2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee

Abstract

Objective To develop an evidence‐based guideline for the comprehensive management of osteoarthritis (OA) as a collaboration between the American College of Rheumatology (ACR) and the Arthritis Foundation, updating the 2012 ACR recommendations for the management of hand, hip, and knee OA. Methods We identified clinically relevant population, intervention, comparator, outcomes questions and critical outcomes in OA. A Literature Review Team performed a systematic literature review to summarize evidence supporting the benefits and harms of available educational, behavioral, psychosocial, physical, mind‐body, and pharmacologic therapies for OA. Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of the evidence. A Voting Panel, including rheumatologists, an internist, physical and occupational therapists, and patients, achieved consensus on the recommendations. Results Based on the available evidence, either strong or conditional recommendations were made for or against the approaches evaluated. Strong recommendations were made for exercise, weight loss in patients with knee and/or hip OA who are overweight or obese, self‐efficacy and self‐management programs, tai chi, cane use, hand orthoses for first carpometacarpal (CMC) joint OA, tibiofemoral bracing for tibiofemoral knee OA, topical nonsteroidal antiinflammatory drugs (NSAIDs) for knee OA, oral NSAIDs, and intraarticular glucocorticoid injections for knee OA. Conditional recommendations were made for balance exercises, yoga, cognitive behavioral therapy, kinesiotaping for first CMC OA, orthoses for hand joints other than the first CMC joint, patellofemoral bracing for patellofemoral knee OA, acupuncture, thermal modalities, radiofrequency ablation for knee OA, topical NSAIDs, intraarticular steroid injections and chondroitin sulfate for hand OA, topical capsaicin for knee OA, acetaminophen, duloxetine, and tramadol. Conclusion This guideline provides direction for clinicians and patients making treatment decisions for the management of OA. Clinicians and patients should engage in shared decision‐making that accounts for patients’ values, preferences, and comorbidities. These recommendations should not be used to limit or deny access to therapies.

A Randomized Clinical Trial of Prehabilitation Using Aquatic Exercise in Older Adults with Knee Osteoarthritis Undergoing Total Knee Arthroplasty

“…In a Cochrane review of 54 randomized controlled trials of land-based exercise for knee osteoarthritis, exercise has shown to reduce pain, improve physical function and quality of life immediately after treatment (31) and the 2019 American College of Rheumatology osteoarthritis guidelines strongly recommended exercise as a treatment for osteoarthritis (32). Interestingly, a study of 126 participants with knee OA and at least one morbidity found that a 20-week individualized, comorbidity adapted land-based exercise program resulted in improvement in WOMAC physical function score of 7.43 (33) while our study of 4-8 weeks of water exercise intervention saw a similar effect (WOMAC physical function score improvement of 7.6) with a much shorter intervention time.…”

Sustained Acoustic Medicine as a Non-surgical and Non-opioid Knee Osteoarthritis Treatment Option: A Health Economic Cost-effectiveness Analysis for Symptom Management 

“…(54,55) Other limitations include specialty societies and payers in making recommendations for ultrasound treatment of knee OA or lack thereof. (8,(56)(57)(58) Unfortunately, some payer coverage and utilization policies have not been updated for over 10 years, failing to account for recent, high quality evidence in establishing coverage determinations. (13,14,58) Additionally, there appears to be an issue with the use of o ce-based ultrasound devices causing harm (e.g.…”

“…(67) Costs used in the analysis were based off accepted treatment guidelines as identi ed by the American College of Rheumatology and were not prospectively captured. 8 As well, costs were assumed to be national averages and thus would vary by region of the country.…”

“…(7) Recent recommendations by the American College Rheumatology (ACR)/Arthritis Foundation for treating knee OA call for a comprehensive plan including the above therapies which may be used in sequence, again depending upon pain severity. (8) The effectiveness of ultrasound as a therapy for OA-related pain and disability has been substantiated in a number of systematic reviews and meta-analyses. (9-12) However, one of the challenges with current ultrasound delivery is that reimbursement requires administration via constant attendance by a care provider in a professional setting, generally for a short duration of time (5-10 minutes) over approximately a 30-day period.…”

Outcomes of a medical second opinion programme before knee arthroplasty: A prospective cohort study

“…Financial incentives for KA implantation and surgery plannability as well as a limited budget for the prescription of exercise therapy are mentioned (9). It has also been discussed that some patients and some physicians have negative attitudes towards conservative osteoarthritis treatment despite many guidelines with consistent evidence-based recommendations for exercise therapy, self-management programmes and weight loss in overweight patients (11,28,29). They consider osteoarthritis as fateful and later surgery as inevitable (30).…”