ATLANTA – The best available evidence suggests that exercise should be recommended as a nonpharmacologic treatment option for hip and knee osteoarthritis.
So says a technical panel of experts convened by the American College of Rheumatology to revise existing treatment recommendations on the nonpharmacologic treatment of hand, hip, and knee OA. The panel began work in 2008; the proposed consensus revisions are now under review by the ACR.
The panel found “strong” evidence that aerobic land-based exercise, resistance land-based exercise, aquatic exercise, and weight loss for overweight patients can be helpful for reducing pain and improving physical function in hip and knee osteoarthritis, and the panel plans to recommend them, reported Carol Oatis, Ph.D., professor of physical therapy at Arcadia University in Glenside, Pa., and a panel member.
This was the only time the panel deemed supporting evidence to be “strong,” based on the GRADE (grades of recommendations, assessment, development, and evaluation) methodology used in developing the revised recommendations. GRADE rates the available evidence as “strong,” “weak,” or “none.”
Strong evidence is of high quality with a large gradient between benefits and risks, and little uncertainty or variability in values and preferences; weak evidence has moderate quality with a small gradient between benefits and risks, and moderate uncertainty or variability in values and preferences; and “none” means the evidence was of low or very low quality with no difference between benefits and risks.
Weak evidence of benefit in hip OA was found for manual therapy in combination with supervised exercise programs; the panel suggests – but does not recommend – that this modality be considered for patients with hip OA, Dr. Oatis said.
No evidence was found either in support of or against balance exercises or tai chi, so the panel provided no guidance for these approaches, Dr. Oatis said.
The panel also considered the evidence for hand OA, and for various specific nonpharmacologic approaches to treating OA.
For hand OA, weak evidence was found for the following:
▸ Evaluating patients regarding activities of daily living.
▸ Providing instruction on joint protection techniques.
▸ Providing assistive devices as needed.
▸ Instructing patients regarding the use of thermal modalities.
▸ Using splints for the trapezio-metacarpal joint (carpal metacarpal joint at the base of the thumb).
Thus, the panel “suggests” use of these modalities, said Catherine Backman, Ph.D., an occupational therapist at the University of British Columbia, Vancouver, and a panel member.
When it comes to suggestions based on weak evidence, patient preference comes into play, because this generally means there is no evidence against – and there is some evidence in favor of – use of these modalities, Dr. Backman said.
“Clinicians may want to discuss [these modalities] with patients,” she said.
No other recommendations or suggestions were made for hand OA.
As for specific treatment modalities, weak evidence was found for the following:
▸ Medial wedge shoe insoles for lateral compartment knee OA.
▸ Subtalar strapping and lateral wedge insoles for medial compartment knee OA.
▸ Medial patellar femoral taping.
▸ Transcutaneous electrical nerve stimulation (TENS) for knee OA with chronic moderate to severe pain.
▸ Traditional Chinese acupuncture for knee OA with moderate to severe pain.
▸ Thermal modalities.
▸ Walking aids.
No evidence was found for or against valgus bracing for knee OA, or for lateral patellar-femoral taping; therefore, the panel chose not to provide guidance on these, said G. Kelley Fitzgerald, Ph.D., a physical therapist at the University of Pittsburgh, and a panel member.
The panel, which reviewed existing English-language studies and existing guidelines from the ACR and other organizations, based its evidence-strength determinations on the quality of the evidence and the extent to which the evidence demonstrated pain relief and improved physical functionality.
The panel did not determine that any of the reviewed modalities should not be used.
“The lack of 'do not do' recommendations or suggestions means that there was no definitive evidence of harm or lack of efficacy for the interventions examined, Dr. Oatis explained.
These proposed revisions to the current ACR recommendations, which were last revised in 2000 with an update in 2005 following the withdrawal of rofecoxib from the market, are currently under review by the journal Arthritis Care and Research, and have been submitted to the ACR Committee on Quality of Care for review before they are sent the ACR board of directors for final approval, said Dr. Marc C. Hochberg, head of the division of rheumatology and clinical immunology at the University of Maryland, Baltimore.
The ACR awarded the contract for the project to the University of Maryland with Dr. Hochberg as the principal investigator. He is also a member of the project steering committee.