Knee osteoarthritis - Thinking beyond the joint - WordPress.com

Knee osteoarthritis: Thinking beyond the joint Drew Quinton, MPT, BHSc Physiotherapy Department, La Trobe University, Melbourne, Australia

Key Points • Knee osteoarthritis (OA) is a major cause of disability and pain in adults. While high-quality management guidelines exist for knee OA, recommendations are being poorly implemented in clinical practice (particularly first line management) • The influences on knee OA extend beyond the local joint, and the effects of erroneous language, such as ‘wear and tear’, need to be recognised • First line management, consisting of education, exercise and weight management, is safe and recommended for all adults with knee OA • Pharmacological, surgical and alternative treatment modalities are appropriate for some patients, but should be used as an adjunct to first line management

Introduction Osteoarthritis (OA) is one of the leading causes of musculoskeletal pain and disability amongst older adults, affecting approximately 10-15% of the total population.1-3 OA places a tremendous individual and socioeconomic burden through direct healthcare expenditure and decreased work force participation due to disability.1, 4, 5 The joint most frequently affected by OA is the knee, with an estimated prevalence of 3.8% of the population, or about one in 25 people.2, 3 With Australia’s current population, that equates to almost a million people living with knee OA. Multiple clinical guidelines for the management of knee OA exist with consensus on non-pharmacological first-line management involving education, exercise and weight management.6-9 These interventions have been shown to be safe and effective for reducing pain, increasing function and improving quality of life.10-12 Despite the recommendations of clinical guidelines, conservative management is underutilised by medical practitioners and allied health professionals13, 14 and rates of joint replacement surgery in Australia have increased.15 Research would suggest that there is uncertainty within the medical community about the benefits of conservative management,13 particularly exercise,16 suggesting that issues lie with the dissemination and implementation of recommendations, particularly in a primary care setting.10 Consequently, current management of knee OA is not optimising patient outcomes nor reducing unsustainable growth in healthcare expenditure.17 With the incidence of knee OA rising globally, due in part to increasing obesity and an ageing population,2 there are renewed calls for improved management of adults with knee OA through better implementation of clinical recommendations.13, 17 This review aims to summarise the recommendations, from conceptualisation to management, in an effort to improve adherence to guidelines and ultimately improve patient outcomes.

Thinking beyond the joint Traditionally, knee OA has been considered a localised joint disease, with local changes, symptoms and effects that are only amenable to surgical correction.18 Contemporary views consider knee OA as a whole body disease, that develops over decades, with top-down and bottom-up contributing factors.18 In some individuals knee OA can cause sleep disturbances, anxiety and depression as well as central sensitisation leading to chronic, widespread pain.13, 19-21 Psychosocial factors such as stress, pain catastrophising, fatigue, gender, ethnicity, and attitudes towards health can all alter an individual’s perception of pain and disability.22-24 It is clear that knee OA should not be viewed simply as a localised knee disorder but as a complex, chronic, multifactorial condition with psychological and social impacts.25 The majority of interventions targeting knee OA, including surgery, are primarily implemented to attenuate the effects of impairments such as pain, weakness or reduced range of movement (ROM). However, these interventions do not directly address activity and participation restrictions (Figure 1).26, 27 In order to properly address the factors that contribute to and are affected by knee OA, health practitioners must adopt a biopsychosocial model of management that looks beyond the local joint changes.25

It is NOT ‘wear and tear’ One of the important elements to consider when implementing a biopsychosocial approach is the language used by health professionals and the impact it has on patient’s beliefs. Knee OA has traditionally been referred to as a ‘degenerative’ condition caused by ‘wear and tear’ – a description that is still used today by many health professionals and health websites.12 It’s not uncommon for

Figure 1. The International Classification of Functioning, Disability and Health, by WHO 26

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Box 1. Messages that can harm patients with knee OA, inspired by O’Sullivan & Lin 30

Box 2. Messages that can heal patients with knee OA, inspired by O’Sullivan & Lin 30

Messages that promote beliefs about structural damage ‘It’s wear and tear/degeneration/arthritis’ ‘Your X-rays don’t look too good’ ‘Your knees are bone-on-bone’ ‘You have the knees of an 80-year-old’

Messages that promote a biopsychosocial approach to pain ‘Knee pain doesn’t mean your knees are being damaged – just that they are sensitised’ ‘The brain acts as an amplifier – the more you worry and think about your pain, the worse it gets’

Messages that promote fear and avoidance ‘You shouldn’t be running/playing sport’ ‘You need to take it easy from now on’ ‘You should stop if you feel pain’ ‘Let your pain guide you’

Messages that encourage physical activity ‘Exercise helps to strengthen the muscles around your knee, which stabilises the knee and reduces pain’ ‘Your knees are one of the strongest joints in the body’ ‘Joints like to keep moving – they get stiff and sore if they stay in the same place too long’

Messages that promote a negative future outlook ‘Your knees are going to get worse, they wear out as you get older” ‘You will probably need surgery soon’ ‘There is no cure’

individuals with knee OA to explain their own knees as being ‘worn out’ or ‘bone-on-bone’ – beliefs that have likely been created and perpetuated by the medical community. When viewing knee OA through a psychosocial lens, it is understandable that these terms may shape an individual’s beliefs towards their health, future prospects, as well as their attitudes towards physical activity and conservative management. Survey data shows that there is uncertainty in older adults about the benefits and safety of physical activity,28 and that adherence to physical exercise regimes is disappointingly low.29 If an individual believes that their knees are worn out due to years of use it is understandable that recommendations to increase physical activity may be met with resistance and scepticism.12 In an effort to improve adherence and optimise patient management health professionals must move towards descriptions of knee OA that empower self-management and encourage physical activity. Box 1 demonstrates messages that have the potential of causing negative health beliefs that could influence exercise adherence, whereas Box 2 contains language with the capacity to be beneficial for individuals with knee OA.30

Diagnosis Knee OA is clinically defined by cartilage degradation, joint inflammation, bone remodelling and loss of normal joint function.31 The diagnosis of knee OA can be acutely established without investigation by the presence of multiple signs and symptoms. Box 3 shows the diagnostic criteria for

Box 3. Osteoarthritis diagnosis, by NICE 6 Diagnose osteoarthritis clinically without investigations if a person: • is 45 or over and • has activity-related joint pain and • has either no morning joint-related stiffness or morning stiffness that lasts no longer than 30 minutes. Be aware that atypical features, such as a history of trauma, prolonged morning joint-related stiffness, rapid worsening of symptoms or the presence of a hot swollen joint, may indicate alternative or additional diagnoses. Important differential diagnoses include gout, other inflammatory arthritides (for example, rheumatoid arthritis), septic arthritis and malignancy (bone pain).

Messages that address concerns about imaging results and pain ‘The changes on your scans are normal – just like grey hairs and wrinkles – and don’t mean you need surgery’

OA by the National Institute for Health and Care Excellence (NICE).6 Three symptoms (persistent knee pain, short-lived morning stiffness, functional limitation) and three signs (crepitus, restricted movement, bony enlargement) can also be used to diagnose knee OA.32 If all six features are present in adults over the age of 45, there is a 99% probability of OA on imaging.32

Imaging Imaging is not required for the diagnosis of knee OA, however, it is still routinely ordered.14 Radiographic changes are not well correlated with pain or disability,33 and abnormalities on imaging may negatively impact an individual’s belief about their condition, especially if the results of imaging are poorly explained to the patient (consider Box 1). There are times when imaging is indicated and important for diagnosis and treatment. The European League Against Rheumatism (EULAR) propose seven recommendations for the use of imaging in the management of peripheral joint OA, presented in Box 4.34 Recommendations 1, 2, 3 and 6 are particularly applicable to health professionals considering referring a patient for imaging.

Risk factors Risk factors for the development of knee OA can also be used to aid in the diagnosis of knee OA and in screening of individual’s who may have an increased susceptibility of developing and progressing knee OA.2 Figure 2 shows a summary of the risk factors.2 Women are at a significantly higher risk of developing knee OA, and progressing to severe OA.35 Increased body mass is the largest modifiable risk factor for the development and progression of knee OA.36, 37 People who are obese are twice as likely to develop knee OA when compared to non-obese individuals.38 The link between knee OA and increased body mass is believed to be multifactorial, involving increased mechanical joint loading, decreased physical activity participation, and systemic inflammatory load driven by adipose tissue cytokine production.18, 39 Weight management is a core component of treatment and prevention of knee OA, and is explained in more detail later.

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Box 4. Imaging recommendations, by EULAR 34 1. Imaging is not required to make the diagnosis in patients with typical presentation of OA 2. In atypical presentations, imaging is recommended to help confirm the diagnosis of OA and/or make alternative or additional diagnoses 3. Routine imaging in OA follow-up is not recommended. However, imaging is recommended if there is unexpected rapid progression of symptoms or change in clinical characteristics to determine if this relates to OA severity or an additional diagnosis 4. If imaging is needed, conventional (plain) radiography should be used before other modalities. To make additional diagnoses, soft tissues are best imaged by US or MRI and bone by CT or MRI 5. Consideration of radiographic views is important for optimising detection of OA features; in particular for the knee, weight bearing and patellofemoral views are recommended 6. According to current evidence, imaging features do not predict non-surgical treatment response and imaging cannot be recommended for this purpose 7. The accuracy of intra-articular injection depends on the joint and on the skills of the practitioner and imaging may improve accuracy. Imaging is particularly recommended for joints that are difficult to access due to factors including site (eg, hip), degree of deformity and obesity

Age is the greatest determinant of knee OA. The exact mechanism by which age affects OA is poorly understood, with a decreased capacity for joints to adapt to biomechanical insult, coupled with an increased rate of bone turnover likely to be contributing factors.2 Joint injury is an important and preventable risk factor for knee OA.18 50% of individuals who sustain an anterior cruciate ligament (ACL) rupture will develop radiographically detectable knee OA within 10-15 years of injury.18 Occupations involving repetitive joint use, particularly kneeling and squatting, as well as elite athletes involved in high-impact sports are at a higher risk of developing knee OA,2 although the precise causative mechanism is unclear.40 Knee injury sustained during high impact athletic activities or repetitive occupations may account for the increased risk of developing knee OA.2

Joint and compartment involvement The knee joint is comprised of the tibiofemoral (TF) and patellofemoral (PF) joints, both of which have medial and lateral compartments. Knee OA can occur in an isolated compartment, or across multiple compartments and joints concurrently.41 The lateral compartment is more severely affected in the PF joint,42 and the medial compartment is more commonly affected in the TF joint.43 The majority of knee OA research and treatment guidelines focuses on TF OA, however recent studies have found PF OA highly prevalent and a significant cause of pain and disability.44 It is estimated that approximately half of individuals with knee OA have PF involvement.44 Diagnosis of joint involvement for research purposes is made via imaging, but as explored previously, imaging is not required for the diagnosis of typical knee OA in a clinical setting. Currently there is no well-established clinical diagnostic tools for the differentiation of PF or TF knee OA.41 Anterior (patella) knee pain during weight-bearing activities,

such as climbing stairs, and crepitus felt over the patella have been linked to PF knee OA.41 Although the general management of knee OA is similar between PF and TF, determining joint and compartment involvement is important when tailoring exercise programs and when considering second line biomechanical aids.

Assessment It is important to be holistic when assessing knee OA, evaluating the individual’s function, quality of life, occupation, mood, relationships, leisure activities and the impact that knee OA has on these activities.6 Knee OA can present with a range of physical impairments, including muscle weakness, decreased ROM, reduced balance, altered proprioception and gait abnormalities.13 Impairment-based assessment can be used to determine deficits and track progression but do not provide a detailed representation of function. Osteoarthritis Research Society International (OARSI) recommends the use of five performance-based tests to assess the physical function of adults with knee and hip OA45: • 30-second chair stand test • 40m fast-paced walking test • Stair climb test • 6-minute walk test • Timed up and go test Full description of the performance-based tests can be found in the additional resources section at the end of this article. The use of questionnaires such as the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)46 and Knee injury and Osteoarthritis Outcome Score (KOOS)47 can be used to quantify the level of pain and disability experienced by individuals with knee OA, as well as used to monitor the progress and efficacy of conservative treatment. Links to the WOMAC and KOOS are available in the additional resources section. Observation is required to determine the alignment of the knee and the presences of varus or valgus knee malalignment. It is unclear whether knee malalignment is a risk factor for the initial development of knee OA or a marker of disease severity.48, 49 Malalignment is, however, a risk factor for increased rate of disease progression.2 Alignment variances in knee OA are believed to be caused by cartilage loss, bone attrition, meniscal degradation and ligamentous damage.50 It is worth noting that there is no evidence to suggest that correction of malalignment can slow disease progression.2

Figure 2. Potential risk factors for susceptibility to OA incidence, by Johnson & Hunter 2

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First line management Education and advice The first, and arguably one of the most important, steps in managing knee OA is education, advice and shared decision making between the therapist and the patient. In order for information to be successfully received, the patient’s own beliefs and attitudes need to be assessed so that potentially maladaptive health beliefs are adequately corrected.25 Figure 3 provides a theoretical framework of aligning the beliefs of therapists and patients in order for treatment to be successful.25 Education must include an explanation of knee OA, bearing in mind the impact that the language used can have on a patient. The benefits of conservative management needs to be explained to the patient, including a regular exercise regime, weight loss and pacing strategies.9 There is uncertainty in older adults about the benefits and potential harms of exercise,28, 29 and this especially needs to be addressed. Arthritis Australia has produced a number of highquality handouts for adults affected by OA, including a twopage summary and a detailed 32-page booklet. Both of these resources are suitable to supplement and reinforce the information provided to patients from health professional. Links to both handouts are available in the additional resources section. Self-management strategies are recommended for adults with knee OA9 in order to encourage adults with chronic diseases to take an active role in the management of their own condition.51 However, self-management programmes in isolation have failed to demonstrate a large effect on pain or function in clinical trials.51 It is important to incorporate a modern, biopsychosocial approach to pain education, with an emphasis on the concept that pain does not equal harm, and therefore knee pain with exercise doesn’t mean structural damage or disease progression.25 Regardless of the recommendations given to patients, they must be tailored to fit the individual’s needs through shared decision making.13 Adherence to exercise, and the benefit it brings, declines over time.13 A survey of physical therapists found that they believed adherence to exercise recommendations was the responsibility of the patient, and not the therapist.16 Exercise for adults with knee OA needs to move away from a prescriptive model and towards one that focuses on adherence; identifying barriers and facilitators to exercise and improving individual participation.13 Adherence needs to be seen as a goal in which patient and therapist collaborate to achieve.16

Figure 3. Five-step approach to aligning beliefs between therapists (T) and patients (P), by Nijs et al.25

Aerobic exercise Physical activity is safe and recommended for all adults with knee OA, irrespective of disease severity.6-13 Box 5 by Bennell et al.52 provides practical exercise prescription tips. Physical activity reduces pain, and improves physical function and quality of life in the short-term for individuals with knee OA,11, 13 including those with severe OA awaiting surgery.53 The benefits of aerobic exercise in all adults is well established. WHO recommends at least 150 minutes of moderate-intensity aerobic physical activity throughout the week in adults over 65 years.54 A systematic review found that adults with knee OA do not meet sufficient levels of physical activity55 and are at a higher risk of mortality and morbidity due to cardiovascular causes.56 A variety of exercise types have been shown to be effective, with limited comparisons between exercise types.13, 57 Exercise should be selected based on patient-preference in order to enhance adherence.13 Reduced weight bearing exercises, such as cycling or aquatic therapy, may be beneficial to those who are overweight or with severe disease progression.52 A study found that adults with severe knee OA could tolerate up to 70 minutes of moderate intensity walking per week without exacerbation of knee pain58. A 12-week program at this intensity did not significantly improve pain, however may have led to improved cardiovascular health.56 This would suggest that 70 minutes of moderate intensity walking per week is a safe and well tolerated starting dose, but a graded exercise dose increasing towards the recommended 150 minutes per week may be more beneficial for pain and cardiovascular health. Individual, group and home-based exercise have all been shown to be effective, with individual supervised exercise shown to have the largest positive effect.11 Twelve or more face-to-face supervised contacts were more effective for pain and physical function compared to fewer than twelve.11 Patients need to be advised that exercise may cause some discomfort or pain, which is normal.13 Reiteration that hurt does not equal harm is advised.

Strengthening exercises Muscle weakness, particularly of the quadriceps muscles, is a risk factor for the development of knee OA, and is common in people with knee OA.59 It has been suggested that muscles provide dynamic support to the knee, and reductions in strength may modify movement biomechanics, alter articular tissue loading, and thereby playing a role in initiation and progression of knee OA.11 Improving muscle strength has been suggested as a method for reducing the risk of developing knee OA, and may be protective against knee injury.18, 60 Whether strengthening exercises in adults with knee OA can influence disease progression is still yet to be fully understood.59, 60 Lower limb strengthening exercises have been shown to reduce pain and improve function, however there is little comparative data to suggest one method is better than another.11, 61 A systematic review found strengthening exercises with or without weight-bearing improved outcomes, although non-weight-bearing showed greater improvements.61 An example of a lower limb strengthening program involving weight-bearing and non-weight-bearing exercises is available in the additional resources section.62

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Some clinical guidelines specifically recommend strengthening of lower limb muscles, particularly the quadriceps, however no specific exercise program is recommended.6-9 A combination of aerobic exercises and broad lower limb strengthening exercises is recommended.52 One specific protocol for the conservative treatment of knee OA is involves neuromuscular exercise. Neuromuscular exercise aims to improve sensorimotor control and functional stability, with an emphasis on quality, efficiency and alignment of movement.63-65 An example of a neuromuscular exercise training program lasting for 60 minutes with exercise progressions is included in the additional resources section.65 Neuromuscular exercises are included in a recently developed comprehensive knee and hip OA management program – Good Life with osteoarthritis in Denmark (GLA:D). GLA:D is a program run by physiotherapists which implements a multi-modal treatment plan including comprehensive patient education followed by 12 sessions of supervised neuromuscular exercise classes, and has shown significant improvements in patient outcomes.66, 67 GLA:D has been expanded to Australia and is provided at 30 locations nationwide, offering services to the public without a medical referral required. A link to GLA:D Australia can be found in the additional resources section.

Weight management Increased body mass increases the risk of developing knee OA,36, 37 increased progression of knee OA radiographically,2 increased level of knee pain experienced (with severity of joint changes controlled),68 and an increased rate of joint replacement surgery.69 Weight management is an incredibly important area of intervention in adults with knee OA who are overweight, and is supported by multiple clinical guidelines.6, 8, 9 A reduction of ≥7.7% of body weight has been suggested as the minimal clinically important change required to improve physical function,70 with the goal of 10% loss suggested as a cornerstone in the management of overweight individuals with OA.39 If overweight individuals reduced their weight by 5kg, 24% of surgical knee replacement might be avoided.71 A combination of diet and exercise has been shown to lead to the greatest reduction of body weight and improvements in pain and disability scores (Figure 4).72 Health professionals not comfortable with diet and weight loss recommendations should ensure the patient is referred to an appropriate service.

Figure 4. Effects of diet, exercise and combined diet + exercise on knee pain (via WOMAC questionnaire), by Messier et al.72

Box 5. Practical Exercise Prescription for Patients with Knee OA, by Bennell et al.52 • • • •

• • • • •

• •

• •

As similar reductions in pain and improvements in function can be gained with various types of exercise, the patient should choose the type of exercise they prefer 
 An exercise programme to improve muscle strength, aerobic capacity and flexibility is recommended 
 Strengthening exercises should target major lower limb muscles such as the quadriceps, hip abductors and extensors, hamstrings and gastrocnemius 
 Aerobic exercise such as walking can also assist in weight loss/prevention of weight gain and in improving mood and anxiety 
 Aquatic exercise may be beneficial for those who are overweight/obese or those with more severe disease 
 Tai chi may be a useful exercise option for some 
 Balance exercises should be included if assessment reveals balance impairments or if the patient has a history of falls 
 Increasing overall general physical activity levels during everyday life is important in addition to structured exercise Treatment benefits in terms of reduced pain and improved function can be gained from individual, class-based and
home-based programmes 
 Although individual treatments show the greatest treatment benefits for pain and function, superiority of one delivery mode over the other remains unclear 
 Group exercise and home exercise are similarly effective and patient preference should be considered in the decisionmaking process of preferred delivery mode 
 Home-based programmes can be supplemented with supervised programmes (class or individual) to maximize the cost-effective benefits 
 Discomfort or pain during exercise is to be expected. However, severe or intense pain during exercise, pain that does not subside to usual levels within a few hours after exercise, increased night pain following exercise, or swelling or increased swelling in the hours following exercise or the next morning indicate that the type or dosage of exercise needs to be modified

Second line management Pharmacological management Many clinical guidelines endorse pharmacological interventions for knee OA, the majority of which recommend paracetamol (acetaminophen) as the first-line analgesia.6-8, 10 Recent reviews have questioned paracetamol’s efficacy, finding only small effects on pain that are unlikely to be clinically meaningful, calling for reconsideration of the use of paracetamol in knee OA. 73-75 Oral nonsteroidal anti-inflammatory drugs (NSAIDs) are also recommended as a first line pharmacological treatment option for knee OA, however their potential for causing adverse effects, including death, are well documented.76 It’s worth noting that the magnitude of effect that NSAIDs have on pain and function is similar to that of exercise.77 NSAIDs should be used in conjunction with first line non-pharmacological management, not an alternative.78 A recent systematic review found that diclofenac 150mg/day is the most effective NSAID for improving pain and function,75 however given the potential side effects of NSAIDs, patients should consult with their GP or pharmacist

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before starting medications. Advising patients on taking pain relief 15-20 minutes before exercise may reduce discomfort and improve quality of activity.13 Opioid use in the treatment of OA has also come under question recently. Opioids have a well-established risk of respiratory depression, dependence, abuse, and are a leading cause of death due to overdose.79, 80 The benefits of opioids on pain and function for people with OA appear minimal, and may not outweigh the risk of adverse events.76, 81 Chronic opioid use before total knee replacement increases the risk of complications and prolonged painful recovery postoperatively.82 It has been recommended that if opioids are to be considered at all, it should only be prescribed on a shortterm basis, with clear goals and regular reviews of treatment response.17 Topical therapies, including topical NSAIDs and topical capsaicin, can be used as an alternative to oral medications, particularly if the patient has precluding comorbidities.8, 76 Topical therapies are recommended for knee only OA, with their benefits less clear for multi-joint OA. Topical diclofenac (NSAID) showed similar benefits for pain and functions when compared to oral diclofenac, with significantly less serious systemic adverse effects.83 Topical capsaicin reduced knee OA pain by 50% compared to placebo.8 Topical therapies have the potential of causing local adverse reactions, such as rash, burning and itching.76 Intra-articular corticosteroids can provide 1-2 weeks of pain relief and improved function, however repeated use can cause cartilage and joint damage, and increase the risk of infection.76, 84 Intra-articular corticosteroids may be useful for acute exacerbations of knee pain, with local joint effusion and inflammation,76 however repeated use is discouraged.17 Duloxetine is a serotonin-norepinephrine reuptake inhibitor (SNRI) used to treat depression, anxiety, fibromyalgia, neuropathic pain and chronic musculoskeletal pain.85 As previously explored, knee OA can lead to widespread pain and depression. Duloxetine may be appropriate for such patients, and can be used in conjunction with other pain relief medications to improve pain and function.76 Multiple dietary supplements for the treatment of OA are available, most notably glucosamine and chondroitin. A recent review of 20 supplements, including glucosamine and chondroitin, found that none of the supplements had clinically important effects on pain and function at medium-term and long-term follow-ups.86 The review concluded that they were unable to recommend most widely used supplements, including glucosamine or chondroitin, based on current evidence.86 A short-term benefit was found in Boswellia serrata extract, pycnogenol and curcumin, and these supplements may be cautiously considered over a short period for patients who are very enthusiastic about taking supplements.86 The review was unable to find any high quality trials of fish oil, and its use in OA is currently not recommended.76, 86 A summary of management options that should be recommended (green), used judiciously (orange) and discouraged (red) are seen in Figure 5.17 All allied health professionals should be aware of the medications that a patient is taking, the potential adverse effects and precautions of medications, and the confidence to flag any possible misuse of medication in order to facilitate a cohesive multidisciplinary team approach.

Figure 5. Standards to aim for (green box) in the management of OA and practices that should be limited (orange box) or discouraged (red box), by Hunter & Bowden 17

Gait aids The use of a cane (single point stick, walking stick) on the contralateral side can reduce pain and improve function in patients with OA of just one knee.8, 9, 87 The use of a cane reduces the compression and adduction moment action upon the knee.43 The benefits of a cane are improved when it is placed at a greater distance laterally, and body weight is put through the cane earlier in stance phase of the affected leg.52 The benefits of a cane are less clear when multiple joints are affected by OA, as the use of the gait aid may increase loading of the contralateral hand and hip, and which may not be appropriate for some patients.8 Some clinical guidelines also recommend the use of walking frames and ‘wheelie walkers’ where appropriate.9 This would be particularly appropriate for patients with balance deficits and recurrent falls.

Biomechanical aids Biomechanical aids consist of devices that can alter the alignment and subsequent mechanical tissue loading of the knee in an effort to reduce pain, improve function and potentially alter disease progression.43 As biomechanical aids aim to correct biomechanical deficits, they need to be tailored to the individual’s presentation. Valgus braces and lateral wedge shoe insoles (orthoses) aim to decreased loading of the medial compartment of the tibiofemoral joint.88 Biomechanical studies have found that they decrease knee adduction moment, however this has not translated into clinical improvements in pain or function.52, 88 A recent review found that lateral wedge insoles appear ineffective at attenuating structural changes in people with medial knee OA.89 The use of lateral wedge insoles have been rejected by one clinical guideline due to their lack of clinical effectiveness.9 Appropriate and comfortable shoes are recommended for patients with knee OA,9 yet there is little evidence for what shoes are appropriate for adults with knee OA.90 Patella bracing and taping has been suggested for PF OA with the aim of improving patella alignment.41 There is a lack of high quality evidence for the use of patella taping or

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bracing in PF OA, with preliminary results suggesting it may lead to reductions in pain and improvements in function.41 A training video for patella taping is available in the additional resources section. Soft knee braces, made out of neoprene or elastic materials, do not have the ability to alter knee alignment, and are therefore not a biomechanical aid, however, they appear to have a moderate effect on pain and physical function.91 The mechanism behind their action is largely unknown, with increased proprioception, increased muscle activity, compression, heat and a placebo effect all suggested possibilities.91

Complimentary modalities Cochrane reviews into acupuncture for peripheral joint OA,92 and transcutaneous electrical nerve stimulation (TENS) for knee OA93 failed to find compelling evidence for their respective use, prompting uncertain use by clinical guidelines.8 There is also limited evidence for the effectiveness of thermotherapies (eg, ice packs, heat pack), but they may provide symptomatic relief for patients, particularly ice packs for reducing swelling.94, 95 Patient preference needs to be factored into the decisionmaking process. Complimentary modalities may be appropriate if the patient feels they are beneficial, if they increase exercise participation, and if they have minimal costs and risk associated with their use.

Third line management Surgery Total knee replacement (arthroplasty) is a commonly performed procedure used to treat end-stage knee OA in patients who are not obtaining adequate pain relief and functional improvements from first and second line treatments.95 Total joint replacement is considered an effective treatment, with larger improvements in pain, function and quality of life compared to conservative management, but comes with an increased risk of adverse events.96 A large cohort study in the USA found that joint replacement had a minimal effect on quality of life, and suggested that the procedure would be more effective if it was restricted to more severely affected patients.97 Evidence would also suggest that joint replacement does not greatly improve physical activity, despite improvements in pain and physical function, suggesting that joint replacement is unlikely to change sedentary behaviour.98 Joint replacement

Fig 6. Lifetime risk of revision after total knee replacement, by Bayliss et al.100

Figure 7. The OA treatment pyramid, by Roos & Juhl 78

can lead to post-operative persistent pain, with one study finding that 44% of patients had persistent pain 3-4 years after joint replacement of any severity, with 15% reporting severeextreme persistent pain.99 Multiple patient characteristics, beyond OA severity and pain, need to be examined when considering joint replacement. Age is a significant factor in predicting the likelihood of having to undergo revision surgery. The lifetime risk of requiring revision surgery for a patient over the age of 70 years is about 5%, however the risk increases up to 35% for those under the age of 70 years (Figure 6).100 These results are likely to reflect the fact that younger joint replacement recipients live longer and more active lives than their older counterparts, increasing the likelihood of prosthesis failure. Obesity has a negative impact on joint replacement outcomes, increasing the risk of infection and revision.101 Preoperative functional limitation, diabetes, chronic and/or severe pain, chronic opioid use, low mental health score and depression/anxiety are all associated with an increased risk of poor surgical outcomes.82, 102, 103 In patients with OA affecting a single compartment of the TF joint, unicompartmental knee replacement is an effective alternative to total joint replacement.95 Osteotomy involves removing a wedge shape piece of bone in the tibia to improve varus malalignment. Osteotomy may offer an alternative that can delay joint replacement up to 10 years, particularly for young and physically active patients.95 Osteotomy reduces pain and improves function, but there is a lack of evidence comparing it to alternative surgical and non-surgical management techniques.104 There is high quality evidence to suggest that arthroscopic debridement and lavage for knee OA do not provide any improvements in pain and function compared to sham surgery.95, 105, 106

Embracing technology In an effort to improve long-term patient adherence to conservative management of knee OA, new approaches to delivering healthcare have been proposed. MyJointPain is an Australian website that has been created by Arthritis Australia and medical experts to disseminate evidence-based health information about OA directly to people affected by the disease.107 Web-based health information and management resources may improve patients outcomes, however preliminary results suggest the effects are small.107 Another proposed method is the use of telephone or internet delivered consultations. Surveys suggest adults with

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hip and/or knee OA are mostly receptive to the idea of remote exercise therapy delivered by physical therapists,108 however physical therapists are concerned with the lack of physical contact.109 A limited number of trials have been conducted into remotely delivered interventions for OA, examining modalities such as telephone consultation,110 interactive online self-management programs made specifically for OA111 and video-delivered exercise coaching by a physiotherapist112 – all of which have demonstrated promising initial results. Remotely delivered interventions have the potential to improve access and cost-effectiveness of management for adults with OA, and are a promising new area of innovation.

References 1. 2. 3. 4. 5. 6. 7.

8.

Conclusion Knee OA is a complex condition with effects that extend beyond the joint. Management of knee OA requires a biopsychosocial approach, with careful use of language to avoid negatively impacting health beliefs. Education, exercise and weight management are safe and appropriate for all adults with knee OA (Figure 7), although they are often underutilised. Second and third line management, including pharmacological therapies and surgery, are appropriate for some, but not all, patients and should be used judiciously.

9. 10.

11. 12. 13. 14. 15. 16.

Additional resources

17.

1. OARSI performance-based testing https://goo.gl/yJs1wU

19.

18.

20.

2. WOMAC Questionnaire https://goo.gl/yk7NWC 3. KOOS Questionnaire https://goo.gl/Be5xH1 4. Osteoarthritis information sheet (two-pages) https://goo.gl/xvsBp1 5. Taking control of your Osteoarthritis (32-page booklet) https://goo.gl/LWwfwu 6. Lower limb strengthening exercises, eTable 1 https://goo.gl/eV464c 7. Neuromuscular exercise training program https://goo.gl/vDrBfe

21. 22. 23.

24. 25. 26.

27. 28. 29.

8. GLA:D Australia https://goo.gl/kHLBkz 9. Patella taping for knee OA https://goo.gl/xPPaVh Drew Quinton is a Master of Physiotherapy Practice and Bachelor of Health Science, Human Anatomy and Physiology major, graduate of La Trobe University, Melbourne, Australia. This article was created and submitted as part of the ‘Professional Evaluation and Exchange of Knowledge’ (PEEK) project completed in 2017. Email: [email protected]

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