Guideline for the management of knee and hip osteoarthritis

Recommendations

Manual therapy, weight management and heat/cold therapy

Guideline for the management of knee and hip osteoarthritis
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Last revised: 01 Jul 2018

Non-pharmacological interventions

Manual therapy, weight management and heat/cold therapy


 

Massage therapy – Knee and/or hip

Recommendation

It may be appropriate to offer a short course of massage therapy for some people with knee and/or hip osteoarthritis (OA). This should be considered only as an adjunctive treatment to enable engagement with active management strategies, and only for  short term, cognisant of issues related to cost and access.

Strength of recommendation

Conditional for recommendation

Quality of evidence

Low

What is it?

Manual therapy generally refers to skilled hands-on techniques where accurately determined and specifically directed manual force is applied to the body. The purported aims of manual therapy include:

  • reducing pain
  • increasing range of motion and mobility
  • reducing soft tissue inflammation
  • increasing circulation
  • improving soft tissue repair
  • inducing relaxation
  • facilitating movement
  • improving function.

Manual therapy comprises a number of techniques, the most common being manipulation and mobilisation. Manipulation techniques are defined as forceful small-amplitude, high-velocity movements of a joint, often applied at end range. Mobilisation techniques are repetitive passive movements of low velocity and varying amplitudes applied at different points throughout range. Other techniques include soft tissue mobilisation and stretching, and myofascial techniques. Massage may also be considered by some to be a form of manual therapy. 

Rationale

The evidence is from very low-quality or low-quality data. For some people with knee and/or hip OA, these therapies may have a positive effect on pain and/or function over a short term (low-quality to very low-quality evidence), and there is a very low risk of harm (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document).  The working group felt that for some people with knee and/or hip OA, these therapies may be useful as a single, short-term  (eg up to 8–12 weeks) trial, and should be used only as an adjunct to active rehabilitation interventions, given they emphasise a passive approach to treatment. When considering manual therapies, clinicians and individuals should be aware of possible cost, time and access barriers. 

Harms

There is a very low risk of harm reported.  

Manual therapy (stretching, soft tissue and/or joint mobilisation and/ or manipulation) – Knee and/or hip

Recommendation

It may be appropriate to offer a short course of manual therapy (stretching, soft tissue and/or joint mobilisation and/ or manipulation) for some people with knee and/or hip OA. This should be considered only as an adjunctive treatment to enable engagement with active management strategies and only for short term, cognisant of issues related to cost and access.

Strength of recommendation

Conditional for recommendation

Quality of evidence

Very low

What is it?

Manual therapy generally refers to skilled hands-on techniques where accurately determined and specifically directed manual force is applied to the body. The purported aims of manual therapy include:

  • reducing pain
  • increasing range of motion and mobility
  • reducing soft tissue inflammation
  • increasing circulation
  • improving soft tissue repair
  • inducing relaxation
  • facilitating movement
  • improving function.

Manual therapy comprises a number of techniques, the most common being manipulation and mobilisation. Manipulation techniques are defined as forceful small-amplitude, high-velocity movements of a joint, often applied at end range. Mobilisation techniques are repetitive passive movements of low velocity and varying amplitudes applied at different points throughout range. Other techniques include soft tissue mobilisation and stretching, and myofascial techniques. Massage may also be considered by some to be a form of manual therapy. 

Rationale

The evidence is from very low-quality or low-quality data. For some people with knee and/or hip OA, these therapies may have a positive effect on pain and/or function over a short term (low-quality to very low-quality evidence), and there is a very low risk of harm (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document).  The working group felt that for some people with knee and/or hip OA, these therapies may be useful as a single, short-term  (eg up to 8–12 weeks) trial, and should be used only as an adjunct to active rehabilitation interventions, given they emphasise a passive approach to treatment. When considering manual therapies, clinicians and individuals should be aware of possible cost, time and access barriers. 

Harms

There is a very low risk of harm reported.  

Weight management – Knee and/or hip

Recommendation

We strongly recommend weight management for people with knee and/or hip OA. For those who are overweight (body mass index [BMI] ≥25 kg/m2) or obese (BMI ≥30 kg/m2), a minimum weight loss target of 5–7.5% of body weight is recommended. It is beneficial to achieve a greater amount of weight loss given that a relationship exists between the amount of weight loss and symptomatic benefits. Weight loss should be combined with exercise for greater benefits. For people of healthy body weight, education about the importance of maintaining healthy body weight is essential.

Strength of recommendation

Strong for recommendation
(weight management)

Conditional for recommendation
(combination weight management plus exercise)

Quality of evidence

Very low

What is it?

Weight loss is usually achieved through a combination of dietary modification and exercise, and in extreme cases, bariatric surgery.  

Rationale

Overweight/obesity is a major risk factor for the onset and progression of symptomatic and radiographic OA, particularly at the knee, and is common among people with knee and/or hip OA. People with OA often present with comorbidities associated with overweight/obesity (eg cardiovascular, gastrointestinal, endocrine conditions), and weight management for these conditions is considered best practice. There is limited evidence of very low quality that weight loss alone (achieved through diet and exercise) has no significant effect on either pain or function in people with knee OA (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document), although benefits appear to be more significant with higher amounts of weight loss – starting at a minimum of 5–7.5% body weight loss. Ideally, it is beneficial to achieve a greater amount of weight loss. 81,82Dietary weight loss should also be combined with exercise for greater benefits (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document). There is no randomised controlled trial (RCT) on the effects of bariatric surgery in people with hip and/or knee OA. There are no RCTs investigating weight management specifically in people with hip OA, although the numerous other systemic health benefits of weight loss and maintaining a healthy body weight are most likely transferable to people with hip OA.  

Despite the limitations of the available RCT evidence in OA, the working group felt that the benefits of weight loss in people who are overweight/obese with knee and/or hip OA outweigh the risks. Clinicians are advised to refer to the National Health and Medical Research Council’s (NHMRC’s) guidelines for the most effective strategies for managing overweight/obesity in primary care.83

Harms

There are low risk of harms associated with this recommendation. However, there are currently no clearly defined BMI thresholds for older adults (aged >65 years). There is evidence to suggest that the cut-offs should be higher for older adults.84 The need for weight loss in older adults should be considered on an individual basis. If weight loss is appropriate, care should be taken to ensure maintenance of lean body mass and bone density, especially when it is accompanied with high intensity resistance and/or impact loading training.85 People should be monitored for bone health if needed and strengthening exercise included as part of the treatment program.

Heat therapy – Knee and/ or hip

Recommendation

It may be appropriate to offer local heat therapy (eg hot packs) as a self-management home strategy for some people with knee and/or hip OA. This should be considered only as an adjunctive treatment.

Strength of recommendation

Conditional for recommendation

Quality of evidence

Very low

What is it? 

Superficial heat can be applied via the use of hot packs or hot water bottles. Heat therapy is purported to relieve muscle tension and soreness, and improve blood flow. 

Rationale

Heat therapy may be effective in reducing pain for some people with knee and/or hip OA, but the quality of evidence is very low (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document). Heat therapy is cheap and generally feasible for people to undertake independently as a self-management strategy. 

Harms

There are no adverse effects reported. However, individuals should be warned about the risks of burns and heat therapy may not be suitable in those with compromised sensation. 

Cold therapy – Knee and/or hip

Recommendation

We suggest not offering local cold application  (eg ice packs) for people with knee and/or hip OA.

Strength of recommendation

Conditional against recommendation

Quality of evidence

Very low

What is it? 

Cold therapy is the local application of cold via techniques (eg ice packs). It aims to reduce swelling, muscle spasm and pain. 

Rationale 

There is very low-quality evidence suggesting that the use of cold therapy is not effective in improving pain, function or quality of life in people with knee and/or hip OA (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document). 

Harms 

While no adverse events have been identified in trials of cold therapy in people with knee OA, there is emerging clinical evidence that individuals with symptomatic knee OA may experience cold hyperalgesia,86,87 suggesting therapeutic use of cold may be unhelpful.

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