Systematic Review of Guidelines for the Physical Management of Osteoarthritis
Published Online: November 04, 2013
Abstract
Objective
To undertake a systematic critical appraisal of guidelines to provide a summary of recommendations for the physical management of osteoarthritis (OA).
Data Sources
The Cochrane Library, MEDLINE, CINAHL, SPORTDiscus with Full Text, Scopus, ScienceDirect, PEDro, and Google Scholar databases were searched (2000–2013) to identify all guidelines, protocols, and recommendations for the management or treatment of OA. In addition, Internet searches of all relevant arthritis organizations were undertaken. All searches were performed between July 2012 and end of April 2013. Guidelines that included only pharmacological, injection therapy, or surgical interventions were excluded. Guidelines published only in English were retrieved.
Study Selection
OA guidelines developed from evidence-based research, consensus, and/or expert opinion were retrieved. There were no restrictions on severity or site of OA, sex, or age. Nineteen guidelines were identified for evaluation.
Data Extraction
The quality of all guidelines was critically appraised using the Appraisal of Guidelines for REsearch and Evaluation II instrument. Each guideline was independently reviewed. All relevant recommendations for the physical management of OA were synthesized, graded, and ranked according to available evidence.
Data Synthesis
Seventeen guidelines with recommendations on the physical management of OA met the inclusion criteria and underwent a full critical appraisal. There were variations in the interventions, levels of evidence, and strength of recommendations across the guidelines. Forty different interventions were identified. Recommendations were graded from “strongly recommended” to “unsupported.” Exercise and education were found to be strongly recommended by most guidelines.
Conclusions
Exercise and education were key recommendations supporting the importance of rehabilitation in the physical management of OA. This critical appraisal can assist health care providers who are involved in the management of people with OA.
List of abbreviations:
AGREE II (Appraisal of Guidelines for REsearch and Evaluation II), LOE (level of evidence), MA (meta-analysis), NICE(National Institute of Clinical Excellence), OA (osteoarthritis), RCT (randomized controlled trial), SOR (strength of recommendation)
Osteoarthritis (OA) is the most common form of arthritis and is identified as one of the leading causes of pain and disability worldwide.1, 2 By the year 2020, the prevalence of OA is expected to double.3 The risk factors associated with OA include age, sex, genetics, occupation, past injuries, and obesity.4 Hip and knee pain associated with OA often leads to inactivity and loss of mobility, resulting in deconditioning, weight gain, loss of independence, and decreased quality of life.5 There are substantial personal and societal costs associated with OA.1 Personal costs may include the inability to participate in work, sport, hobbies, or caring for others because of pain. Societal costs may include visits to the doctor, medication costs, and assistance equipment. Joint replacement is an effective intervention to alleviate pain and improve quality of life for those with advanced OA. However, despite a growing number of joint replacements undertaken each year, many people are still placed on a waiting list often for a considerable time.6, 7 To reduce the burden of OA, safe and effective health services, involving a range of nonsurgical treatments options, are required. These services must be effective with respect to intervention and cost as well as meet the affected person's needs.
Evidence-based clinical guidelines are developed to assist the practitioner, patient, and/or policymaker to make informed clinical decisions.8 Guidelines are valuable resources that play an integral role in improving treatment and management of various health conditions. They can be used by health practitioners and people suffering with OA seeking information to determine how their disease can best be managed. A preliminary search of the literature identified many international guidelines developed for the management of OA. The preliminary search identified that the guidelines included evidence and recommendations for a number of interventions including pharmacological, nonpharmacological, surgical, and injection therapies, physical management, and lifestyle changes for the management of OA. However, because of adverse effects, patients and health care providers may pursue physical management options rather than surgery, pharmacology, or injection-based therapy. A number of guidelines highly recommend exercise as an intervention for OA. However, Gill and McBurney9 in a recent systematic review concluded that while exercise interventions were beneficial for those people awaiting hip replacement, this was not the case for those awaiting knee replacement. It was also noted that there were variations across the guidelines in the recommendations made. Currently, there is no critical appraisal of international guidelines that has synthesized, graded, and comprehensively presented all the relevant recommendations for the physical management of OA. Therefore, a systematic critical appraisal of international OA guidelines was undertaken to comprehensively present all the relevant evidence-based recommendations on the physical management of OA.
Methods
Electronic database searches
A systematic literature search was performed. The Cochrane Library, MEDLINE, CINAHL, SPORTDiscus with Full Text, Scopus, ScienceDirect, PEDro, and Google Scholar databases were searched (2000–2013) to identify all guidelines, protocols, and recommendations for the management or treatment of OA. An experienced health science librarian assisted with the development of the search strategy. MEDLINE, CINAHL, and SPORTDiscus with Full Text databases were searched using key word proximity searches to identify guidelines or recommendations for the management of OA ([osteoarthrit* N5 guideline*] OR [osteoarthrit* N5 evidence*] OR [osteoarthrit* N5 recommend] OR [osteoarthrit* N5 best*]). Scopus and ScienceDirect databases used the same proximity search logic but with the appropriate syntax. PEDro and The Cochrane Libraries were searched using ([osteoarthriti* and guideline] AND [osteoarthriti* and protocol]). A manual search was conducted on reference lists found in relevant guidelines, systematic reviews, and meta-analysis (MA), which returned additional resources.
Internet searches
A thorough Internet search was conducted to identify international arthritis organizations and guideline clearinghouses. The names of organizations were also found during the process of reviewing guidelines and recommendations identified during the electronic database searches. The websites of these organizations were reviewed, and any relevant guidelines were included. A list of these organizations is given in appendix 1.
Eligibility criteria
The primary source of literature for this review was recommended guidelines developed from evidence-based research, consensus, and/or expert opinion. Guidelines that included only pharmacological therapy, injection therapy, or surgical interventions were excluded. There were no restrictions on severity or site of OA, sex, or age. The search was confined to articles published in English and available electronically between the period of 2000 and end of April 2013. Animal-based studies were not included. If there had been updates to guidelines, only the latest version of the guideline was reviewed.
Selection of guidelines
All titles and/or abstracts were reviewed to determine whether they met the eligibility criteria of this critical appraisal. When citations met the criteria, the full-text articles were retrieved and reviewed. Nineteen guidelines were identified for evaluation. The details of results returned are illustrated in figure 1.
Fig 1
Results of the search strategy for international guidelines that contain recommendations for the physical management of OA.
Quality appraisal
The Appraisal of Guidelines for REsearch and Evaluation II (AGREE II) tool was used to critique the guidelines.10 AGREE II is a guideline quality appraisal tool that has been found to have high construct validity.11 It consists of 23 items arranged into 6 domains: scope and purpose (3 items), stakeholder involvement (3 items), rigor of development (8 items), clarity of presentation (3 items), applicability (4 items), and editorial independence (2 items). Each item is scored between strongly agree (4) and strongly disagree (1). The items scores within a domain were then added and calculated as a percentage. A domain was determined to be effectively addressed if its score was ≥60%, as has been used in other critical appraisals of arthritis guidelines.12, 13 Before a full critique of the guidelines, all members of the research team undertook a training review process to ensure consistency and reliability in grading. All guidelines were then reviewed independently to ensure sufficient reliability as suggested by previous authors.11 Differences in scoring were resolved through discussions and consensus between all 4 authors. Where guidelines were not clear, the identified author was contacted for clarification if possible. Finally, based on their overall domain scores, the guidelines received an overall assessment from the research team of “recommended,” “recommended with modifications,” or “not recommended.”10
Synthesis of recommendations
Following the AGREE II appraisal of the guidelines, recommendations that were specific to the physical management of OA were identified for data extraction. This analysis involved categorizing recommendations by intervention (eg, exercise, education) with their associated level of evidence (LOE) and strength of recommendation (SOR). For the purposes of this review, the interventions have been grouped for similarity into 12 interventions. For each guideline recommendation, the associated interventions were scored on an individual weighting scale from +4 to −4 (table 1) on the basis of their LOE and SOR values. The levels of the scale were derived from LOE and SOR values found in each guideline. There was variation in how individual guidelines provided grading scales for both LOE and SOR. A list of individual guideline scales is provided in appendix 2. Guidelines based on MA, systematic reviews, and definitive randomized controlled trials (RCTs) that were strongly recommended were weighted highest (individual weighting=4), whereas expert opinion with a weak SOR was weighted low (individual weighting=1). Where a guideline provided a recommendation against an intervention, this was weighted negatively (individual weighting=−1 to −4). There were 2 exceptions to this process. First, the recommendations from the National Health and Medical Research Council guideline14 were already graded on a 4-point scale on the basis of LOE and SOR. Second, the National Institute of Clinical Excellence (NICE) guideline1 provided extensive level I evidence (MA, systematic review, RCTs) throughout the article. However, it did not present recommendations with an LOE or SOR. Because of the support of a high LOE, we have graded each of the NICE recommendations with a weighting of 4.
NOTE. Because of the variability in LOE scales throughout the guidelines, we have standardized LOE to Roman numerals wherever possible.
∗A full list of individual guideline grading systems for LOE and SORs is provided in appendix 2.
†Where there was an LOE or SOR against an intervention, a negative score was given.
Overall recommendation scores of interventions were determined by the median value of the specific intervention's individual weightings. Table 2 illustrates how the overall intervention recommendations were then grouped on the basis of their median score into strongly recommended, recommended, recommended with caution, and unsupported. For example, knee bracing is recommended by 5 guidelines with weighted scores of 4, 3, 4, 4, and 2, resulting in a median score of 4 and grading of strongly recommended.
| Median Value of Intervention | Overall Recommendation Level |
|---|---|
| 3–4 | Strongly recommended |
| 2–2.9 | Recommended |
| 1.1–1.9 | Recommended with caution |
| 0–1 | Unsupported |
| (−1 to −4) to 0 | Not recommended |
Results
The systematic literature search yielded 19 guidelines. One15 was excluded because there were no stated methods for evidence gathering or developing recommendations, recommendations were not clear, and no method for grading recommendations was stated. One16 was excluded because no conclusive recommendations were provided for the physical management of glenohumeral joint OA. This resulted in 17 guidelines available for full data extraction.
AGREE II appraisal results
Table 3 lists the 17 guidelines' AGREE II domain scores with an overall quality assessment rating and a comment on weaknesses of the specific guideline. There was variability in the domains that were effectively addressed by the guidelines. Of the 17 guidelines, 2 effectively addressed 4 of the 6 AGREE II domains,14, 17 9 effectively addressed 3 domains,18, 19, 20, 21, 22, 23, 24, 25, 26 and 6 effectively addressed at least 2 domains.1, 5, 27, 28, 29, 30 Stakeholder involvement was effectively addressed by 6 guidelines,1, 14, 17, 18, 26, 28 editorial independence was effectively addressed by 1 guideline,22 and applicability was not effectively addressed in any guideline. Six guidelines can be recommended without modifications.14, 17, 20, 24, 25, 26 Eleven guidelines1, 5, 18, 19, 21, 22, 23, 27, 28, 29, 30 were recommended with modifications.
| Organization (Year) | Scope and Purpose | Stakeholder Involvement | Rigor of Development | Clarity of Presentation | Applicability | Editorial Independence | Overall Quality Assessment Rating • Comment |
|---|---|---|---|---|---|---|---|
| AAOS17(2008) | 94 | 67 | 96 | 100 | 0 | 58 | Recommended |
| ACR19 (2012) | 89 | 56 | 79 | 83 | 4 | 8 | Recommended with modifications
|
| BSR21 (2005) | 83 | 44 | 63 | 67 | 0 | 58 | Recommended with modifications
|
| EULAR26(2013) | 89 | 83 | 56 | 100 | 8 | 58 | Recommended |
| EULAR24(2007) | 78 | 33 | 60 | 78 | 21 | 8 | Recommended |
| EULAR23(2005) | 83 | 6 | 73 | 72 | 0 | 8 | Recommended with modifications
|
| EULAR20(2003) | 83 | 28 | 67 | 83 | 4 | 8 | Recommended |
| EULAR29(2001) | 83 | 39 | 56 | 83 | 4 | 8 | Recommended with modifications
|
| NHMRC14(2009) | 100 | 61 | 88 | 83 | 29 | 58 | Recommended |
| NICE1 (2008) | 72 | 100 | 54 | 50 | 42 | 33 | Recommended with modifications
|
| OARSI25(2008) | 89 | 56 | 94 | 89 | 21 | 58 | Recommended |
| Ottawa5(2012) | 83 | 50 | 71 | 39 | 25 | 50 | Recommended with modifications
|
| Ottawa27(2011) | 94 | 67 | 65 | 56 | 0 | 8 | Recommended with modifications
|
| Ottawa18(2011) | 94 | 50 | 67 | 39 | 8 | 0 | Recommended with modifications
|
| Ottawa28(2005) | 83 | 61 | 52 | 44 | 0 | 8 | Recommended with modifications
|
| KNGF30(2011) | 89 | 33 | 50 | 83 | 4 | 8 | Recommended with modifications
|
| TLAR22(2012) | 89 | 39 | 58 | 83 | 0 | 100 | Recommended with modifications
|
NOTE. Values represent %.
Abbreviations: AAOS, American Academy of Orthopaedic Surgeons; ACR, American College of Rheumatology; BSR, British Society for Rheumatology; EULAR, European League Against Rheumatism; KNGF, Royal Dutch Society for Physical Therapy; NHMRC, National Health and Medical Research Council; OARSI, Osteoarthritis Research Society International; Ottawa, Ottawa Panel; TLAR, Turkish League Against Rheumatism.
Interventions
Forty interventions were identified across the guidelines. Table 4 lists the grouped interventions covered by the 17 guidelines. The grouped interventions are listed in descending order with the number of guidelines that recommended them: exercise (16 guidelines), education (13 guidelines), equipment (11 guidelines), weight loss/diet (11 guidelines), taping, heat/ice (9 guidelines), electrical-based therapy (7 guidelines), self-management (7 guidelines), acupuncture (5 guidelines), manual therapy (5 guidelines), psychosocial interventions (5 guidelines), and balneotherapy/spa therapy (2 guidelines).
| Guideline | Grouped Interventions | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Organization: (Date) | Exercise | Education | Equipment | Weight Loss/Diet | Taping, Heat/Ice | Electrical-Based Therapy | Self- Management | Acupuncture | Manual Therapy | Psychosocial Interventions | Balneotherapy/Spa |
| AAOS17 (2008) | X | X | X | X | X | X | |||||
| ACR19 (2012) | X | X | X | X | X | X | X | X | X | X | |
| BSR21 (2005) | X | X | X | ||||||||
| EULAR26(2013) | X | X | X | X | X | ||||||
| EULAR24(2007) | X | X | X | X | X | ||||||
| EULAR23(2005) | X | X | X | X | |||||||
| EULAR20(2003) | X | X | X | X | |||||||
| EULAR29(2001) | X | X | X | X | X | X | X | ||||
| NHMRC14(2009) | X | X | X | X | X | X | X | X | X | ||
| NICE1 (2008) | X | X | X | X | X | X | X | X | X | ||
| OARSI25(2008) | X | X | X | X | X | X | X | X | X | ||
| Ottawa5 (2012) | X | ||||||||||
| Ottawa27(2011) | X | X | |||||||||
| Ottawa18(2011) | X | ||||||||||
| Ottawa28(2005) | X | X | |||||||||
| KNGF30 (2011) | X | X | X | X | X | X | |||||
| TLAR22 (2012) | X | X | X | X | X | X | X | X | |||
Abbreviations: AAOS, American Academy of Orthopaedic Surgeons; ACR, American College of Rheumatology; BSR, British Society for Rheumatology; EULAR, European League Against Rheumatism; KNGF, Royal Dutch Society for Physical Therapy; NHMRC, National Health and Medical Research Council; OARSI, Osteoarthritis Research Society International; Ottawa, Ottawa Panel; TLAR, Turkish League Against Rheumatism.
Balneotherapy refers to the passive relaxation in mineral or thermal water, whereas hydrotherapy refers to therapeutic methods (eg, exercise) that take advantage of the physical properties of water. All guidelines except the NICE guideline stated grading scales for their recommendations, using either LOE or SOR or both. The grading criteria used by guideline developers varied among guidelines.
Guideline intervention recommendations
The median weighting of the specific interventions across guidelines was calculated and then given an overall recommendation. These are presented as strongly recommended (table 5), recommended (table 6), recommended with caution (table 7), unsupported (table 8), and not recommended (table 9).
| Intervention | Guideline (Date) | LOE | SOR | Individual Weighting | Median (Overall Recommendation) |
|---|---|---|---|---|---|
| Exercise | |||||
| Combined exercise or unspecified type | AAOS17(2008) | V | C | 1 | 3 (strongly recommended) |
| BSR21(2005) | IV | D | 1 | ||
| EULAR26(2013) | Ia | 89% | 4 | ||
| EULAR23(2005) | NS | 72% | 2 | ||
| EULAR20(2003) | 1B | A | 4 | ||
| EULAR29(2001) | IB | A | 4 | ||
| Ottawa5(2012) | 1 | A–D | 3 | ||
| Ottawa27(2011) | 1 | A–D | 3 | ||
| Ottawa28(2005) | 1 | A–C | 3 | ||
| KNGF30(2011) | I–II | NS | 3 | ||
| TLAR22(2012) | 1a, 1b | 97% | 4 | ||
| Aerobic | AAOS17(2008) | I | A | 4 | 3 (strongly recommended) |
| ACR19(2012) | NS | Strongly recommended | 2 | ||
| BSR21(2005) | Ib–IV | A–C | 4, 1 | ||
| EULAR26(2013) | Ia | NS | 3 | ||
| NICE1(2008) | NS | NS | 4 | ||
| OARSI25(2008) | Ia–IV | 96% | 4, 2 | ||
| Ottawa5(2012) | 1 | A–C | 3 | ||
| Ottawa28(2005) | 1 | A–C | 3 | ||
| Strengthening | AAOS17(2008) | II | B | 4 | 3 (strongly recommended) |
| ACR19(2012) | NS | Strongly recommended | 2 | ||
| BSR21(2005) | Ib–IV | A–C | 4, 1 | ||
| EULAR26(2013) | Ia | NS | 3 | ||
| EULAR24(2007) | IV | C | 1 | ||
| EULAR29(2001) | IB | A | 4 | ||
| NICE1(2008) | NS | NS | 4 | ||
| OARSI25(2008) | Ia–IV | 96% | 4, 2 | ||
| Ottawa28(2005) | 1 | A–C | 3 | ||
| Aquatic/hydrotherapy | ACR19(2012) | NS | Strongly recommended | 2 | 3 (strongly recommended) |
| NHMRC14(2009) | NS | C | 2 | ||
| NICE1(2008) | NS | NS | 4 | ||
| OARSI25(2008) | Ib | 96% | 4 | ||
| Ottawa28(2005) | 1 | A–C | 3 | ||
| KNGF30(2011) | I | NS | 3 | ||
| Land-based | NHMRC14(2009) | NS | B | 3 | 3 (strongly recommended) |
| Yoga | Ottawa28(2005) | 1 | A–C | 3 | 3 (strongly recommended) |
| Electrical-based therapy | |||||
| Transcutaneous electrical nerve stimulation | ACR19(2012) | NS | Conditionally recommended | 1 | 3 (strongly recommended) |
| NHMRC14(2009) | NS | C | 2 | ||
| NICE1(2008) | NS | NS | 4 | ||
| OARSI25(2008) | 1a | 58% | 4 | ||
| KNGF30(2011) | IV | NS | 1 | ||
| TLAR22(2012) | Ib | 96% | 4 | ||
| Equipment Knee bracing | EULAR20(2003) | 1B | B | 4 | 4 (strongly recommended) |
| NHMRC14(2009) | NS | B | 3 | ||
| NICE1(2008) | NS | NS | 4 | ||
| OARSI25(2008) | Ia | 76% | 4 | ||
| TLAR22(2012) | III, Ia | 86% | 2 | ||
| Appropriate footwear | EULAR26(2013) | Ib | 87% | 4 | 3 (strongly recommended) |
| NICE1(2008) | NS | NS | 4 | ||
| OARSI25(2008) | IV | 77% | 2 | ||
| TLAR22(2012) | IV | 86% | 2 | ||
| Wedged insoles | AAOS17(2008) | II | B | 4 | 4 (strongly recommended) |
| ACR19(2012) | NS | Conditionally recommended | 1 | ||
| EULAR26(2013) | Ib | 80% | −4 | ||
| EULAR23(2005) | IV | 61.7% | 2 | ||
| EULAR20(2003) | 1B | B | 4 | ||
| EULAR29(2001) | IIA | B | 4 | ||
| NHMRC14(2009) | NS | B | 3 | ||
| NICE1(2008) | NS | NS | 4 | ||
| OARSI25(2008) | Ia | 77% | 4 | ||
| TLAR22(2012) | Ib | 86% | 4 | ||
| Education | |||||
| Education type unspecified | AAOS17(2008) | II | B | 4 | 4 (strongly recommended) |
| ACR19(2012) | NS | Conditionally recommended | 1 | ||
| BSR21(2005) | IV | D | 1 | ||
| EULAR24(2007) | IV | 59% | 1 | ||
| EULAR23(2005) | Ib | 72% | 4 | ||
| EULAR20(2003) | 1A | A | 4 | ||
| EULAR29(2001) | IA | A | 4 | ||
| NICE1(2008) | NS | NS | 4 | ||
| OARSI25(2008) | Ia | 97% | 4 | ||
| KNGF30(2011) | II | NS | 3 | ||
| TLAR22(2012) | Ib, III, IV | 96%, 94% | 4 | ||
| Pain management program | Ottawa18(2011) | 1 | A–D | 3 | 3 (strongly recommended) |
| Individual education | EULAR26(2013) | Ia | 84% | 4 | 3.5 (strongly recommended) |
| Ottawa18(2011) | 1 | A–D | 3 | ||
| Group education | Ottawa18(2011) | 1 | A–D | 3 | 3 (strongly recommended) |
| Preoperative education | Ottawa18(2011) | 1 | A–D | 3 | 3 (strongly recommended) |
| Collective information | Ottawa18(2011) | 1 | A–D | 3 | 3 (strongly recommended) |
| Manual therapy | |||||
| Manual therapy with supervised exercise | ACR19(2012) | NS | Conditionally recommended | 1 | 3 (strongly recommended) |
| Ottawa28(2005) | I | A–C | 3 | ||
| KNGF30(2011) | II | NS | 3 | ||
| Manipulation and stretching | NICE1(2008) | NS | NS | 4 | 4 (strongly recommended) |
| Diet and weight loss | |||||
| Weight loss | AAOS17(2008) | I | A | 4 | 4 (strongly recommended) |
| ACR19(2012) | NS | Strongly recommended | 2 | ||
| EULAR26(2013) | Ia–III | 98% | 4–2 | ||
| EULAR23(2005) | III | 68% | 2 | ||
| EULAR20(2003) | 1B | B | 4 | ||
| EULAR29(2001) | IB | B | 4 | ||
| NHMRC14(2009) | NS | B | 3 | ||
| NICE1(2008) | NS | NS | 4 | ||
| OARSI25(2008) | Ia | 96% | 4 | ||
| TLAR22(2012) | III | NS | 1 | ||
| Diet | Ottawa27(2011) | I | A–D | 3 | 3 (strongly recommended) |
| Combinations of diet, physical activity, and social cognitive theory | Ottawa27(2011) | I | A–D | 3 | 3 (strongly recommended) |
| Self-management and psychosocial-based therapy | |||||
| Self-management | AAOS17(2008) | II | B | 4 | 3 (strongly recommended) |
| ACR19(2012) | NS | Conditionally recommended | 1 | ||
| NHMRC14(2009) | NS | C | 1 | ||
| NICE1(2008) | NS | N/S | 4 | ||
| OARSI25(2008) | IV | 97% | 2 | ||
| Ottawa18(2011) | I | C–D | 3 | ||
| KNGF30(2011) | II | NS | 3 | ||
| Balneotherapy/spa | |||||
| Balneotherapy | TLAR22(2012) | Ia, Ib, III | 91% | 4 | 4 (strongly recommended) |
| Spa | EULAR29(2001) | IB | C | 3 | 3 (strongly recommended) |
Abbreviations: AAOS, American Academy of Orthopaedic Surgeons; ACR, American College of Rheumatology; BSR, British Society for Rheumatology; EULAR, European League Against Rheumatism; KNGF, Royal Dutch Society for Physical Therapy; NHMRC, National Health and Medical Research Council; NS, not stated; OARSI, Osteoarthritis Research Society International; TLAR, Turkish League Against Rheumatism.
∗A full list of individual guideline grading systems for LOE and SORs is provided in appendix 2.
| Intervention | Guideline (Date) | LOE | SOR | Individual Weighting | Median (Overall Recommendation) |
|---|---|---|---|---|---|
| Exercise | |||||
| Tai chi | ACR19(2012) | NS | Conditionally recommended | 1 | 2 (recommended) |
| NHMRC14(2009) | NS | C | 2 | ||
| Ottawa28(2005) | I | A–C | 3 | ||
| Electrical-based therapy | |||||
| Electrical stimulation | NHMRC14(2009) | NS | B | 3 | 2 (recommended) |
| KNGF30(2011) | III | NS | −1 | ||
| TLAR22(2012) | NS | 88% | 2 | ||
| Equipment | |||||
| Devices to assist with activities of daily living | ACR19(2012) | NS | Conditionally recommended | 1 | 2.5 (recommended) |
| NICE1(2008) | NS | NS | 4 | ||
| Walking aids | ACR19(2012) | NS | Conditionally recommended | 1 | 2 (recommended) |
| EULAR26(2013) | III | 89% | 2 | ||
| EULAR23(2005) | IV | 61% | 2 | ||
| NICE1(2008) | NS | NS | 4 | ||
| OARSI25(2008) | IV | 90% | 2 | ||
| TLAR22(2012) | Ib | 96% | 4 | ||
| Acupuncture | NHMRC14(2009) | NS | C | 2 | 2 (recommended) |
| OARSI25(2008) | Ia | 59% | 3 | ||
| TLAR22(2012) | NS | 93% | 2 | ||
| Manual therapy | |||||
| Multimodal physical therapy | NHMRC14(2009) | NS | C | 2 | 2 (recommended) |
| Taping | AAOS17(2008) | II | B | 4 | 2.5 (recommended) |
| ACR19(2012) | NS | Conditionally recommended | 1 | ||
| EULAR29(2001) | Ib | B | 4 | ||
| NHMRC14(2009) | NS | D | 1 | ||
| KNGF30(2011) | II | NS | 3 | ||
| TLAR22(2012) | III | 86% | 2 | ||
| Thermal-based therapy | ACR19(2012) | NS | Conditionally recommended | 1 | 2 (recommended) |
| EULAR24(2007) | IV | 77% | 2 | ||
| NHMRC14(2009) | NS | C | 2 | ||
| NICE1(2008) | NS | NS | 4 | ||
| OARSI25(2008) | Ia | 64% | 4 | ||
| KNGF30(2011) | IV | NS | 1 | ||
| TLAR22(2012) | Ib | 86% | 4 | ||
| Self-management and psychosocial-based therapy | |||||
| Adherence strategies | BSR21(2005) | IV | D | 1 | 2.5 (recommended) |
| OARSI25(2008) | Ib | 97% | 4 | ||
| Telephone support | AAOS17(2008) | IV | C | 1 | 2.5 (recommended) |
| EULAR29(2001) | Ib | B | 4 | ||
| NHMRC14(2009) | NS | D | 1 | ||
| OARSI25(2008) | Ia, IV | 66%, 66% | 4, 2 | ||
| Ottawa18(2011) | I | C–D | 3 |
Abbreviations: AAOS, American Academy of Orthopaedic Surgeons; ACR, American College of Rheumatology; BSR, British Society for Rheumatology; EULAR, European League Against Rheumatism; KNGF, Royal Dutch Society for Physical Therapy; NHMRC, National Health and Medical Research Council; NS, not stated; OARSI, Osteoarthritis Research Society International; TLAR, Turkish League Against Rheumatism.
∗A full list of individual guideline grading systems for LOE and SORs is provided in appendix 2.
| Intervention | Guideline (Date) | LOE | SOR | Individual Weighting | Median (Overall Recommendation) |
|---|---|---|---|---|---|
| Electrical-based therapy | |||||
| Ultrasound | EULAR24(2007) | IV | 25% | 1 | 1.5 (recommended with caution) |
| NHMRC14(2009) | NS | C | 2 | ||
| KNGF30(2011) | II | NS | −3 | ||
| TLAR22 (2012) | Ia, Ib, III | 95% | 4 | ||
| Equipment | |||||
| Hand splints | ACR19 (2012) | NS | Conditionally recommended | 1 | 1.5 (recommended with caution) |
| EULAR24(2007) | IV | 67% | 2 |
Abbreviations: ACR, American College of Rheumatology; EULAR, European League Against Rheumatism; KNGF, Royal Dutch Society for Physical Therapy; NHMRC, National Health and Medical Research Council; NS, not stated; TLAR, Turkish League Against Rheumatism.
∗A full list of individual guideline grading systems for LOE and SORs is provided in appendix 2.
| Intervention | Guideline (Date) | LOE | SOR | Individual Weighting | Median (Overall Recommendation) |
|---|---|---|---|---|---|
| Electrical-based therapy | |||||
| Laser therapy | NHMRC14(2009) | NS | D | 1 | 0 (unsupported) |
| KNGF30(2011) | IV | NS | −1 | ||
| Equipment | |||||
| Magnetic bracelets | NHMRC14(2009) | NS | D | 1 | 1 (unsupported) |
| Acupuncture | |||||
| Chinese acupuncture | ACR19(2012) | NS | Conditionally recommended | 1 | 1 (unsupported) |
| Manual therapy | |||||
| Massage therapy | NHMRC14(2009) | NS | D | 1 | 0 (unsupported) |
| KNGF30(2011) | II | NS | −1 | ||
| Self-management and psychosocial-based therapy | |||||
| Psychosocial interventions | ACR19(2012) | NS | Conditionally recommended | 1 | 1 (unsupported) |
| Cognitive behavior therapy (CBT) | NHMRC14(2009) | NS | D | 1 | 1 (unsupported) |
Abbreviations: ACR, American College of Rheumatology; KNGF, Royal Dutch Society for Physical Therapy; NHMRC, National Health and Medical Research Council; NS, not stated.
∗A full list of individual guideline grading systems for LOE and SORs is provided in appendix 2.
| Intervention | Guideline (Date) | LOE | SOR | Individual Weighting | Median (Overall Recommendation) |
|---|---|---|---|---|---|
| Acupuncture | |||||
| Electroacupuncture | NICE1 (2008) | NS | NS | −4 | −4 (not recommended) |
Abbreviation: NS, not stated.
Strongly recommended interventions included unspecified types of education (n=11, where n=recommended by number of guidelines), combined modalities of exercise or exercise of an unspecified type (n=11), wedged insoles for knee OA (n=10), weight loss (n=10), strengthening exercise (n=9), aerobic exercise (n=8), self-management (n=7), aquatic therapy/hydrotherapy (n=6), transcutaneous electrical nerve stimulation (n=6), knee bracing for knee OA (n=5), and appropriate footwear (n=4). Yoga, manual therapy with supervised exercise, manipulation and stretching, land-based exercise, and balneotherapy/spa therapies were also graded as strongly recommended interventions. However, only 3 or fewer guidelines provided recommendations for each of these interventions. Extensive research in regard to specific forms of education and diet strategies was described by 2 of the Ottawa Panel guidelines,18, 27 warranting their interventions to be strongly recommended. With respect to exercise, there were few studies that investigated individualized or tailored exercise; however, 9 guidelines1, 14, 20, 21, 22, 23, 24, 26, 29 indicated that this should be an important consideration when prescribing exercise.
Recommended interventions included thermal-based therapy (n=7), taping (n=6), walking aids (n=6), and telephone support (n=5). Tai chi, electrical stimulation, devices to assist with activities of daily living, acupuncture, multimodal physical therapy, and adherence strategies were also graded as recommended interventions. However, only 3 or fewer guidelines provided recommendations for each of these interventions.
Two interventions—ultrasound and hand splints—were recommended with caution.
Interventions reported as unsupported recommendations were laser therapy, magnetic bracelets, Chinese acupuncture, massage therapy, psychosocial interventions, and cognitive behavioral therapy.
Discussion
This review is the first published critical appraisal of guidelines for the physical management of OA. Of the 19 guidelines that we identified, 2 were excluded. First, the South Africa Arthritis Foundation guideline15 was not included because recommendations were not clearly stated. Second, the recommendations from the American Academy of Orthopaedic Surgeons glenohumeral OA guideline16 were not included because the focus of the guideline was surgical and pharmacological, with no conclusive recommendations provided for the physical management of OA. It was also noted that there were no allied health members (physiotherapists or occupational therapists) on the guideline development group. The group consisted entirely of medical doctors. In the future, patients with glenohumeral OA may be better served if the working group included individuals from all relevant health professional groups.
The AGREE II instrument was used to assess the methodological quality of the remaining 17 guidelines. When reviewing the AGREE II domain scores, the authors chose to use 60% as the value that represented adequate coverage of the criteria in a particular domain. The same approach was also used in other critical appraisals of arthritis guidelines.12, 13This allowed comparisons of the domains among the 17 guidelines and recommendations to be made on the areas that could be improved in the future development of guidelines. In this appraisal, the domains of scope and purpose, rigor of development, and clarity of presentation were addressed effectively by the majority of the guidelines. However, there were 3 domains that were consistently weak or unfulfilled by most guidelines: stakeholder involvement, applicability, and editorial independence. On reviewing previous appraisals on clinical practice guidelines, it became apparent that the same 3 domains have consistently scored poorly.12, 31, 32 While AGREE II scores have no bearing on the actual content of the recommendations, strong AGREE II scores add to the credibility of the recommendations.
Stakeholder involvement was adequately addressed by only 6 of the 17 guidelines, and improvement is needed within this domain. It requires the inclusion of all relevant information pertaining to the authors involved, target users clearly identified, and the views of the target population considered when developing guidelines. Guyatt and Rennie33 reported that the patient's values need to be considered when developing evidence-based literature. A failure in doing so is likely to overlook the person's lived experience of OA and what is important to him/her. The applicability domain addresses resource implications, facilitators, and barriers as well as advice on the implementation of the recommendation. None of the guidelines fulfilled the criteria for this domain. These elements play a role in decision making for the consumer, and these should be addressed within the guideline. Editorial independence adds to the rigor of the guideline. Only 1 guideline fulfilled this criterion. Guideline developers are required to declare the funding body and any competing interests. However, it is important that authors not only declare the funding body and competing interests but also clearly state editorial independence. When this is omitted, the reader is unsure whether there is actually a conflict of interest or whether it was simply not mentioned. While this may be taken for granted, it is an important statement that adds to the rigor of the guideline. Improving all these areas of guideline development will allow the consumer to have more confidence in the recommendations made within the guideline.
The method used to determine our overall combined intervention recommendations is novel and untested. We calculated a median score in an attempt to provide a balance on individual guideline's LOE and SOR. The variability across guidelines made any attempt at aggregating recommendations difficult. It is also important to note that while some interventions were strongly recommended, some were based on only 1 or 2 guidelines. Balneotherapy was based on 2 guidelines,22, 29 while land-based exercise,14 yoga,28 and diet18 were based on only 1 guideline. In comparison, other intervention recommendations were supported by many guidelines and therefore provide greater confidence in recommending that intervention.
There were some inconsistencies found among the guidelines. Peter et al30 specifically recommended not to use massage therapy, electrical stimulation, laser therapy, and ultrasound, while ultrasound was recommended by Brand,14Tuncer,22 Zhang24 and colleagues. Electrical stimulation was recommended by Brand14 and Tuncer,22 and massage therapy and laser therapy received a recommendation based on expert opinion.14 Consumers of evidence-based literature should be aware that there may be conflicting evidence among the research. This critical appraisal has assisted the user by identifying these inconsistencies and by providing a balanced interpretation.
The Ottawa group's 4 guidelines,5, 18, 27, 28 while very comprehensive, failed to provide specific recommendations for the management of OA. The group provided extensive evidence of the research. However, the articles were presented in a population, intervention, comparator, outcome, and time frame format for different comparisons of interventions, making it difficult for consumers to take recommendations from the article. The Ottawa panel was contacted and responded to questions surrounding the usability of the recommendations. The panel replied that a Cochrane Collaboration methodology was used and directed us to an Arthritis Society of Canada website. The Ottawa group report on highly relevant information concerning the physical management of OA. However, it would assist the guideline user if the group synthesized the data and presented key recommendations in an easily identifiable summarized box or grouped together in 1 section.
The NICE guidelines are very comprehensive, with extensive evidence supporting the use of nonpharmacological interventions. The 3 core recommendations from the guidelines were for strength and aerobic fitness, education, and weight loss if overweight. However, there are several user issues with the NICE guidelines. The guidelines provided evidence statements in tables throughout the guidelines. However, it did not grade the evidence; instead, it referred the reader to an online link. Unfortunately, the webpage was no longer available. After corresponding with the author, we were informed that their recommendations were no longer graded and we were advised to use the language in the recommendation as a guide. Although they provided strong evidence, without grading the LOEs and SORs it was difficult to interpret the recommendations. The authors have endeavored to use a consistent methodology when grading the NICE guideline recommendations. While it is not mandatory to use a grading system for the SORs, it provides the reader with valuable information. Finally, the layout of the NICE recommendations was very difficult to follow. The guidelines provided 36 recommendations (18 nonpharmacological recommendations). These were dispersed throughout the document, making it difficult to locate all the recommendations. It would assist the reader if the recommendations were presented in an easily identifiable box summarizing the recommendations or presenting them grouped together at the beginning of the document.
Exercise and education were found to be among the strongest interventions recommended throughout the guidelines. While the exercise recommendations ranged from very specific (aerobic, strength training, hydrotherapy) to very general (exercise of unspecified type), the message was clear that exercise in all its forms is strongly recommended for OA, most specifically for knee OA. The important benefits of exercise include an improvement in pain and function, which are the main complaints reported by OA sufferers. Exercise is a low-cost option in the management of OA, which makes it accessible to all OA sufferers. Education was also considered a strong recommendation. Education was found to reduce pain, increase coping skills, and result in fewer visits to primary care practitioners in knee OA.5, 20, 29 In addition, although the supporting evidence concerning tailored exercises was sparse, the consensus from 9 guidelines recommended prescribing individualized patient exercise and education and these are key components of rehabilitation.
Study limitations
This critical appraisal has 2 key limitations. First, a new grading scale to grade the overall strength of each recommendation was developed. This was a nonstandardized grading system and requires further testing. Second, guidelines published only in English were reviewed, leading to a potential publication bias. This criterion may misrepresent the amount of research that has been conducted on the physical management of OA globally.
Conclusions
The objective of this appraisal was to review the available guidelines and present the treatment recommendations for the physical management of OA in a format that was useful to the user. Throughout the research, there is strong evidence to support aspects of the use of exercise, electrical-based therapy, equipment, education, diet and weight loss, manual therapy, and self-management. Laser therapy, magnetic bracelets, Chinese acupuncture, massage therapy, aspects of psychosocial-based therapy, and electroacupuncture were either unsupported or not recommended. With the prevalence of OA expected to double by 2020 and the personal and societal costs associated with OA being substantial, it is important to establish the best strategy to manage and treat OA. Because exercise and education were found to be among the strongest recommendations within the guidelines and can be relatively cost-effective to provide, there is an opportunity for those engaged in rehabilitation to move into a leading role in the management of OA.
In this critical appraisal we have taken a unique approach. Not only have we appraised the quality of the guidelines but also synthesized, graded, and comprehensively presented all the relevant recommendations for the physical management of OA. It is hoped that this will inform health care providers on the best evidence interventions available for the physical management of OA.
| Organization Name |
|---|
| 3e Initiative in Rheumatology |
| African League of Associations for Rheumatology |
| American Academy of Orthopaedic Surgeons |
| American College of Rheumatology |
| American Geriatrics Society |
| American Pain Society |
| Arthritis.com |
| Arthritis New Zealand |
| Arthritis Research UK |
| Arthritis Society—Canada |
| Asia Pacific League of Associations for Rheumatology |
| Assessment of SpondyloArthritis International Society |
| Brazilian Society of Rheumatology |
| British Paediatric Rheumatology Group |
| British Society for Rheumatology |
| Canadian Medical Association Clinical Guidelines |
| Canadian Rheumatology Association |
| Centers for Disease Control and Prevention Guidelines |
| Cochrane Review—Osteoarthritis |
| European League Against Rheumatism |
| Group for Research in Psoriasis and Psoriatic Arthritis |
| Hong Kong Society of Rheumatology |
| Institute for Clinical Systems Improvement |
| International League of Association for Rheumatology |
| Italian Society of Rheumatology |
| Medical Journal of Australia Clinical Guidelines |
| National Guidelines Clearinghouse |
| National Health and Medical Research Council |
| National Institute for Health and Care Excellence |
| New South Wales Therapeutic Assessment Group |
| New Zealand Guidelines Group (completed voluntary liquidation mid-2012) |
| Orthopedic Research Society |
| Osteoarthritis Research Society International |
| Ottawa Panel Evidence |
| Pan-American League of Associations for Rheumatology |
| Queensland University Clinical Practice Guidelines |
| Royal Dutch Society for Physical Therapy |
| Scottish Intercollegiate Guidelines Network |
| South Africa Arthritis Foundation |
| Therapeutic Goods Administration |
| Therapeutic Guidelines |
| Turkish League Against Rheumatism |
| U.S. Agency for Healthcare Research & Quality |
| Author Criteria for LOEs/Recommending Grading | |
|---|---|
| AAOS17 | |
| Grading the recommendations | |
| A | Good evidence (level I studies with consistent finding) for or against recommending intervention |
| B | Fair evidence (level II or III studies with consistent findings) for or against recommending intervention |
| C | Poor-quality evidence (level IV or V) for or against recommending intervention |
| I | Insufficient or conflicting evidence not allowing a recommendation for or against intervention |
| LOE | Study type |
| Level I | Systematic reviews, high-quality RCTs |
| Level II or III | Poor-quality RCTs, prospective or retrospective comparative studies, case-control |
| Level IV or V | Case series, expert opinion |
| None or conflicting | |
| ACR19 | |
| Strong recommendation to use | |
| Weak (or conditional) recommendation to use | |
| No recommendation | |
| Weak (or conditional) recommendation not to use | |
| Strong recommendation not to use | |
| Strong recommendations mean that most informed patients would choose the recommended management and that clinicians can structure their interactions with patients accordingly. | |
| Conditional recommendations mean that the majority of informed patients would choose the recommended management but many would not, and so clinicians must ensure that patients’ care is in keeping with their values and preferences. | |
| BSR21 | |
| SOR | |
| A | Directly based on category I evidence |
| B | Directly based on category II evidence or extrapolated recommendation from category I evidence |
| C | Directly based on category III evidence or extrapolated recommendation from category I or II evidence |
| D | Directly based on category IV evidence or extrapolated recommendation from category I, II, or III evidence |
| Categories of evidence | |
| Ia | MA of RCT |
| Ib | At least 1 RCT |
| IIa | At least 1 controlled study without randomization |
| IIb | At least 1 type of quasi-experimental study |
| III | Descriptive studies (comparative, correlation, case-control) |
| IV | Expert committee reports/opinions and/or clinical opinion of respected authorities |
| EULAR20, 23, 24, 26, 29 | |
| SOR | |
| A | Category I evidence |
| B | Category II evidence or extrapolated recommendation from category I evidence |
| C | Category III evidence or extrapolated recommendation from category I or II evidence |
| D | Category IV evidence or extrapolated recommendation from category II or III evidence |
| Categories of evidence | |
| Ia | MA or RCTs |
| Ib | At least 1 RCT |
| IIa | At least 1 controlled study without randomization |
| IIb | At least 1 quasi-experimental study |
| III | Descriptive studies, such as comparative, correlation, or case-control studies |
| IV | Expert committee reports or opinions and/or clinical experience of respected authorities |
| NHMRC14 | |
| Grade of recommendations | |
| A | Body of evidence can be trusted to guide practice |
| B | Body of evidence can be trusted to guide practice in most situations |
| C | Body of evidence provides some support for recommendation(s), but care should be taken in its application |
| D | Body of evidence is weak, and recommendation must be applied with caution |
| Note: A recommendation cannot be graded A or B unless the volume and consistency of evidence components are both graded either A or B | |
| LOE | |
| I | Evidence obtained from a systematic review of all relevant RCTs |
| II | Evidence obtained from at least 1 properly designed RCT |
| III-1 | Evidence obtained from well-designed pseudo RCTs (alternate allocation or some other method) |
| III-2 | Evidence obtained from comparative studies with concurrent controls and allocation not randomized (cohort studies), case-control studies, or interrupted time series with a control group |
| III-3 | Evidence obtained from comparative studies with historical control, 2 or more single-arm studies, or interrupted time series without a parallel control group |
| IV | Evidence obtained from case series, either posttest or pretest and posttest |
| NICE1 | |
| Grading the evidence statements | |
| 1++ | High-quality MAs, systematic reviews of RCTs, or RCTs with a very low risk of bias |
| 1+ | Well-conducted MAs, systematic reviews of RCTs, or RCTs with a low risk of bias |
| 1– | MAs, systematic reviews of RCTs, or RCTs with a high risk of bias |
| 2++ | High-quality systematic reviews of case-control or cohort studies |
| 2+ | High-quality case-control or cohort studies with a very low risk of confounding, bias, or chance and a high probability that the relation is causal |
| 2− | Well-conducted case-control or cohort studies with a low risk of confounding, bias, or chance and a moderate probability that the relation is causal |
| 3 | Case-control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the relation is not causal |
| 4 | Nonanalytic studies (eg, case reports, case series) Expert opinion, formal consensus |
| OARSI22, 25 | |
| SOR: VAS (0%–100%) | |
| Evidence hierarchy | |
| Ia | MA of RCTs |
| Ib | At least 1 RCT |
| IIa | At least 1 well-designed controlled study, but without randomization |
| IIb | At least 1 well-designed quasi-experimental study |
| III | At least 1 nonexperimental descriptive study (comparative, correlation, or case-controlled study) |
| IV | Expert committee reports, opinions, and/or experience of respected authorities |
| Ottawa Panel5, 18, 27, 28 | |||
|---|---|---|---|
| Grade | Clinical Importance (%) | Statistical Significance | Study Design |
| A (strongly recommended) | ≥15 | <.05 | RCT (single or meta-analysis) |
| B (recommended) | ≥15 | <.05 | CCT or observational (single or meta-analysis) |
| C+ (suggested used) | ≥15 | Not significant | RCT/CCT or observational (single or meta-analysis) |
| C (neutral) | <15 | Not significant | Any study design |
| D (neutral) | <15 (favors control) | Not significant | Any study design |
| D+ (suggested no use) | <15 (favors control) | Not significant | RCT/CCT or observational (single or meta-analysis) |
| D− (strongly not recommended) | ≤15 (favors control) | <.05 (favors control) | Well-designed RCT with >100 patients (if <100 patients, becomes grade D) |
| KNGF30 | |
|---|---|
| LOE | |
| I | One A1 study or at least 2 A2 studies |
| II | One A2 study or at least 2 B studies |
| II | 1 B or multiple C studies |
| IV | Expert opinion |
| Grades of recommendation | |
| A1 | MA (systematic reviews) that includes at least 2 RCTs at quality level A2 that show consistent results between studies |
| A2 | RCTs of a good methodological quality (randomized double-blind controlled studies) with sufficient power and consistency |
| B | RCT of a moderate methodological quality of insufficient power, or nonrandomized, cohort of patient-control group study involving intergroup comparisons |
| C | Patient series |
| D | Expert opinion |
Abbreviations: AAOS, American Academy of Orthopaedic Surgeons; ACR, American College of Rheumatology; BSR, British Society for Rheumatology; CCT, controlled clinical trial; EULAR, European League Against Rheumatism; KNGF, Royal Dutch Society for Physical Therapy; NHMRC, National Health and Medical Research Council; OARSI, Osteoarthritis Research Society International; TLAR, Turkish League Against Rheumatism; VAS, visual analog scale.
∗Studies with an LOE ‘–’ are not used as a basis for making a recommendation.
Acknowledgments
We thank Andrew South, MSocSci (Hons), GradDipLib, a library technician at the Auckland University of Technology, for his assistance with designing the literature search criteria.
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