Viscosupplementation: A Part of Physiotherapy

Viscosupplementation as Part of a Multi-Faceted Physiotherapy Regime


Viscosupplementation is an internationally recognised treatment for Osteoarthritis (OA) of the knee and other synovial joints1. It involves the intra-articular instillation of Hyaluronic Acid (HA) derived from either an avian or bio-fermentative source. Historically, a course of between 3 and 5 injections, delivered at weekly intervals, has constituted the treatment regime for mild to moderate knee OA. More recently the introduction of licensed single injection viscosupplement options, which offer effective symptomatic control for 6 months and longer following a single IA injection, have been introduced to the market. This has made the adoption of viscosupplementation as a therapeutic option less time consuming and more convenient to patient and clinician alike, and more economically viable to Commissioning Bodies.



Joint pain and impaired joint function are common symptoms of Osteoarthritis1. Conservative measures, as recommended by all recognised medical and rehabilitation authorities, include weight loss and exercise to facilitate improved joint function. Failure to engage with weight loss and rehabilitation programmes – often as a result of unremitting joint pain on movement - is a major contributing factor in the failure of some patients to attain satisfactory symptomatic reduction and improved function2. Viscosupplementation has been clinically and statistically proven to significantly reduce pain and improve joint function in OA joints3, 4, 5, both as a singular intervention3 and as part of a multi-faceted physiotherapy programme6.  



Intra-articular instillation of sodium hyaluronate has been demonstrated to significantly reduce pain and improve joint function. It can significantly reduce the need for potentially gastro-toxic systemic analgesics, demonstrably improves Quality of Life for patients, and is safe and easy to administer in a community setting by an increasing number of qualified MSk clinicians. For those patients who have consistently failed to respond adequately to all conservative measures, but who are unable or unwilling to undergo surgery, viscosupplementation offers a proven and safe intervention to ameliorate suffering, improve clinical outcomes, reduce visits to GP surgeries, and ultimately maintain the integrity of articular function for longer. Some MSk services, often due to CCG directives, have adopted clinical pathways which are failing to adequately treat this cohort of patients, resulting in the frustrating patient experience whereby they are sent back and forth from Primary to Secondary Care without being offered any effective treatment, and thus no improvement in their symptoms. 


Viscosupplementation can enhance the patient’s experience in a variety of ways: studies demonstrate it can delay total knee replacement,7  allowing for a better quality of life for longer, without the trauma and considerable rehabilitation time associated with arthroplasty. The potential complications associated with surgery (e.g. neurological damage, infection, scarring and revision surgery), as well as the costs to Commissioning Services are considerable. Reducing hospital appointments, enabling patients to exercise an informed choice over their preferred treatment modality, and utilising the considerable resource available within Primary Care frameworks, has been shown to improve patient satisfaction3, and reduce expenditure on secondary referrals8.

Viscosupplementation can be administered by any clinician qualified to perform an intra-articular injection, meaning that patients can be treated at their local GP surgery or even in the comfort of their own home, creating a more community based care approach.  A single intra-articular injection can provide 6 months of symptomatic relief and improved function3, with a corresponding improvement in Quality of Life, and maintenance of independence.  Adverse events associated with viscosupplementation are rare9 and associated with the transient effects of the injection itself, ensuring patient safety is optimised.

1. Bellamy N, Campbell J, Welch V, Gee TL, Bourne R, Wells GA. Viscosupplementation for the treatment of osteoarthritis of the knee. Cochrane Database of Systematic Reviews. 2006; Issue 35 2:CD005321. DOI:10.1002/14651858.CD005321.pub2.
2. Manek NJ, Lane NE. Osteoarthritis: current concepts in diagnosis and management. Am Fam Physician 2000;61(6):1795-804.
3. A. Borrás-Verderaa,*, V. Calcedo-Bernalb, J. Ojeda-Levenfeldb and C. Clavel-Sainzc  Efficacy and safety of a single intra-articular injection of 2% hyaluronic acid and mannitol in knee osteoarthritis over a 6-month period. Rev Esp Cir Ortop Traumatol. 2012;56(4):274-280.
4. Altman RD, Rosen JE, Bloch DA, Hatoum HT, Korner P. A double-blind, randomized, saline-21 controlled study of the efficacy and safety of EUFLEXXA for treatment of painful osteoarthritis 22 of the knee, with an open-label safety extension (the FLEXX trial). Seminars in Arthritis and 23 Rheumatism. 2009; 39(1):1-9.
5. A 40-month multicentre, randomised placebo controlled study to assess the efficacy and carry over effect of repeated intra-articular injections of hyaluronic acid in knee osteoarthritis: the AMELIA project. F Navarro-Sarabia,  P Coronel,  E Collantes,  F J Navarro,  A Rodriguez de la Serna, A Naranjo,  M Gimeno,  G Herrero-Beaumont,  on behalf of the AMELIA study group. Ann Rheum Dis 2011;70:1957–1962. doi:10.1136/ard.2011.152017.
6. Hempfling, H. (2007). Intra-articular hyaluronic acid after knee arthroscopy: a two-year study. Knee Surg Sports Traumatol Arthrosc. 15 (1), p537-546.
7. Torrance GW, Raynauld JP, Walker V, et al. Canadian Knee OA Study Group. A prospective, randomized, pragmatic, health outcomes trial evaluating the incorporation of hylan G-F 20 into the treatment paradigm for patients with knee osteoarthritis (Part 2 of 2): economic results. Osteoarthritis Cartilage 2002;10(7): 518–527.
8. Wadell DD, Bricker DC. Total knee replacement delayed with hylan G-F 20 use in patients with grade IV osteoarthritis. J Manag Care Pharm 2007; 13(2): 113–121.
9. Robert J Petrella, Anthony Cogliano, Joseph Decaria. Comparison of avian and non-avian hyaluronic acid in osteoarthritis of the knee. Orth. Res. And Rev. January 2010 Volume 2010:2 Pages 5 – 9.

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