clinical practice guidelines for the non-surgical management of hip and knee osteoarthritis

8/6/2019 Clinical Practice Guidelines for the Non-Surgical Management of Hip and Knee Osteoarthritis

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Guideline forthe non-surgicalmanagementof hip and kneeosteoarthritis

The Royal Australian College of General Practitioners, 1 Palmerston Crescent, South Melbourne, Vic 3205 AustraliaACN 000 223 807, ABN 34 000 223 807

July 2009

Approved by NHMRC

on 23 February 2009


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Guideline or the non-surgical management o hip and knee osteoarthritis

The National Health and Medical Research Council (NHMRC) is Australias leading unding body or health andmedical research. The NHMRC also provides the government, health proessionals and the community with expertand independent advice on a range o issues that directly aect the health and wellbeing o all Australians.

The NHMRC provided support to this project through the Guidelines Assessment Register (GAR) process. The GARconsultant on this project was Karen Grimmer-Somers.

The guidelines were approved by the Chie Executive Ocer o the NHMRC on 23 February 2009 under section14A o the National Health and Medical Research Council Act1992. Approval or the guidelines by NHMRC isgranted or a period not exceeding 5 years, at which date the approval expires. The NHMRC expects that allguidelines will be reviewed no less than once every 5 years.

This publication was supported by unding rom the Australian Government. The publication refects the views othe authors and not necessarily refects the views o the Australian Government.

Published by:The Royal Australian College o General PractitionersCollege House1 Palmerston CrescentSouth Melbourne, Victoria 3205AustraliaTel 03 8699 0414Fax 03 8699 0400www.racgp.org.au

ISBN 978-0-86906-299-9

Published July 2009

The Royal Australian College o General Practitioners. All rights reserved.


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Guideline or the non-surgical management o hip and knee osteoarthritis July 2009

CONTENTS

IntroductIon 3

The role o general practitioners 4

Endorsement and expiry date or the recommendations 4

Acknowledgments 5Commonly used abbreviations 6

BAcKGround 7

Osteoarthritis 7

Aim o the guideline 7

Scope and target population 7

Focus o the guideline 7

Methods 9

The guideline 11

Limitations o the guideline 11

ALGorItHMS 13

Hip/knee osteoarthritis diagnosis and assessment algorithm 13

Hip/knee osteoarthritis care planning and management algorithm 14

Hip/knee osteoarthritis management fow chart 15

SuMMArY oF rEcoMMEndAtIonS 16

HIP And KnEE oStEoArtHrItIS rEcoMMEndAtIonS 19

General recommendations 19

GP education 19

Perorming intra-articular injections 20

Multidisciplinary care 20

Comprehensive patient assessment 21

Non-pharmacological interventions 23

Weight reduction 23

Exercise 23

Multimodal physical therapy 25

Tai chi 26

Sel management education programs 27

Thermotherapy 27

TENS 28

Acupuncture 29

Patellar taping 30

Massage therapy 31

Telephone support 31

Magnetic bracelets 32

Laser therapy 32

Leech therapy 33


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Pharmacological interventions 34

Paracetamol 34

Oral NSAIDs 35

Weak and strong opioids 37

Intra-articular corticosteroid injection 38Topical NSAIDs 38

Topical capsaicin 39

Viscosupplementation (hyaluronan and hylan derivatives) or knee OA 39

Glucosamine hydrochloride and glucosamine sulphate 40

Interventions not supported by current evidence 42

Braces and orthoses 42

Electromagnetic elds (pulsed electromagnetic elds or electrical stimulation) 42

Viscosupplementation (hyaluronan and hylan derivatives) or hip OA 43

Chondroitin sulphate 43

Vitamin, herbal and other dietary therapies 44

Therapeutic ultrasound 45

Social support 45

FurtHEr InForMAtIon 46

rEFErEncES 47

APPEndIX A. ProcESS rEPort 52

APPEndIX B. rESourcES 60

APPEndIX c. MEMBErSHIP oF tHE rAcGP oStEoArtHrItIS WorKInG GrouP 68


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INTrOduCTION

Chronic disease is a major public health burden on Australian society. An increasing proportion o thepopulation has risk actors or, or at least one, chronic disease, leading to increasing public health costs.Health service policy and delivery must not only address acute conditions, it must also eectively respondto the wide range o health and public service requirements o people with chronic illness.1,2 Strong primary

health care policy is an important oundation or a successul national health delivery system and long termmanagement o public health, and is linked to practical outcomes including lower mortality, decreasedhospitalisation and improved health outcomes.1 National strategic health policy has recently given increasedrecognition to the importance o chronic disease management, with the Australian Federal Governmentendorsement o a number o initiatives or the prevention (or delay in onset), early detection and evidencebased management o chronic disease, including osteoarthritis.1,3

Chronic musculoskeletal conditions, including arthritis, account or over 4% o the national disease burdenin terms o disability adjusted lie years. Over 6 million Australians (almost one-third o the population) areestimated to have a chronic musculoskeletal disease; chronic musculoskeletal disease represents the maincause o long term pain and physical disability. In Australia, osteoarthritis is sel reported by more than 1.4million people (7.3% o the population4) and is the tenth most commonly managed problem in generalpractice.5 This number is set to rise as the elderly population grows. Osteoarthritis exerts a signicant burden

on the individual and the community through reduction in quality o lie, diminished employment capacityand an increase in health care costs. For urther details, reer to the Evidence to support the National ActionPlan for Osteoarthritis, Rheumatoid Arthritis and Osteoporosis: Opportunities to improve health-relatedquality of life and reduce the burden of disease and disability(2004).6

As such, ederal government health policy has identied arthritis as a National Health Priority Area andadopted a number o initiatives aimed at decreasing the burden o chronic disease and disability; raisingawareness o preventive disease actors; providing access to evidence based knowledge; and improving theoverall management o arthritis within the community.4 In 2002, all Australian health ministers designatedarthritis and musculoskeletal conditions as Australias seventh National Health Priority Area. In response,a National Action Plan was developed in 2004 by the National Arthritis and Musculoskeletal ConditionsAdvisory Group (NAMSCAG).6 The aim o this document was to provide a blueprint or national initiativesto improve the health related quality o lie o people living with osteoarthritis, rheumatoid arthritis and

osteoporosis; reduce the cost and prevalence o these conditions; and reduce the impact on individuals,their carers and their communities within Australia. The National Action Plan was developed to complementboth the National Chronic Disease Strategy which is broader and the National Service ImprovementFramework or Osteoarthritis, Rheumatoid Arthritis and Osteoporosis, in addition to other national and state/territory structures.


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the le geeal paiies

General practice plays an important role within the Australian health care system in the prevention, earlydetection and management o chronic disease. The nature o general practice provides opportunity orearly screening or chronic disease and the address o preventable risk actors. Musculoskeletal conditions,particularly osteoarthritis, represented some o the diseases most commonly managed by Australian general

practitioners in 20032004, accounting or 17% o consultations. To manage chronic illness eectivelyrequires well coordinated, patient centred care that is continuous, comprehensive and consistent. Generalpractitioners are well placed to provide care and coordination, as well as to play a monitoring role, or themultidisciplinary management o chronic disease.1,2,4 The GP undertakes this role in consultation with othermedical specialists as required. The role GPs play in chronic disease management through multidisciplinarycare coordination and long term care planning is recognised within the national Medicare rebate ramework.Patients with arthritis are eligible or broader unding arrangements under chronic disease managementitems or GP management plans and associated reviews.2

As part o the ederal governments Better Arthritis and Osteoporosis Care (BAOC) 20062007 budgetinitiative,7 guidelines or the management o arthritic conditions have been developed to inorm evidencebased primary care o chronic disease in general practice. Three guidelines ocusing on osteoarthritis,rheumatoid arthritis and juvenile idiopathic arthritis have been developed.

This guideline on the management o osteoarthritis presents recommendations to assist GPs in managingpatients with osteoarthritis. The guideline ocuses on short term care; long term care planning andmanagement; and coordination o multidisciplinary care needs. It is accompanied by algorithms andresources to assist in implementation o the recommendations.

Eseme a expiy ae he emmeais

This guideline presents a comprehensive review o both pharmacological and nonpharmacologicalmanagement o osteoarthritis within the Australian health care context, based on the best available evidenceavailable up to July 2007. Evidence published ater this date has not been reviewed or the guideline.

Recommendations for the non-surgical management of hip and knee osteoarthritis was approved by theCEO o the National Health and Medical Research Council (NHMRC) on 23 February 2009, under section14A o the National Health and Medical Research Council Act, 1992. Approval or the guidelines by the

NHMRC is granted or a period not exceeding 5 years; ater 5 years the approval expires. The NHMRCexpects that the guideline will be reviewed, and revised i necessary, no less than once every 5 years.Readers should check with The Royal Australian College o General Practitioners (RACGP) or any reviews o,or updates to, this guideline.

This document is a general guide to appropriate practice, to be ollowed only subject to the clinicians (ormedical practitioner and patients) judgment in each individual case. The guideline is designed to provideinormation to assist in decision making and is based on the best inormation available at the date ocompilation. The guideline is not intended to have a regulatory eect. This project was managed by theEvidence Translation Section, National Health and Medical Research Council.


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Akwlegmes

This project was supported by the RACGP and the Australian Government Department o Health and Ageing(DoHA). The ollowing experts were involved in the development o the guideline as part o the RACGPOsteoarthritis Working Group:

Associate Proessor Caroline Brand (Chair), MBBS, BA, MPH, FRACP

Proessor Rachelle Buchbinder MBBS(Hons), MSc, PhD, FRACP

Dr Anita Wluka MBBS, PhD, GradCert(HealthEcon), FRACP

Dr Denise Ruth MBBS, MPH, FAFPHM, FRACGP

Dr Suzanne McKenzie MBBS, MMedSci(ClinEpid), GCertULT, FRACGP

Dr Kay Jones BSW, MT&D, PhD

Proessor Tracey Bucknall RN, BN, ICUCert, GradDipAdvNsg, PhD, MRCNA

Dr Lerma Ung PhD, BS, DipAppSc(Educ), MHlthSc, RN

Associate Proessor Geo McColl MBBS, BMedSc, PhD, FRACP

Dr Rana Hinman BPhysio(Hons), PhD

Proessor Karen Grimmer-Somers PhD, MMedSc, BPhty, LMusA, CertHlthEc

Amy Jasper MBA GradDipHumServRes, BAppSci(AdvNsg)

Emily Haesler BN, GradDipAdvNsg

Dr Jiri Rada PhD, FRSH, MSc, BPHE, BA


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cmmly se abbeviais

ACEI angiotensin converting enzyme inhibitor

AE adverse event

BMI body mass index

CDM chronic disease management

CI condence interval

COX-2 cyclooxygenase-2 selective inhibitor

DBRCT double blind randomised controlled trial

ES eect size (0.2 small eect, 0.5 moderate eect, 0.8 large eect)

ESR erythrocyte sedimentation rate

GIT gastrointestinal tract

GP general practitioner

HA hyaluronan and hylan derivatives

IA intra-articularITT intention-to-treat analysis

LLLT low level laser therapy

MA meta-analysis

MACTAR McMaster Toronto Arthritis Patient Preerence questionnaire

MSK musculoskeletal

NNH number needed to harm

NSAIDs nonsteroidal anti-infammatory drugs

NNT number needed to treat

NHMRC National Health and Medical Research CouncilOA osteoarthritis

OARSI Osteoarthritis Research Society International

OMERACT outcome measures in rheumatoid arthritis clinical trials

OR odds ratio

PEMF pulsed electromagnetic eld

PPI proton pump inhibitor

RACGP [The] Royal Australian College o General Practitioners

RCT randomised controlled trial

ROM range o movement/motion

RPD relative percentage dierence

SMD standardised mean dierence

SMEP sel management education program

SR systematic review (also used in this report to describe meta-analysis)

SRM standardised response mean

TENS transcutaneous electrical nerve stimulation

VAS visual analogue scale

WOMAC Western Ontario McMaster Osteoarthritis Index

WMD weighted mean dierence


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BACKGrOuNd

oseahiis

Osteoarthritis (OA) is the most common orm o chronic arthritis, with radiological evidence o OA inmore than 50% o people over 65 years o age.8 Approximately 10% o men and 18% o women suer

symptomatic OA.9

Osteoarthritis is characterised by joint pain and mobility impairment associated with the gradual wearingo cartilage. There is currently no cure or OA. Treatment is aimed primarily at symptom relie, improvingjoint mobility and unction, and optimising consumer quality o lie.10 The treatment o OA o the hip and/or knee (and other sites) includes the use o both nonpharmacological and pharmacological interventions.Joint replacement surgery is a cost eective intervention or people with severe OA who are unresponsive toconservative therapy.10, 11

Aim he gielie

This guideline seeks to achieve some o the aims o the National Action Plan and National ServiceImprovement Framework by providing recommendations or eective non-surgical management o patientsdiagnosed with OA o the hip and/or knee within the primary care setting. The guideline seeks to assist

primary health care proessionals to: optimise quality o lie

optimise sel management

prevent repeated acute episodes

prevent or delay complications associated with OA

prevent progression to established disease.

Spe a age pplai

This guideline is intended primarily or use in the primary care setting by both GPs and their patients. It isintended that through the use o this guideline, all health care proessionals that patients choose to consultregarding OA, will be aware o the evidence regarding eective management.

This guideline is intended to reer to all adult patients diagnosed with symptomatic OA o the hip and/or knee up until reerral or joint replacement. Many o the recommendations may be considered ormanagement o OA in other sites, where to date there is limited evidence available to guide management.Health care proessionals managing patients waiting or joint replacement surgery should reer to careguidelines or the multidisciplinary management o patients on waiting lists or joint replacement.

This guideline has been developed or use in primary care settings in metropolitan, regional, rural and remoteareas o Australia. It is also applicable to other settings in which patients with OA may be treated, such asspecialist rheumatologist and orthopaedic practices.

Fs he gielie

The ocus o this guideline is on OA o the hip and knee. Although many o the recommendations are relevant

to OA in other sites, research relating to other orms o OA was not included in the literature review. Theollowing process model identies the stages in chronic disease management (CDM) and the ocus o theguideline.


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reig he isk seahiis

Reduce joint injury

Health promotion

Pimay s gielie Gielie hes p

Ealy iagsis seahiis

Early and accurate diagnosis

Care and reerral pathways

teame a maageme i ealy sage seahiis

Best practice management:

optimal use o medicines

non-pharmacological management

care and reerral pathways

patient sel management education patient psychosocial support requirements

teame a maageme ig ae epises seahiis

Best practice management:




patient sel management education

patient psychosocial support requirementsEpisode prevention

Lg em maageme seahiis

Best practice management o chronic conditions:





patient psychosocial support requirements

teame a maageme i avae sages seahiis

Best practice management to optimise quality o lie:





patient psychosocial support requirements

Carer support and inormation


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Mehs

The process used to develop this guideline is outlined in ull detail in the Process Report (Appendix A).The guideline is based on an evidence based literature review conducted to NHMRC requirements. TheRACGP Osteoarthritis Working Group, who has overseen the development o the guideline and supportingdocuments comprised rheumatologists, GPs, patient representatives, arthritis organisation representatives

and an NHMRC advisor.The evidence or the guideline is based on:

a review o the literature identied through a systematic search or Level 1 and Level 2 evidence publishedrom June 2005 to March 2007

an Australian national guideline or OA12 which was assessed using the Appraisal o Guidelines Researchand Evaluation (AGREE) instrument13 and identied rom 13 OA guidelines as being the most appropriate,recently published, high quality guideline to use as a primary reerence

a review o pertinent studies reported in the national guideline or OA12 in areas where no additionalevidence had been published rom June 2005 to March 2007, and

the RACGP Working Groups expert opinion.

Liteate eviewThe method used to conduct the evidence based literature review is outlined in ull in the Process Report(Appendix A) and in Non-surgical management of hip and knee osteoarthritis: a literature review of recentevidence (www.racgp.org.au/guidelines/osteoarthritis/literaturereview).

The literature review extended the search conducted in the primary reerence guideline Evidence-basedclinical pathway for best practice management of OA of the hip and knee (2006).12 A search o Medline,EMBASE, CINAHL and the Cochrane library or English language publications published between June 2005and December 2006 that contained papers on management o OA was perormed. A second search wasconducted in July 2007 or more recent literature; articles were also identied through review o reerencelists o retrieved papers and research known to Working Group members. For interventions not representedin the initial search, pertinent studies reported in the national guideline or OA12 were appraised andreported. Papers were initially selected or inclusion based on the reading o their title and/or abstract.

Included literature was limited to Level 1 and Level 2 evidence graded according to the NHMRCAdditionallevels of evidence and grades for recommendations for developers of guidelines (2005).14 Papers that metthe inclusion criteria were critically appraised using checklists developed by The Scottish IntercollegiateGuidelines Network (SIGN)15 and given an overall quality grade o high, moderate or low. Findings rom theliterature were reported descriptively and in a tabulated ormat. The ull methods and ndings are presentedin Non-surgical management of hip and knee osteoarthritis: a literature review of recent evidence(www.racgp.org.au/guidelines/osteoarthritis/literaturereview).

recommenations

The method used to develop and grade recommendations is outlined in ull in the Process Report (AppendixA). Recommendations were based on the literature review and primary reerence guideline. The workinggroup developed evidence statements rom which each recommendation was developed; these are availablein Recommendations for the non-surgical management of hip and knee osteoarthritis (www.racgp.org.au/

guidelines/osteoarthritis/recommendations). Each recommendation statement is supported by a gradingthat refects the strength o the recommendation and refects how readily it can be implemented in termso the trust or condence practitioners can use it with in a clinical situation. The recommendation gradingsused throughout the guideline are based on the NHMRCAdditional levels of evidence and grades forrecommendations for developers of guidelines (2005)14 presented in Table 1.


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Table 1. recommenation gaes14

A Excellent evidence: body o evidence can be trusted to guide practice

B Good evidence: body o evidence can be trusted to guide practice in most situations

c Some evidence: body o evidence provides some support or recommendation(s) but care should be

taken in its applicationd Weak evidence: body o evidence is weak and recommendation must be applied with caution

The overall grade o each recommendation is based on a summation o an appraisal o individualcomponents o the body o evidence on which the recommendation is based, including volume andconsistency o the evidence. Table 2 shows the body o evidence assessment matrix, listing all thecomponents that were considered when assessing the body o evidence, together with the grades used.14

Table 2. Boy o evience assessment matix14

cmpe A B c d

Exelle G Saisay P

Vlme eviee

At least one goodquality SR that hasat least two goodquality RCTs

At least two goodquality RCTs or amoderate qualitySR that has at leasttwo moderate togood quality RCTs

At least twomoderate qualityRCTs

Less than twomoderate qualityRCTs

csisey All studiesconsistent

Most studiesconsistent andinconsistencies maybe explained

Someinconsistencyrefecting genuineuncertainty aroundclinical question

Evidence isinconsistent

cliial impa Very large Substantial Moderate Slight or restricted

Geealisabiliy Population/sstudied in body oevidence are thesame as the targetpopulation or theguideline

Population/sstudied in the bodyo evidence aresimilar to the targetpopulation or theguideline

Population/sstudied in thebody o evidencedierent to thetarget populationor the guidelinebut it is clinicallysensible to applythis evidence

to the targetpopulation

(eg. results inadults that areclinically sensibleto apply tochildren)

Population/sstudied in thebody o evidencedierent to thetarget populationor the guidelineand hard tojudge whetherit is sensible to

generalise to thetarget population

Appliabiliy Directly applicableto Australian healthcare context

Applicable toAustralian healthcare context withew caveats

Probablyapplicable toAustralian healthcare context with

some caveats

Not applicable toAustralian healthcare context


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the gielie

This guideline has been designed to provide clear inormation to assist clinical decision making andsupport optimal patient care. It is based on the best evidence available up to July 2007. Where appropriate,the evidence has been interpreted with regard to the Australian context in which the guideline will beimplemented. It is intended that the guideline be considered according to the limitations outlined in

Section 7and used in conjunction with clinical judgment and patient preerence. The guideline consists o:Algoithms (ow chats)

The algorithms are detailed fowcharts or the diagnosis and management o OA and summarise the mainrecommendations o the guideline. They also provide an accessible desktop reerence.

recommenations

The 34 recommendations contained in the guideline are limited to patients over 18 years o age presentingwith arthritic symptoms o the hip or knee, as well as those diagnosed as having OA o the hip or knee. Therecommendations have been developed on the basis o the best evidence available up to July 2007.

Each recommendation has been graded (rom A to D) according to the NHMRCAdditional levels of evidenceand grades for recommendations for developers of guidelines (2005).14 The grade refects the degree otrust that the clinician can place in the clinical application o the recommendation. Each recommendation

is supported by a summary o the evidence and pertinent inormation related to the recommendation. TheWorking Group supports all 34 recommendations and intends that they be used in conjunction with clinicaljudgment and patient preerences. The ull grading and evidence base or each recommendation can beound in Recommendations for the non-surgical management of hip and knee osteoarthritis (www.racgp.org.au/guidelines/osteoarthritis/recommendations).

resoces

Useul reerences and supporting inormation are provided throughout the guideline.Appendix B containsadditional resources, including an OA management plan template and contact details or organisationsproviding services and support to people with OA.

The Working Group recommends consulting the Therapeutic Guidelines (www.tg.com.au) and the NationalPrescribing Service (www.nps.org.au) or detailed prescribing inormation, including adverse eects.

Limiais he gielie

Meication inomation

The literature search was not designed to retrieve saety trials or pharmacological interventions. Theguideline does not seek to provide ull saety and usage inormation on pharmacological interventions.The pharmacological interventions outlined in the guideline should not be applied without considerationo the patients clinical prole and personal preerences. The Working Group recommends consulting theTherapeutic Guidelines (www.tg.com.au) and the National Prescribing Service (www.nps.org.au) or detailedprescribing inormation, including:

indications

drug dosage

method and route o administration contraindications

supervision and monitoring

product characteristics.


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Seach ate

The guideline is based on the best evidence available up to July 2007. Evidence published ater this date hasnot been reviewed or considered or the guideline.

Inteventions incle

The search strategy was limited to include only papers graded as Level 1 or Level 2 evidence. As such, only

interventions that could be investigated using a randomised controlled trial design, or that had been includedin a previous systematic review/meta-analysis, were reviewed in the development o the recommendations.Other interventions that may have been investigated using dierent study designs (or example, dieticianreerral and complex, multiaceted interventions) are not represented in the guideline. The guideline is notintended to conrm or reute the eectiveness o, nor provide guidance on the use o, interventions that havenot been included, as the evidence has not been reviewed.

Lack o evience

For some interventions included in the recommendations there was limited evidence rom which to drawconclusions on the interventions eectiveness. The Working Group acknowledges that lack o evidenceis not evidence o lack o eect, and has attempted to refect this in the strength o the grading givento recommendations on interventions that are not supported. In addition, some interventions were notsupported in the recommendations due to lack o evidence o eect. The Working Group acknowledges that

this reers to lack o evidence o eect over placebo that is, patients may receive some benecial outcomesrom the intervention; however these do not exceed the benecial eects that can be expected rom aplacebo therapy.

Cost eectiveness

This guideline does not cover the cost eectiveness o the recommended practice versus current/establishedpractice. It does not include the economic easibility o the recommendations. When relevant evidencerelating to cost eectiveness was reported in individual systematic reviews or randomised controlled trials(RCTs), this has been included in the guideline.


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ALGOrITHMS

Hip/kee seahiis iagsis a assessme algihm

Pmps eisi aassessme

tage pplai: Als age ve 18 yeas wih sigs/sympms hip/kee oA

Key sages i oAiagsis a assessme

cae plaig a maageme

dmeai a ais

cii assessme

Pain, swelling

Function, impairment

Emotional disability

Other disability

cmbiiies

Nutritional assessment (BMI, girth)

Falls risk assessment

nSAId isk

Age, hypertension, Upper GIT events,cardiovascular, renal or liver disease

Meiai isk

Polypharmacy

Aspirin allergy

Diuretics, ACEI

Anticoagulants

Kwlege, expeais a gals

Clinical history

Weight bearing radiographs

Exle:

TraumaSot tissue conditions

Reerred pain syndromes

Septic/crystal arthritis

Haemarthrosis

cm oA iagsis

Pem mpehesiveassessme

Date o weight bearing X-ray

Basis or diagnosis o OA

Basis or dierential diagnosis

Document baseline/current OA status

Document BP, renal unction i using orconsidering NSAID/COX-2

Use inormation to assess need ormedication review (HMR, RMMR), CDMitems

Use inormation to develop goal settingcare plan


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Hip/kee seahiis ae plaig a maageme algihm

Eviee base ieveis

[Gae A, B, c emmeais]

Key sages i oA aeplaig

Severe OA and ails to respond toconservative therapy

dmeai a ais

Pesipi

Phamalgial heapy

Sh em

Simple analgesia (paracetamol)

[GaeA, page 34]Oral NSAID/COX-2 (with caution)[GaeB, page 35]

Intra-articular corticosteroid[GaeB, page 38]

Topical NSAIDs[Gaec, page 38]

Lge em

Simple analgesia (paracetamol)[GaeA, page 34]

Weak and strong opioids (with caution)[GaeA, page 37]

Viscosupplementation (513 weeks orOA knee) [Gaec, page 39]

Joint replacement surgery (JRS) guidelines

Hip and knee questionnaire (MAPT)

JRS reerral template

n-phamalgial heapy

Weight reduction [GaeB, page 23]

Land based exercise [GaeB, page 23]

Aquatic exercise [Gaec, page 23]

Multimodal physical therapy[Gaec, page 25]

Tai chi [Gaec, page 26]

Sel management education programs(SMEP) [Gaec, page 27]

Thermotherapy [Gaec, page 27]

TENS [Gaec, page 28]

Acupuncture [Gaec, page 29]

Develop goal setting care planbased on:

identiedneed

evidenceforeffectiveness

patientpreferences

Optimise conservative therapy

Optimise quality o lie

Minimise risk o adverse eventsMonitor and review

GP Management Plan

Document plan or BP/renal unctionmonitoring i using NSAID/COX-2

Reer or allied health/health careprovider assessment

Reer to rheumatologist or intra-articularinjection/pain management input as

requiredMedicare CDM items used

Document health care prescription

Complete JRS reerral or orthopaedicassessment

Patient completes hip and kneequestionnaire (MAPT)

see www.racgp.org.au/Content/NavigationMenu/ClinicalResources/RACGPGuidelines/Arthritis/Reerral_or_Joint_Replacement_2008.pd


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Hip/kee seahiis maageme fw ha

Assess -phamalgial ieveis all paies aig iivial ee a all sages oA

Assess ee a isk aiial phamalgial ieveis

Pvie phamalgial ieveis i aae wih g paie piiples

ree phamais meiai eview as eqie (HMr, rMMr)Search medication good practice principles at www.health.gov.au

Assess eaiess sgey pgessive oA whee sympms ae aeqaely

lle wih sevaive heapy

Reer to joint replacement surgery guidelines at www.racgp.org.au/Content/NavigationMenu/ClinicalResources/RACGPGuidelines/Arthritis/Reerral_or_Joint_Replacement_2008.pd

opimise weigh

[Gae B]

Optimal weight BMI 18.5to 25

Combination o twoor more interventions:nutritional education,cognitive behaviouraltherapy, low energy diet,exercise regimen

Dietician reerral

Mil-meae pesisesympms

Simple aalgesia [Gae A]

Regular paracetamol (maximum 4 g/day)

and/or:

tpial heapies

Trial short term:

NSAIDs [Gae c]

capsaicin [Gae d]

i symptoms persist:

oal nSAId [Gae B]

Trial short term

Check risk www.nps.org.au

Monitor blood pressure, renal unction

Meae-sevee pesisesympms i hse whmmil-meae saegies have

bee sesslchek se simple aalgesia [Gae A]


and consider:

oal nSAId [Gae B]

Trial short term



then consider:

Visspplemeai he kee(eg. Hyalae) [Gae c]

opii heapy [Gae A]

Consider or severe symptoms where surgery iscontraindicated or patient is on surgical waitinglist and surgery cannot be expedited

Maageme a ae fae sympms

Simple aalgesia [Gae A]


and/or:

tpial heapies

Trial short term:

NSAIDs [Gae B]

capsaicin [Gae d]

and/or:

oal nSAId [Gae B]

Trial short term



and/or:

Intra-articular corticosteroid injection [Gae B]

Allie healh ieveis

Land based exercise program [Gae B]

Aquatic therapy [Gae c]

Multimodal physical therapy [Gae c]

Tai chi (especially i at risk/ear o all)[Gae c]

Thermotherapy [Gae c]

TENS [Gae c]

Acupuncture [Gae c]

Patellar taping [Gae d]

Massage therapy [Gae d]

Low level laser therapy [Gae d]

Eai/Selmaageme Spp

Sel management and educationprograms (SMEP) [Gae c]

Miig saegies

Telephone support [Gae d]


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SuMMArY OF rECOMMENdATIONS

Geeal emmeais

rECOMMENdATION 1 GP EduCATION (Gae d)

Health care proessionals should have appropriate knowledge and skills to support assessment andmanagement o exercise and nutrition liestyle behaviour change.

rECOMMENdATION 2 PErFOrMING INTrA-ArTICuLAr INJECTIONS (Gae d)

GPs who choose to perorm intra-articular (IA) knee joint aspiration and injection should be appropriatelytrained. Intra-articular injection o the hip should be perormed using appropriate imaging assistance.

rECOMMENdATION 3 MuLTIdISCIPLINArY CArE (Gae d)

Health care proessionals should assess individual patient need or multidisciplinary care intervention ormanagement o OA o the hip and/or knee.

rECOMMENdATION 4 COMPrEHENSIVE PATIENT ASSESSMENT (Gae d)Health care proessionals should perorm a comprehensive assessment to conrm the diagnosis, assess healthand medication risks, and to inorm management or people with OA o the hip and/or knee.

n-phamalgial ieveis

rECOMMENdATION 5 WEIGHT rEduCTION (Gae B)

There is good evidence to support GPs recommending weight reduction or obese patients with OA o the knee.

rECOMMENdATION 6 LANd BASEd EXErCISE (Gae B)

There is good evidence to support GPs recommending land based exercise or people with OA o the hip and knee.

rECOMMENdATION 7 AQuATIC THErAPY (Gae C)

There is some evidence to support GPs recommending aquatic therapy or treatment o OA o the hip and knee.

rECOMMENdATION 8 MuLTIMOdAL PHYSICAL THErAPY (Gae C)

There is some evidence to support GPs recommending multimodal physical therapy (up to 3 months) ortreatment o OA o the hip or knee.

rECOMMENdATION 9 TAI CHI (Gae C)

There is some evidence to support GPs recommending tai chi or treatment o OA o the knee.

rECOMMENdATION 10 SELF MANAGEMENT EduCATION PrOGrAMS (Gae C)There is some evidence to support GPs recommending sel management education programs or treatment oOA o the hip and knee.

rECOMMENdATION 11 THErMOTHErAPY (Gae C)

There is some evidence to support GPs recommending cold therapy.

rECOMMENdATION 12 TENS (Gae C)

There is some evidence to support GPs recommending use o TENS or at least 4 weeks or treatment o OA othe knee.


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rECOMMENdATION 13 ACuPuNCTurE (Gae C)

There is some evidence to support GPs recommending acupuncture or treatment o OA o the knee.

rECOMMENdATION 14 PATELLAr TAPING (Gae d)

There is weak evidence to support GPs recommending patellar taping or treatment o OA o the knee.

rECOMMENdATION 15 MASSAGE THErAPY (Gae d)

There is weak evidence to support GPs recommending massage therapy or treatment o OA o the hip or knee.

rECOMMENdATION 16 TELEPHONE SuPPOrT (Gae d)

There is weak evidence to support GPs recommending telephone treatment counselling support rom a trainedhealth or non-medical person.

rECOMMENdATION 17 - MAGNETIC BrACELETS (Gae d)

There is weak evidence to support GPs recommending magnetic bracelets or treatment o OA o the hip or knee.

rECOMMENdATION 18 LOW LEVEL LASEr THErAPY (Gae d)

There is weak evidence to support GPs recommending low level laser therapy or short term treatment o OA othe knee.

rECOMMENdATION 19 LEECH THErAPY (Gae d)

There is weak evidence to support GPs recommending leech therapy or treatment o OA o the hip or knee.

Phamalgial ieveis

rECOMMENdATION 20 PArACETAMOL (Gae A)

There is excellent evidence to support GPs prescribing paracetamol in regular divided doses to a maximum o

4 g/day as rst line pharmacological therapy or treating persistent pain in people with OA o the hip or knee.

ne: the ms ee eseah paaeaml sggess i is eais i he maageme pai elae kee a hip oA. Alhgh as eeive as seial ai-ifammaygs (nSAIds), he lwe isk avese eves, pailaly he gasiesial sysem,makes paaeaml a s lie meiai sieai.

rECOMMENdATION 21 OrAL NSAIdS (Gae B)

There is good evidence to support GPs prescribing NSAIDs or COX-2 NSAIDs or reducing pain in the short termtreatment o OA o the hip or knee where simple analgesia and non-pharmacological measures are ineective.The potential small benets o NSAIDs need to be measured in relation to potential harms.

ne: GPs shl apply ai whe sig aiial nSAIds a coX-2 nSAIds i view

he kw sie ees, espeially i hse a isk sh as he elely, a hse mia meiai. cael miig bl pesse a eal i is iiae le peple a hes a isk whe sig hese ages. F paies wih high nSAIdisk whm nSAIds ae siee a eessay pa eame, GPs shl pesibe aaiial nSAId pls p pmp ihibi (PPI) coX-2 ihibi.

rECOMMENdATION 22 WEAK ANd STrONG OPIOIdS (Gae A)

There is good evidence that GPs consider prescribing weak or strong opioids with caution or treating at leastmoderate or severe pain in people with OA o the hip or knee who have not responded to, or are unable to tolerate,other analgesic medications or NSAIDS, and in whom joint replacement surgery is contraindicated or delayed.

ne: GPs shl mmee piis a a lw saig se wih slw iai se,

pailaly i peple a iease isk avese ees, sh as he elely, a lsely mipaies avese eves.


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rECOMMENdATION 23 INTrA-ArTICuLAr COrTICOSTErOId INJECTION (Gae B)

There is good evidence to support GPs prescribing IA corticosteroid injections or short term treatment o OA othe hip and knee.

rECOMMENdATION 24 TOPICAL NSAIdS (Gae C)

There is some evidence to support GPs recommending short term treatment o OA o the knee with topical NSAIDs.

rECOMMENdATION 25 TOPICAL CAPSAICIN (Gae d)

There is weak evidence to support GPs recommending topical capsaicin or short term treatment o OA o thehip and knee.

rECOMMENdATION 26 VISCOSuPPLEMENTATION FOr KNEE OA (Gae C)

There is some evidence to suggest hyaluronic acid is o some benet or OA o the knee.

rECOMMENdATION 27 GLuCOSAMINE (Gae C)

The role o glucosamine products, including types and dose, remains uncertain. GPs may inorm patients about

the availability and saety o these agents.

Ieveis sppe by e eviee

rECOMMENdATION 28 BrACES ANd OrTHOSES (Gae B)

There is good evidence to suggest that knee brace, neoprene sleeve or lateral wedged insoles are o little or nobenet or treatment o OA o the knee. GPs could inorm patients about lack o evidence o benet over placebo.

rECOMMENdATION 29 ELECTrOMAGNETIC FIELdS (Gae B)

There is good evidence to suggest that electromagnetic eld or electric stimulation interventions are o no benetin the treatment o OA o the knee. GPs could inorm patients about lack o evidence o benet over placebo.

rECOMMENdATION 30 VISCOSuPPLEMENTATION FOr HIP OA (Gae C)

There is some evidence to suggest hyaluronic acid is o no benet or OA o the hip. GPs could inorm patientswith hip OA about the lack o evidence o benet over placebo.

rECOMMENdATION 31 CHONdrOITIN SuLPHATE (Gae C)

There is some evidence to suggest that chondroitin sulphate is o no benet in treating OA o the knee. GPscould inorm patients about the lack o evidence o benet over placebo.

rECOMMENdATION 32 VITAMIN, HErBAL ANd OTHEr dIETArY THErAPIES (Gae C)

There is some evidence to suggest that vitamin, herbal and other dietary therapies are o limited or no benet

in treating OA o the hip or knee. GPs could inorm patients about the lack o evidence o benet, or limitedevidence or benet over placebo.

rECOMMENdATION 33 THErAPEuTIC uLTrASOuNd (Gae C)

There is some evidence to suggest that therapeutic ultrasound is o no benet in treating OA o the knee or hip.GPs could inorm patients about lack o evidence o benet over placebo.

rECOMMENdATION 34 SOCIAL SuPPOrT (Gae d)

There is weak evidence to suggest cognitive behavioural therapy is o limited or no benet in treating OA. GPscould inorm patients about lack o available evidence.


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HIP ANd KNEE OSTEOArTHrITIS rECOMMENdATIONS

These recommendations are intended or adult patients diagnosed with symptomatic OA o the hip and/or knee up until reerral or joint replacement. Many o the recommendations may be considered ormanagement o OA in other sites where, to date, there is limited evidence available to guide management.Full evidence statements and grading or each recommendation are outlined in Recommendations for the

non-surgical management of hip and knee osteoarthritis (www.racgp.org.au/guidelines/osteoarthritis/recommendations).

the Wkig Gp spps he se he emmeais i ji wih liialjgme a paie peeee. csl he theapei Gielies (www.g.m.a) ahe naial Pesibig Sevie (www.ps.g.a) eaile pesibig imai,ilig avese ees.

Geneal ecommenations

GP eai

recommenation 1 (Gae d)Health care proessionals should have appropriate knowledge and skills to support assessment andmanagement o exercise and nutrition liestyle behaviour change.

The importance o liestyle modication, particularly weight loss and undertaking appropriate exercise, hasbeen well recognised in both the prevention and management o OA.6, 16 Health proessionals require access tocurrent education on liestyle modication including risk modication, smoking cessation, joint protection andevidence based management strategies or OA to ensure patients receive the most recent health advice. 17

Evience statement

It is the opinion o the Working Group that promotion o preventive and therapeutic liestyle strategies by

GPs is important in the management o hip and knee OA. A ull review o the literature relevant to thisconsensus recommendation was not undertaken.

Management o chronic disease requires both preventive and therapeutic liestyle strategies. Educationand behavioural modication can reduce the risk o developing OA and prevent urther joint injury in atrisk populations. The role o the GP in CDM increasingly incorporates sel management support, includingemphasis on patient sel education, sel care, and counselling in behavioural change. To undertake theimportant role o providing patients with sel care skills and knowledge, the GP needs a current awareness ohealth promotion and disease prevention issues.6, 1820

A large multicentre study investigated the eectiveness o a training program or GPs that ocused on non-pharmacological and liestyle pain management interventions and appropriate analgesic prescription orpatients with OA. Patients o GPs who received this training intervention were ound to have improved painrelie (316 +/ 290 mm/day vs. 265 +/ 243 mm; p


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Pemig ia-aila ijeis

recommenation 2 (Gae d)

GPs who choose to perorm IA knee joint aspiration and injection should be appropriately trained. Intra-articular injection o the hip should be perormed using appropriate imaging assistance.

Evience statement

It is the opinion o the Working Group that sae perormance o IA injection is imperative. A ull review o theliterature relevant to this consensus recommendation was not undertaken.

Clinicians should be appropriately trained and experienced in the sae perormance o IA injectionprocedures.24 Adverse reactions o IA injection (eg. injury, inection, bruising) are minimised and clinicalecacy is increased by accuracy o needle placement and adherence to an appropriate sterile techniqueduring the injection procedure.25, 26

One Irish survey o GPs experiences and attitudes ound that the main perceived barrier to perormingIA injections or GPs was lack o ability to maintain appropriate clinical skills. GPs who had access to

postgraduate training and the ability to maintain injection skills were more condent in perorming IAinjection and more likely to perorm the procedure.27 An Australian study into the eectiveness o continuingmedical education on patient clinical outcomes ound statistically signicant improvements in pain andphysical unction in those receiving IA injection rom a GP who had recently acquired the necessary jointinjection skills.28

Depth o the joint, as well as the close proximity o sensitive structures such as the emoral artery and nerves,complicates IA injection o the hip joint. One study reported that specialist rheumatologists were only 53%accurate in the placement o IA hip injections administered blindly.25 To increase the precision o medicationadministration to the joint, and to reduce the risk o adverse events, hip IA injection should always beperormed under X-ray screening or ultrasound guidance.2426, 29

Mliisipliay ae


Health care proessionals should assess individual patient need or multidisciplinary care intervention ormanagement o OA o the hip and/or knee.

Management o OA requires a multidisciplinary approach with regular communication between healthpractitioners (eg. GP, rheumatologist, physiotherapist) to acilitate holistic management or the patient. GPsshould reer patients to appropriate health practitioners or input in the patients management plan. Reerralto a rheumatologist should be considered or elderly patients, patients with signicant comorbidity, thosewith extensive disease or when the diagnosis is uncertain.17, 30, 31

Evience statement

It is the opinion o the Working Group that multidisciplinary care is important in the management o hip andknee OA. A ull review o the literature relevant to this consensus recommendation was not undertaken.

National strategic health policy has given increased recognition to the importance o CDM, with a numbero recent ederal government initiatives or the prevention or delay in onset; early detection; and evidencebased management o chronic disease, including OA. The role o multidisciplinary input in the managemento chronic disease is highlighted throughout CDM policy, with ocus on improving capacity, eectiveness andeciency o multidisciplinary collaboration.13, 32


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There is support throughout this guideline, and other primary OA guidelines, o the importancemultidisciplinary collaboration plays in the ongoing management o patients with hip or knee OA, particularlyor patients accessing the broad range o non-pharmacological interventions used in OA treatment.Weight loss, a range o exercise interventions and multimodal therapies, as well as numerous other non-pharmacological interventions, are regularly provided by multidisciplinary health care providers includingphysiotherapists, occupational therapists, massage and manual therapists, personal trainers, dieticians, and

nurses. In addition, various health proessionals (eg. GP, rheumatologist, orthopaedic surgeon, other specialists,pharmacist) may have involvement in the patients pharmacological regimen. Multidisciplinary collaborationand communication is essential to promote continuous, coordinated, patient centred care.11, 12, 3335

A wide range o interventions implemented by multidisciplinary health care providers were reviewed orthese recommendations. In the vast majority o trials, the intervention o interest was implemented by ahealth care provider with specic training and qualications. Seeking health advice and management rom anappropriately trained health care provider is considered to be a component o eective and sae therapy.36

cmpehesive paie assessme

recommenation 4 (Gae d)Health care proessionals should perorm a comprehensive assessment to conrm the diagnosis, assesshealth and medication risks, and to inorm management or people with OA o the hip and/or knee.

Confm osteopoosis iagnosis

Diagnosis o OA is usually made based on a detailed patient history and clinical presentation. Presentingsigns and symptoms suggestive o OA include: symmetrical joint symptoms, usually in one or two joints; painand stiness; decreased joint mobility; joint swelling; crepitus; and increased age.6, 17, 31, 3740

I the patient has a recent history o inection or ever, is less than 40 years o age, or presents with abnormalroutine blood tests, other orms o arthritis (eg. rheumatoid, septic) should be considered. Laboratory tests (eg.ESR, rheumatoid actor, synovial fuid analysis) may be used to rule out alternative diagnoses.31, 37, 39, 40

Radiographs (particularly weight bearing X-rays) may be used to conrm diagnosis and exclude alternativediagnoses (eg. trauma), however ndings are oten non-specic. Radiographic ndings indicative o OAinclude narrowing o the cartilage space, marginal osteophyte ormation, subchondral sclerosis, andbreaking o the tibial spines; however, these may not be observed in early disease. In addition, some patientsmay show radiographic changes o OA without signicant symptoms, thereore X-ray should be used inconjunction with clinical presentation to make a diagnosis.6, 3740

Peom a compehensive assessment

Comprehensive assessment o the patient with knee and/or hip OA should include:

1. Joint signs and symptoms:17, 31, 3739, 41

jointpain,oftenafterweightbearingactivity

jointstiffness,particularlyafterperiodsofinactivity(eg.morning) jointinammation

decreaseinjointmobilityand/orfunction

crepitus(acrinkly,cracklingorgratingfeelinginthejoint)

jointtendernessuponpalpation.


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2. Comorbidities:

nutritionalassessment:overweightandobesityareriskfactorsfordevelopmentofOAandmaycontribute to disease progression. Patients with OA should be screened or the need to lose weight, asthis is one o the most signicant modiable risk actors6, 17

othercomorbidities:otherdiseasesmayimpactonthemanagementofOA.Comorbiditiessuch

as cognitive impairment, cardiovascular disease, peptic ulcer disease, renal disease, diabetes,asthma, allergies and liver disease may infuence the patients ability to sel manage their OA, theappropriateness o specic non-pharmacological interventions, and implications or pharmacologicaltherapy.17, 41

3. Psychosocial assessment:

Patients with chronic disease such as OA have a higher rate o depression and anxiety than the generalpopulation. Chronic pain is related to eelings o helplessness, anxiety and sel image. Understandingo the disease process and management; ability to manage sel care and make health care decisions;and ability to cope with the oten debilitating eects o OA are infuenced by the patients psychosocialstate. Osteoarthritis may also have a signicant impact on the patients social wellbeing and participationin leisure, relationships, and community, and these actors should be considered in holistic patientassessment.6, 41

4. Falls risk assessment:

Pain and decline in unction rom knee or hip OA may impact upon mobility and contribute to risk oalls. Assessment or a history o alls is recommended. A alls risk assessment should be consideredor patients with a history o alls. In high risk settings, such as residential care, regular assessment isrecommended.17

5. Medication and NSAIDs risk:

Assess or the presence o risk actors or OA medications (particularly NSAIDs) including age,hypertension, upper gastrointestinal events, and cardiovascular, renal or liver disease. Consider aspirinallergy and polypharmacy (eg. concurrent use o diuretics, ACEI and/or anticoagulants).17

the Wkig Gp emmes slig he theapei Gielies (www.g.m.a)

a he naial Pesibig Sevie (www.ps.g.a) eaile pesibig imai,ilig avese ees.

development o a cae plan

Development o an OA management plan should be based on individual needs established during patientassessment, evidence o eectiveness o specic interventions and the patients personal preerences. Aimso management plans should ocus on optimising the patients quality o lie (eg. decreasing pain, improvingunction), providing the patient with appropriate knowledge and skills to manage chronic disease andminimising risk o adverse events.31 An OA management plan template is included in the resources section(Appendix B).


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Non-phamacological inteventions

Non-pharmacological interventions are the mainstay management strategies or knee and hip OA. Non-pharmacological interventions, which oten involve the clinical input o the multidisciplinary health care team,include patient education; aerobic and resistive exercises; liestyle changes and weight loss; and variousphysical therapies. These interventions generally have low or no side eects and are used in conjunction with

a pharmacological regimen to decrease pain and promote unctioning and quality o lie.

Weigh ei

recommenation 5 (Gae B)

There is good evidence to support GPs recommending weight reduction or obese patients with OA o the knee.

Obesity is a risk actor or developing OA, particularly or women. Overweight people are at higher risk otheir OA being symptomatic and progressing. This is thought to be related to the increased load placed onweight bearing joints and increased stress on cartilage.6, 39, 42, 43 Body mass index (BMI) (kg/m2) is suggestedas the most appropriate determinate o healthy weight range. An acceptable weight range is considered to

be a BMI 18.525; BMI o 2529 is considered overweight; and BMI over 30 is obese.4

Weight loss and strategies to avoid gaining weight are suggested as primary preventive strategies or kneeand hip OA.39 For patients with OA who are overweight or obese, weight loss is related to an improvement insymptoms o pain and disability, and weight control programs are appropriate.6, 30, 42, 43

An excellent volume o evidence o satisactory consistency provided support or the recommendation thatobese patients with knee OA undertake weight reduction programs.

Evience statement

There is evidence rom a recent good quality SR including our RCTs and 454 participants, to support thebenet o weight reduction (6.1 kg, 95% CI: 4.77.6) in reducing pain (eect size 0.2) and physical disability(eect size 0.23) in obese people with knee OA. A signicant benet was noted with more than 5% weight

reduction or, at a weight reduction rate o at least 0.24% per week.44

Exeise

recommenation 6 (Gae B)

There is good evidence to support GPs recommending land based exercise or people with OA o the hipand knee.

recommenation 7 (Gae C)

There is some evidence to support GPs recommending aquatic therapy or treatment o hip and knee OA.

cai e: csieai shl be give mbiiies, pailaly aivaslaisease, i pesibig exeise pgams paies wih oA. Exeise is geeally a-iiae paies wih lle ahyhmias; hi egee hea blk; ee hages EcG; sable agia; ae myaial iai a ae gesive hea aile.Exeise shl be pesibe wih ai a spevisi paies wih aimypahy,valvla hea isease, lle meabli isease ply lle bl pesse.42Bee eakig a physial exeise pgam he paie shl eeive a mpehesiveassessme by a apppiaely qalie healh ae pvie. this assessme shl ileliial evalai he paies oA, as well as ieiai he healh iis hamay be exaebae by exeise. Exeise pgams shl be iivialise he paies

spei ees, abiliies a peeees a implemee by a apppiaely aie healhae pvie.11, 42, 43


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Exercise is an important component o management o OA as both a preventive strategy and to treatsymptoms. Increasing physical activity improves general physical health; reduces the risk o other chronicdisease development (eg. coronary artery disease, diabetes); acilitates weight control; and may havepsychological and social benets that improve the patients overall quality o lie.39, 42, 43

Particularly in OA o the knee, weakness o the quadriceps muscles contributes to unctional disability causedby joint instability, thereore appropriate exercise also has a role in reducing signs and symptoms o OA.42Physical exercise o a light to moderate intensity increases muscle strength as well as range o motion,aerobic capacity, and endurance that contributes to improved physical unctioning and pain reduction. Arange o both supervised and home based exercise programs are available or patients with OA, includingquadriceps muscle strengthening, resistance training, aerobic exercise, and fexibility exercises. Variousprograms oer dierent benets and no specic type o exercise regimen has been shown to be superior.11, 31,39, 42, 43

Aquatic exercise programs, perormed in either group or individual settings, provide the same generalbenets as land based exercise programs but with reduced stress to the joints due to buoyancy. This orm oexercise may be better tolerated than land based exercise or some patients with hip and knee OA (eg. obesepatients with excess joint stress). Patients do not need the ability to swim to undertake aquatic exercise,however level o comort in the water and personal preerences are primary considerations in selecting thisorm o exercise.11, 30, 39

A large volume o evidence o good consistency provided support or the recommendation that GPsrecommend exercise or patients with knee and hip OA.

Evience statement: lan base execise

One good quality SR including 13 RCTs with 2304 participants with knee OA, reported benet rom aerobicwalking in reducing pain (ES 0.52) and sel reported disability (ES 0.46), and rom quadriceps strengtheningexercise in reducing pain (ES 0.39) and sel reported disability (ES 0.46) compared to education and liestyleadvice, telephone support, no intervention and sham intervention. There was variation in program contentand duration (8 weeks to 2 years) o program. Adverse events were not reported.45

One moderate quality SR including 16 RCTs and two quasi controlled trials with 2154 participants withknee OA, reported modest benet or exercise in improving perceived physical health (ES 0.29) and overall

impacts (a composite measure) (ES 0.20) compared to no treatment, standard care, attention, sham electricalstimulation. There was heterogeneity in study design, denition o exercise program, intensity o exerciseprogram, and methods o impact assessment. Adverse events were not reported.46

A moderate quality systematic review including 17 RCTs (knee OA) and two RCTs (hip OA) with 2562participants reported small benets o land based exercise (simple to complex programs including aerobicwalking, resistance, stretching, strengthening, and manual therapy) or treatment o hip or knee OA, deliveredeither individually or in groups, compared to controls (including no treatment, waiting list, education,telephone support). The benets varied with SMD 0.39 (95% CI: 0.30.47) or sel reported pain, and SMD0.31 (95% CI: 0.230.39) or sel reported physical unction. The benet was similar or both individual andgroup exercise classes. Adverse events were not reported.47

A good quality SR, including one low-moderate quality small RCT, with only 39 participants with knee OA,reported no dierence in pain, unctional state, gait and aerobic capacity between low intensity and highintensity exercise or knee OA over 10 weeks ollow up. It is doubtul with a sample size o 39 whether therewas adequate power to detect a dierence i one truly existed. Adverse events were not reported.48

A moderate quality RCT that included 109 participants over 55 years with hip OA assessed the eectivenesso an exercise program with routine treatment. The study reported a small positive clinical eect measuredby Harris hip scale (HHS) pain (ES 0.38), HHS total score (ES 0.34), timed Up and go test (ES 0.35), andwalking test (0.22).49


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Evience statement: aqatic theapy

There is evidence rom a good quality single blinded RCT with 312 participants with hip or knee OA reportedbenet or aquatic therapy in reducing WOMAC pain scores (ES 0.44, 95% CI: 0.030.85) and improvingWOMAC physical unction (ES 0.76, 95% CI: 0.331.17) at 12 week assessment compared to usual care.A small benet was also reported at 12 months (ES 0.25, 95% CI: 0.020.47), however the eect was notsignicant at 18 months.50

Evidence is also provided by a moderate quality single blinded RCT with 71 participants with hip or kneeOA or the benet o a 6 week course o twice weekly aquatic physical therapy. Improvements in primaryoutcome measure o VAS pain on movement (ES 0.24) and secondary outcomes including WOMAC pain(ES 0.28), stiness (ES 0.24), unction (ES 0.08) and physical unction (75% vs. 17%) were achieved atthe 6 week assessment compared to a waiting control group. The benets were sustained at 12 weeksalthough control data was not available at this time point. The number needed to treat (NNT) or both painand or physical unction improvement was two. Minor adverse events were reported that did not aectparticipation.51

A urther moderate quality RCT included 152 participants with hip or knee OA and compared 12 weeksaquatic therapy to two control groups, tai chi and waiting list control. Benets were reported or aquatictherapy and tai chi in improving WOMAC unction scores (aquatic therapy SRM 0.62, 95% CI: 0.490.75, tai

chi SRM 0.63, 95% CI: 0.50.76) at 12 week assessment. Aquatic therapy, but not tai chi reduced WOMACpain scores (SRM 0.43, 95% CI: 0.30.56). O those assessed as OMERACT responders at 12 weeks, 66%aquatic therapy and 58% tai chi responders demonstrated sustained response at 24 weeks. The 11 reportedadverse events did not relate to the interventions.52

Mlimal physial heapy


There is some evidence to support GPs recommending multimodal physical therapy (up to 3 months) ortreatment o OA o the knee or hip.

cai e: Mlimal physial heapy is geeally well leae, wih avese eesepe i he eviewe sies.5356 Mlimal physial heapy egimes e ile-phamalgial ieveis issse i me eail elsewhee i he gielie.cai es eah spei ievei ha have bee ile wih he elevaemmeais shl be siee.

Multimodal physical therapy involves dierent therapeutic strategies aimed at relieving pain and stinessand improving joint mobility and overall unction. Therapies include: range o motion exercise, sot tissuemobilisation, and muscle strengthening and stretching.30, 31, 56 Multimodal therapy generally includes manualtherapy consisting o muscle stretching and passive range o movement exercise as an adjunct to an activeexercise component o treatment.53 Studies suggest that patients with OA receive moderate short term (up to8 weeks) clinical impact measured on WOMAC global and pain scores rom multimodal physical therapy.5356

A satisactory volume o evidence that was o good consistency provided support or the recommendationthat GPs recommend multimodal physical therapy or patients with knee OA.

Evience statement

A moderate quality RCT involving 134 participants with knee OA, provided evidence that participantsin a clinically based physical therapy (CPT) program that included supervised exercise and individualisedmanual therapy (no placebo group) achieved greater benet at 8 weeks measured by global WOMACscore (p


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Evidence rom a moderate quality RCT involving 109 participants with hip OA showed participants in amanual physiotherapy program ocusing on specic manipulations and mobilisation o the hip had greaterbenet at 5 weeks in general improvement measured on a Likert scale (OR 1.92, 95% CI: 1.302.60), VASpain at rest and on walking (both ES 0.5,p


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Sel maageme eai pgams


There is some evidence to support GPs recommending sel management education programs or treatment oOA o the hip and knee.

Sel management education programs (SMEPs) are interventions designed to educate the patient on selcare activities that promote health and management o chronic diseases such as OA. SMEPs aim to providepatients with knowledge o their disease, and the motivation and practical skills to relieve pain and reducethe impact o unctional decits on their lie. By combining patient education with behavioural modicationand empowerment techniques, SMEPs also aim to increase patient adherence to treatment, promote decisionmaking related to CDM, and manage psychosocial impacts o disease such as anxiety, low sel image and/orcondence, depression and helplessness.6, 6063 For some patients, participation in SMEPs has been associatedwith positive outcomes such as decreased pain and improved quality o lie.39, 43, 46, 62, 63

Eectiveness o SMEPs is likely to be infuenced by the content o the program (eg. relevance o inormationto patient, level to which inormation is aimed), delivery o the program (eg. ormat, speed) and patientcharacteristics (eg. readiness or education).43 There is insucient research on these actors to recommend

specic SMEPs. In reviewed studies, one program included education, demonstration and participation in agroup setting62 and another used lecture style delivery.46 Content o programs included joint preservation andprotection; evaluating and controlling pain; treatments recommended or OA; aids and devices; exercise; anddiet management including low at ood, setting goals and weight loss counselling.46, 62

A good volume o evidence o good consistency provided support or the recommendation that GPsrecommend SMEPs or patients with OA.

Evience statement

There is evidence rom one moderate quality SR o 16 RCTs46 and two moderate quality RCTs.62, 64 There isvariation in content and denition o the SMEP interventions, which makes comparisons o the results odierent studies dicult. In addition, studies commonly use outcomes o pain and physical unction, whichmay not be the primary ocus o the intervention. There is evidence o a small positive benet o SMEP onpsychological outcomes ater participating in a program.46, 64

There was evidence o benet o SMEP in conjunction with an exercise component on psychologicaloutcomes (mean ES 0.19). There was some evidence that SMEPs without an exercise component have noeect on physical unction.46

The research methods (particularly the outcomes measured) may not have been able to answer the questiono interest. There is currently a lack o evidence pertaining to other patient health outcomes, such as ability tosel manage.

themheapy


There is some evidence to support GPs recommending cold therapy to treat symptoms o OA.

cai e: themheapy is geeally well leae, wih ew avese ees epei he lieae.65, 66 H a l paks shl be plae iely agais he ski e he isk b sbie. themheapy is aiiae paies wih eesesai, impaie mmiai a/ gii hemeglay impaimes. Avihea heapy whe a maligay ae ijy (eg. pe ws, aeas ee bleeig,ae emaiis, psiasis, iei) is pese. Paies wih a hisy peipheal vaslaisease, iabees, aivasla isease a hypeesi, wh ae pega, shl sehemheapy wih ai.67


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Thermotherapy involves the application o heat or cold (eg. heat or ice pack, ice massage) to treat symptomso OA.43,66 Cold has an eect by reducing swelling and infammation, numbing pain and blocking nervesimpulses and muscle spasms to the joint.61, 68 Treatment appears to be most eective in an acute fare oOA, when minor joint infammation is present, and is administered through the application o an ice packwrapped in a towel or 20 minutes, 5 days a week or 2 weeks. 66, 69

There was no research using sound study designs available on use o heat therapy in managing OA, howeversome patients may preer it to cold treatments. Application o heat to the joint may reduce pain and stinessthrough promotion o relaxation, joint fexibility and blood fow to the joint, although these eects maycontribute to infammation and oedema.66, 69 Mild to moderate heat is applied using moist towels or heatpacks wrapped in a towel or 1520 minutes.30, 68

A good volume o evidence that was o poor consistency provided support or the recommendation that GPsrecommend cold thermotherapy or patients with knee OA. No evidence was available on the use o heattherapy in managing OA.

Evience statement

A moderate quality SR including three RCTs, studying dierent types o thermotherapy and including a totalo 179 patients, reported conficting results or treatment o knee OA. One RCT reported that ice massage

had a benecial eect on range o movement (ROM), unction and knee strength but not on pain whenused or 20 minutes, 5 days per week or 2 weeks. Another trial reported that cold packs decreased swelling,but hot packs had no similar benecial eect. A urther trial reported that ice packs did not aect painsignicantly. No adverse eects were reported in included trials.66

tEnS


There is some evidence to support GPs recommending use o TENS or at least 4 weeks or treatment o OAo the knee.

cai e: Maaes tEnS evies wa ha hey may ieee wih paemakes he meial evies (eg. hlea implas), a may be siable hse wih epilepiiis. Bease tEnS may ieee wih bl pesse, he elees shl beplae ve he ai sis. I is emmee ha elees be plae aeas wihee sesiiviy ve bke ski. the saey tEnS ig pegay has beeesablishe.70, 71

Transcutaneous electrical nerve stimulation (TENS) is a non-invasive therapy with no known side eects.TENS is administered through the stimulation o cutaneous nerve bres by a device worn and operatedby the patient.61, 68, 72 It is theorised that TENS provides pain relie by inhibiting the transmission o painulstimuli to the spinal cord and brain pain receptors. The type o device, wave orm produced by the device (eg.amplitude, rate and width o pulse), and the location in which stimulators are placed, all infuence the quality

o TENS administered to the patient and are generally adjusted by the clinician depending on the patientsresponse. Various TENS regimens are used in clinical practice: high requency (>50 Hz), low requency(


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A low quality RCT including 60 participants with knee OA reported no dierence over a 6 month ollow upbetween use o IA injection o hylan (three injections given once weekly over 3 weeks) in reducing pain andstiness and improving unction and Lequesne index compared to TENS (applied ve times per week or 20minutes at 150 Hz or 3 weeks). There was no placebo group. Eect sizes were not stated and adverse eventswere not reported.73

A second low quality RCT including 51 participants with knee OA provided evidence that TENS orintererential current (IFC) treatments given twice weekly at standard doses or 20 minutes and in associationwith 20 minutes exercises had no benet over a 20 minute exercise program alone (isometric quadricepsexercises, aerobic and resistance training). All groups showed improvement in WOMAC score over time. Therewas no placebo group.74

Ape


There is some evidence to support GPs recommending acupuncture or treatment o OA o the knee.

Acupuncture is a therapy administered through the insertion o sterile needles into specically identiedacupuncture points. Ater insertion needles are manually manipulated. The therapy is theorised to havean eect on pain through the triggering o endogenous opioid pathways.68 Acupuncture has ew reportedserious side eects when administered by an appropriately trained health care provider.16

A good volume o evidence that was inconsistent in its ndings provided support or the recommendationthat GPs recommend acupuncture or patients with knee OA.

Evience statement

There is evidence rom a moderate quality SR o acupuncture used or chronic knee pain in OA, including13 RCTs, eight o which were included in a meta-analysis with 2362 participants, or a small benet oracupuncture in reducing pain and improving unction compared to sham acupuncture or treatment o knee

OA (when used or at least six treatments given at least once weekly with at least 4 points per painul kneeneedled or 20 minutes or up to 12 weeks). The overall eect size or use o acupuncture in chronic kneepain was 0.4 (95% CI: 0.10.6). Caution needs to be applied as the SR provided an overall validity score butdid not clearly indicate which studies had adequate randomisation, randomisation allocation, or blinding.There was considerable heterogeneity between studies. Adverse events were not reported.75

A urther moderate quality SR included 18 RCTs, o which 14 were knee OA RCTs, and 12 o these wereincluded in the review by White (2006). Meta-analysis data rom three trials (two knee OA, one hip OA)ound small benets in pain reduction (SMD 0.24, 95% CI: 0.010.47) or manual acupuncture compared tosham acupuncture or treatment o hip and knee OA. When two o the knee trials were analysed alone theheterogeneity o studies or electromagnetic acupuncture precluded meta-analysis.76

One recent and large good quality RCT included 3633 participants with hip or knee OA, o whom 357were randomised to receive acupuncture (non-standardised intervention or up to 3 months duration), 355

randomised to a control (delayed treatment) group and 2921 included in a preerence based non-randomisedintervention group. Neither patients nor doctors were blinded to randomisation status. The study reportedsignicant benets (based on WOMAC scores) or the acupuncture group at 3 months. The proportion oresponders (dened as 50% reduction in WOMAC score) was 34.5% in the intervention group comparedto 6.5% in the control group. Caution is required in interpreting these results in view o the lack o blindingand questionable appropriateness o the control group. Adverse eects were reported in 5.2% (n=184)participants including minor local bleeding (66%), and pain at the needle site (5%). No lie threatening sideeects were seen.77

There is additional evidence rom a recent moderate quality RCT with 52 participants with knee OA that904 nm low level laser acupuncture provided 20 minutes per day or 5 days per week (total 10 sessions),in association with an exercise program, provides no additional benet to sham laser acupuncture otherthan or knee circumerence measurement when assessed at 2 and 12 weeks. No inormation was provided


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regarding the inter- or intra-rata reliability o this measurement. Both laser and sham laser acupuncture wereassociated with improvements in pain on walking (VAS scale) and 50 eet walking time over 12 weeks. Therewere no local nor systemic adverse events.78

One urther moderate quality placebo (Streitberger needle) controlled RCT provided evidence or benetin reducing VAS pain or true acupuncture when used once weekly or 12 sessions in conjunction withdicloenac 50 mg three times daily compared to placebo.79

Paella apig


There is weak evidence to support GPs recommending patellar taping or treatment o OA o the knee.

Patellar taping has been used as a strategy to reduce pain in knee OA by stabilising the knee joint andaltering the distribution o stress and joint pressure, thereby reducing strain on infamed joint tissue. Patellartaping is generally used as a short term, intermittent treatment, particularly when the patient is perorming

activities that aggravate their condition.

8082

Eectiveness o patellar taping appears to be related to thestrapping technique used and the length o time taping remains in place. Although some patients mayexperience topical irritation rom tape application, no signicant adverse eects have been reported.8083

A poor volume o evidence o satisactory consistency provided support or the recommendation that GPsrecommend patellar taping or patients with knee OA.

Evience statement

A moderate quality RCT involving 87 participants with knee OA showed those treated with therapeuticmedial patellar taping had signicant improvement on 10 cm VAS or pain on movement (ES 1.19) andduring worst activity (ES 1.00) ater 3 weeks o taping (reapplied weekly) compared to neutral taping orno tape. This eect was sustained at 6 weeks. Compared to no taping, there was a RR o 7.0 (95% CI:2.3420.92) o participants in the therapeutic taping group reporting improvement in pain status ollowing 3

weeks o treatment (neutral taping group RR 4.67, 95% CI: 1.5014.53). Therapeutic taping was associatedwith improvements in WOMAC pain (ES 0.82) and WOMAC unction (ES 0.83) at 3 weeks but not at 6weeks. Outcome measures were subjective and participants were not blinded. 28% o participants in thetherapeutic taping group experienced minor skin irritations.81

There is one small low quality RCT involving 18 participants with painul OA knee randomly assigned totwo dierent knee taping techniques (therapeutic tape or neutral tape) or no taping. The study reportedbenets or participants in the therapeutic taping group o reduced pain during gait (p


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Massage heapy


There is weak evidence to support GPs recommending massage therapy or treatment o OA o the knee or hip.

cai e: Massage heapy is geeally a sae ievei. Paies may expeiee miism. A small mbe seis avese eves have bee epe, hweve he isk islw i he heapy is peme by a aie paiie.85

Massage is the use o manual techniques such as stroking, riction and compression to apply traction andpressure to the sot tissues, including skin and underlying muscle tissue. The therapy aims to relieve painand promote unction through reduction o muscle tension and spasm, increase in circulation o blood andlymph, and promotion o mental relaxation. Massage may also contribute to positive outcomes or the patientthrough the therapeutic benet o touch.61, 68, 85, 86 A wide variation o massage types are available includingconventional muscular massage (Swedish massage), deep tissue massage, and Shiatsu, however there islimited research on their use in osteoarthritis and no research comparing the eective various massage orms.86

There was only one low quality study on massage therapy, hence the recommendation that there is weakevidence to support massage therapy in the treatment o OA o the knee or hip.

Evience statement

There is one low quality RCT involving 68 participants aged over 35 years with radiographically conrmedand symptomatic knee OA that reported a reduction in mean WOMAC scores or global pain, stiness, andphysical unction domains (allp


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Magei baeles


There is weak evidence to support GPs recommending magnetic bracelets or treatment o OA o the hipor knee.

cai e: Maaes magei baeles wa ha magei evies may ieeewih paemakes a he meial evies. Bease mage heapy may iease he blfw i aeas whee mages ae plae, i is emmee ha hey be plae eaasemal meiai elivey pahes (eg. iie).89

A range o static magnetic devices are used or therapeutic purposes. These include bracelets, shoe insertsand pillows.90 Static magnets have an unchanging magnetic eld that has a unidirectional conguration andare available in dierent intensities, measured in gauss (G).91, 92 Magnets are either worn directly over theaected area or a specied period each day, or on the wrist to provide an eect on the entire body.92

There are many theories on how magnetic therapy may have an eect on pain, however, research onmagnetic therapy is hindered by the diculty in adequately blinding participants to the presence o magneticelds.90, 91 One theory suggests that magnets may increase blood fow through the skin and muscles; whileothers ocus on biological changes related to polarisation.91 Only one study provided evidence on theeectiveness o magnetic bracelets in treating OA.

Evience statement

One moderate quality RCT including 194 participants aged 4580 years with hip or knee OA, reported thatpain measured on the WOMAC scale rom hip and knee OA decreased by a small amount (mean dierencebetween standard strength and placebo or WOMAC pain scale was 1.3 points) when wearing standardstrength static bipolar magnetic bracelets compared to weak magnetic or non-magnetic dummy magnetsor 12 weeks. The mean dierence between standard and weak magnet groups was not signicant. T

clinical practice guidelines for the non-surgical management of hip and knee osteoarthritis

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