Applied Evidence

Managing osteoarthritis: What’s best for your patient?

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New guidelines rate the evidence for hip and knee OA treatments. Handy chart provides at-a-glance summary


 

References

Practice recommendation
  • Teach patients that self-care is key to successful management of osteoarthritis (Osteoarthritis Research Society International [OARSI] Evidence 1a
  • Encourage patients to regularly engage in aerobic, muscle-strengthening, and range-of-motion exercise (Ia: knee; IV: hip).
  • Recommend that patients try acetaminophen (≤4 g/d) before considering other analgesics for mild to moderate joint pain (Ia: knee; IV: hip).
  • Prescribe the lowest effective dose of nonsteroidal anti-inflammatory drugs (NSAIDs) and avoid using them for long-term therapy (Ia).

OARSI level of evidence:

Ia: Meta-analysis of randomized controlled trials (RCTs)
Ib: RCT
IIa: Controlled study without randomization
IIb: Quasi-experimental study
III: Nonexperimental, descriptive studies
IV: Expert committee reports/opinion/experience

Osteoarthritis (OA) and other rheumatic conditions account for as many office visits as cardiovascular disease or essential hypertension, according to national data, and most involve primary care physicians.1 As the population ages, the prevalence of OA—estimated at 46.4 million in 2005 in the United States alone—will continue to rise.2,3 So, too, will the number of patients needing treatment for pain and functional limitations related to OA of the hips and knees.

Physicians who treat these patients have a new tool at their disposal: the Osteoarthritis Research Society International (OARSI)’s evidence-based, expert consensus guidelines for the management of hip and knee OA. These recommendations, published in February 2008, are the first “internationally agreed and universally applicable guidelines for the management of these global disorders.”4

In caring for patients with OA of the hips or knees, family physicians should keep in mind 2 guiding principles at the heart of the OARSI recommendations:

  • the importance of lifestyle modification, including regular exercise, in coping with this degenerative, potentially debilitating disease; and
  • the need to incorporate both nonpharmacologic interventions and drug therapy to achieve optimal care.4

International team sifts through the evidence

To develop the guidelines, OARSI convened a committee of 16 physicians from 6 countries and 2 continents, with expertise in 4 disciplines: rheumatology, orthopedics, evidence-based medicine, and primary care. The team reviewed national and regional guidelines and studied systematic reviews; meta-analyses; randomized controlled trials (RCTs); controlled and uncontrolled trials; cohort, case-control, and cross-sectional studies; and economic evaluations from 1945 through 2001. The team also conducted a systematic review of evidence from January 2002 through January 2006.4,5 To ensure the quality of evidence hierarchy, the team used internationally accepted research tools.

AP and tunnel images are key to OA diagnosis

A diagnosis of knee or hip osteoarthritis (OA) requires a medical history; physical examination; radiologic assessment, with standing X-rays of the lower extremities, including anterior-posterior and tunnel views for knee OA; and the exclusion of other conditions.30 The tunnel view shown here reveals bone-on-bone articulation in the medial compartment of the left knee, and demonstrates the importance of standing X-rays.

Differential diagnosis includes gout, pseudogout, rheumatoid arthritis, patella-femoral pain, pes anserine (knee) bursitis, iliotibial band pathology, meniscal tear, cruciate tears, and tumors. No blood tests are indicated unless an inflammatory process is suspected. Synovial fluid in an osteoarthritic knee has a white cell count of <2000/uL.31

The team used several criteria to rate the recommended strategies, including level of evidence, effect size for pain relief, level of consensus, and strength of recommendation (SOR). All of these criteria are included (and defined) in an at-a-glance summary of the OARSI recommendations ( TABLE ).

In particular, the SOR, which is used throughout this article, is an overall rating that reflects the opinions of the team members after consideration of the research evidence for efficacy, safety, and cost-effectiveness. It is based on a visual analog scale of 0 to 100 mm and is expressed as a percentage.

TABLE
OARSI guidelines rate the evidence for osteoarthritis treatment options

RECOMMENDATION SOR, % (95% CI)*/ LEVEL OF CONSENSUS, % LEVEL OF EVIDENCE ES (95% CI)§
Nonpharmacologic
Education, self-help, patient-driven treatment97 (95 to 99)/NAIa: educationNA
Aerobic, muscle-strengthening, and range-of-motion exercises96 (93 to 99)/85Ia: knee
IV: hip
Ib: hip, water-based
0.52 (0.34 to 0.70): aerobic
0.32 (0.23 to 0.42): strength
0.25 (0.02 to 0.47): water-based
Weight loss96 (92 to 100)/100Ia0.13 (-0.12 to 0.38)
Walking aids90 (84 to 96)/100IVNA
Physical therapy89 (82 to 96)/100IVNA
Appropriate footwear/insoles77 (66 to 88)/92IV: footwear
Ia: insoles
NA
Knee braces76 (69 to 83)/92IaNA
Telephone contact66 (57 to 75)/77Ia: knee; IV: hip0.12 (0 to 0.24)
Thermal modalities64 (60 to 68)/77Ia0.69 (-0.07 to 1.45)
Acupuncture59 (47 to 71)/69Ia0.51 (0.23 to 0.79)
TENS58 (45 to 72)/69IaNA
Pharmacologic
Oral NSAIDs93 (88 to 99)/100Ia0.32 (0.24 to 0.39)
Acetaminophen ≤4 g/d92 (88 to 99)/77Ia: knee; IV: hip0.21 (0.02 to 0.41)
Topical NSAIDs/capsaicin85 (75 to 95)/100Ia0.41 (0.22 to 0.59)
Weak opioids/narcotics82 (74 to 90)/92IaNA
IA corticosteroid injections78 (61 to 95)/69Ia: knee; Ib: hip0.72 (0.42 to 1.02)
IA hyaluronate injections64 (43 to 85)/85Ia0.32 (0.17 to 0.47)
Glucosamine and/or chondroitin63 (44 to 82)/92Ia: glucosamine0.45 (0.04 to 0.86)
Surgical treatments
Joint replacement96 (94 to 98)/92IIINA
Unicompartmental knee replacement76 (64 to 88)/100IIIbNA
Osteotomy/joint preservation75 (64 to 86)/100IIbNA
Joint fusion69 (57 to 82)/100IVNA
Joint lavage/arthroscopic debridement60 (47 to 82)/100Ib0.09 (-0.27 to 0.44): lavage
-0.01 (-0.37 to 0.35): debridement
CI, confidence interval; ES, effect size for pain relief; IA, intraarticular; NA, not available; NSAIDs, nonsteroidal anti-inflammatory drugs; OARSI, Osteoarthritis Research Society International; SOR, strength of recommendation; TENS, transcutaneous electrical nerve stimulation
* SOR (strength of recommendation) is an overall rating that reflects the opinions of OARSI team members after consideration of the research evidence for efficacy, safety, and cost-effectiveness. SOR is based on a visual analog scale of 0 to 100 mm and is expressed as a percentage.
Level of consensus is the estimated extent of agreement among committee members, expressed as a percentage.
Level of evidence is broken into 6 categories: Ia: meta-analysis of randomized controlled trials (RCTs); Ib: RCT; IIa: controlled study without randomization; IIb: quasi-experimental study; III: nonexperimental, descriptive studies; and IV: expert committee reports/opinion/experience.
§ES (effect size for pain relief) is a measure of the standard mean difference between interventions (eg, treatment vs placebo): 0.2 (small); 0.5 (moderate); and >0.8 (large). The ES refers to the knee and hip unless otherwise specified.
Adapted from: Zhang et al.4

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