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Diagnosis and Management of Osteoarthritis of the Knee and Hip - Adult - Ambulatory

Diagnosis and Management of Osteoarthritis of the Knee and Hip - Adult - Ambulatory - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Orthopedics


1



Diagnosis and Management of
Osteoarthritis of the Knee and Hip
– Adult – Ambulatory
Clinical Practice Guideline


Note: Active Table of Contents – Click to follow link
EXECUTIVE SUMMARY ........................................................................................................... 3
SCOPE ................................................................................................................................... 5
METHODOLOGY .................................................................................................................... 5
RECOMMENDATIONS ............................................................................................................ 7
Pre-Osteoarthritis .................................................................................................................... 7
Diagnosis .................................................................................................................................. 7
Imaging .................................................................................................................................... 8
Weight Management............................................................................................................... 9
Physical Activity and Exercise .................................................................................................. 9
Physical Therapy .................................................................................................................... 12
Pharmacologic Therapy ......................................................................................................... 15
Referral for Consultation Total Joint Replacement ............................................................... 19
UW HEALTH IMPLEMENTATION ........................................................................................... 21
APPENDIX A. EVIDENCE GRADING SCHEME(S) ...................................................................... 23
APPENDIX B. SAMPLE AFTER VISIT SUMMARY ..................................................................... 25
REFERENCES ........................................................................................................................ 26


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Contact for Content:
Name: Katie Miller, MD- Internal Medicine/Sports Medicine
Phone Number: (608) 287-2262
Email Address: Kathryn.Miller2@uwmf.wisc.edu
Contact for Changes:
Name: Lindsey Spencer, MS- Center for Clinical Knowledge Management (CCKM)
Phone Number: (608) 890-6403
Email Address: lspencer2@uwhealth.org
Coordinating Team Members:
Matthew Squire, MD, MS- Orthopedics/Rehabilitation
Deborah Boushea, MD- Internal Medicine
Ann Schmidt, MD- Internal Medicine
Jeff Huebner, MD- Family Medicine/Population Health
Bobby Nourani, DO- Family Medicine
Doug Smith, MD- Family Medicine
Matthew Brown, MD, DPT- Family Medicine Resident
Todd Domeyer, MD- Family Medicine Resident
Chantal Girod, MD- SwedishAmerican (Family Medicine)
Kathleen Kelly, MD- SwedishAmerican (Internal Medicine)
Christie Bartels, MD- Medicine- Rheumatology
Ken Lee, MD- Radiology
Richard Kijowski, MD- Radiology
Gina Greenwood- Radiology
Cindy Gaston, PharmD- Drug Policy Program
Carin Endres, PharmD- Pharmacy- Inpatient Services
Kristina Bennwitz, PharmD- Pharmacy Resident
Kip Schick- TAC Administration
Kristen Traino- Rehabilitation- General Services
Steven Hill, PT- Rehabilitation- Ortho and Hands
Tiffany Houdek, PT- Rehabilitation- The American Center
Lori Brody, PT- Rehabilitation- Orthopedics- Research Park
Amy Mihm- Clinical Nutrition
Katheryn Hoff- Clinical Nutrition
Nicole Mendolla- NP Student
Diane Scherschel- Wellness- TAC
Tami Towne- Unity Health Insurance
Beth Weinman, DO- Meriter- Unity Point
Jim Porter, MD- Dean
Stephen Almasi, MD- Group Health Cooperative- Southcentral Wisconsin
Jen Grice, PharmD, BCPS- Center for Clinical Knowledge Management (CCKM)
Review Individuals/Bodies:
Thomas Zdeblick, MD- Orthopedics/Rehabilitation
Richard Illgen, MD- Orthopedics/Rehabilitation
Luke Funk, MD, MPH- Surgery- General Surgery
Committee Approvals/Dates:
Clinical Knowledge Management (CKM) Council (04/28/2016)
Release Date: June 2016 | Next Review Date: April 2018
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Executive Summary
Guideline Overview
Osteoarthritis of the knee and hip is a common and debilitating condition. UW Health has
created guidelines to address the evaluation and treatment of this condition. Treatment
recommendations include core treatment options such as weight loss, exercise, physical
therapy. It also included secondary treatment options including pharmacologic therapy, intra-
articular injections, orthotics and walking aids. It also gives guidance on when and who to refer
for total joint replacement.

These guidelines were adopted from several available guidelines for the treatment of
osteoarthritis, as well as the latest review of the literature. Guidelines published by the following
organizations were used in the development of this document:
ξ Osteoarthritis Research Society International (OARSI)1
ξ National Clinical Guideline Centre (NICE)2
ξ American College of Rheumatology (ACR)3
ξ American Academy of Orthopaedic Surgeons (AAOS)4
ξ American Association of Hip and Knee Surgeons (AAHKS)5

Key Practice Recommendations
1. Always obtain knee radiographs (3 views ± Standing AP, Lateral, and Laurin).6,7 (UW Health
Low quality evidence, strong recommendation) Hip radiographs should be the first imaging
obtained for patients with chronic hip pain (AP, lateral, and pelvis). (UW Health Low quality of
evidence, strong recommendation) Alternatively, 2 view radiographs with low AP pelvis and
cross-table lateral radiographs can be considered. These views slightly decrease the
amount of radiation and time spent obtaining radiographs and can provide similar
information. (UW Health Very low quality of evidence, weak/conditional recommendation)
2. Patients with osteoarthrLWLV�RI�WKH�NQHH�RU�KLS�DQG�D�%0,�•����kg/m2 can experience an
improvement in symptoms by moving towards a healthier weight. Achieving and maintaining
a healthy weight is a core therapy for the management of osteoarthritis and should be the
goal of any patient with a BMI > 25 kg/m2.4 (UW Health Moderate quality evidence, strong
recommendation) Providers should provide education to overweight and obese patients on
the importance of weight loss and resources to help them lost weight.
3. All patients with osteoarthritis of the knee or hip should engage in regular physical activity
and exercise consistent with national guidelines, including both general aerobic fitness and
muscle strengthening.1-4 (UW Health Moderate quality evidence, strong recommendation) Low
joint stress activities such as walking, cycling, aquatic exercise class, and swimming are
most appropriate for individuals with lower joint osteoarthritis.
4. Certain groups of patients are likely to do better with formal physical therapy (rather than
initiating a home exercise program) (UW Health Moderate quality evidence, strong
recommendation):
ξ Milder disease
ξ unilateral OA
ξ symptoms for less than 1 year
ξ 40-m self-paced walking test of less than 25.9 seconds
ξ those who have pain of 6 or greater on the numerical pain rating scale

5. Patients who also may benefit from PT referral (UW Health Very low quality evidence,
weak/conditional recommendation):
ξ Functional limitations with persistent pain
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ξ High levels of anxiety, fear avoidance, and those who have problems fulfilling
their roles within the home or at work due to pain that limits functional tasks
ξ Patients who are deconditioned and/or do not participate in regular exercise or
physical activity
ξ Multiple questions/concerns about exercise for appropriate exercise prescription
ξ failed to find a general exercise program that is tolerated
ξ made worse by current exercise program
6. Opioid therapy should NOT be considered first line treatment for patient with osteoarthritis
related pain.1,4,8,9 (UW Health Moderate quality evidence, strong recommendation)
7. Corticosteroid intra-articular injections (UW Health High quality evidence, strong
recommendation) or hyaluronic acid intra-articular injections (UW Health Low quality evidence,
weak/conditional recommendation) can be considered for individual patients who continue to
have moderate-to-severe pain and loss of function after appropriate first line treatment has
been implemented.
8. The following criteria may be used by primary care providers to help decide which patients
may be appropriate for surgical referral (UW Health Low quality evidence, weak/conditional
recommendation):5,10-13
ξ No improvement after 3 months of conservative management
ξ Moderate or severe symptoms (with presence of mild to moderate radiographic
findings)
ξ Moderate/severe functional limitations affecting quality of life
ξ BMI < 40 kg/m2*
ξ Medically appropriate after consideration of surgical risk factors (e.g., tobacco use,
diabetes, cardiovascular disease**, anticoagulation and antiplatelet therapy)
ξ Would consider surgery following discussion of TJR

*Assessment and treatment of potential operative risk factors should be optimized for all obese patients.
Due to the risk of surgical and postoperative complications (e.g., infection, DVT, revision surgery),
patients with a BMI > 45 kg/m2 should not be referred for total joint replacement.14 (UW Health Low
quality evidence, strong recommendation) Patients with a BMI 40-44 kg/m2 may be considered for referral
for consideration of total joint replacement on an individual basis, whereby the referring primary care team
and evaluating orthopedics team asses patient motivation, previous weight loss and other treatments,
chronic disease status, and perioperative risk.14-17 (UW Health Low quality evidence, weak/conditional
recommendation)

**Regardless of history of cardiac disease, risk factors for 90-day cardiac events include female gender
and American Society of Anesthesiology (ASA) class of III-IV after THA and older age (> 65 years) and
ASA class III-IV after TKA. Female gender and higher comorbidity index were also risk factors for 90-day
thromboembolic events in TKA, regardless of past history of thromboembolism.12

Companion Documents
1. UW Health Obesity ± Adult ± Ambulatory Clinical Practice Guideline

External Resources
1. www.arthritis.org

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Scope
Disease/Condition(s): Hip and knee osteoarthritis

Clinical Specialty: Primary Care, Sports Medicine, Rheumatology, Pain Management,
Orthopedic Surgery, Nursing, Physical Therapy, Occupational Therapy

Intended Users: Physicians, Advanced Practice Providers, Nurses, Physical Therapists.
Pharmacists

Objective(s): Evidence based management of knee and hip osteoarthritis including core and
non-measures. Core measures include weight management, exercise including physical
therapy. Non-core measures include orthotics, topical and oral medications, walking assist
devices, intra-articular injections. Guidelines also include recommendations on when to discuss
and refer a patient for total joint replacement.

Target Population: Adults age 18 years or older with knee and hip joint pain from primary and
post- traumatic osteoarthritis.

Interventions and Practices Considered:
ξ Weight loss and exercise
ξ Physical therapy, orthotics and assist devices
ξ Topical medications, oral medications (including acetaminophen, NSAIDS, opioids)
ξ Intra-articular injections (including corticosteroids, hyaluronic acid injections and
prolotherapy)
ξ Referral recommendations for total joint replacement surgery

Major Outcomes Considered:
ξ Patient function and disability
ξ Pain
ξ Disparities in treatment and referral for joint replacement surgery by age, gender, race,
disability and education level18-24
Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches (e.g., PUBMED) were conducted by the guideline author(s) and
workgroup members to collect evidence for review. Expert opinion and clinical experience were
also considered during discussions of the evidence.

Methods Used to Formulate the Recommendations:
The workgroup members agreed to adopt recommendations developed by external
organizations and/or arrived at a consensus through discussion of the literature and expert
experience. All recommendations endorsed or developed by the guideline workgroup were
reviewed and approved by other stakeholders or committees (as appropriate).

Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:
Recommendations developed by external organizations maintained the evidence grade
assigned within the original source document and were adopted for use at UW Health.

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Internally developed recommendations, or those adopted from external sources without an
assigned evidence grade, were evaluated by the guideline workgroup using an algorithm
adapted from the Grading of Recommendations Assessment, Development and Evaluation
(GRADE) methodology (see Figure 1 in Appendix A).

Rating Scheme for the Strength of the Evidence/Recommendations:
See Appendix A for the rating scheme(s) used within this document.

Introduction
Osteoarthritis (OA) is a common and debilitating condition. Over 1/3 of Americans over the age
of 65 were affected by OA in 2005.25 The prevalence of this condition is increasing as the age
and weight of the US population also increases, making OA one of the leading causes of
disability in the U.S.26 OA leads to increased morbidity27 and mortality28, and it is strongly
associated with metabolic syndrome, diabetes, walking disability as well as atherosclerotic
cardiovascular disease.27,28 Patients with OA tend to have multiple co-morbid conditions28 that
make treatment of each condition more complex. In addition, there is mounting evidence of a
new metabolic syndrome associated phenotype of OA in which joint inflammation and cartilage
destruction is influenced by individual metabolic factors such as diabetes, dyslipidemia, and
hypertension.29-31

A 2003 study found that 33% of individuals diagnosed with arthritis were obese compared to
21% of those without arthritis. By 2009 this prevalence had increased to 35% compared to 26%
in those without arthritis.32 In Wisconsin, the prevalence of osteoarthritis is higher than the
national average, with 53% of individuals over the age of 65 having this diagnosis. In Wisconsin,
54% of all diabetics, 44% of all hypertensives, and 34% of all obese patients have a diagnosis
of osteoarthritis. Half of Wisconsin adults with a diagnosis of arthritis have work limitations due
to this condition.

OA like many chronic health conditions is often inadequately treated. Initial treatment is focused
in primary care, where patients are treated for nearly 6 years prior to referral to a specialist.33
Diagnostic procedures, referrals and use of treatment modalities including education in primary
care tend to be inadequate.34-36 Only 47-57% of osteoarthritic patients managed in primary care
actually receive the recommended treatments.35-37 Large disparities in treatment and referral for
total joint replacement have been found and treatment advice differs according to patient sex,
age, disability, and education level.18-21 Lack of appropriate treatment and management of
osteoarthritis associated pain, leads to a slow decline in patient function and activity which
negatively impacts their overall health.34

The demand for total joint replacement is expected to continue to escalate. From 2005-2030 in
the United States, the demand for total hip replacement is expected to increase by 174% and
the demand for total knee replacement is expected to increase by 673%.38 This increase is
being driven by an aging, overweight population who has higher expectations for an active old
age.39 Because of this increased demand, there will be some rationing as the current health
care system cannot accommodate this number of procedures.

Several challenges and barriers prevent patients from receiving high quality care both nationally
and at UW Health. These include lack of time and expertise among primary care providers as
well as specialists. Primary care providers are often forced to manage and discuss treatment of
osteoarthritis within the context of an appointment aimed at the attention of co-morbid
conditions40, leaving inadequate time to address this condition which requires a significant
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amount of counseling. In addition there is a perception from both patients and medical providers
that there is a lack of effective treatment.40 Patients cite numerous barriers to receiving care for
osteoarthritis including difficulty obtaining referrals or appointments, work-related issues
including taking time off for appointments, and medical opinions about saving surgery for later.41
These guidelines are intended to help primary care providers address these barriers and help
patient receive appropriate care to improve their pain and function caused by this debilitating
condition.
Recommendations
PRE-OSTEOARTHRITIS
Osteoarthritis of the knee and hip has a long pre-clinical phase in which individuals do not
experience symptoms. The biochemical and structural changes that lead to symptomatic
osteoarthritis start to occur more than a decade prior to the development of symptoms. Risk
IDFWRUV�VXFK�DV�WUDXPD�DQG�REHVLW\�LQFUHDVH�D�SDWLHQW¶V�OLNHOLKRRG�RI�GHYHORSLQJ�V\PSWRPDWLF�
osteoarthritis.42

Patients at risk for development of symptomatic osteoarthritis, including those who are obese,
have history of trauma to knee or hip (e.g. ACL tear), or have a strong family history of
osteoarthritis, should be counseled to maintain or lose weight and remain physically active. (UW
Health Very low quality evidence, weak/conditional recommendation)

For example, a weight loss of 5 kg in a woman of average height (the equivalent of a decrease
in 2 BMI units) over a decade decreased the risk of development of symptomatic OA by half.43

Diagnostic criteria for knee pre- osteoarthritis are being studied and include patient symptoms,
biochemical markers, and advanced imaging and/or knee arthroscopy.44 However, these are
not recommended for clinical use at this time. (UW Health Low quality evidence, weak/conditional
recommendation)
DIAGNOSIS
Osteoarthritis of the knee and hip is a clinical diagnosis that should be made in a patient with
chronic knee or hip pain that meets the following criteria after considering differential diagnoses
or coexisting diagnoses if a person meets the following criteria2 (UW Health Moderate quality
evidence, strong recommendation):
ξ is 45 years or older and
ξ has activity-related joint pain and
ξ has either no morning joint-related stiffness, or morning stiffness that lasts no longer
than 30 minutes.

Patients with prior traumatic knee injury such as ACL or meniscal tear, are at high risk of
developing knee OA in the affected knee. This typically is seen as soon as 5-10 years after
injury. Therefore, a diagnosis of osteoarthritis should also be considered as a potential etiology
of knee joint pain in patients younger than 45 years of age with prior history of ACL tear,
meniscal tear, or other significant knee trauma. (UW Health Moderate quality evidence,
weak/conditional recommendation)

Presence of the following features indicate an increased likelihood of an additional or alternative
diagnosis:2
ξ history of trauma
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ξ prolonged morning joint-related stiffness
ξ rapid worsening of symptoms
ξ presence of a hot, swollen joint; severe local inflammation; erythema
ξ progressive pain unrelated to usage
ξ involvement of other joints and/or systemic symptoms
ξ knee or hip pain that does not meet the above criteria

The following differential diagnoses should be considered in patients presenting with pain
localized to the knee or hip joint pain:2
ξ gout
ξ inflammatory arthritides (including rheumatoid arthritis)
ξ septic arthritis
ξ malignancy with bone pain
ξ referred pain
ξ bursitis/tendonitis including IT band
ξ ligamentous injuries
ξ meniscal injuries (acute)
ξ fracture
IMAGING
It is recommended to perform the following imaging recommendations for non-traumatic knee
pain adapted from American College of Radiology Appropriateness Criteria:6,7
1. Always obtain knee radiographs (3 views ± Standing AP, Lateral, and Laurin) (UW Health
Moderate quality evidence, strong recommendation)
a. If knee OA on radiographs then no further imaging is necessary unless the SDWLHQW¶V�
symptoms are not explained by radiographic findings of OA (e.g. stress fracture) or
mechanical symptoms (e.g. bucket handle meniscal tear). MRI of the knee should be
obtained even if knee OA present on radiographs if symptoms are not explained by
the OA (e.g. stress fracture) or patient has mechanical symptoms (e.g. bucket handle
meniscal tear). (UW Health Moderate quality evidence, strong recommendation)
b. MRI should not be obtained to document degenerative meniscal tear if no
mechanical symptoms (UW Health moderate quality evidence, strong recommendation)
2. Be aware that knee pain can be referred from the hip and obtain hip radiographs if clinical
concern for hip pathology. (UW Health Moderate quality evidence, weak/conditional
recommendation)
3. Consider MRI if: (UW Health Moderate quality of evidence, weak/conditional recommendation)
a. Negative radiographs and persistent knee pain
b. Negative radiographs except for a joint effusion
c. Concern for internal derangement (meniscal tear or ligament injury)
d. Additional information is necessary before instituting treatment
4. Consider MRI with and without contrast if (UW Health Moderate quality of evidence,
weak/conditional recommendation):
a. Concern for inflammatory arthritis/synovitis
b. Concern for infection/septic arthritis
c. Concern for neoplasm
5. 'RQ¶W�SHUIRUP a CT scan in non-traumatic knee pain in adults unless concern for intra-
articular abnormality and WKH�SDWLHQW�FDQ¶W�XQGHUJR�05, (i.e. contraindicated, large body
habitus, claustrophobia). In such instances, CT arthrogram may be used instead of MRI.
(UW Health Moderate quality evidence, weak/conditional recommendation) CT without intra-
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articular contrast has a very low sensitivity for internal knee derangements and should
not be used. (UW Health Moderate quality of evidence, strong recommendation)

It is recommended to perform hip radiographs as the first imaging obtained in patients with
chronic hip pain (AP, lateral, and pelvis), as adapted from the American College of Radiology
Appropriateness Criteria.45,46 (UW Health Low quality of evidence, strong recommendation)
Alternatively in cases where radiation or time spent obtaining radiographs is of concern, 2 view
radiographs with low AP pelvis and cross-table lateral radiographs can be considered as they
can provide similar information. (UW Health Very low quality of evidence, weak/conditional
recommendation)
WEIGHT MANAGEMENT
Achieving and maintaining a healthy weight is a core therapy for the management of
osteoarthritis and should be the goal of any patient with a BMI > 25 kg/m2.4 (UW Health Moderate
quality evidence, strong recommendation) PDWLHQWV�ZLWK�RVWHRDUWKULWLV�RI�WKH�NQHH�RU�KLS�DQG�D�%0,�•�
25 kg/m2 can experience an improvement in symptoms by moving towards a healthier weight.
Evidence supports a patient who is successful in losing 10% of his/her starting weight would
have a moderate-to-high clinical effect in self-reported disability.47 Patients successful at weight
loss can expect to experience a simultaneous decrease in pain and improvement in function.
Even modest weight loss is beneficial; losing one pound of weight equates to an eight pound
load reduction across the joint.

&OLQLFLDQV�VKRXOG�FDOFXODWH�D�SDWLHQW¶V�ERG\�PDVV�LQGH[��%0,��IRU�VFUHHQLQJ�DQG�DV�QHHGHG�IRU�
weight management. Classify BMI based on the body mass categories. Educate patients about
their body mass index and associated risks.48 (ICSI Strong Recommendation, High Quality Evidence)
Clinicians must carefully consider BMI and its associated mortality risk across different ethnicity,
gender and age groups.48 (ICSI Strong Recommendation/Moderate Quality Evidence) For additional
recommendations, refer to the UW Health Obesity ± Adult ± Ambulatory Clinical Practice
Guideline.

Motivational Interviewing techniques are an essential tool for encouraging behavior change.48
Referral to a Registered Dietitian, RD or RDN, with a comprehensive knowledge of weight
management strategies and can also HQKDQFH�D�SDWLHQW¶V�VXFFHVV�LQ�DFKLHYLQJ�D�KHDOWK\�
weight. (UW Health Very low quality evidence, weak/conditional recommendation) For additional
detailed recommendations, refer to the UW Health Obesity ± Adult ± Ambulatory Clinical
Practice Guideline.

Local Weight Management Services:
1. UW Health - Health and Wellness
2. UW Health - Clinical Nutrition Services
3. UW Health - Medical and Surgical Weight Management
4. Unity Health Insurance - Weight Management
5. SwedishAmerican ± Weight Management
6. Group Health Cooperative - Weight Management
7. UnityPoint Health-Meriter - Weight Management
8. Dean - Weight Management
PHYSICAL ACTIVITY AND EXERCISE
All patients with osteoarthritis of the knee or hip should engage in regular physical activity and
exercise consistent with national guidelines including both general aerobic fitness and muscle
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strengthening.1-4 (UW Health Moderate quality evidence, strong recommendation) This
recommendation is a core treatment for the management of osteoarthritis associated pain and
disability. This should be recommended to patients regardless of age, comorbidity, pain
severity, or disability.

Starting an Exercise Program
A written exercise prescription can be helpful in engaging patients in exercise. This can
be done using the standard exercise prescription format: FITT (Frequency, Intensity,
Time, Type, Progression).49 A sample After Visit Summary (AVS) for Patient Exercise
Guidance for Osteoarthritis is outlined in Appendix B . Further guidance for writing an
exercise prescription is outlined below:

Frequency
o Aerobic exercise 3-5 days weekly
o Resistance (strength training) exercise 2-3 days weekly
o Flexibility and range of motion exercises are essential and should be performed daily if
possible, focusing on motions that are limited noted by musculoskeletal examination

Intensity
o Aerobic exercise
 Optimal intensity of aerobic exercise has not been determined for patients with
osteoarthritis
 Light-to-moderate aerobic intensity are recommended because they are
associated with lower risk of injury or pain exacerbation,
o Very light aerobic intensity activities are appropriate for deconditioned patients.
o As activity level and exertion can subjectively vary based on patient perspective, the
Borg scale (Figure 1) may be used as an objective tool to define activities associated
with a certain level of exercise intensity in order to engage patients in appropriate
activity. Another way to gauge the intensity of aerobic exercise may be E\�D�SDWLHQWV¶�
ability to converse or sing a song while performing the designated activity. For example,
an individual should be able to hold a conversation during moderate exercise but
FRXOGQ¶W�VLQJ�D�VRQJ. During intense aerobic activity, it should be difficult to speak in
complete sentences.

Figure 1. Borg Scale
Borg scale Feeling Possible examples
6 No exertion at all Sitting, lying, resting
7 Extremely light
8
9 Very light Slow walking
10
11 Light (Low intensity) Walking (2.5 to 3.0 mph)
12
13
Somewhat hard
(moderated intensity)
Brisk walking (3.7 to 4.5 mph depending on height of
patient) cycling, aqua jogging. Light jog
14
15 Hard (heavy) (high intensity) Running, spinning, stair climbing
16
17 Very hard
18
19 Extremely hard
20 Maximal exertion
Exercise intensity correlates with Rate of Perceived Exertion. Studies show that perceived exertion correlates well with heart rate.
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o World Health Organization (WHO) (Figure 2)
http://www.who.int/dietphysicalactivity/physical_activity_intensity/en/
 Metabolic Equivalents (METs) are commonly used to express the intensity of
physical activities.
 MET is the ratio of a
person's working
metabolic rate relative
to their resting
metabolic rate.
 One MET is defined
as the energy cost of
sitting quietly and is
equivalent to a caloric
consumption of
1kcal/kg/hour. It is
estimated that
compared with sitting
quietly, a person's
caloric consumption is
three to six times
higher when being
moderately active (3-6
METs) and more than
six times higher when
being vigorously
active (>6 METs).
Figure 2. WHO Metabolic Equivalents (METs)
o Resistance exercise
 Optimal intensity of resistance exercise has not been determined for
patients with osteoarthritis
 Light and higher intensity training has been associated with
improvements in function, pain, and strength
ξ Light: 50% of 1 repetitions maximum
ξ Moderate: 70% of 1 repetition maximum
ξ Heavy 85% of 1 repetitions maximum
Time
o Aerobic exercise
 GOAL: 150 minutes per week (consider framing as a daily goal to patients) of
aerobic activity is appropriate for many individuals with osteoarthritis
 Long continuous bouts of exercise may be difficult
 It is appropriate to start with short bouts of 10 minutes (or less) according to a
SDWLHQW¶V�SDLQ
ξ Example: 3 bouts of 10 minutes of brisk walking per day on a level
surface (30 minutes total per day)
ξ 5 minutes of low to no resistance stationary bicycling can often be
comfortable and improve pain temporarily but consistently. While this
does not yet qualify for being aerobic, it may be needed to ramp towards
longer times.
o Resistance Exercise
 The optimal number of sets and repetitions is not known
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 Strength training should use overload principle: 70% of 1 repetition maximum; 3
sets x 8-10 repetitions; 3x/week. Reassess 1 repetition maximum every 2 weeks

Type
o Aerobic exercise
o Low joint stress activities such as walking, cycling, aquatic exercise class, and
swimming are most appropriate for individuals with lower joint osteoarthritis.
o Resistance exercise
o Should include all major muscles groups

Progression
o Progression of all exercise should be very gradual (e.g., no more than 10% per week)
DQG�LQGLYLGXDOL]HG�EDVHG�RQ�DQ�LQGLYLGXDO¶V�SDin and other symptoms. Patients should
perform the same exercise for 3 sessions without symptoms before progression.
PHYSICAL THERAPY
Physical therapists are dynamic professionals with a theoretical and scientific knowledge of the
ERG\¶V�PRYHPHQW�V\VWHP��Their ability to diagnose and develop comprehensive care plans
offers widespread clinical applications, making physical therapists integral members of the
primary care team. Physical therapy is appropriate for many patients with knee and hip
osteoarthritis due to their expertise in treating the impairments and activity limitations commonly
seen in patients with hip and knee OA. Physical therapists use therapeutic exercise (both land
and aquatic based), manual therapy, and patient education to improve patienW¶V�PXVFOH�
performance (strength, power and endurance), range of motion/mobility, gait mechanics,
balance and stability, functional skills, and ability to self-manage symptoms. Physical therapists
also help patients transition from therapeutic rehabilitative exercise to exercise for health and
wellness. Patient specific recommendations for modalities, assistive devices and bracing can be
made by physical therapists.

Barriers to the acceptance of PT as a therapeutic treatment for OA include fatalistic patient and
provider perspectives, inadequate analgesia, and a fear among some patients and providers
that increased activity will lead to progression of their OA.50

Referral to Physical Therapy
Not all patients require physical therapy to actively engage in physical movements or exercise;
however certain groups of patients are likely to achieve better health outcomes with formal
physical therapy.

Physical therapy should be recommended for the following patient groups:50 (UW Health
Moderate quality evidence, strong recommendation)
ξ Milder disease
ξ Unilateral OA
ξ Symptoms for less than 1 year
ξ 40-m self-paced walking test of less than 25.9 seconds
ξ Those who have pain of 6 or greater on the numerical pain rating scale.

Physical therapy may be considered in patients who (UW Health Very low quality evidence,
weak/conditional recommendation):
ξ Have functional limitations with persistent pain
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ξ Who are deconditioned and/or do not participate in regular exercise or physical
activity
ξ Have multiple questions/concerns about exercise for appropriate exercise
prescription
ξ Have failed to find a general exercise program that is tolerated
ξ Experience pain or other symptoms made worse by current exercise program
ξ Have high levels of anxiety or fear avoidance,
ξ Have problems fulfilling their roles within the home or at work due to pain that limits
functional tasks.

Type of Physical Therapy

Therapeutic Exercise
Strength training, aquatic therapy, and balance and perturbation therapy are recommended in
patients with osteoarthritis. (UW Health Moderate quality evidence, strong recommendation). These
therapies were the most beneficial exercises with respect to reducing pain and improving
function for patients performing physical therapy with a history of lower extremity OA.50 Physical
therapist should focus on these type of activities over other less evidence based modalities
reviewed below.

Strength Training
o Major muscle groups to consider
 Knee extensors
 Knee flexors
 Hip abductors
o In addressing strength deficits, therapist should address any range of motion deficits to
allow for full strengthening in normalized range of motion.
o Pooling the results of 10 RCTs demonstrated that land-based therapeutic exercise
programmes can reduce pain and improve physical function among people with
symptomatic hip OA.51
o High-quality evidence indicates that land-based therapeutic exercise provides short-term
benefit that is sustained for at least two to six months after cessation of formal treatment in
terms of reduced knee pain, and moderate-quality evidence shows improvement in physical
function among people with knee OA.
o The magnitude of the treatment effect would be considered moderate (immediate) to small
(two to six months) but comparable with estimates reported for non-steroidal anti-
inflammatory drugs.51,52

Balance and Perturbation Therapy
Multiple modes of balance and perturbation therapy have been shown to be beneficial for
persons with knee OA including strength training, Tai Chi, aerobics, and aquatic therapy. 53,54

Aquatic Therapy
Use of the water in aquatic therapy is another mode used to treat impairments in strength and
motion and to improve balance, gait and other functional activities. The pool is useful for
patients who do not tolerate land-based activities, need the hydrostatic pressure for swelling
control, or need the unweighting of buoyancy. Significant effects have been demonstrated on
pain, self-reported function, physical functioning, in addition to changes in stiffness and quality
of life.55 Aquatic therapy can address balance impairments and fear of falling54 and can provide
cost effective conservative care which improves with regular attendance/ performance.56
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Aerobic exercise
Aerobic exercise is recommended for persons with physical deconditioning and/or obesity. (UW
Health Low quality evidence, strong recommendation) Physical therapists can help patients return to
these types of exercise in the presence of hip and knee OA to decrease aggravation of
symptoms.

Manual Therapy
There is inconclusive evidence to recommend for or against manual therapy in treatment of
osteoarthritis.4 This can be considered based as part of a physical therapy treatment but should
not be the only component of a physical therapy treatment plan.2,3 (UW Health Low quality
evidence, weak/conditional recommendation) Manual therapy appears to be most effective in mild to
moderate OA of the lower extremity. Recent research has started to support use of mobilization
in patients with knee osteoarthritis.57

Electrotherapeutic Modalities
Transcutaneous electrical nerve stimulation (TENS) units should not routinely be used in the
management of knee osteoarthritis.1,3,4 (UW Health Moderate quality evidence, strong
recommendation)They can be considered to try in certain patients with knee osteoarthritis with
moderate to severe pain that have failed other primary treatments and are either not a
candidate (due to co-morbid medical conditions) or are not willing to undergo total joint
replacement.2,3 (UW Health Very low quality evidence, weak/conditional recommendation) There is
inconclusive evidence to support use of physical agents including electrotherapeutic modalities
in patients with knee osteoarthritis.1,4

Orthotics/Bracing
Orthotics/bracing can be considered as adjuvant therapy when patients continue to have
moderate to severe pain despite participation in therapy.1-3 (UW Health Low quality evidence,
weak/conditional recommendation) Overall there is a low level evidence base for supporting the
use of knee braces including knee sleeves, unloader braces, and shoe orthotics (lateral or
medial heel wedges and variable stiffness walking shoes). These devices often have a co-
payment for patients. However, a trial of these devices is unlikely to cause significant or lasting
harm. Physical therapy can be helpful in evaluating for the appropriateness of these devices.
Within UW Health, a referral to the orthotics clinic is another way to have patients assessed for
appropriateness.

Assistive Devices
Walking poles: These devices may be considered in patients with symptomatic knee and hip
osteoarthritis.1-3 (UW Health Very low quality evidence, weak/conditional recommendation) Walking
poles can be helpful in decreasing pain and improving balance.

Single point cane: Use of a single point cane can be considered and should be patient-
dependent; gait trials in physical therapy clinic can be helpful in determining the best assistive
device. (UW Health Low quality evidence, weak/conditional recommendation) At least one study would
suggest that the cane can be effectively used on either the contralateral or ipsilateral to the most
symptomatic side.58 There is less clear benefit for use of a cane with patients with multijoint
osteoarthritis as use of a cane may put more stress and cause increased symptoms in other
joints.1

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PHARMACOLOGIC THERAPY
Acetaminophen
Given its favorable side effect profile, acetaminophen should be tried for osteoarthritis related
pain if the patient has not already done so. (UW Health High quality evidence, strong
recommendation) However, there should be short term follow up from such a trial, as
acetaminophen is not often affective of pain control. Based on systematic reviews and meta-
analysis, acetaminophen overall has low-level effect for osteoarthritis associated pain.1 One trial
showed no benefit over placebo in pain control in patients with osteoarthritis.59

Acetaminophen has a favorable side effect profile compared to other oral pain medications but
recent meta-analysis and safety reviews have showed greater risk of long-term use.60 If
acetaminophen is recommended as treatment for osteoarthritis associated pain, it should be
prescribed and used in ways consistent with approved prescribing limits (up to 4 grams daily)
and consideration of patient behavior (e.g., alcohol use). Treatment response should be
assessed and monitored so that if not effective, further treatment recommendations can be
made.

Topical NSAIDs
Topical NSAIDs are recommended for the management of osteoarthritis-associated pain in
patients with knee only osteoarthritis ZKR�GRQ¶W�KDYH�DQ\�FRQWUD-indications to use of these
medications.1,4 (AAOS Strong Recommendation) The use of these medications is uncertain in
patients with multi-joint osteoarthritis or with hip osteoarthritis. (UW Health Low quality evidence,
weak/conditional recommendation) The benefit of topical NSAIDs in patients with multi-joint
osteoarthritis or with hip osteoarthritis is uncertain due to questionable penetration as a result of
the increased soft tissue in this area.1

Topical NSAIDS have a similar efficacy of that of oral NSAIDS for knee only osteoarthritis and
were associated with lower risk of GI adverse events.9 They are associated with higher risk of
dermatologic adverse events. Cost may be prohibitive and should be considered.

Topical Lidocaine (including patches and gels)
Topical lidocaine can be considered for pain management in patients with knee osteoarthritis.
(UW Health Low quality of evidence, weak/conditional recommendation) Several studies have found
improvement in pain in patients with knee osteoarthritis when treated with 5% or 2% lidocaine
patches. Both studies found that this treatment is generally well tolerated. Cost of lidocaine
patches may be prohibitive and should be considered. Lidocaine gel may be a reasonable
alternative if the cost of lidocaine patches is prohibitive.61-63 Although the use of these
medications may be considered in patients with multijoint osteoarthritis or with hip osteoarthritis,
their benefit is uncertain due to questionable penetration as a result of the increased soft tissue
in this area. (UW Health Low quality evidence, weak/conditional recommendation)

Capsaicin Cream
Use of capsaicin cream is not recommended. (UW Health High quality evidence, weak/conditional
recommendation) Capsaicin cream has mixed evidence to support it use in knee only
osteoarthritis.1,64-66 Overall, there is likely little if any benefit over placebo in reducing pain or
improving function in knee osteoarthritis. There are significant local adverse effects that often
prompt patients to discontinue use.

Oral NSAIDs (including COX2 inhibitors)
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Oral NSAIDs are appropriate for treatment for pain in patients with single or multiple- joint
osteoarthritis who do not have other co-morbid conditions that would preclude their use (e.g.,
renal or hepatic insufficiency, heart failure, recent gastric bleed, cardiovascular disease), as
these medications are not recommended for individuals with high co-morbidity risk.1,4 (AAOS
Strong recommendation) When used, patients should take the lowest affective dose for the
shortest period of time.

In patients taking a low dose aspirin for cardioprotection, if a NSAID is chosen to help manage
OA associated pain, it is recommended that providers use a non-selective NSAID other than
ibuprofen and prescribe with a PPI. (UW Health Low quality evidence, strong recommendation) Use
of non-selective NSAIDs in addition to low dose aspirin may make aspirin less affective in
prevention of cardiac events or strokes.3 In patients taking aspirin for cardioprotection and who
require a NSAID, it is recommended that aspirin be taken at least 2 hours prior to dosing of
NSAIDs to maximize the effectiveness of the aspirin.67-69 NSAID use in this population should be
limited to occasional-short term use.

NSAIDs are not recommended for patients with stage IV or V chronic kidney disease (eGFR <
30 cc/minute). (UW Health Very low quality evidence, strong recommendation) Consideration and
discussion of risks and benefits of NSAID use should occur prior to use in patients with stage III
CKD (eGFR (30-59 cc/minute).3

Use of oral NSAIDs is recommended with conservative dosing and treatment duration.
Individual patients may respond to different NSAIDs differently. Providers and patients may
need to try a variety of agents before finding one that is affective and does not have limiting side
effects. Prior to initiating therapy with NSAIDs, providers should discuss potential risks with
patients (see Figure 3).
Figure 3. NSAID Selectivity70


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For a review of all orally available non opioid analgesic medications including NSAIDs (including
those that would not typically be used for treatment of osteoarthritis associated pain) the
following link to Up-to-Date can be used for reference.

Oral NSAIDs and GI Prophylaxis
Consider co-prescribing H2-antagonist or proton pump inhibitor (PPI) with oral NSAID
medications to decrease the risk of gastroduodenal ulcers, particularly in patients at moderate to
high risk of developing NSAID-related ulcer complications (Table 1).9 (UW Health High quality
evidence, strong recommendation)

Table 1. NSAID-related Ulcer Risk Factors71
Level of Risk Factors
High Risk ξ History of complicated peptic ulcer disease
ξ Multiple (>2) risk factors (see below)
Moderate Risk
(1-2 factors)
ξ Age > 65 years
ξ High dose NSAID therapy
ξ A history of an uncomplicated ulcer
ξ Concurrent use of aspirin (including low dose) or
glucocorticoids
Low Risk ξ No risk factors

Given the increase risk of infection, particularly Clostridium difficile infection, and other potential
long term side effects of PPI use, high dose H2- antagonist should be considered for GI
prophylaxis rather than PPI in patients with no prior history of GI bleed or other indication for
PPI therapy.72,73 (UW Health Low quality evidence, weak/conditional recommendation)
If the patient has a history of symptomatic or complicated GI ulcer, but has not had one in the
past year and an oral NSAID is chosen, it is recommended that either a cyclooxygenase 2
selective inhibitor or a non-selective NSAID in combination with a GI prophylaxis be used.3 (UW
Health Low quality evidence, weak/conditional recommendation)

If the patient has had an upper GI bleed within the past year, it is recommended that a
cyclooxygenase 2 selective inhibitor be used in addition to a PPI if a NSAID is needed.3 (UW
Health Low quality evidence, strong recommendation)

Opioids
Opioid therapy should NOT be considered for patient with osteoarthritis related pain. .1,4,8,9 (UW
Health Moderate quality evidence, strong recommendation) Chronic use of these medications for
osteoarthritis related pain should be limited to patients who have not benefitted from an
appropriate trial of other pharmacologic agents including acetaminophen, topical and oral
NSAIDS or have significant co-morbid conditions which preclude the use of other pharmacologic
agents. In addition, patients should also be engaged in core treatments for osteoarthritis
including weight management, physical activity, and physical therapy modalities.

Use of opioids in the treatment of osteoarthritis related pain is uncertain. Several systematic
reviews have found small to moderate benefit from use of codeine, oxycodone, tramadol or
morphine in patients with knee or hip osteoarthritis. However, patients receiving opioid therapy
are more likely to have a serious adverse event.

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If opioid therapy is considered, use of combination products including an opioid in combination
with acetaminophen are not recommended since this can lead to long term acetaminophen
toxicity. If acetaminophen provides a therapeutic benefit to an individual patient administer as a
separate entity. (UW Health Low quality evidence, strong recommendation) The prescription of
opioid therapy should be done in a responsible matter. There should be specific functional goals
identified and monitored routinely with initiation and each dose change. If these goals are not
met, then opioid therapy should be discontinued. If a decision is made to proceed with chronic
opioid therapy for osteoarthritis related pain, providers should follow the UW Health Clinical
Policy for Opioid Management (see UW Health policy 1.2.3).

Glucosamine-Chondroitin
Glucosamine and/or chondroitin may be considered as second-line treatment options to improve
pain. (UW Health Low quality evidence, weak/conditional recommendation) These supplements do not
have any role of disease modification. There is not high quality evidence to support the use of
glucosamine and/or chondroitin in the treatment of osteoarthritis related pain; however, there
are likely no significant side effects from taking these medications.1,74

Intra-articular Injections75,76
Intra-articular injections should be administered only by experienced providers. Intra-articular
injections into the knee can be done with or without ultrasound guidance depending on provider
and patient characteristics. There is evidence that knee injections done under ultrasound
guidance with experienced providers are more accurate than anatomically guided injections.
However, differences in outcomes are not as well established. Cost of imaging guided
procedures is higher. Intra-articular hip injections should be done with imaging. Intra-articular
hip injections can be done either with ultrasound guidance or fluoroscopically guided.

It is recommended that if intra-articular injection is used for treatment, that the patient be
evaluated after injection to determine treatment response. This can be done using the
OMERACT-OARSI responder survey or by asking the patient to track pain and function before
and after the injection. This post procedure evaluation should be done at expected peak
treatment response (1-2 weeks after corticosteroid injection or 6 weeks after hyaluronic acid
injections).

There are 2 type of intra-articular injections routinely used in the management of osteoarthritis
related hip and knee pain (corticosteroid and hyaluronic acid). These injections are not
considered first line therapy for management of this condition and should be used only in select
patients as outlined below. Individuals with multijoint osteoarthritis or diffuse chronic pain are
less likely to benefit from intra-articular injections particularly hyaluronic acid injections and use
in these patients should be limited. (UW Health Low quality evidence, weak/conditional
recommendation)

New evidence supports the use of ketorolac intra-articular knee injections for treatment of
osteoarthritis. This injection is likely to be less expensive and may be more affective for pain
management than either corticosteroid or hyaluronic acid injections. Ketorolac injections are not
recommended at this time. (UW Health Very low quality evidence, strong recommendation)
Further data is needed prior to this being available for routine use.

Corticosteroid Injections1-3,77
Corticosteroid intra-articular injections can be considered for individual patients who continue to
have moderate-to-severe pain and loss of function after appropriate first line treatment has been
implemented. (UW Health High quality evidence, weak/conditional recommendation) Individuals who
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have significant pain in multiple joints related to osteoarthritis are less likely to benefit from intra-
articular injections and use in these patients should be limited. Any benefit that a patient
received after these types of injection is very limited in terms of duration. There may be different
slightly different duration of action depending on the corticosteroid used. This limited duration of
benefit should be considered when deciding to offer these injections. Most providers would
recommend use of these injections for patients who have a sudden increase in osteoarthritis
related pain (pain flare) or are anticipating an upcoming event for which they want to temporarily
decrease their pain for.

Hyaluronic Acid Injections
Hyaluronic acid intra-articular injections can be considered for individual patients who continue
to have moderate-to-severe pain and loss of function after appropriate first line treatment has
been implemented. (UW Health Low quality evidence, weak/conditional recommendation)

There is mixed evidence for use of hyaluronic acid injections in the management of hip and
knee osteoarthritis. The American Academy of Orthopedic Surgeons 2013 osteoarthritis
guidelines recommends against it use as does the NICE 2014 guidelines.4 The American
College of Rheumatology (2012) and OARSI guidelines (2014) have an uncertain
recommendation for use.1,3 In contrast, The American Medical Society for Sports Medicine
published a position statement in 2015 that supports use of these products in the management
of knee osteoarthritis.75

These injections have the most evidence in patients with mild to moderate (Kellgren and
Lawrence (KL) grade II-III) knee OA.75 There is also more evidence to support use of HA
injections in individuals greater than 60 years of age, but individuals under the age of 60 are
likely to have equal benefit. If used, no difference in efficacy has been demonstrated between
products therefore providers are encouraged to consider cost. Providers and patients should be
aware that therapeutic benefit of these medications is not expected until 6 weeks after treatment
and duration of benefit is short typically a few weeks.

Prolotherapy
Prolotherapy is a complementary and alternative medicine injection therapy used for the
treatment of chronic musculoskeletal pain. This therapy may be considered after first line
treatment has been implemented.78-80 (UW Health Low quality evidence, weak/conditional
recommendation) Prolotherapy is performed by injecting small volumes of dextrose solution at
tender tendon and ligament attachment sites and inside joints. Access to prolotherapy may be
limited by the number of providers trained in the technique. Based on the result of one
randomized control trial, prolotherapy may improve function and decrease pain in patients with
knee osteoarthritis. More study is needed to further understand the role prolotherapy may play
in the treatment of knee arthritis.
REFERRAL FOR CONSULTATION TOTAL JOINT REPLACEMENT
Total joint replacement is the definitive treatment for osteoarthritis of the knee and hip. There is
currently no national consensus on indications for total joint replacement.39 Studies have found
large differences in referral patterns and recommendations for total joint replacement among
both primary care physicians and orthopedic surgeons.22-24,39

Criteria for referral for total joint replacement
Referral decisions should be based on discussions between patient representatives, referring
clinicians, and surgeons. When discussing the possibility of joint surgery, clinicians should
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ensure that the patient has been offered at least the core (non-surgical) treatment options.2
Information should be provided about the benefits and risks of surgery, the potential
consequences of not having surgery, and the process of postoperative recovery and
rehabilitation. Shared decision-making tools, such as the following, may be useful to aid in
facilitating this process in the primary care or orthopedic surgery offices.81 (UW Health High quality
evidence, strong recommendation)

Patient Decision Aids
ξ Health Information- Arthritis: Should I Have Knee Replacement Surgery?
ξ Health Information- Arthritis: Should I Have Hip Replacement Surgery?

The following criteria may be used by primary care providers to help decide which patients may
be appropriate for surgical referral (UW Health Low quality evidence, weak/conditional
recommendation):5,10-13
‡ No improvement after 3 months of conservative management
‡ Moderate or severe symptoms (with presence of mild to moderate radiographic findings)
‡ Moderate/severe functional limitations affecting quality of life
‡ BMI < 40 kg/m2*
‡ Medically appropriate after consideration of surgical risk factors (e.g., tobacco use**,
diabetes, cardiovascular disease***, anticoagulation and antiplatelet therapy)
‡ Would consider surgery following discussion of TJR

*Assessment and treatment of potential operative risk factors should be optimized for all obese
patients. Due to the risk of surgical and postoperative complications (e.g., infection, DVT,
revision surgery), patients with a BMI > 45 kg/m2 should not be referred for total joint
replacement.14 (UW Health Low quality evidence, strong recommendation) Patients with a BMI 40-44
kg/m2 may be considered for referral for consideration of total joint replacement on an individual
basis, whereby the referring primary care team and evaluating orthopedics team asses patient
motivation, previous weight loss and other treatments, chronic disease status, and
perioperative risk.14-17 (UW Health Low quality evidence, weak/conditional recommendation)

**Current and former tobacco use has been associated with significantly higher risk of
postsurgical complications, including deep infection and implant revision after THA and TKA.82-84

***Regardless of history of cardiac disease, risk factors for 90-day cardiac events include female
gender and American Society of Anesthesiology (ASA) class of III-IV after THA and older age (>
65 years) and ASA class III-IV after TKA. Female gender and higher comorbidity index were
also risk factors for 90-day thromboembolic events in TKA, regardless of past history of
thromboembolism.12

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UW Health Implementation
Potential Benefits:
ξ Reduction of pain
ξ Improved quality of life

Potential Harms:
ξ Adverse reactions to pharmacotherapy
ξ Injury from exercise

Pertinent UW Health Policies & Procedures
1. UW Health Policy # 1.2.3- Opiate Management

Patient Resources
1. Health Facts For You #5725- Arthritis in the Elderly- Osteoarthritis
2. Healthwise- Arthritis
3. Healthwise- Osteoarthritis
4. Healthwise- Knee Arthritis
5. Healthwise- Knee Arthritis: Exercises
6. Healthwise- Knee Replacement: Surgery: Deciding About
7. Healthwise- Hip Arthritis
8. Healthwise- Hip Arthritis: Exercises
9. Healthwise- Hip Replacement Surgery: General Info
10. Healthwise- Hip Replacement: Surgery: Deciding About
11. Health Information- Osteoarthritis
12. Health Information- Osteoarthritis: Exercising with Arthritis
13. Health Information- Osteoarthritis: Heat and Cold Therapy
14. Health Information- Arthritis: Should I Have Knee Replacement Surgery?
15. Health Information- Arthritis: Should I Have Hip Replacement Surgery?
16. http://www.arthritis.org/living-with-arthritis/tools-resources/

Weight Management Resources:
1. Healthy Plate Handout
2. Frequently Asked Questions
3. Exploring Why you Eat
4. Seven Ways to Size Up Your Servings
5. Empty Calories Count
6. 7KH�$OWHUQDWLYH�WR�³'LHWV´

Guideline Metrics
1. % of patients with a referral to a weight loss program or nutrition services
2. % of patients with an OA diagnosis that have a PT referral and complete visit with PT
3. % of patients with standing x-rays completed (or rate of duplicate orders due to incorrect
imaging)
4. % of patients with an opioid prescribed during a visit with an encounter diagnosis of OA
5. % of patients referred for surgery who meet the referral criteria, and of those who undergoes
surgery

Implementation Plan/Clinical Tools
1. Guideline will be posted on uConnect in a dedicated location for Clinical Practice Guidelines.
2. Release of the guideline will be advertised in the Physician/APP Briefing newsletter.
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3. Content and hyperlinks within clinical tools, documents, or Health Link related to the
guideline recommendations (such as the following) will be reviewed for consistency and
modified as appropriate.

Order Sets & Smart Sets
Arthritis [95]
Arthritis ACHC [146]
Hip Problems- Ortho Consult/Visit OP [3401]
Knee Problems- Ortho Consult/Visit OP [3418]
Knee Injections ± Degenerative Joint Disease [4058]

Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
LQWHQGHG�WR�UHSODFH�D�FOLQLFLDQ¶V�MXGJPHQW�RU�WR�HVWDEOLVK�D�SURWRFol for all patients. It is
understood that some patients will not fit the clinical condition contemplated by a guideline and
that a guideline will rarely establish the only appropriate approach to a problem.

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Appendix A. Evidence Grading Scheme(s)

Figure 4. American Academy of Orthopedic Surgeons (AAOS) Grading Methodology4

Evidence
Rating
Description of Evidence Strength
Strong
(YLGHQFH�LV�EDVHG�RQ�WZR�RU�PRUH�³+LJK´�VWUHQJWK�VWXGLHV�ZLWK�FRQVLVWHQW�ILQGLQJV�LQ�
support of recommending for or against the intervention.
A Strong (positive) recommendation means that the benefits of the recommended
approach clearly exceed the potential harm, and/or that the strength of the supporting
evidence is high.
A Strong (negative) recommendation means that the quality of the supporting evidence
is high. A harms analysis on this recommendation was not performed.
Moderate
(YLGHQFH�IURP�WZR�RU�PRUH�³0RGHUDWH´�VWUHQJWK�VWXGLHV�ZLWK�FRQVLVWHQW�UHVXOWV��RU�
HYLGHQFH�IURP�D�VLQJOH�³+LJK´�VWUHQJWK�VWXG\�UHFRPPHQGLQJ�IRU�RU�DJDLQVW�WKH�
intervention.
A Moderate recommendation means that the benefits exceed the potential harm (or that
the potential harm exceeds the benefits in the case of a negative recommendation), but
the quality/applicability of the supporting evidence is not as strong.
Limited
(YLGHQFH�IURP�WZR�RU�PRUH�³/RZ´�VWUHQJWK�VWXGLHV�ZLWK�FRnsistent results, or evidence
from a single Moderate strength study recommending for or against the intervention.
A Limited recommendation means that the strength of the supporting evidence is
unconvincing, or that well-conducted studies show little clear advantage to one
approach over another.
Inconclusive
Evidence from a single low strength study or otherwise conflicting evidence that does
not allow a recommendation to be made for or against the intervention.
An Inconclusive recommendation means that there is a lack of compelling evidence
that has resulted in an unclear balance between benefits and potential harm.
Consensus
The supporting evidence is lacking and requires the work group to make a
recommendation based on expert opinion by considering the known potential harm and
benefits associated with the treatment.
A Consensus recommendation means that expert opinion supports the guideline
recommendation even though there is no available empirical evidence that meets the
inclusion criteria in the systematic review.
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Figure 5. GRADE Methodology adapted by UW Health


GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate We are quite confident that the effect in the study is close to the true effect, but it
is also possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.

GRADE Ratings for Recommendations For or Against Practice
Strong The net benefit of the treatment is clear, patient values and
circumstances are unlikely to affect the decision.
Weak/conditional
Recommendation may be conditional upon patient values and
preferences, the resources available or the setting in which the
intervention will be implemented.






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Appendix B. Sample After Visit Summary

Exercising With Osteoarthritis –
According to the National Arthritis Foundation
Physical activity is the best non-drug treatment for improving pain and function.
1. Try to have a goal to build up to 150 minutes per week (which is 30 minutes per day, 5
days per week) of moderate exercise + strength training 2-3 days weekly.
ξ Start with least 10 minutes at a time of moderate activity. Moderate is defined as
being able to talk while doing it, but unable to sing while doing it. This has more to
do with your ability to breathe comfortably during exercise than it does your singing
voice quality!
ξ It can help to start on an every other day basis, and see how the next day goes
before doing another bout of exercise. Soreness is normal. Intense pain is not and a
sign that you need to change exercise type, or stop a movement for now. You can
always ask to discuss exercises with your physical therapist or physician if you have
questions about specific things that you have found to be bothersome.
2. Incorporate balance and flexibility exercises daily, as these are often less strenuous.
3. Avoid strenuous activity during flair ups but keep moving with gentler movements and
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back into a good day.
4. Adequate warm up and cool down are critical to decrease pain.
5. Any amount of physical activity is better than none.
6. Slight discomfort with and after activity is common, but should improve over time as you
establish your tolerance level to activity. This soreness does not mean that joints are
being damaged further. It is simply your nervous system notifying you that you have
added something challenging to your routine, and that care is needed during this
process.
ξ If pain remains high to the point of significant pain or challenge with walking, rising
from sitting, and/or taking stairs, you have definitely done too much.
7. Exercise during time of day that pain is typically less severe. However, it can help
reverse the pain cycle by trying gentler movements during your typically more painful
time. It is absolutely safe to try this, and you can be surprised by the results.
8. Wear appropriate shock absorbing shoes.
9. Warm water exercise helps relax muscles and can be soothing enough to allow you to be
more active out of the water as well.
10. When starting out, it can be necessary to avoid hills, uneven surfaces and motions that
require bending knee or hips past 90 degrees of flexion. However, for some this is just
fine.
11. Incorporate functional exercises that move against body weight, if tolerated.
ξ Sit-to-stand squats
ξ Step ups
ξ These can be something that require a bit of training to master, as it is common that
pain during squatting and stair-like step ups can be changed with a few simple
mechanical tweaks. If you have pain with these, it can be helpful to visit with your
physical therapist to see if there is a more comfortable version of body weight
movements that you can do.
12. Look into community and online osteoarthritis exercise programs
ξ Madison School and Community Recreation
ξ YMCA
ξ National Arthritis Foundation
ξ Local Health Clubs
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26


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