Managing Patients with Knee Osteoarthritis
Part I: Introduction and Diagnosis
By James W. Brantingham DC, PhD; Gary Globe, MBA, DC, PhD; Tammy Kay Cassa, DC; Debra Bonnefin, DC, MAppSc, DACRB
Some practitioners may ask why a DC should treat knee osteoarthritis (KOA) or any joint-specific pathology. Much discussion has occurred along these lines between narrow- and broad-scope chiropractic practitioners. In our opinion, there is no way to separate the treatment of injury/pathology in appendicular joints from axial spinal joint problems. The body is a closed kinetic chain, and any change in joint function could be expressed above or below the initially affected joint. To optimally treat spinal joints, the DC must evaluate and treat, as necessary or indicated, any primary joint dysfunction in the appendicular system, with the same being true for the optimal treatment of appendicular joint conditions.
It is incumbent upon practitioners to be competent as to the standard of care for pathological conditions affecting joints throughout the body, including the soft tissues. That includes being knowledgeable in literature associated with the treatment of any condition related to that joint and staying up to date with continuing education. As with many other conditions, clinical experience and judgment coupled with individual patient needs, preference and presentation, are important factors in managing patients with KOA. This paper is not meant to be used as a “cookbook,” and its recommendations should be appropriately modified according to patient safety and need.
Knee osteoarthritis is the major cause of chronic musculoskeletal pain, disability and decreased mobility in elderly populations, especially women and minorities 50 years of age or older. Increased cardiovascular risk, fall risk and depression are present in 30 percent of those suffering with KOA by age 60.1-8,27Prevalence varies from 4 percent in young adults to 80 percent in those aged 65 or over.3,9 Annual financial costs in the United States associated with arthritis, including KOA, reached $128 billion in 2003.3,6,9-11 One in five people, or approximately 46 million people, have had physician-diagnosed arthritis. In 2003, this resulted in 992,100 hospitalizations, 44 million outpatient visits and 5 percent reporting decreased ability to work.1,6,10,12-14These numbers will rise with the large aging cohort of baby boomers.
The etiology of KOA is unknown, but damage to chondrocytes (cartilage) may potentially cause osteoarthritis (OA). Inflammation is typically mild and isolated to the peri-articular tissues.15 Previous injury, female gender, obesity, overuse, increasing age, decreased bone density, incongruent and/or unequal joint spacing and genetic predisposition are frequently associated risk factors.7,15-18
Common pharmacological KOA treatment consists of non-steroidal anti-inflammatory drugs (NSAIDS) and/or acetaminophen. However,15 percent to 30 percent of people are unable to tolerate NSAIDS due to gastrointestinal injuries, cardiovascular injuries, ulcers, myocardial infarction and stroke.19-23 Furthermore, NSAIDS have no impact on KOA progression.1 Each year NSAID use results in hospitalization of more than 100,000 people and has a higher related mortality rate than that of AIDS in the United States. Invasive arthroplasty also carries serious risks and should be a last resort.21-34Arthroscopic KOA surgery has been found to achieve outcomes no better than placebo, while cost-effectiveness for arthroplasty is currently under the microscope secondary to the frequency of costly initial failure and need for repeat surgeries, which can double the cost.29 This leaves few safe and effective conservative treatment options. 22-30,35
Rehabilitation or exercise therapy is of limited, short-term value in reducing knee pain and improving function.28 Combined manipulative therapy and rehabilitation may be superior and significantly more efficacious for KOA and other lower-extremity arthritis than rehabilitation or exercise alone.1,25,36,37 However, despite the success of manual therapeutic interventions in the treatment of KOA reported in the literature, confirmatory studies are needed.3,12,25,36,38-40 Nevertheless, based on the current level of evidence, the Osteoarthritis Research Society International, Bronfort et al., and other evidence-based consensus guidelines support a trial of rehabilitation, with and without manipulative therapy, as a first-line treatment in KOA.1,26,41-45
If delivered by a suitably educated chiropractor, these combined treatments may provide a safe, efficacious and potentially cost-minimizing relief to patients with problematic KOA. Side effects, when they occur, appear to be minimal stiffness and pain that resolves. Severe adverse reactions have not been reported.46-51 Therefore, recommendations will be suggested for management of KOA based on manual therapy and rehabilitation trials.25,28 However, determining the best rehabilitative program (high-tech, low-tech, one-on-one, group or home-based program), or dosage (type, frequency, intensity or duration) is neither fully clear nor established.1,28 Interestingly, “low-tech” rehabilitation using simple floor exercise, elastic bands and slow, careful increases in walking, progressing toward aerobic walking, appears helpful—as helpful for the average patient as “high-tech” rehabilitation.25,28,52
It should come as no surprise that DCs are the most frequent complementary and alternative medicine (CAM) providers in the United States treating back and neck disorders. Doctors of chiropractic also frequently provide CAM physical treatment for KOA in Britain, the United States, Australia and other developed countries.3,12,27,36,38,41,53,54 Three RCTs have demonstrated that manipulative therapy alone decreased pain and disability, as well as increased function and range of motion in KOA.3,12,24 Because manual therapy trials that have included exercises have the strongest evidence, and rehabilitation is the standard of care among allopathic and allied health practitioners, exercises should be added to any manipulation/mobilization intervention for KOA.25,28
Many DCs utilize full kinetic chain manipulative therapy (FKC), based on the work of Illi, Gillet and Faye.36,55-58 The principal explanation for this approach is that the entire locomotor system is interconnected, so a change in function at one joint may be compensated at a proximal or distal site/joint.57-60 The most frequently recognized occurrence may be in the spine where a prolonged hypomobility may trigger hypermobility and/or compensation at another proximal and/or distal site.61,62
Applying this model to KOA, the DC might include manipulative (operationally defined as manipulation and/or mobilization) therapy to not only the knee, but also any indicated appendicular or axial joint where joint hypomobility was assessed.
There is biological plausibility and there is clinical evidence that FKC, along with rehabilitation may be efficaciously superior to local treatment for KOA.1,3,12,25,36,37,63-65 Strikingly, recent magnetic resonance imaging studies suggest manipulative therapy for KOA may even increase lost cartilage volume and space.36,37,66,67 Joint dysfunction, known as subluxation, in both the appendicular and axial skeleton, is assessed by physical examinations and other functional assessments, such as those comprised by the Medicare-based “PARTS” formula.
Diagnosis of KOA is primarily clinical and should be made based on American College of Rheumatology (ACR) guidelines.68 Patients who fulfill the ACR guidelines should have a radiographic study of the knee to rule out a severe level (grade 4) of OA and other exclusionary pathology, such as avascular necrosis or severe osteoporosis.25 At this time, for the average practitioner in the United States, it is recommended for medico-legal reasons that only KOA patients with grade 0-3 OA be treated.25,37 Additionally, a patient using an assistive device for more than 25 percent of the day may not be a candidate for this care and should be referred or co-managed with a medical practitioner.
The degree of KOA can be determined by using the Kellgren-Lawrence (K-L) grading scale (0-4). Even with lesser grades, 0 to 2 of KOA, there is still a minimal but nevertheless potential risk associated with manipulative and/or rehabilitative intervention justifying necessity for X-ray in many cases.69
ACR guidelines include self-report of knee pain for at least six to 12 months and certain examination findings. Examination findings include either: 1) knee pain and crepitus with active motion, and morning stiffness of at least 30 minutes with or without bony enlargement or 2) knee pain with bony enlargement but no crepitus.25,68 Joint dysfunction/subluxation (JD/S) should also be present.
Next Month: KOA and chiropractic manipulative therapy
James W. Brantingham, DC, PhD, is director of research and associate professor of Cleveland Chiropractic College Los Angeles, as well as adjunct research faculty of Durban University of Technology, South Africa. Gary Globe, MBA, DC, PhD, is provost and academic dean at Cleveland Chiropractic College Los Angeles. Tammy Kay Cassa, DC, is research assistant and instructor at Cleveland Chiropractic College Los Angeles. Debra Bonnefin, DC, MAppSc, DACRB, is clinician and assistant professor at Cleveland Chiropractic College Los Angeles. For questions about the paper, e-mailjame[email protected].
1. Zhang W, Moskowitz R, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis and Cartilage. 2008;16:137-162.
2. Fransen M, McConnell S, Bell M. Exercise for osteoarthritis of the hip or knee. Cochrane Database Syst Rev.2003(3):CD004286.
3. Fish D, Kretzmann H, Brantingham JW, Globe G, Korporaal C, Moen J. A randomized clinical trial to determine the effect of combining a topical capsaicin cream and knee joint mobilization in the treatment of osteoarthritis of the knee. J Amer Chiropr Assoc. 2008 Aug;45(6):8-23.
4. Salaffi F, Cavalieri F, Nolli M, Ferraccioli G. Analysis of disability in knee osteoarthritis. Relationship with age and psychological variables but not with radiographic score. J Rheumatol. 1991 Oct;18(10):1581-1586.
5. Axford J, Heron C, Ross F, Victor CR. Management of knee osteoarthritis in primary care: pain and depression are the major obstacles. J Psychosom Res. 2008 May;64(5):461-467.
6. National Center for Chronic Disease Prevention and Health Promotion: Arthritis (CDC).www.cdc.gov/nccdphp/publications/aag/arthritis.htm. (Accessed 2/19/09).
7. Felson DT. Epidemiology of hip and knee osteoarthritis. Epidemiol Rev. 1988;10:1-28.
8. Felson DT, Zhang Y, Hannan MT, et al. The incidence and natural history of knee osteoarthritis in the elderly. The Framingham Osteoarthritis Study. Arthritis Rheum. Oct 1995;38(10):1500-1505.
9. Helewa A, Walker J. Epidemiology and economics of arthritis In: Walker JM, Helewa A, editors. Physical therapy in arthritis: W.B. Saunders Co; 1996 p. 13.
10. 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 Sep;87(9):1106-1119.
11. Yelin E, Murphy L, Cisternas M, Foreman A, Pasta D, Helmick C. Medical care expenditures and earnings losses among persons with arthritis and other rheumatic conditions in 2003, and comparisons to 1997. Arthritis Rheum. 2007;56(5):1397-1407.
12. Pollard H, Ward G, Hoskins W, Hardy K. The effect of a manual therapy knee protocol on osteoarthritic knee pain: a randomised controlled trial. J Can Chiropr Assoc. 2008 Dec;52(4):229-242.
13. Peat G, McCarney R, Croft P. Knee pain and osteoarthritis in older adults: a review of community burden and current use of primary health care. Ann Rheum Dis. 2001;60:91-97.
14. D'Ambrosia RD. Epidemiology of osteoarthritis. Orthopedics. 2005;28(2 Suppl):s201-205.
15. Hinton R, Moody RL, Davis AW, Thomas SF. Osteoarthritis: diagnosis and therapeutic considerations. Am Fam Physician. 2002 Mar 1;65(5):841-848.
16. Calliet R. Knee pain and disability: Pain series. 3rd ed. Philadelphia: F.A. Davis; 1992:190-202.
17. Creamer P, Hochberg M. Osteoarthritis. Lancet. 1997 Aug 16;350(9076):503-508.
18. Cooper C, Inskip H, Croft P, et al. Individual risk factors for hip osteoarthritis: obesity, hip injury, and physical activity. Am J Epidemiol. 1998 Mar 15;147(6):516-522.
19. Coles LS, Fries JF, Kraines RG, Roth SH. From experiment to experience: side effects of nonsteroidal anti-inflammatory drugs. Am J Med. 1983 May;74(5):820-828.
20. Graham GG, Graham RI, Day RO. Comparative analgesia, cardiovascular and renal effects of celecoxib, rofecoxib and acetaminophen (paracetamol). Curr Pharm Des. 2002;8(12):1063-1075.
21. Kuehn BM. FDA focuses on drugs and liver damage: labeling and other changes for acetaminophen. JAMA 2009 Jul 22;302(4):369-371.
22. McGettigan P, Henry D. Cardiovascular risk and inhibition of cyclooxygenase: a systematic review of the observational studies of selective and nonselective inhibitors of cyclooxygenase 2. JAMA 2006 Oct 4;296(13):1633-1644.
23. American Gastroenterological Association: www.gastro.org/wmspage.cfm?parm1=2. (Accessed_5/272008.)
24. Gandhi T, Weingart S, Borus J, et al. Adverse drug events in ambulatory care. NEJM 2003;348(16):1556-1564.
25. Delye 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 Dec;85(12):1301-1317.
26. Conaghan PG, Dickson J, Grant RL. Care and management of osteoarthritis in adults: summary of NICE guidance. BMJ2008 Mar 1;336(7642):502-503.
27. Tucker M, Brantingham J, Myburgh C. The relative effectiveness of a non-steroidal anti-inflammatory medication (meloxicam) versus manipulation in the treatment of osteoarthritis of the knee. Euro J Chiropr 2003;50(3):163-184.
28. Fransen M, McConnell S. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev. 2008(4):CD004376.
29. Moseley J, O’Malley K, Petersen N, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. NEJM2002;347(2):81-88.
30. Sturnieks DL, Tiedemann A, Chapman K, Munro B, Murray SM, Lord SR. Physiological risk factors for falls in older people with lower limb arthritis. J Rheumatol. 2004 Nov;31(11):2272-2279.
31. Malonne H, Coffiner M, Fontaine D, et al. Long-term tolerability of tramadol LP, a new once-daily formulation, in patients with osteoarthritis or low back pain. J Clin Pharm Ther. 2005 Apr;30(2):113-120.
32. Mongin G. Tramadol extended-release formulations in the management of pain due to osteoarthritis. Expert Rev Neurother. Dec 2007;7(12):1775-1784.
33. www.emedicinehealth.com/knee_joint_replacement/page10_em.htm. (Accessed 3/20/2009.)
34. Senay EC, Adams EH, Geller A, et al. Physical dependence on Ultram (tramadol hydrochloride): both opioid-like and atypical withdrawal symptoms occur. Drug Alcohol Depend. 2003 Apr 1;69(3):233-241.
35. Laupattarakasem W, Laopaiboon M, Laupattarakasem P, Sumananont C. Arthroscopic debridement for knee osteoarthritis. Cochrane Database Syst Rev. 2008(1):CD005118.
36. Brantingham JW, Globe G, Pollard H, Hicks M, Korporaal C, Hoskins W. Manipulative therapy of lower extremity conditions: expansion of a literature review. J Manipulative Physiol Ther. 2009;32(1):53-57.
37. Hoeksma HL, Dekker J, Ronday HK, et al. Comparison of manual therapy and exercise therapy in osteoarthritis of the hip: a randomized clinical trial. Arthritis Rheum. 2004 Oct 15;51(5):722-729.
38. Martinez DA, Rupert RL, Ndetan HT. A demographic and epidemiological study of a Mexican chiropractic college public clinic. Chiropr Osteopat. 2009 Mar;17(1):4.
39. Cheung CK, Wyman JF, Halcon LL. Use of complementary and alternative therapies in community-dwelling older adults. J Altern Complement Med. Nov 2007;13(9):997-1006.
40. Cambron JA, Cramer GD, Winterstein J. Patient perceptions of chiropractic treatment for primary care disorders. J Manipulative Physiol Ther. 2007 Jan;30(1):11-16.
41. Jordan KM, Sawyer S, Coakley P, Smith HE, Cooper C, Arden NK. The use of conventional and complementary treatments for knee osteoarthritis in the community. Rheumatology (Oxford). 2004 Mar;43(3):381-384.
42. Ottawa panel evidence-based clinical practice guidelines for therapeutic exercises and manual therapy in the management of osteoarthritis. Phys Ther. 2005 Sep;85(9):907-971.
43. Jamtvedt G, Dahm KT, Christie A, et al. Physical therapy interventions for patients with osteoarthritis of the knee: an overview of systematic reviews. Phys Ther. 2008 Jan;88(1):123-136.
44. Walsh NE, Hurley MV. Evidence based guidelines and current practice for physiotherapy management of knee osteoarthritis. Musculoskeletal Care. 2009 Mar;7(1):45-56.
45. Bronfort G, Haas M, Evans R, Leiniger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiropr Osteopat. 2010 Feb 25;18(1):3.
46. Skargren EI, Carlsson PG, Oberg BE. One-year follow-up comparison of the cost and effectiveness of chiropractic and physiotherapy as primary management for back pain. Subgroup analysis, recurrence, and additional health care utilization.Spine (Phila Pa 1976). 1998 Sep 1;23(17):1875-1883; discussion 1884.
47. Cambron JA, Gudavalli MR, McGregor M, et al. Amount of health care and self-care following a randomized clinical trial comparing flexion-distraction with exercise program for chronic low back pain. Chiropr Osteopat. 2006;14:19.
48. Enthoven P, Skargren E, Oberg B. Clinical course in patients seeking primary care for back or neck pain: a prospective 5-year follow-up of outcome and health care consumption with subgroup analysis. Spine (Phila Pa 1976). 2004 Nov 1;29(21):2458-2465.
49. Mosley C, Llava A. Cost-effectiveness of chiropractic care in a managed care setting. The American Journal of Managed Care. 1996;2:280-282.
50. Legorreta AP, Metz RD, Nelson CF, Ray S, Chernicoff HO, Dinubile NA. Comparative analysis of individuals with and without chiropractic coverage: patient characteristics, utilization, and costs. Arch Intern Med. 2004 Oct 11;164(18):1985-1992.
51. Nelson CF, Metz RD, LaBrot T. Effects of a managed chiropractic benefit on the use of specific diagnostic and therapeutic procedures in the treatment of low back and neck pain. J Manipulative Physiol Ther. 2005 Oct;28(8):564-569.
52. Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions for knee pain.Phys Ther. 2001 Oct;81(10):1675-1700.
53. Barnes P M, Powell-Griner E, McFann K, Nahin R L. Complementary and alternative medicine use among adults: United States, 2002. Adv Data. May 27 2004(343):1-19.
54. Barnes PM, Bloom B, Nahin R. Complementary and Alternative Medicine Use Among Adults and Children: United States 2007. nccam.nih.gov/news/camstats/. CDC National Health Statistics Report #12 Dec 2008.
55. Hoskins W, McHardy A, Pollard H, Windsham R, Onley R. Chiropractic treatment of lower extremity conditions: a literature review. J Manipulative Physiol Ther. 2006 Oct;29(8):658-671.
56. McHardy A, Hoskins W, Pollard H, Onley R, Windsham R. Chiropractic treatment of upper extremity conditions: a systematic review. J Manipulative Physiol Ther. 2008 Feb;31(2):146-159.
57. Illi F. High lights and 45 years of experience and 35 years of research Institute for the Study of Statics and Dynamics of the Human Body. Geneva; 1971.
58. Schafer RC, Faye LJ. Motion palpation and chiropractic technique:principles of dynamic chiropractic. Huntington Beach, CA: The Motion Palpation Institute; 1990.
59. Vaux P. Hip osteoarthritis: a chiropractic approach. Euro J Chiropr 1998;46(1):17-22.
60. Cliborne AV, Wainner RS, Rhon DI, et al. Clinical hip tests and a functional squat test in patients with knee osteoarthritis: reliability, prevalence of positive test findings, and short-term response to hip mobilization. J Orthop Sports Phys Ther. 2004 Nov;34(11):676-685.
61. Iverson CA, Sutlive TG, Crowell MS, et al. Lumbopelvic manipulation for the treatment of patients with patellofemoral pain syndrome: development of a clinical prediction rule. J Orthop Sports Phys Ther. 2008 Jun;38(6):297-312.
62. Suter E, McMorland G, Herzog W, Bray R. Decrease in quadriceps inhibition after sacroiliac joint manipulation in patients with anterior knee pain. J Manipulative Physiol Ther. 1999;22(3):149-153.
63. Brantingham JW, Globe GA, Jensen ML, et al. A feasibility study comparing two chiropractic protocols in the treatment of patellofemoral pain syndrome. J Manipulative Physiol Ther. 2009 Sep;32(7):536-548.
64. Dimou E, Brantingham J, Wood T. A randomized, controlled trial (with blinded observer) of chiropractic manipulation and Achilles stretching vs orthotics for the treatment of plantar fasciitis. J Amer Chiropr Assoc. 2004;41(9):32-42.
65. Cleland JA, Abbott JH, Kidd MO, et al. Manual physical therapy and exercise versus electrophysical agents and exercise in the management of plantar heel pain: a multicenter randomized clinical trial. J Orthop Sports Phys Ther. 2009 Aug;39(8):573-585.
66. Du N, Lu Y, Gu X, Hu J. [Magnetic resonance assessment the effect of manipulation on knee cartilaginous recovery of osteoarthritis]. Zhongguo Gu Shang. 2008 Nov;21(11):824-827.
67. Hu J, Du N, Lu Y, Dai LH. [Application of magnetic resonance imaging in evaluating the effects of manipulation on knee osteoarthritis]. Zhong Xi Yi Jie He Xue Bao. 2009 Feb;7(2):110-115.
68. Altman R. Criteria for classification of clinical osteoarthritis. J Rheumatol Suppl. Feb 1991;27:10-12.
69. Kellgren JH, Lawrence JS. Radiological assessment of osteo-arthrosis. Ann Rheum Dis. Dec 1957;16(4):494-502.