ACR 2010: ACR to Approve Updated Non-pharmacologic Guidelines for Osteoarthritis

Revised evidence-based guidelines for non-pharmacologic treatments of hip, knee, and hand osteoarthritis (OA) were unveiled at a session at the 2010 Annual Scientific Meeting of the American College of Rheumatology (ACR).

In general, these proposed guidelines are expected to be an improvement over existing guidelines from ACR and other organizations, because they are based on the quality of existing evidence for specific modalities. “We used the Grades of Recommendation, Assessment, Development, and Evaluation method (GRADE) and voted on the strength of the evidence,” explained Marc Hochberg, MD, University of Maryland in Baltimore, who moderated the session.

Other differences from existing guidelines include incorporating Patient Important Clinical Outcomes (PICO), representing the stakeholder’s (ie, patients) point of view, which include reduced pain and improved function. Clinically important side effects were also considered, and the number needed to treat (NNT) for benefit and NNT for harm were also included.

The updated version of these non-pharmacologic OA guidelines are currently under review by ACR, and publication in the Journal of Arthritis Care and Research is expected in 2011, Hochberg told listeners.

Recommendations fall into three categories, based on the available evidence: strong (“we recommend”), weak (“we suggest”), and no recommendation (“we choose not to provide guidance”).

Regarding hand OA, evidence favoring five different modalities was weak, and the benefits were modest, but there was no evidence that any of the modalities could cause harm. Therefore, a “We suggest” recommendation was given to evaluation of activities of daily living, assistive devices, heat and cold, joint protection and exercise, and splinting at the base of the thumb joint. “We had no specific evidence on type of splint,” noted Catherine Blackman, PhD, University of British Columbia in Vancouver, who presented the OA hand recommendations.

For hip and knee OA, the following earned a “we recommend” recommendation, said Carol Oatis, PT, PhD, Arcadia University, Glenside, PA, who presented these proposed guidelines:

• Aerobic land-based exercise
• Resistance land-based exercise
• Aquatic exercise
• Weight loss if overweight

Evidence for these recommendations was consistently high, although these modalities had a moderate effect on pain and function. Only a short-term benefit was seen for aquatic exercise, she said.

Weight loss was deemed of benefit for knee OA; there was no evidence for hip OA. A “we suggest” recommendation (ie, weak recommendation) was given to manual therapy in combination with exercise for hip OA, and no recommendation was forthcoming for balance exercise or tai chi for knee and hip OA. “We had no ‘do not do’ recommendations for hip and knee OA,” she said.

Only weak (“we suggest”) recommendations for knee OA were given to valgus bracing, shoe insoles, patellar taping, transcutaneous electrical nerve stimulation (TENS), acupuncture, and thermal modalities and walking aids. Of these, only acupuncture had high quality evidence, which still did not lead to a strong recommendation. Both TENS and acupuncture were “suggested” for patients with knee OA and moderate to severe pain who cannot undergo total knee arthroplasty.

Interestingly, other societies, such as EULAR and the American Academy of Orthopedic Surgeons (AAOS) do recommend valgus bracing and shoe insoles, said Kelley Fitzgerald, PT, PhD, University of Pittsburgh, who discussed these modalities.