Non-surgical management of hip and knee osteoarthritis guidelines
Osteoarthritis is the most common reason for total hip and total knee replacement. Osteoarthritis is a type of arthritis that is caused by breakdown of cartilage with eventual loss of the cartilage of the joints. Cartilage is a protein substance that serves as a "cushion" between the bones of the joints. Osteoarthritis is also known as degenerative arthritis. Before age 45, osteoarthritis occurs more frequently in males. After age 55 years, it occurs more frequently in females.
Osteoarthritis usually affects the hands, feet, spine, and large weight-bearing joints, such as the hips and knees. Most cases of osteoarthritis have no known cause, and are called primary osteoarthritis. When the cause of the osteoarthritis is known, the condition is called secondary osteoarthritis.
The Department of Veterans Affairs and the Department of Defence have published clinical guidelines on 'Non-Surgical Management of Hip and Knee Osteoarthritis.' Following are its major recommendations.
Module A: Diagnosis and Evaluation
History and Physical Examination
Recommendation
- Clinicians should conduct a history and physical examination for all patients, with an emphasis on the musculoskeletal examination. [EO]
Plain Radiography
Recommendation
- Clinicians may use plain radiography to confirm the clinical diagnosis of hip and knee OA. [C]
Magnetic Resonance Imaging (MRI)
Recommendation
- Clinicians should not use MRI as an evaluative tool to diagnose, confirm, or manage the treatment of OA. [D]
Routine Use of Laboratories and Synovial Fluid Analysis
Recommendation
- Clinicians should avoid routine use of laboratory examinations or synovial fluid analysis to diagnose OA of the hip and/or knee. [EO]
Module B: Core Non-surgical Treatment Principles
Patient Education
Recommendation
- The decision to prescribe any intervention should be based on consideration of assessment findings, risk vs. benefit analysis, pain severity, functional status, patient preference, and resource utilization. [EO]
Comprehensive Management Plan
Recommendations
- For patients with OA of the hip and/or knee, clinicians should attempt the core non-surgical therapies prior to referral for surgery. [C]
- For patients with OA of the hip and/or knee, clinicians should refer for physical therapist services early on, as part of a comprehensive management plan. [B]
Weight Reduction in Patients with Knee or Hip OA and Elevated Body Mass Index (BMI)
Recommendations
- Clinicians should refer overweight or obese patients (defined by a BMI >25 kg/m2) with OA of the knee to a weight management program to lose a minimum of five percent body weight and maintain this new level of weight. [C]
- Clinicians should refer overweight or obese patients (defined by a BMI >25 kg/m2) with OA of the hip to a weight management program to lose a minimum of five percent body weight and maintain this new level of weight. [EO]
Module C: Physical Therapy Approaches
Manual Physical Therapy
Recommendations
- For patients with OA of the knee, the addition of manual physical therapy as an adjunct to traditional physical therapy and supervised exercise can improve pain, function, and walking distance. [B]
- For patients with OA of the hip, the addition of manual physical therapy as an adjunct to traditional physical therapy and supervised exercise can improve pain, function, and range of motion. [B]
Aquatic Therapy
Recommendation
- For adults with OA of the knee who do not tolerate land-based therapeutic exercise, clinicians should consider adjunctive aquatic physical therapy. [C]
Walking Aids
Recommendation
- For patients with OA of the knee or hip, the prescription and training of ambulation or walking aids should be carried out by a physical therapist or the referring provider. [EO]
Module D: Pharmacologic Therapies
Acetaminophen and Non-steroidal Anti-inflammatory Drugs (NSAIDs)
Recommendations
- In patients with no contraindications to pharmacologic therapy, clinicians should consider acetaminophen or oral NSAIDs as first line treatment. [B]
- Clinicians should ensure that patients receive no more than four grams of acetaminophen daily from all sources of prescribed and non-prescribed medications. [A]
- In patients requiring treatment with oral NSAIDs and who are at high risk for serious adverse upper gastrointestinal (GI) events, clinicians should consider the addition of a proton-pump inhibitor (PPI) or misoprostol. [A]
- Clinicians should consider the balance of benefit and potential harm in prescribing oral NSAIDs in patients at risk for or with known cardiovascular disease or renal injury/disease. [B]
Topical Capsaicin
Recommendations
- In patients with mild to moderate pain associated with OA of the knee, topical capsaicin can be considered as first line therapy or adjunctive therapy. [C]
- There is insufficient evidence to recommend the use of topical capsaicin for the hip as first line or adjunctive therapy. [I]
Other Pain Management Pharmacotherapies
Recommendations
- For patients with persistent moderate or moderately severe OA pain, clinicians may offer duloxetine or tramadol as an alternative or adjunct to oral NSAIDs. [B]
- For patients with persistent severe OA pain who have contraindications, inadequate response, or intolerable adverse effects with non-opioid therapies and tramadol, clinicians may consider prescribing non-tramadol opioids. [C]
Intra-articular Injections (Corticosteroids and Hyaluronic Acid)
Recommendations
- For patients with symptomatic OA of the knee, clinicians may consider intra-articular corticosteroid injection. [C]
- There is insufficient evidence to recommend for or against the use of intra-articular hyaluronate/hylan injection in patients with OA of the knee; however it may be considered for patients who have not responded adequately to nonpharmacologic measures and who have an inadequate response, intolerable adverse events, or contraindications to other pharmacologic therapies. [I]
- For patients with moderate to severe OA of the hip, clinicians may consider imaging/ultrasound directed corticosteroid injection to reduce pain. [C]
- Intra-articular injection of hyaluronate/hylan is not recommended for patients with symptomatic OA of the hip. [EO]
Module E: Complementary and Alternative Medicine
Nutritional Supplements/Nutraceuticals/Dietary Supplements
Recommendations
- In patients with hip and/or knee OA, there is insufficient evidence to recommend for or against the use of dietary supplements for relief of pain and improved function. [I]
- In patients with hip and/or knee OA, clinicians should not prescribe chondroitin sulfate, glucosamine, and/or any combination of the two, to treat joint pain or improve function. [D]
Acupuncture and Chiropractic Care
Recommendation
- In patients with hip and/or knee OA, there is insufficient evidence to recommend for or against referral for short term trial of needle acupuncture or chiropractic therapy for relief of pain and improved function. [I]
Module F. Referrals for Surgical Consultation
Recommendations
- For patients with OA of the hip and/or knee, who experience joint symptoms (such as pain, stiffness, and reduced function) with substantial impact on their quality of life (individualized based upon patient assessment), and who have not benefited from the core non-surgical therapies, clinicians may offer referral for joint replacement surgery. [B]
- In patients with OA of the hip and/or knee considered for surgical consultations, clinicians should obtain weight-bearing plain radiographs within 6 months prior to the referral to surgical consultation. [B]
- In candidates for joint replacement of the hip and/or knee, joint injections should not be given into the involved joint if surgery is anticipated within three months. [EO]
To read the complete guideline click on the following link:
http://www.healthquality.va.gov/guidelines/CD/OA/VADoDOACPGFINAL090214.pdf
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