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## Complete Summary

#### GUIDELINE TITLE

Osteoarthritis of the knees.

#### BIBLIOGRAPHIC SOURCE(S)

Singapore Ministry of Health. Osteoarthritis of the knee. Singapore:
Singapore Ministry of Health; 2007 May. 51 p. \[91 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory information
has been released.

-   [April 7, 2005, Bextra (valdecoxib), Cox-2 inhibitors, Celebrex
    (celecoxib), Non-steroidal anti-inflammatory drugs (NSAIDS)
    (prescription and OTC, including ibuprofen and
    naproxen](http://www.fda.gov/medwatch/SAFETY/2005/safety05.htm#BEXTRA):
    Bextra (valdecoxib) withdrawn from the market and labels for other
    Cox-2 inhibitors and NSAIDS revised to include a boxed warning and a
    Medication Guide, highlighting the potential for increased risk of
    cardiovascular (CV) events and life-threatening gastrointestinal
    (GI) bleeding.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Osteoarthritis of the knees

#### GUIDELINE CATEGORY

Diagnosis\
Management\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Orthopedic Surgery\
Physical Medicine and Rehabilitation\
Podiatry\
Rheumatology\
Surgery

#### INTENDED USERS

Advanced Practice Nurses\
Nurses\
Occupational Therapists\
Physical Therapists\
Physicians

#### GUIDELINE OBJECTIVE(S)

To provide guidelines for the diagnosis and treatment of osteoarthritis
of the knees

#### TARGET POPULATION

Patients with osteoarthritis of the knees

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Diagnosis**

1.  History and physical examination, including palpation

2.  Laboratory and radiological testing

**Treatment/Management**

1.  Oral paracetamol

2.  Non-selective non-steroidal anti-inflammatory drugs (NSAIDs)

3.  Cyclo-oxygenase 2 (COX-2) selective inhibitors

4.  Concomitant gastroprotective agents

5.  NSAIDs with preferential cyclo-oxygenase 2 inhibition

6.  Tramadol

7.  Oral corticosteroids (not recommended)

8.  Glucosamine/chondroitin

9.  Viscosupplementation

10. Intra-articular (IA) corticosteroid

11. Topical non-steroidal anti-inflammatory drugs and capsaicin

12. Non-pharmacological management including exercise, weight reduction,
    hydrotherapy, transcutaneous electrical nerve stimulation (TENS),
    interferential current therapy, taping, braces and wedges, manual
    therapy, thermal therapy, ice therapy, and alternative therapies
    such as electro-acupuncture

13. Surgery

#### MAJOR OUTCOMES CONSIDERED

-   Accuracy of diagnostic tests

-   Symptoms (pain, stiffness, physical functioning)

-   Muscle strength

-   Range of motion

-   Joint destruction

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

  -----------------------------------------------------------------------------
  **Level**   **Type of Evidence**
  ----------- -----------------------------------------------------------------
  **1++**     High quality meta-analyses, systematic reviews of randomised
              controlled trials (RCTs), or RCTs with a very low risk of bias.

  **1+**      Well conducted meta-analyses, systematic reviews of RCTs or RCTs
              with a low risk of bias

  **1-**      Meta-analyses, systematic reviews of RCTs, or RCTs with a high
              risk of bias.

  **2++**     High quality systematic reviews of case control or cohort
              studies. High quality case control or cohort studies with a very
              low risk of confounding or bias and a high probability that the
              relationship is causal.

  **2+**      Well conducted case control or cohort studies with a low risk of
              confounding or bias and a moderate probability that the
              relationship is causal.

  **2-**      Case control or cohort studies with a high risk of confounding or
              bias and a significant risk that the relationship is not causal.

  **3**       Non-analytic studies (e.g. case reports, case series).

  **4**       Expert opinion.
  -----------------------------------------------------------------------------

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

These guidelines have been produced by a committee comprising
rheumatologists, an orthopaedic surgeon, a family physician and a
physiotherapist appointed by the Ministry of Health. They were developed
using the best available current evidence and expert opinion.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Grades of Recommendation**

  -----------------------------------------------------------------------
  **Grade**   **Recommendation**
  ----------- -----------------------------------------------------------
  **A**       At least one meta-analysis, systematic review of RCTs, or
              RCT rated as 1++ and directly applicable to the target
              population; or\
              A body of evidence consisting principally of studies rated
              as 1+, directly applicable to the target population, and
              demonstrating overall consistency of results.

  **B**       A body of evidence including studies rated as 2++, directly
              applicable to the target population, and demonstrating
              overall consistency of results; or\
              Extrapolated evidence from studies rated as 1++ or 1+.

  **C**       A body of evidence including studies rated as 2+, directly
              applicable to the target population and demonstrating
              overall consistency of results; or\
              Extrapolated evidence from studies rated as 2++.

  **D**       Evidence level 3 or 4; or\
              Extrapolated evidence from studies rated as 2+.

  **GPP**\    Recommended best practice based on the clinical experience
  (good       of the guideline development group.
  practice    
  points)     
  -----------------------------------------------------------------------

#### COST ANALYSIS

Published cost analyses were reviewed in the preparation of this
guideline. Cost-effectiveness issues are summarized in the \"Major
Recommendations\" field as well as in the original guideline document.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Definitions of the grades of the recommendations (A, B, C, D, and Good
Practice Point \[GPP\]) and level of the evidence (Level 1++, 1+, 1-,
2++, 2+, 2-, 3, 4) are presented at the end of the \"Major
Recommendations\" field.

**Diagnostic Approach to Joint Pain and Osteoarthritis**

**GPP** - The diagnosis of osteoarthritis is made clinically based on
history and physical examination, with laboratory and radiologic
investigations selectively undertaken to exclude inflammatory arthritis,
secondary osteoarthritis, and non-articular causes of joint pain.
**(GPP)**

**Analgesics in Osteoarthritis of the Knees**

**A** - Paracetamol (acetaminophen) should be considered as the first
line of treatment for relieving pain and improving physical functioning
in osteoarthritis (Towheed et al., 2003; Jordan et al., 2003; Altman et
al., 2000). **(Grade A, Level 1+)**

**A** - Non-selective non-steroidal anti-inflammatory drugs should be
used for the acute relief of pain and improvement in function for as
short a period as possible. The benefits of using non-steroidal
anti-inflammatory drugs should be weighed against the potential adverse
reactions, especially with long-term use, in individuals at risk (Watson
et al., 2000). (**Grade A, Level 1+**)

**GPP** - The selection of a non-steroidal anti-inflammatory drug for
prescription for osteoarthritis knee should be based upon relative
safety, patient acceptability and cost effectiveness. (**GPP**)

**GPP** - Patients who develop hypersensitivity reactions to
non-selective non-steroidal anti-inflammatory drugs are usually able to
tolerate cyclo-oxygenase 2 selective inhibitors. These should preferably
be prescribed following demonstration of tolerance through supervised
drug provocation tests. (**GPP)**

**A** - Patients with moderately high risk for gastroduodenal bleeds
should receive concomitant gastroprotective agents (GPA) when using
nonselective non-steroidal anti-inflammatory drugs (Gabriel,
Jaakkimainen, & Bombadier, 1991).

Risk factors for gastrointestinal complications include (Gabriel,
Jaakkimainen, & Bombadier, 1991):

-   Age greater than 60 years

-   Previous history of gastrointestinal events (e.g. peptic ulcer
    disease)

-   Concomitant corticosteroid use

**(Grade A, Level 1+)**

**A** - Recommended prophylactic gastroprotective agents (GPA) against
gastroduodenal ulcers include (Rostom et al., 2002):

-   Standard dose of proton-pump inhibitors (omeprazole 20 mg once
    daily)

-   Misoprostol 400-800 mcg/day

-   Double dose of H2-receptor antagonists (famotidine 40 mg bd,
    ranitidine 300 mg bd)

**(Grade A, Level 1+)**

**A** - Cyclo-oxygenase 2 selective inhibitors may be used acutely in
the reduction of pain from osteoarthritis of the knees (Bombardier et
al., 2000; Silverstein et al., 2000; Schnitzer et al., 2004). Although
these drugs have relatively lower risk of gastroduodenal adverse
effects, long-term use has been associated with myocardial and cerebral
infarction (Bresalier et al., 2005; Solomon et al., 2005; Nussmeier et
al., 2005). (**Grade A, Level 1+**)

**GPP** - When non-steroidal anti-inflammatory drugs (including both
cyclooxygenase 2 selective and non-selective non-steroidal
anti-inflammatory drugs) are needed for the management of an individual
patient, they should be prescribed at the lowest effective dose. The
duration of treatment should be periodically reviewed and kept as short
as possible. (**GPP**)

**GPP** - All non-steroidal anti-inflammatory drugs should not be
prescribed in patients who have recently undergone coronary artery
bypass graft (CABG) surgery and revascularization procedures. (**GPP**)

**GPP** - The benefits and risks of celecoxib and etoricoxib should be
carefully assessed before they are prescribed to any individual patient,
taking into consideration other available therapeutic options. (**GPP**)

**GPP** - Celecoxib or etoricoxib should not be prescribed for patients
with established ischaemic heart disease, stroke or congestive heart
failure. (**GPP**)

**GPP** - Caution should be exercised when prescribing celecoxib or
etoricoxib to patients who have the following risk factors:
hypertension, hyperlipidaemia, diabetes and smoking, as well as patients
with peripheral arterial disease. (**GPP**)

**GPP** - Etoricoxib should not be prescribed for patients with
hypertension whose blood pressure has not been adequately controlled.
(**GPP**)

**A** - Meloxicam and nimesulide are two non-steroidal anti-inflammatory
drugs with preferential cyclo-oxygenase 2 inhibition which may be used
in the short term relief of pain from osteoarthritis of the knees
(Bianchi & Broggini, 2003; Herrera & Gonzalez, 2003; Chang et al., 2001;
Hawkey et al., 1998). (**Grade A, Level 1+**)

**A**- Tramadol may be used as an alternative to non-steroidal
anti-inflammatory drugs for pain relief and improvement in physical
functioning, especially where the risks of adverse effects from
nonsteroidal anti-inflammatory drugs outweigh the benefits (Cepeda et
al., 2006; Babul et al., 2004). (**Grade A, Level 1+**)

**GPP** - Oral corticosteroids are not indicated for management of knee
osteoarthritis. (**GPP**)

**Glucosamine/Chondroitin in the Treatment of Osteoarthritis**

**B** - Patients who have failed to respond to analgesics and
nonpharmacologic measures and want to try glucosamine may be given
glucosamine sulphate 1500 mg once daily as pharmacologic studies suggest
that maximal benefit is better achieved at this dose (Persiani et al.,
2005). (**Grade B, Level 2++**)

**B** - Patients who are already taking glucosamine and report
improvement in symptoms may discontinue after a period of 6 months as
evidence suggests that regular use for more than 6 months is no more
effective than placebo in the relief of joint pain (Cibere et al.,
2004). (**Grade B, Level 1+**)

**GPP** - Patients allergic to shellfish should be warned about possible
allergic reactions to glucosamine. (**GPP**)

**Intra-articular Injections**

**B** - Viscosupplementation can be used for treatment of osteoarthritis
of the knee, where general measures or systemic therapies have failed or
are contraindicated. It is effective with beneficial effects on pain,
function and patient global assessment; and at different post injection
periods but especially at the 5 to 13 week post injection period when
compared with placebo (Bellamy et al., 2006). (**Grade B, Level 1+**)

**GPP** - In Singapore, data on effectiveness are too limited to allow
any conclusions to be drawn regarding cost-effectiveness of
viscosupplementation. However, in view of the relative high cost of
viscosupplementation and its comparable efficacy with other forms of
systemic intervention, it should be considered only if general measures
and systemic therapies have failed or are contraindicated. (**GPP**)

**B** - In patients with knee osteoarthritis who are symptomatic despite
general measures and systemic therapies, evidence supports short term
(up to two weeks) improvement of symptoms from intra-articular
corticosteroid injection (Arroll & Goodyear-Smith, 2004). (**Grade B,
Level 1**)

**GPP** - Regular use of intra-articular steroids is not recommended for
osteoarthritis of the knees in the general practice setting. (**GPP**)

**Topical Non-Steroidal Anti-inflammatory Drugs (NSAIDs) and
Medications**

**A** - Topical non-steroidal anti-inflammatory drugs (NSAIDs) can be
considered for the short-term symptomatic relief of pain in
osteoarthritis. Side effects of topical NSAIDs are usually minor.
(**Grade A, Level 1+**)

**A** - Topical capsaicin may also be considered in relieving pain due
to osteoarthritis. Transient local burning sensation may occur at the
site of application. (**Grade A, Level 1+**)

**Non-Pharmacological Management**

**A** - Regular knee strengthening and aerobic exercises should be
encouraged and taught to patients with osteoarthritis of the knees, as
these improve functional ability, aerobic and endurance capacity and
reduce knee pain. (**Grade A, Level 1+**)

**A** - Weight loss can result in significant changes in knee joint
biomechanics with improved knee function for stair climbing and other
daily activities. It is most effectively achieved by a combination of
exercise and dietary control. (**Grade A, Level 1+**)

**A** - Regular water-based exercise or exercises in the pool are
recommended as these exercises reduce pain and improve physical function
in patients with osteoarthritis of the knees. (**Grade A, Level 1++**)

**B** - Transcutaneous electrical nerve stimulation, in the form of
strong burst mode with high frequency, should be used to provide
short-term relief of osteoarthritis of the knee pain, reduce stiffness
and improve knee range of motion, with effects lasting for 4 weeks.
(**Grade B, Level 1+**)

**B** - Interferential current may be used to reduce pain and increase
in knee range of motion for osteoarthritis of the knee patients.
(**Grade B, Level 1+**)

**A** - Taping may be used to shift the patella medially and provide
effective relief of pain in osteoarthritis of the knee. (**Grade A,
Level 1++**)

**B** - Lateral wedge insoles (tilt angle of 8.5 to 11 degrees) should
be used to provide pain relief for osteoarthritis of the knee with
medial osteoarthritis symptoms. (**Grade B, Level 1+**)

**B** - Valgus knee brace and knee sleeves may be used to provide
significant improvement in functional tasks and unloading of varus
deformity. (**Grade B, Level 1+**)

**A** - Manual therapy applied to the knee together with an exercise
programme may be used to improve knee function and pain relief for
patients with osteoarthritis of the knee. (**Grade A, Level 1+**)

**A** - Needle electro-acupuncture may be used as an adjunct for
symptomatic relief of pain and improvement of knee function. (**Grade A,
Level 1++**)

**Surgery**

**GPP** - A referral to the orthopaedic surgeon should be made when
conservative management mentioned previously has failed. (**GPP**)

**Cost-Effectiveness Issues**

**GPP** - Pain medications are important in managing osteoarthritis
symptoms and should be used concurrently with nutritional, physical, and
educational interventions. Doctors should consider efficacy, adverse
side effects, dosing frequency, and cost to the patient when
recommending osteoarthritis treatments. (**GPP**)

**C** - For mild to moderate osteoarthritis pain, paracetamol is the
drug of choice as it is cost-effective and has minimal side-effects. In
treating moderate to severe osteoarthritis pain, the use of
non-steroidal anti-inflammatory drugs and cyclo-oxygenase 2 specific
inhibitors (for a patient who is at high risk of adverse upper
gastrointestinal events) should be considered only if the patient is not
responding to paracetamol (Kamath et al., 2003). (**Grade C, Level 2+**)

**C** - For patients who have failed medical therapy and who are
suitable for surgical interventions, both unicompartmental and total
knee arthroplasty are cost effective in terms of quality of life gain
(Soohoo et al., 2006; Slover et al., 2006; Lavernia, Guzman, &
Gachupin-Garcia, 1997). (**Grade C, Level 2+**)

**Definitions**:

**Levels of Evidence**

  -----------------------------------------------------------------------------
  **Level**   **Type of Evidence**
  ----------- -----------------------------------------------------------------
  **1++**     High quality meta-analyses, systematic reviews of randomised
              controlled trials (RCTs), or RCTs with a very low risk of bias.

  **1+**      Well conducted meta-analyses, systematic reviews of RCTs or RCTs
              with a low risk of bias

  **1-**      Meta-analyses, systematic reviews of RCTs, or RCTs with a high
              risk of bias.

  **2++**     High quality systematic reviews of case control or cohort
              studies. High quality case control or cohort studies with a very
              low risk of confounding or bias and a high probability that the
              relationship is causal.

  **2+**      Well conducted case control or cohort studies with a low risk of
              confounding or bias and a moderate probability that the
              relationship is causal.

  **2-**      Case control or cohort studies with a high risk of confounding or
              bias and a significant risk that the relationship is not causal.

  **3**       Non-analytic studies (e.g. case reports, case series).

  **4**       Expert opinion.
  -----------------------------------------------------------------------------

**Grades of Recommendation**

  -----------------------------------------------------------------------
  **Grade**   **Recommendation**
  ----------- -----------------------------------------------------------
  **A**       At least one meta-analysis, systematic review of RCTs, or
              RCT rated as 1++ and directly applicable to the target
              population; or\
              A body of evidence consisting principally of studies rated
              as 1+, directly applicable to the target population, and
              demonstrating overall consistency of results.

  **B**       A body of evidence including studies rated as 2++, directly
              applicable to the target population, and demonstrating
              overall consistency of results; or\
              Extrapolated evidence from studies rated as 1++ or 1+.

  **C**       A body of evidence including studies rated as 2+, directly
              applicable to the target population and demonstrating
              overall consistency of results; or\
              Extrapolated evidence from studies rated as 2++.

  **D**       Evidence level 3 or 4; or\
              Extrapolated evidence from studies rated as 2+.

  **GPP**\    Recommended best practice based on the clinical experience
  (good       of the guideline development group.
  practice    
  points)     
  -----------------------------------------------------------------------

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=11086)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is specifically stated for each
recommendation (see \"Major Recommendations\" field).

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Appropriate management of osteoarthritis of the knees

-   Reduction in pain and improved physical functioning

#### POTENTIAL HARMS

**Oral Paracetamol**

Gastrointestinal discomfort was more frequent with non-steroidal
anti-inflammatory drugs (NSAIDs) than with paracetamol.

**Non-Selective NSAIDs**

-   Gastrointestinal (gastroduodenal perforations, ulcers and bleeds,
    small bowel perforations)

-   Renal (hyperkalaemia, hypertension, oedema, acute renal
    insufficiency)

-   Hypersensitivity reactions including periorbital angioedema,
    urticaria, rhinitis or attacks of asthma.

Emerging evidence suggests that there are cardiovascular risks
associated with non-selective NSAIDs as well although this could not be
conclusively demonstrated in a recent meta-analysis.

**Cyclo-oxygenase 2 (COX-2) Selective Inhibitors**

-   Supervised drug provocation tests by specialists trained in
    allergy/immunology are recommended before using COX-2 inhibitors in
    NSAID-sensitive individuals.

-   Although these drugs have relatively lower risk of gastroduodenal
    adverse effects, long-term use has been associated with myocardial
    and cerebral infarction.

-   The COX-2 selective inhibitors have recently been found to be
    associated with increased cardiovascular events, leading to the
    withdrawal of rofecoxib in Singapore in October 2004.

-   In addition to the increased cardiovascular risks, reports of severe
    cutaneous reactions (Stevens-Johnson syndrome, erythema multiforme,
    toxic epidermal necrolysis) among patients taking valdecoxib
    resulted in the drug being removed from the market in several
    countries including Singapore in April 2005.

-   All non-steroidal anti-inflammatory drugs should not be prescribed
    in patients who have recently undergone coronary artery bypass graft
    (CABG) surgery and revascularization procedures.

-   Celecoxib or etoricoxib should not be prescribed for patients with
    established ischaemic heart disease, stroke or congestive heart
    failure.

-   Caution should be exercised when prescribing celecoxib or etoricoxib
    to patients who have the following risk factors: hypertension,
    hyperlipidaemia, diabetes and smoking, as well as patients with
    peripheral arterial disease.

-   Etoricoxib should not be prescribed for patients with hypertension
    whose blood pressure has not been adequately controlled.

**NSAID with preferential COX-2 inhibitors**

Although it is indicated for the short-term relief of joint pain, there
have been reports of elevated liver enzymes and hepatitis.

**Tramadol**

Nausea/giddiness

**Glucosamine/Chondroitin**

Patients allergic to shellfish should be warned about possible allergic
reactions to glucosamine.

**Viscosupplementation**

Viscosupplements were comparable in efficacy to systemic forms of active
intervention (e.g. NSAIDs), with more local reactions (post injection
inflammation) but fewer systemic adverse events.

**Topical NSAIDs and Medications**

Topical capsaicin may cause local burning sensation and this may limit
its use in some patients.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   These guidelines are not intended to serve as a standard of medical
    care. Standards of medical care are determined on the basis of all
    clinical data available for an individual case and are subject to
    change as scientific knowledge advances and patterns of care evolve.

-   The contents of this publication are guidelines to clinical
    practice, based on the best available evidence at the time of
    development. Adherence to these guidelines may not ensure a
    successful outcome in every case. These guidelines should neither be
    construed as including all proper methods of care, nor exclude other
    acceptable methods of care. Each physician is ultimately responsible
    for the management of his/her unique patient, in the light of the
    clinical data presented by the patient and the diagnostic and
    treatment options available.

-   Some treatments which are widely available suffer from a paucity of
    good clinical evidence for efficacy and safety. These include the
    use of glucosamine, chondroitin and other nutraceutical products as
    well as alternative therapies such as acupuncture and reflexology.
    However where data does exist, the workgroup has stated
    recommendations which hopefully will be beneficial to the clinician.

-   Evidence-based clinical practice guidelines are only as current as
    the evidence that supports them. Users must keep in mind that new
    evidence could supercede recommendations in these guidelines.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

The following clinical quality indicators are proposed:

1.  Knee pain and function should be assessed yearly.

2.  Exercise in the form of a directed or supervised muscle
    strengthening or aerobic exercise program should have been
    prescribed at least once and reviewed at least once per year in
    ambulatory patients with no contraindication to exercise.

3.  Weight should be measured yearly. Weight reduction should be
    advocated for patients with body mass index of \>25 kg/m^2^. Obese
    patients with body mass index \>30 kg/m^2^ should be referred to a
    medically-supervised weight reduction programme.

4.  Activities of daily living should be assessed and physiotherapy
    assessment for assisted devices made should ADL be impaired.

#### IMPLEMENTATION TOOLS

Audit Criteria/Indicators\
Personal Digital Assistant (PDA) Downloads\
Quick Reference Guides/Physician Guides\
Staff Training/Competency Material

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Singapore Ministry of Health. Osteoarthritis of the knee. Singapore:
Singapore Ministry of Health; 2007 May. 51 p. \[91 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2007 May

#### GUIDELINE DEVELOPER(S)

Singapore Ministry of Health - National Government Agency \[Non-U.S.\]

#### SOURCE(S) OF FUNDING

Singapore Ministry of Health

#### GUIDELINE COMMITTEE

Workgroup on Osteoarthritis of the Knee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Workgroup Members*: Dr Leong Keng Hong, Leong Keng Hong Arthritis and
Medical Clinic, Gleneagles Medical Centre (*Chairperson*); Dr Lau Tang
Ching, Consultant, Dept of Rheumatology, Allergy & Immunology, Tan Tock
Seng Hospital; Dr Thong Yu Hor Bernard, Consultant, Dept of
Rheumatology, Allergy & Immunology, Tan Tock Seng Hospital; Dr Eugene
Lim, Elim Rheumatic Centre (Bone, Joint, Rheumatism) Gleneagles Medical
Centre; A/Prof Fong Kok Yong, Senior Consultant, Dept of Rheumatology &
Immunology, Singapore General Hospital; Dr Koh Wei Howe, Koh Wei Howe
Arthritis & Rheumatism Medical Clinic, Mt Elizabeth Medical Centre; Dr
Ng Swee Cheng, Senior Consultant, Dept of Medicine, Alexandra Hospital;
Dr Lo Ngai Nung, Senior Consultant & Director, Adult Reconstruction
Service and Deputy Head, Dept of Orthopaedic Surgery, Singapore General
Hospital; Dr Celia Tan, Assistant Director, Allied Health Division,
Singapore General Hospital; Dr Kong Kok Ooi, Consultant, Dept of
Rheumatology, Allergy & Immunology, Tan Tock Seng Hospital; Dr Adrian Ee
Guan Liang, Director, Clinical Services, SingHealth Polyclinics; Dr
Sheila Vasoo Sushilan, Consultant, Div of Rheumatology, Dept of
Medicine,National University Hospital; Dr Tan Chyn Hong, Registrar, Dept
of Orthopaedic Surgery, National University Hospital

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [Singapore Ministry of Health Web
site](http://www.moh.gov.sg/mohcorp/publications.aspx?id=16686).

Print copies: Available from the Singapore Ministry of Health, College
of Medicine Building, Mezzanine Floor 16 College Rd, Singapore 169854.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Osteoarthritis of the knees summary card. 2007 Apr. 8 p. Available
    in Portable Document Format (PDF) from the [Singapore Ministry of
    Health Web
    site](http://www.moh.gov.sg/mohcorp/uploadedFiles/Publications/Guidelines/Clinical_Practice_Guidelines/OA Knees summary card.pdf).

The following are also available:

-   Audit criteria and a continuing medical education (CME)
    self-assessment are available in the [original guideline
    document](http://www.moh.gov.sg/mohcorp/publications.aspx?id=16686).

-   The full text guideline and summary card are available for PDA
    download in ISilo and MSReader formats from the [Singapore Ministry
    of Health Web
    site](http://www.moh.gov.sg/mohcorp/publications.aspx?id=16686).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI Institute on October 29, 2007.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions. Please contact the
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Date Modified: 11/3/2008