×

The RACGP website is undergoing scheduled maintenance on Tuesday, 5th December 2023 from 7:00 AM to 9:00 AM AEDT. During this time, the application will be unavailable. We apologise for any inconvenience caused.


Guideline for the management of knee and hip osteoarthritis

Recommendations

Intra-articular injections

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

Pharmacological interventions

Intra-articular injections


 

Intervention: Corticosteroid injection - Knee (OA) and/or hip

Recommendation

It may be appropriate to offer an intra-articular corticosteroid injection for some people with knee and/or hip osteoarthritis for short-term pain relief. Clinicians need to be cautious of the potential harms of repeated use.

Strength of recommendation

Conditional for recommendation

Quality of evidence

Very low

What is it?

Corticosteroids are medications that mimic the effects of the hormone cortisol, which is produced naturally by the adrenal glands. Cortisol helps to lower the levels of prostaglandins and downplays the interaction between certain white blood cells involved in the immune response. Corticosteroid injections are frequently used for the short-term symptom relief of a flare of joint symptoms or when a rapid reduction in symptoms is required.

Rationale

The studies upon which the recommendation is based were at serious risk of bias and generally small in size. The overall quality of the evidence was judged to be low to very low (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document). Beneficial effects on knee pain and function were demonstrated at up to six weeks. These findings were not present when follow-up was extended to three months.

For hip pain, the clinical benefits were demonstrated for up to 12 weeks; however, there is lack of long-term data. In addition, considering the complexity of the hip joint, image guidance would be required, which would further add to the costs.
The working group considered intra-articular corticosteroid injections can be used as an adjunct to core treatment for short-term reduction of moderate-to-severe pain in people with knee or hip OA.

Harms

Serious and total adverse events were not significantly increased, compared with placebo. However, there are concerns of more rapid cartilage loss with repeated injections with no benefit in long-term symptom outcomes at two years, so these injections should be used judiciously.118

Intervention: Viscosupplementation injection - Knee/hip

Recommendation

We suggest not offering viscosupplementation injection for people with knee hip OA.

 

Strength of recommendation

Conditional against recommendation

Quality of evidence

Low

Recommendation

We do not recommend offering viscosupplementation injection for people with hip OA.

Strength of recommendation

Strong against recommendation

Quality of evidence

Low

What is it?

Hyaluronate is a naturally occurring component of cartilage and synovial fluid, and responsible for the rheologic properties of synovial fluid, enabling it to act as a lubricant or shock absorber. In OA, synovial hyaluronate is depolymerised and cleared at higher rates than normal. The therapeutic goal of intraarticular hyaluronate administration is to provide and maintain intraarticular lubrication. This in turn increases the viscoelastic properties of synovial fluid, and is sometimes termed ‘viscosupplementation’. It has also been reported that hyaluronate exerts anti-inflammatory, analgesic and possibly chondroprotective effects on the articular cartilage and joint synovium.119

Rationale

The major analyses upon which the recommendation is based were considered to be at serious risk of bias, but the large number of studies analysed involved, in total, a large number of participants. For knee pain, function and adverse events, the overall quality of the evidence was judged to be moderate. Despite some inconsistency on the conclusions among the analyses, a positive effect, albeit small and not clinically relevant, was demonstrated for pain and function.

The recommendation for hip OA is based on three small randomised controlled trials (RCTs), which were judged to not be at serious risk of bias (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document). The overall quality of evidence was judged to low. No effect on pain nor function was demonstrated, and the risk of total and serious adverse events and local reactions was greater in the viscosupplementation group. In addition, for a hip injection, image guidance would be required, further adding to complexity and cost. However, the increased risk of total and serious adverse events concerned the working group, and when cost and the complexity of the intervention were taken into account, a conditional against recommendation was agreed upon.

Harms

Minor side effects include pain at the injection site (1–33%), local joint pain and swelling (<1–30%), and local skin reactions (3–21%). Pseudoseptic reactions (1–3%), which are characterised by inflammation and swelling of the joint that are not caused by infection, can be severe and may require further medical treatment. These reactions usually occur after sensitisation with the second or third injection of a series, or with a repeat treatment course. True joint infections have also been reported, but these appear to be rare.120

Intervention: Platelet-rich plasma (PRP) injection – Knee and/or hip

Recommendation

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

Strength of recommendation

Conditional (neutral) recommendation

Quality of evidence

Very low

What is it?

PRP is an autologous concentration of a high number of platelets in a small volume of plasma, and it is prepared by centrifugation of blood. Platelets contain significant amounts of cytokines and growth factors, which are capable of stimulating cellular growth, vascularisation, proliferation, tissue regeneration and collagen synthesis.

Rationale

The studies upon which the recommendation is based were at serious risk of bias and inconsistency, and were generally small in size (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document). The overall quality of the evidence was judged to be very low. Beneficial effects on both knee pain and Western Ontario and McMaster Universities (WOMAC) function were demonstrated at six months. With the concern of potential reporting bias and low-quality data, the beneficial effects are likely to be overinflated. In addition, there is no consensus on eligible participant selection, number and frequency of injections, preparation technique, or appropriate platelet concentration,121 leading to large variations in the design of PRP trials.

No RCT was conducted in hip OA. However, during working group discussions, it was suggested that the mechanism of action should be no different in hip OA. Therefore, the findings might be transferrable to hip OA, but with a particular caution in terms of the complexity of the hip joint.

The cost of PRP treatment is high, and additional equipment might be required for the preparation and administration.

Harms

Most common treatment-related adverse events were local swelling and transient regional pain. PRP did not increase the risk of adverse events, compared with hyaluronic acid and saline according to other systematic reviews.122

Intervention: Stem cell therapy – Knee and/or hip

Recommendation

We do not recommend offering stem cell therapy  for people with knee and/or hip OA.

Strength of recommendation

Strong against recommendation

Quality of evidence

Very low

What is it?

Stem cells are cells that have the ability to divide and develop into many different types of cell in the body, and can be categorised as pluripotent and multipotent. Mesenchymal stem cells (MSCs) are a common form of multipotent cells that may offer an alternative to cartilage repair techniques that is not hampered by availability and donor site morbidity. MSCs can be isolated from adipose tissue, bone marrow, synovial tissue and other sources.

Rationale

The two studies upon which the recommendation is based were at very serious risk of bias and were small in size. The overall quality of the evidence was judged to be low to very low. Beneficial effects on pain and function were demonstrated at up to six months. The between-group differences reported for pain and function appeared to be remarkably good (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document). As they deviate significantly from those of other successful interventions, replication is required in high quality, large RCTs before a more favourable recommendation can be considered.

Consistent with a recent position statement from the Australian College of Sports and Exercise Physicians, stem cell administration should be part of a rigorously designed study and the priority for individual health and welfare.123

Harms

No serious adverse events were reported in those trials. There are two groups reporting minor adverse events, including mild pain and effusion after the injections, which persisted for no more than seven days.124,125

Intervention: Dextrose prolotherapy – Knee and/or hip

Recommendation

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

Strength of recommendation

Conditional against recommendation

Quality of evidence

Low

What is it?

Hypertonic dextrose injection, also termed as prolotherapy, is an injection-based treatment used for a variety of painful chronic musculoskeletal pain conditions. The core practice principle of prolotherapy is injection of relatively small volumes (0.5–6 ml) of an irritant solution, usually hypertonic dextrose, at painful ligament and tendon attachments, and in adjacent joint spaces. The hypothesised mechanisms for pain relief include stimulation of local healing, reduction of joint instability through the strengthening of stretched or torn ligaments and stimulation of cellular proliferation.

Rationale

The recommendation is based on the evidence of only one small RCT of low quality. The risk of bias in this study was not determined to be serious. No clinically significant effects were found for pain at 24 and 52 weeks follow-up. In terms of function, no clinically significant effects were found for pain at 24 weeks, but a marginally significant effect was recorded at  52 weeks (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document). Furthermore, high-quality RCTs with low risk of bias and specifically for hip OA are required.
As prolotherapy is relatively cheap and accessible, it is likely to be injudiciously used. The working group agreed on a ‘Conditional against recommendation’.

Harms

The study reported self-limited bruises after dextrose (n = 3) and saline (n = 5) injections. This was an expected side effect and deemed to be of minimal clinical relevance because of its transient nature. No serious adverse events were reported; however, this may be because the study sample size is not large enough to detect uncommon adverse events.126

  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:// 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. [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].
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