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.

Figure 1.

Recommended therapies for the management of osteoarthritis (OA). Strongly and conditionally recommended approaches to management of hand, knee, and/or hip OA are shown. No hierarchy within categories is implied in the figure, with the recognition that the various options may be used (and reused) at various times during the course of a particular patient’s disease. *= Exercise for knee and hip OA could include walking, strengthening, neuromuscular training, and aquatic exercise, with no hierarchy of one over another. Exercise is associated with better outcomes when supervised. ** = Knee brace recommendations: tibiofemoral (TF) brace for TF OA (strongly recommended), patellofemoral (PF) brace for PF OA (conditionally recommended). *** = Fland orthosis recommendations: first carpometacarpal (CMC) joint neoprene or rigid orthoses for first CMC joint OA (strongly recommended), orthoses for joints of the hand other than the first CMC joint (conditionally recommended). RFA = radiofrequency ablation; NSAIDs = nonsteroidal antiinflammatory drugs; IA = intraarticular.

Figure 2.

Therapies recommended against (physical, psychosocial, and mind-body approaches [A] and pharmacologic approaches [B] in the management of hand, knee, and/or hip osteoarthritis. No hierarchy within categories is implied in the figure. TENS = transcutaneous electrical nerve stimulation; TNF = tumor necrosis factor; IL-1 = interleukin-1; PRP = platelet-rich plasma; IA = intraarticular.