×

The RACGP is undergoing scheduled system maintenance: Wednesday, 17 April 2024 from 8:15PM – 10:15 PM AEST. During the maintenance window, some RACGP services will experience disruptions.
We apologise for any inconvenience caused.


Guideline for the management of knee and hip osteoarthritis

Chapter 2

Method

Guideline for the management of knee and hip osteoarthritis
Download PDF
  3. Figures and tables
  4. Provided under licence

The (PICO) format

The key questions to be answered in the guideline were determined using the patient/population/problem, intervention, comparison/control, outcome (PICO) format. PICO questions are provided in Appendix 2. PICO.

Literature searches

The initial systematic literature search was designed to build upon the literature in the first edition, and to update the evidence published after the last search date for those guidelines.8 To accomplish this, we searched PubMed, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Library (including Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials [CENTRAL]) for studies published from January 2005 to December 2016. (For detailed information on search strategies, refer to Appendix 1 of the Guideline for the management of knee and hip osteoarthritis: Technical document.)

A medical librarian developed and conducted searches using search terms determined by the working group’s preliminary recommendations, database-specific medical subject headings, free-text terms, and study type filters were applied where appropriate. Studies of adults with hip and/or knee OA that involved one or more therapeutic interventions of interest were sought. Searches were limited to systematic reviews and randomised controlled trials (RCTs), which are classified as Level 1 and Level 2 evidence according to the National Health and Medical Research Council (NHMRC) hierarchy of evidence (Table 1).63

Adapted with permission from National Health and Medical Research Council. Additional levels of evidence and grades for recommendations for developers of guidelines. Canberra: NHMRC, 2009.

No limits were placed on language, and studies published in languages other than English were translated whenever possible. Details of the search strategies are available in Appendix 1 of the Guideline for the management of knee and hip osteoarthritis: Technical document. Electronic searches were supplemented with manual searches of reference lists of recent systematic reviews to ensure all pertinent resources were obtained. Searches were also performed within published supplements of relevant conference proceedings up to and including August 2017. Working group members were consulted regarding the evidence procured for each topic and, based on their expert knowledge of prior and emerging research in the field, reference to any additional resources that were not collected were requested. All electronic searches were updated in August 2017.

The initial searches for most interventions were then expanded to identify studies published prior to 2005. This was done to accommodate the transition of the current guideline to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, thus to provide a comprehensive assessment of the quality of the entire body of evidence available for a given intervention. Consequently, the working group reviewed a GRADE summary table, which comprised all available RCT evidence regarding a given intervention to date, in order to make the most informed voting decision.

Study selection and PICO question matching

Systematic reviews and RCTs of adults with hip and/or knee OA in which the majority of the enrolled study population (≥80%) was aged 45 years or older were included. Only studies reporting participant health outcomes that were determined to be of interest by the working group’s recommendations were considered eligible for inclusion. Detailed patient health outcomes of interest, and inclusion and exclusion criteria are presented in Appendix 2 of the Guideline for the management of knee and hip osteoarthritis: Technical document.

The results of the literature searches were uploaded onto the Centre for Treatment Comparison and Integrative Analysis (CTCIA) web-based screening platform, which was used for primary and secondary literature screenings. Primary literature screening involved reviewing each record’s title and abstract for eligibility. Primary screening of each record was performed in duplicate by two independent reviewers (any paired combination among the pool of investigators from the working group or named in the Guideline for the management of knee and hip osteoarthritis: Technical document – Xia Wang, Mikala Osani, Elizaveta Vaysbrot and Mia-Cara Musetti), with conflicts resolved by a third reviewer (Raveendhara Bannuru).

Secondary literature screening involved the thorough review of fulltext articles. This was performed on all publications considered potentially eligible during the primary screening. Secondary literature screening followed the same independent duplicate review procedure, with conflict resolution undertaken by the same third reviewer. During secondary screening, all included articles were tagged with PICOrelated terms (eg intervention type(s), reported outcome(s)), to facilitate more efficient matching of the literature with PICO questions. Upon completion of secondary screening, the screening input for the references were exported on a database, and references were sorted in sequence by ‘Study design’, then by ‘Intervention’, ‘Comparator’, and finally ‘Date’.

Preliminary PICO designations were assigned to the references within the sorted document based on their ‘Interventions’ and ‘Comparators’; these designations were verified by a manual review of the included publications. Prior to the initiation of data extraction, the included articles were summarised by order of their matched PICO questions for the members of the working group, who assisted with reconciling possible mismatches or omissions. The study flow diagram in Figure 1, Appendix 2 of the Guideline for the management of knee and hip osteoarthritis: Technical document illustrates in detail the numbers of abstracts identified, full-text manuscripts retrieved, and studies selected for inclusion in the systematic literature review for these guidelines.

Data from eligible studies for each PICO question were extracted into the RevMan software. Risk of bias of the individual studies was assessed using the Cochrane Risk of Bias tool.64 Data extraction and risk of bias ratings were reviewed for consistency, and any discrepancies were resolved by consensus within the working group. Data were extracted on:

  • study and population characteristics
  • intervention dosage and frequency of administration
  • concomitant medications
  • all critical and important efficacy outcomes
  • all critical and important safety outcomes.

Random effects meta-analyses were conducted in anticipation of some heterogeneity among the studies.

Dichotomous outcomes were analysed using the Mantel–Haenszel method, and were reported as risk ratios (relative risk; RR) with 95% confidence intervals (CIs).65 For all continuous outcomes, the mean change from baseline was extracted; when change values were not available, these were calculated using baseline and followup means. Continuous outcomes were analysed using the DerSimonian and Laird inverse variance method, and reported as standardised mean differences (SMDs) with 95% CI.66 SMDs were calculated to account for variation in the outcome scales. All meta-analyses were also conducted using RevMan.

The results of the analyses were exported from RevMan into GRADEpro, a web-based software, to generate a GRADE Evidence Profile for each PICO question.67 The quality of evidence available for each outcome was assessed in GRADEpro using GRADE quality assessment criteria (Table 3.1, Appendix 3 of the Guideline for the management of knee and hip osteoarthritis: Technical document).68 This assessment was performed in duplicate by two independent reviewers (Investigators Raveendhara Bannuru and Mikala Osani as named in the Guideline for the management of knee and hip osteoarthritis: Technical document), with discrepancies resolved by consensus.

The evidence was rated for each outcome judged by the following criteria:69–72

  • risk of bias assessment of all individual studies
  • inconsistency between trial results
  • indirectness of evidence
  • imprecision of the effect estimate
  • potential reporting bias.

As per GRADE methodology, the eventual quality ratings are sorted into four categories: ‘High’, ‘Moderate’, ‘Low’ and ‘Very low’. These categories reflect the reviewers’ confidence in the effect estimate and its proximity to the true effect of an intervention.73 ‘High’ grade evidence is designated a numerical equivalent of 4, with quality downgrades carrying a weight of –1 for ‘serious’ risk or –2 for ‘very serious’ risk. The ‘Very low’ rating carries a numerical equivalent of 1; once the quality of evidence has been downgraded to this point, it cannot be downgraded further.

Once the quality of evidence has been assessed for all reported outcomes, the overall evidence quality was evaluated based on the lowest quality rating given to any of the outcomes that were designated a priori to be ‘Critical’ by the working group.74 When no data was available for a recommendation, the overall quality of evidence was automatically marked as ‘Very low’ to signify that this recommendation was made based on clinical experience alone. The resulting GRADE Evidence Profile contained:

  • pooled effect estimates calculated for each outcome
  • quality ratings for each outcome
  • footnotes containing brief qualitative summaries of the rationales behind quality downgrades
  • importance of each outcome
  • overall quality of evidence rating.

The final evidence report comprised all the GRADE Evidence Profiles (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document).

GRADE methodology specifies that guideline working groups formulate recommendations based on:74

  • consideration of the balance of relative benefits and harms of the treatment options under consideration
  • quality of the evidence (ie confidence in the effect estimates)
  • a person’s values and preferences
  • resource implications.

Key to the recommendation is the trade-off between desirable and undesirable patient outcomes; recommendations require estimating the relative value individuals place in the outcomes.

A recommendation could either be in favour or against the proposed treatment option, and strong or conditional. The recommendation can also be labelled as conditional neutral, where the working group cannot determine the direction of the recommendation.

A GRADE recommendation is categorised as strong if the working group is very confident that the benefits of an intervention clearly outweigh the harms (or vice versa). A conditional recommendation denotes uncertainty over the balance of benefits and harms (eg evidence quality is low or very low), or when personal preferences or costs are expected to affect the decision.75 Thus, conditional recommendations refer to decisions where incorporation of personal preferences is an essential element of decision-making.

Consensus building

The working group received the evidence report for review before meeting to discuss and decide on the final recommendations. For each PICO question, the working group provided initial votes, and discussed the direction of the recommendation during monthly teleconferences and two face-to-face meetings until general consensus was reached. Once the recommendations were drafted, the working group was asked to indicate their extent of support for each recommendation through an online survey voting process.76 An 11-point numerical scale was used to rate the extent of support for each recommendation. A 70% consensus agreement was set as the threshold for accepting a recommendation. If a 70% consensus was not achieved during the initial vote, additional discussions were convened to finalise the recommendation. A second and final voting process (with an agree/ disagree response) was then conducted. Final recommendations were accepted with a 70% consensus agreement by working group members. Details on the survey and voting data are available in Appendix 4 of the Guideline for the management of knee and hip osteoarthritis: Technical document.

In some instances, the working group decided to combine certain treatment options based on the review of the evidence and clinical scenario (eg different types of exercise). In addition, the working group identified a number treatments (and the resultant evidence reviews) not required for the guideline as the clinical scenario was uncommon, irrelevant, or redundant (Table 3.2, Appendix 3 of the Guideline for the management of knee and hip osteoarthritis: Technical document), or because one of the treatment options for that scenario had been eliminated by another recommendation. Consistent with GRADE guidance, there were some treatment options where the working group chose to provide a strong recommendation despite a low-quality rating of evidence.74 In these instances, a written explanation is provided describing the reasons for this decision.

  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 2014;10(7):437–41. [Perspective]
  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:// gradepro.org [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.
  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.
  96. Moss P, Knight E, Wright A. Subjects with knee osteoarthritis exhibit widespread hyperalgesia to pressure and cold. PLoS One 2016;11(1):e0147526.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  106. Crofford LJ. Use of NSAIDs in treating patients with arthritis. Arthritis Res Ther 2013;15 Suppl 3(Suppl 3):S2.
  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.
  108. Vithlani RH, Baranidharan G. Transdermal opioids for cancer pain management. Rev Pain 2010;4(2):8–13.
  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.
  110. Guedes V, Castro JP, Brito I. Topical capsaicin for pain in osteoarthritis: A literature review. Reumatol Clin 2016;14(1):40–45.
  111. Laslett LL, Jones G. Capsaicin for osteoarthritis pain. Prog Drug Res 2014;68:277–91.
  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.
  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.
  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.
  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.
  116. European Medicines Agency. Guideline on clinical investigation of medicinal products used in the treatment of osteoarthritis. London: EMA, 2010.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  126. Schnabel A, Herlyn K, Burchardi C, Reinhold-Keller E, Gross
  127. WL. Long-term tolerability of methotrexate at doses exceeding 15 mg per week in rheumatoid arthritis. Rheumatol Int 1996;15(5):195–200.
  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.
  129. Hunter DJ. Viscosupplementation for osteoarthritis of the knee. N Engl J Med 2015;372(11):1040–47.
  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.
  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.
  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.
  133. Osborne H, Anderson L, Burt P, Young M, Gerrard D.
  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.
  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.
  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.
  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.
  138. Cameron M, Chrubasik S. Oral herbal therapies for treating osteoarthritis. Cochrane Database Syst Rev 2014;22(5):CD002947.
This event attracts CPD points and can be self recorded

Did you know you can now log your CPD with a click of a button?

Create Quick log

Related documents

  Administrative-report.pdf (PDF 2.76 MB)

  Implementation-plan.pdf (PDF 1.79 MB)

  Technical-document.pdf (PDF 5.79 MB)

Advertising