Consensus on non-pharmacological interventions for mild and moderate knee osteoarthritis among stakeholders/experts of various disciplines is still elusive –A preliminary report

1. Introduction

In India, prevalence of knee osteoarthritis (KOA) has been reported to be in the range of 17–61% seriously affects the quality of life of the patients.^1,2 Pain and inflammation of the joint capsule, impaired muscular stabilization, reduced range of motion lead to disability among KOA patients.

Once KOA develops, it leads to alteration in knee joint biomechanics. Excessive load on knee joint further aggravate the situation.³ Patient gait and posture are affected. Patients face more difficulty in walking or moving around. This further accelerates the development and progression of KOA. When patients take analgesics for pain relief, increased joint loads again contribute to disease progression.^3,4 Thus overload of joint aggravates symptoms and disease progresses to chronicity. Hence, KOA management focusing on reduction of joint load are more successful.

Studies have reported that non-pharmacological interventions (NPIs) viz., patient education, lifestyle modification, weight reduction, regular exercise, physiotherapy and the use of orthopaedic appliances (canes, insoles, and braces) are effective in ameliorating the symptoms of mild and moderate KOA.^5,6 Sufficient evidence is there on the effectiveness of load reduction strategies for knee joint e.g. cane use, shoe insoles, variable-stiffness shoes, knee bracing, and gait-modification.^3,4. Besides these approaches, acupuncture is under investigation as a therapeutic approach for KOA.⁷

In present era of super specialization in hospitals, routine treatment of KOA requires teamwork i.e. Orthopaedic surgeons, physical medicine and rehabilitation Medicine (PMR) specialists and physiotherapists. Along with them patients are major stakeholders for use of NPIs in management of pain and other associated problems in patients with KOA.⁸

In the current scenario in hospitals in India, KOA patients are seen first by Orthopaedists in OPD. Necessary investigations are advised, prescription is given and then the patient is referred to PMR department for exercise which is explained by physiotherapist. But studies have reported lack of consensus among experts of these disciplines on the extent and pattern of use of different modalities of NPIs.^9,10

Hence this study was conducted to explore the level/degree of consensus on various NPIs for mild and moderate KOA among Orthopaedic surgeons, PMR specialists and physiotherapists. The results of our preliminary report are presented in this paper.

2. Methodology

Self-administered questionnaires were distributed to the 100 delegates from various Medical Institutes of North India during a continuing medical education (CME) session on KOA held at Postgraduate Institute of Medical Research and Education, Chandigarh, India. These included orthopaedic surgeons, physiotherapists and PMR specialists from different parts of North India. The questionnaire sought their opinion about indication of the exercises (listed with names and pictorial representation) viz; knee triangles, calf raises, leg extensions, SLR (straight leg raise),SLR(prone), heel cord stretch, standing quadriceps stretch, supine hamstring stretch, half squats, hamstring curls, hip abduction, hip adduction, leg presses, short arc life, standing toe raise, stationary bike (with resistance and without resistance). It also included list of yoga exercises and deep relaxation techniques. In-depth interviews of orthopaedic surgeons (10), Physiotherapists (12) and PMR specialists (6) were also conducted. Website of Clinical Establishment Acts (CEA) was also explored for standard operating procedures on OA.¹¹ Consent was duly take. Confidentiality of data was assured.

3. Results

Of the 100 questionnaires distributed and 30 were incomplete. The data was analyzed for remaining 70 responders (44 Orthopaedists, 10 PMR specialists and 16 physiotherapists).

Table 1 depicts that orthopaedists were not aware about the type of stationary bike to be advocated for KOA patients. Eight of the ten PMR specialists advocated stationary bike without resistance for KOA patients whereas 87% (n = 14) physiotherapists advocated stationary bike without resistance.

Table 1.

Type of exercises recommended by experts of different disciplines for mild/moderate KOA.

Exercises	Recommended by specialists
	Ortho N = 44	PMR N = 10	Physio N = 16
Quadriceps stretch (standing) Hamstring stretch (supine) SLR (supine) Hip abduction Hip adduction short arc lift	✓	✓	✓
Heel cord stretch SLR(Prone) Stationary bike with resistance	X	X	X
Half squats Calf raises Toe raise Leg extensions	X	✓	X
Hamstring curls Stationary bike without resistance	X	✓	✓
Knee triangles	✓	X	X
Leg presses	✓	✓	X
Exercises useful in Mild KOA	✓	✓	✓
Exercise useful in moderate KOA	✓ 86% (n = 38)	✓	✓
Contraindication of exercises in KOA	✓11% (n = 5)	✓20% (n = 2)	✓50% (n = 8)

None of the respondents recommended CAM (complementary alternative medicine), acupuncture or lateral wedge insoles for KOA patients. Most (95%) Orthopaedists and PMR (90%) specialists recommended deep relaxation techniques/meditation for KOA patients. In contrast, (75%) physiotherapists recommended deep relaxation techniques/meditation. All respondents recommended that treating health care providers should encourage self-care by patients. They should also encourage adherence to the regimen of NPIs by the patients.

CEA website showed no mention of specific roles of these disciplines in the standard operating procedures. No details of exercises for KOA on the website given.

One of the respondents told the researcher that as medical specialty Orthopaedics and physiotherapy had parted ways long ago. In the present era, most of the orthopaedists are considered super-specialists. He further explained that a spine specialist cannot tell knee exercises; besides that knee/hip specialists are very few in numbers.

A physiotherapist said, “Orthopaedists & PMR specialists do not know about exercises”. He said that physiotherapists were well versed with exercises as it is part of their curriculum. Another physiotherapist reported, “Generally SWD is recommended indiscriminately to all KOA patients by Orthopaedic surgeons. They don't consider that if inflamed and hot to touch, SWD can worsen the KOA. But Orthopaedic surgeons don't listen and ask us to comply with their instructions”.

PMR specialists opined, “Doctor writes the details of exercises and knows which muscle need strengthening but explanation to the patient is supposed to be done by physiotherapists”. They emphasized that doctor should also be aware about exercises.

Table 2 depicts that different packages of NPIs prescribed by specialists for KOA. Table 3 shows the comparison of profile of the 3 disciplines.

Table 2.

Different packages of Non Pharmacological Interventions prescribed for KOA by experts (N = 45).

Package of Non Pharmacological interventions advocated	No. of experts advocating N (%)
Exercises + Weight reduction + Meditation/Relaxation techniques + Knee cap + Physiotherapy modalities (Electrotherapy modalities viz., SWD, Ultrasound)+Hot pack/cold pack + braces	8 (18%)
Exercises + Weight reduction + Meditation/Relaxation techniques + Knee cap + Physiotherapy modalities (Electrotherapy modalities viz., Shortwave diathermy, Ultrasound)	20 (44.4%)
Exercises + Weight reduction + Meditation/Relaxation techniques	13 (29%)
Exercises only	4 (8.9%)

Table 3.

Comparison of the profile of different disciplines involved in the treatment of KOA.

	Orthopaedics	Physical Medicine Rehabilitation	Physiotherapy
Recommendations by Sub-Committee (October 2013) on “Categorization & Classification of Clinical Establishments under the Clinical Establishments (Registration and Regulation) Act, 2010.	Included under surgical specialties and candidates must possess recognized degree of M.S. (Master Of Surgery)	Included under medical specialties and candidates must possess recognized degree of M.D (Doctor of Medicine)	Indicated under Allied Health professions. Indicates that they are health professions distinct from medicine, dentistry, pharmacy and nursing.
Eligibility criteria for admission to PG course (MS,DNB)	MBBS	MBBS	BPT:After 10 + 2 (12th)examination Then MPT and PhD
Professional Associations in India and members	Indian Association of Orthopaedics Founded in 1955 and has 10,000 members Membership is for PG/diploma in Orthopaedics27	Indian Association of Physical Medicine and Rehabilitation (400 members) Website launched in 2002. Membership is open to all doctors working in PMR.28	Indian Association of physiotherapists (more than 30,000) Founded in 1962. Membership is open to all physiotherapist from U.G.C. recognized institutions29
Syllabus	As per Medical council of India (MCI)- Diagnostic Imaging, Metabolic Bone Diseases, Bone and Joint Infections, Fracture and Fracture-Dislocations, Dislocations and Subluxations, Arthrodesis, Arthroplasty, Minimally Invasive Surgery, Amputations and Disarticulations, Rehabilitation - Prosthetics and Orthotics, spine etc	As per MCI -Impairment, disability, gait analysis, Therapeutic exercises, Physical agents/modalities, orthotic devices, Rehabilitation of persons from sports injury, arthritis, spine and burns, surgical Emergencies etc	As per Ministry of Health and Family Welfare Allied Health Section (MoHFW) Anatomy, community based rehabilitation, exercise therapy, neuro physiotherapy,Orthopaedics and sports physiotherapy
Exercises included in the syllabus of the course as per MCI/MoHFW	No	Yes	Yes
Course started in India	1951	1960	1953

4. Discussion

There is enough evidence to suggest that NPIs slow down the progression of KOA.12, 13, 14 National level expert committees of many developed countries have endorsed that KOA management involves lifestyle modifications (LSM), medicinal treatment, intraarticular injections (corticosteroid, hyaluronic acid, platelet rich plasma) and surgery.^15,16

All respondents in our study have recommended self-care. This is also included in OARSI recommendations and PANLAR Consensus Recommendations for the Management in Osteoarthritis of Hand, Hip, and Knee.¹⁷

An RCT completed recently by authors also showed the benefit of using a package of exercises, weight reduction, physiotherapy modalities for providing relief in symptoms in mild/moderate KOA patients. Majority (75 out of 123) patients enrolled in the study had moderate to severe pain initially. At the end of 12 months of intervention only 2 patients remained in these categories; 57 patients (46%) reported complete relief in symptoms.^18,19

A number of exercises are prescribed as a part of NPI based management of KOA patients across the globe, viz., knee extension, knee flexion, hip abduction, hip adduction, hip internal rotation, hip external rotation, leg press (hip and knee extension). However, there is no standard protocol available in India for KOA exercises.⁹

Our results indicate that there was a consensus in prescribing above mentioned six basic exercises in all KOA patients. However, there was some reluctance among Orthopaedists and PMR specialists for prescribing exercise programs or conservative management for KOA patients. We found that there was a general lack of awareness among them about contraindication of exercises. This is also depicted by their verbatim responses. This is understandable since neither the details of the exercises are included in their curriculum/syllabus nor are these inculcated rigorously in their training during ward rounds. Basically, both are medical postgraduates. Orthopaedician surgeons tend to have a surgical approach to manage KOA cases and it is too early to comment on the role of PMR specialists (Table- 3).

PMR department have been established only recently in medical colleges as a compulsion after formulation of National Policy for Persons with Disability (2005).²⁰ This was also revealed by a response to an RTI (Right to Information Act) that there were no PMR departments in Medical Colleges of Delhi as in 2014.²¹

In the current study, there was no consensus of orthopaedic surgeons with PMR and physiotherapists on exercises (hamstring curls and stationary bike without resistance, leg presses, Knee triangles). Studies have reported that basic components of the OA prescription should include seated leg presses (or a variation of a squats), leg extensions and leg curls.²². Orthopaedic surgeons did not recommend hamstring curls. Their main focus of attention regarding muscle strength deficit in KOA usually directed to quadriceps strengthening.²³

As a contrast, physiotherapists in our study did not recommend leg presses exercise. McQuade et al. reported that isotonic knee extension and flexion and leg-press exercises on weight training machines for mild KOA patients showed improvements in function, pain, and other symptoms.²⁴

Knee triangles exercise were recommended only by Orthopaedic surgeons. These are said to improve range of motion and are considered as a warm-up before more vigorous exercises.

Reasons for this scenario can be traced to origin of these disciplines in India. Originally, orthopaedics experts were the exclusive treatment providers for KOA. They diagnosed and prescribed the treatment (including exercises) to KOA patients in hospitals. Eventually, teaching of exercises was abolished in Orthopaedics after the physiotherapy was established as a separate entity in medical colleges of India.

So, by and large, on reaching the hospital, KOA patients first report to Orthopaedics OPD. Even if they go to rheumatology/medicine OPD, they are referred to orthopaedics. They first assess whether that ligament surgery or total knee replacement is required. If none is indicated they refer the patient to physiotherapy for exercises.⁹

Physiotherapy unit has now been put under the charge of PMR department. For all practical purposes physiotherapy only deals with referred cases from Orthopaedics or PMR experts. As revealed by their verbatim responses they are keen to establish and maintain a sense of technical distinct identity of their discipline.²⁵

Theoretically PMR experts are expected to lead the rehabilitation team. Their role is expected to be the restoration of function of patients to the highest possible level, through a multi-disciplinary team approach, making use of diagnostic and therapeutic armamentarium including education and counseling, prescription of medicines, therapeutic exercises, equipments (mobility aids, orthotic-prosthetic appliances, assistive technology, physical agents and modalities, etc.), injections, surgical interventions for correction of deformities etc.²⁶

During the phase of evolution of the 3 disciplines some hierarchy related teething troubles between these have emerged with respect to their roles and responsibilities. Yet all have the same goal of benefitting the patient. Thus, all 3 disciplines are complementary to each other. In fact, one cannot function effectively without the other. Only their professional responsibility differs.

Any KOA patient needs relief from symptom and seeks improvement in quality of life by attaining independence in ADLs. They desire easy access to low cost and effective treatment for KOA that includes explanation, counseling, doctor-patient interaction, guidance for self-care. Patients are usually not keen for surgery or intra-articular injections. Given proper guidance and supervision most of them would be willing to self-management.

It is clear that such therapy would need a) Time – since we cannot rush up the listed interventions; b) Patience – since patient/caregiver need to be explained about the procedure and its importance to ensure optimum compliance and c) an Interdisciplinary approach-since one discipline cannot, on its own, handle all the listed modalities.

In the present scenario in OPDs KOA patients are confused due to contradictory set of instructions given by proponents of these 3 disciplines. Hence consensus needs to be built upon list of exercises for patients suffering from mild and moderate KOA.

There is a need to ensure a functional team effort of orthopaedicians, PMR specialists and physiotherapists for KOA management. We may also add dietician, psychologist, yoga expert and a health promotion educator to the team to derive the best results.

Limitation of the study

A small sample was a limitation to the current study. However this is just a preliminary report. Still it offers an insight about discordance in recommendation of the various NPIs.The current study explored views of various stakeholders as well as their perception of treatment modalities for KOA. We recommend that future research should focus on review of individual modalities evaluated separately involving larger respondent population base.

Conflicts of interest

None declared.