Recommendations

Nutraceuticals

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

Last revised: 01 Jul 2018

This clinical guideline was published in 2018  and is currently being updated.

The information provided may not reflect the most current evidence or best practice.

Herbal therapies, supplements and nutraceuticals

Nutraceuticals


 

Glucosamine – Knee and/or hip

Recommendation

We suggest not offering glucosamine for people with knee and/or hip osteoarthritis (OA).

Strength of recommendation

Conditional against recommendation

Quality of evidence

Very low (knee)
Low (hip)

What is it? 

Glucosamine is a naturally produced sugar by the body, and one of the building blocks of cartilage. It comes in two forms – glucosamine sulfate and hydrochloride, and the usual dose is 1500 mg daily. Glucosamine supplements are usually made from crab, lobster or shrimp shells, although some supplements are made from a plant form of glucosamine. These are available as tablets or liquid, and often in combination with chondroitin. 

Rationale 

Overall, there is very low-quality evidence from a large number of randomised controlled trials (RCTs) that found that glucosamine provides some benefits to pain in the short term, but no apparent benefits to function, quality of life or joint space narrowing. When the studies are restricted to higher quality trials, no benefit is demonstrated. There is only one RCT on the effect on hip OA, which failed to demonstrate a benefit. 

The working group discussed the concerns in the literature of publication bias, effects being driven by small industry-sponsored trials, and the overall poor quality of the positive trials. Larger publicly funded trials generally demonstrate no effect over placebo. In the context of high-quality trial data that suggest no effect, the working group decided on a conditional against recommendation to increase awareness of the unlikely benefit of glucosamine and chondroitin. This discussion occurred in the context of the costs associated with ongoing supplement use, competing treatment priorities where this might be prioritised over more effective interventions, and the possible influence of direct-to-consumer marketing of supplements. If someone who is taking glucosamine or chondroitin is feeling marked symptomatic benefit as a consequence of its consumption, it is appropriate not to discourage whatever placebo effects may come from use of these supplements. 

Harms 

Overall, there was a low risk of adverse effects reported in the trials. Shellfish allergy and interactions with warfarin and diabetes are of concern, and trials are likely to have excluded participants with those conditions more carefully than usual practice (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document).

Chondroitin – Knee and/or hip

Recommendation

We suggest not offering chondroitin for people with knee and/or hip OA.

Strength of recommendation

Conditional against recommendation

Quality of evidence

Very low

What is it? 

Chondroitin is a component of connective tissues and bone, which is believed to help draw water and nutrients into the cartilage, keeping it spongy and healthy. Chondroitin is available as chondroitin sulfate supplements, which are made from bovine (cow) or shark cartilage. The usual dose is 800–1200 mg daily as a tablet, capsule or powder. 

Rationale 

There are a large number of trials on the use of chondroitin (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document), where at least seven are industry sponsored. When all 16 studies are pooled, there is a clinically and statistically significant effect on pain and function in the short term (up to three months), which lessens to clinically not significant by six to 12 months, and no effect is demonstrated at 24 months. However, when the analysis is restricted to studies of higher quality or free of industry sponsorship, no benefit is demonstrated.

There are some moderate-term to long-term (12–24 months) benefits on joint space narrowing, but these are not clinically meaningful (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document). The studies are all on participants with knee OA, so extrapolation to OA of hip or other joints requires further caution. 

The working group discussed the concerns in the literature of publication bias, effects being driven by small industry-sponsored trials, and the overall poor quality of the positive trials. In the context of high-quality trial data that suggest no effect, the working group decided on a conditional against recommendation to increase awareness of the unlikely benefit of widespread use of glucosamine and chondroitin. This discussion occurred in the context of the costs associated with ongoing supplement use, competing treatment priorities where this might be prioritised over more effective interventions, and current use as a consequence of direct-to-consumer marketing that may be inconsistent with the scientific evidence. If someone who is taking glucosamine or chondroitin is feeling marked symptomatic benefit as a consequence of its consumption, it is appropriate not to discourage whatever placebo effects may come from use of these supplements.

Harms

Pooled data from six trials with more than 1000 participants found that the risk of adverse events is comparable to placebo 

Glucosamine and chondroitin in compound form – Knee and/or hip

Recommendation

We suggest not offering glucosamine and chondroitin in compound form for people with knee and/or hip OA.

Strength of recommendation

Conditional against recommendation

Quality of evidence

Very low

What is it? 

Glucosamine and chondroitin are often marketed in a combination at the same doses as individual components. There does not appear to be any beneficial drug–drug synergistic interaction. 

Rationale 

With pooling (where possible) of results from the nine available RCTs, no benefit for pain, function or joint space narrowing was demonstrated. Participants in all trials had knee OA, so extrapolation to hip OA needs additional caution (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document)

The working group discussed the concerns in the literature of publication bias, effects being driven by small industry-sponsored trials, and the overall poor quality of the positive trials. In the context of high-quality trial data that suggest no effect, the working group decided on a conditional against recommendation to increase awareness of the unlikely benefit of widespread use of glucosamine and chondroitin. This discussion occurred in the context of the costs associated with ongoing supplement use, competing treatment priorities where this might be prioritised over more effective interventions, and current use as a consequence of direct-to-consumer marketing which may be inconsistent with the scientific evidence. If someone who is taking glucosamine or chondroitin is feeling marked symptomatic benefit as a consequence of its consumption, it is appropriate not to discourage whatever placebo effects may come from use of these supplements. 

Harms 

As with the individual components, the reported rates of adverse events were similar to placebo.

Vitamin D – Knee and/or hip

Recommendation

We suggest not offering vitamin D for people with knee  and/or hip OA.

Strength of recommendation

Conditional against recommendation

Quality of evidence

Low (knee)
Very low (hip

What is it?

Vitamin D is a hormone that controls calcium levels in the blood, which is crucial for bone, cartilage and muscle development. Oral supplementation with vitamin D is readily available. In the studies analysed, a daily dose of 800–2000 IU, or a monthly dose of 50,000–60,000 IU, were used.

Rationale 

There were four RCTs (one to three years’ duration), all without serious risk of bias. However, there was very serious inconsistent results, leading to low-quality evidence. When combined, there is a suggestion of a favourable effect, statistically significant but not reaching what was regarded as clinical significance (standardised mean difference [SMD] >0.4). The results for function were similar to the effect estimates. There was no evidence of favourable structural effects on cartilage volume or joint space narrowing. Notably, one study in participants who were vitamin D deficient also failed to show clinically meaningful beneficial effects (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document). Participants in all studies had knee OA, so extrapolation to OA of hip or other joints requires additional caution.

Harms 

Vitamin D is relatively safe; however, there is a non-statistically significant increase in hypercalciuria. There is no clinical effect or safety concern.

Omega-3 fatty acids – Knee and/or hip

Recommendation

We suggest not offering omega-3 fatty acids for people with knee and/or hip OA.

Strength of recommendation

Conditional against recommendation

Quality of evidence

Very low

What is it? 

Omega-3 polyunsaturated fatty acids are mainly produced by marine organisms (eg oil from whole fish, seal, mussels). This is widely available, and the usage is generally varied by region and disease (usual dose is 1–2 g/day). 

Rationale 

Pooled data from five RCTs (15–26 weeks) demonstrated no benefits on pain and function in people with hip and knee OA. Three studies received at least one high risk of bias. Most trials used marine oil from whole fish, but some used cod liver oil and mussel extracts. High heterogeneity was expected from pooling different sources of omega-3 fatty acids, and measures within each outcome (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document). The optimal type of omega-3 fatty acids could not be established in OA because only a few trials included marine oil from sources other than whole fish. There are high variations in doses of eicosapentaenoic acid (EPA; 0.01–1.7 g/day), and doses of docosahexaenoic acid (DHA; 0.01–1.10 g/day). 

A controlled trial that was not included found no additional benefit of high dose fish oil (4.5 g/day), compared with low dose fish oil (0.45 g/day). 

Harms 

Side effects are usually minor and uncommon.

Collagen – Knee and/or hip

Recommendation

We are unable to recommend either for or against the use of collagen for people with knee and/or hip OA.

Strength of recommendation

Conditional (neutral) recommendation

Quality of evidence

Low (knee)
Very low (hip)

What is it?

There are many types of collagen and collagen-related derivatives, which can be extracted from chicken cartilage, pork skin and bovine bone. These are sometimes available in hydrolysed form to help absorption and distribution to joint tissues. There is insufficient research to recommend a particular dose. 

Rationale 

Pooled results from six studies found short-term (13–26 weeks) clinical benefits in pain; however, there have been very serious inconsistent results across the studies (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document).

Available data from four studies found no effect in function. All of the studies were conducted in knee OA, so extrapolation to hip or other OA requires additional caution.
The working group discussed the concerns in the literature of publication bias, effects being mostly driven by industrysponsored trials, and the overall poor quality of the positive trials. 

Harms 

Collagen use is relatively safe; however, there is a non-statistically significant increase in adverse gastrointestinal events.

Methylsulfonylmethane (MSM) – Knee and/or hip

Recommendation

We are unable to recommend either for or against the use of MSM for people with knee and/or hip OA.

Strength of recommendation

Conditional (neutral) recommendation

Quality of evidence

Very low

What is it? 

MSM is an organosulfur molecule that can be synthesised commercially from dimethylsulfoxide (DMSO). DMSO is a pungent solvent that has been used as an application for pain relief over arthritic joints. MSM has the advantage of being odourless, and can be easily taken orally in the form of a pill or a powder. The optimal dosing of MSM is not known, but 1–2 g twice a day is often offered in clinical practice.

Rationale 

There are three trials with short study durations (12–13 weeks), and pooled data found statistically and clinically significant benefits in pain. Even larger effects were found in function, but with very serious inconsistent results and high heterogeneity across studies. One trial had a high risk of bias because of inappropriate randomisation technique; while the other had potential reporting bias (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document). The doses in the trials ranged from 1.5–6 g/day for 12 weeks. All of the studies were conducted in knee OA, so extrapolation to hip or other OA sites requires additional caution. 

The working group discussed the concerns in the literature of publication bias, effects being mostly driven by industrysponsored trials, and the overall poor quality of the positive trials. 

Harms 

The use of MSM for OA is relatively safe. Minor side effects were recorded, including gastrointestinal adverse events, fatigue and headaches; however, these were not statistically significant compared with placebo.

Diacerein – Knee and/or hip

Recommendation

We suggest not offering diacerein for people with knee and/or hip OA.

Strength of recommendation

Conditional against recommendation

Quality of evidence

Very low

What is it?

Diacerein is purified compound with an anthraquinone structure that interferes with pro-inflammatory interleukin-1 (IL-1) and the secretion of metalloproteinases, without affecting the synthesis of prostaglandins. It is widely available on prescription in Europe, but not available in Australia. The dose used in the trials was 50 mg twice a day.

Rationale 

Five trials were included, with time durations ranging from eight weeks to 12 months, all receiving high risk of bias because of weak allocation concealment and random sequence generation. Very low-quality evidence from four trials indicated a small clinical benefit on pain reduction. Data from five trials indicated statistically significant effects on function, but this did not reach the clinically meaningful threshold. Analysis of one study demonstrated no benefit in reducing joint space narrowing (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document). The working group discussed the concerns in the literature of publication bias, effects being mostly driven by industrysponsored trials, and the overall poor quality of the positive trials.

A search of regulatory websites found a recommendation from the European Medicines Agency (EMA) Pharmacovigilance Risk Assessment Committee (PRAC) that the marketing authorisation of diacerein should be suspended across Europe because of harms (particularly the risk of severe diarrhoea and potentially harmful effects on the liver) outweighing benefits. However, this guidance is not final as the PRAC recommendation will be re-examined. All of the studies were conducted in knee OA, so extrapolation to hip or other OA sites requires additional caution. 

Harms 

Adverse events were significantly increased after using diacerein, mainly diarrhoea (relative risk [RR]: 3.50; 95% confidence interval [CI]: 1.95, 6.27). There is an increase in rash, but the between-group difference was not significant.

  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.) 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