Skip to main content


Log in

“Beating osteoARThritis”: Development of a stepped care strategy to optimize utilization and timing of non-surgical treatment modalities for patients with hip or knee osteoarthritis

  • Brief Report
  • Published:
Clinical Rheumatology Aims and scope Submit manuscript


Inadequacies in health care practices have been reported despite existing guidelines to manage hip or knee osteoarthritis. To facilitate guideline implementation and improve utilization of non-surgical treatment options a care strategy should be developed. This study describes the development of an evidence-based, multidisciplinary, patient-centered, stepped care strategy. A national, multidisciplinary, steering group developed the strategy in three phases: (1) consensus among steering group members (first draft); (2) written consultation of 23 representatives of patient organizations and professional associations involved in osteoarthritis care (second draft); (3) consensus of the final draft after discussion in two rounds during a conference with representatives from the different disciplines. The final stepped care strategy presents, in three tiers, the optimal order for non-surgical treatment modalities. It recommends that more advanced options should only be considered if options listed in previous steps failed to produce satisfactory results. Hence, the first step treatment options can be offered to all patients but may also be provided through self care (education, life style advice, and acetaminophen). The second step (exercise therapy, dietary therapy, and non-steroidal anti-inflammatory drugs) and third step treatment options (multidisciplinary care, intra-articular injections, and transcutaneous electrical nerve stimulation) can be considered for people with persisting complaints. Trough a consensus procedure, we succeeded to develop a multidisciplinary, patient-centered, stepped care strategy based on national guidelines. This strategy provides a framework for health care providers and patients with hip or knee osteoarthritis to discuss the optimal timing of the various treatment options.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others


  1. Dutch Orthopadic Association (2007) Diagnostiek en behandeling van heup- en knieartrose. Diagnostics and treatment of osteoarthritis of the hip and knee. Kwaliteitsinstituut voor de Gezondheidszorg (CBO).

  2. Zhang W, Doherty M, Arden N, Bannwarth B, Bijlsma J, Gunther KP et al (2005) EULAR evidence based recommendations for the management of hip osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis 64(5):669–681

    Article  PubMed  CAS  Google Scholar 

  3. Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N et al (2007) OARSI recommendations for the management of hip and knee osteoarthritis: Part I. Critical appraisal of existing treatment guidelines and systematic review of current research evidence. Osteoarthritis Cartil 15(9):981–1000

    Article  CAS  Google Scholar 

  4. National Collaborating Centre for Chronic Conditions (2008) Osteoarthritis: national clinical guideline for care and management in adults. Royal College of Physicians, London

    Google Scholar 

  5. Swierstra BA, Bijlsma JWJ, Beer de JJA, Kuijpers T (2009) Richtlijn ‘Diagnostiek en behandeling van heup- en knieartrose’. (Guideline ‘Diagnostics and treatment of osteoarthrosis of the hip and knee’). Ned Tijdschr Geneeskd 153(B39 (Richtlijnen))

  6. Shrier I, Feldman DE, Gaudet MC, Rossignol M, Zukor D, Tanzer M et al (2006) Conservative non-pharmacological treatment options are not frequently used in the management of hip osteoarthritis. J Sci Med Sport 9(1–2):81–86

    Article  PubMed  CAS  Google Scholar 

  7. DeHaan MN, Guzman J, Bayley MT, Bell MJ (2007) Knee osteoarthritis clinical practice guidelines — how are we doing? J Rheumatol 34(10):2099–2105

    PubMed  Google Scholar 

  8. Mitchell HL, Hurley MV (2008) Management of chronic knee pain: a survey of patient preferences and treatment received. BMC Musculoskelet Disord 9:123

    Article  PubMed  Google Scholar 

  9. Glazier RH, Dalby DM, Badley EM, Hawker GA, Bell MJ, Buchbinder R et al (1998) Management of common musculoskeletal problems: a survey of Ontario primary care physicians. CMAJ 158(8):1037–1040

    PubMed  CAS  Google Scholar 

  10. Snijders GF, den Broeder AA, van Riel PL, Straten VH, de Man FH, van den Hoogen FH et al (2011) Evidence-based tailored conservative treatment of knee and hip osteoarthritis: between knowing and doing. Scand J Rheumatol 40(3):225–231

    Article  PubMed  CAS  Google Scholar 

  11. Jamtvedt G, Dahm KT, Christie A, Moe RH, Haavardsholm E, Holm I et al (2008) Physical therapy interventions for patients with osteoarthritis of the knee: an overview of systematic reviews. Phys Ther 88(1):123–136

    Article  PubMed  Google Scholar 

  12. Grol R, Grimshaw J (2003) From best evidence to best practice: effective implementation of change in patients’ care. Lancet 362(9391):1225–1230

    Article  PubMed  Google Scholar 

  13. Brand C, Cox S (2006) Systems for implementing best practice for a chronic disease: management of osteoarthritis of the hip and knee. Intern Med J 36(3):170–179

    Article  PubMed  CAS  Google Scholar 

  14. Hunter DJ (2010) Quality of osteoarthritis care for community-dwelling older adults. Clin Geriatr Med 26(3):401–417

    Article  PubMed  Google Scholar 

  15. Hunter DJ, Neogi T, Hochberg MC (2011) Quality of osteoarthritis management and the need for reform in the US. Arthritis Care Res (Hoboken) 63(1):31–38

    Article  Google Scholar 

  16. Williams B, Poulter NR, Brown MJ, Davis M, McInnes GT, Potter JF et al (2004) Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004—BHS IV. J Hum Hypertens 18(3):139–185

    Article  PubMed  CAS  Google Scholar 

  17. Von Korff M, Tiemens B (2000) Individualized stepped care of chronic illness. West J Med 172(2):133–137

    Article  Google Scholar 

  18. McFarland KF (1997) Type 2 diabetes: stepped-care approach to patient management. Geriatrics 52(10):22–26, 35, 39

    Google Scholar 

  19. Katon W, Von Korff M, Lin E, Simon G, Walker E, Unutzer J et al (1999) Stepped collaborative care for primary care patients with persistent symptoms of depression: a randomized trial. Arch Gen Psychiatry 56(12):1109–1115

    Article  PubMed  CAS  Google Scholar 

  20. Von Korff M (1999) Pain management in primary care: an individualized stepped care approach. In: Gatchel R, Turk D (eds) Psychosocial factors in pain: evolution and revolutions. Guilford Press, New York, NY, pp 260–373

    Google Scholar 

  21. Porcheret M, Jordan K, Croft P (2007) Treatment of knee pain in older adults in primary care: development of an evidence-based model of care. Rheumatology (Oxford) 46(4):638–648

    Article  CAS  Google Scholar 

  22. van den Ende CM, Bierma-Zeinstra SM, Vlieland TP, Swierstra BA, Voorn TB, Dekker J (2010) Conservatieve behandeling van heup- en knieartrose: Systematische en stapsgewijze behandelstrategie. (Conservative treatment of hip and knee osteoarthritis: a systematic, step-by-step treatment strategy). Ned Tijdschr Geneeskd 154:A1574

    PubMed  Google Scholar 

  23. Bijlsma JW, Knahr K (2007) Strategies for the prevention and management of osteoarthritis of the hip and knee. Best Pract Res Clin Rheumatol 21(1):59–76

    Article  PubMed  CAS  Google Scholar 

  24. Doherty M, Dougados M (2001) Evidence-based management of osteoarthritis: practical issues relating to the data. Best Pract Res Clin Rheumatol 15(4):517–525

    Article  PubMed  CAS  Google Scholar 

  25. Farley FA, Weinstein SL (2006) The case for patient-centered care in orthopaedics. J Am Acad Orthop Surg 14(8):447–451

    PubMed  Google Scholar 

  26. Bijl D, Dirven-Meijer PC, Opstelten W, Raaijmakers AJ, Scholten RJPM, Eizenga WH et al (1998) NHG-Standaard: Niet-Traumatische Knieproblemen bij Volwassenen. (NHG-Standard: Non-traumatic knee complaints in adolescents). Huisarts Wet 41(7):344–350

    Google Scholar 

  27. Belo JN, Bierma-Zeinstra SM, Raaijmakers AJ, Van der Wissel F, Opstelten W (2008) NHG Standaard Niet traumatische knieproblemen bij volwassenen (eerste herziening). (NHG-Standard: Non-traumatic knee complaints in adolescents (first revision)). Huisarts Wet 51(5):229–240

    Article  Google Scholar 

  28. Vogels EMHM, Hendriks HJM, Van Baar ME, Dekker J, Hopman-Rock M, Oostendorp RAB, et al. (2005) KNGF-richtlijn Artrose heup-knie. (KNGF—guideline Osteoarthritis hip-knee). Neder Tijdschr Fysiother 1(supplement):115

  29. Campbell SM, Cantrill JA (2001) Consensus methods in prescribing research. J Clin Pharm Ther 26(1):5–14

    Article  PubMed  CAS  Google Scholar 

Download references


The authors are indebted to the participants of the written consultation and invitational conference for their contribution in the development of the stepped care strategy. Our thanks go to Hans Bloo, Roessingh Research & Development, Enschede; Alfons den Broeder, Department of Rheumatology, Sint Maartenskliniek, Nijmegen; Sjoerd Bulstra, Department of Orthopaedics, University Medical Center Groningen; Martin van der Esch, Department of Rehabilitation and Rheumatology, Reade, Amsterdam; Wim Hilberdink, Paramedical center for rheumatology and rehabilitation, Groningen; Ria Jansen, Patient Society Poly-Osteoarthritis Companions, Hoogerheide; Caroline Kielstra, Bone and Joint Decade NL, Leiden; Margreet Kloppenburg, Department of Rheumatology, University Medical Center, Leiden; Marianne Krijgsman, Dutch patient organization for rheumatic diseases, Amersfoort; Annet Lievense, Department of General Practice, Erasmus University Medical Center Rotterdam; Sjoerd Olthof, Royal Dutch Society for Physical Therapy, Utrecht; Rob Oostendorp, Dutch Institute of Allied Health Care, Amersfoort; Wim Opstelten, The Dutch College of General Practitioners, Utrecht; Susan Picavet, National Institute for Public Health and the Environment, Bilthoven; Ruud Pöll, EMGO Institute for Health and Care Research VU University Medical Center, Amsterdam; Victor Pop, Faculty of Social and Behavioural Sciences, Tilburg University; Peter van Roermund, Bone and Joint Decade NL, Leiden; Marieke Scholte, Bone and Joint Decade NL, Leiden; Rosalinda Schuil-Menninga, Paramedical center for rheumatology and rehabilitation, Groningen; Gijs Snijders, Department of Rheumatology, Sint Maartenskliniek, Nijmegen; Cindy Veenhof, Netherlands Institute for Health Services Research, Utrecht; Cora Verberk; Gust Verbruggen, Department of Rheumatology, Ghent University Hospital, Belgium; Jan Verhaar, Department of Orthopaedics, Erasmus University Medical Center Rotterdam; Kees Verheijen, Department of Orthopaedics, Isala clinics, Zwolle; Geert Walenkamp, Department of Orthopaedics, Maastricht University Medical Center, Research Institute Caphri.



Author information

Authors and Affiliations


Corresponding author

Correspondence to Agnes J. Smink.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Smink, A.J., van den Ende, C.H.M., Vliet Vlieland, T.P.M. et al. “Beating osteoARThritis”: Development of a stepped care strategy to optimize utilization and timing of non-surgical treatment modalities for patients with hip or knee osteoarthritis. Clin Rheumatol 30, 1623–1629 (2011).

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: