Exercise remains only nondrug intervention for OA as draft guidelines progress
ATLANTA — Exercise is the one nonpharmacological intervention for which there is a strong recommendation in hip, knee, and hand osteoarthritis, according to a guideline update presented at ACR/ARP 2019.
“These are considered draft recommendations at this time because they have not yet been published,” Sharon L. Kolasinski, MD, of the division of rheumatology at the University of Pennsylvania.
Kolasinski, who serves as the primary author of the recommendations, was on hand to describe process of the guideline development, which included identifying interventions and outcomes measurement tools; assessing for potential harms; and formulating Population- Intervention- Comparator- Outcomes (PICO) questions. “An example of a PICO question might be: For patients with osteoarthritis of the knee, what are nonsteroidal interventions that might be considered?” Kolasinski said.
The guideline development process included defining the scope of the document, identifying a team of panelists, and posting a draft for public comment. After the public comment stage, the guideline moved to a literature review that began with more than 8,000 papers and ultimately included 536 articles.
The guideline development team used the grading of recommendations assessment, development and evaluation (GRADE) methodology to make decisions and included a patient panel. Kolasinski added that 70% agreement among the voting panel was required for the finalization of each recommendation.
The guideline includes strong and conditional recommendations. “A strong recommendation means there is compelling evidence of efficacy, and the benefits clearly outweigh the harms,” Kolasinski said. “However, very few recommendations are strong.”
For conditional recommendations, either the quality of evidence was low or very low, or the balance of benefits and harms to patients was too close to call.
Recommendations for hand OA
Carole Dodge, OT, of the department of physical medicine and rehabilitation at the University of Michigan, stressed that there was only one strong recommendation for hand OA. “That was for exercise,” she said. “In fact, exercise is strongly recommended for all types of osteoarthritis.”
Dodge said that activities should zero in on the specific joints that are impacted, and suggested that various ways of holding a tennis ball or exercise putty can strengthen and stabilize the joints.
As for conditional recommendations, Dodge listed a number of options for rheumatologists to consider, including kinesiotaping of the CMC joint, use of orthotics, use of specialized gloves, acupuncture, other physical modalities such as paraffin baths, and massage.
“After wearing kinesio tape for a couple of weeks, our hope is that patients can maintain proper hand position on their own,” Dodge said. “Orthotics can be worn in the daytime or nighttime.”
The evidence is variable for massage and acupuncture, according to Dodge. “For acupuncture, you need to be a trained provider, or send the patient to one,” she said.
As for interventions that can be performed by rheumatologists, Dodge suggested manual therapy is a good option. “Soft tissue mobilization can make the patient more comfortable,” she said. “Our goal is to have less hand pain.”
Interventions for knee/hip OA
Daniel Kenta White, PT, ScD, MSc, assistant professor in the department of physical therapy at the University of Delaware STAR Health Sciences Complex, also stressed exercise for knee and hip OA, and added that weight loss is also encouraged for patients who are obese or overweight.
White focused on walking as a key form of exercise. “Pedometers work,” he said. “Also, the more walking you do, the less risk you have of developing functional limitations from osteoarthritis.”
A daily step count of 6,000 is the key target for preventing functional limitation, while 4,400 steps have been shown to reduce mortality associated with OA.
As for contraindications, White noted that the guidelines conditionally recommend against modified shoes, lateral and medial wedged insoles, massage therapy, manual therapy, and pulse vibration therapy for patients with hip or knee OA.
Looking beyond shoes and walking, other types of light or moderate exercise, ranging from resistance training to neuromuscular exercises, are conditionally recommended. “Aquatic exercises have shown small short-term benefits on pain and disability,” White said.
Importantly, there is no specific order or hierarchy of how and when various exercise approaches can be implemented. White encouraged shared decision-making with patients regarding the nature of exercise, step counts, and other goals. “Be specific,” White said. “Don’t just say, ‘Go be active and get healthy.’ A specific plan with supervision is better.” – by Rob Volansky
Kolasinski S. Nondrug interventions for hip, knee & hand OA: 2019 guideline update. Presented at: American College of Rheumatology/Association of Rheumatology Professionals Annual Meeting; Nov. 9-13, 2019; Atlanta.
Disclosure: Kolasinski, Dodge and White report no relevant financial disclosures.