What are the evidence-based recommendations for managing nonsurgical knee pain/osteoarthritis, from highest to lowest?

From the Guidelines

For managing nonsurgical knee pain or osteoarthritis, the highest-level recommendations begin with non-pharmacological approaches, prioritizing weight management, exercise therapy, and education, as emphasized by the most recent guidelines 1.

Key Recommendations

• Start with weight management and exercise therapy, particularly low-impact activities like swimming, cycling, and walking, which strengthen muscles around the knee joint and improve function without excessive joint loading.
• Physical therapy focusing on quadriceps strengthening and range-of-motion exercises should be implemented early.
• For pain relief, topical NSAIDs like diclofenac gel are recommended as first-line medication due to their favorable safety profile and localized effect.
• Oral NSAIDs such as naproxen or ibuprofen can be used for short-term pain control, but should be limited due to gastrointestinal and cardiovascular risks.
• Acetaminophen offers modest benefit with minimal side effects.
• For patients with inadequate response, intra-articular corticosteroid injections can provide temporary relief for 1-3 months.
• Duloxetine may help with pain modulation in chronic cases.
• Opioids should be considered only as a last resort for severe pain unresponsive to other treatments, used at the lowest effective dose for the shortest duration.
• Knee braces, walking aids, and thermal therapies (heat or cold) can provide additional symptomatic relief.

Rationale

The rationale behind these recommendations is based on the latest evidence from high-quality studies and guidelines, including those from ESCEO and OARSI in 2019 1 and the American College of Rheumatology/Arthritis Foundation in 2019 1, which emphasize the importance of a stepped approach to management, starting with non-pharmacological interventions and progressing to pharmacological treatments based on patient response and risk factors.

Considerations

When considering the management of knee osteoarthritis, it's crucial to tailor the treatment to the individual patient, taking into account factors such as age, comorbidity, and the presence of inflammation, as well as the level of pain intensity and disability, and signs of inflammation, such as effusion 1. The treatment should also be based on the best available evidence, with a focus on minimizing harm and maximizing benefit, as outlined in the guidelines from reputable organizations 1.

From the Research

Nonsurgical Knee Pain/Osteoarthritis Management Recommendations

The evidence-based recommendations for managing nonsurgical knee pain/osteoarthritis, from highest to lowest, are as follows:

• Topical NSAIDs: Topical NSAIDs are superior to acetaminophen and have a lower risk of gastrointestinal adverse effects compared to oral NSAIDs 2.
• Weight Loss: Weight loss is a safe and effective way to improve knee pain, function, and stiffness without adverse effects 3.
• Physical Therapy: Physical therapy leads to significant improvements in pain and function, and decreased compliance is often due to high copayments, pain with activities, lack of transportation, and high time commitments 3.
• Bracing: Bracing for knee OA is a noninvasive, non-pharmacologic option that can significantly reduce pain and improve function with minimal adverse effects 3.
• Oral NSAIDs: Oral NSAIDs are effective for pain relief and functional improvements, but may have a higher risk of gastrointestinal adverse effects compared to topical NSAIDs 3, 4, 2.
• Acetaminophen: Acetaminophen is recommended as a first-choice analgesic for patients with OA of the knee or hip, but may not be as effective as NSAIDs for pain relief and functional improvements 4, 2.
• Intra-articular Injections: Intra-articular injections have had mixed results, with findings from recent studies indicating long-term outcomes to be equivocal 3.
• Activity Modification: Activity modification, therapy, and shoe orthotics are nonoperative options available for managing knee osteoarthritis, but their effectiveness may vary depending on the individual patient 5.

Mediators of Nonsurgical Interventions

The mediators of nonsurgical interventions on pain and physical function in people with osteoarthritis include:

• Self-efficacy: Increased self-efficacy is a common mediator of intervention effects on pain and physical function 6.
• Knee Muscle Strength: Increased knee extensor strength is a mediator of exercise effects on pain and physical function 6.
• Weight Loss: Reduced weight is a mediator of diet and exercise effects on pain and physical function 6.
• Systemic Inflammation: Decreased systemic inflammation is a mediator of diet and exercise effects on pain and physical function 6.
• Pain Beliefs: Changes in pain beliefs are a mediator of high-expectation communication style effects on pain and physical function 6.