Osteoarthritis (OA)

Osteoarthritis is described as a “primarily non-inflammatory, degenerative joint disease characterized by progressive loss of articular cartilage, subchondral bone sclerosis, osteophyte formation, changes in the synovial membrane, and an increased volume of synovial fluid with reduced viscosity and hence changed lubrication properties.” (Gerwin et al., 2006)

ACR Criteria for the Classification and Reporting of OA of the Knee

Criteria for classification of idiopathic OA of the knee

Clinical and Laboratory - Knee pain plus at least five of nine:

• Age >50
• Stiffness <30 min
• Crepitus
• Bony tenderness
• Bony enlargement
• No palpable warmth
• ESR <40 mm/hour
• RF <1:40
• SF OA

92% sensitive, 75% specific

Clinical and Radiographic - Knee pain plus at least one of three:

• Age >50
• Stiffness <30 min
• Crepitus Plus Osteophytes

91% sensitive, 86% specific

Clinical* - Knee pain plus at least three of six:

• Age >50
• Stiffness <30 min
• Crepitus
• Bony tenderness
• Bony enlargement
• No palpable warmth

95% sensitive, 69% specific

*Alternative for the clinical category would be four of six, which is 84% sensitive and 89% specific.

RF=rheumatoid factor; SF OA= synovial fluid signs of OA (clear, viscous, or white blood cell count <2000/mm3) (Altman et al., 1986)

Clinical Criteria for Diagnosis (Ringdahl & Sandesh, 2011):

• Age older than 50 years
• Bony enlargement
• Bony tenderness
• Crepitus
• No palpable warmth
• Stiffness for less than 30 minutes

See OA knee classification above

• Lifestyle advice
• Weight and pain management
• Progressive low load non-impact exercise
• Not wishing surgery/responding: 6-8 weeks rehab
• Unresponding: 2-6 weeks rehab

Patient centred care

Treatment should take into account individual patient needs, preferences, expectations and functional status. Clinical reasoning should inform treatment, based on subjective and objective findings. Good communication between therapist and patient is essential if a successful outcome is to be achieved. Treatment options should be clearly explained so that patients can make informed decisions with regard to their care and management.

Evidence based strategies

Reassurance and Patient Education

Patients with symptomatic OA of the knee should be encouraged to participate in self-management educational programs and incorporate activity modifications into their lifestyle (AAOS, 2008; Petrella, 2007; Denoeud et al., 2005)

Land based exercise program

A large volume of evidence of good consistency provided support for the recommendation of exercise for patients with knee OA.

Exercise should include: local muscle strengthening, and general aerobic fitness.

Various programs offer different benefits and no specific type of exercise regimen has been shown to be superior (Jordan et al., 2003; Manek & Lane, 2000; Oliver & Ryan, 2004; Zhang et al., 2007; Bellamy et al., 2006). A large volume of evidence of good consistency provided support for the recommendation of exercise for patients with knee OA making it an important core component of management as both a preventive strategy and to treat symptoms irrespective of age, co morbidity, pain severity or disability. Particularly in OA of the knee, weakness of the quadriceps muscles contributes to functional disability caused by joint instability, therefore appropriate exercise also has a role in reducing signs and symptoms of OA. (Tak et al., 2005; Roddy et al., 2005; Devos-Comby & Cronan, 2006; Fransen et al., 2006; Brosseau et al 2006).

Although exercise has been found to be beneficial, the clinician needs to make a judgement in each case on how to effectively ensure patient participation. This will depend upon the patient's individual needs, circumstances, self-motivation and the availability of local facilities.

Aquatic therapy

Aquatic exercise programs, performed in either group or individual settings, provide the same general benefits as land based exercise programs but with reduced stress to the joints due to buoyancy (Franzen et al., 2007; Cochrane et al., 2005; Hinman et al., 2007)

Exercise and manual therapy / Multimodal physical therapy

There is some evidence for trying multimodal physical therapy for up to 3 months to treat OA knee.

These could include range of motion exercise, soft tissue mobilisation, and muscle strengthening and stretching as an adjunct to an active exercise component of treatment (Deyle et al., 2000; Deyle et al., 2005; Hay, 2006; Hoeksma et al., 2004)

Aids and devices

Although there are no RCTs to support their use, there was complete expert consensus for the proposition that walking aids can reduce pain in patients with knee OA.  Patients should be given instruction in the optimal use of a stick or crutch in the contralateral hand. (Zhang et al., 2008).  Should be considered as an adjunct to core treatment for OA of the knee (NICE Guideline, 2008)

Healthcare professionals should offer advice on appropriate footwear (including shock-absorbing properties). If joint instability is present, then the person should be considered for assessment for bracing as an adjunct to their core treatment.

However: there is good evidence to suggest that knee brace, neoprene sleeve or lateral wedged insoles are of little or no benefit for treatment of OA of the knee (Clark, 2000, Hunter & Felson, 2006; Brouwer et al., 2005)

Thermotherapy

There is some evidence to support cold therapy to treat symptoms of OA (Brosseau et al., 2003).

Patellar Taping

Patients with symptomatic OA of the knee use patellar taping for short-term relief of pain and improvement in function. (Cushnaghan et al., 1994; Hinman et al., 2003a; Hinman et al., 2003b; Vagal, 2004)

TENS

There is some evidence to support the use of Transcutaneous Electrical Nerve Stimulation (TENS) for at least 4 weeks as an adjunct to core treatment for pain relief in OA of the knee (Osiri et al., 2000).

Intra-articular injections

Intra-articular corticosteroid injections should be considered as an adjunct to core treatment for the relief of moderate to severe pain in people with osteoarthritis. (Bellamy et al., 2006b).

Intra-articular corticosteroid injections are indicated for short term symptom management when the patient has an acutely painful, swollen joint. Generally synovial fluid is aspirated from the joint to reduce swelling prior to the administration of the corticosteroid directly into the joint cavity. The procedure allows for a greater concentration of medication at the site of action, with a lower risk of systemic side effects (Bellamy et al., 2006b).

Non evidence based strategies

Acupuncture

Electro-acupuncture should not be used to treat people with osteoarthritis NICE 2008). There is insufficient consistent evidence of clinical or cost effectiveness to allow a firm recommendation on use of acupuncture on OA knee. (NICE, 2008)

The OARSI guideline reports conflicting evidence, from two RCTs and one systematic review, regarding the symptomatic benefit of acupuncture in patients with OA of the knee. One RCT and the systematic review support the use of acupuncture and one RCT does not support the use of acupuncture. The benefit of adding acupuncture to mainstream, recommended treatments for this population remain unanswered (Richmond et al., 2009; Witt et al., 2005; Ezzo et al., 2001; Foster et al., 2007).

Electromagnetic fields

There is good evidence to suggest that electromagnetic field or electric stimulation interventions are of no benefit in the treatment of OA of the knee (Hulme et al., 2002; McCarthy et al., 2006).

Therapeutic ultrasound

There is some evidence to suggest that therapeutic ultrasound is of no benefit in treating OA of the knee (Robinson et al., 2006).

Low level laser therapy

Could not be recommended due to insufficient evidence (Bjordal et al., 2007).

Massage therapy

Could not be recommended due to insufficient evidence.

Intra-articular hyaluronan injections

A recommendation cannot be made for or against the use of intra-articular hyaluronic acid for patients with mild to moderate symptomatic OA of the knee due to conflicting evidence from trials (AAOS Guideline, 2008).

Progressing as expected (up to 3 Rxs) before discharge or onward referral.

Refer to ortho, GP, other.

Escalation

Criteria to refer on:

• Moderate to severe changes on x-ray
• Moderate – severe persistent pain not controlled by NSAID’s / analgesia or unable to tolerate same
• Significant sleep disturbance
• Aged> 55
• Some require patients to have a BMI < 35-40
• Significantly reduced walking distance- tried / uses walking aid
• Significantly interfering with simple ADL’s
• Keen to consider surgical intervention

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