In adults with osteoarthritis of the knee, is conservative management more effective than intra-articular corticosteroid injections in relieving pain?

Abstract

Clinical Question:

In adults with osteoarthritis of the knee, do conservative management methods such as weight reduction, physical therapy, Tai Chi, non-steroidal anti-inflammatory drugs (NSAIDs), and others provide more and longer pain relief and functionality of the knee, as well as overall well-being, when compared to corticosteroid knee injections?

Answer:

Yes. Although there are limited head-to-head trials directly comparing each alternative method to corticosteroid injections, overall evidence appears to indicate conservative methods as being more effective than injections, especially when considering long-term pain relief and functionality.

LEVEL OF EVIDENCE: B

Search Terms: Knee osteoarthritis, steroid injection, conservative management, weight reduction OR loss, physical therapy, tai chi, NSAIDs, pain relief.

Date Search Was Conducted: July 2017

Limits: Human, English, publication dates 2008 to present, randomized-controlled trials, systematic reviews, meta-analyses

Inclusion Criteria: adults, meta-analyses, randomized-controlled trials or systematic reviews published from 2008 to present comparing conservative treatment methods to intra-articular corticosteroid injections for treatment of osteoarthritis knee pain.

Exclusion Criteria: children, surgery, hyaluronic/hyaluronate, hip, published prior to 2008

SUMMARY OF THE ISSUES

Osteoarthritis (OA) is the most common form of joint pain, affecting 30 million adults in the US, with the knee being the most common site involved. The cause is due to impaired joint integrity, inflammation, and mechanical forces leading to joint degradation. OA not only leads to significant pain, functional impairment, and morbidity, but also places a burden on the healthcare system. The two most common risk factors are obesity and age, with incidence of OA reaching upwards of 80% in those >80 years old. With that in mind and considering the increasing prevalence of obesity and the aging population, more focus needs to be centered on the treatment of OA.¹ Although there are limited trials comparing conservative management such as physical therapy, weight reduction, and NSAIDs to more invasive procedures like intra-articular steroid injections and surgery, there is an abundance of evidence validating the effectiveness of patient oriented therapy in improving knee pain and functionality. Surgery was not evaluated in this review, however it is worth mentioning that invasive procedures such as this places the patient at inherent surgical risks, incapacitates them for weeks to months during recovery, and costs them and the healthcare system thousands of dollars.

SUMMARY OF THE EVIDENCE

Due to an unexpected paucity of head-to-head randomized controlled trials (RCTs) comparing the relevant treatment options for OA of the knee, limited RCTs and a systematic review (SR) were studied instead.

A SR performed by Osteoarthritis Research Society International (OARSI) compiled the results from meta-analyses (MAs), SRs, and RCTs for the purpose of updating their guidelines for the treatment of OA of the knee. A panel assessed the effectiveness of 29 different treatments, including exercise and weight reduction as well as oral and topical medications and intra-articular steroid injections. The OARSI used a point scale to assess appropriateness (based on number of joints involved and comorbidities), therapeutic benefit, and overall risk of each treatment modality. They also assessed the level and quality of evidence allowing them to determine a recommendation and appropriateness level for each modality. The results of the OARSI study revealed that exercise (water- and land-based), strength training, weight management, and steroid injection (although short-term benefit) received appropriate rating. Acetaminophen and oral NSAIDs were appropriate only if relevant comorbidities did not exist, due to their effects on the kidney and gastrointestinal (GI) and cardiovascular (CV) systems. Topical NSAIDs proved appropriate with knee-only involvement, but uncertain for multiple joints. They were comparable to oral NSAIDs in benefit but had less GI side-effects and more dermatological side-effects. Both oral and transdermal opioids were rated as uncertain appropriateness due to withdrawal of treatment due to high risk for side-effects, especially if used long-term. However, tramadol showed greater benefit and fewer side-effects compared to other opioids. The OARSI review suggests that multiple interventions, including steroid injections and exercise, can be effective in treating knee OA, but no head-to-head comparisons of these treatments were studied.²

An RCT of 70 participants (average age of 53 years; 60 women and 10 men) with knee OA was reviewed. Participants were assigned to either the NSAID arm or the “steroid intra-articular infiltration” (SIAI) arm, to compare the effects of oral NSAIDs to SIAI in the treatment of pain in congestive OA of the knee (congestive refers to intra-articular effusion). Seventy percent of patients had stage III OA based on the Kellgren and Lawrence scale. For the NSAID arm, diclofenac 150mg and aceclofenac 200mg were administered twice a day for 21 days. The SIAI arm participants received three administrations of either cortivazol 3 75mg or betamethasone 2mg at 1 week intervals. Patients were then monitored for an additional 6 weeks. The NSAID arm proved to have a greater decrease in pain and functional impairment scores in all categories from initiation of treatment to day 42. Three obvious limitations existed in this trial. No side-effects were reported from the treatments, the average age of the NSAID arm was 13 years older than the SIAI arm, and the SIAI participants had higher initial pain and functional impairment compared to the NSAID participants.³

An additional prospective, single-blinded RCT was reviewed that included 40 participants, 20 of which performed 60 minutes of Tai Chi per week and 20 attended 60 minutes of OA education with 20 minutes of stretching per week, both groups for a duration of 12 weeks. An assessment of effectiveness was conducted at 12, 24 and 48 weeks based on the Western Ontario and McMaster Universities OA (WOMAC) pain scores, functionality of the knee, patient and physician global assessments, timed chair stand, depression index, self-efficacy scale, and quality of life. Tai Chi appeared to have a greater reduction in pain and depression with improvement in functionality, global VAS, chair to stand time, self-efficacy, and overall well-being. Limitations that existed in this study were a small power (40 participants), less severe OA and comorbidities in the treatment group, and continually decreasing adherence to the regimen in both the Tai Chi and control groups.⁴

CONCLUSION

There are no RCTs that directly compare multiple conservative therapies to intra-articular corticosteroid injections for knee OA. The evidence from multiple RCTs and the OARSI systematic review suggests that conservative strategies such as physical therapy, Tai Chi, and weight reduction can be effective in managing these patients, and with minimal side effects. There may be a place for injections when attempting to relieve pain immediately and for a short duration, but the trial above shows that NSAIDs can be more effective. NSAIDs are shown to be beneficial but involve potentially significant side-effects, especially when used chronically or in those with comorbidities. Injections may then be an appropriate alternative.