% (95% CI 84–96)2 present during normal human gait. ature, added constituents, or pressure Canes are a practical, affordable Alternatively, isolated lateral com- from jets. means to off-load the affected joint, partment OA can result from a valgus The effectiveness of active aquatic improve balance, assist in muscular knee alignment. While multiple high- exercise for the treatment for osteo- compensation, and, hopefully, reduce quality studies are lacking, knee “off- arthritis was recently assessed in a pain symptoms. Patients should be loader” braces have demonstrated Cochrane review that included six instructed to hold the cane in the con- improved pain scores and walking tol- studies of patients with both hip and tralateral hand and take steps with the erance at 1 year, particularly in the knee OA and knee OA only.13 Imme- affected limb and cane in tandem. The medial compartment OA group.22 diately after an exercise period, sig- total length of the cane should equal Compliance can be inconsistent, par- nificant improvements in function, the distance from the upper border of ticularily in the context of obesity where quality of life, and mental health were the greater trochanter to the base of effective fitting can be challenging. found in patients with both hip and the heel. The patient should be able to Every patient with hip or knee OA knee OA, along with pain reduction in stand with the cane with level shoul- should receive advice concerning the knee OA group. The rate of patient ders and elbow flexion at 20 to 30 appropriate footwear. In patients with withdrawal was relatively low (20% degrees. Lastly, patients should ascend knee OA insoles can reduce pain and to 28%) and reports of adverse events stairs with the good leg (“moving up improve ambulation. Lateral wedged (such as increased pain or drug con- is good”) and descend stairs with the insoles can be of symptomatic benefit sumption) were absent.14 affected leg and cane together.20 for some patients with medial tibio- Walkers are typically prescribed femoral compartment OA. SOR: 77% Strengthening exercises for patients who require maximum (95% CI 66–68)2 Muscle weakness is a common assistance with balance. This includes While the degree of observed lat- impairment among patients with knee the elderly, the fearful, and the unco- eral thrust and compressive forces osteoarthritis.15,16 A longitudinal study ordinated. The patient must have good experienced at the knee may be re- suggests that quadriceps weakness grasp and arm strength bilaterally, duced by lateral wedged insoles, the precedes the onset of knee osteoarthri- although forearm supports are avail- primary role of these insoles should tis and hence could increase the risk of able. Unfortunately, patients can be- be to improve pain symptoms.23 Two disease development.17,18 Quadriceps come dependent on walkers and there- prospective RCTs of patients with strengthening, when combined with fore their use should be reserved for medial femorotibial OA showed re- general strength, flexibility, and func- rehabilitation, severe disease, or other duced NSAID use and better compli- tional exercises, has been shown to select circumstances.20 ance in the treatment group using the improve OA symptoms.19 There is, In patients with knee OA and mild/ lateral wedged shoe insert.24,25 Ortho- however, limited evidence to suggest moderate varus or valgus instability, tics should be smaller (between 8 and that stronger muscles can prevent dis- a knee brace can reduce pain, improve 12 mm) and ideally a patient’s toler- ease progression.15 stability and diminish the risk of ance, including gait pattern, should be Any loss of muscle strength may falling. SOR: 76% (95% CI 69–83)2 noted within the first 2 weeks of use.23 be associated with pain, anxiety, lack Braces and orthoses are defined as The clinical status of patients with of motivation, effusion, muscle atro- “any medical device added to a per- hip or knee OA can be improved if phy, and altered joint mechanics.15 son’s body to support, align, position, patients are contacted regularly by Exploring a patient’s physical and immobilize, prevent or correct defor- phone. SOR: 66% (95% CI 57–75)2 emotional barriers to exercise can help mity, assist weak muscles, or improve Regular phone contact with a guide behavioral change and promote function.”21 A knee brace may reduce trained nonclinical professional may long-term adherence to exercise. both the muscular contraction needed help improve a patient’s pain symp- Walking aids can reduce pain in to stabilize the affected knee, and the toms.26 Self-management strategies www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 401
  4. 4. Evidence-based guidelines for the nonpharmacological treatment of osteoarthritis of the hip and knee for knee and hip OA that provide TENS can help with short-term ment plan will depend on patient patients with opportuntity for educa- pain control in some patients with hip familiarity, preference, and treatment tion and treatment are also deemed or knee OA. SOR: 58% (95% CI 45– response. effective ways to improve pain and 72) 2 disability.27 In British Columbia, the Transcutaneous electrical nerve Conclusions Vancouver Coastal Health Osteoar- stimulation is typically provided by The OARSI guidelines describe num- thri tis Service Integration System physiotherapists, although patients erous useful strategies for the treat- (OASIS) team consists of nurse clini- can purchase their own devices. In ment of hip and knee osteoarthritis. cians, physiotherapists, occupational contrast to electrical muscle stimula- While the literature will continue to therapists, and dietitians, and is de- tion, TENS primarily blocks pain trans- grow in this field, these recommenda- signed to support OA patients (physi- mission. TENS has been well studied tions provide clinicians with a number cian referral is required).28 The BC in knee osteoarthritis, and in some of practical options for managing their Ministry of Health Services web site patients can provide clinically signif- unique patients. Generally speaking, provides other provincial resource icant pain relief, particularly over the treatments receiving lower SOR options.29 short-term (first 2 to 4 weeks of ther- scores require further research to clar- ify ideal candidate patients and to help refine each therapy. Overall, the OARSI guidelines show that early intervention for OA should include In some studies, real acupuncture disease education, guidance on weight is shown to be better than sham loss and exercise, and timely referrals. A global patient assessment will help acupuncture for treating pain, suggesting to shape a comprehensive approach to that acupuncture can be an effective care, and hopefully reduce the need for medications or surgery. treatment for knee osteoarthritis. Competing interests None declared. Some thermal modalities may be apy).30,31 While no serious side effects References effective for relieving symptoms in have been reported,31 conditions in- 1. Lawrence RC, Helmick CG, Arnett FC, et hip and knee OA. SOR: 64% (95% CI volving skin breakdown and pace- al. Estimates of the prevalence of arthri- 60–80)2 maker implantation are contraindica- tis and selected musculoskeletal dis- There is no strong evidence sup- tions. orders in the United States. Arthritis porting the use of thermal modalities; Acupuncture may be of sympto- Rheum 1998;41:778-799. however, these are still included in the matic benefit in patients with knee OA. 2. Zhang W, Moskowitz RW, Nuki G, et al. majority of guidelines for OA man- SOR: 59% (95% CI 47–71)2 OARSI recommendations for the man- agement.3 Thermal modalities are In some studies, real acupuncture agement of hip and knee osteoarthritis, likely still included in most OA treat- is shown to be better than sham part I: Critical appraisal of existing treat- ment guidelines because they are acupuncture for treating pain,3,32 sug- ment guidelines and systematic review accessible, affordable, and often the gesting that acupuncture can be an of current research evidence. Osteo- patient’s first-line choice for manag- effective treatment for knee osteo- arthritis Cartilage 2007;15:981-1000. ing acute pain. Heat may be applied in arthritis. A recent study showed that 3. Zhang W, Moskowitz RW, Nuki G, et al. the form of warm water, heat packs, or acupuncture alone was helpful with OARSI recommendations for the man- wax therapy, and may serve as an pain at 2 and 6 weeks, while adding it agement of hip and knee osteoarthritis, adjunct during stretching or perhaps to advice and exercise recommenda- part II: OARSI evidence-based, expert during painful episodes. Cryotherapy tions delivered by a physiotherapist consensus guidelines. Osteoarthritis typically involves ice packs—a prac- provided no additional benefit.33 As Cartilage 2008;16:137-162. tical consideration for acute episodes with other alternative therapies, the 4. Serdula MK, Mokdad AH, Williamson DF, of inflammation and pain. utility of acupuncture in a manage- et al. Prevalence of attempting weight 402 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org
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Rheumatology 2004;43:880- arthritis: An update. Am J Phys Med based physiotherapy for osteoarthritis of 886. Rehabil 2006;85(suppl):S82-S97. the knee: Randomised controlled trial. 13. Bartels EM, Lund H, Hagen KB, et al. 24. Maillefert JF, Hudry C, Baron G, et al. Lat- BMJ 2007;335:436. Aquatic exercise for the treatment of erally elevated wedged insoles in the knee and hip osteoarthritis. Database treatment of medial knee osteoarthritis: Syst Rev 2007;(4):CD005523. A prospective randomized controlled 14. Wyatt FB, Milam S, Manske RC, et al. study. Osteoarthritis Cartilage 2001;9: The effects of aquatic and traditional 738-745. www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 403