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Treatment of Osteoarthritis of the Knee: An Update Review
Comparative Effectiveness Reviews, No. 190
Investigators: Sydne J Newberry, PhD, John FitzGerald, MD, PhD, Nelson F SooHoo, MD, Marika Booth, MS, Joyce Marks, BS, Aneesa Motala, BA, Eric Apaydin, MS, MPP, Christine Chen, MD, Laura Raaen, MPH, Roberta Shanman, MLS, and Paul G Shekelle, MD, PhD.
Author Information and AffiliationsStructured Abstract
Objectives:
To assess the evidence for the efficacy of the following interventions for improving clinical outcomes in adults with osteoarthritis (OA) of the knee: cell-based therapies; glucosamine, chondroitin, or glucosamine plus chondroitin; strength training, agility, or aerobic exercise (land or water based); balneotherapy, mud bath therapy; electrical stimulation techniques (including transcutaneous electrical stimulation [TENS], neuromuscular electrical stimulation, and pulsed electromagnetic field therapy [PEMF]); whole body vibration; heat, infrared, or ultrasound; orthoses (knee braces, shoe inserts, or specially designed shoes); weight loss diets; and home-based therapy or self-management.
Data sources:
PubMed®, Embase®, the Cochrane Collection, Web of Science, and the Physiotherapy Evidence Database (PEDRO) from 2006 to September 2016, and ClinicalTrials.gov and the proceedings from the 2015 American College of Rheumatology annual meetings.
Review methods:
We included randomized controlled trials conducted in adults 18 years or over diagnosed with OA of the knee, comparing any of the interventions of interest with placebo (sham) or any other intervention of interest that reported a clinical outcome (including pain, function, and quality of life). We also included single-arm and prospective observational studies that analyzed the effects of weight loss in individuals with OA of the knee on a clinical outcome. Standard methods were used for data abstraction and analysis, assessment of study quality, and assessment of the quality of the evidence, according to the Agency for Healthcare Research and Quality Methods Guide. Findings were stratified according to duration of interventions and outcomes: short term (4–12 weeks), medium term (12–26 weeks), and long term (>26 weeks).
Results:
Evidence was insufficient to draw conclusions about the effectiveness of many interventions, largely due to heterogeneous and poor-quality study design, which limited the number of studies that met inclusion criteria and could be pooled.
Interventions that show beneficial effects on short-term outcomes of interest include TENS for pain (moderate strength of evidence [SoE]); strength and resistance training on Western Ontario and McMaster University Arthritis Index (WOMAC) total scores; tai chi on pain and function; and agility training, home-based programs, and PEMF on pain (low SoE).
Interventions that show beneficial effects on medium-term outcomes include weight loss for pain (moderate SoE) and function, intra-articular platelet-rich plasma on pain and quality of life, glucosamine plus chondroitin on pain and function, chondroitin sulfate alone on pain, general exercise programs on pain and function, tai chi on pain and function, whole-body vibration on function, and home-based programs on pain and function (low SoE).
Interventions that show beneficial long-term effects include agility training and general exercise programs for pain and function, and manual therapy and weight loss for pain (low SoE). Moderate SoE supports a lack of long-term benefit of glucosamine-chondroitin on pain or function, and glucosamine or chondroitin sulfate alone on pain. No consistent serious adverse effects were reported for any intervention.
Almost no studies conducted subgroup analysis to assess the participant characteristics associated with better outcomes, and few studies systematically compared interventions head to head. Additional limitations included lack of blinding and sham controls in studies of physical interventions and the potentially limited applicability of study results to patients seen in nonacademic health care settings.
Conclusions:
A variety of interventions assessed for their efficacy in treating OA of the knee in this review demonstrate shorter term beneficial effects on pain and function. With the exception of weight loss, agility training, and general exercise programs, few have been tested for or show long-term benefits. Larger randomized controlled trials are needed, with more attention to appropriate comparison groups and longer duration, to assess newer therapies and to determine which types of interventions are most effective for which patients.
Contents
- Preface
- Acknowledgments
- Technical Expert Panel
- Peer Reviewers
- Executive Summary
- Introduction
- Methods
- Results
- Results of Literature Searches
- Key Question 1a: What is the clinical effectiveness of cell-based therapies, oral glucosamine and/or chondroitin, physical treatment interventions, weight loss, or home-based and self-management therapies in patients with OA of the knee, compared with appropriate placebo/sham controls or compared with other active interventions? Key Question 1b: How do the outcomes of each intervention differ by the following population and study characteristics: sex, disease subtype (lateral, patellofemoral), severity (stage/baseline pain and functional status), weight status (body mass index), baseline fitness (activity level), comorbidities, prior or concurrent treatments (including self-initiated therapies), and treatment duration or intensity?
- Key Question 2a: What harms are associated with each intervention in patients with primary or secondary OA of the knee? Key Question 2b: How do the harms associated with each intervention differ by the following population or study characteristics: sex, disease subtype (lateral tibiofemoral, patellofemoral), severity (stage/baseline pain and functional status), weight status (body mass index), baseline fitness (activity level), comorbidities, prior or concurrent treatments (including self-initiated therapies), and treatment duration or intensity?
- Discussion
- References
- Abbreviations/Acronyms
- Appendix A. Search Strategy
- Appendix B. List of Excluded Studies
- Appendix C. Evidence Table for All Included Studies
- Appendix D. Data Abstraction Tools
- Appendix E. Strength of Evidence
- Appendix F. Quality of Included Studies
- Appendix G. Policies, Guidelines, Coverage, and Stakeholder Information on Interventions of Interest
- Appendix H. Adverse Events
- Appendix I. MCID Cutoffs
Suggested citation:
Newberry SJ, FitzGerald J, SooHoo NF, Booth M, Marks J, Motala A, Apaydin E, Chen C, Raaen L, Shanman R, Shekelle PG. Treatment of Osteoarthritis of the Knee: An Update Review. Comparative Effectiveness Review No. 190. (Prepared by the RAND Southern California Evidence-based Practice Center under Contract No. 290-2015-00010-I.) AHRQ Publication No.17-EHC011-EF. Rockville, MD: Agency for Healthcare Research and Quality; May 2017. www.effectivehealthcare.ahrq.gov/reports/final.cfm. DOI: https://doi.org/10.23970/AHRQEPCCER190.
This report is based on research conducted by the Southern California Evidence-based Practice Center under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2015-00010-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.
The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.
AHRQ or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality enhancement tools, or reimbursement or coverage policies, may not be stated or implied.
This report may periodically be assessed for the currency of conclusions. If an assessment is done, the resulting surveillance report describing the methodology and findings will be found on the Effective Health Care Program Web site at www.effectivehealthcare.ahrq.gov. Search on the title of the report.
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