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VA/Dod CLINICAL PRACTICE GUIDELINE for OSTEOARTHRITIS

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VA/Dod CLINICAL PRACTICE GUIDELINE for OSTEOARTHRITIS VA/DoD CLINICAL PRACTICE GUIDELINE FOR THE NON-SURGICAL MANAGEMENT OF HIP & KNEE OSTEOARTHRITIS Department of Veterans Affairs Department of Defense QUALIFYING STATEMENTS The Department of Veterans Affairs and the Department of Defense guidelines are based upon the best information available at the time of publication. They are designed to provide information and assist decision-making. They are not intended to define a standard of care and should not be construed as one. Neither should they be interpreted as prescribing an exclusive course of management. This Clinical Practice Guideline is based on a systematic review of both clinical and epidemiological evidence. Developed by a panel of multidisciplinary experts, it provides a clear explanation of the logical relationships between various care options and health outcomes while rating both the quality of the evidence and the strength of the recommendations. Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every healthcare professional making use of these guidelines is responsible for evaluating the appropriateness of applying them in the setting of any particular clinical situation. These guidelines are not intended to represent TRICARE policy. Further, inclusion of recommendations for specific testing and/or therapeutic interventions within these guidelines does not guarantee coverage of civilian sector care. Additional information on current TRICARE benefits may be found at www.tricare.mil or by contacting your regional TRICARE Managed Care Support Contractor. Version 1.0 – 2014 Prepared by: THE NON-SURGICAL MANAGEMENT OF HIP & KNEE OSTEOARTHRITIS Working Group With support from: The Office of Quality and Performance, VA, Washington, DC & Office of Evidence Based Practice, US Army Medical Command Version 1.0 – 2014 Table of Contents Executive Summary ............................................................................................................................................................... 5 Background ............................................................................................................................................................................ 7 Methods ................................................................................................................................................................................. 8 Scope and Structure .............................................................................................................................................................. 9 Guideline Working Group ................................................................................................................................................... 14 Recommendations .............................................................................................................................................................. 15 Algorithm ............................................................................................................................................................................. 17 Module A: Diagnosis & Evaluation ...................................................................................................................................... 18 A1. History & Physical Examination ............................................................................................................... 18 A2. Plain Radiography ..................................................................................................................................... 19 A3. Magnetic Resonance Imaging (MRI) ........................................................................................................ 20 A4. Routine Use of Laboratories and Synovial Fluid Analysis ........................................................................ 21 Module B: Core Non-Surgical Treatment Principles........................................................................................................... 22 B1. Patient Education ..................................................................................................................................... 22 B2. Comprehensive Management Plan ......................................................................................................... 22 B3. Weight Reduction in Patients with Knee or Hip Osteoarthritis and Elevated BMI ................................ 24 Module C: Physical Therapy Approaches ........................................................................................................................... 26 C1. Manual Physical Therapy ......................................................................................................................... 26 C2. Aquatic Therapy ....................................................................................................................................... 26 C3. Walking Aids ............................................................................................................................................. 28 Module D: Pharmacologic Therapies .................................................................................................................................. 30 D1. Acetaminophen and Non-steroidal Anti-inflammatory Drugs................................................................ 30 D2. Topical Capsaicin ...................................................................................................................................... 36 D3. Other Pain Management Pharmacotherapies ........................................................................................ 38 D4. Intra-articular Injections (Corticosteroids and Hyaluronic Acid) ............................................................ 40 Module E: Complementary & Alternative Medicine .......................................................................................................... 43 E1. Nutritional Supplements/Nutraceuticals/Dietary Supplements ............................................................ 43 E2. Acupuncture and Chiropractic Care ......................................................................................................... 45 Module F. Referrals for Surgical Consultation .................................................................................................................... 47 Appendix A: Guideline Development Process .................................................................................................................... 50 Introduction .................................................................................................................................................................... 50 Methodology ................................................................................................................................................................... 50 Appendix B: Evidence Table ................................................................................................................................................ 83 Clinical Practice Guideline for the Non-Surgical Management of Osteoarthritis Page 3 of 126 Appendix C: Patient History and Physical Examination ..................................................................................................... 88 Knee History .................................................................................................................................................................... 88 Knee Physical Examination ............................................................................................................................................. 88 Hip History ....................................................................................................................................................................... 88 Hip Physical Examination ................................................................................................................................................ 88 Appendix D: Pharmacologic Therapies ............................................................................................................................... 89 Tramadol ......................................................................................................................................................................... 89 Non-Tramadol Opioids .................................................................................................................................................... 92 Corticosteroids versus Placebo ...................................................................................................................................... 93 Hyaluronate/Hylan (HA) ................................................................................................................................................. 94 Corticosteroids versus Hyaluronate/Hylan .................................................................................................................... 96 Corticosteroid Injection prior to Hip or Knee Arthroplasty ........................................................................................... 97 Appendix E: Nutraceuticals and Dietary Supplements .................................................................................................... 103 Appendix F: Participants List ............................................................................................................................................
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