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SMF Treatment & Referral GuidelineKnee Osteoarthritis 

March, 2012

Introduction………………………………………………………………………………….Page 2

Diagnosis…………………………………………………………………………………….Page 2

Prognosis…………………………………………………………………………………….Page 2

Interventions – Therapeutic Exercise…….………………………………………………….Page 2

Interventions – Manual Therapy…………………………………………………………….Page 2

Interventions- Electrical Stimulation…….………………………………………………….Page 3

Interventions- Ultrasound…………….….…………………………………………….…….Page 3

Interventions- Bracing…….…………………………………………………………...…….Page 3

Interventions- Insoles…………………………………………………………………..……Page 3

Interventions-Taping………………………………………………………………………...Page 3

                 

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Sutter Physical Therapy Clinical Guidelines  Knee Osteoarthritis Summary of Recommendations

Introduction Patients with symptomatic hip and knee OA may benefit from referral to a physical therapist for evaluation and instruction in appropriate exercises to reduce pain and improve functional capacity. This evaluation may result in provision of assistive devices as appropriate. Referral to a physical therapist was strongly recommended by 100% of the expert panel and 5/5 existing guidelines where referral to physiotherapy was considered. SOR: 89% (95% CI 82-96) (Zhang, et al., 2007)

The bold letter to the left of the heading represents the strength of the evidence presented. A table at the bottom of this document identifies the definition of this letter.

B Diagnosis-Recent recommendations suggest the following findings improve the likelihood of a patient presenting with knee OA: Persistent knee pain (+LR 1.67), Morning stiffness (+ LR1.84), Impaired function (+LR 1.50), Crepitus (+LR 2.23), Restricted movement (+LR 4.4), and Bony Enlargement (+LR 11.81). The likelihood of knee OA diagnosis increases with the clustering of these 6 signs and symptoms. (Zhang W. , 2010)

B Prognosis-There is moderate evidence that basic clinical findings can aide clinicians predicting the likelihood of knee OA progression. The following factors have strong evidence for knee OA progression: older age, presence of OA in multiple joints, and varus deformity measured via radiograph. Higher BMI is a strong predictor of knee OA progression over time (> 3 years). Physical activity or moderate participation in sports is not significantly associated with knee OA progression (strong evidence). (Chapple & Nicholson, 2011)

A Interventions- Therapeutic Exercise There is strong evidence that both strengthening and aerobic exercise can reduce pain and improve function in patients with knee OA (Jamtvedt, Dahm, Christie, Moe, Holm, & Hagen, 2008) (Ottowa, 2005) (Zhang, et al., 2007). To be effective, exercise programs should include advice and education to promote a positive lifestyle change with an increase in physical activity (Roddy, et al., 2005). There is high quality evidence for the use of exercise and weight reduction to reduce pain and improve function in patients with knee OA (Jamtvedt, Dahm, Christie, Moe, Holm, & Hagen, 2008) (Zhang, et al., 2007)

B Interventions- Manual Therapy Clinicians should consider using manual therapy interventions for the knee to improve pain and function. There is moderate evidence to support the use of a multimodal approach to management of knee OA for improving pain and function (WOMAC scores). Combining manual therapy interventions to the knees, hips, lumbar spine, and ankle/foot with exercise is effective for reducing pain in the short and long term. There is weak evidence for the use of manual therapy alone for the treatment of knee OA. (Currier, J, Carrow, & al., 2007), (Deyle, Henderson, & Matekel, Effectiveness of Manual Physical Therapy and Exercise in Osteoarthritis of the Knee: A Randomized, Controlled Trial, 2000), (Deyle,

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Allison, & Matekel, 2005) (Cliborne, Wainner, & Rhon, 2004) (French, Brennan, White, & Cusack, 2011) (Ottowa, 2005) (Jansen, Veichtbauer, Lenssen, Hendricks, & de Bie, 2011)

C Interventions- Electrical Stimulation There is weak evidence to support the use of transcutaneous electrical nerve stimulation (TENS) for pain relief in patients with knee OA. Systematic reviews indicate TENS has demonstrated short term (< 4 weeks) pain relief as measured by visual analogue scale. There is moderate evidence to support the use of TENS for short-term and long-term pain relief, with high-intensity burst modes and AL-TENS being the most effective. Therapists should consider there is limited evidence for the long term benefit of TENS and pain relief and improved function for knee OA. (Philadelphia, 2001) (Fitzgeral & Oatis, 2004) (Jamtvedt, Dahm, Christie, Moe, Holm, & Hagen, 2008) (Bjordal & Johnson, 2007) (Zhang, et al., 2007)

D Interventions- Ultrasound There is conflicting evidence regarding the benefits of ultrasound (US) for the management of patients with knee OA. Therapists must consider this conflicting evidence, low powered studies, and lack of evidence for long term benefit when considering use of US for knee OA patients. The use of ultrasound therapy has been found to be effective for decreasing pain in patients with knee OA in the short term (2-4 weeks). Pulsed US appears to be the most effective form of delivery for short term pain relief. (Loyola-Sanchez, Richardson, & MacIntyre, 2010) (Tascioglu & Kuzgun, 2010) (Rutjes & Neusch, 2010) (Philadelphia, 2001)

C Interventions- Bracing Clinicians may consider using bracing interventions for the knee to improve pain and function. There is weak evidence to support the use of bracing for knee OA for improving pain and function. (Brouwer, Van Raaij, Raja, Warden, Pollo)

D Interventions- Insoles Clinicians may consider using wedged insole interventions for the knee to improve pain and function. There are conflicting results from well-designed studies in the literature. The studies examined medially wedged insoles for management of valgus deformity and laterally wedged insoles with subtalar strapping for management of varus deformity. (Baker, Brouwer, Kuroyanagi, Toda, Bennell, Raja, Van Raaij)

B Interventions-Taping Clinicians should consider using patellar taping interventions for the knee to improve pain and function. There is moderate evidence to support the use of patellar taping in patients with patellofemoral OA. The tape should medially glide and correct lateral and anterior to posterior tilt of the patella with two pieces of tape with resultant unloading of the infrapatellar fat pad. (Warden, Crossley, Hinman x2, Hunter)

The level of evidence and strength of the recommendation used to support this guideline is based on the guidelines developed by Guyatt et al. (Guyatt, Rennie, Meade, & Cook, 2008) The strength of evidence system used has also been used in clinical practice guidelines developed for physical therapy practice for neck pain (Childs, Cleland, & Elliot, 2008). Table 1 below defines the level of evidence and Table 2 the strength of evidence for each guideline.

             

  

            

  

   

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Table 1 : Level of Evidence

Table 2: Strength of Evidence

APPROVAL:

_________________________________ March 14, 2012 _____________________ SMF Medical Director Date

Approval/Revision Summary: SMF QM/UM Committee Date: _03/14/2012___________________ SPA Steering Committee Date: FYI Only

   

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Works Cited Bjordal, J., & Johnson, M. (2007). Short-term efficacy of physical interventions in osteoarthritic knee

pain. A systematic review and meta-analysis of randomised placebo-controlled trials. BMC Musculoskeletal Disorders, 51-65.

Chapple, C., & Nicholson, H. (2011). Patient characteristics that predict progression of knee osteoarthritis: A systematic review of prognostic studies. Arthritis Care & Research, 1-43.

Childs, J. D., Cleland, J. A., & Elliot, J. M. (2008). Neck Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Diability, and Health From the Orthopedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther, A1-A34.

Cliborne, A. V., Wainner, R. S., & Rhon, D. L. (2004). Clinical Hip tests and a Functional Squat Test in Patients with Knee Osteoarthritis: Reliability, Prevelance of Positive Test Findings, and Short-Term Response to Hip Mobilization. J Orthop Sports Phys Ther, 676-685.

Currier, L. L., J, F. P., Carrow, S. D., & al., e. (2007). Development of a Clinical Prediction Rule to Identify Patients with Knee pain and Clinical Evidence of Knee Osteoarthritis Who Demonstrate a Favorable Short-Term Response to Hip Mobilization. Physical Therapy, 1106-1119.

Deyle, G. D., Allison, S., & Matekel, R. L. (2005). Physical Therapy Treatment Effectiveness of Osteoarthritis of the Knee: A Randomized Comparison of Supervised Clinical Exercise and Manual Therapy Procedures versus a Home Exercise Program. Physical Therapy, 1301-1317.

Deyle, G. D., Henderson, N. E., & Matekel, R. L. (2000). Effectiveness of Manual Physical Therapy and Exercise in Osteoarthritis of the Knee: A Randomized, Controlled Trial. Annals of Internal Medicine, 173-181.

Fitzgeral, G., & Oatis, C. (2004). Role of physical therapy in management of knee osteoarthritis. Current opinion. Rheumatology, 143-147.

French, H., Brennan, A., White, B., & Cusack, T. (2011). Manual therapy for osteoarthritis of the hip or knee- A systematic review. Manual Therapy, 100-117.

Guyatt, G., Rennie, D., Meade, M., & Cook, D. (2008). User's Guide to the Medical Literature Essentials of Evidence-Based Clinical Practice. New York: McGraw Hill.

Jamtvedt, G., Dahm, K., Christie, A., Moe, R. H., Holm, I., & Hagen, K. (2008). Physical Therapy Interventions for Patients with Osteoarthritis of the Knee: An Overview of Systematic Reviews. Physical Therapy, 123-136.

Jansen, M., Veichtbauer, W., Lenssen, A., Hendricks, E., & de Bie, R. (2011). Strength training alone, exercise therapy alone and exercise therapy with passive manual mobilizatation each reduce pain and disability in people with knee osteoarthritis: A systematic review. . Journal of Physiotherapy , 11-20.

Loyola-Sanchez, A., Richardson, N., & MacIntyre, N. (2010). Efficacy of ultrasound therapy for the management of knee osteoarthritis: a systematic review with meta-analysis. Osteoarthritis and Cartilage, 1117-1126.

Ottowa. (2005). Ottowa Panel Evidence-Based Clinical Practice Guidelines for Therapeutic Exercise and Manual Therapy in the Management of Ostearthritis. Physical Therapy, 907-971.

Philadelphia. (2001). Philadelphia Panel Evidence-Based Clinical Practice Guidelines on Selected Rehabilitation Interventions for knee pain. Physical Therapy, 1675-1700.

Roddy, E., Zhang, W., Doherty, M., Arden, N., Barlow, J., Birrell, F., et al. (2005). Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or knee- the MOVE consensus. Rheumatology, 67-73.

 

             

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Rutjes, A., & Neusch, E. (2010). Therapuetic Ultrasound for osteoarthritis of the knee or hip. Cochrane Collaboration, Issue 1.

Tascioglu, F., & Kuzgun, F. (2010). Short-term effectiveness of ultrasound therapy in knee osteoarthritis. J International Medical Res, 1233-1242.

Zhang, W. (2010). EULAR evidence based recommendations for the diagnosis of knee osteoarthritis. Ann Rheum Dis, 483-489.

Zhang, W., Moskowitz, R., Nuki, G., Abramson, S., Altman, R., Arden, N., et al. (2007). OARSI Recommendations for the Management of Hip and Knee Osteoarthritis, Part II: OARSI Evidence-based, Expert Consensus Guidelines. . Osteoarthritis and Cartilage, 137-162.

Works Cited For Bracing, Taping, and Insoles Baker, K., Goggins, J., Xie, H., Szumowski, K., LaValley, M., Hunter, D. J., et al. (2007). A

Randomized Crossover Trial of a Wedged Insole for Treatment of Knee Osteoarthritis. ARTHRITIS & RHEUMATISM, 1198-1203.

Bennell, K. L., Bowles, K.-A., Payne, C., Cicuttini, F., Williamson, E., Forbes, A., et al. (2011, March). Lateral wedge insoles for medial knee osteoarthritis: 12 month randomised controlled trial. Retrieved 2011, from www.BMJ.com: BMJ 2011;342:d2912 doi:10.1136/bmj.d2912

Brouwer, R. W., Van Raaij, T. M., Jakma, T. T., Verhagen, A. P., Verhaar, J. A., & Bierma-Zeinstra, S. M. (2009). Braces and orthoses for treating osteoarthritis of the knee. The Cochrane Collaboration.

Crossley, K., Marino, G. P., Macilquham, M. D., Schache, A. G., & Hinman, R. S. (2009). Can Patellar Tape Reduce the Patellar Malalignment and Pain Associated With Patellofemoral Osteoarthritis? Arthritis & Rheumatism (Arthritis Care & Research), 1719-1725.

Hinman, R. S., Crossley, K. M., McConnell, & Bennell, K. L. (2003, July 19). Efficacy of knee tape in the management of osteoarthritis of the knee: blinded randomised controlled trial. Retrieved 2011, from WWW.BMJ.Com: bmj.com 2003;327:135

Hinman, R., Bennell, K., Crossley, K., & McConnell, J. (2003). Immediate effects of adhesive tape on pain and. Rheumatology, 865-869.

Hunter, D., Zhang, Y., Niu, J., DT, F., Kwoh, K., Newman, A., et al. (2007). Patella malalignment, pain and patellofemoral progression: The Health ABC Study. Osteoarthritis Cartilage, 1120-1127.

Kuroyanagi, Y., Nagura, T., Matsumoto, H., Otani, T., Suda, Y., Nakamura, T., et al. (2007). The lateral wedged insole with subtalar strapping significantly reduces. Osteoarthritis and Cartilage, 932-936.

http:WWW.BMJ.Comhttp:www.BMJ.com

 

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Pollo, F. E., Otis, J. C., Backus, S. I., Warren, R. F., & Wickiewicz, T. L. (2002). Reduction of Medial Compartment Loads with Valgus Bracing of the Osteoarthritic Knee. American Journal of Sports Medicine, 414-421.

Raja, K., & Dewan, N. (2011). Efficacy of knee braces and foot orthoses in conservative managment of knee osteoarthritis: a systematic review. American Journal of Physical Medicine & Rehabilitation, 247-262.

Toda, Y., & Segal, N. (2002). Usefulness of an Insole With Subtalar Strapping. Arthritis & Rheumatism, 468–473.

Van Raaij, T. M., Reijman, M., Brouwer, R. W., Bierma-Zeinstra, S. M., & Verhaar, J. A. (2010). Medial Knee Osteoarthritis Treated by Insoles or Braces: A Randomized Trial. Clinical Orthopaedics and Related Research, 1926-1932.

Warden, S. j., Hinman, R. S., Watson JR, M. A., Avin, K. G., Bialocerkowski, A. E., & Crossley, K. M. (2008). Patellar Taping and Bracing for the Treatment of Chronic Knee Pain: A Systematic Review and Meta-Analysis. Arthritis & Rheumatism (Arthritis Care & Research), 73-78.

Knee OsteoarthritisSUTTER MEDICAL FOUNDATION (SMF) Sacramento, CA 95816 Introduction W. , 2010) A Interventions- Therapeutic Exercise B Interventions- Manual Therapy C Interventions- Bracing B Interventions-Taping APPROVAL: Approval/Revision Summary: Works Cited Works Cited For Bracing, Taping, and Ins