Non-Surgical Treatment of Knee Osteoarthritis: Multidisciplinary Italian Consensus on Best Practice

Figures & data

Table 1 Selected Guidelines

AAOS^Citation25	Treatment of osteoarthritis of the knee evidence-based guideline 2nd edition. 2013
VA/DoD^Citation18	Clinical practice guideline for the non-surgical management of hip & knee osteoarthritis. Version 1.0–2014
ESCEO^Citation96	An algorithm recommendation for the management of knee osteoarthritis in Europe and internationally: A report from a task force of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis – 2014
OARSI^Citation26	Guidelines for the non-surgical management of knee osteoarthritis – 2014
NICE^Citation27	Osteoarthritis: the care and management of osteoarthritis – 2014
ACR^Citation94	Recommendations for the Use of Nonpharmacologic and Pharmacologic Therapies in Osteoarthritis of the Hand, Hip, and Knee - 2012
RACGP^Citation17	Guideline for the management of knee and hip osteoarthritis. Second edition – 2018. Royal Australian College of General Practitioners.

Figure 1 Elaboration process of the consensus document.

Table 2 Consensus Table – Consensus Reached with 66% Favourable Votes

Recommendation	Full Agreement	Sufficient Agreement	Slight Disagreement	Total Disagreement	Consensus
General principles – Education and life style Patients with knee osteoarthritis should be provided with the information necessary to understand the disease and treatment objectives and to encourage them to make some changes to their life style, by adopting behaviour that may have a beneficial effect or at least avoid worsening the condition. The strategies proposed must take account of the peculiar features of each individual patient and their social and family setting.	76.3%	18.4%	0.0%	5.3%	Recommendation approved
General principles – Body weight control Body weight control is strongly recommended in patients with knee osteoarthritis. Obese or overweight patients should follow a weight loss program following an adequate multidisciplinary assessment. It is important to inform patients with a normal weight of the importance of maintaining their weight within the normal range.	92.1%	5.3%	0.0%	2.6%	Recommendation approved
Conservative treatments – Physical agents Consider the use of physical agents for the treatment of knee osteoarthritis. Interferential therapy, laser therapy, magnetotherapy and application of vibrational energy seem to be the most effective physical agents.	40.5%	29.7%	10.8%	18.9%	Recommendation approved
Conservative treatments – Therapeutic exercise Therapeutic exercise, which can even be performed at home, is recommended for treating patients with knee osteoarthritis.	75.0%	20.0%	5.0%	0.0%	Recommendation approved
Conservative treatments - Mind-body exercises Mind-body exercises (such as Hatha Yoga, Tai Chi Qigong and Tai Chi Sun style) can be taken into consideration as a therapeutic approach for patients with knee osteoarthritis.	27.5%	40.0%	15.0%	17.5%	Recommendation approved
Conservative treatments – Muscle-strengthening exercises Muscle-strengthening exercises (with or without other types of therapeutic exercises), with specific characteristics (type of resistance, type of contractions, method of supervision, intensity and duration of exercise program) can be indicated to treat knee osteoarthritis.	63.2%	23.7%	13.2%	0.0%	Recommendation approved
Conservative treatments – Aerobic exercises A short-term program of aerobic exercises (with or without muscle-strengthening exercises) can be considered in order to reduce pain, improve physical function and quality of life of people with knee osteoarthritis.	51.3%	30.8%	10.3%	7.7%	Recommendation approved
Conservative treatments - Hydrokinesitherapy Hydrokinesitherapy can be used for patients with knee osteoarthritis.	72.5%	25.0%	2.5%	0.0%	Recommendation approved
Conservative treatments - Balneotherapy Balneotherapy represents a complementary approach with short and long-term efficacy in terms of pain relief and articular function in patients with knee osteoarthritis. It is indicated above all in patients with comorbidities and/or contraindications for pharmacological treatment.	52.5%	22.5%	12.5%	12.5%	Recommendation approved
Conservative treatments - Acupuncture At present, there is little reliable evidence on the use of acupuncture in the management of patients with knee osteoarthritis.	50.0%	31.6%	5.3%	13.2%	Recommendation approved
Conservative treatments – Patellar taping At present, there is little reliable evidence on the use of patellar taping in the management of patients with knee osteoarthritis.	57.9%	28.9%	2.6%	10.5%	Recommendation approved
Intra-articular injections – Hyaluronic acid Intra-articular injections of hyaluronic acid are useful in the treatment of patients with knee osteoarthritis. The procedure can be repeated safely.	55.0%	30.0%	7.5%	7.5%	Recommendation approved
Intra-articular injections - Corticosteroids Intra-articular injections of corticosteroids are useful for short-term treatment of pain symptoms in patients with knee osteoarthritis. Particular attention should be paid to the potential damage caused by repeated use.	63.4%	26.8%	4.9%	4.9%	Recommendation approved
Intra-articular injections – Platelet-rich plasma At present, there is little reliable evidence on the use of intra-articular injections of platelet-rich plasma in the management of patients with knee osteoarthritis. No major safety problems have emerged up to now.	60.5%	31.6%	2.6%	5.3%	Recommendation approved
SYSADOAs – Glucosamine Glucosamine can be used for continuous treatment of the symptoms (pain and function) of knee osteoarthritis for at least 12 months. The data available in the literature suggest long-term efficacy for the prescription drug glucosamine sulfate but not for formulations containing other glucosamine salts.	52.5%	30.0%	5.0%	12.5%	Recommendation approved
SYSADOAs – Chondroitin Chondroitin can be considered for the treatment of symptoms (pain and function) in patients with knee osteoarthritis in the short term only (up to 6 months).	34.3%	48.6%	5.7%	11.4%	Recommendation approved
SYSADOAs – Diacerein Diacerein can only be considered for short-term treatment (< 3 months) in patients with knee osteoarthritis who can tolerate it.	37.5%	20.0%	30.0%	12.5%	Consensus NOT reached
SYSADOAs –Avocado soybean unsaponifiables The use of avocado soybean unsaponifiables is not supported by any scientific evidence.	79.5%	7.7%	5.1%	7.7%	Recommendation approved
Pharmacological therapy - NSAIDs The use of non-steroidal anti-inflammatory drugs (NSAIDs), including COX-2 inhibitors, can be considered for patients with knee osteoarthritis. The drug chosen should be administered at the lowest effective dose on pain and function for a limited period of time, considering the patient’s comorbidities and monitoring any adverse gastrointestinal, hepatic, cardiovascular and renal effects.	89.2%	10.8%	0.0%	0.0%	Recommendation approved
Pharmacological therapy - Opioids The use of opioids can be considered for the treatment of pain in patients with knee osteoarthritis in which NSAIDs are ineffective or contraindicated.	71.1%	26.3%	2.6%	0.0%	Recommendation approved
Pharmacological therapy – Paracetamol The administration of paracetamol can be considered in patients with knee osteoarthritis, but only slight pain relief is obtained.	51.3%	30.8%	10.3%	7.7%	Recommendation approved
Pharmacological therapy – Topical preparations The application of NSAIDs can be taken into consideration. The use of other topical preparations is not recommended in patients with knee osteoarthritis due to the lack of scientific evidence.	59.5%	24.3%	13.5%	2.7%	Recommendation approved
Walking aids The use of walking aids (walking stick, crutches, walking frame, etc.) may be appropriate for selected patients, taking into consideration also their individual comorbidities, preferences and capabilities. The patients must be taught to use the prescribed aids so as to ensure their efficacy and safety.	84.2%	13.2%	0.0%	2.6%	Recommendation approved
Walking aids - Braces At present, there is little reliable evidence on the use of knee braces for the management of patients with knee osteoarthritis.	52.8%	38.9%	2.8%	5.6%	Recommendation approved
Walking aids – Foot orthoses At present, there is little reliable evidence on the use of foot orthoses for the management of patients with knee osteoarthritis.	72.2%	25.0%	0.0%	2.8%	Recommendation approved
Conservative surgery – Arthroscopic surgery Routine arthroscopic surgery (debridement, meniscectomy and cartilage repair methods) is not recommended. Arthroscopic surgery can be considered for treating the causes of mechanical articular blockage, above all in patients unresponsive to conservative treatment and suffering from mild/moderate knee osteoarthritis.	68.4%	28.9%	2.6%	0.0%	Recommendation approved
Conservative surgery – Realignment osteotomy Knee realignment osteotomy (tibial/femoral) can be proposed to selected patients (eg active adults not overweight) with mild to moderate single-region symptomatic knee osteoarthritis.	72.2%	25.0%	2.8%	0.0%	Recommendation approved
Indications for substitute surgery Substitutive surgery should be taken into consideration for patients with severe symptoms and unresponsive to pharmacological and conservative treatments. The most significant criteria to be considered for a knee prosthesis are: •Joint pain with limited function •Proven structural damage •Failure of pharmacological/conservative treatments •Deterioration in quality of life •Significant subjective suffering	83.3%	16.2%	0%	0%	Recommendation approved

Table 3 Classification of Agents According to Their Prevalent Effect on Tissues

Energy	Physical Agent	Treatments
Electromagnetic energy	Electric current, electromagnetic fields.	TENS, IFC, microcurrents, HVPC, F.E.S., NMES, PEMF, magnetic fields
Thermal energy	Micro-waves, short waves.	Hyperthermia, microwave diathermia, short-wave diathermia, CRet, laser therapy.
Mechanical energy	Mechanical sound waves.	Shock waves, ultrasound, cryoultrasound
	Vibrations.	Vibrational energy

Abbreviations: TENS, transcutaneous electrical nerve stimulation; IFC, interferential current; HVPC, high voltage pulsed current; FES, functional electrical stimulation; NMES, neuromuscular electrical stimulation; PEMF, pulsed electromagnetic field therapy; CRet, capacitive and resistive energy transfer.

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