by Tyler Tice, PT, DPT, MS, ATC
Introduction:
As life expectancy increases globally as modern medicine becomes more advanced, chronic diseases will affect a larger portion of our population as a result. One of the leading causes of chronic pain and disability worldwide is knee osteoarthritis (OA). Knee OA affects the entire joint and its symptoms are frequently related to physical inactivity. Currently, there are many lines of treatment that a patient with knee OA can undergo. There is substantial research supporting the use of exercise in positively impacting knee OA symptoms, however pharmacological intervention continues to be the primary form of treatment. This purpose of this article was to provide updated information regarding current treatment interventions for knee OA.
Key Treatments – Non-pharmacological
Patient education: Patient education is an essential role in decision-making, disease self-management, and medication adherence of individuals with knee OA. As healthcare providers, it’s essential to develop a clear understanding of the disease to effectively direct patients towards high-quality health information. Some key messages that should be included in your education should be: 1) regular physical activity and individualized exercise programs can reduce pain, prevent worsening, and improve daily function in OA; 2) losing weight for overweight individuals is a benefit, as well as maintaining a healthy weight through appropriate diet and exercise; and 3) OA symptoms can often be significantly reduced without the need for undergoing surgery.
Exercise: The role of physical activity and exercise therapy to reduce symptoms and improve physical function in individuals with knee OA is well-established in the world of research. Current research shows that 150 minutes per week of moderate intensity aerobic exercise or 2 days per week of moderate to vigorous physical activity muscle-strengthening exercises are beneficial for individuals with knee OA. Additionally, more pain reduction was observed when quadriceps-specific exercises were incorporated to exercise routines compared to general lower-limb strengthening exercises and were performed at least 3 times per week. When creating a patient’s exercise program it should focus on patient-centered rehabilitation, consider patient preferences and access to exercise equipment. A key piece that patients should be educated on prior to beginning an exercise program is that pain/discomfort during physical activity does not mean increased structural damage to the joint.
Weight loss: Because of its systemic effects on the body due to inflammatory and metabolic changes, obesity and overweight are considered primary risk factors related to chronic disease, including knee OA. A reduction in weight of approximately 5.1 kilograms (11.22 pounds) decreases the risk of developing knee OA by more than 50% in women with a baseline BMI higher than 25 kg/m2. For individuals with knee OA, a combination of diet and exercise has a moderate effect on relieving pain. After successfully losing weight, maintenance of weight loss remains a substantial challenge. Successful strategies for weight maintenance included creating consecutive weight loss goals, having a regular meal pattern that includes breakfast and healthier eating, having a physically activity lifestyle, and controlling over-eating through self-monitoring behaviors.
Thermal modalities: There is a lack of evidence that supports the use of thermal modalities such as ice packs or moist hot packs in individuals with knee OA.
Laser, therapeutic ultrasound, and electrical stimulation: The Osteoarthritis Research Society International (OARSI) strongly recommends against the use of laser therapy for knee OA. There is currently low-quality evidence that supports the use of therapeutic ultrasound for individuals with knee OA. There is currently very low-quality evidence that supports the use of transcutaneous electrical stimulation in patients with knee OA.
Manual therapy techniques, taping, and acupuncture: There is currently low-level evidence showing that manual therapy techniques provide additional benefit when compared to exercise intervention alone in patients with knee OA. There is very low-level of evidence to support the use of taping for the management of knee OA. When utilizing traditional acupuncture, there is low-level evidence that supports the use of this intervention in patients with knee OA.
Pharmacological strategies
Non-steroidal anti-inflammatory drugs (NSAIDs): Topical NSAIDs are strongly recommended as first-line treatment in both the OARSI and American College of Rheumatology (ACR). OARSI recommends topical NSAIDs for individuals with GI or cardiovascular comorbidities as well as frailty. In addition to topical NSAIDs, the ACR strongly recommends the use of oral NSAIDs and intra-articular glucocorticoid injections.
Opioids: There is high-quality evidence that demonstrates opioids only have small effects on pain and physical function in individuals with knee OA. Additionally, when compared to placebo, patients that used opioids have 3-4 times higher risk of serious adverse effects and/or dropouts due to adverse events.
Nutraceuticals: Nutraceuticals are foods or food supplements that are thought to have health benefits. Glucosamine and chondroitin sulfate are commonly used by patients with knee OA; however, they lack scientific evidence to support their use.
Surgery: Surgery is typically the last resort for knee OA management. There are a wide variety of surgical intervention options available with arthroscopic joint lavage being the most common procedure performed. There are several studies that demonstrate low efficacy of this surgical intervention and the clinical practice guideline published by the Journal of the American Academy of Orthopedic Surgeons strongly recommends against the use of arthroscopy in nearly all patients with degenerative knee disease. Joint replacement surgery is another popular surgery for individuals with end-stage knee OA. Before undergoing this surgery, individuals should trial conservative management for 6 months. If conservative management is unsuccessful in improving symptoms and function, then joint replacement should be considered. However, it is important to note that one in five patients that undergo total knee replacement (TKR) is not satisfied with the outcome. When assessing patients following TKR, it is important for clinicians to measure both self-reported measures and objective measures to comprehensively assess individuals with knee OA.
Take Home Messages:
Knee OA is a degenerative disease that effects a high number of individuals, many of which utilize physical therapy to manage their symptoms and improve their function. It is important for clinicians to stay up to date on evidence-based treatment interventions to provide the best first line care that would most benefit their patients. When it comes to interventions that may not have strong evidence supporting them, if they are interventions that the patient reports pain reduction with, there is little harm in including them into your treatment, however overall treatment should still include evidence-backed intervention like exercise.
Reference:
Dantas, L. O., Salvini, T. F., & McAlindon, T. E. (2021). Knee osteoarthritis: key treatments and implications for physical therapy. Brazilian journal of physical therapy, 25(2), 135–146. https://doi.org/10.1016/j.bjpt.2020.08.004