Updated guidelines and new appropriate use criteria for nonoperative management of knee osteoarthritis aim to focus more directly on typical knee OA patients, who often have comorbidities that can complicate care and are not well represented in the medical literature.
By Larry Hand
Recent nonsurgical treatment guidelines and appropriate-use criteria give clinicians and practitioners more patient-centric guidance on how to treat osteoarthritis (OA) of the knee, and underscore the need to expand research efforts to include more study participants who reflect today’s real-world patients.
The Osteoarthritis Research Society International (OARSI) published the most recent treatment guidelines in the March issue of Osteoarthritis and Cartilage.1 The American Academy of Orthopaedic Surgeons (AAOS) released a set of appropriate-use criteria2 as a follow-up to its updated treatment guidelines published last year.3
The evidence-based OARSI guidelines for the first time offer recommendations for four different types of patients based on their comorbidities rather than a single set of recommendations for patients in general. In stratifying patients by one or more comorbidities, the OARSI guidelines working group members were able to rank therapies according to appropriateness for different patient situations.
The four patient categories are:
- Patients with knee OA knee only;
- Patients with knee OA and other health problems, including diabetes, hypertension, and heart disease;
- Patients with knee OA and OA of other joints including hips, spine, and hands; and
- Patients with OA in multiple joint sites and other health problems.
Also for the first time, instead of numerical rankings, the recommendations now are presented by further categorization as “appropriate,” “not appropriate,” or “uncertain” (which is not intended as a negative, but as an indication that more research is needed before experts determine a guideline).
Aiming for real patients
The new OARSI guidelines came about after working group members had heart-to-heart discussions with family clinicians who treat knee OA patients every day.
“We had a wonderful conversation with primary care providers at the table about how we’re not providing them with a heck of a lot of useful information about how to take the evidence that’s out there and apply it to real people in front of them in their offices,” Gillian A. Hawker, MD, professor of medicine and rheumatology at the University of Toronto in Ontario, Canada, OARSI board member, and a coauthor of the guidelines, told LER in a telephone interview.
“Many of us are osteoarthritis researchers and know that the majority of studies that have been done tend to recruit healthy knees—healthy people with a knee that’s bothersome. They will tend to, for obvious reasons, exclude people with lots of other health problems and with lots of other joint problems, because they want low risk, low toxicity, and they want a fairly simple story. But that doesn’t represent most of our patients,” she said.
“So creating these categories,” she continued, “gave us a way to shine a big bright light showing that we have most of the evidence available for therapies on a relatively small proportion of people with OA and a lot of holes for missing information or lack of studies in the biggest group. Most people who are sixty five and older with osteoarthritis have at least one other chronic condition, including diabetes, heart disease, or high blood pressure, which makes osteoarthritis management very tough.”
Bucket of possibilities
The OARSI guidelines recommend a “bucket of non-drug therapies” as first-line strategies that any clinician can apply, Hawker said. In that bucket are interventions involving biomechanics,4-7 exercise,8-12 and weight loss.13
“It’s work to exercise or lose weight, as opposed to taking a pill, but the fact is exercise, weight loss, and attention to biomechanics—which may be a splint, a brace, a walker, or a cane—works,” she said.
Biomechanical therapies need to be carefully matched to individual patients, Hawker said.
“Many patients buy something off the shelf and end up worse off,” she said. “Ideally, somebody should look at a patient and assess what might be most sensible based on particular circumstances.”
In cases that involve the medial tibiofemoral compartment, any strategy that reduces the load through that medial compartment is usually going to be better than strategies that don’t, Hawker said. In addition to bracing, this might include lateral wedges or targeted strengthening interventions.4-7
Exercise is extremely important, she said, but many patients lack direction in terms of how much to do and how far to push themselves.
“Many people are uncomfortable knowing how far to push their joints safely. And some people will avoid being physically active or doing things they want to do because they think they’re going to hurt their joints,” said Hawker.
Seeing a physical therapist, at least to go through a set of recommended exercises, including strengthening, aerobics, and probably neuromuscular training, could get a patient on the right track, she said. OARSI’s expert panel included physical therapists.
There’s an app for that
The AAOS published its appropriate-use criteria in both a journal article2 in April this year and in the form of a web-based application late last year. The application can be downloaded from aaos.org/ auc. The first screen on the app lists eight disclaimers about knee OA patients and clinicians, after which the user proceeds to a menu from which a patient’s characteristics can be matched with procedure recommendations. The application works on mobile devices as well as personal computers.
“You can use the application to describe a specific patient scenario,” James O. Sanders, MD, orthopedic surgeon and professor of orthopedics at University of Rochester Medical Center in New York, and first author of the journal article, told LER in a telephone interview. “Clicking on different items gives you various combinations of patient scenarios, which we believe are at least relatively inclusive of patients you might see.”
While AAOS guidelines represent evidence-based recommendations, the web application also incorporates clinician expertise, he said.
Three separate panels of clinicians representing a variety of medical disciplines developed the appropriate-use criteria. Members of a writing panel drew on their own expertise and the AAOS guidelines to develop a list of patient indications, assumptions, and treatments. A review panel suggested improvements, and members of a voting panel representing multiple specialties used their experience and the guidelines to assign level of appropriateness as “appropriate,” “may be appropriate,” or “rarely appropriate.”
The panels ended up with 576 different patient scenarios, ranging from a 25-year-old patient with post-traumatic OA wanting to play baseball to an 80-year-old OA patient having trouble walking.
Using guidelines and experience
So how does a clinician or practitioner sort out how to use recommendations provided by specialty medical societies?
“The guidelines are just that: they are a guide. Not every patient will fit the guidelines. There are always exceptions,” Elizabeth G. Matzkin, MD, surgical director of women’s musculoskeletal health at Brigham and Women’s Hospital and an assistant professor of orthopedic surgery at Harvard Medical School in Boston, told LER in an email. “But the guidelines give credibility to some of the treatment options we can recommend to our patients.”
The main difference between the two sets is the AAOS guidelines include some surgical interventions, but not total knee replacement, while the OARSI guidelines address only nonsurgical treatments. Together, the two sets of guidelines capture the needs of today’s patients with the best currently available evidence, said Matzkin, who helped to develop the AAOS guidelines.
Amanda E. Nelson, MD, assistant professor of medicine in the Division of Rheumatology, Allergy, and Immunology at the University of North Carolina at Chapel Hill, and colleagues conducted a systematic review14 published online December 13, 2013, of recommendations and guidelines for OA management, but the review did not include these latest guidelines.
“Our paper summarizes several of these [evidence summaries], highlighting areas of agreement and discordance,” Nelson told LER in an email. “In general, busy physicians should focus on the most widely accepted and agreed-upon guidelines, which for OA will include nonpharmacologic interventions such as exercise, weight loss, education, and self-management.”
But she and her colleagues concluded in their paper that organizations should do more to get the word out.
“Yes, it is important for the organizations making guidelines and recommendations to disseminate them as broadly as possible in order to encourage implementation in practice, although this is difficult to accomplish,” Nelson told LER. “The creation of web-based tools for both providers and patients could improve awareness and uptake of recommendations.”
For instance, a need still exists for sorting out information on braces and other orthotic devices, she said.
“Unfortunately, there is disagreement in the literature regarding specific braces and orthotics. Unloader braces were recommended by some organizations but not by others, similarly for lateral and medial heel wedges. This is also true for the recent OARSI guidelines [which characterized existing evidence for biomechanical interventions as “Fair”]. In the absence of such general guidelines, the best approach is likely consultation with a qualified specialist to address the needs of a specific patient,” she said.
Practitioners should also note that guidelines are not a substitute for patient-specific care and clinician experience. In fact, the OARSI guideline on biomechanical treatment reads specifically, “We recommend use of biomechanical interventions as directed by an appropriate specialist.”
“For recommendations that are inconclusive, when you really can’t make a recommendation one way or the other, that’s really for a discussion with the patient, carefully looking at their situation and what you think you have to offer them,” said Rochester’s James Sanders, who was coauthor of a journal article on the “use, misuse, and future directions” of clinical practice guidelines.15
“The guidelines can also help inform a physician’s experience,” he said. “Our own experience may show us that some things seem to work or don’t work, when better studies show us that our own experience is too limited to do that.”
He suggested practitioners assess guidelines by evaluating:
- The level of guideline developers’ conflict of interest;
- The thoroughness of the guideline development process;
- Whether some guidelines may actually be appropriate-use criteria; and
- Whether guidelines are based on real or statistical outcomes.
“Statistical outcomes may be based on what is common practice, but more likely they’re based on the fact that you may have a large study that shows results that are not terribly important to patients,” Sanders said.
Roy Lidtke, DPM, of Rush University Medical Center in Chicago, said he keeps up with guidelines by staying on email alert systems. That’s the easy part.
“Then you have to read the guidelines. That’s the hard part, to get clinicians to actually read them and see if it’s information that you agree with and would use,” Lidtke told LER in a telephone interview. “I think that’s some of the stumbling block with clinical guidelines. A clinician might look at one of the guidelines and say, ‘I don’t agree with that.’ What they’re saying is, ‘from my clinical experience, that’s not what I’ve observed.’”
Most practitioners will consider the evidence-based guidelines in the context of their clinical experience, Lidtke said.
“These are called guidelines for a reason, because each patient is different. You’re using your clinical expertise and background judgment to determine how it’s going to work for a particular patient. It’s still a guideline. The practice of medicine is not an exact science,” he said.
“I think I get more exercise [information] from guidelines, and it might be because personally I leave the exercise stuff up to therapists. They’re the experts at this, not me,” he said.
Practical considerations may limit the utility of some recommended treatments, Anil Bhave, PT, director of the Wasserman Gait Laboratory at the Rubin Institute for Advanced Orthopedics in Baltimore, MD, told LER in a telephone interview.
“How practical is it to go to physical therapy three times a week for six weeks for your OA knee, when your Medicare only gives you nineteen hundred dollars for one year of physical therapy and speech therapy together? If you use your PT benefits for OA early in the year, you have no PT benefits left in case you get injured,” he said. “How many Medicare patients can afford a health club?”
As for water-based exercises, which are recommended in the OARSI guidelines,12 he questioned how many patients could take advantage of them year round, especially patients living in the Northeast.
“It’s a good start. But many of these [recommendations] are very useful and valid but may not be practical unless insurance companies start subsidizing them,” Bhave said. “The reality is that it may be difficult to accomplish in a large population.”
But, he said, there may be a middle ground.
“Educating patients about exercise is important, and education about weight management is important. Maybe they should wear some type of brace if they have biomechanical problems, and maybe they should wear fitness shoes, or at least have better footwear,” he said. “And you have to be really careful about what drugs you choose, because of all the side effects and dependency that can develop.”
Where to now?
The new format of the OARSI guidelines is intended to underscore those practical considerations, as well as the extent to which existing research in many instances does not address them, Hawker said.
“It was a pragmatic, practical conversation about how do we do better and provide better guidance to people with OA and their primary care providers,” she said. “We’re trying to underscore the need for more research that will actually provide evidence to guide the treatment of the majority of patients with OA, who are living with OA and other health problems.”
Larry Hand is a writer in Massachusetts.
1. McAlindon TE, Bannuru RR, Sullivan MC, et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage 2014;22(3):363-388.
2. Sanders JO, Murray J, Gross L. Non-arthroplasty treatment of osteoarthritis of the knee. J Am Acad Orthop Surg 2014;22(4):256-260.
3. Jevsevar DS, Brown GA, Jones DL, et al. Treatment of osteoarthritis of the knee: evidence-based guideline, 2nd edition. J Am Acad Orthop Surg 2013;21(9):571-576.
4. Raja K, Dewan N. Efficacy of knee braces and foot orthoses in conservative management of knee osteoarthritis: a systematic review. Am J Phys Med Rehabil 2011;90(3):247-262.
5. Bennell KL, Bowles KA, Payne C, et al. Lateral wedge insoles for medial knee osteoarthritis: 12 month randomised controlled trial. BMJ 2011;342:d2912.
6. van Raaij TM, Reijman M, Brouwer RW, et al. Medial knee osteoarthritis treated by insoles or braces: a randomized trial. Clin Orthop Relat Res 2010;468(7):1926-1932.
7. Erhart JC, Mundermann A, Elspas B, et al. Changes in knee adduction moment, pain, and functionality with a variable-stiffness walking shoe after 6 months. J Orthop Res 2010;28(7):873-879.
8. Jansen MJ, Viechtbauer W, Lenssen AF, et al. Strength training alone, exercise therapy alone, and exercise therapy with passive manual mobilisation each reduce pain and disability in people with knee osteoarthritis: a systematic review. J Physiother 2011;57(1):11-20.
9. Iversen MD. Rehabilitation interventions for pain and disability in osteoarthritis: a review of interventions including exercise, manual techniques, and assistive devices. Orthop Nurs 2012;31(2):103-108.
10. Fransen M, McConnell S, Hernandez-Molina G, Reichenbach S. Does land-based exercise reduce pain and disability associated with hip osteoarthritis? A meta-analysis of randomized controlled trials. Osteoarthritis Cartilage 2010;18(5):613-620.
11. Fransen M, McConnell S. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev 2008;(4):CD004376.
12. Bartels EM, Lund H, Hagen KB, et al. Aquatic exercise for the treatment of knee and hip osteoarthritis. Cochrane Database Syst Rev 2007;(4):CD005523.
13. Christensen R, Bartels EM, Astrup A, Bliddal H. Effect of weight reduction in obese patients diagnosed with knee osteoarthritis: a systematic review and meta-analysis. Ann Rheum Dis 2007;66(4):433-439.
14. Nelson AE, Allen KD, Golightly YM, et al. A systematic review of recommendations and guidelines for the management of osteoarthritis: The Chronic Osteoarthritis Management Initiative of the US Bone and Joint Initiative. Semin Arthrit Rheum Dec 4. [Epub ahead of print]
15. Sanders JO, Bozic KJ, Glassman SD, et al. Clinical practice guidelines: their use, misuse, and future directions. J Am Acad Orthop Surg 2014;22(3):135-144.