Managing Patients with Knee Osteoarthritis
Part I: Introduction and Diagnosis
By James W. Brantingham DC, PhD; Gary Globe, MBA, DC, PhD; Tammy Kay Cassa, DC; Debra Bonnefin, DC, MAppSc, DACRB
Some practitioners may ask why a DC should treat knee osteoarthritis (KOA) or any joint-specific pathology. Much discussion has occurred along these lines between narrow- and broad-scope chiropractic practitioners. In our opinion, there is no way to separate the treatment of injury/pathology in appendicular joints from axial spinal joint problems. The body is a closed kinetic chain, and any change in joint function could be expressed above or below the initially affected joint. To optimally treat spinal joints, the DC must evaluate and treat, as necessary or indicated, any primary joint dysfunction in the appendicular system, with the same being true for the optimal treatment of appendicular joint conditions.
It is incumbent upon practitioners to be competent as to the standard of care for pathological conditions affecting joints throughout the body, including the soft tissues. That includes being knowledgeable in literature associated with the treatment of any condition related to that joint and staying up to date with continuing education. As with many other conditions, clinical experience and judgment coupled with individual patient needs, preference and presentation, are important factors in managing patients with KOA. This paper is not meant to be used as a “cookbook,” and its recommendations should be appropriately modified according to patient safety and need.
Knee osteoarthritis is the major cause of chronic musculoskeletal pain, disability and decreased mobility in elderly populations, especially women and minorities 50 years of age or older. Increased cardiovascular risk, fall risk and depression are present in 30 percent of those suffering with KOA by age 60.1-8,27Prevalence varies from 4 percent in young adults to 80 percent in those aged 65 or over.3,9 Annual financial costs in the United States associated with arthritis, including KOA, reached $128 billion in 2003.3,6,9-11 One in five people, or approximately 46 million people, have had physician-diagnosed arthritis. In 2003, this resulted in 992,100 hospitalizations, 44 million outpatient visits and 5 percent reporting decreased ability to work.1,6,10,12-14These numbers will rise with the large aging cohort of baby boomers.
The etiology of KOA is unknown, but damage to chondrocytes (cartilage) may potentially cause osteoarthritis (OA). Inflammation is typically mild and isolated to the peri-articular tissues.15 Previous injury, female gender, obesity, overuse, increasing age, decreased bone density, incongruent and/or unequal joint spacing and genetic predisposition are frequently associated risk factors.7,15-18
Common pharmacological KOA treatment consists of non-steroidal anti-inflammatory drugs (NSAIDS) and/or acetaminophen. However,15 percent to 30 percent of people are unable to tolerate NSAIDS due to gastrointestinal injuries, cardiovascular injuries, ulcers, myocardial infarction and stroke.19-23 Furthermore, NSAIDS have no impact on KOA progression.1 Each year NSAID use results in hospitalization of more than 100,000 people and has a higher related mortality rate than that of AIDS in the United States. Invasive arthroplasty also carries serious risks and should be a last resort.21-34Arthroscopic KOA surgery has been found to achieve outcomes no better than placebo, while cost-effectiveness for arthroplasty is currently under the microscope secondary to the frequency of costly initial failure and need for repeat surgeries, which can double the cost.29 This leaves few safe and effective conservative treatment options. 22-30,35
Rehabilitation or exercise therapy is of limited, short-term value in reducing knee pain and improving function.28 Combined manipulative therapy and rehabilitation may be superior and significantly more efficacious for KOA and other lower-extremity arthritis than rehabilitation or exercise alone.1,25,36,37 However, despite the success of manual therapeutic interventions in the treatment of KOA reported in the literature, confirmatory studies are needed.3,12,25,36,38-40 Nevertheless, based on the current level of evidence, the Osteoarthritis Research Society International, Bronfort et al., and other evidence-based consensus guidelines support a trial of rehabilitation, with and without manipulative therapy, as a first-line treatment in KOA.1,26,41-45
If delivered by a suitably educated chiropractor, these combined treatments may provide a safe, efficacious and potentially cost-minimizing relief to patients with problematic KOA. Side effects, when they occur, appear to be minimal stiffness and pain that resolves. Severe adverse reactions have not been reported.46-51 Therefore, recommendations will be suggested for management of KOA based on manual therapy and rehabilitation trials.25,28 However, determining the best rehabilitative program (high-tech, low-tech, one-on-one, group or home-based program), or dosage (type, frequency, intensity or duration) is neither fully clear nor established.1,28 Interestingly, “low-tech” rehabilitation using simple floor exercise, elastic bands and slow, careful increases in walking, progressing toward aerobic walking, appears helpful—as helpful for the average patient as “high-tech” rehabilitation.25,28,52
It should come as no surprise that DCs are the most frequent complementary and alternative medicine (CAM) providers in the United States treating back and neck disorders. Doctors of chiropractic also frequently provide CAM physical treatment for KOA in Britain, the United States, Australia and other developed countries.3,12,27,36,38,41,53,54 Three RCTs have demonstrated that manipulative therapy alone decreased pain and disability, as well as increased function and range of motion in KOA.3,12,24 Because manual therapy trials that have included exercises have the strongest evidence, and rehabilitation is the standard of care among allopathic and allied health practitioners, exercises should be added to any manipulation/mobilization intervention for KOA.25,28
Many DCs utilize full kinetic chain manipulative therapy (FKC), based on the work of Illi, Gillet and Faye.36,55-58 The principal explanation for this approach is that the entire locomotor system is interconnected, so a change in function at one joint may be compensated at a proximal or distal site/joint.57-60 The most frequently recognized occurrence may be in the spine where a prolonged hypomobility may trigger hypermobility and/or compensation at another proximal and/or distal site.61,62
Applying this model to KOA, the DC might include manipulative (operationally defined as manipulation and/or mobilization) therapy to not only the knee, but also any indicated appendicular or axial joint where joint hypomobility was assessed.
There is biological plausibility and there is clinical evidence that FKC, along with rehabilitation may be efficaciously superior to local treatment for KOA.1,3,12,25,36,37,63-65 Strikingly, recent magnetic resonance imaging studies suggest manipulative therapy for KOA may even increase lost cartilage volume and space.36,37,66,67 Joint dysfunction, known as subluxation, in both the appendicular and axial skeleton, is assessed by physical examinations and other functional assessments, such as those comprised by the Medicare-based “PARTS” formula.
Diagnosis of KOA is primarily clinical and should be made based on American College of Rheumatology (ACR) guidelines.68 Patients who fulfill the ACR guidelines should have a radiographic study of the knee to rule out a severe level (grade 4) of OA and other exclusionary pathology, such as avascular necrosis or severe osteoporosis.25 At this time, for the average practitioner in the United States, it is recommended for medico-legal reasons that only KOA patients with grade 0-3 OA be treated.25,37 Additionally, a patient using an assistive device for more than 25 percent of the day may not be a candidate for this care and should be referred or co-managed with a medical practitioner.
The degree of KOA can be determined by using the Kellgren-Lawrence (K-L) grading scale (0-4). Even with lesser grades, 0 to 2 of KOA, there is still a minimal but nevertheless potential risk associated with manipulative and/or rehabilitative intervention justifying necessity for X-ray in many cases.69
ACR guidelines include self-report of knee pain for at least six to 12 months and certain examination findings. Examination findings include either: 1) knee pain and crepitus with active motion, and morning stiffness of at least 30 minutes with or without bony enlargement or 2) knee pain with bony enlargement but no crepitus.25,68 Joint dysfunction/subluxation (JD/S) should also be present.
Next Month: KOA and chiropractic manipulative therapy
James W. Brantingham, DC, PhD, is director of research and associate professor of Cleveland Chiropractic College Los Angeles, as well as adjunct research faculty of Durban University of Technology, South Africa. Gary Globe, MBA, DC, PhD, is provost and academic dean at Cleveland Chiropractic College Los Angeles. Tammy Kay Cassa, DC, is research assistant and instructor at Cleveland Chiropractic College Los Angeles. Debra Bonnefin, DC, MAppSc, DACRB, is clinician and assistant professor at Cleveland Chiropractic College Los Angeles. For questions about the paper, e-mail[email protected].
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