Friday, June 14, 2013

New Guidelines for Treating Knee Osteoarthritis

Knee OsteoarthritisOsteoarthritis (OA) of the knee is an increasing problem associated with chronic pain and disability, especially among women and aging populations worldwide. According to some estimates, more than 27 million persons in the United States alone have OA, with the knee being a most commonly affected area. What can be done? The AAOS (American Academy of Orthopaedic Surgeons) recently issued updated treatment guidelines that should be of interest to healthcare providers and patients.

Along with input from the American College of Rheumatology, the American Academy of Family Practice, and the American Physical Therapy Association, an AAOS panel and 16 peer-reviewers took a fresh look at all available evidence to develop a collaborative clinical practice guideline (CPG) that replaces an earlier document from 2008. The new 1,229-page guidelines document — Treatment of Osteoarthritis (OA) of the Knee (Non-Arthroplasty), 2nd Edition — and a 13-page summary are available [here].

The evidence-based guidelines consist of 18 statements resulting from a review of more than 10,000 research articles and reports that focused on less invasive alternatives to surgical knee replacement. The statements are organized according to conservative, pharmacologic, procedural, and surgical treatments. Among the 18 statements, 3 propose recommended treatments, 7 list treatments that are not recommended, and 8 treatments have equivocal or inconclusive recommendations, as follows [strength of evidence for each statement is in brackets]:

Recommended Treatments

  • We recommend that patients with symptomatic osteoarthritis of the knee participate in self-management programs, strengthening, low-impact aerobic exercises, and neuromuscular education; and engage in physical activity consistent with national guidelines. [Strong]

  • We recommend nonsteroidal anti-inflammatory drugs (NSAIDs; oral or topical) or Tramadol for patients with symptomatic osteoarthritis of the knee. [Strong]

  • We suggest weight loss for patients with symptomatic osteoarthritis of the knee and a BMI ≥25. [Moderate]

Not Recommended Treatments

  • We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee. [Strong]

  • We cannot recommend using glucosamine and chondroitin for patients with symptomatic osteoarthritis of the knee. [Strong]

  • We cannot recommend using acupuncture in patients with symptomatic osteoarthritis of the knee. [Strong]

  • We cannot recommend performing arthroscopy with lavage and/or debridement in patients with a primary diagnosis of symptomatic osteoarthritis of the knee. [Strong]

  • We cannot suggest that the practitioner use needle lavage for patients with symptomatic osteoarthritis of the knee. [Moderate]

  • We cannot suggest that lateral wedge insoles be used for patients with symptomatic medial compartment osteoarthritis of the knee. [Moderate]

  • In the absence of reliable evidence, it is the opinion of the work group not to use the free-floating (un-fixed) interpositional device in patients with symptomatic medial compartment osteoarthritis of the knee. [Consensus]

Equivocal/Inconclusive Recommendations

  • We are unable to recommend for or against the use of acetaminophen, opioids, or pain patches for patients with symptomatic osteoarthritis of the knee. [Inconclusive]

  • We are unable to recommend for or against the use of intraarticular (IA) corticosteroids for patients with symptomatic osteoarthritis of the knee. [Inconclusive]

  • We are unable to recommend for or against growth factor injections and/or platelet rich plasma for patients with symptomatic osteoarthritis of the knee. [Inconclusive]

  • We are unable to recommend for or against manual therapy in patients with symptomatic osteoarthritis of the knee. [Inconclusive]

  • We are unable to recommend for or against the use of physical agents (including electrotherapeutic modalities) in patients with symptomatic osteoarthritis of the knee. [Inconclusive]

  • We are unable to recommend for or against arthroscopic partial meniscectomy in patients with osteoarthritis of the knee with a torn meniscus. [Inconclusive]

  • We are unable to recommend for or against the use of a valgus directing force brace (medial compartment unloader) for patients with symptomatic osteoarthritis of the knee. [Inconclusive]

  • The practitioner might perform a valgus producing proximal tibial osteotomy in patients with symptomatic medial compartment osteoarthritis of the knee. [Limited]

The full guidelines or summary provide more details. All clinical studies eligible for review in developing the guidelines had at least 30 participants and followup periods demonstrating efficacy for a minimum of 4 weeks. However, it is interesting that merely one-third (6/18) of the guidelines statements are supported by high-quality, strong evidence. The majority of statements had to rely on evidence that was weak, unconvincing, inconclusive, and/or limited. Unfortunately, this may exemplify the deficient state of research in the pain field overall.

The only treatments qualifying for a “recommended” rating were activity-based (eg, exercise and self-management), weight loss, and NSAIDs or the weak opioid, tramadol. Of some concern, NSAIDs may be a risky choice of analgesia for many patients and especially in the elderly who are most often affected by OA [see recent Pain-Topics UPDATE discussing this issue here]. On the other hand, the AAOS guidelines equivocate on acetaminophen and stronger opioids, which are often most recommended in the elderly with pain by organizations like the American Geriatrics Society [eg, see UPDATE here and review article on adverse effects of analgesics for OA in geriatrics here].

Also of importance, the AAOS guidelines recommend against the use of hyaluronic acid injections and they are equivocal about corticosteroid injections. Similarly, an UPDATE article [here] described how hyaluronic acid injections are ineffective and even may cause exacerbations of pain or other adverse effects. Yet, we often hear or read of pain clinics advertising these injections as “cures” for OA.

Steroid injections have demonstrated efficacy for pain relief of limited duration, but the evidence is generally from small, lower-quality studies. The value of regenerative injection therapies, using other solutions — eg, dextrose, growth factor, platelet rich plasma — is largely undetermined and receives an equivocal/inconclusive rating in the AAOS guidelines, as do steroid injections.

Apparently, the AAOS panel looks rather askance at CAM (Complementary and Alternative Medicine) modalities. Based on strong evidence they eschew the use of glucosamine and chondroitin supplements, which is consistent with most opinions regarding these agents, and despite the fact that they are widely promoted and sold commercially as arthritis nostrums. In fair balance, however, we should note that a research review published in Rheumatology International [details and access here] found that glucosamine sulfate may significantly reduce symptoms of OA in the lower limbs. But, the authors concede that the glucosamine preparations and dosing used in successful research trials, and available by prescription in some countries, are quite different from the glucosamine/chondroitin products and dosages commercially available in the U.S.

The panel also makes a strong recommendation against acupuncture for knee OA (as we have suggested in numerous UPDATES articles). Still, allegedly evidence-based organizations like the U.S. National Center for Complementary and Alternative Medicine (NCCAM, website here) speak favorably of acupuncture for OA (as they also do for glucosamine/chondroitin).

The AAOS guidelines do not address the evidence or provide recommendations for or against other popular CAM therapies for arthritis, such as homeopathy, herbal remedies, magnets, copper bracelets, energy-field therapies, and others. Probably, these were considered outside the purview of allopathic medicine and/or deemed unworthy of consideration, since questions have been raised about the scientific validity of those modalities.

However, it is disappointing that beyond a cursory mention of vitamin D supplementation there is no statement regarding this agent, which might rate at least an inconclusive recommendation — of possible benefit to patients with OA, but based on limited high-quality evidence. We have extensively discussed in a series of UPDATES [here] vitamin D and research supporting its potential to help ameliorate musculoskeletal pain conditions

Finally, it is worth noting that — assuming the AAOS guidelines are as evidence-based and reliable as they appear to be — other guidelines developers will need to go back to the drawing board. For example, updated guidelines from the Work Loss Data Institute discuss treatment recommendations that are consulted by the Workers’ Compensation and rehabilitation field for knee arthritis and other knee/leg disorders [available here]. In opposition to the AAOS guidelines, acupuncture and glucosamine are recommended therapies, as are intra-articular hyaluronic acid and steroid injections. Acetaminophen is recommended as a first-line choice of analgesic over NSAIDs, which may be best, but opioids are not mentioned as an option even for short-term use.

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