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  • Updated Guideline for Management of Hand, Hip, Knee OA Strongly Recommends Exercise-Based Approaches

    In this review: 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee
    (Arthritis Care & Research, February, 2020)

    The Message
    Although researchers were not able to recommend precisely what kind and how much, exercise interventions in general have once again emerged as one of the most strongly recommended approaches to treating knee, hip, or hand osteoarthritis, according to an updated practice guideline issued by the American College of Rheumatology and the Arthritis Foundation. The recommendation for exercise is the result of an extensive review of physical, psychosocial, and pharmacological approaches that evaluated the evidence base for their use. Other strongly recommended approaches for all three types of OA included self-management programs and oral nonsteroidal anti-inflammatory drugs, or NSAIDs. Weight loss (when appropriate) and tai chi were also strongly recommended approaches for individuals with hip or knee OA.

    The study
    Authors based their recommendations on an extensive review of studies, most of them randomized controlled trials, conducted through August 2018. The literature identification, review, and ultimate recommendation process involved five teams that included both provider subject matter experts and patient panel, ending with a voting panel that included PTs, rheumatologists, an internist, occupational therapists, and patients.

    Analysis was focused on approaches available in the U.S. and used what’s called the GRADE system that resulted in recommendations for or against a particular approach, accompanied by a note of either "strong" or "conditional" support for each recommendation, as well as an intended range of patients (hip, knee, or hand OA alone or in combinations). APTA members Carol Oatis, PT, PhD; Louise Thoma, PT, DPT, PhD; and Daniel White, PT, were among the authors of the guideline.

    The recommendations were divided into two broad areas: physical, psychosocial, and mind-body approaches; and pharmacologic management. Here are a few of the recommendations included in the guideline.

    Physical, Psychosocial, and Mind-Body

    • Exercise, self-management programs (strongly recommended for hip, knee, or hand OA).
    • Weight loss, tai chi (strongly recommended for hip or knee OA).
    • Cognitive behavioral therapy, acupuncture, thermal interventions (conditionally recommended for hip, knee, or hand OA).

    Pharmacologic Management

    • Oral NSAIDs (strongly recommended for hip, knee, or hand OA).
    • Intraatricular glucocorticoid injections (strongly recommended for hip or knee OA).
    • Acetaminophen, Tramadol, Duloxetine (conditionally recommended for .hip, knee, or hand OA).

    The guideline also includes strong and conditional recommendations for approaches limited to a specific OA location, including balance exercises (conditionally recommended for knee or hip OA), yoga (conditionally recommended for knee OA), and topical NSAIDs (strongly recommended for knee OA).

    Approaches recommended against using

    As with the recommended-for approaches, the guideline contains a mix of strong and conditional recommendations against certain approaches, usually applicable to some but not all three OA locations. Among the approaches authors recommend against using:

    • Massage therapy, transcutaneous electrical stimulation, modified shoes, lateral and wedged insoles (conditionally recommended against for knee or hip OA).
    • Fish oil, vitamin D, glucosamine (strongly recommended against for knee, hip, or hand OA).
    • Platelet-rich plasma treatments, stem cell injections (strongly recommended against for hip or knee OA).

    Why it matters
    As the most common form of arthritis, OA is a leading cause of disability among older adults and a condition that can be present for decades. Authors view the guideline as a tool for pursuing a "comprehensive, multimodal approach … offered in the context of shared decision-making with patients to choose the safest and most effective treatment possible."

    More from the study
    Authors write that while "current evidence is insufficient to recommend specific exercise prescriptions," the evidence is strong that exercise can lessen pain and improve function. The guideline urges providers to provide exercise advice "that is as specific as possible" for the patient, and assert that "overall, most exercise programs are more effective if supervised, often by physical therapists and sometimes in a class setting."

    The "self-management programs" are described by authors as those that "use a multidisciplinary, group-based format combining sessions on skill-building … education about the disease and about medication effects and side effects, joint protection measures, and fitness goals and approaches."

    One of the more notable changes in the most recent version of the guideline was around the use of glucosamine, a popular supplement thought to improve joint health. While glucosamine was a conditionally recommended approach in the previous guideline, authors moved it to "strongly recommended against" status due to "a lack of efficacy and large placebo effects."

    Keep in mind …
    Authors point out that in addition to a lack of clarity as to what types and dosages of exercise were most beneficial for OA (and for which joints), the current guideline also was unable to assess factors such as optimal footwear types, broader outcomes such as falls prevention, and the "role of integrative medicine, including massage, herbal products, medical marijuana, and additional mind-body interventions."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.


    • Very useful article, it is a support to our practice here in the clinic.

      Posted by CUTAtherapie on 2/11/2020 4:18 PM

    • What does OA stand for. Thank you Dr. Louise Thoma Van Duran. Need specific exercises for lower back stiffness

      Posted by Suzie Donahue on 2/11/2020 6:56 PM

    • Thanks for sharing a recap and spread the new guidelines. I want to ask what your thoughts are towards the OA manual therapy recommendation of conditionally against vs. the JOSPT published revision of Hip OA CPG, where manual therapy was promoted from a grade B to grade A?

      Posted by Mike Stroud on 2/13/2020 12:17 AM

    • I did not find this article in anyway useful. It would be helpful for each patient with knee OA to research and develop their own self care program. Example specific knee exercises, acupuncture, cupping, TENs, and definitely topical creams (CBD) and fish oil, vitamin D and Collagen. Maybe some of your recommendations (steroid injections, nsaids) are needed for more advanced OA. Treatment is individual.

      Posted by Sherri Belluomini on 2/13/2020 11:00 AM

    • Hmm. I think that this article is too dated and does not reflect the improvements our clients currently seeing in our practices when we use the "non recommended" techniques such as Myofascial release( not massage therapy), E-stim other than TENS, Dry Needling (not acupuncture) , Stem Cell injections and Platement -rich plasma and/or looking/recommending better shoe wear including some inserts where needed. Clients are often able to avoid joint replacement surgery when we look at more options than exercise & avoiding pain meds and steroids.

      Posted by Kathryn Hammer on 2/14/2020 10:48 AM

    • This article is from the Dark Ages and next to useless. We were ahead of this in practice 35 years ago and WAY ahead of it now. What the heck is going on here? They seem to be regressing rather than progressing.

      Posted by Brian Miller on 2/14/2020 6:35 PM

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