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A Review of Non-Exercise Interventions for Knee OA

Annemarie Erich, SPT




My motivation for this project was sparked during my first clinical at the VA Hospital in Salisbury, NC. I worked in an outpatient rehabilitation facility affiliated with the hospital there for two months. Our patient population was mostly comprised of men over 50 who typically had extensive problem lists with many concomitant musculoskeletal issues. These patients were among the first on which I practiced PT evaluation skills with my main reference point being  young, healthy classmates. Day after day I examined osteoarthritic knees that were stiff, painful, and frankly, loud. The disease process was having a major impact on the patients ability to exercise and preform activities of daily living. Each patient had a one of three different stories to tell regarding their treatment plan for knee osteoarthritis (OA). Some were going to receive an injection (usually steroid or hyaluronic acid) in the near future and in hopes their problems were going to be resolved. Or, they had already received and injection 2 weeks ago that worked wonders on their pain and stiffness allowing them to be more active than they had in quite some time. Then, there were those who were not so lucky. These patients had received multiple injections over several years with no noticeable benefit.

At times the results of our exercise-based interventions were less than desirable, leaving patients asking my CI and myself; what’s next? I didn’t know the answer. I was puzzled by what seemed a multitude of different treatment options (Synvisc, PRP, corticosteroids, etc.). Why did some patients get results when others did not? I decided to look deeper into this issue for my capstone project.


OA is a disease process causing the breakdown of articular cartilage and eventually the underlying bone. The knee joint is among the most common joints to develop the typical symptoms of pain, swelling, stiffness, decreased motion, and/or clicking or cracking sound during movement (1). People of all ages can have OA, but it occurs most often in people over 65 (1-2). When conservative treatments fail, there are many other interventions available for treating OA in the knee.

A large majority of care for OA occurs in a primary care setting (2). Though physical therapists are not necessarily primary care providers, patients often look to us for answers about treatment options related to joint pain. While we respond with a referral to an MD, we can also provide generalized education on treatment options without making concrete recommendations. Arthritis is one of the leading causes of disability in the US with osteoarthritis being the most common form affecting approximately half of the adult population. Managing this chronic condition is highly important given its significant impact on the ability and function of those affected (2).

There is a wealth of information published about non-exercise treatment for knee OA. These publications include five treatment options on which I’ve chosen to focus this project. Three interventions are delivered through intra-articular injection. Viscosupplementation is the attempt to restore the degenerated cartilage via injection of hyaluronic acid (HA) into the joint (3). In similar fashion, corticosteroid injections, a widely used procedure, are administered in hopes to decrease pain and inflammation of the joint (4). A third injection option is platelet rich plasma (PRP), a fairly new treatment in the orthopedic world, involving injection of concentrated blood components into the joint space in hopes to accelerate the healing process (5).

The other two interventions are surgical procedures to restore the physical structure to the joint. First is the osteochondral autologous transplant (OATS) procedure, which replaces defective joint surfaces with cartilage/bone plugs from non-weight bearing joint surfaces (6). Finally, autologous chondrocyte implantation (ACI) involves filling the cartilage defect with chondrocytes and placing a biomembrane patch to hold the cells in place (7).

The purpose of this project was to provide an update of the available literature on these five non-exercise treatment options for practicing therapists. Additional, products will provide clinicians with a patient education handout to deliver information about OA, explain treatment options, and provide resources for more information.

Gathering the Evidence

During EBP II, I completed a critically appraised topic on a related question. I asked which treatment option, exercise interventions or intra-articular treatment, was better at decreasing disability in those with OA. This was a step towards finding the body of literature that would prove helpful for my capstone. In the spring, I researched more focused questions about the five treatment options above and found that many researchers have been interested in these topics for over three decades.

The Project

I chose to create an evidence-based Voicethread presentation describing and summarizing the current evidence on the five non-exercise interventions for knee OA for clinicians in the outpatient physical therapy group at UNC. I chose this audience because busy clinicians often have limited time to do in depth research on the newest treatments available.

In preparation for the Voicethread, I created an evidence table with 3-5 articles per intervention including some that compare between interventions. As my CI at the VA experienced, clinicians are often questioned by patients about available treatments beyond the exercise interventions they receive in physical therapy. I decided that a patient handout with brief, simple explanations of each procedure would be a nice way to thank clinicians for viewing and evaluating my work.

Lastly, Jon Hacke,PT, DPT, MA, OCS and professor of MSK 2 has agreed to add the Voicethread presentation to the resource section on Sakai for students to view this coming fall semester.


I sought feedback from Mike Gross, PT, PhD, FAPTA, Jenn Cooke, PT, DPT, and Yvonne Golightly, PhD via email, in-person meetings, and phone calls. The outpatient physical therapy group at UNC will be evaluating the Voicethread presentation soon via online survey. A summary of the evaluations can be found here.


This process has taught me a lot about looking into the pros and cons of any intervention. Research articles typically have a limited scope and we must be careful not to generalize results that cannot be applied to our patient population. We must look at factors as: how does the treatment work, who has it been tested on, do the risks outweigh the potential benefits?

I have learned a few things about myself during this project as well. I set deadlines, and then life got in the way. I let other academic pursuits have priority and struggled to stay accountable to myself to chip away at this project throughout the semester. Working in pairs or with a group of my peers may have been a better choice for added accountability partnerships. Though the last stretch of project completion has been challenging, I was able to stay calm and work towards the finished product.


I am indebted to my committee members, Jenn Cooke PT, DPT and Yvonne Golightly, PhD for their input and provision of resources in the beginning stages as well as their communication throughout the project timeline. I left every meeting/phone call feeling much more optimistic than I was prior to speaking with them. I also want to thank my capstone advisor, Mike Gross, PT, PhD, FAPTA for helping me lay the groundwork for and providing quick, helpful feedback when I needed it most.


  1. Lai L, Stitik T, Foye P, Georgy J, Patibanda V, Chen B. Use of Platelet-Rich Plasma in Intra-Articular Knee Injections for Osteoarthritis: A Systematic Review. PM&R. 2015;7(6):637-648. doi:10.1016/j.pmrj.2015.02.003.
  1. Nelson A, Allen K, Golightly Y, Goode A, Jordan J. A systematic review of recommendations and guidelines for the management of osteoarthritis: The Chronic Osteoarthritis Management Initiative of the U.S. Bone and Joint Initiative. Seminars in Arthritis and Rheumatism. 2014;43(6):701-712. doi:10.1016/j.semarthrit.2013.11.012.
  1. Evanich J, Evanich C, Wright M, Rydlewicz J. Efficacy of Intraarticular Hyaluronic Acid Injections in Knee Osteoarthritis. Clinical Orthopaedics and Related Research. 2001;390:173-181. doi:10.1097/00003086-200109000-00020.
  1. Bellamy N, Campbell J, Robinson V, Gee T, Bourne R, Wells G. Intraarticular corticosteroid for treatment of osteoarthritis of the knee. The Cochrane Database of Systematic Reviews. 2005. doi:10.1002/14651858.cd005328.
  1. Khoshbin A, Leroux T, Wasserstein D et al. The Efficacy of Platelet-Rich Plasma in the Treatment of Symptomatic Knee Osteoarthritis: A Systematic Review With Quantitative Synthesis. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2013;29(12):2037-2048. doi:10.1016/j.arthro.2013.09.006.
  1. Chow J, Hantes M, Houle J, Zalavras C. Arthroscopic autogenous osteochondral transplantation for treating knee cartilage defects: A 2- to 5-year follow-up study. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2004;20(7):681-690. doi:10.1016/j.arthro.2004.06.005.
  1. Harris J, Siston R, Pan X, Flanigan D. The Journal of Bone and Joint Surgery (American). 2010;92(12). doi:10.2106/jbjs.j.00049.

5 Responses to “A Review of Non-exercise Interventions for Knee OA”

  1. Annemarie Erich

    Thanks to everyone for the kind words and appreciation of the work I put into this project. I’ll address each of your comments here:
    Jeremy- Thanks for the kind words and your comments saying that you have experienced the same problem in the clinic makes me hopeful that this presentation will be helpful for other clinicians as well.

    Corrine- So glad you can use the brochure for a family member! Your question is spot on with the thoughts running through my head when reading this mountain of literature. I would choose the OATS procedure as it has it has great efficiacy and long-term benefit. I like it over ACI in that it is done and over with, with only one procedure. Of course, like I said in the presentation, it depends on the size, severity, and whether conservative treatment fails me.

    Christie- So honored to have contributed to your patient education materials! As for the severity, it was rated mostly with the radiographic grading scale. There were some studies that used length of time of symptoms, pain level, and others just said patients with symptomatic OA. AH! good point about the link. I also included it in the email to the therapists but will change it on the VT. Thanks again!

    Seanie- I had the toughest time just choosing these interventions as there are so many options. These 5 interventions have so much information in the literature that preoccupied my time once I focused in on these. The artificial cartilage sounds interesting and like it may be a great option with possible long-term benefits exceeding that of natural cartilage given its poor healing capacity.
    Guatemala is rocking my world! Thank you all for taking the time to read and comment!! See you soon.



    Great project idea and presentation. I think that tackling this subject was very important especially with the rapidly changing demographics of the patient populations we will likely treat during our time as clinicians (i.e. baby boomers). Knee OA is a very serious concern that be disabling for many patients and one that is often overlooked. I think that your voicethread and handout were very well done and informative of the subject matter. (I liked your brochure theme, I chose the same one for my capstone project). One question I do have, as I have seen and read some information on this subject is the future of medical procedures that may be coming, pertains the future advancements in surgical medicine. I saw a video recently on a biomedical materials company who were experimenting with new cartilage replacements for patients with OA and other soft tissue injuries. I was just wondering if you came across any research examining the use of synthetic materials for cartilage replacement and whether or not they were effective.

    Again Great Job, Have fun in Guatemala!

    ~Sean O”Kelley

  3. Christie Clem


    I definitely learned more about the various medical options for knee OA by viewing your VoiceThread. I agree that even though these are not treatments offered by PTs, these are all interventions patients will ask us about at some point in time. I’ve added the patient brochure to my collection; its always nice to have file of go to patient education resources. The overview of each technique improved my understanding, but I think the evidence for the expected outcomes with each procedure will be the most beneficial. I did not realize the pain reduction benefit of a steroid injection lasted such a short period of time or that HA injections could take several weeks before any benefits are realized.

    Several times you mentioned that patients with less severe OA had better outcomes. Did any of the studies specifically define what they considered less severe? Was this based on the I-!V OA grading scale?

    Nice work on your project!


    PS. Since it’s not possible to click on a hyperlink in VoiceThread, you may want to consider changing the slide related to the feedback survey…maybe type out the specific link instead of it being “click here.”

  4. Corinne Bohling

    Annemarie, thank you for choosing this topic and for creating such useful products! I enjoyed listening to your voicethread, it was well organized and presented in a way that was easy to understand and very informative. I also really appreciated the evidence table for my own clinical reference and the brochure as a quick resource to provide for patients who are concerned about their options. (I am planning to print out your brochure to give to a family member!) Like Jeremy said in his comment, your hard work is evident and has likely saved your audience a lot of research time!

    My one question: based on your research, if you were to choose an intervention for yourself in 30 years, which would you choose?

  5. Jeremy Evans


    I really appreciate your capstone project! I am familiar with a couple of these non-exercise interventions, but it is great to have clear, concise information all in one place! My capstone project is also related to knee OA, and it really is such a pertinent topic for those who plan to practice in an orthopedic setting. I am grateful for having read through your materials, especially the evidence table, so I can be more educated when patients ask me about these treatment options. Also, as you stated, sometimes people just don’t seem to respond to typical exercise interventions so it’s great to know what is and is not supported by the literature as far as other options. I can tell you have put a lot of work into this project, and I look forward to utilizing this information in the future in clinical situations. Thank you!


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