Home Current Issue Previous Issues Published Ahead-of-Print Collections For Authors Journal Info
Skip Navigation LinksHome > 2009 - Volume 32 - Issue 1 > Recommendations for the Treatment of Knee Osteoarthritis, Us...
Journal of Geriatric Physical Therapy:
Systematic Reviews

Recommendations for the Treatment of Knee Osteoarthritis, Using Various Therapy Techniques, Based on Categorizations of a Literature Review

Thomas, Anthony1; Eichenberger, Gary1; Kempton, Curtis1; Pape, Darin1; York, Sarah1; Decker, Ann Marie MSA, PT, GCS1; Kohia, Mohamed PT, PhD1

Free Access
Article Outline
Collapse Box

Author Information

1Rockhurst University, Department of Physical Therapy, Kansas City, MO

Address all correspondence to: Mohamed Kohia, Rockhurst University, Department of Physical Therapy, 1100 Rockhurst Road, Kansas City, MO 64110

Ph: 816‐501‐4812 (mohamed.kohia@rockhurst.edu).

Collapse Box

Abstract

Purpose:: This literature review is to evaluate current research articles pertinent to physical therapy treatment of osteoarthritis (OA) of the knee. Osteoarthritis of the knee is an increasingly common diagnosis, with a prognosis that can lead to loss in an individual's functional abilities. Literature on the subject of OA and its physical therapy treatment is vast and current, however, obtaining and analyzing it can be time consuming and costly to a Physical Therapist. The primary aim of this paper is to review current trends for treatment of OA of the knee, and to compare each intervention for effectiveness. This article provides a systematic categorization as well as recommendations for physical therapists based on current (1996 or sooner) literature.

Methods:: Twenty‐two articles were located using various online databases, critically analyzed, and categorized using Sackett's levels of evidence. Recommendations for the treatment of OA of the knee by a physical therapist were then made.

Results:: Two grade A recommendations, 5 grade B recommendation, and 2 grade C recommendations were made from the categorization of the articles. This article also contains recommendations outside the scope of a therapist's practice, which a physical therapist could consider when treating a patient with knee osteoarthritis. Further research recommendations are also provided.

Back to Top | Article Outline

INTRODUCTION

Osteoarthritis (OA) is a disease characterized by the breakdown of articular joint cartilage, and often causes severe pain and disability.1‐4 In particular, the knee joint is most commonly affected, with more than 30% of adults over 60 years of age experiencing functional limitations, such as inability to perform Activities of Daily Living (ADL) or Instrumental Activities of Daily Living (IADL) due to OA of the knee.3,5,6 With the decrease in function an individual's quality of life is susceptible to deterioration. By 2020, the number of people with functional limitations due to OA of the knee is expected to rise to 11.6 million.3 Currently, health care costs related to OA of the knee are $60 billion per year.3

There are multiple interventions to treat OA of the knee. Current popular methods of treatment include, but are not limited to physical therapy based on practice pattern 4E; as well as nonsteroidal anti‐inflammatory drugs (NSAIDS), surgery, and knee capsule injections, which are commonly followed by physical therapy. It should be noted, however, that NSAIDs though frequently prescribed, often have significant side effects.2,5,7‐9 Arthroscopic surgery has not been shown to have a major role in the management of OA of the knee.3 Similarly, knee capsule injections have been shown to be equal to arthroscopy in effective management of the disorder.7 Exercise‐based interventions are extensive, and include pool‐based strengthening exercise, muscular strengthening, stretching, cardiovascular programs, and mechanical unloading.10,11 Modalities include, but are not limited to, knee bracing, heat, ice massage, cold packs, ultrasound, acupuncture, and taping.

Because the risk of disability due to OA of the knee is greater than that due to any other medical condition in aging adults,11 it is essential for physical therapists to have a thorough understanding of different treatment methods, if they wish to make an impact in the reduction of this risk. Due to a lack of systematic reviews on the effectiveness of physical therapy management of OA of the knee, as well as the conflicting evidence about modalities, the primary aim of this paper is to review current trends for treatment of OA of the knee, and to compare the effectiveness of each intervention. This article explores various methods of treating OA of the knee and makes recommendations for physical therapy management of the disorder.

Back to Top | Article Outline

METHODS

Several common databases and search engines that the authors were familiar with were used for this review, including PubMed, EBSCO, The Cochrane Library, and Google Scholar.12‐15 Articles included were written in English, peer‐reviewed, and published from 1996 to 2007. Key search words and phrases for the physical therapy treatment of knee osteoarthritis included “physical therapy or physiotherapy,” “knee osteoarthritis,” and “management or treatment.” Only studies that included a control group or presented a case report (ie, having true experimental design) of physical therapy management of knee osteoarthritis were included. Two additional articles evaluating acupuncture were also included, because they had sufficient scientific rigor, level of evidence, and close connection with rehabilitation. Previously conducted review articles on the subject of physical therapy management of knee osteoarthritis were excluded.

Five first year physical therapy students evaluated the studies selected for inclusion. The student's goals were to identify and classify the studies according to their quality and adherence to scientific rigor. The quality of each study was determined by using the rating system of Sackett's 5 levels of evidence, which then allows for 3 grades of recommendations to be made.16 The procedural rigor of each study was graded according to the list of criteria created previously by Megens and Harris.17

Sackett's levels of evidence include 5 hierarchal categories: Studies classified at Level I studies are randomized controlled trials with a sample size of 100 or more subjects, with a low incidence of false‐positive and false‐negative errors. Level II studies consist of randomized, controlled trials with a sample size of less than 100 subjects, with a high incidence of false‐positive and false‐negative errors. Level III studies consist of nonrandomized, concurrent, cohort comparisons between subjects that did and did not receive treatment. Level IV studies consist of nonrandomized, historical cohort comparisons between current subjects, who did receive treatment and former subjects who did not receive treatment. Level V studies consist of case series without control16

The grades of recommendations will be assigned in the following manner: a grade A recommendation is supported by at least one level I study, a grade B recommendation is supported by at least one level II study, and a grade C recommendation is supported by any combination of levels III, IV, or V studies.16,17 The grading of the recommendations is based purely on the level of scientific study. Scientific studies with higher levels should be considered as having increased validity, and therefore should be considered weighted higher by a physical therapist as a treatment option.

The scientific rigor of each study was evaluated using the following 6 criteria developed by Megens and Harris: (1) inclusion and exclusion criteria noted for the subjects and an operational definition of the clinical condition provided; (2) treatment methodology described adequately enough to allow replication; (3) outcome measures assessed for reliability; (4) validity of outcome measure's assessed; (5) blind assessment of outcome; and (6) accounting for attrition.17 Each study was assigned a “Y” for “yes” if it met the specific criteria and an “N” for “no” if it failed to meet the criteria. The scientific rigor is a broader spectrum of analysis of each article as compared to Sackett's levels of evidence and therefore gives the reader a more through inspection about specific aspects of each article. An increase in an article's scientific rigor should increase the confidence of the treating therapist in the validity of the article. Each article was independently evaluated by all 5 reviewers and graded according to Sackett's levels of evidence and Megens and Harris' criteria for scientific rigor to establish inter‐rater reliability. Any discrepancies between rater's grades were decided by a round‐table discussion over the articles. A rating was determined from the discussion or majority vote. Inter‐rater reliability was determined using an Intraclass Correlation Coefficient (ICC). ICC measures association and agreement for more than two raters.

Back to Top | Article Outline

RESULTS

Twenty‐two articles were found pertaining to physical therapy management of osteoarthritis of the knee. Fifteen of these articles met the inclusion criteria and were reviewed and evaluated according to Sackett's levels of evidence.16 A summary of the articles evaluated can be found in Table 1. The inter‐rater reliability for grading the articles according to Sackett's levels of evidence was ICC(3,1)=.93.

Table 1
Table 1
Image Tools
Table 1
Table 1
Image Tools
Table 1
Table 1
Image Tools

Studies included in this review either evaluated or described procedures or tools used in PT procedural interventions of OA of the knee. Four studies dealt with analysis or development of a tool to treat knee OA.18‐21 Ten studies evaluated the effects of exercise programs.4,5,7,20,22‐27 Two studies evaluated the use of acupuncture.2,28

A variety of techniques in physical therapy management of knee osteoarthritis were included in the articles presented in this study. Studies differed in research design, level of evidence, and type of intervention. The research design distribution of the articles consisted of the following: 13 studies2,4,5,7,10,18,20,23‐28 were randomized, controlled clinical trials, 2 studies were case studies,19,22 and one was a nonrandomized convenience sample trial.21

In order to determine the weight of evidence, articles were evaluated according to Sackett's levels of evidence. The results of this analysis produced 2 level I trials,2,25 12 level II trials,4,5,7,10,18,20,21,23‐28 and 2 level V trials.19,22 Studies were classified as level I or II trials based on randomization, presence of a control group and number of participants in each group. Level III and IV studies were nonrandomized cohort trials with or without a control group. Level V studies consisted of case studies or observational studies.

Grades of recommendation were developed based on these levels of evidence. Grade A recommendations were made according to level I results, Grade B recommendations were made according to level II studies and Grade C recommendations were made according to level III, IV, and V results.

Back to Top | Article Outline
Grade A Recommendations:

1. Class based exercise is more effective than home based exercise to decrease the pain associated with OA of the knee.25

2. True or electro acupuncture has been shown to relieve pain in patients with OA of the knee when compared to patients that received placebo or “sham” acupuncture.2,28

Back to Top | Article Outline
Grade B Recommendations:

1. Mechanical unloading using a Zuni Exercise System of patients with OA of the knee may not help with pain reduction.21

2. The use of a neoprene brace and/or therapeutic tape on patients with OA of the knee may help reduce pain and regain function.10,18

3. Patients that are treated in a clinic or classroom setting benefit more from exercise and manual therapy, than those patients given instructions for home based exercise.25,27

4. Aquatic or hydrotherapy has positive effects on the strengthening of patients with OA of the knee.20,23

5. Manual therapy and exercise is shown to increase quadriceps strength, while decreasing disability.4,5,7,26

Back to Top | Article Outline
Grade C Recommendations:

1. An evidence‐based exercise and health education program to inform patients of OA is useful in patient comprehension of the disease.19

2. Stretching, strengthening exercise, and perturbations are all useful interventions for aging adults with OA of the knee.22

The studies were assessed according to Megens and Harris' criteria for scientific rigor and the results are presented in Table 2. The inter‐rater reliability for this classification was ICC(3,1) = .93. Overall, the evaluations revealed a moderately strong attention to scientific rigor. All the studies contained inclusion and exclusion criteria as well as operational definitions. Only one study19 did not include enough information for the procedure to be replicated. Many studies did not include blinding.3,9,18,19,21,22,24,25 or accounting for attrition.8,19,21 The reliability2,5,22,24 and validity2,24 of measures used in the study were sometimes absent as well.

Table 2
Table 2
Image Tools
Back to Top | Article Outline

DISCUSSION

After a thorough literature search and filtering of numerous articles on osteoarthritis of the knee, the usefulness of various physical therapy interventions in the treatment of OA of the knee were determined. Sackett's levels of evidence offered a basis on which to categorize and assess various research articles, which led to numerous recommendations for physical therapy management of OA of the knee.

Megens and Harris' criteria for scientific rigor were also used in this review to categorize the articles. According to the criteria (Table 2), very few articles reviewed met each of the scientific rigors and this should be noted when accepting any recommendations from these studies.

While the recommendations of this review are based on varying degrees of scientific levels, it should be noted that none of them should be accepted without caution. The significant clinical recommendations that can be made from this review include:

1. Use of either neoprene sleeves or therapeutic tape to supplement the bone loss in patients with knee osteoarthritis;

2. Patients that receive therapy in direct contact from the therapist have lower pain and better Western Ontario and McMaster Osteoarthritis Index (WOMAC) scores than those that are given a take home therapeutic plan;

3. Class based exercise with instruction from a physical therapist is more effective than a home based exercise program;

4. Aquatic or hydrotherapy can be very useful in the treatment of OA;

5. Manual therapy has the ability to decrease pain and increase strength in for aging adults with OA of the knee.

A trend that was noted while reading and classifying articles was that patients who received treatment from a physical therapist directly showed better WOMAC scores and had decreased pain when compared to individuals that received no treatment for their knee osteoarthritis. Therefore, physical therapy is recommended to patients with OA of the knee in order to increase their functioning ability. Exercise is shown to be beneficial for patients suffering from OA of the knee, however, it is important that the program be designed properly. Two modalities were directly addressed in the studies reviewed. It should be noted that hot packs have been shown to be of little therapeutic value, while ultrasound, based on 2 studies, has shown contradicting evidence.4,7

Additional studies about the usefulness of physical therapy interventions in the treatment of knee osteoarthritis are needed in order to further support the role of a physical therapist in the recovery and adaptability of patients with OA of the knee. Furthermore, most operational definitions used in these studies relied on physician and radiological diagnosis of knee osteoarthritis. While this is currently acceptable, in the spirit of APTA Vision 2020, there should be an operational definition in place for the physical therapist to objectively determine the presence or absence of knee osteoarthritis. Finally, the base of research needs to be expanded assessing the usefulness of tools, such as neoprene braces and therapeutic tape, in the physical therapist's treatment of OA of the knee based on the preliminary success of these tools.10,18.

Back to Top | Article Outline

REFERENCES

1. Porth CM. Chapter 43: Disorders of the Skeletal System: Metabolic and Rheumatic Disorders. 1043-1047. In: Porth CM Essentials of Pathophysiology. 2nd ed. Lippincott Williams & Wilkins; 2006.

2. Berman BM, Lao L, Langenberg P, et al. Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee. Ann Intern Med. 2004;141:901.

3. Currier LL, Froehlich PJ, Carow SD, et al. Development of a clinical prediction rule to identify patients with knee pain and clinical evidence of knee osteoarthritis who demonstrate a favorable short-term response to hip mobilization. Phys Ther. 2007;87:1106.

4. Huang MH, Yang RC, Lee CL et al. Preliminary results of integrated therapy for patients with knee osteoarthritis. Arthritis Rheum. 2005;53:812-820.

5. Deyle GD, Henderson NE, Matekel RL, et al. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee. Ann Intern Med. 2000;132:173-181.

6. Maly MR, Costigan PA, Olney SJ. Contribution of psychosocial and mechanical variables to physical performance measures in knee osteoarthritis. Phys Ther. 2005;85:1318.

7. Deyle GD, Allison SC, Matekel RL et al. Physical therapy treatment effectiveness for osteoarthritis of the knee: A randomized comparison of supervised clinical exercise and manual therapy procedures versus a home exercise program. Phys Ther. 2005;85:1301.

8. Hurley M. Muscle dysfunction and effective rehabilitation of knee osteoarthritis: What we know and what we need to find out. Arthritis Rheum. 2003;49:444-452.

9. Roddy E, Zhang W, Docherty M et al. Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or knee- the MOVE consensus. Rheumatol. 2005;44:67.

10. Hinman RS, Crossley KM, McConnell J et al. Efficacy of knee tape in the management of osteoarthritis of the knee: Blinded randomized controlled trial BMJ. 2003;327:135.

11. Sharma L. Examination of exercise effects on knee osteoarthritis outcomes: Why should the local mechanical environment be considered? Arthritis Rheum. 2003;49:255-260.

12. Ebsco Information Services. Available at http://www.ebsco.com. Accessed Sept. 10, 2007-Oct 7, 2007.

13. Pubmed Central. National Library of Medicine. Available at: http://www.pubmedcentral.nih.gov. Accessed Sept. 10, 2007-Oct 7, 2007.

14. The Cochrane Library. Available at http://http://www3.interscience.wiley.com. Accessed Sept. 10, 2007-Oct 7, 2007.

15. Google Scholar. Available at http://scholar.google.com. Accessed Sept. 10, 2007-Oct 7, 2007.

16. Sackett DL. Rules of evidence and clinical recommendations of the use of antithrombotic agents. Chest. 1989; 95:2S-4S.

17. Megans A, Harris SR. Physical therapist management of lymphedema following treatment for breast cancer: a critical review of its effectiveness. Phys Ther. 1998;78:1302-1311.

18. Chuang SH, Huang MH, Chen TW et al. Effect of knee sleeve on static and dynamic balance in patients with knee osteoarthritis. J Med Sci. 2007;23:405-411.

19. De Jong ORW, Hopman-Rock M, Tak ECMP, et al. An implementation study of two evidence-based exercise and health education programmes for older adults with osteoarthritis of the knee and hip. Health Educ Res. 2004;19:316.

20. Hinman RS, Heywood SE, Day AR. Aquatic physical therapy for hip and knee osteoarthritis: Results of a singleblind randomized controlled trial. Phys Ther. 2007;87:32.

21. Mangione KK, Axen K, Haas F. Mechanical unweighting effects on treadmill exercise and pain in elderly people with osteoarthritis of the knee. Phys Ther. 1996;76:387-394.

22. Fitzgerald GK, Childs JD, Ridge TM, et al. Agility and perturbation training for a physically active individual with knee osteoarthritis Phys Ther. 2002;82:372-382.

23. Foley A, Hakbert J, Hewitt T et al. Does hydrotherapy improve strength and physical function in patients with osteoarthritis-a randomized controlled trial comparing a gym based and a hydrotherapy based strengthening programme. Ann Rheum Dis. 2003;62:1162-1167.

24. Hurley MV, Scott DL. Improvements in quadriceps sensorimotor function and disability of patients with knee osteoarthritis following a clinically practicable exercise regime. Br J Rheumatol. 1998;37:1181.

25. McCarthy CJ, Mills PM, Pullen R, et al. Supplementing a home exercise programme with a class-based exercise programme is more effective than home exercise alone in the treatment of knee osteoarthritis. Rheumatol. 2004;43:880.

26. Thorstensson CA, Roos EM, Petersson IF, et al. Six-week high-intensity exercise program for middle-aged patients with knee osteoarthritis: A randomized controlled trial. BMC Musculoskel Dis. 2005;6:1471.

27. Van Barr ME, Dekker J, Oostendorp RAB et al. Effectiveness of exercise in patients with osteoarthritis of hip or knee: Nine months' follow up. Ann Rheum Dis. 2001;60:1123-1130.

28. Sangdee C, Teekachunhatean S, Sananpanich K et al. Electroacupuncture versus diclofenac in symptomatic treatment of osteoarthritis of the knee: A randomized controlled trial. BMC Comp Altern Med. 2002;2:1472.

Key Words:: knee osteoarthritis; physical therapy; treatment; literature review

Copyright © 2009 the Section on Geriatrics of the American Physical Therapy Association

Login

Article Tools

Images

Share

Search for Similar Articles
You may search for similar articles that contain these same keywords or you may modify the keyword list to augment your search.