What are the guidelines on nonpharmacologic treatment of knee osteoarthritis (OA)?

Updated: Jun 10, 2020
  • Author: Carlos J Lozada, MD; Chief Editor: Herbert S Diamond, MD  more...
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Answer

The Osteoarthritis Research Society International (OARSI) guidelines provide separate recommendations for treatment of symptomatic arthritis in one or both knees (knee-only OA) and in the knee(s) in addition to other joints (eg, hip, hand, spine, etc). Separate recommendations are made based on the absence or presence of comorbidities (ie, diabetes; hypertension; cardiovascular disease; kidney failure; gastrointestinal (GI) bleeding; depression; or physical impairment limiting activity, including obesity). The following nonpharmacologic recommendations apply to all subphenotypes [69] :

  • Biomechanical interventions such as knee braces, knee sleeves, and foot orthoses as directed by an appropriate specialist
  • Land-based exercise and strength training
  • Aquatic exercise
  • Self-management and education
  • Weight management

The OARSI recommmends use of a cane in knee-only OA to diminish pain and improve function and some aspects of quality of life. However, there was a lack of evidence for benefit in mutiple-joint OA. The guidelines noted that cane use could be inappropriate for some patients because relieving knee pain may require an increase in the weight-bearing load on other affected joints (eg, contralateral hand and hip joints). [69]

For multiple-joint OA with comorbidities, balneotherapy (defined as the use of baths containing thermal mineral waters) is recommended and includes practices such as Dead Sea salt or mineral baths, sulfur baths, and radon-carbon dioxide baths. [69]  

Updated and expanded OARSI guidelines provide the following recommendations on treatment of patients with knee OA [153] :

  • Core treatments include arthritis education and structured land-based exercise programs with or without dietary weight management.
  • Topical nonsteroidal anti-inflammatory drugs (NSAIDs) are strongly recommended.
  • For individuals with gastrointestinal comorbidities, the use of cyclooxygenase (COX)-2 inhibitors or NSAIDs with proton pump inhibitors (PPIs) is recommended.
  • For individuals with cardiovascular comorbidities or frailty, the use of any oral NSAID is not recommended.
  • Intra-articular (IA) corticosteroids, IA hyaluronic acid, and aquatic exercise are recommended, depending upon comorbidity status.
  • The use of acetaminophen (paracetamol) is conditionally not recommended.
  • The use of oral and transdermal opioids is strongly not recommended.

For knee osteoarthritis, the American College of Rheumatology (ACR)/Arthritis Foundation recommends the following regarding nonpharmacologic measures [152] :

  • Exercise is strongly recommended; balance exercises are conditionally recommended
  • Weight loss is strongly recommended for patients who are overweight or obese
  • Self‐efficacy and self‐management programs are strongly recommended
  • Tai chi is strongly recommended
  • Yoga is conditionally recommended
  • Cognitive behavioral therapy is conditionally recommended
  • Cane use is strongly recommended for patients in whom disease in 1 or more joints is causing a sufficiently large impact on ambulation, joint stability, or pain to warrant use of an assistive device
  • Tibiofemoral knee braces are strongly recommended for patients in whom disease in 1 or both knees is causing a sufficiently large impact on ambulation, joint stability, or pain to warrant use of an assistive device, and who are able to tolerate the associated inconvenience and burden associated with bracing
  • Patellofemoral braces are conditionally recommended for patients with patellofemoral knee OA in whom disease in 1 or both knees is causing a sufficiently large impact on ambulation, joint stability, or pain to warrant use of an assistive device.
  • Kinesiotaping is conditionally recommended
  • Modified shoes and lateral and medial wedged insoles are conditionally recommended  against
  • Acupuncture is conditionally recommended
  • Thermal interventions (locally applied heat or cold) are conditionally recommended
  • Radiofrequency ablation is conditionally recommended
  • Massage therapy is conditionally recommended  against
  • Manual therapy with exercise is conditionally recommended  against over exercise alone
  • Pulsed vibration therapy is conditionally recommended  against 
  • Transcutaneous electrical stimulation (TENS) is strongly recommended  against

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