Objectives: To update the EULAR recommendations for management of knee osteoarthritis (OA) by an evidence based medicine and expert opinion approach. Methods: The literature search and guidelines were restricted to treatments for knee OA pertaining to clinical and/or radiological OA of any compartment of the knee. Papers for combined treatment of knee and other types of OA were excluded. Medline and Embase were searched using a combination of subject headings and key words. Searches for those treatments previously investigated were conducted for January 1999 to February 2002 and for those treatments not previously investigated for 1966 to February 2002. The level of evidence found for each treatment was documented. Quality scores were determined for each paper, an effect size comparing the treatment with placebo was calculated, where possible, and a toxicity profile was determined for each treatment modality. Results: 497 new publications were identified by the search. Of these, 103 were intervention trials and included in the overall analysis, and 33 treatment modalities were identified. Previously identified publications which were not exclusively knee OA in the initial analysis were rejected. In total, 545 publications were included. Based on the results of the literature search and expert opinion, 10 recommendations for the treatment of knee OA were devised using a five stage Delphi technique. Based on expert opinion, a further set of 10 items was identified by a five stage Delphi technique as important for future research. Conclusion: The updated recommendations support some of the previous propositions published in 2000 but also include modified statements and new propositions. Although a large number of treatment options for knee OA exist, the evidence based format of the EULAR Recommendations continues to identify key clinical questions that currently are unanswered. O steoarthritis (OA) is the most common form of arthritis in Western populations. It is characterised pathologically by both focal loss of articular cartilage and marginal and central new bone formation. OA of the knee, the principal large joint to be affected, results in disabling knee symptoms in an estimated 10% of people older than 55 years, a quarter of whom are severely disabled.1 The risk of disability attributable to knee OA alone is as great as that due to cardiac disease and greater than that due to any other medical disorder in the elderly.2 A recent World Health Organisation report on the global burden of disease indicates that knee OA is likely to become the fourth most important global cause of disability in women and the eighth most important in men. 3 The annual costs attributable to knee OA are immense. There is therefore a burden on health from both morbidity and cost. Radiographic evidence of knee OA in men and women aged over 65 is reported in 30% of subjects, 4 around one third of whom are symptomatic. Annual arthroplasty rates in Europeans over the age of 65 vary from country to country but are of the order of 0.5-0.7 p...

Ethical guidelines in the United Kingdom require written consent from participants in epidemiologic studies for follow-up or review of medical records. This may cause bias in samples used for follow-up or medical record review. The authors analyzed data from seven general population surveys conducted in the United Kingdom (1996-2002), to which over 25,000 people responded. Associations of age, gender, and symptom under investigation with consent to follow-up and consent to review of medical records were examined. Consent to follow-up was approximately 75-95% among survey responders under age 50 years but fell among older people, particularly females. Consent to follow-up was also higher among responders who had the symptom under investigation (pooled odds ratio = 1.61, 95% confidence interval: 1.36, 1.92). Consent to review of medical records followed a similar pattern. Patterns of consent were relatively consistent and represented a high proportion of responders. Males, younger people, and subjects reporting the symptom under investigation were more likely to give consent, and these groups may be overrepresented in follow-up samples or reviews of medical records. Although consent is high among responders, the additive effect of nonresponse and nonconsent can substantially reduce sample size and should be taken into account in epidemiologic study planning.

In this population, physiotherapy is an under-utilized treatment for knee OA, in spite of its recommendation as first-line treatment in all guidelines. Complementary medicines and therapies are commonly used, particularly in affluent populations.

Interventions recommended as core treatment for knee pain in older adults were underused-in particular, exercise, weight loss and the provision of written information. There appeared to be early reliance on pharmacological treatments with underuse of non-pharmacological interventions in early treatment choices. Self care played an important role in the management of this condition. The study provides clear evidence on the need to improve the delivery of core treatments for osteoarthritis and highlights the need to support and encourage self care.

Previous evidence-based guidelines for the treatment of knee problems have been developed in secondary care. A systematic search for recommended interventions, and a consensus exercise, has now enabled an evidence-based and practical model of care for knee pain in older adults to be developed for use in primary care.

Study objective: There has been little prospective investigation of what predicts general practice consultation. The objective of this study was to investigate the extent to which previous primary care consultation and self reported health status are predictors of future primary care consultation. Design: Population based cohort study in two phases. Firstly, a baseline survey (1995/96) to identify the cohort and to obtain self reported health status using the UK census limiting long term illness (LLI) question and the Short Form-36 (SF-36) health profile. Secondly, analysis of general practice medical records for two years (1994/1995) before the survey and for two years (1997/1998) after the survey. Analysis was performed on: (a) all contacts coded by the GP, (b) the subgroup of contacts given a diagnostic morbidity code by the GP. Setting: One general practice in North Staffordshire, UK. Participants: 738 survey respondents who had consented to viewing of medical records including all those who reported LLI together with an age-gender matched control group of those who reported no LLI. Main results: High frequency consulters in 1994/95 were more likely than non-consulters or average consulters in that year to be high consulters in 1997/98 (odds ratio 5.6, 95% confidence interval 3.82 to 8.25, for all contacts; 4.4 for diagnostic coded consultations). Self reported role disability and physical limitation from the SF-36 at baseline increased the probability of being a future high consulter but the effects were weaker than for previous consultation. Previous consultation within a diagnostic group was the main predictor for future consultation within that group with weaker but significant prediction by self reported health status. Conclusions: Reliable morbidity coding in general practice provides the best available basis for predicting future demand in primary care. Self reported health status survey instruments add to this information but on their own are weaker predictors of future consultation.

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