Knee Osteoarthritis: What Works
Australians are living longer, yet the growing burden of chronic disease means society is living longer but in poorer health.
Osteoarthritis of the knee (KOA) is a primary contributor to this situation. Due to an aging population and increasing obesity, KOA’s prevalence has more than doubled in the past ten years, pointing to an impending endemic state.1,2. As the world’s tenth largest contributor to years lived with disabilities, KOA surgeries and hospitalisations cost world healthcare systems billions of dollars yearly.3,4 This scenario heightens the importance of focusing on the most effective treatments.
Guidelines strongly recommend exercise, patient education, and weight loss among first- line treatments, and recommended first-line treatments are non-surgical and largely non pharmacological.5-11 Despite definitive evidence in support of these guidelines dating back two decades, six out of ten Australians with KOA do not access gold-standard care.
Physiotherapists are a large part of the problem. They often do not provide evidence-based exercise therapy and patient education, and Australian doctors report frustration with the lack of standardised physiotherapy.12 This results in a small percentage of general practice patients receiving physiotherapy referrals, with first-line pharmacology being more than twice as likely and referral to a surgeon being three times more likely.13
What should physiotherapists be doing to earn more KOA referrals from general practitioners? Lucas Ogura Dantas of the Federal University of San Carlos, Brazil, recently published a review of studies and guidelines.14
Exercise Therapy: While more research is needed to refine detailed issues such as frequency and duration, the research showing the efficacy of exercise therapy for KOA is definitive. Physiotherapy ameliorates OA progression while quickly reducing pain and improving function with effects comparable to surgery.15-17
Weight Loss: Adults with KOA and a body mass index higher than 25kg/m2, report improved pain, ability, and quality of life from weight reductions as modest as 5% to 10%.18 Diet-only treatments do not seem to relieve pain.19 However, diet strategies with nutritional education, exercise, and behavioural therapy can help patients with osteoarthritis achieve clinically effective weight loss.18 Exercise physiologists have training in these approaches, making the combination of physiotherapy and exercise physiology an ideal referral for KOA. The combination of exercise therapy and weight loss proves more effective than either approach alone.20
Patient Education: Misleading beliefs that osteoarthritis is an incurable, progressive disease have been associated with reduced physical activity, self-restrictions on healthy lifestyles, reduced spontaneity, and even feelings of loss and isolation. Consensus opinion recommends educating patients toward more productive behaviours.
Physiotherapy Modalities (Largely Not Recommended): Physiotherapists attempt multiple modalities in the treatment of KOA, sometimes to the exclusion of evidence-based, guideline recommended treatments. These include thermal modalities, therapeutic ultrasound, electrical stimulation, manual therapy, taping, nutraceuticals (glucosamine, chondroitin sulphate) and various forms of needling or acupuncture. Generally, these modalities are conditionally recommended or recommended against in the guidelines. Some guidelines recommend against taping that is not KinesioTaping, laser therapy, TENS, and manual therapies. Some guidelines conditionally recommend in favour of Kinesio Taping and traditional acupuncture. Generally speaking, therapeutic benefits tend to be small, and the research tends to evaluate them against placebo rather than evaluating whether they add to the effectiveness of gold-standard exercise, patient education, & weight loss.
1. Englund M, Turkiewicz A. Osteoarthritis increasingly common public disease. Lakartidningen. 2014;111(21):930.
2. Kyu HH, Abate D, Abate KH, Abay SM, Abbafati C, Abbasi N, Abbastabar H, Abd-Allah F, Abdela J, Abdelalim A, Abdollahpour I. Global, regional, and national disability-adjusted life-years (DALYs) for 359 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. The Lancet. 2018 Nov 10;392(10159):1859-922.
3. Hawker GA. Osteoarthritis is a serious disease. Clin Exp Rheumatol. 2019 Sep 1;37(Suppl 120):3-6.
4. Palazzo C, Nguyen C, Lefevre-Colau MM, Rannou F, Poiraudeau S. Risk factors and burden of osteoarthritis. Annals of Physical and Rehabilitation Medicine. 2016 Jun 1;59(3):134-8.
5. Chae KJ, Choi MJ, Kim KY, Ajayi FF, Chang IS, Kim IS. National Institute for Health and Care Excellence, Osteoarthritis: Care and Management. Natl Clin Guidel Cent (UK). 2014 Dec.
6. Bannuru RR, Osani MC, Vaysbrot EE, Arden NK, Bennell K, Bierma-Zeinstra SM, Kraus VB, Lohmander LS, Abbott JH, Bhandari M, Blanco FJ. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis and Cartilage. 2019 Nov 1;27(11):1578-89.
7. Kolasinski SL, Neogi T, Hochberg MC, Oatis C, Guyatt G, Block J, Callahan L, Copenhaver C, Dodge C, Felson D,
Gellar K. American College of Rheumatology/Arthritis foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Rheumatol. 2020; 72 (2): 220–33.
8. Fernandes L, Hagen KB, Bijlsma JW, Andreassen O, Christensen P, Conaghan PG, Doherty M, Geenen R, Hammond A, Kjeken I, Lohmander LS. EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis. Annals of the Rheumatic Diseases. 2013 Jul 1;72(7):1125-35.
9. Brosseau L, Taki J, Desjardins B, Thevenot O, Fransen M, Wells GA, Mizusaki Imoto A, Toupin-April K, Westby M, Alvarez Gallardo IC, Gifford W. The Ottawa panel clinical practice guidelines for the management of knee osteoarthritis. Part two: strengthening exercise programs. Clinical Rehabilitation. 2017 May;31(5):596-611.
10. Brosseau L, Taki J, Desjardins B, Thevenot O, Fransen M, Wells GA, Imoto AM, Toupin-April K, Westby M, Gallard IC, Gifford W. The Ottawa panel clinical practice guidelines for the management of knee osteoarthritis. Part one: introduction, and mind-body exercise programs. Clinical Rehabilitation. 2017 May;31(5):582-95.
11. Brosseau L, Taki J, Desjardins B, Thevenot O, Fransen M, Wells GA, Mizusaki Imoto A, Toupin-April K, Westby M, Alvarez Gallardo IC, Gifford W. The Ottawa panel clinical practice guidelines for the management of knee osteoarthritis. Part three: aerobic exercise programs. Clinical Rehabilitation. 2017 May;31(5):612-24.
12. Barton CJ, Kemp JL, Roos EM, Skou ST, Dundules K, Pazzinatto MF, Francis M, Lannin NA, Wallis JA, Crossley KM. Program evaluation of GLA: D® Australia: Physiotherapist training outcomes and effectiveness of implementation for people with knee osteoarthritis. Osteoarthritis and Cartilage Open. 2021 Sep 1;3(3):100175.
13. Liang L, Abi Safi J, Gagliardi AR. Number and type of guideline implementation tools varies by guideline, clinical condition, country of origin, and type of developer organization: content analysis of guidelines. Implementation Science. 2017 Dec;12(1):1-2.
14. Dantas LO, de Fátima Salvini T, McAlindon TE. Knee osteoarthritis: key treatments and implications for physical therapy. Brazilian Journal of Physical Therapy. 2021 Mar 1;25(2):135-46.
15. Katz J, Brophy R, Chaisson C, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. NEJM. Mar 19 2013; DOI: 10.1056/NEJMoa1301408.
16. Pinto D, Robertson M, Abbott J, et al. Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee. 2: economic evaluation alongside a randomized controlled trial. Osteoarthritis andCartilage. 2013; joca.2013.06.014.
17. Fransen M, McConnell S, Harmer A, et al. Exercise for osteoarthritis of the knee. Br J Sports Med. 2015; 49 (24):1554-1557.
18. Chu IJ, Lim AY, Ng CL. Effects of meaningful weight loss beyond symptomatic relief in adults with knee osteoarthritis
and obesity: a systematic review and meta‐analysis. Obesity Reviews. 2018 Nov;19(11):1597-607.
19. Hall M, Castelein B, Wittoek R, Calders P, Van Ginckel A. Diet-induced weight loss alone or combined with exercise in overweight or obese people with knee osteoarthritis: a systematic review and meta-analysis. In Seminars in Arthritis and Rheumatism 2019 Apr 1 (Vol. 48, No. 5, pp. 765-777). WB Saunders.
20. Messier SP, Mihalko SL, Legault C, Miller GD, Nicklas BJ, DeVita P, Beavers DP, Hunter DJ, Lyles MF, Eckstein F,Williamson JD. Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: the IDEA randomized clinical trial. JAMA. 2013 Sep 25;310 (12):1263-73.
21. Nyvang J, Hedström M, Gleissman SA. It's not just a knee, but a whole life: A qualitative descriptive study on patients’ experiences of living with knee osteoarthritis and their expectations for knee arthroplasty. International Journal of Qualitative Studies on Health and Well-being. 2016 Jan 1;11(1):30193.
22. Dantas LO, Moreira RD, Norde FM, Mendes Silva Serrao PR, Alburquerque-Sendín F, Salvini TF. The effects of cryotherapy on pain and function in individuals with knee osteoarthritis: a systematic review of randomized controlled trials. Clinical Rehabilitation. 2019 Aug;33(8):1310-9.
23. Bannuru RR, Osani MC, Vaysbrot EE, Arden NK, Bennell K, Bierma-Zeinstra SM, Kraus VB, Lohmander LS, AbbotJH, Bhandari M, Blanco FJ. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis and Cartilage. 2019 Nov 1;27(11):1578-89.