[h=3]From Dyna Med on OA:
Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
Management[/h]
- Exercise therapy (including physical therapy) and weight loss (if indicated) are the mainstays of nonsurgical management of symptomatic knee OA. [LIST]
- Self-management programs are recommended for patients with knee OA (Strong recommendation); primary components of self-management programs include patient education, weight management, exercise, use of assistive/adaptive devices, and appropriate footwear. [LIST]
- Weight loss is recommended for patients with BMI ≥ 25 kg/m[SUP]2[/SUP] (Strong recommendation).
- Patients should participate in a regular (daily) exercise program (matching his or her ability) (Strong recommendation).
- Consider the use of walking aids, assistive technology, and adaptations at home and/or work to reduce pain and increase participation in daily activities (Weak recommendation).
- A walking cane should be used on the contralateral side.
- Patients should receive individualized therapeutic exercise programs, with primary components including (Strong recommendation): [LIST]
- strengthening exercise
- low-impact aerobic exercise
- neuromuscular reeducation
- adjunctive range of motion and stretching exercises
- physical modalities such as ice or heat therapy, therapeutic ultrasound, or electrical stimulation (such as transcutaneous electrical nerve stimulation [TENS] or neuromuscular electrical stimulation [NMES])
- manual therapy (Weak recommendation)
- nonelastic therapeutic knee taping (also called Leukotaping, McConnell taping, and patellar taping) (in patients with patellofemoral OA) (Weak recommendation)
- valgus knee braces (in patients with medial knee OA)
- In patients for whom nonpharmacologic treatments are not effective, consider acetaminophen (up to 4 g/day), a topical nonsteroidal anti-inflammatory drug (NSAID) (such as diclofenac or ketoprofen), or an oral NSAID (Weak recommendation).
- In patients ≥ 75 years old or patients at risk for adverse effects from oral NSAIDs, use a topical NSAID such as diclofenac or ketoprofen (Strong recommendation) or consider acetaminophen (Weak recommendation).
- Consider adding acetaminophen to NSAID treatment for symptom control.
- Consider corticosteroid injections in patients with a knee OA flare (joint inflammation and effusion) (Weak recommendation).
- In patients with inadequate response to first-line pharmacologic agents, consider tramadol or duloxetine (Weak recommendation).
- Consider nontramadol opioids only in patients without any other medical or surgical options, and persistent symptoms (Weak recommendation).
- Consider hyaluronic acid injections (viscosupplementation) only in patients with less advanced OA who do not respond to other treatments (Weak recommendation) and who are < 65 years old.
- Dietary and herbal therapies that may be considered include curcumin (turmeric extract), or ginger.
- Do not recommend glucosamine and chondroitin for patients with symptomatic knee OA (Strong recommendation).
- Consider enrollment in a Tai Chi program as part of nonpharmacologic management of OA of the knee (Weak recommendation).
- Other alternative therapies to consider include: [LIST]
- yoga
- massage therapy
- balneotherapy (spa therapy/mineral baths)
- magnet therapy
- whole body vibration
- mud pack therapy
- leech therapy
- Acupuncture is not recommended for most patients with symptomatic knee OA (Strong recommendation), but acupuncture may be considered if chronic moderate-to-severe pain is present and the patient is a candidate for total knee arthroplasty (TKA) but is unwilling to have the procedure, has comorbid conditions, or is taking concomitant medication that contraindicates surgery (Weak recommendation).
- Moxibustion, a type of acupuncture with higher-quality evidence of efficacy, may be considered in the management of knee OA.
- Base type and timing of surgery on the patient's symptoms and degree of suffering (impact on quality of life and activities of daily living), stage of knee OA, age, physical activity level, and comorbidities.
- Joint-preserving surgery: [LIST]
- Consider high tibial osteotomy (HTO) only in active patients with symptomatic medial knee OA and varus knee alignment (Weak recommendation).
- Consider distal femoral osteotomy (DFO) only in patients with substantial knee valgus (> 10-15 degrees between anatomic and mechanical axes) and lateral compartment knee OA.
- Arthroscopic surgery (knee debridement and/or lavage) is not recommended for most patients with symptomatic knee OA (Strong recommendation); however, it may be considered for short-term symptom relief in select patients (such as those wanting to delay more invasive procedures such as total knee arthroplasty).
- Consider unicompartmental knee arthroplasty (UKA) in younger patients with less severe knee OA which is limited to 1 compartment.
- Consider TKA in patients with knee OA not achieving adequate pain relief and functional improvement from both nonpharmacologic and pharmacologic treatment (Weak recommendation).
