Latest Osteoarthritis Guidelines Address Benefits of Exercise

Abstract

The American College of Rheumatology's latest recommendations on treatment of osteoarthritis place new emphasis on early use of nonpharmacologic therapies, such as tai chi and acupuncture, and advise against use of glucosamine/chondroitin.“We placed an emphasis on non-pharmacologic treatments…. Reimbursement is one of the issues. We really wanted to put some gravitas on the evaluation of the non-pharmacologic modalities [before providers] consider pharmacologic agents,” lead author Dr. Marc C. Hochberg, head of the division of rheumatology and clinical immunology at the University of Maryland, Baltimore, said in an interview.The new recommendations, which replace those issued in 2000, are the first to be developed by a multidisciplinary panel that included geriatricians, primary care physicians, and physiatrists, along with rheumatologists (both academic and private practice), an orthopedic surgeon, and both physical and occupational therapists.Based on the strength of the evidence and using real-life patient examples, the panelists ranked each recommendation as either strong in favor of use, weak (or conditional), no recommendation, weak or conditional recommendation not to use, and strong recommendation not to use (Arthritis Care Res. 2012;64:465-74).“These are much more real-world recommendations based on patients who present for consultation and would be applicable for the provider in their office situation when they see a patient…. They're meant for primary care physicians as well as rheumatologists,” said Dr. Hochberg.For hand osteoarthritis (OA), the panel conditionally recommended evaluation of the patient's ability to perform activities of daily living, instruction in joint protection techniques, assistive devices as needed, instruction in the use of thermal modalities, and splints for patients with trapeziometacarpal joint OA. Conditional pharmacologic recommendations for hand OA include topical capsaicin, topical nonsteroidal anti-inflammatory drugs (NSAIDs), and oral NSAIDs. The panel also conditionally recommended against the use of intra-articular therapies and opioid analgesics.No strong recommendation was made for hand OA. “We only provided conditional recommendations for hand OA, which points to the relative dearth of studies in this area and the lack of good quality evidence to support treatments for it. Hand OA is an area that is in need of well-designed, large placebo-controlled and active-comparator studies,” Dr. Hochberg commented.For initial management of knee OA, the panel strongly recommended the nonpharmacologic interventions of participation in cardiovascular (aerobic) and/or resistance land-based exercise, participation in aquatic exercise, and weight loss if indicated. They conditionally recommended a long list of nonpharmacologic interventions, including participation in self-management programs, manual therapy in combination with supervised exercise, psychosocial intervention, use of medially directed patellar taping, wedged insoles, thermal agents, walking aids as needed, participation in tai chi programs, treatment with Chinese acupuncture, and transcutaneous electrical stimulation.No strong pharmacologic recommendation was made for the initial treatment of knee OA. Conditional recommendations included any of the following: acetaminophen, oral NSAIDs, topical NSAIDs, tramadol, or intra-articular corticosteroid injections. Conditional recommendations were made to not use chondroitin sulfate, glucosamine, or topical capsaicin.Strong nonpharmacologic recommendations for hip OA included participation in cardiovascular and/or resistance land-based exercise, participation in aquatic exercise, and weight loss, if indicated. Conditional nonpharmacologic recommendations included participation in self-management programs, manual therapy in combination with supervised exercise, psychosocial interventions, instruction in the use of thermal agents, and walking aids as needed.Conditional pharmacologic recommendations for hip OA include one of either acetaminophen, oral NSAIDs, tramadol, or intra-articular corticosteroid injections. The guidelines also conditionally recommend against the use of chondroitin and glucosamine for hip OA.Dr. Hochberg acknowledged that despite the panel's use of the rigorous evidence-based approach, the conditional recommendations for use of tai chi and acupuncture might prove controversial, as might the conditional recommendations against the use of intra-articular therapies for hand OA and glucosamine/chondroitin. The non-recommendation for the latter nutraceuticals was based on negative studies conducted on the products that are sold over the counter in the United States and Canada, which are different from the pharmaceutically produced preparations tested and sold in Europe, Dr. Hochberg explained.Of note, there is no strong recommendation for pharmaceutical treatment of any joint area.Dr. Hochberg disclosed that he has financial relationships with various makers of osteoarthritic products. He receives research support from the NIH. The American College of Rheumatology's latest recommendations on treatment of osteoarthritis place new emphasis on early use of nonpharmacologic therapies, such as tai chi and acupuncture, and advise against use of glucosamine/chondroitin. “We placed an emphasis on non-pharmacologic treatments…. Reimbursement is one of the issues. We really wanted to put some gravitas on the evaluation of the non-pharmacologic modalities [before providers] consider pharmacologic agents,” lead author Dr. Marc C. Hochberg, head of the division of rheumatology and clinical immunology at the University of Maryland, Baltimore, said in an interview. The new recommendations, which replace those issued in 2000, are the first to be developed by a multidisciplinary panel that included geriatricians, primary care physicians, and physiatrists, along with rheumatologists (both academic and private practice), an orthopedic surgeon, and both physical and occupational therapists. Based on the strength of the evidence and using real-life patient examples, the panelists ranked each recommendation as either strong in favor of use, weak (or conditional), no recommendation, weak or conditional recommendation not to use, and strong recommendation not to use (Arthritis Care Res. 2012;64:465-74). “These are much more real-world recommendations based on patients who present for consultation and would be applicable for the provider in their office situation when they see a patient…. They're meant for primary care physicians as well as rheumatologists,” said Dr. Hochberg. For hand osteoarthritis (OA), the panel conditionally recommended evaluation of the patient's ability to perform activities of daily living, instruction in joint protection techniques, assistive devices as needed, instruction in the use of thermal modalities, and splints for patients with trapeziometacarpal joint OA. Conditional pharmacologic recommendations for hand OA include topical capsaicin, topical nonsteroidal anti-inflammatory drugs (NSAIDs), and oral NSAIDs. The panel also conditionally recommended against the use of intra-articular therapies and opioid analgesics. No strong recommendation was made for hand OA. “We only provided conditional recommendations for hand OA, which points to the relative dearth of studies in this area and the lack of good quality evidence to support treatments for it. Hand OA is an area that is in need of well-designed, large placebo-controlled and active-comparator studies,” Dr. Hochberg commented. For initial management of knee OA, the panel strongly recommended the nonpharmacologic interventions of participation in cardiovascular (aerobic) and/or resistance land-based exercise, participation in aquatic exercise, and weight loss if indicated. They conditionally recommended a long list of nonpharmacologic interventions, including participation in self-management programs, manual therapy in combination with supervised exercise, psychosocial intervention, use of medially directed patellar taping, wedged insoles, thermal agents, walking aids as needed, participation in tai chi programs, treatment with Chinese acupuncture, and transcutaneous electrical stimulation. No strong pharmacologic recommendation was made for the initial treatment of knee OA. Conditional recommendations included any of the following: acetaminophen, oral NSAIDs, topical NSAIDs, tramadol, or intra-articular corticosteroid injections. Conditional recommendations were made to not use chondroitin sulfate, glucosamine, or topical capsaicin. Strong nonpharmacologic recommendations for hip OA included participation in cardiovascular and/or resistance land-based exercise, participation in aquatic exercise, and weight loss, if indicated. Conditional nonpharmacologic recommendations included participation in self-management programs, manual therapy in combination with supervised exercise, psychosocial interventions, instruction in the use of thermal agents, and walking aids as needed. Conditional pharmacologic recommendations for hip OA include one of either acetaminophen, oral NSAIDs, tramadol, or intra-articular corticosteroid injections. The guidelines also conditionally recommend against the use of chondroitin and glucosamine for hip OA. Dr. Hochberg acknowledged that despite the panel's use of the rigorous evidence-based approach, the conditional recommendations for use of tai chi and acupuncture might prove controversial, as might the conditional recommendations against the use of intra-articular therapies for hand OA and glucosamine/chondroitin. The non-recommendation for the latter nutraceuticals was based on negative studies conducted on the products that are sold over the counter in the United States and Canada, which are different from the pharmaceutically produced preparations tested and sold in Europe, Dr. Hochberg explained. Of note, there is no strong recommendation for pharmaceutical treatment of any joint area. Dr. Hochberg disclosed that he has financial relationships with various makers of osteoarthritic products. He receives research support from the NIH.