Guideline for the management of knee and hip osteoarthritis

Chapter 1


Osteoarthritis (OA) is a chronic disease that mostly affects the hands, knees and hips

The 2014–15 National health survey shows that an estimated 2.1 million Australians (9% of the population) of all ages have this condition.1 A more rapid increase in OA prevalence occurs after the age of 45 years; for those aged >55 years, the prevalence of OA increases to more than 60%.1

With the ageing Australian population, and increasing rates of obesity, the numbers of Australians with OA is expected to increase from an estimated 2.1 million in 2015 to an estimated 3.1 million (12% of the population) by 2030.1 Globally, hip and knee OA was ranked as the 11th highest contributor to global disability,2 and is the most notable non-communicable disease, with total disability-adjusted life-years (DALYs) rising by 35% between 1990 and 2015.3 OA is placing an increasing burden on individuals, societies and healthcare systems.

Overall health expenditure on arthritis exceeds that of numerous other chronic conditions, including coronary heart disease, diabetes, depression, stroke and asthma.4 Direct healthcare costs for OA were estimated to be more than $2.1 billion in 2015, and by 2030, these are forecast to exceed $2.9 billion.5 Broader economic costs are estimated to be around $22 billion annually.6

Strategies for relieving pain, minimising disability and slowing disease progression around OA are key treatment goals of conservative, non-surgical management. Implementing conservative management strategies at a population level for people with OA could result in substantial cost savings for the Australian healthcare system. For example, the potential cost savings from delaying knee replacements alone would be more than $233 million in 2030.5

General practitioners (GPs) are often the first point of contact within the healthcare system for someone with OA. In 2015–16, OA was managed in 26 per 1000 general practice encounters at all ages.7 While OA is a chronic condition that imposes a significant burden in terms of years lived with disability, it has a much lesser impact on mortality; therefore, it is often not prioritised by treating health practitioners.

The Royal Australian College of General Practitioners (RACGP) published Guidelines for the non-surgical management of hip and knee osteoarthritis in 2009.8 Since then, substantial progress has been made, evaluating the effectiveness and safety of commonly used and new therapies for OA. The objective of this review is to present the most up-to-date evidence for OA interventions, other than joint replacement for the hip and knee. Additionally, it is to inform the development of evidence-based recommendations for GPs working in the Australian healthcare setting.

The questions of specific interest to this literature review and guideline were:

  • What is the efficacy and safety of non-pharmacological (including complementary) interventions for adults with symptomatic knee and/or hip OA?
  • What is the efficacy and safety of pharmacological interventions for adults with symptomatic knee and/or hip OA?
  • What is the efficacy and safety of arthroscopic surgical procedures for adults with symptomatic knee and/or hip OA?

In developing and updating the guideline, we also aimed to ensure that the:

  • recommendations were based on the best available evidence
  • content was practical, useful and appropriate for GPs
  • accompanying treatment algorithm and summary of recommendations were updated.

A formal communication and implementation plan has been developed to promote the guideline to general practice and key stakeholders. This plan aims to:

  • increase awareness of the new release and improve uptake of the guideline
  • build awareness of project initiation and progress
  • seek support and buy-in from stakeholders
  • increase awareness and alignment with other national initiatives, including the Australian Commission on Safety and Quality in Health Care’s Osteoarthritis of the knee clinical care standard, RACGP’s Handbook of non-drug interventions (HANDI), RACGP gplearning’s osteoarthritis education module, and Arthritis Australia’s MyJointPain website.

This update of the 2009 guideline:

  • incorporates a review of the evidence of the safety and efficacy of new therapies for the management of knee and/or hip OA
  • revisits established therapies in light of more recent evidence.

This guideline will apply to all adults diagnosed with symptomatic OA of the knee and/or hip across the disease trajectory, and is intended primarily for use in the primary care setting by GPs to guide patient care. The recommendations are also relevant for other health professionals working in the management of people with knee and/or hip OA in the community. Although foot osteoarthritis is an important source of symptoms in the general community and a prevalent problem, it was not practical within the scope of work to include it in this guideline.

The primary target audience for this guideline is Australian GPs in primary care settings in metropolitan, regional, rural and remote areas. Given the wide range of health professionals who treat this condition, consideration of the relevance of this guideline was also given to other health professionals.

Additional target audiences include sport and exercise medicine physicians, rheumatologists, orthopaedic surgeons, physiotherapists, occupational therapists, pharmacists, podiatrists, pain physicians, psychologists, exercise physiologists, dietitians, nurses, chiropractors and osteopaths.

This is reflected in the composition of the guideline development working group.

Poor health outcomes are more frequent among individuals living in communities of low socioeconomic status (SES) who are more likely to be disadvantaged in receiving adequate healthcare. As seen with many other chronic conditions, areas of low SES have also been reported to have higher prevalence of OA.9 Social and economic circumstances, including income, education, employment and social support affect the health of individuals in these areas, placing them at greater risk of poor health.9 Furthermore, evidence suggests that poor health, including high rates of arthritis, may worsen poverty in low-income to middle-income countries because of the inability of individuals to work and fulfil community roles.10

In providing quality healthcare, the needs and issues faced by disadvantaged groups, including Aboriginal and Torres Strait Islander peoples and culturally and linguistically diverse (CALD) communities must be considered. In 2009–10, people in lower socioeconomic households spent proportionately less on medical and healthcare than those in households with higher SES (3% in low compared with 5.1% in high of weekly equivalised expenditure).11 The Australian Institute of Health and Welfare (AIHW) reports that Aboriginal and Torres Strait Islander peoples and CALD communities often lack access to nutritious and affordable food,12,13 are less likely to engage in physical activity and have higher rates of overweight and obesity.9,14

After adjusting for age, the prevalence of OA in Aboriginal and Torres Strait Islander peoples is similar to prevalence in the total Australian population.15 However, areas of lower socioeconomic status generally have higher prevalence of OA in comparison with areas with high socioeconomic status (9.5% compared to 7.2%).15

In Australia, Aboriginal and Torres Strait Islander peoples with arthritis have fewer visits to GPs and other health professionals.16 Ensuring access to appropriate and specialised services are particularly important to reduce any disparity gaps for Australians who live in rural and remote settings. In addition to good access to care, the provision of comprehensible resources in multiple languages for those with low literacy and low health literacy, relevant education materials, and interpreter services when required, will contribute to addressing the needs of socially disadvantaged groups.17 In Aboriginal and Torres Strait Islander and CALD communities, connecting individuals to community-based health programs has also been demonstrated to be effective.18,19

Barriers such as difficulties in communication and understanding cultural differences, and coordinated planning for better service provision also need to be addressed. Appropriate assistance and consumer consultation also needs to be in place for these communities to ensure uptake of services provided.

Holistic assessment

An initial assessment of people with OA should be based on a complete history and physical examination, including ascertaining the effect of OA on the person’s function, quality of life, occupation, mood, sleep, relationships and leisure activities.20 OA is a multifaceted disease in which the structural evidence of joint damage frequently does not correlate with the presence and severity of joint pain and disability. A holistic assessment better facilitates the patient–professional partnership, and collaborative care in which patients and healthcare professionals make shared decisions related to treatment to improve outcomes.21 Personal preferences for certain types of therapies should also be considered, as adherence to treatment recommendations and outcomes can be compromised if the management plan does not meet the person’s preferences and beliefs. Furthermore, people with OA are predominantly older adults and often have different personal priorities and aspirations, which may affect treatment choice. The use of patientreported measures, inclusive of outcomes and experience, is an important beginning of, and component of, holistic assessment of individuals with hip and/or knee OA. These measures capture a patients’ perspective about how their OA impacts on their life, health and wellbeing, and their experience in receiving care. Patient-reported measures are important tools used during the clinical consultation and in multidisciplinary team discussions to contribute to shared clinical decision making and patient-centred care.

People with knee and/or hip OA should be asked about their knowledge of the disease and treatment alternatives, previous experiences with treatment, and expectations of current treatment. The presence of some misconceptions (eg exercise will worsen OA, OA will inevitably get worse) may hamper the development of an appropriately tailored plan and limit the success of treatment, if not properly identified. Key factors that should be considered as part of the holistic assessment:

  • Social factors – effect of the condition on activities of daily living, relationships and quality of life; recreational and occupational activities
  • Health beliefs and concerns – previous knowledge of OA; expectations of treatment; understanding of treatment options, including benefits and harms
  • Psychological factors – screen for depression; stresses in life;  mood
  • Attitudes to physical activity and exercise – concerns; participation restriction; beliefs
  • Pain assessment – nature of pain, other sites of pain, self-help strategies; analgesics use, doses, frequency and side effects; current understanding about persistent pain
  • Functional capacity including walking ability, stair climbing, sit-to-stand, balance
  • Presence of support – concerns and expectations of carers; isolation issues
  • Influence of comorbidities – interaction of two or more morbidities; falls risk
  • Modifiable risk factors – overweight/obesity; joint alignment; injury/buckling

While not every factor will be a concern for a person with knee and/or hip OA, some issues may warrant greater consideration, depending on the person’s situation, preferences and priorities. After taking into account these factors, a personalised management plan can be developed in collaboration with the person.

Evaluation of treatment response

Periodic clinical assessments should be performed at regularly agreed intervals to assess the effects of treatment on symptoms, function and status, and to quantify objective changes in metrics related to interventions (eg weight, muscle strength). Assessing the person periodically enables regular coaching and reinforcement of the management plan. This also allows for monitoring of treatment effectiveness, side effects and alterations to the management plan according to outcome.

Diagnosis and evaluation of treatment response in OA is primarily based on clinical assessment. There is no established role for laboratory or imaging tests in assessing disease activity/status in clinical practice. As a result, these are not required for OA diagnosis or disease monitoring (refer to Section 1.7.1 Clinical diagnosis and Section 1.7.2 Limited role for imaging).

There is a variety of clinical tools aimed at evaluating the clinical status and patient-reported outcomes that are mainly used in clinical research. A few commonly used instruments for assessing self-reported pain and function include:

  • Numeric Pain Rating Scale (NPRS)22
  • Visual Analog Scale (VAS) for Pain23
  • Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire24
  • Knee Injury and Osteoarthritis Outcome Score (KOOS)25
  • Hip Disability and Osteoarthritis Outcome Score (HOOS).26

In addition, the 30-second chair-stand test, 40-metre fast-paced walk test, stair-climb test, timed up-and-go test, and six-minute walk test were recommended as complementary tests to patient report measures. The 30-second chair-stand test, 40-metre fast-paced walk test and stair-climb test were recommended by the Osteoarthritis Research Society International (OARSI) advisory group as the minimal core set of performance-based tests for hip or knee OA.27

Clinical diagnosis

The diagnosis of knee and/or hip OA can be made based on:

  • Background risk – population prevalence of knee or hip OA
  • Person’s risk factors for OA – for example, age, gender, body mass index (BMI), occupation
  • Person’s symptoms – persistent knee/hip pain, brief morning stiffness and functional limitation
  • Adequate physical examination – crepitus, restricted movement and bony enlargement. Plain radiograph is not needed, but could be considered for atypical presentations.28

A typical knee OA diagnosis can be made without requiring further investigations if a person:29,30

  • is aged 45 years or older
  • has activity-related joint pain
  • has morning stiffness that lasts <30 minutes20
  • has crepitus on active motion
  • has bony enlargement
  • has no detectable warmth.

Additional features that may be present include:31

  • deformity – fixed flexion and/or varus (less commonly valgus for the knee)
  • instability
  • peri-articular or joint-line tenderness
  • pain on patellofemoral compression.

Similar to knee OA, hip OA can be diagnosed by clinical features alone, according to American College of Rheumatology (ACR) criteria.32 Early physical signs of hip OA include restriction of internal rotation and abduction of the affected hip, with pain occurring at the end of the range of motion.32

Be aware that atypical features – such as a history of trauma, prolonged morning joint-related stiffness, rapid worsening of symptoms or the presence of a swollen hot joint – may indicate alternative or additional diagnoses. Consideration of concerning clinical features (eg severe local inflammation, erythema, progressive pain unrelated to usage) that are suggestive of tumour, septic arthritis, crystal arthritis, other inflammatory arthritides (eg rheumatoid arthritis), osteonecrosis, fracture or serious bony pathology, is required during the clinical examination. If any of these are detected, the individual should be referred to an appropriate health practitioner. Involvement of other joints may suggest a wide range of alternative diagnoses.

In clinical practice, laboratory tests (eg rheumatoid factor, erythrocyte sedimentation rate [ESR], synovial fluid aspirate for crystal confirmation, C-reactive protein [CRP]) would be requested to confirm or exclude co-existent inflammatory disease (eg calcium pyrophosphate crystal deposition, gout, rheumatoid arthritis) in people with suggestive symptoms or signs. However, laboratory tests on blood, urine or synovial fluid are not needed as a diagnosis of OA can be readily made in their absence. If a palpable effusion is present, synovial fluid should be aspirated and analysed to exclude inflammatory disease, and to identify urate and calcium pyrophosphate crystals. OA synovial fluid is typically non-inflammatory with <2000 leucocytes/mm3; if specifically sought, basic calcium phosphate crystals are often present.31

Limited role for imaging

OA is typically diagnosed clinically, and the role of imaging is limited. In atypical presentations, imaging might be considered when diagnoses other than OA are suspected. Imaging can also be helpful when the clinical diagnosis is uncertain. It may be beneficial for people with atypical symptoms to be referred to a specialist for magnetic resonance imaging (MRI) investigation as referral by a GP is not reimbursed by the Medicare Benefits Schedule (MBS). Imaging for OA follow-up is recommended only if there are unexpected rapid progression of symptoms or change in clinical characteristics that need to be confirmed (eg increasing severity of OA).20, 28 However, it has been noted that many structural abnormalities seen on imaging are very common in older populations,33 and these abnormalities should be considered in the appropriate clinical context.

There is a lack of co-occurrence of the radiographic changes and symptoms of OA.34 In people with frequent hip pain, only 15.6% showed evidence of radiographic OA (Kellgren–Lawrence grade 3 or 4).35 Studies have shown that 15–81% of people with radiographic OA have knee pain.34 In addition, the accuracy of the association between symptoms and radiographic OA could be affected by:36–38

  • extent of radiographic views
  • definitions of pain measurements
  • different groups (eg ethnicity, gender) included in the study
  • other potential confounders.

If imaging is required, conventional (plain) radiography should be used before other modalities. Soft tissues are best imaged by ultrasound or MRI, and bone by computed tomography (CT) or MRI.

Consideration of radiographic views is important for optimising detection of OA features; in particular, for the knee, weight-bearing and patellofemoral views28 are recommended. A full history, clinical examination and anteroposterior X-ray of the affected hip should be the first-line choice of imaging to diagnose the cause of hip pain. However, MRI has a definite role in excluding or confirming infrequent differential diagnoses (eg osteonecrosis, avascular necrosis, insufficiency fracture). The systematic use of imaging in the diagnostic process is not recommended in cases with a typical clinical presentation because of the absence of strong evidence supporting the additional impact on the certainty of diagnosis using imaging.28

Key messages regarding imaging in OA:

  • OA can be diagnosed clinically, and imaging is not needed but could be considered for atypical presentations. • Radiographic changes and meniscal tears are an almost universal finding in people with OA, and are typically just age-related abnormalities and not related to symptoms.39, 40
  • Serious underlying pathologies are unlikely to be missed, even if people with a clinical diagnosis of OA have no routine imaging.20
  • Imaging can lead to increased use of harmful interventions.

OA management should include a holistic assessment considering the global needs of the individual.20 Personal preferences for certain types of therapies should be assessed, as adherence and outcomes may be compromised if the management plan does not match the person’s preferences and beliefs.

Broadly speaking, OA management goals are to minimise pain, optimise function and participation, and to empower the person to self-manage. Given the modest effects of individual treatment approaches, a combination of therapeutic approaches is commonly used. Clinicians should also aim to target modifiable risk factors (eg obesity, strength, depression).

The principles of chronic disease management apply to the care of people with OA, and are based on the following:41

  • care should be continuous; tailored to the person according to individual needs, goals, and values; and be person-centred
  • decision-making should be based on the best evidence available, and personal preferences and values
  • information should be widely accessible to individuals
  • anticipation of needs should be prioritised over a reactive health service.

The number of joints involved, degree of pain, movement restriction and functional impairment, and presence of comorbidities should also guide the management plan. Involvement of partners, family and friends is important to provide the individual with support to self-manage their condition, and is one of the pillars of patient-centred care.

Efforts should be made to prioritise interventions that are safer, more accessible and more cost-effective over treatments that have greater adverse events, are less feasible and more expensive. Active, non-pharmacological interventions are the mainstay of OA management, and should be tried first, followed by or in concert with medications to relieve pain when necessary. Non-pharmacological therapies include weight management, promotion of physical activity, strengthening exercises, education and behaviour change support.42

Patient adherence, optimal uptake of recommendations and behaviour modifications are key elements of OA treatment, and can be optimised by education, establishing treatment goals and periodic monitoring.


Education for people with OA is important to improve their understanding of their disease and the importance of self-management.43 Individuals should be informed about the aetiology of OA, the typical fluctuating nature of pain, risk factors (especially those that are modifiable and specific to the person), and expected prognosis, including most people not progressing to requiring joint replacement.44

Clear information about treatment options along with their benefits, harms and costs should be discussed. Providing this information helps to counter common misconceptions and encourages individuals to adopt an active approach in the management of their own disease.45 Language is important, and terms such as ‘wear and tear’ and ‘bone-on-bone’ should be avoided, as this can lead to pessimism about treatment outcomes (ie nothing can be done) and misbeliefs (eg exercise is detrimental and unsafe) that can affect individual engagement. It is also important to instil a sense of optimism and hope, and facilitate positive expectations about treatment outcome.

Goal setting helps the informed person identify current issues, set priorities and focus on specific changes. To develop a realistic plan, goals should be agreed upon with the individual, considering their preferences and biopsychosocial context. In addition, appropriate goals should be specific, timely and measurable, and should be reviewed periodically.

Multidisciplinary care

As OA is a chronic condition that is often associated with a number of comorbidities and psychosocial issues, many people receive substantial benefits when care is provided using a multidisciplinary team approach. While it is recognised that not all people will require such an approach to management, a key role of GPs is to determine whether a multidisciplinary team approach is necessary, and if so, to refer to appropriately skilled health professionals (actual or virtual) in the community or hospital settings. Many people with chronic pain are best managed in primary care or the community level with multidisciplinary support, including self-care, while specialist services in hospitals typically focus on treating people who are more complex. GPs are ideally placed to play the role of care coordinator to ensure management continuity, whereby there is a consistent, coherent and collaborative approach to management from all team members who are responsive to the person’s changing needs. The GP can also delegate certain care coordination activities to another suitable health professional, such as practice nurse or team physiotherapist.

Practice nurses can be invaluable in partnership with GPs in care planning and goal setting. Support of allied health professionals will greatly enhance capacity to include all the concepts of chronic care. It will also add value to the person’s experience and outcomes with allied health professionals’ expertise in the care of people with OA and the common comorbidities. Some people may need to be referred to practitioners with requisite knowledge and skills in exercise therapy and behaviour change (eg physiotherapists, sports and exercise physicians, exercise physiologists) to prescribe an individualised exercise/physical activity program and facilitate long-term adherence. Physiotherapists and other practitioners with expertise in manual therapy/massage can provide this as a short-term adjunct to facilitate engagement in lifestyle interventions. Referral to dietitians/nutritionists may benefit people who are overweight or obese and require an individualised dietary assessment and management plan. Occupational therapists can provide specific approaches to self-management (eg occupational and home adaptations). Podiatrists/orthotists may be consulted for prescription of shoe orthoses and braces.

While pain management is a high priority in the clinical care of people, there are broader psychological effects arising from a physical health condition that may necessitate psychological intervention to improve a person’s ability to live with and manage OA. For some individuals, referral to a multidisciplinary pain clinic or a pain specialist may be warranted, particularly if the person is having difficulties managing pain despite current best practice. Based on a systematic assessment of falls risk, referral to a falls clinic may be beneficial. Referral to other medical practitioners (eg rheumatologists, sports and exercise physicians) may be appropriate for complicated cases, or if symptoms persist or worsen. For people with advanced knee and/or hip OA who continue to have substantial pain and functional difficulty despite high-quality conservative management, referral to an orthopaedic surgeon could be considered in discussion with the person (refer to Section 1.9 Timing of and need for referral to an orthopaedic surgeon).

Implementation and referral pathways

As part of the development of this guideline, a specific implementation plan was developed to ensure and optimise appropriate dissemination and use of the guideline. It is important to recognise that there are already a number of good resources in existence that should be used to facilitate evidence-based care. These include:

Consumer information resources and services for patient education and support for self-management are provided by support organisations:

These organisations provide printed and online information, which help reinforce education and self-management advice provided to individuals by clinicians. They may also offer support groups, exercise sessions and other services valuable for social support.

Where possible, GPs should use existing services and referral pathways to optimise targeting appropriate evidencebased care and recommendations within this guideline. These could include allied health referrals (using the Chronic Disease Management MBS items) and access to relevant multidisciplinary state/territory government initiatives.

Total joint replacement surgery is the most cost-effective and clinically effective treatment for end-stage OA46,47 in appropriately selected individuals. It should be noted that the lifetime risk of undergoing total joint replacement is estimated to be substantially less than the risk of developing symptomatic hip and/or knee OA. In the UK, the estimated mortality-adjusted lifetime risk of total hip replacement at age 50 in 2005 was 11.6% for women and 7.1% for men. For total knee replacement, the risks were 10.8% for women and 8.1% for men.48

GPs should consider referring individuals with end-stage OA when all appropriate conservative options, delivered for a reasonable period of time, have failed. The indication for referral to an orthopaedic surgeon should be based on a significant decline in quality of life because of established and end-stage joint OA. The hallmarks of end-stage OA include significant joint pain, swelling and deformity, which disrupts normal sleep patterns, causes a severe reduction in walking distance such that people become housebound and avoid ambulation outside, and marked restriction of activities of daily living (eg rising from a chair or toilet seat, difficulty with climbing stairs).48 It is important that careful history, examination and investigations (plain joint radiography) are obtained to avoid up to 25% of people who have been shown to undergo inappropriate joint replacement surgery, including minimal symptoms, less radiographic abnormality and unrealistic expectations.49 People who receive the best outcomes following total joint replacement have:

  • significant pre-operative radiographic joint change (Kellgren–Lawrence grade 3 or 4)50,51
  • well-controlled comorbidities
  • a BMI no greater than 30 or no lower than 20
  • good mental health status.52

GPs should consider optimising the medical status of people to improve post-operative outcomes and reduce peri-operative complications.53 In this regard, individuals may benefit from pre-operative expert internal medicine referral. The most common pre-operative morbidities include low ferritin, diabetes, hypertension, hyperlipidaemia, back pain, depression, cardiac arrhythmia, coronary artery disease, chronic obstructive pulmonary disease and obesity.54

People who are planning surgery should maintain the range of motion of their arthritic joint, and should engage in as much strengthening and physical activity as possible (eg walking, hydrotherapy).55,56 Individuals should also ensure that their dental and pedal health is maintained, and any dermatologic conditions are treated and stabilised prior to surgery to minimise the devastating complication of prosthetic joint infection.

Not all people do well even after uncomplicated surgery. Up to 25% of individuals who had a total joint replacement continue to complain of pain and disability after well-performed surgery.57,58 These individuals continue to use health resources. Careful pre-operative patient selection – including considering the poor outcomes that are more common in people who are depressed, have minimal radiographic disease, minimal pain and who are morbidly obese – shared decision-making about surgery and informing individuals about realistic outcomes of surgery are required to minimise the likelihood of dissatisfaction. Objective evidence is available that may identify this cohort of individuals,52 and for whom alternate non-operative interventions may be more appropriate.

Patient decision aids support individuals by making their decisions explicit, providing information about options and associated benefits/harms, and helping clarify congruence between decisions and personal values.59 According to the International Patient Decision Aids Standards (IPDAS) collaboration description, decision aids are evidence-based tools designed to prepare individuals to participate in making specific and deliberated choices among healthcare options.60 Patient decision aids should not replace, but may act as an adjunct to, good clinical practice. Patient decision aids are not necessary to deliver good shared decision-making; however, well-developed tools will facilitate patient engagement and can be used at various points throughout the person’s journey, and surround decisions on every aspect of care including exercise and diet, pharmacological management and in consideration of joint replacement.20 Decision aids are different from patient information leaflets, which aim to only provide information.

In 2014, the UK National Institute for Health and Care Excellence (NICE) reviewed the clinical effectiveness of OA-specific decision aids that may be used to enable individuals to participate in the management of their condition. There was moderate-quality evidence that the video booklet decision aid may reduce decisional conflict more than an education leaflet alone,61 and low-quality evidence that patients’ confidence in decision making, selfefficacy and preparation for decision making are increased with decision aids.62 Despite a paucity of high-quality evidence for any given decision aid, it is important to highlight that decision aids should be used as support tools as part of a discussion with a clinician and not as stand-alone tools.

There is currently no systematic way of determining what types of clinical decision-making support tools are used in Australia, or how commonly they are used by clinicians and their patients. However, practitioners could refer to the principles of shared decision making outlined in the patient experience guideline. The UK National Health Service RightCare has recently developed shared decision programs that are available on the NICE evidence search website, including aids specifically designed for hip and knee OA.

  1. Australian Institute of Health and Welfare. AIHW analysis of ABS Microdata: National Health Survey 2014–15. Canberra: AIHW, 2015.
  2. Cross M, Smith E, Hoy D, et al. The global burden of hip and knee osteoarthritis: Estimates from the global burden of disease 2010 study. Ann Rheum Dis 2014;73(7):1323–30.
  3. Kassebaum NJ, Arora M, Barber RM, et al. Global, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990–2013: A systematic analysis for the Global Burden of Disease Study 2015. Lancet 2015;388(10053):1603–58.
  4. Hunter DJ, Schofield D, Callander E. The individual and socioeconomic impact of osteoarthritis. Nat Rev Rheumatol [Perspective] 2014;10(7):437–41.
  5. Arthritis Australia. Count the Costs and Bank the Savings: The current and future burden of arthritis. Sydney: Arthritis Australia, 2016.
  6. Arthritis Australia. Time to move: Osteoarthritis. Sydney: Arthritis Australia, 2014.
  7. Britt H, Miller G, Henderson J, et al. General practice activity in Australia 2015–16. General practice series no. 40. Sydney: Sydney University Press, 2016.
  8. The Royal Australian College of General Practitioners. Guideline for the non-surgical management of hip and knee osteoarthritis. South Melbourne, VIC: RACGP, 2009.
  9. Mackenbach JP. Socioeconomic inequalities in health in high-income countries: The facts and the options. In: Detels R, Gulliford M, Karim QA, Tan CC, editors. Oxford Textbook of Global Public Health. 6th edn. Oxford: Oxford University Press, 2015.
  10. Brennan-Olsen SL, Cook S, Leech MT, et al. Prevalence of arthritis according to age, sex and socioeconomic status in six low and middle income countries: Analysis of data from the World Health Organization study on global AGEing and adult health (SAGE) Wave 1. BMC Musculoskelet Disord 2017;18(1):271.
  11. Australian Institute of Health and Welfare. Australia’s health 2016. Cat. no. AUS 199. Canberra: AIHW, 2016.
  12. Brimblecombe JK, O’Dea K. The role of energy cost in food choices for an Aboriginal population in northern Australia. Med J Aust 2009;190(10):549–51.
  13. Lo YT, Chang YH, Lee MS, Wahlqvist ML. Health and nutrition economics: Diet costs are associated with diet quality. Asia Pac J Clin Nutr 2009;18(4):598–604.
  14. Sommer I, Griebler U, Mahlknecht P, et al. Socioeconomic inequalities in non-communicable diseases and their risk factors: An overview of systematic reviews. BMC Public Health 2015;15(1):914.
  15. Australian Institute of Health and Welfare. Arthritis and other musculoskeletal conditions. Canberra: AIHW, 2017.
  16. Australian Bureau of Statistics. 4704.0 – The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples, Oct 2010. Canberra: ABS, 2010.
  17. The Royal Australian College of General Practitioners.
  18. Guidelines for preventive activities in general practice. 9th edn. East Melbourne, VIC: RACGP, 2016.
  19. Abbott P, Reath J, Gordon E, et al. General practitioner supervisor assessment and teaching of registrars consulting with Aboriginal patients – Is cultural competence adequately considered? BMC Med Educ 2014;14(1):167.
  20. Ethnic Communities’ Council of Victoria. An investment not an expense: Enhancing health literacy in culturally and linguistically diverse communities. Carlton, Vic: Ethnic Communities’ Council of Victoria, 2012.
  21. National Institute for Health and Care Excellence.
  22. Osteoarthritis: Care and management. London: NICE, 2014.
  23. Lim AY, Doherty M. What of guidelines for osteoarthritis? Int J Rheum Dis 2011;14(2):136–44.
  24. Turk DC, Rudy TE, Sorkin BA. Neglected topics in chronic pain treatment outcome studies: Determination of success. Pain 1993;53(1):3–16.
  25. Williamson A, Hoggart B. Pain: A review of three commonly used pain rating scales. J Clin Nurs 2005;14(7):798–804.
  26. Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW. Validation study of WOMAC:A health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol 1988;15(12):1833–40.
  27. Roos EM, Roos HP, Lohmander LS, Ekdahl C, Beynnon BD. Knee Injury and Osteoarthritis Outcome Score (KOOS) – Development of a self-administered outcome measure. J Orthop Sports Phys Ther 1998;28(2):88–96.
  28. Nilsdotter AK, Lohmander LS, Klassbo M, Roos EM. Hip
  29. Disability and Osteoarthritis Outcome Score (HOOS) – Validity and responsiveness in total hip replacement. BMC Musculoskelet Disord 2003;4(1):10.
  30. Dobson F, Hinman RS, Roos EM, et al. OARSI recommended performance-based tests to assess physical function in people diagnosed with hip or knee osteoarthritis. Osteoarthritis Cartilage 2013;21(8):1042–52.
  31. Sakellariou G, Conaghan PG, Zhang W, et al. EULAR recommendations for the use of imaging in the clinical management of peripheral joint osteoarthritis. Ann Rheum Dis 2017;76(9):1484–94.
  32. Altman R, Asch E, Bloch D, et al. Development of criteria for the classification and reporting of osteoarthritis: Classification of osteoarthritis of the knee. Diagnostic and Therapeutic Criteria Committee of the American Rheumatism Association. Arthritis Rheum 1986;29(8):1039–49.
  33. Altman RD, Hochberg M, Murphy WA Jr, Wolfe F, Lequesne M. Atlas of individual radiographic features in osteoarthritis. Osteoarthritis Cartilage 1995;3 Suppl A:3–70.
  34. Zhang W, Doherty M, Peat G, et al. EULAR evidence-based recommendations for the diagnosis of knee osteoarthritis. Ann Rheum Dis 2010;69(3):483–89.
  35. Altman R, Alarcon G, Appelrouth D, et al. The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hip. Arthritis Rheum 1991;34(5):505–14.
  36. Guermazi A, Niu J, Hayashi D, et al. Prevalence of abnormalities in knees detected by MRI in adults without knee osteoarthritis: Population based observational study (Framingham Osteoarthritis Study). BMJ 2012;345:e5339.
  37. Bedson J, Croft PR. The discordance between clinical and radiographic knee osteoarthritis: A systematic search and summary of the literature. BMC Musculoskelet Disord 2008;9:116.
  38. Kim C, Nevitt MC, Niu J, et al. Association of hip pain with radiographic evidence of hip osteoarthritis: Diagnostic test study. BMJ 2015;351:h5983.
  39. Ang DC, Ibrahim SA, Burant CJ, Kwoh CK. Is there a difference in the perception of symptoms between African Americans and whites with osteoarthritis? J Rheumatol 2003;30(6): 1305–10.
  40. Bruyere O, Honore A, Rovati LC, et al. Radiologic features poorly predict clinical outcomes in knee osteoarthritis. Scand J Rheumatol 2002;31(1):13–16.
  41. Lethbridge-Cejku M, Scott WW, Jr, Reichle R, et al. Association of radiographic features of osteoarthritis of the knee with knee pain: Data from the Baltimore Longitudinal Study of Aging. Arthritis Care Res 1995;8(3):182–88.
  42. Bhattacharyya T, Gale D, Dewire P, et al. The clinical importance of meniscal tears demonstrated by magnetic resonance imaging in osteoarthritis of the knee. J Bone Joint Surg Am 2003;85(1):4–9.
  43. Englund M, Guermazi A, Gale D, et al. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. N Engl J Med 2008;359(11):1108–15.
  44. Brand C, Hunter D, Hinman R, March L, Osborne R,
  45. Bennell K. Improving care for people with osteoarthritis of the hip and knee: How has national policy for osteoarthritis been translated into service models in Australia? Int J Rheum Dis 2011;14(2):181–90.
  46. McAlindon TE, Bannuru RR, Sullivan M, et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage 2014;22(3):363–88.
  47. Kroon FP, van der Burg LR, Buchbinder R, Osborne RH, Johnston RV, Pitt V. Self-management education programmes for osteoarthritis. Cochrane Database Syst Rev 2014;15(1):CD008963.
  48. French SD, Bennell KL, Nicolson PJ, Hodges PW, Dobson FL, Hinman RS. What do people with knee or hip osteoarthritis need to know? An international consensus list of essential statements for osteoarthritis. Arthritis Care Res 2015;67(6):809–16.
  49. Hill J, Bird H. Patient knowledge and misconceptions of osteoarthritis assessed by a validated self-completed knowledge questionnaire (PKQ-OA). Rheumatology (Oxford) 2007;46(5):796–800.
  50. Higashi H, Barendregt JJ. Cost-effectiveness of total hip and knee replacements for the Australian population with osteoarthritis: Discrete-event simulation model. PLoS One 2011;6(9):e25403.
  51. Ruiz Jr D, Koenig L, Dall TM, et al. The direct and indirect costs to society of treatment for end-stage knee osteoarthritis. J Bone Joint Surg Am 2013;95(16):1473–80.
  52. Culliford DJ, Maskell J, Kiran A, et al. The lifetime risk of total hip and knee arthroplasty: Results from the UK general practice research database. Osteoarthritis Cartilage 2012;20(6):519–24.
  53. Cobos R, Latorre A, Aizpuru F, et al. Variability of indication criteria in knee and hip replacement: An observational study. BMC Musculoskelet Disord 2010;11(1):249.
  54. Dowsey M, Nikpour M, Dieppe P, Choong P. Associations between pre-operative radiographic changes and outcomes after total knee joint replacement for osteoarthritis. Osteoarthritis Cartilage 2012;20(10):1095–102.
  55. Dowsey MM, Nikpour M, Dieppe P, Choong PF. Associations between pre-operative radiographic osteoarthritis severity and pain and function after total hip replacement. Clin Rheumatol 2016;35(1):183–89.
  56. Dowsey MM, Spelman T, Choong PF. Development of a prognostic nomogram for predicting the probability of nonresponse to total knee arthroplasty 1 year after surgery. J Arthroplasty 2016;31(8):1654–60.
  57. Kehlet H, Thienpont E. Fast-track knee arthroplasty – Status and future challenges. Knee 2013;20 Suppl 1:S29–33.
  58. Bjorgul K, Novicoff WM, Saleh KJ. Evaluating comorbidities in total hip and knee arthroplasty: Available instruments. J Orthop Traumatol 2010;11(4):203–9.
  59. Ageberg E, Nilsdotter A, Kosek E, Roos EM. Effects of neuromuscular training (NEMEX-TJR) on patient-reported outcomes and physical function in severe primary hip or knee osteoarthritis: A controlled before-and-after study. BMC Musculoskelet Disord 2013;14(1):232.
  60. Villadsen A, Overgaard S, Holsgaard-Larsen A, Christensen R, Roos EM. Immediate efficacy of neuromuscular exercise in patients with severe osteoarthritis of the hip or knee:
  61. A secondary analysis from a randomized controlled trial. J Rheumatol 2014;41(7):1385–94.
  62. Singh JA, Lewallen D. Predictors of pain and use of pain medications following primary Total Hip Arthroplasty (THA): 5,707 THAs at 2-years and 3,289 THAs at 5-years. BMC Musculoskelet Disord 2010;11(1):90.
  63. Wylde V, Hewlett S, Learmonth ID, Dieppe P. Persistent pain after joint replacement: Prevalence, sensory qualities, and postoperative determinants. Pain 2011;152(3):566–72.
  64. Stacey D, Legare F, Lewis K, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2017;4:CD001431.
  65. Elwyn G, O’Connor A, Stacey D, et al. International Patient Decision Aids Standards (IPDAS) collaboration. Developing a quality criteria framework for patient decision aid: Online international Delphi consensus process. BMJ 2006;333(7565):417–19.
  66. de Achaval S, Fraenkel L, Volk RJ, Cox V, Suarez-Almazor ME. Impact of educational and patient decision aids on decisional conflict associated with total knee arthroplasty. Arthritis Care Res 2012;64(2):229–37.
  67. Fraenkel L, Rabidou N, Wittink D, Fried T. Improving informed decision-making for patients with knee pain. J Rheumatol 2007;34(9):1894–98.
  68. Coleman K, Norris S, Weston A, et al. NHMRC additional levels of evidence and grades for recommendations for developers of guidelines. Canberra: NHMRC, 2009.
  69. Higgins JP, Altman DG, Gotzsche PC, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ 2011;343:d5928.
  70. Mantel N, Haenszel W. Statistical aspects of the analysis of data from retrospective studies of disease. J Natl Cancer Inst 1959;22(4):719–48.
  71. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials 1986;7(3):177–88.
  72. GRADEpro G. GRADEpro GDT: GRADEpro Guideline
  73. Development Tool [Software]. McMaster University, 2015 (developed by Evidence Prime, Inc.). Available at https:// [Accessed 19 June 2018].
  74. Guyatt GH, Oxman AD, Vist GE, et al. GRADE: An emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336(7650):924–26.
  75. Guyatt GH, Oxman AD, Kunz R, et al. GRADE guidelines 6.
  76. Rating the quality of evidence-imprecision. J Clin Epidemiol 2011;64(12):1283–93.
  77. Guyatt GH, Oxman AD, Kunz R, et al. GRADE guidelines: 8. Rating the quality of evidence – Indirectness. J Clin Epidemiol 2011;64(12):1303–10.
  78. Guyatt GH, Oxman AD, Kunz R, et al. GRADE guidelines: 7. Rating the quality of evidence – Inconsistency. J Clin Epidemiol 2011;64(12):1294–302.
  79. Guyatt GH, Oxman AD, Vist G, et al. GRADE guidelines: 4.
  80. Rating the quality of evidence – Study limitations (risk of bias). J Clin Epidemiol 2011 Apr;64(4):407–15.
  81. Guyatt G, Oxman AD, Sultan S, et al. GRADE guidelines:
  82. Making an overall rating of confidence in effect estimates for a single outcome and for all outcomes. J Clin Epidemiol 2013;66(2):151–57.
  83. Andrews J, Guyatt G, Oxman AD, et al. GRADE guidelines: 14. Going from evidence to recommendations: The significance and presentation of recommendations. J Clin Epidemiol 2013 Jul;66(7):719–25.
  84. Andrews JC, Schunemann HJ, Oxman AD, et al. GRADE guidelines: 15. Going from evidence to recommendationdeterminants of a recommendation’s direction and strength. J Clin Epidemiol 2013;66(7):726–35.
  85. Jaeschke R, Guyatt GH, Dellinger P, et al. Use of GRADE grid to reach decisions on clinical practice guidelines when consensus is elusive. BMJ 2008;337:a744.
  86. O’Moore KA, Newby JM, Andrews G, et al. Internet cognitive behaviour therapy for depression in older adults with knee osteoarthritis: A randomized controlled trial. Arthritis Care Res 2017;70(1):61–70.
  87. Broderick JE, Keefe FJ, Schneider S, et al. Cognitive behavioral therapy for chronic pain is effective, but for whom? Pain 2016;157(9):2115–23.
  88. Dear BF, Gandy M, Karin E, et al. The Pain Course: A randomised controlled trial examining an internet-delivered pain management program when provided with different levels of clinician support. Pain 2015;156(10):1920–35.
  89. Quicke JG, Foster NE, Thomas MJ, Holden MA. Is longterm physical activity safe for older adults with knee pain? A systematic review. Osteoarthritis Cartilage 2015;23(9):1445–56.
  90. Atukorala I, Makovey J, Lawler L, Messier SP, Bennell K, Hunter DJ. Is there a dose-response relationship between weight loss and symptom improvement in persons with knee osteoarthritis? Arthritis Care Res 2016;68(8):1106–14.
  91. Messier SP, Mihalko SL, Legault C, et al. Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: The IDEA randomized clinical trial. JAMA 2013;310(12):1263–73.
  92. National Health and Medical Research Council. Clinical practice guidelines for the management of overweight and obesity in adults, adolescents and children in Australia. Melbourne: NHMRC, 2013.
  93. Queensland Government. Queensland Health 2014: Nutrition education materials online – Using body mass index resources/hphe_usingbmi.pdf [Accessed 25 April 2018].
  94. Hunter GR, Plaisance EP, Fisher G. Weight loss and bone mineral density. Curr Opin Endocrinol Diabetes Obes 2014;21(5):358–62. [Accessed 25 April 2018].
  95. Cardoso JS, Riley JL, Glover T, et al. Experimental pain phenotyping in community-dwelling individuals with knee osteoarthritis. Pain 2016;157(9):2104–14. [Accessed 25 April 2018].
  96. Moss P, Knight E, Wright A. Subjects with knee osteoarthritis exhibit widespread hyperalgesia to pressure and cold. PLoS One 2016;11(1):e0147526. [Accessed 25 April 2018].
  97. Erhart JC, Dyrby CO, D’Lima DD, Colwell CW, Andriacchi TP. Changes in in vivo knee loading with a variable-stiffness intervention shoe correlate with changes in the knee adduction moment. J Orthop Res 2010;28(12):1548–53. [Accessed 25 April 2018].
  98. Trombini-Souza F, Kimura A, Ribeiro AP, et al. Inexpensive footwear decreases joint loading in elderly women with knee osteoarthritis. Gait Posture 2011;34(1):126–30. [Accessed 25 April 2018].
  99. Bennell KL, Kean CO, Wrigley TV, Hinman RS. Effects of a modified shoe on knee load in people with and those without knee osteoarthritis. Arthritis Rheum 201;65(3):701–9. [Accessed 25 April 2018].
  100. Radzimski AO, Mundermann A, Sole G. Effect of footwear on the external knee adduction moment – A systematic review. Knee 2012;19(3):163–75. [Accessed 25 April 2018].
  101. Crossley KM, Marino GP, Macilquham MD, Schache AG, Hinman RS. Can patellar tape reduce the patellar malalignment and pain associated with patellofemoral osteoarthritis? Arthritis Rheum 2009;61(12):1719–25. [Accessed 25 April 2018].
  102. Hinman RS, Bennell KL, Crossley KM, McConnell J. Immediate effects of adhesive tape on pain and disability in individuals with knee osteoarthritis. Rheumatology 2003;42(7):865–69. [Accessed 25 April 2018].
  103. Stelian J, Gil I, Habot B, et al. Improvement of pain and disability in elderly patients with degenerative osteoarthritis of the knee treated with narrow-band light therapy. J Am Geriatr Soc 1992;40(1):23–26. [Accessed 25 April 2018].
  104. Machado GC, Maher CG, Ferreira PH, et al. Efficacy and safety of paracetamol for spinal pain and osteoarthritis: Systematic review and meta-analysis of randomised placebo controlled trials. BMJ 2015;350:h1225. [Accessed 25 April 2018].
  105. Roberts E, Delgado Nunes V, Buckner S, et al. Paracetamol: Not as safe as we thought? A systematic literature review of observational studies. Ann Rheum Dis 2016;75(3):552–59. [Accessed 25 April 2018].
  106. Crofford LJ. Use of NSAIDs in treating patients with arthritis. Arthritis Res Ther 2013;15 Suppl 3(Suppl 3):S2. [Accessed 25 April 2018].
  107. Kaplovitch E, Gomes T, Camacho X, Dhalla IA, Mamdani MM, Juurlink DN. Sex differences in dose escalation and overdose death during chronic opioid therapy: A populationbased cohort study. PLoS One 2015;10(8):e0134550. [Accessed 25 April 2018].
  108. Vithlani RH, Baranidharan G. Transdermal opioids for cancer pain management. Rev Pain 2010;4(2):8–13. [Accessed 25 April 2018].
  109. Simon LS, Grierson LM, Naseer Z, Bookman AA, Zev Shainhouse J. Efficacy and safety of topical diclofenac containing dimethyl sulfoxide (DMSO) compared with those of topical placebo, DMSO vehicle and oral diclofenac for knee osteoarthritis. Pain 2009;143(3):238–45. [Accessed 25 April 2018].
  110. Guedes V, Castro JP, Brito I. Topical capsaicin for pain in osteoarthritis: A literature review. Reumatol Clin 2016;14(1):40–45. [Accessed 25 April 2018].
  111. Laslett LL, Jones G. Capsaicin for osteoarthritis pain. Prog Drug Res 2014;68:277–91. [Accessed 25 April 2018].
  112. Brown JP, Boulay LJ. Clinical experience with duloxetine in the management of chronic musculoskeletal pain. A focus on osteoarthritis of the knee. Ther Adv Musculoskelet Dis 2013;5(6):291–304. [Accessed 25 April 2018].
  113. Smith Jr GN, Mickler EA, Hasty KA, Brandt KD. Specificity of inhibition of matrix metalloproteinase activity by doxycycline: Relationship to structure of the enzyme. Arthritis Rheum 1999;42(6):1140–46. [Accessed 25 April 2018].
  114. Davis AJ, Smith TO, Hing CB, Sofat N. Are bisphosphonates effective in the treatment of osteoarthritis pain? A metaanalysis and systematic review. PLoS One 2013;8(9):e72714. [Accessed 25 April 2018].
  115. Manicourt D, Devogelaer J, Azria M, Silverman S. Rationale for the potential use of calcitonin in osteoarthritis. J Musculoskelet Neuronal Interact 2005;5(3):285–93. [Accessed 25 April 2018].
  116. European Medicines Agency. Guideline on clinical investigation of medicinal products used in the treatment of osteoarthritis. London: EMA, 2010. [Accessed 25 April 2018].
  117. Dinarello CA, Simon A, van der Meer JW. Treating inflammation by blocking interleukin-1 in a broad spectrum of diseases. Nat Rev Drug Discov 2012;11(8):633–52. [Accessed 25 April 2018].
  118. Cohen SB, Proudman S, Kivitz AJ, et al. A randomized, double-blind study of AMG 108 (a fully human monoclonal antibody to IL-1R1) in patients with osteoarthritis of the knee. Arthritis Res Ther 2011;13(4):R125. [Accessed 25 April 2018].
  119. Lane NE, Corr M. Osteoarthritis in 2016: Anti-NGF treatments for pain – Two steps forward, one step back? Nat Rev Rheumatol 2017;13(2):76–78. [Accessed 25 April 2018].
  120. Schnitzer TJ, Marks JA. A systematic review of the efficacy and general safety of antibodies to NGF in the treatment of OA of the hip or knee. Osteoarthritis Cartilage 2015;23 Suppl 1:S8–17. [Accessed 25 April 2018].
  121. Hochberg MC, Tive LA, Abramson SB, et al. When is osteonecrosis not osteonecrosis? Adjudication of reported serious adverse joint events in the Tanezumab Clinical Development Program. Arthritis Rheumatol 2016;68(2):382–91. [Accessed 25 April 2018].
  122. Dahlberg LE, Aydemir A, Muurahainen N, et al. A first-inhuman, double-blind, randomised, placebo-controlled, dose ascending study of intra-articular rhFGF18 (sprifermin) in patients with advanced knee osteoarthritis. Clin Exp Rheumatol 2016;34(3):445–50. [Accessed 25 April 2018].
  123. Leung YY, Yao Hui LL, Kraus VB. Colchicine – Update on mechanisms of action and therapeutic uses. Semin Arthritis Rheum 2015;45(3):341–50. [Accessed 25 April 2018].
  124. Wenham CY, Grainger AJ, Hensor EM, Caperon AR, Ash ZR, Conaghan PG. Methotrexate for pain relief in knee osteoarthritis: An open-label study. Rheumatology 2013;52(5):888–92. [Accessed 25 April 2018].
  125. Salaffi F, Carotti M, Sartini A, Cervini C. A prospective study of the long-term efficacy and toxicity of low-dose methotrexate in rheumatoid arthritis. Clin Exp Rheumatol 1995;13(1):23–28. [Accessed 25 April 2018].
  126. Schnabel A, Herlyn K, Burchardi C, Reinhold-Keller E, Gross [Accessed 25 April 2018].
  127. WL. Long-term tolerability of methotrexate at doses exceeding 15 mg per week in rheumatoid arthritis. Rheumatol Int 1996;15(5):195–200. [Accessed 25 April 2018].
  128. McAlindon TE, LaValley MP, Harvey WF, et al. Effect of intraarticular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis: A randomized clinical trial. JAMA 2017;317(19):1967–75. [Accessed 25 April 2018].
  129. Hunter DJ. Viscosupplementation for osteoarthritis of the knee. N Engl J Med 2015;372(11):1040–47. [Accessed 25 April 2018].
  130. Albert C, Brocq O, Gerard D, Roux C, Euller-Ziegler L. Septic knee arthritis after intra-articular hyaluronate injection. Two case reports. Joint Bone Spine 2006;73(2):205–7. [Accessed 25 April 2018].
  131. Chang KV, Hung CY, Aliwarga F, Wang TG, Han DS, Chen WS. Comparative effectiveness of platelet-rich plasma injections for treating knee joint cartilage degenerative pathology: A systematic review and meta-analysis. Arch Phys Med Rehabil 2014;95(3):562–75. [Accessed 25 April 2018].
  132. Dai WL, Zhou AG, Zhang H, Zhang J. Efficacy of platelet-rich plasma in the treatment of knee osteoarthritis: A meta-analysis of randomized controlled trials. Arthroscopy 2017;33(3):659–70. [Accessed 25 April 2018].
  133. Osborne H, Anderson L, Burt P, Young M, Gerrard D. [Accessed 25 April 2018].
  134. Australasian College of Sports Physicians position statement: The place of mesenchymal stem/stromal cell therapies in sport and exercise medicine. Br J Sports Med 2016;50(20):1237– 44. [Accessed 25 April 2018].
  135. Centeno CJ, Busse D, Kisiday J, Keohan C, Freeman M, Karli D. Increased knee cartilage volume in degenerative joint disease using percutaneously implanted, autologous mesenchymal stem cells. Pain Physician 2008;11(3):343–53. [Accessed 25 April 2018].
  136. Vega A, Martin-Ferrero MA, Del Canto F, et al. Treatment of knee osteoarthritis with allogeneic bone marrow mesenchymal stem cells: A randomized controlled trial. Transplantation 2015;99(8):1681–90. [Accessed 25 April 2018].
  137. Rabago D, Patterson JJ, Mundt M, et al. Dextrose prolotherapy for knee osteoarthritis: A randomized controlled trial. Ann Fam Med 2013;11(3):229–37. [Accessed 25 April 2018].
  138. Cameron M, Chrubasik S. Oral herbal therapies for treating osteoarthritis. Cochrane Database Syst Rev 2014;22(5):CD002947. [Accessed 25 April 2018].
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