It has been well established that hip and knee osteoarthritis (OA) is one of the major causes of disease burden worldwide. There is currently no cure and joint replacement is typically reserved for advanced disease, whilst arthroscopy has been shown to have little or no benefit. For over 10 years now there has been substantial evidence supporting non-drug non-operative management strategies as the cornerstone of OA treatment (1).
All current clinical guidelines recommend aerobic exercise, resistance exercise, hydrotherapy and weight loss (for those who are overweight) for people with hip or knee OA. The American College of Rheumatology (ACR) guidelines strongly recommend these four interventions for all people with hip and knee OA, irrespective of disease severity, pain levels or functional status (2). In addition, a myriad of patient resources, websites, and consumer groups strongly support the use of these evidence-based interventions. But is this translating into action?
Our recent short report in Arthritis Care and Research examined the patterns of use of non-drug non-operative interventions, classified according to the ACR guidelines, among a large cohort of older adults with hip or knee OA (3). We also compared treatment use between those with hip and those with knee OA. To do this, 591 participants completed a survey on treatment usage prior to taking part in a number of clinical studies.
So what did we find? Perhaps not entirely surprisingly the use of non-drug non-operative interventions was low amongst the entire group of people with hip or knee OA. Participants were currently using a mean of less than one of the four strongly recommended interventions. Concerningly, 12% of the group had never used any of the interventions included in the questionnaire.
Making efforts to lose weight (50%) and shoe orthoses (30%) were the most commonly reported interventions being currently used. Our cohort was generally overweight to obese, thus weight loss was warranted in many participants. Strengthening (26%) and stretching (23%) exercises were the most common interventions that participants reported they had tried in the past but were no longer utilising. Although half reported making efforts to lose weight, very few were undertaking muscle strengthening, hydrotherapy or aerobic exercises, all of which are the strategies most strongly endorsed by international guidelines.
Interestingly, use of five treatments was significantly higher among those with knee OA than those with hip OA. It appears that people with knee OA are more likely to try non-drug non-operative treatments than those with hip OA, however there is no clear explanation for this.
So what are we to take from the findings, other than that there is a definite evidence-practice gap? Weight loss and exercise should be the first course of action in managing hip and knee OA. Both have well established research demonstrating their benefits, but are still being under-utilised by clinicians and patients. This questionnaire did not allow us to explore whether interventions had been prescribed by a health professional or were self-prescribed, but we know there is still uncertainty among both groups around the use and benefits of exercise for OA (4, 5). Improved and increased education is required if we are to move forward – an ongoing challenge for us all in bridging the evidence-practice gap.
About Kim Bennell
Kim is a Professor and Director of the Centre for Health, Exercise and Sports Medicine at the Department of Physiotherapy, University of Melbourne, and an NHMRC Principal Research Fellow. Her research is focused on the conservative management of musculoskeletal conditions particularly osteoarthritis. Kim has published over 250 papers and given over 100 keynote or invited presentations at interdisciplinary meetings around the world. Kim currently holds a NHMRC Program grant and Centre of Research Excellence with colleagues from the University of Queensland and University of Sydney. http://chesm.unimelb.edu.au/
References
1. Uthman OA, van der Windt DA, Jordan JL, Dziedzic KS, Healey EL, Peat GM, & Foster NE (2013). Exercise for lower limb osteoarthritis: systematic review incorporating trial sequential analysis and network meta-analysis. BMJ, 347 PMID: 24055922
2. Hochberg MC, Altman RD, April KT, Benkhalti M, Guyatt G, McGowan J, Towheed T, Welch V, Wells G, Tugwell P, & American College of Rheumatology (2012). American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis care & research, 64 (4), 465-74 PMID: 22563589
3. Hinman RS, Nicolson PJ, Dobson FL, & Bennell KL (2015). Use of nondrug, nonoperative interventions by community-dwelling people with hip and knee osteoarthritis. Arthritis care & research, 67 (2), 305-9 PMID: 25048646
4. Holden MA, Nicholls EE, Hay EM, & Foster NE (2008). Physical therapists’ use of therapeutic exercise for patients with clinical knee osteoarthritis in the United kingdom: in line with current recommendations? Physical therapy, 88 (10), 1109-21 PMID: 18703675
5. Holden MA, Nicholls EE, Young J, Hay EM, & Foster NE (2012). Role of exercise for knee pain: what do older adults in the community think? Arthritis care & research, 64 (10), 1554-64 PMID: 22511582