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Treatment of Osteoarthritis of the Knee, 2nd edition SUMMARY OF RECOMMENDATIONS This summary of the AAOS clinical practice guideline, “Treatment of Osteoarthritis of the Knee” 2nd edition, contains a list of the evidence based treatment recommendations and includes only less invasive alternatives to knee replacement. Discussion of how each recommendation was developed and the complete evidence report are contained in the full guideline at www.aaos.org/guide
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  1 Treatment of Osteoarthritis of the Knee, 2  nd   edition SUMMARY OF RECOMMENDATIONS This summary of the AAOS clinical practice guideline, “ Treatment of Osteoarthritis of the  Knee ”  2 nd  edition, contains a list of the evidence based treatment recommendations and includes only less invasive alternatives to knee replacement. Discussion of how each recommendation was developed and the complete evidence report are contained in the full guideline at www.aaos.org/guidelines. Readers are urged to consult the full guideline for the comprehensive evaluation of the available scientific studies. The recommendations were established using methods of evidence-based medicine that rigorously control for bias, enhance transparency, and  promote reproducibility. This summary of recommendations is not intended to stand alone. Medical care should be based on evidence, a physician’s expert judgment and the patient’s circumstances,  values, preferences and rights. For treatment procedures to provide benefit, mutual collaboration with shared decision-making between patient and physician/allied healthcare provider is essential. Conservative Treatments: Recommendations 1-6 RECOMMENDATION 1   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. Strength of Recommendation: Strong Description:   Evidence is based on two or more “High” strength studies with consistent findings for recommending for or against the intervention. A Strong  recommendation means that the benefits of the recommended approach clearly exceed the potential harm and/or that the quality of the supporting evidence is high. Implications: Practitioners should follow a Strong recommendation unless a clear and compelling rationale for an alternative approach is present. RATIONALE This recommendation is rated strong because of seven high-strength studies of which five showed beneficial outcomes. The exercise interventions were predominantly conducted under supervision, most often by a physical therapist. The self-management interventions were led by various healthcare providers including rheumatologists, nurses, physical and occupational therapists, and health educators. The evidence supports the use of self-management programs in primary care patients with knee osteoarthritis. One of the studies used an existing evidence- based program, the Arthritis Self-Management Program (ASMP), which was modified to include an exercise component. 20  In a high-strength study by Coleman et al., 21  patients in a 6-week self-management program demonstrated statistically significant and possibly minimum clinically important improvements in WOMAC Pain, Stiffness, Function, and Total scores at eight weeks as compared to wait-listed controls. The program in that study was based on the same theoretical framework as the ASMP, but included content that was specifically tailored to  patients with knee osteoarthritis.  2 Studies in this review reported improvements in 29 of 37 outcomes favoring strength training over a control (usual care, education, or no treatment). Statistically significant and clinically important improvements were reported for VAS Pain, WOMAC Pain, and WOMAC Function scores. In addition, 7 of 23 outcomes indicated statistically significant improvements with strengthening exercises, when performed as part of a physical therapy treatment program, versus control. 22-24  Three of the seven outcomes were clinically significant and one was possibly clinically significant. One study reported statistically significant and possibly clinically significant improvement in WOMAC Total score following a combination of knee exercise and manual  physical therapy as compared to subtherapeutic ultrasound (control). 25  Studies also addressed the type and setting for strength training. Long-term outcomes did not vary among isometric, isotonic, or isokinetic exercises. 26  Both weight-bearing and nonweight- bearing exercises were superior to control in improving physical function, however, the results were conflicting when the exercises were compared to each other. 27  High-resistance strength training led to significantly faster walk times on spongy surfaces as compared to low-resistance training 28 . Ebnezar et al. 29-31  compared a combination of yoga and physical therapy to physical therapy alone. All eight outcomes were statistically and clinically significant favoring the combined treatment group measured by WOMAC Function and the SF-36 Physical Function and Bodily Pain subscales. Aquatic therapy was also deemed a suitable alternative to land-based strengthening exercises. 32  Of the three studies that investigated exercise in the home setting, the highest strength study favored home exercise versus no exercise in reducing patie nts’  global pain rating; however, this finding did not meet the minimum clinically important improvement threshold. 33  Three studies the effects of aerobic walking versus health education and one compared it to usual care in adults with osteoarthritis of the knee. There were statistically significant improvements with aerobic exercise in all but one of the performance-based functional tasks as compared to the education group. In the study by Kovar et al., 34 favorable outcomes were reported by the supervised walking group rather than usual care with statistically significant improvements in 6-minute walking distance and the Arthritis Impact Measurement Scale (AIMS) Physical Activity and Pain subscales. For neuromuscular education, three of four outcomes were statistically significant favoring combined kinesthesia, balance, and strength training exercises versus strength training alone. A high-strength study by Fitzgerald et al. 35  applied an effective treatment for anterior cruciate ligament injury to patients with osteoarthritis of the knee; they found that standard exercise combined with agility and perturbation therapy was not more effective than standard exercise therapy alone. Five of five outcomes were statistically significant for proprioception training. Lin et al. 36  randomized 108 patients to nonweight-bearing proprioception training, nonweight- bearing strength training, and non treatment groups. Both proprioception and strength training were significantly more effective in improving WOMAC Pain and Function scores than no treatment.  3 A number of fitness-related organizations have disseminated guidelines for physical activity. They generally emphasize the importance of aerobic conditioning and muscle- and bone- strengthening, regular activity, and balance exercises for older adults. In 2008, the federal government for the first time published national guidelines. Here is the link to the US Department of Health and Human Service’s physical activity guidelines:  http://www.health.gov/paguidelines/guidelines/default.aspx.  RECOMMENDATION 2 We suggest weight loss for patients with symptomatic osteoarthritis of the knee and a BMI ≥ 25.   Strength of Recommendation: Moderate Description: Evidence from two or more “Moderate” strength studies with consistent findings, or evidence from a single “High” quality  study for recommending for or against the intervention. A  Moderate recommendation means that the benefits exceed the potential harm (or that the potential harm clearly exceeds the benefits in the case of a negative recommendation), but the quality/applicability of the supporting evidence is not as strong. Implications: Practitioners should generally follow a Moderate  recommendation but remain alert to new information and be sensitive to patient preferences. RATIONALE There was one moderate- and two low- strength studies included in this recommendation. Physical Function on the SF-36 showed minimum clinically important improvement in outcomes for this patient population. WOMAC function also showed statistical improvement which was  possibly clinically significant. Diet and exercise combined revealed improved results. The workgroup considers that the public and patient health benefits of weight loss warranted an upgrade of the recommendation strength to moderate.  53-55   RECOMMENDATION 3A We cannot recommend using acupuncture in patients with symptomatic osteoarthritis of the knee. Strength of Recommendation: Strong Description:   Evidence is based on two or more “High” strength studies with consistent findings for recommending for or against the intervention. A Strong  recommendation means that the quality of the supporting evidence is high. A harms analysis on this recommendation was not performed. Implications: Practitioners should follow a Strong recommendation unless a clear and compelling rationale for an alternative approach is present. RATIONALE There were five high- and five moderate- strength studies that compared acupuncture to comparison groups receiving non-intervention sham, usual care, or education. The five moderate-strength studies were included because they reported outcomes that were different than the high-strength evidence. High-strength studies included: Berman et al, 61  Suarez-Almazor et al., 62  Weiner et al., 63  Williamson et al. 64  and Taechaarpornkul et al. 65  Moderate-strength studies included: Sandgee et al., 66  Vas et al., 67  Witt et al. 68  and Berman et al. 69  The majority of studies were not statistically significant and an even larger proportion of the evidence was not clinically  4 significant. Some outcomes were associated with clinical- but not statistical- significance. The strength of this recommendation was based on lack of efficacy, not on potential harm. RECOMMENDATION 3B We are unable to recommend for or against the use of physical agents (including electrotherapeutic modalities) in patients with symptomatic osteoarthritis of the knee. Strength of Recommendation: Inconclusive   Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence that has resulted in an unclear balance between benefits and potential harm. Implications: Practitioners should feel little constraint in following a recommendation labeled as  Inconclusive,  exercise clinical judgment, and be alert for emerging evidence that clarifies or helps to determine the balance  between benefits and potential harm. Patient preference should have a substantial influencing role. RATIONALE The evidence was mixed regarding the efficacy of physical agents and electrotherapeutic modalities because of contradiction in findings, design flaws, or a low count of like studies. A single low-strength 70  and a single-moderate strength study 71 comparing pulsed electrical stimulation to placebo produced contradictory results. See the results of the Fary et al. 70  and Zizic et al. 71  articles in table 96. Trock et al. 72  conducted a moderate-strength study evaluating  pulsed electromagnetic stimulation and found that it did not generate a statistically significant effect on pain dur  ing passive motion, but that tenderness and physician’s overall assessment scores were superior in the experimental group. Atamaz et al. 73  conducted a moderate-strength study that compared transcutaneous electrical nerve stimulation (TENS), shortwave diathermy, and interferential current to a sham procedure. None of the treatments were associated with statistically significant effects on pain, physical mobility, or ambulation time at four, 12, or 26 weeks. Battisti et al., 74  also in a moderate-strength study, found that therapeutic application of modulated electromagnetic field therapy (TAMMEF) did not produce statistically significant improvements in pain or Lequesne Index scores, compared to extremely low-frequency electromagnetic field therapy. However, there was evidence that ultrasound was effective in patients with knee osteoarthritis. Huang et al. 75  and Yang et al. 76  conducted moderate-strength studies that compared ultrasound to a control group. Huang et al. found that patients who received isotonic exercise with ultrasound had significantly superior ambulation speed, Lequesne Index scores, and VAS pain scores. Yang et al. found VAS pain and Lequesne Index scores were significantly superior at 4 weeks in  patients who received ultrasound over those who received a sham treatment. Due to the overall inconsistent findings for various physical agents and electrotherapeutic modalities, we were unable to make a recommendation for or against their use in patients with symptomatic osteoarthritis of the knee.
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