Osteoarthritis year in review: rehabilitation and outcomes

Abstract

Purpose: This review highlights seminal publications of rehabilitation and outcomes in osteoarthritis (OA) of the hip or knee. Methods: A systematic literature search was performed in Medline from July 2011 up to January 24, 2012 using the terms ‘osteoarthritis, knee’, ‘osteoarthritis, hip’ rehabilitation, physical therapy, exercise and preoperative intervention, outcomes. Trials evaluating rehabilitation interventions were included if they were randomized trials (RCT) or systematic reviews. Surgical interventions and pharmacology studies were excluded unless they included evaluation of a rehabilitation intervention. Outcome studies were included if they contributed methodologically to advancing outcome measurement. Results: The literature search identified 259 hits. 21 publications were selected and reviewed that related to cost-effectiveness of non-pharmacological and non-surgical interventions, interventions evaluating care processes, decision making and information, weight loss, exercise (balance training, walking, neuromuscular, combined with self-management, aquatic vs. landbased, adherence), bracing, whole body vibration, short wave therapy and acupuncture/moxibustion. One systematic review provided limited evidence for the cost-effectiveness of conservative treatments for the management of hip and/or knee osteoarthritis. This was supported by a large RCT showing patients randomized to exercise and self-management having a high probability of being cost-effective at 30 months. Another meta-analysis found low to moderate evidence from mostly small RCTs demonstrating that pre-operative interventions, particularly exercise, reduce pain for patients with hip and knee osteoarthritis prior to joint replacement, and exercise with education programs may improve activity after hip replacement. The increased focus on care strategies, decision-making instruments and patient information in osteoarthritis treatment was highlighted by several publications. A consensus-based strategy provided a framework for health care providers and patients with hip or knee osteoarthritis to discuss the optimal timing of the various treatment options. An audiovisual patient decision aid aiming at changing disadvantageous beliefs and encourage physical activity was associated with a small effect. The studies on exercise added information on treatment effect of important aspects such as type, combined treatments, and adherence to exercise. A single high quality RCT found low-energy-diet induced weight loss to relieve pain also at one year and lead to independent losses of leg muscle tissue and strength, indicating the need for exercise in conjunction with low-energy-diet induced weight loss programs. A systematic review failed to provide conclusive evidence for the effectiveness of moxibustion (warm acupuncture) compared with drug therapy in rheumatic conditions. The total number of RCTs included in this review and their methodological quality were low. An RCT found moxibustion combined with intra-articular injection of sodium hyaluronate to be more effective than intra-articular injection of sodium hyaluronate alone. A secondary analysis of 10 000 patients included in one of four RCTs for one of four chronic pain problems, including hip or knee osteoarthritis, found that age, education, duration of illness, baseline pain, and some concomitant diseases predicted treatment outcome in both groups (routine care with or without acupuncture). Patients' characteristics that enlarged the acupuncture effect were being female, living in a multi-person household, failure of other therapies before the study, and former positive acupuncture experience. A single high quality RCT among persons with symptomatic lateral PF OA found the effects of a specific realigning PF brace not to be of clinical or statistical significance. One RCT found pulsed shortwave treatment to be an effective method for pain relief and improvement of function and quality of life in the short term in women with knee OA. The 16 outcomes papers considered relevant did not add significantly to current knowledge. Conclusion: The current clinical focus on non-pharmacological and non-surgical treatment of hip or knee OA translates into research findings that increasingly are included in meta-analysis improving the evidence level for non-pharmacological and non-surgical treatments in hip or knee OA. Information, exercise and weight loss are supported as first line treatments and as adjunctive treatments prior to surgery.