Treatment of knee pain in older adults in primary care: development of an evidence-based model of care

OBJECTIVE: To develop a stepped model of care for the treatment of knee pain in older adults in primary care based on recommended interventions. METHODS: A systematic search was undertaken to identify interventions recommended for knee osteoarthritis or knee pain in clinical guidelines and systematic reviews. Following this, a nominal group consensus exercise was conducted with members of the Primary Care Rheumatology Society to allocate the interventions to a stepped model of care. RESULTS: Twenty-seven recommended interventions were identified from 77 publications following the systematic search. A four-step model of care incorporating these interventions was developed through the consensus exercise. Step 1 comprised ten interventions that should be offered to all older adults with knee pain, but could also be provided through self-care. These included exercise, weight loss, paracetamol and written information. Steps 2 and 3 comprised 10 and 6 interventions, respectively, to be considered for people with persisting pain and disability. These included pharmacological interventions such as non-steroidal anti-inflammatory drugs in step 2 and intra-articular corticosteroids in step 3, and non-pharmacological interventions such as physiotherapy in step 2 and occupational therapy in step 3. Step 4 was referral for surgery. CONCLUSIONS: 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.