VA/DoD CLINICAL PRACTICE GUIDELINE FOR …
VA/DoD CLINICAL PRACTICE GUIDELINE FOR
THE NON-SURGICAL MANAGEMENT OF HIP &
KNEE OSTEOARTHRITIS
Department of Veterans Affairs
Department of Defense
QUALIFYING STATEMENTS
The Department of Veterans Affairs and the Department of Defense guidelines are based upon the best
information available at the time of publication. They are designed to provide information and assist
decision-making. They are not intended to define a standard of care and should not be construed as one.
Neither should they be interpreted as prescribing an exclusive course of management.
This Clinical Practice Guideline is based on a systematic review of both clinical and epidemiological
evidence. Developed by a panel of multidisciplinary experts, it provides a clear explanation of the logical
relationships between various care options and health outcomes while rating both the quality of the
evidence and the strength of the recommendations.
Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of
individual patients, available resources, and limitations unique to an institution or type of practice. Every
healthcare professional making use of these guidelines is responsible for evaluating the appropriateness of
applying them in the setting of any particular clinical situation.
These guidelines are not intended to represent TRICARE policy. Further, inclusion of recommendations for
specific testing and/or therapeutic interventions within these guidelines does not guarantee coverage of
civilian sector care. Additional information on current TRICARE benefits may be found at tricare.mil
or by contacting your regional TRICARE Managed Care Support Contractor.
Version 1.0 ¨C 2014
Prepared by:
THE NON-SURGICAL MANAGEMENT OF HIP & KNEE OSTEOARTHRITIS
Working Group
With support from:
The Office of Quality and Performance, VA, Washington, DC
&
Office of Evidence Based Practice, US Army Medical Command
Version 1.0 ¨C 2014
Table of Contents
Executive Summary ............................................................................................................................................................... 5
Background ............................................................................................................................................................................ 7
Methods................................................................................................................................................................................. 8
Scope and Structure .............................................................................................................................................................. 9
Guideline Working Group ................................................................................................................................................... 14
Recommendations .............................................................................................................................................................. 15
Algorithm ............................................................................................................................................................................. 17
Module A: Diagnosis & Evaluation ...................................................................................................................................... 18
A1.
History & Physical Examination ............................................................................................................... 18
A2.
Plain Radiography ..................................................................................................................................... 19
A3.
Magnetic Resonance Imaging (MRI) ........................................................................................................ 20
A4.
Routine Use of Laboratories and Synovial Fluid Analysis........................................................................ 21
Module B: Core Non-Surgical Treatment Principles........................................................................................................... 22
B1.
Patient Education ..................................................................................................................................... 22
B2.
Comprehensive Management Plan ......................................................................................................... 22
B3.
Weight Reduction in Patients with Knee or Hip Osteoarthritis and Elevated BMI ................................ 24
Module C: Physical Therapy Approaches ........................................................................................................................... 26
C1.
Manual Physical Therapy ......................................................................................................................... 26
C2.
Aquatic Therapy ....................................................................................................................................... 26
C3.
Walking Aids ............................................................................................................................................. 28
Module D: Pharmacologic Therapies .................................................................................................................................. 30
D1.
Acetaminophen and Non-steroidal Anti-inflammatory Drugs................................................................ 30
D2.
Topical Capsaicin ...................................................................................................................................... 36
D3.
Other Pain Management Pharmacotherapies ........................................................................................ 38
D4.
Intra-articular Injections (Corticosteroids and Hyaluronic Acid) ............................................................ 40
Module E: Complementary & Alternative Medicine .......................................................................................................... 43
E1.
Nutritional Supplements/Nutraceuticals/Dietary Supplements ............................................................ 43
E2.
Acupuncture and Chiropractic Care......................................................................................................... 45
Module F. Referrals for Surgical Consultation .................................................................................................................... 47
Appendix A: Guideline Development Process .................................................................................................................... 50
Introduction .................................................................................................................................................................... 50
Methodology ................................................................................................................................................................... 50
Appendix B: Evidence Table ................................................................................................................................................ 83
Clinical Practice Guideline for the Non-Surgical Management of Osteoarthritis
Page 3 of 126
Appendix C: Patient History and Physical Examination ..................................................................................................... 88
Knee History .................................................................................................................................................................... 88
Knee Physical Examination ............................................................................................................................................. 88
Hip History ....................................................................................................................................................................... 88
Hip Physical Examination ................................................................................................................................................ 88
Appendix D: Pharmacologic Therapies ............................................................................................................................... 89
Tramadol ......................................................................................................................................................................... 89
Non-Tramadol Opioids.................................................................................................................................................... 92
Corticosteroids versus Placebo ...................................................................................................................................... 93
Hyaluronate/Hylan (HA) ................................................................................................................................................. 94
Corticosteroids versus Hyaluronate/Hylan .................................................................................................................... 96
Corticosteroid Injection prior to Hip or Knee Arthroplasty ........................................................................................... 97
Appendix E: Nutraceuticals and Dietary Supplements .................................................................................................... 103
Appendix F: Participants List ............................................................................................................................................. 108
Appendix G: References .................................................................................................................................................... 110
Clinical Practice Guideline for the Non-Surgical Management of Osteoarthritis
Page 4 of 126
Executive Summary
According to the Centers for Disease Control and Prevention (CDC), 13.9 percent of adults age 25 years
and older and 33.6 percent of adults age 65 years and older are affected by osteoarthritis (OA).
Arthritis appears to be a significant burden among Veterans of the United States (US) Armed Forces.
[1] Research suggests that military service-related overuse and injuries may be a contributing factor
for the increased risk of developing OA. One study examined the incidence of OA among active duty
US Service Members between 1999 and 2008 where they concluded that rates of OA were
¡°significantly higher in military populations than in comparable age groups in the general population.¡±
Severe OA of the hip and knee causes debilitating pain and is a common cause of mobility impairment
in elderly patients. [2]
The Department of Veterans Affairs (VA) and Department of Defense (DoD) have an obligation to
ensure that all patients with OA receive a full range of high quality care. This clinical practice guideline
(CPG) recommends a framework that includes a structured evaluation and diagnosis of Veterans and
Service Members who may be suffering from hip and knee OA. Additionally, the CPG provides
treatment options, including pharmacological, non-pharmacological, complementary and alternative
medicine, as well as options for referral for surgical consultation.
Topics discussed in this CPG include:
?
Diagnosis and evaluation of OA
?
Comparative effectiveness of pharmacological therapies for OA
?
Comparative effectiveness of non-pharmacologic therapies
?
Comparative effectiveness of complementary and alternative medicine
?
Referrals for surgical consultation
OA is typically diagnosed based on the patient¡¯s medical history and a physical examination. Patients
with OA may have morning joint stiffness that usually resolves within 30 minutes. As the disease
progresses, prolonged joint stiffness and joint enlargement may also become evident. Although
radiographs are not required to make a diagnosis of knee OA, they can be used to confirm the
diagnosis and to rule out fracture, osteonecrosis, malignancy, or other conditions. Primary care
providers could consider radiographs such as the weight-bearing tunnel or Rosenberg view to aid in
differential diagnosis and guide the overall treatment plan.
A management plan for a patient with OA involves a partnership between the patient and primary
care provider to develop an individualized course of treatment that can provide optimal results.
Decisions regarding pharmacological therapy should be based on a risk benefit assessment, patient
preference, and resource utilization. This process will allow selection of pharmacologic agents with
proven benefit to be used in conjunction with non-pharmacologic interventions. Non-pharmacologic
therapies (i.e., physical therapy (including aquatic therapy, land-based strength therapy, and manual
physical therapy), as well as acupuncture and chiropractic care) should also be considered during the
development of a patient¡¯s management plan. Lastly, the primary care provider may consider referral
Clinical Practice Guideline for the Non-Surgical Management of Osteoarthritis
Page 5 of 126
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