Accepted Manuscript A systematic review of guidelines for the physical management of osteoarthritis Peter J. Larmer, DHSc, MPH, FNZCP Nicholas David Reay, BBS Elizabeth Richmond Aubert, BSc Paula Kersten, PhD, MSc, BSc PII:
S0003-9993(13)01105-2
DOI:
10.1016/j.apmr.2013.10.011
Reference:
YAPMR 55636
To appear in:
ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION
Received Date: 14 June 2013 Revised Date:
26 August 2013
Accepted Date: 8 October 2013
Please cite this article as: Larmer PJ, Reay ND, Aubert ER, Kersten P, A systematic review of guidelines for the physical management of osteoarthritis, ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION (2013), doi: 10.1016/j.apmr.2013.10.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Title: A systematic review of guidelines for the physical management of osteoarthritis.
Additional authors:
M AN U
Nicholas David Reay BBS Department of Physiotherapy Faculty of Health and Environmental Sciences AUT University Private Bag 92006 Auckland 1142 New Zealand
SC
Peter J. Larmer DHSc, MPH, FNZCP Head, School of Rehabilitation and Occupation Studies Faculty of Health and Environmental Sciences AUT University Private Bag 92006 Auckland 1142 New Zealand Ph;64-9-9219999 x 7322 Fax:64-9-9219620 Email: [email protected]
RI PT
Contact person and primary author:
EP
TE D
Elizabeth Richmond Aubert BSc Department of Physiotherapy Faculty of Health and Environmental Sciences AUT University Private Bag 92006 Auckland 1142 New Zealand
AC C
Paula Kersten PhD, MSc, BSc Associate Professor Person Centred Research Centre School of Rehabilitation and Occupation Studies Faculty of Health and Environmental Sciences AUT University New Zealand
Authors contributions All authors participated in the conception and design of the study, revision of the manuscript, acquired and interpreted the data, and drafted the manuscript. All authors read and approved the final manuscript. Acknowledgements The authors would like to acknowledge Andrew South, a library technician at the Auckland University of Technology, for his assistance with designing the literature search criteria.
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
Keywords: Osteoarthritis, Guideline, Rehabilitation, Critical appraisal
ACCEPTED MANUSCRIPT
1
A systematic review of guidelines for the physical management of osteoarthritis.
2 Abstract
RI PT
3 4
SC
5
Objective: To undertake a systematic critical appraisal of guidelines to provide a summary of
7
recommendations for the physical management of Osteoarthritis (OA).
M AN U
6
8 9
Data Sources: The Cochrane Library, MEDLINE, CINAHL, SPORTDiscuss with Full Text, Scopus, ScienceDirect, PEDro and Google Scholar databases were searched (2000 to 2013)
11
to identify all guidelines, protocols and recommendations for the management or treatment of
12
osteoarthritis. In addition internet searches of all relevant arthritis organisations were
13
undertaken. All searches were performed between July 2012 and end of April 2013.
14
Guidelines that included only pharmacological, injection therapy or surgical interventions
15
were excluded. Only guidelines published in English were retrieved.
EP
AC C
16
TE D
10
17
Study Selection: Osteoarthritis guidelines developed from evidence based research,
18
consensus and/or expert opinion were retrieved. There were no restrictions on severity or site
19
of OA, gender or age. Nineteen guidelines were identified for evaluation.
20
1
ACCEPTED MANUSCRIPT
Data Extraction: The quality of all guidelines was critically appraised using the AGREE II
22
instrument. Each guideline was independently reviewed. All relevant recommendations for
23
the physical management of OA were synthesised, graded and ranked according to available
24
evidence.
RI PT
21
25
Data Synthesis: Seventeen guidelines with recommendations on the physical management of
27
OA met the inclusion criteria and underwent a full critical appraisal. There were variations in
28
the interventions, levels of evidence and strength of recommendations across the guidelines.
29
Forty different interventions were identified. Recommendations were graded from ‘strongly
30
recommended’ to ‘unsupported’. Exercise and education were found to be strongly
31
recommended by most guidelines.
32
M AN U
SC
26
Conclusion: Exercise and education were key recommendations supporting the importance
34
of rehabilitation in the role in the physical management of OA. This critical appraisal can
35
assist health care providers who are involved in the management of people with OA.
EP
TE D
33
37 38 39
AC C
36
Keywords: Osteoarthritis, Guideline, Rehabilitation, Critical appraisal
40
Abbreviations:
41
OA Osteoarthritis
42 2
ACCEPTED MANUSCRIPT
SOR strength of recommendation
44
MA meta-analysis
45
RCT randomised controlled trials
46
TENS transcutaneous electrical nerve stimulation
47
Osteoarthritis (OA) is the most common form of arthritis and is identified as one of the
48
leading cause of pain and disability worldwide (1, 2). By the year 2020 the prevalence of OA is
49
expected to double (3). The risk factors associated with OA include: age, gender, genetics,
50
occupation, past injuries and, obesity (4). Hip and knee pain associated with OA often leads to
51
inactivity and loss of mobility resulting in deconditioning, weight gain, loss of independence
52
and decreased quality of life (5). There are substantial personal and societal costs associated
53
with OA (1). Personal costs may include the inability to participate in work, sport, hobbies or
54
caring for others due to pain. Societal costs may include visits to the doctor, medication costs
55
and assistance equipment. Joint replacement is an effective intervention to alleviate pain and
56
improve quality of life for those with advanced OA. However, despite a growing number of
57
joint replacements undertaken each year many people are still placed on a waiting list often
58
for a considerable time (6, 7). In order to reduce the burden of OA, safe and effective health
59
services, involving a range of non surgical treatments options are required. These services
60
must be effective with respect to intervention and cost as well as meet the affected person’s
61
needs.
SC
M AN U
TE D
EP
AC C
62
RI PT
43
63
Evidence based clinical guidelines are developed to assist the practitioner, patient and/or
64
policy-maker to make informed clinical decisions (8). Guidelines are valuable resources that
65
play an integral role in improving treatment and management of various health conditions. 3
ACCEPTED MANUSCRIPT
They can be used by health practitioners and people suffering with OA seeking information
67
to determine how their disease can best be managed. A preliminary search of the literature
68
identified many international guidelines developed for the management of OA. The
69
preliminary search identified that the guidelines included evidence and recommendations for
70
a number of interventions including: pharmacological, non-pharmacological, surgical and
71
injections therapies, physical management and lifestyle changes for the management of OA.
72
However, due to adverse side effects, patients and health care providers may pursue physical
73
management options rather than surgery, pharmacology, or injection based therapy. A
74
number of guidelines highly recommend exercise as an intervention for OA. However, Gill
75
et al (9) in a recent systematic review concluded that while exercise interventions were
76
beneficial for those people awaiting hip replacement, this was not the case for those awaiting
77
knee replacement. It was also noted that there were variations across the guidelines in the
78
recommendations made. Currently there is no critical appraisal of international guidelines
79
that has synthesised, graded and comprehensively presented all the relevant recommendations
80
for the physical management of OA. Therefore, a systematic critical appraisal of international
81
OA guidelines was undertaken to comprehensively present all the relevant evidence based
82
recommendations on the physical management of OA.
EP
TE D
M AN U
SC
RI PT
66
84 85 86 87
AC C
83 Methods
Electronic database searches
88 89
A systematic literature search was performed. The Cochrane Library, MEDLINE, CINAHL,
90
SPORTDiscuss with Full Text, Scopus, ScienceDirect, PEDro and Google Scholar databases 4
ACCEPTED MANUSCRIPT
were searched (2000 to 2013) to identify all guidelines, protocols and recommendations for
92
the management or treatment of osteoarthritis. An experienced health science librarian
93
assisted with the development of the search strategy. MEDLINE, CINAHL, SPORTDiscuss
94
with Full Text databases were searched using key word proximity searches to identify
95
guidelines or recommendations for the management of osteoarthritis ((osteoarthrit* N5
96
guideline*) OR (osteoarthrit* N5 evidence*) OR (osteoarthrit* N5 recommend) OR
97
(osteoarthrit* N5 best*)). Scopus and ScienceDirect databases used the same proximity
98
search logic but with the appropriate syntax. PEDro and The Cochrane Libraries were
99
searched using ((osteoarthriti* and guideline) AND (osteoarthriti* and protocol)). A manual
100
search was conducted on reference lists found in relevant guidelines, systematic reviews and
101
meta-analysis, which returned additional resources.
M AN U
SC
RI PT
91
102 Internet searches
TE D
103 104
A thorough internet search was conducted to identify international arthritis organisations and
106
guideline clearinghouses. The names of organisations were also found during the process of
107
reviewing guidelines and recommendations identified during the electronic database searches.
108
The websites of these organisations were reviewed and any relevant guidelines were
109
included. A list of these organisations is shown in Appendix 1.
111
AC C
110
EP
105
Eligibility Criteria
112 113
The primary source of literature for this review is recommended guidelines developed from
114
evidence based research, consensus and/or expert opinion. Guidelines that included only
115
pharmacological, injection therapy or surgical interventions were excluded. There were no 5
ACCEPTED MANUSCRIPT
restrictions on severity or site of OA, gender or age. The search was confined to papers
117
published in English and available electronically between the period of 2000 and end of April
118
2013. Animal based studies were not included. If there had been updates to guidelines, only
119
the latest version of the guideline was reviewed.
RI PT
116
120 121
Selection of guidelines
SC
122
All titles and/or abstracts were reviewed to determine if they met the eligibility criteria of this
124
critical appraisal. When citations met the criteria, the full text articles were retrieved and
125
reviewed. Nineteen guidelines were identified for evaluation. The details of results returned
126
are shown in Figure 1.
M AN U
123
127
Insert Figure 1 about here
TE D
128 129
131
Quality appraisal
EP
130
The Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool was used to
133
critique the guidelines (10). AGREE II is a guideline quality appraisal tool that has been found
134
to have high construct validity (11). The AGREE II consists of 23 items arranged into six
135
domains: scope and purpose (3 items), stakeholder involvement (3 items), rigour of
136
development (8 items), clarity of presentation (3 items), applicability (4 items) and editorial
137
independence (2 items). Each item is scored between strongly agree (4) to strongly disagree
138
(1). The items scores within a domain were then added and calculated as a percentage. A
AC C
132
6
ACCEPTED MANUSCRIPT
domain was determined to be effectively addressed if its score was ≥ 60%, as has been used
140
in other critical appraisals of arthritis guidelines (12, 13). Prior to a full critique of the guidelines
141
all members of the research team undertook a training review process to ensure consistency
142
and reliability in grading. All guidelines were then reviewed independently to ensure
143
sufficient reliability as suggested by previous authors (11). Differences in scoring were
144
resolved through discussions and consensus between all four authors. Where guidelines were
145
not clear, the identified author was contacted for clarification if possible. Finally, based on
146
their overall domain scores, the guidelines received an overall assessment from the research
147
team of either ‘recommended’, ‘recommended with modifications’, or ‘not recommended’
148
(10)
.
149 150
Synthesis of Recommendations
TE D
151
M AN U
SC
RI PT
139
Following the AGREE II appraisal of the guidelines, recommendations that were specific to
153
the physical management of OA were identified for data extraction. This analysis involved
154
categorising recommendations by intervention (e.g. exercise, education) with their associated
155
level of evidence (LOE) and strength of recommendation (SOR). For the purposes of this
156
review the interventions have been grouped for similarity into twelve interventions. For each
157
guideline recommendation, the associated interventions were scored on a +4 to -4 individual
158
weighting scale (Table 1) based on their LOE and SOR values. The levels of the scale were
159
derived from LOE and SOR values found in each guideline. There was variation in how
160
individual guidelines provided grading scales for both LOE and SOR. A list of individual
161
guideline scales is provided in Appendix 2. Guidelines based on meta-analysis (MA),
162
systematic reviews (SR) and definitive randomised controlled trials (RCTs) that were
163
strongly recommended were weighted highest (individual weighting = 4) while expert
AC C
EP
152
7
ACCEPTED MANUSCRIPT
opinion with a weak strength of recommendation was weighted low (individual weighting =
165
1). Where a guideline provided a recommendation against an intervention this was weighted
166
negatively (individual weighting = -1 - -4). There were two exceptions to this process. Firstly,
167
the recommendations from the National Health and Medical Research Council (NHMRC)
168
guideline (14) were already graded on a 4-point scale based on LOE and SOR. Secondly, the
169
NICE guideline (1) provided extensive level one evidence (MA, SR, and RCTs) throughout
170
the paper. However, it did not present recommendations with a LOE or SOR. Due to the
171
support of a high level of evidence we have graded each of the NICE recommendations with
172
a weighting of four.
M AN U
SC
RI PT
164
173
Overall recommendation scores of interventions were determined by the median value of the
175
specific interventions individual weightings. Table 2 illustrates how the overall intervention
176
recommendations were then grouped based on their median score into strongly
177
recommended, recommended, recommended with caution, and unsupported. For example,
178
knee bracing is recommended by five guidelines with weighted scores of 4, 3, 4, 4 and 2
179
resulting in a median score of 4 and grading of strongly recommended.
EP
TE D
174
180
182 183
Results
AC C
181
184
The systematic literature search yielded 19 guidelines. One (15) was excluded as there were
185
no stated methods for evidence gathering or developing recommendations, recommendations
186
were not clear and no method for grading recommendations was stated. One (16) was excluded 8
ACCEPTED MANUSCRIPT
187
because no conclusive recommendations were provided for the physical management of
188
glenohumeral joint OA. This resulted in 17 guidelines available for full data extraction.
190
RI PT
189 AGREE II appraisal results
191
Table 3 presents the 17 guidelines AGREE II domain scores with an overall quality
193
assessment rating and a comment on weaknesses of the specific guideline. There was
194
variability in the domains that were effectively addressed by the guidelines. Of the 17
195
guidelines, two effectively addressed four of the six AGREE II domains (14, 17), nine
196
effectively addressed three domains (18-26), and six effectively addressed at least two domains
197
(1, 5, 27-30)
198
28)
199
in any guideline. Six guidelines can be recommended without modifications (14, 17, 20, 24-26).
200
Eleven guidelines (1, 5, 18, 19, 21-23, 27-30) were recommended with modifications.
M AN U
SC
192
. Stakeholder involvement was effectively addressed by six guidelines (1, 14, 17, 18, 26,
TE D
, editorial independence in one guideline (22) and applicability was not effectively addressed
202 203
Interventions
EP
201
Forty interventions were identified across the guidelines. Table 4 presents the grouped
205
interventions covered by the 17 guidelines. The grouped interventions are listed in
206
descending order with the number of guidelines that recommended them: exercise (16
207
guidelines), education (13 guidelines), equipment (11 guidelines), weight loss/diet (11
208
guidelines), taping, heat/ice (9 guidelines), electrical based therapy (7 guidelines), self-
209
management (7 guidelines), acupuncture (5 guidelines), manual therapy (5 guidelines),
210
psychosocial interventions (5 guidelines) and balneotherapy/spa therapy (2 guidelines).
AC C
204
9
ACCEPTED MANUSCRIPT
Balneotherapy, refers to the passive relaxation in mineral or thermal water whereas
212
hydrotherapy refers to therapeutic methods (e.g. exercise) that take advantage of the physical
213
properties of water. All guidelines except the NICE guideline stated grading scales for their
214
recommendations, either using level of evidence (LOE), strength of recommendation (SOR),
215
or both. The grading criteria used by guideline developers varied among guidelines.
RI PT
211
216 Guideline intervention recommendations
SC
217
M AN U
218 219
The median weighting of the specific interventions across guidelines was calculated and then
220
given an overall recommendation. These are presented as strongly recommended (Table 5),
221
recommended (Table 6), recommended with caution (Table 7), unsupported (Table 8) and not
222
recommended (Table 9).
TE D
223
Strongly recommended interventions included: unspecified types of education (n=11(where
225
n= recommended by number of guidelines)), combined modalities of exercise or exercise of
226
an unspecified type (n=11), wedged insoles for knee OA (n=10), weight loss (n=10),
227
strengthening exercise (n=9), aerobic exercise (n=8), self-management (n=7), aquatic/hydro
228
therapy (n=6), transcutaneous electrical nerve stimulation (TENS) (n=6), knee bracing for
229
knee OA (n=5) and appropriate footwear (n=4). Yoga, manual therapy with supervised
230
exercise, manipulation and stretching, land based exercise and balneotherapy/spa therapies
231
were also graded as strongly recommended interventions. However, only three or fewer
232
guidelines provided recommendations for each of these interventions. Extensive research in
233
regards to specific forms of education and diet strategies were described by two of the Ottawa
AC C
EP
224
10
ACCEPTED MANUSCRIPT
Panel guidelines (18, 27) warranting their interventions to be strongly recommended. With
235
respect to exercise, there were few studies that investigated individualised or tailored
236
exercise, however nine guidelines (1, 14, 20-24, 26, 29) indicated that this should be an important
237
consideration when prescribing exercise.
RI PT
234
238
Recommended interventions included: thermal based therapy (n=7), taping (n=6), and
240
walking aides (n=6), and telephone support (n=5). Tai chi, electrical stimulation, devices to
241
assist with activities of daily living, acupuncture, multi modal physical therapy and adherence
242
strategies were also graded as recommended interventions. However, only three or fewer
243
guidelines provided recommendations for each of these interventions.
M AN U
SC
239
244
Two interventions, ultrasound and hand splints, were recommended with caution.
TE D
245 246
Interventions reported as unsupported recommendations were laser therapy, magnetic
248
bracelets, Chinese acupuncture, massage therapy, psychosocial interventions, and cognitive
249
behavioural therapy.
AC C
250
EP
247
251
One intervention, electro acupuncture, was explicitly not recommended by one guideline (1)
252
(Table 9). While there were a number of interventions that were either unsupported or not
253
recommended by their authors, there were no interventions that were specified as harmful.
254 255
Discussion 11
ACCEPTED MANUSCRIPT
256 257 This review is the first published critical appraisal of guidelines for the physical management
259
of OA. Of the 19 guidelines that we identified, two were excluded. Firstly, the South Africa
260
Arthritis Foundation guideline (15) was not included because recommendations were not
261
clearly stated. Secondly, the recommendations from the American Academy of Orthopaedic
262
Surgeons (AAOS) glenohumeral OA guideline (16) was not included as the focus of the
263
guideline was surgical and pharmacological, with no conclusive recommendations provided
264
for the physical management of OA. It was also noted that there were no allied health
265
members (physiotherapists or occupational therapists) on the guideline development group.
266
The group consisted entirely of medical doctors. In the future, patients with glenohumeral
267
OA may be better served if the working group included individuals from all relevant health
268
professional groups.
TE D
269
M AN U
SC
RI PT
258
The AGREE II instrument was used to assess the methodological quality of the remaining 17
271
guidelines. When reviewing the AGREE II domain scores, the authors chose to use 60% as
272
the value that represented adequate coverage of the criteria in a particular domain. The same
273
approach was also used in other critical appraisals of arthritis guidelines (12, 13). This allowed
274
comparisons of the domains amongst the 17 guidelines and recommendations to be made on
275
the areas that could be improved in future development of guidelines. In this appraisal the
276
domains of scope and purpose, rigour of development, and clarity of presentation were
277
addressed effectively by the majority of guidelines. However, there were three domains that
278
were consistently weak or unfulfilled by most guidelines: stakeholder involvement,
279
applicability and editorial independence. Reviewing previous appraisals on clinical practice
280
guidelines it became apparent that the same three domains have consistently scored poorly (12,
AC C
EP
270
12
ACCEPTED MANUSCRIPT
281
31, 32)
282
strong AGREE II scores add to the credibility of the recommendations.
. While AGREE II scores have no bearing on the actual content of the recommendations,
RI PT
283 Stakeholder involvement was only adequately addressed by six of the seventeen guidelines
285
and improvement is needed within this domain. It requires the inclusion of all relevant
286
information pertaining to the authors involved, target users clearly identified, and the views
287
of the target population considered when developing guidelines. Guyatt and Rennie (33)
288
reported that patient’s values need to be considered when developing evidence based
289
literature. A failure in doing so is likely to overlook the person’s lived experience of OA and
290
what is important to them. The applicability domain addresses resource implications,
291
facilitators and barriers as well as advice on the implementation of the recommendation.
292
None of the guidelines fulfilled the criteria for this domain. These elements play a role in
293
decision making for the consumer, and these should be addressed within the guideline.
294
Editorial independence adds to the rigour of the guideline. Only one guideline fulfilled this
295
criterion. Guideline developers are required to declare the funding body and any competing
296
interests. However, it is important that authors not only declare the funding body and
297
competing interests, but also clearly state editorial independence. When this is omitted, the
298
reader is unsure if there is actually a conflict of interest or if it was simply not mentioned.
299
While this may be taken for granted, it is an important statement that adds to the rigour of the
300
guideline. Improving all these areas of guideline development will allow the consumer to
301
have more confidence in the recommendations made within the guideline.
AC C
EP
TE D
M AN U
SC
284
302 303
The method used to determine our overall combined intervention recommendations is novel
304
and untested. We calculated a median score in an attempt to provide a balance on individual 13
ACCEPTED MANUSCRIPT
guideline’s LOE and SOR. The variability across guidelines made any attempt at aggregating
306
recommendations difficult. It is also important to note that while some interventions were
307
strongly recommended, some were based on only one or two guidelines. Balneotherapy was
308
based on two guidelines (22, 29), whilst, land based exercise (14), yoga (28), and diet (18) were
309
only based on one guideline. By comparison, other intervention recommendations were
310
supported by many guidelines and therefore provide greater confidence in recommending that
311
intervention.
SC
RI PT
305
312
There were some inconsistencies found among the guidelines. Peter et al. (30) specifically
314
recommended not to use massage therapy, electrical stimulation, laser therapy and
315
ultrasound, while ultrasound was recommended by Brand et al. (14), Tuncer et al. (22), and
316
Zhang et al. (24). Electrical stimulation was recommended by Brand et al. (14) and Tuncer et al.
317
(22)
318
opinion (14). Consumers of evidence based literature should be aware that there may be
319
conflicting evidence among the research. This critical appraisal has assisted the user by
320
identifying these inconsistencies and by providing a balanced interpretation.
TE D
, and massage therapy and laser therapy received a recommendation based on expert
EP
321
M AN U
313
The Ottawa group’s four guidelines (5, 18, 27, 28), while very comprehensive, failed to provide
323
specific recommendations for the management of OA. The group provided extensive
324
evidence of the research. However, the papers were presented in a PICOT (population,
325
intervention, comparator, outcome and timeframe) format for different comparisons of
326
interventions, making it difficult for consumers to take recommendations from the paper. The
327
Ottawa panel was contacted and responded to questions surrounding the usability of the
328
recommendations. The panel replied that a Cochrane Collaboration methodology was utilised
AC C
322
14
ACCEPTED MANUSCRIPT
and directed us to an Arthritis Society of Canada website. The Ottawa group report on highly
330
relevant information concerning the physical management of OA. However, it would assist
331
the guideline user if the group synthesised the data and presented key recommendations in an
332
easily identifiable summarised box or grouped together in one section.
RI PT
329
333
The NICE guidelines are very comprehensive, with extensive evidence supporting the use of
335
non-pharmacological interventions. The three core recommendations from the guideline were
336
for strength and aerobic fitness, education, and weight loss if overweight. However, there are
337
several user issues with the NICE guidelines. The guideline provided evidence statements in
338
tables throughout the guideline. However, it did not grade the evidence, instead it referred the
339
reader to an online link. Unfortunately the webpage was no longer available. After
340
corresponding with the author, we were informed that their recommendations were no longer
341
graded and it was advised to use the language in the recommendation as a guide. Although
342
they provided strong evidence, without grading the levels of evidence and strength of
343
recommendations it was difficult to interpret the recommendations. The authors have
344
endeavoured to use a consistent methodology when grading the NICE guideline
345
recommendations. While it is not mandatory to use a grading system for the strength of
346
recommendations, it provides the reader with valuable information. Finally, the layout of the
347
NICE recommendations was very difficult to follow. The guideline provided 36
348
recommendations (18 non-pharmacological recommendations). These were dispersed
349
throughout the document making it very difficult to locate all of the recommendations. It
350
would assist the reader if the recommendations were presented in an easily identifiable box
351
summarising the recommendations or presenting them grouped together at the beginning of
352
the document.
AC C
EP
TE D
M AN U
SC
334
15
ACCEPTED MANUSCRIPT
353 Exercise and education were found to be amongst the strongest interventions recommended
355
throughout the guidelines. While the exercise recommendations ranged from very specific
356
(aerobic, strength training, or hydrotherapy) to very general (exercise of unspecified type),
357
the message was clear that exercise in all its forms is strongly recommended for OA, most
358
specifically for knee OA. The important benefits of exercise include an improvement in pain
359
and function, which are the main complaints reported by OA sufferers. Exercise is a low cost
360
option in the management of OA, which makes it accessible to all OA sufferers. Education
361
was also considered a strong recommendation. Education was found to reduce pain, increase
362
coping skills and result in fewer visits to primary care practitioners in knee OA (5, 20, 29).
363
Additionally, although the supporting evidence concerning tailored exercises was sparse, the
364
consensus from nine guidelines recommended prescribing individualised patient exercise and
365
education and these are key components of rehabilitation.
TE D
M AN U
SC
RI PT
354
366
369
EP
368
Study Limitations
AC C
367
370
This critical appraisal has two key limitations. Firstly, a new grading scale to grade the
371
overall strength of each recommendation was developed. This was a non-standardised
372
grading system and requires further testing. Secondly, only guidelines published in English
373
were reviewed leading to a potential publication bias. This criterion may misrepresent the
374
amount of research that has been conducted on the physical management of OA globally.
375 16
ACCEPTED MANUSCRIPT
376
Conclusions
377 378 The objective of this appraisal was to review the available guidelines and present the
380
treatment recommendations for the physical management of OA in a format that was useful
381
to the user. Throughout the research, there is strong evidence to support aspects of the use of
382
exercise, electrical based therapy, equipment, education, diet and weight loss, manual therapy
383
and self management. Laser therapy, magnetic bracelets, Chinese acupuncture, massage
384
therapy, aspects of psychosocial based therapy and electro acupuncture were either
385
unsupported or not recommended. With the prevalence of OA expected to double by 2020
386
and the personal and societal costs associated with OA being substantial, it is important to
387
establish the best strategy to manage and treat OA. As exercise and education were found to
388
be among the strongest recommendations within the guidelines and can be relatively cost
389
effective to provide, there is an opportunity for those engaged in rehabilitation to move into a
390
leading role in the management of OA.
391
In this critical appraisal we have taken a unique approach. Not only have we appraised the
392
quality of the guidelines but also synthesised, graded and comprehensively presented all the
393
relevant recommendations for the physical management of OA. It is hoped that this will
394
inform health care providers on the best evidence interventions available for the physical
395
management of OA.
397
SC
M AN U
TE D
EP
AC C
396
RI PT
379
References
398 399
17
ACCEPTED MANUSCRIPT
400
1.
National Collaborating Centre for Chronic Conditions. Osteoarthritis: National
401
clinical guideline for care and management in adults: Royal College of Physicians; 2008.
402
Available from: http://www.nice.org.uk/CG059. Accessed November 26, 2012.
403
2.
404
with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a
405
systematic analysis for the Global Burden of Disease Study 2010. Lancet.
406
2012;380(9859):2163-96.
407
3.
408
disabling hip and knee osteoarthritis (OA) from the perspective of individuals living with this
409
condition. Rheumatology (Oxford). 2005;44(12):1531-7.
410
4.
411
Geneva: World Health Organisation; 2003.
412
5.
413
evidence-based clinical practice guidelines for aerobic walking programs in the management
414
of osteoarthritis. Arch Phys Med Rehabil. 2012;93(7):1269-85.
415
6.
416
waiting for hip and knee replacements in Ontario. Ontario Hip and Knee Replacement Project
417
Team. J Eval Clin Pract. 1997;3(1):59-68.
418
7.
419
reported by more than half of those waiting for joint replacement surgery: a prospective
420
cohort study. BMC Musculoskelet Disord. 2011;12(1):108-16.
421
8.
422
guides to the medical literature: XXV. Evidence-based medicine: Principles for applying the
423
Users' Guides to patient care. JAMA: Journal of the American Medical Association.
424
2000;284(10):1290-6.
SC
RI PT
Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, et al. Years lived
M AN U
Gupta S, Hawker GA, Laporte A, Croxford R, Coyte PC. The economic burden of
Symmons D, Mathers C, Pleger B. Global burden of osteoarthritis in the year 2000.
TE D
Loew L, Brosseau L, Wells GA, Tugwell P, Kenny GP, Reid R, et al. Ottawa panel
EP
Williams JI, Llewellyn Thomas H, Arshinoff R, Young N, Naylor CD. The burden of
AC C
Ackerman IN, Bennell KL, Osborne RH. Decline in Health-Related Quality of Life
Guyatt GH, Haynes RB, Jaeschke RZ, Cook DJ, Green L, Naylor CD, et al. Users'
18
ACCEPTED MANUSCRIPT
425
9.
Gill SD, McBurney H. Does exercise reduce pain and improve physical function
426
before hip or knee replacement surgery? A systematic review and meta-analysis of
427
randomized controlled trials. Arch Phys Med Rehabil. 2013;94(1):164-76.
428
10.
429
2009. Available from: http://www.agreetrust.org/. Accessed January 14, 2013.
430
11.
431
Advancing guideline development, reporting and evaluation in health care. Can Med Assoc J.
432
2010;182(18):E839-E42.
433
12.
434
appraisal of guidelines for the management of knee osteoarthritis using Appraisal of
435
Guidelines Research and Evaluation criteria. Arthritis Research & Therapy. 2007;9(6):R126.
436
13.
437
practice guidelines on the use of physiotherapy in rheumatoid arthritis: a systematic review.
438
Rheumatology (Oxford). 2011;50(10):1879-88.
439
14.
440
the nonsurgical management of hip and knee osteoarthritis 2009. Available from:
441
http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.
442
15.
443
Afr Med J. 2003;93(12, Pt. 2):972-90.
444
16.
445
treatment of glenohumeral joint osteoarthritis: Guideline and evidence report. Rosemont, IL:
446
American Academy of Orthopaedic Surgeons; 2009. Available from:
447
http://www.aaos.org/research/guidelines/gloguideline.pdf.
448
17.
449
Treatment of osteoarthritis of the knee (non-arthroplasty): Full guideline. Rosemont, IL:
RI PT
AGREE. Appraisal of Guidelines for REsearch & Evaluation II: AGREEII instrument
SC
Brouwers M, Kho M, Browman G, Burgers J, Cluzeau F, Feder G, et al. AGREE II:
M AN U
Poitras S, Avouac J, Rossignol M, Avouac B, Cedraschi C, Nordin M, et al. A critical
TE D
Hurkmans EJ, Jones A, Li LC, Vliet Vlieland TPM. Quality appraisal of clinical
EP
Brand C, Buchbinder R, Wluka A, Ruth D, McKenzie S, Jones K, et al. Guideline for
AC C
Brighton S, Mody GM, Tikly M, Bouwer D. Osteoarthritis: Clinical guideline 2003. S
Izquierdo R, Voloshin I, Edwards S, Freehill MQ, Stanwood W, Wiater JM, et al. The
Richmond J, Hunter D, Irrgang J, Jones MH, Snyder-Mackler L, Van Durme D, et al.
19
ACCEPTED MANUSCRIPT
450
American Academy of Orthopaedic Surgeons; 2008. Available from:
451
http://www.aaos.org/research/guidelines/oakguideline.pdf.
452
18.
453
Panel evidence-based clinical practice guidelines for the management of osteoarthritis in
454
adults who are obese or overweight. Phys Ther. 2011;91(6):843-61.
455
19.
456
American College of Rheumatology 2012 recommendations for the use of nonpharmacologic
457
and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res.
458
2012;64(4):465-74.
459
20.
460
EULAR recommendations 2003: An evidence based approach to the management of knee
461
osteoarthritis: Report of a task force of the Standing Committee for International Clinical
462
Studies Including Therapeutic Trials (ESCISIT). Ann Rheum Dis. 2003;62(12):1145-55.
463
21.
464
recommendations for the role of exercise in the management of osteoarthritis of the hip or
465
knee - The MOVE consensus. Rheumatology (Oxford). 2005;44(1):67-73.
466
22.
467
recommendations for the management of knee osteoarthritis: A consensus report of the
468
Turkish League Against Rheumatism. Turkish Journal of Rheumatology. 2012;27(1):1-17.
469
23.
470
evidence based recommendations for the management of hip osteoarthritis: Report of a task
471
force of the EULAR Standing Committee for International Clinical Studies Including
472
Therapeutics (ESCISIT). Ann Rheum Dis. 2005;64(5):669-81.
473
24.
474
evidence based recommendations for the management of hand osteoarthritis: Report of a task
RI PT
Brosseau L, Wells GA, Tugwell P, Egan M, Dubouloz C-J, Casimiro L, et al. Ottawa
M AN U
SC
Hochberg MC, Altman RD, April KT, Benkhalti M, Guyatt G, McGowan J, et al.
Jordan KM, Arden NK, Doherty M, Bannwarth B, Bijlsma JWJ, Dieppe P, et al.
TE D
Roddy E, Zhang W, Doherty M, Arden NK, Barlow J, Birrell F, et al. Evidence-based
AC C
EP
Tuncer T, Çay HF, Kaçar C, Altan L, Atik OS, Aydin AT, et al. Evidence-based
Zhang W, Doherty M, Arden N, Bannwarth B, Bijlsma J, Gunther KP, et al. EULAR
Zhang W, Doherty M, Leeb BF, Alekseeva L, Arden NK, Bijlsma JW, et al. EULAR
20
ACCEPTED MANUSCRIPT
475
force of the EULAR Standing Committee for International Clinical Studies Including
476
Therapeutics (ESCISIT). Ann Rheum Dis. 2007;66(3):377-88.
477
25.
478
recommendations for the management of hip and knee osteoarthritis, Part II: OARSI
479
evidence-based, expert consensus guidelines. Osteoarthritis and Cartilage. 2008;16(2):137-
480
62.
481
26.
482
al. EULAR recommendations for the non-pharmacological core management of hip and knee
483
osteoarthritis. Ann Rheum Dis. 2013;72:1125-35.
484
27.
485
Panel evidence-based clinical practice guidelines for patient education programmes in the
486
management of osteoarthritis. Health Educ J. 2011;70(3):318-58.
487
28.
488
Panel evidence-based clinical practice guidelines for therapeutic exercises and manual
489
therapy in the management of osteoarthritis. Phys Ther. 2005;85(9):907-71.
490
29.
491
the management of knee osteoarthritis. Report of a task force of the Standing Committee for
492
International Clinical Studies Including Therapeutic Trials. Joint Bone Spine.
493
2001;68(3):231-40.
494
30.
495
Physiotherapy in hip and knee osteoarthritis: Development of a practice guideline concerning
496
initial assessment, treatment and evaluation. Acta Reumatológica Portuguesa.
497
2011;36(3):268-81.
RI PT
Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N, et al. OARSI
M AN U
SC
Fernandes L, Hagen KB, Bijlsma JW, Andreassen O, Christensen P, Conaghan PG, et
Brosseau L, Wells GA, Tugwell P, Egan M, Dubouloz C-J, Casimiro L, et al. Ottawa
TE D
Brosseau L, Wells GA, Tugwell P, Egan M, Dubouloz C-J, Casimiro L, et al. Ottawa
AC C
EP
Mazières B, Bannwarth B, Dougados M, Lequesne M. EULAR recommendations for
Peter WFH, Jansen MJ, Hurkmans EJ, Bloo H, Dekker J, Dilling RG, et al.
21
ACCEPTED MANUSCRIPT
498
31.
Pencharz JN, Grigoriadis E, Jansz GF, Bombardier C. A critical appraisal of clinical
499
practice guidelines for the treatment of lower-limb osteoarthritis. Arthritis Research.
500
2002;4(1):36-44.
501
32.
502
quality of clinical practice guidelines over the last two decades: A systematic review of
503
guideline appraisal studies. Qual Saf Health Care. 2010;19(6):e58.
504
33.
505
based clinical practice. Chicago, IL: AMA Press; 2002.
RI PT
Alonso-Coello P, Irfan A, Sola I, Gich I, Delgado-Noguera M, Rigau D, et al. The
M AN U
506
SC
Guyatt GH, Rennie D. Users' guides to the medical literature: Essentials of evidence-
AC C
EP
TE D
507
22
ACCEPTED MANUSCRIPT
Appendix 1 Arthritis related organisations
RI PT
Organisation name 3e Initiative in Rheumatology African League of Associations for Rheumatology American Academy of Orthopaedic Surgeons
SC
American College of Rheumatology American Geriatrics Society
M AN U
American Pain Society Arthritis New Zealand Arthritis Research UK Arthritis Society - Canada
TE D
Arthritis.com
Asia Pacific League of Associations for Rheumatology Assessment of SpondyloArthritis International Society
EP
Brazilian Society of Rheumatology
British Paediatric Rheumatology Group
AC C
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
ACCEPTED MANUSCRIPT
Hong Kong Society of Rheumatology Institute for Clinical Systems Improvement International League of Association for Rheumatology
RI PT
Italian Society of Rheumatology Medical Journal of Australia Clinical Guidelines National Guidelines Clearinghouse
National Institute of Clinical Excellence
M AN U
New South Wales Therapeutic Assessment Group
SC
National Health and Medical Research Council
New Zealand Guidelines Group (completed voluntary liquidation mid-2012) Orthopedic Research Society
Osteoarthritis Research Society International Ottawa Panel Evidence
TE D
Panamerican League of Associations for Rheumatology Queensland University Clinical Practice Guidelines Royal Dutch Society for Physical Therapy
EP
Scottish Intercollegiate Guidelines Network South Africa Arthritis Foundation
AC C
Therapeutic Goods Administration Therapeutic Guidelines
Turkish League Against Rheumatism U.S. Agency for Healthcare Research & Quality
ACCEPTED MANUSCRIPT
Appendix 2
RI PT
Levels of evidence and strengths of recommendation scales Author. Criteria for levels of evidence/recommending grading AAOS(17)
ACR(19) Strong recommendation to use Weak (or conditional) recommendation to use No recommendation Weak (or conditional) recommendation not to use Strong recommendation not to use.
TE D
Study Type: Systematic reviews, high quality RCTs Poor quality RCTs, prospective or retrospective comparative studies, case control Case series, expert opinion
EP
Level of Evidence: Level I Level II or III Level IV or V None or Conflicting
M AN U
SC
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 There is insufficient or conflicting evidence not allowing a recommendation for or against intervention.
AC C
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, so clinicians must ensure that patients’ care is in keeping with their values and preferences. BSR(21) Strength of recommendation: A Directly based on category 1 evidence B Directly based on category 2 evidence or extrapolated recommendation from category 1 evidence C Directly based on category 3 evidence or extrapolated recommendation from category 1 or 2 evidence
ACCEPTED MANUSCRIPT
M AN U
EULAR(20, 23, 24, 26, 29) Strength of recommendation: Category 1 evidence A B Category 2 evidence or extrapolated recommendation from category 1 evidence C Category 3 evidence or extrapolated recommendation from category 1 or 2 evidence D Category 4 evidence or extrapolated recommendation from category 2 or 3 evidence
SC
Categories of evidence: Ia Meta-analysis of RCT Ib At least one RCT IIa At least one CT without randomization IIb At least one type of quasi-experimental study III Descriptive studies (comparative, correlation, case–control) IV Expert committee reports/opinions and/or clinical opinion of respected authorities
RI PT
Author. Criteria for levels of evidence/recommending grading D Directly based on category 4 evidence or extrapolated recommendation from category 1, 2 or 3 evidence
TE D
Categories of evidence: Ia Meta-analysis or RCT's Ib At least one RCT IIa At least one controlled study without randomisation IIb At least one 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
AC C
EP
NHMRC(14) 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. Levels of evidence: I Evidence obtained from a systematic review of all relevant randomised controlled trials. II Evidence obtained from at least one properly designed randomised controlled trial.
ACCEPTED MANUSCRIPT
RI PT
Author. Criteria for levels of evidence/recommending grading III-1 Evidence obtained from well designed pseudo randomised controlled trials (alternate allocation or some other method). III-2 Evidence obtained from comparative studies with concurrent controls and allocation not randomised (cohort studies), case control studies, or interrupted time series with a control group. III-3 Evidence obtained from comparative studies with historical control, two or more single arm studies, or interrupted time series without a parallel control group. IV Evidence obtained from case series, either post-test or pre-test and post-test.
M AN U
SC
NICE(1) Grading the evidence statements: High-quality meta-analyses (MA), systematic reviews of RCTs, or RCTs with a very low risk of bias. 1++ 1+ Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias. 1– Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias.* 2++ High-quality systematic reviews of case-control or cohort studies. High-quality case-control or cohort studies with a very low risk of confounding, bias or chance and a high probability that the relationship 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 relationship is causal. 2Case-control or cohort studies with a high risk of confounding, bias or chance and a significant risk that the relationship is not causal.* 3 Non-analytic studies (for example case reports, case series). 4 Expert opinion, formal consensus.
TE D
*Studies with a level of evidence ‘–’ are not used as a basis for making a recommendation OARSI (22, 25) Strength of Recommendation: VAS Scale (0-100%)
Ottawa Panel(5, 18, 27, 28) Grade: A (strongly recommended) B (recommended)
AC C
EP
Evidence hierarchy: Ia Meta-analysis of randomized controlled trials Ib At least one randomized controlled trial At least one well-designed controlled study, but without randomisation IIa IIb At least one well-designed quasi-experimental study III At least one non-experimental descriptive study (comparative, correlation or case-controlled study) IV Expert committee reports, opinions and/or experience of respected authorities
Clinical Importance (%): >=15 >=15
Statistical Significance:
S0003-9993(13)01105-2
DOI:
10.1016/j.apmr.2013.10.011
Reference:
YAPMR 55636
To appear in:
ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION
Received Date: 14 June 2013 Revised Date:
26 August 2013
Accepted Date: 8 October 2013
Please cite this article as: Larmer PJ, Reay ND, Aubert ER, Kersten P, A systematic review of guidelines for the physical management of osteoarthritis, ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION (2013), doi: 10.1016/j.apmr.2013.10.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Title: A systematic review of guidelines for the physical management of osteoarthritis.
Additional authors:
M AN U
Nicholas David Reay BBS Department of Physiotherapy Faculty of Health and Environmental Sciences AUT University Private Bag 92006 Auckland 1142 New Zealand
SC
Peter J. Larmer DHSc, MPH, FNZCP Head, School of Rehabilitation and Occupation Studies Faculty of Health and Environmental Sciences AUT University Private Bag 92006 Auckland 1142 New Zealand Ph;64-9-9219999 x 7322 Fax:64-9-9219620 Email: [email protected]
RI PT
Contact person and primary author:
EP
TE D
Elizabeth Richmond Aubert BSc Department of Physiotherapy Faculty of Health and Environmental Sciences AUT University Private Bag 92006 Auckland 1142 New Zealand
AC C
Paula Kersten PhD, MSc, BSc Associate Professor Person Centred Research Centre School of Rehabilitation and Occupation Studies Faculty of Health and Environmental Sciences AUT University New Zealand
Authors contributions All authors participated in the conception and design of the study, revision of the manuscript, acquired and interpreted the data, and drafted the manuscript. All authors read and approved the final manuscript. Acknowledgements The authors would like to acknowledge Andrew South, a library technician at the Auckland University of Technology, for his assistance with designing the literature search criteria.
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
Keywords: Osteoarthritis, Guideline, Rehabilitation, Critical appraisal
ACCEPTED MANUSCRIPT
1
A systematic review of guidelines for the physical management of osteoarthritis.
2 Abstract
RI PT
3 4
SC
5
Objective: To undertake a systematic critical appraisal of guidelines to provide a summary of
7
recommendations for the physical management of Osteoarthritis (OA).
M AN U
6
8 9
Data Sources: The Cochrane Library, MEDLINE, CINAHL, SPORTDiscuss with Full Text, Scopus, ScienceDirect, PEDro and Google Scholar databases were searched (2000 to 2013)
11
to identify all guidelines, protocols and recommendations for the management or treatment of
12
osteoarthritis. In addition internet searches of all relevant arthritis organisations were
13
undertaken. All searches were performed between July 2012 and end of April 2013.
14
Guidelines that included only pharmacological, injection therapy or surgical interventions
15
were excluded. Only guidelines published in English were retrieved.
EP
AC C
16
TE D
10
17
Study Selection: Osteoarthritis guidelines developed from evidence based research,
18
consensus and/or expert opinion were retrieved. There were no restrictions on severity or site
19
of OA, gender or age. Nineteen guidelines were identified for evaluation.
20
1
ACCEPTED MANUSCRIPT
Data Extraction: The quality of all guidelines was critically appraised using the AGREE II
22
instrument. Each guideline was independently reviewed. All relevant recommendations for
23
the physical management of OA were synthesised, graded and ranked according to available
24
evidence.
RI PT
21
25
Data Synthesis: Seventeen guidelines with recommendations on the physical management of
27
OA met the inclusion criteria and underwent a full critical appraisal. There were variations in
28
the interventions, levels of evidence and strength of recommendations across the guidelines.
29
Forty different interventions were identified. Recommendations were graded from ‘strongly
30
recommended’ to ‘unsupported’. Exercise and education were found to be strongly
31
recommended by most guidelines.
32
M AN U
SC
26
Conclusion: Exercise and education were key recommendations supporting the importance
34
of rehabilitation in the role in the physical management of OA. This critical appraisal can
35
assist health care providers who are involved in the management of people with OA.
EP
TE D
33
37 38 39
AC C
36
Keywords: Osteoarthritis, Guideline, Rehabilitation, Critical appraisal
40
Abbreviations:
41
OA Osteoarthritis
42 2
ACCEPTED MANUSCRIPT
SOR strength of recommendation
44
MA meta-analysis
45
RCT randomised controlled trials
46
TENS transcutaneous electrical nerve stimulation
47
Osteoarthritis (OA) is the most common form of arthritis and is identified as one of the
48
leading cause of pain and disability worldwide (1, 2). By the year 2020 the prevalence of OA is
49
expected to double (3). The risk factors associated with OA include: age, gender, genetics,
50
occupation, past injuries and, obesity (4). Hip and knee pain associated with OA often leads to
51
inactivity and loss of mobility resulting in deconditioning, weight gain, loss of independence
52
and decreased quality of life (5). There are substantial personal and societal costs associated
53
with OA (1). Personal costs may include the inability to participate in work, sport, hobbies or
54
caring for others due to pain. Societal costs may include visits to the doctor, medication costs
55
and assistance equipment. Joint replacement is an effective intervention to alleviate pain and
56
improve quality of life for those with advanced OA. However, despite a growing number of
57
joint replacements undertaken each year many people are still placed on a waiting list often
58
for a considerable time (6, 7). In order to reduce the burden of OA, safe and effective health
59
services, involving a range of non surgical treatments options are required. These services
60
must be effective with respect to intervention and cost as well as meet the affected person’s
61
needs.
SC
M AN U
TE D
EP
AC C
62
RI PT
43
63
Evidence based clinical guidelines are developed to assist the practitioner, patient and/or
64
policy-maker to make informed clinical decisions (8). Guidelines are valuable resources that
65
play an integral role in improving treatment and management of various health conditions. 3
ACCEPTED MANUSCRIPT
They can be used by health practitioners and people suffering with OA seeking information
67
to determine how their disease can best be managed. A preliminary search of the literature
68
identified many international guidelines developed for the management of OA. The
69
preliminary search identified that the guidelines included evidence and recommendations for
70
a number of interventions including: pharmacological, non-pharmacological, surgical and
71
injections therapies, physical management and lifestyle changes for the management of OA.
72
However, due to adverse side effects, patients and health care providers may pursue physical
73
management options rather than surgery, pharmacology, or injection based therapy. A
74
number of guidelines highly recommend exercise as an intervention for OA. However, Gill
75
et al (9) in a recent systematic review concluded that while exercise interventions were
76
beneficial for those people awaiting hip replacement, this was not the case for those awaiting
77
knee replacement. It was also noted that there were variations across the guidelines in the
78
recommendations made. Currently there is no critical appraisal of international guidelines
79
that has synthesised, graded and comprehensively presented all the relevant recommendations
80
for the physical management of OA. Therefore, a systematic critical appraisal of international
81
OA guidelines was undertaken to comprehensively present all the relevant evidence based
82
recommendations on the physical management of OA.
EP
TE D
M AN U
SC
RI PT
66
84 85 86 87
AC C
83 Methods
Electronic database searches
88 89
A systematic literature search was performed. The Cochrane Library, MEDLINE, CINAHL,
90
SPORTDiscuss with Full Text, Scopus, ScienceDirect, PEDro and Google Scholar databases 4
ACCEPTED MANUSCRIPT
were searched (2000 to 2013) to identify all guidelines, protocols and recommendations for
92
the management or treatment of osteoarthritis. An experienced health science librarian
93
assisted with the development of the search strategy. MEDLINE, CINAHL, SPORTDiscuss
94
with Full Text databases were searched using key word proximity searches to identify
95
guidelines or recommendations for the management of osteoarthritis ((osteoarthrit* N5
96
guideline*) OR (osteoarthrit* N5 evidence*) OR (osteoarthrit* N5 recommend) OR
97
(osteoarthrit* N5 best*)). Scopus and ScienceDirect databases used the same proximity
98
search logic but with the appropriate syntax. PEDro and The Cochrane Libraries were
99
searched using ((osteoarthriti* and guideline) AND (osteoarthriti* and protocol)). A manual
100
search was conducted on reference lists found in relevant guidelines, systematic reviews and
101
meta-analysis, which returned additional resources.
M AN U
SC
RI PT
91
102 Internet searches
TE D
103 104
A thorough internet search was conducted to identify international arthritis organisations and
106
guideline clearinghouses. The names of organisations were also found during the process of
107
reviewing guidelines and recommendations identified during the electronic database searches.
108
The websites of these organisations were reviewed and any relevant guidelines were
109
included. A list of these organisations is shown in Appendix 1.
111
AC C
110
EP
105
Eligibility Criteria
112 113
The primary source of literature for this review is recommended guidelines developed from
114
evidence based research, consensus and/or expert opinion. Guidelines that included only
115
pharmacological, injection therapy or surgical interventions were excluded. There were no 5
ACCEPTED MANUSCRIPT
restrictions on severity or site of OA, gender or age. The search was confined to papers
117
published in English and available electronically between the period of 2000 and end of April
118
2013. Animal based studies were not included. If there had been updates to guidelines, only
119
the latest version of the guideline was reviewed.
RI PT
116
120 121
Selection of guidelines
SC
122
All titles and/or abstracts were reviewed to determine if they met the eligibility criteria of this
124
critical appraisal. When citations met the criteria, the full text articles were retrieved and
125
reviewed. Nineteen guidelines were identified for evaluation. The details of results returned
126
are shown in Figure 1.
M AN U
123
127
Insert Figure 1 about here
TE D
128 129
131
Quality appraisal
EP
130
The Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool was used to
133
critique the guidelines (10). AGREE II is a guideline quality appraisal tool that has been found
134
to have high construct validity (11). The AGREE II consists of 23 items arranged into six
135
domains: scope and purpose (3 items), stakeholder involvement (3 items), rigour of
136
development (8 items), clarity of presentation (3 items), applicability (4 items) and editorial
137
independence (2 items). Each item is scored between strongly agree (4) to strongly disagree
138
(1). The items scores within a domain were then added and calculated as a percentage. A
AC C
132
6
ACCEPTED MANUSCRIPT
domain was determined to be effectively addressed if its score was ≥ 60%, as has been used
140
in other critical appraisals of arthritis guidelines (12, 13). Prior to a full critique of the guidelines
141
all members of the research team undertook a training review process to ensure consistency
142
and reliability in grading. All guidelines were then reviewed independently to ensure
143
sufficient reliability as suggested by previous authors (11). Differences in scoring were
144
resolved through discussions and consensus between all four authors. Where guidelines were
145
not clear, the identified author was contacted for clarification if possible. Finally, based on
146
their overall domain scores, the guidelines received an overall assessment from the research
147
team of either ‘recommended’, ‘recommended with modifications’, or ‘not recommended’
148
(10)
.
149 150
Synthesis of Recommendations
TE D
151
M AN U
SC
RI PT
139
Following the AGREE II appraisal of the guidelines, recommendations that were specific to
153
the physical management of OA were identified for data extraction. This analysis involved
154
categorising recommendations by intervention (e.g. exercise, education) with their associated
155
level of evidence (LOE) and strength of recommendation (SOR). For the purposes of this
156
review the interventions have been grouped for similarity into twelve interventions. For each
157
guideline recommendation, the associated interventions were scored on a +4 to -4 individual
158
weighting scale (Table 1) based on their LOE and SOR values. The levels of the scale were
159
derived from LOE and SOR values found in each guideline. There was variation in how
160
individual guidelines provided grading scales for both LOE and SOR. A list of individual
161
guideline scales is provided in Appendix 2. Guidelines based on meta-analysis (MA),
162
systematic reviews (SR) and definitive randomised controlled trials (RCTs) that were
163
strongly recommended were weighted highest (individual weighting = 4) while expert
AC C
EP
152
7
ACCEPTED MANUSCRIPT
opinion with a weak strength of recommendation was weighted low (individual weighting =
165
1). Where a guideline provided a recommendation against an intervention this was weighted
166
negatively (individual weighting = -1 - -4). There were two exceptions to this process. Firstly,
167
the recommendations from the National Health and Medical Research Council (NHMRC)
168
guideline (14) were already graded on a 4-point scale based on LOE and SOR. Secondly, the
169
NICE guideline (1) provided extensive level one evidence (MA, SR, and RCTs) throughout
170
the paper. However, it did not present recommendations with a LOE or SOR. Due to the
171
support of a high level of evidence we have graded each of the NICE recommendations with
172
a weighting of four.
M AN U
SC
RI PT
164
173
Overall recommendation scores of interventions were determined by the median value of the
175
specific interventions individual weightings. Table 2 illustrates how the overall intervention
176
recommendations were then grouped based on their median score into strongly
177
recommended, recommended, recommended with caution, and unsupported. For example,
178
knee bracing is recommended by five guidelines with weighted scores of 4, 3, 4, 4 and 2
179
resulting in a median score of 4 and grading of strongly recommended.
EP
TE D
174
180
182 183
Results
AC C
181
184
The systematic literature search yielded 19 guidelines. One (15) was excluded as there were
185
no stated methods for evidence gathering or developing recommendations, recommendations
186
were not clear and no method for grading recommendations was stated. One (16) was excluded 8
ACCEPTED MANUSCRIPT
187
because no conclusive recommendations were provided for the physical management of
188
glenohumeral joint OA. This resulted in 17 guidelines available for full data extraction.
190
RI PT
189 AGREE II appraisal results
191
Table 3 presents the 17 guidelines AGREE II domain scores with an overall quality
193
assessment rating and a comment on weaknesses of the specific guideline. There was
194
variability in the domains that were effectively addressed by the guidelines. Of the 17
195
guidelines, two effectively addressed four of the six AGREE II domains (14, 17), nine
196
effectively addressed three domains (18-26), and six effectively addressed at least two domains
197
(1, 5, 27-30)
198
28)
199
in any guideline. Six guidelines can be recommended without modifications (14, 17, 20, 24-26).
200
Eleven guidelines (1, 5, 18, 19, 21-23, 27-30) were recommended with modifications.
M AN U
SC
192
. Stakeholder involvement was effectively addressed by six guidelines (1, 14, 17, 18, 26,
TE D
, editorial independence in one guideline (22) and applicability was not effectively addressed
202 203
Interventions
EP
201
Forty interventions were identified across the guidelines. Table 4 presents the grouped
205
interventions covered by the 17 guidelines. The grouped interventions are listed in
206
descending order with the number of guidelines that recommended them: exercise (16
207
guidelines), education (13 guidelines), equipment (11 guidelines), weight loss/diet (11
208
guidelines), taping, heat/ice (9 guidelines), electrical based therapy (7 guidelines), self-
209
management (7 guidelines), acupuncture (5 guidelines), manual therapy (5 guidelines),
210
psychosocial interventions (5 guidelines) and balneotherapy/spa therapy (2 guidelines).
AC C
204
9
ACCEPTED MANUSCRIPT
Balneotherapy, refers to the passive relaxation in mineral or thermal water whereas
212
hydrotherapy refers to therapeutic methods (e.g. exercise) that take advantage of the physical
213
properties of water. All guidelines except the NICE guideline stated grading scales for their
214
recommendations, either using level of evidence (LOE), strength of recommendation (SOR),
215
or both. The grading criteria used by guideline developers varied among guidelines.
RI PT
211
216 Guideline intervention recommendations
SC
217
M AN U
218 219
The median weighting of the specific interventions across guidelines was calculated and then
220
given an overall recommendation. These are presented as strongly recommended (Table 5),
221
recommended (Table 6), recommended with caution (Table 7), unsupported (Table 8) and not
222
recommended (Table 9).
TE D
223
Strongly recommended interventions included: unspecified types of education (n=11(where
225
n= recommended by number of guidelines)), combined modalities of exercise or exercise of
226
an unspecified type (n=11), wedged insoles for knee OA (n=10), weight loss (n=10),
227
strengthening exercise (n=9), aerobic exercise (n=8), self-management (n=7), aquatic/hydro
228
therapy (n=6), transcutaneous electrical nerve stimulation (TENS) (n=6), knee bracing for
229
knee OA (n=5) and appropriate footwear (n=4). Yoga, manual therapy with supervised
230
exercise, manipulation and stretching, land based exercise and balneotherapy/spa therapies
231
were also graded as strongly recommended interventions. However, only three or fewer
232
guidelines provided recommendations for each of these interventions. Extensive research in
233
regards to specific forms of education and diet strategies were described by two of the Ottawa
AC C
EP
224
10
ACCEPTED MANUSCRIPT
Panel guidelines (18, 27) warranting their interventions to be strongly recommended. With
235
respect to exercise, there were few studies that investigated individualised or tailored
236
exercise, however nine guidelines (1, 14, 20-24, 26, 29) indicated that this should be an important
237
consideration when prescribing exercise.
RI PT
234
238
Recommended interventions included: thermal based therapy (n=7), taping (n=6), and
240
walking aides (n=6), and telephone support (n=5). Tai chi, electrical stimulation, devices to
241
assist with activities of daily living, acupuncture, multi modal physical therapy and adherence
242
strategies were also graded as recommended interventions. However, only three or fewer
243
guidelines provided recommendations for each of these interventions.
M AN U
SC
239
244
Two interventions, ultrasound and hand splints, were recommended with caution.
TE D
245 246
Interventions reported as unsupported recommendations were laser therapy, magnetic
248
bracelets, Chinese acupuncture, massage therapy, psychosocial interventions, and cognitive
249
behavioural therapy.
AC C
250
EP
247
251
One intervention, electro acupuncture, was explicitly not recommended by one guideline (1)
252
(Table 9). While there were a number of interventions that were either unsupported or not
253
recommended by their authors, there were no interventions that were specified as harmful.
254 255
Discussion 11
ACCEPTED MANUSCRIPT
256 257 This review is the first published critical appraisal of guidelines for the physical management
259
of OA. Of the 19 guidelines that we identified, two were excluded. Firstly, the South Africa
260
Arthritis Foundation guideline (15) was not included because recommendations were not
261
clearly stated. Secondly, the recommendations from the American Academy of Orthopaedic
262
Surgeons (AAOS) glenohumeral OA guideline (16) was not included as the focus of the
263
guideline was surgical and pharmacological, with no conclusive recommendations provided
264
for the physical management of OA. It was also noted that there were no allied health
265
members (physiotherapists or occupational therapists) on the guideline development group.
266
The group consisted entirely of medical doctors. In the future, patients with glenohumeral
267
OA may be better served if the working group included individuals from all relevant health
268
professional groups.
TE D
269
M AN U
SC
RI PT
258
The AGREE II instrument was used to assess the methodological quality of the remaining 17
271
guidelines. When reviewing the AGREE II domain scores, the authors chose to use 60% as
272
the value that represented adequate coverage of the criteria in a particular domain. The same
273
approach was also used in other critical appraisals of arthritis guidelines (12, 13). This allowed
274
comparisons of the domains amongst the 17 guidelines and recommendations to be made on
275
the areas that could be improved in future development of guidelines. In this appraisal the
276
domains of scope and purpose, rigour of development, and clarity of presentation were
277
addressed effectively by the majority of guidelines. However, there were three domains that
278
were consistently weak or unfulfilled by most guidelines: stakeholder involvement,
279
applicability and editorial independence. Reviewing previous appraisals on clinical practice
280
guidelines it became apparent that the same three domains have consistently scored poorly (12,
AC C
EP
270
12
ACCEPTED MANUSCRIPT
281
31, 32)
282
strong AGREE II scores add to the credibility of the recommendations.
. While AGREE II scores have no bearing on the actual content of the recommendations,
RI PT
283 Stakeholder involvement was only adequately addressed by six of the seventeen guidelines
285
and improvement is needed within this domain. It requires the inclusion of all relevant
286
information pertaining to the authors involved, target users clearly identified, and the views
287
of the target population considered when developing guidelines. Guyatt and Rennie (33)
288
reported that patient’s values need to be considered when developing evidence based
289
literature. A failure in doing so is likely to overlook the person’s lived experience of OA and
290
what is important to them. The applicability domain addresses resource implications,
291
facilitators and barriers as well as advice on the implementation of the recommendation.
292
None of the guidelines fulfilled the criteria for this domain. These elements play a role in
293
decision making for the consumer, and these should be addressed within the guideline.
294
Editorial independence adds to the rigour of the guideline. Only one guideline fulfilled this
295
criterion. Guideline developers are required to declare the funding body and any competing
296
interests. However, it is important that authors not only declare the funding body and
297
competing interests, but also clearly state editorial independence. When this is omitted, the
298
reader is unsure if there is actually a conflict of interest or if it was simply not mentioned.
299
While this may be taken for granted, it is an important statement that adds to the rigour of the
300
guideline. Improving all these areas of guideline development will allow the consumer to
301
have more confidence in the recommendations made within the guideline.
AC C
EP
TE D
M AN U
SC
284
302 303
The method used to determine our overall combined intervention recommendations is novel
304
and untested. We calculated a median score in an attempt to provide a balance on individual 13
ACCEPTED MANUSCRIPT
guideline’s LOE and SOR. The variability across guidelines made any attempt at aggregating
306
recommendations difficult. It is also important to note that while some interventions were
307
strongly recommended, some were based on only one or two guidelines. Balneotherapy was
308
based on two guidelines (22, 29), whilst, land based exercise (14), yoga (28), and diet (18) were
309
only based on one guideline. By comparison, other intervention recommendations were
310
supported by many guidelines and therefore provide greater confidence in recommending that
311
intervention.
SC
RI PT
305
312
There were some inconsistencies found among the guidelines. Peter et al. (30) specifically
314
recommended not to use massage therapy, electrical stimulation, laser therapy and
315
ultrasound, while ultrasound was recommended by Brand et al. (14), Tuncer et al. (22), and
316
Zhang et al. (24). Electrical stimulation was recommended by Brand et al. (14) and Tuncer et al.
317
(22)
318
opinion (14). Consumers of evidence based literature should be aware that there may be
319
conflicting evidence among the research. This critical appraisal has assisted the user by
320
identifying these inconsistencies and by providing a balanced interpretation.
TE D
, and massage therapy and laser therapy received a recommendation based on expert
EP
321
M AN U
313
The Ottawa group’s four guidelines (5, 18, 27, 28), while very comprehensive, failed to provide
323
specific recommendations for the management of OA. The group provided extensive
324
evidence of the research. However, the papers were presented in a PICOT (population,
325
intervention, comparator, outcome and timeframe) format for different comparisons of
326
interventions, making it difficult for consumers to take recommendations from the paper. The
327
Ottawa panel was contacted and responded to questions surrounding the usability of the
328
recommendations. The panel replied that a Cochrane Collaboration methodology was utilised
AC C
322
14
ACCEPTED MANUSCRIPT
and directed us to an Arthritis Society of Canada website. The Ottawa group report on highly
330
relevant information concerning the physical management of OA. However, it would assist
331
the guideline user if the group synthesised the data and presented key recommendations in an
332
easily identifiable summarised box or grouped together in one section.
RI PT
329
333
The NICE guidelines are very comprehensive, with extensive evidence supporting the use of
335
non-pharmacological interventions. The three core recommendations from the guideline were
336
for strength and aerobic fitness, education, and weight loss if overweight. However, there are
337
several user issues with the NICE guidelines. The guideline provided evidence statements in
338
tables throughout the guideline. However, it did not grade the evidence, instead it referred the
339
reader to an online link. Unfortunately the webpage was no longer available. After
340
corresponding with the author, we were informed that their recommendations were no longer
341
graded and it was advised to use the language in the recommendation as a guide. Although
342
they provided strong evidence, without grading the levels of evidence and strength of
343
recommendations it was difficult to interpret the recommendations. The authors have
344
endeavoured to use a consistent methodology when grading the NICE guideline
345
recommendations. While it is not mandatory to use a grading system for the strength of
346
recommendations, it provides the reader with valuable information. Finally, the layout of the
347
NICE recommendations was very difficult to follow. The guideline provided 36
348
recommendations (18 non-pharmacological recommendations). These were dispersed
349
throughout the document making it very difficult to locate all of the recommendations. It
350
would assist the reader if the recommendations were presented in an easily identifiable box
351
summarising the recommendations or presenting them grouped together at the beginning of
352
the document.
AC C
EP
TE D
M AN U
SC
334
15
ACCEPTED MANUSCRIPT
353 Exercise and education were found to be amongst the strongest interventions recommended
355
throughout the guidelines. While the exercise recommendations ranged from very specific
356
(aerobic, strength training, or hydrotherapy) to very general (exercise of unspecified type),
357
the message was clear that exercise in all its forms is strongly recommended for OA, most
358
specifically for knee OA. The important benefits of exercise include an improvement in pain
359
and function, which are the main complaints reported by OA sufferers. Exercise is a low cost
360
option in the management of OA, which makes it accessible to all OA sufferers. Education
361
was also considered a strong recommendation. Education was found to reduce pain, increase
362
coping skills and result in fewer visits to primary care practitioners in knee OA (5, 20, 29).
363
Additionally, although the supporting evidence concerning tailored exercises was sparse, the
364
consensus from nine guidelines recommended prescribing individualised patient exercise and
365
education and these are key components of rehabilitation.
TE D
M AN U
SC
RI PT
354
366
369
EP
368
Study Limitations
AC C
367
370
This critical appraisal has two key limitations. Firstly, a new grading scale to grade the
371
overall strength of each recommendation was developed. This was a non-standardised
372
grading system and requires further testing. Secondly, only guidelines published in English
373
were reviewed leading to a potential publication bias. This criterion may misrepresent the
374
amount of research that has been conducted on the physical management of OA globally.
375 16
ACCEPTED MANUSCRIPT
376
Conclusions
377 378 The objective of this appraisal was to review the available guidelines and present the
380
treatment recommendations for the physical management of OA in a format that was useful
381
to the user. Throughout the research, there is strong evidence to support aspects of the use of
382
exercise, electrical based therapy, equipment, education, diet and weight loss, manual therapy
383
and self management. Laser therapy, magnetic bracelets, Chinese acupuncture, massage
384
therapy, aspects of psychosocial based therapy and electro acupuncture were either
385
unsupported or not recommended. With the prevalence of OA expected to double by 2020
386
and the personal and societal costs associated with OA being substantial, it is important to
387
establish the best strategy to manage and treat OA. As exercise and education were found to
388
be among the strongest recommendations within the guidelines and can be relatively cost
389
effective to provide, there is an opportunity for those engaged in rehabilitation to move into a
390
leading role in the management of OA.
391
In this critical appraisal we have taken a unique approach. Not only have we appraised the
392
quality of the guidelines but also synthesised, graded and comprehensively presented all the
393
relevant recommendations for the physical management of OA. It is hoped that this will
394
inform health care providers on the best evidence interventions available for the physical
395
management of OA.
397
SC
M AN U
TE D
EP
AC C
396
RI PT
379
References
398 399
17
ACCEPTED MANUSCRIPT
400
1.
National Collaborating Centre for Chronic Conditions. Osteoarthritis: National
401
clinical guideline for care and management in adults: Royal College of Physicians; 2008.
402
Available from: http://www.nice.org.uk/CG059. Accessed November 26, 2012.
403
2.
404
with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a
405
systematic analysis for the Global Burden of Disease Study 2010. Lancet.
406
2012;380(9859):2163-96.
407
3.
408
disabling hip and knee osteoarthritis (OA) from the perspective of individuals living with this
409
condition. Rheumatology (Oxford). 2005;44(12):1531-7.
410
4.
411
Geneva: World Health Organisation; 2003.
412
5.
413
evidence-based clinical practice guidelines for aerobic walking programs in the management
414
of osteoarthritis. Arch Phys Med Rehabil. 2012;93(7):1269-85.
415
6.
416
waiting for hip and knee replacements in Ontario. Ontario Hip and Knee Replacement Project
417
Team. J Eval Clin Pract. 1997;3(1):59-68.
418
7.
419
reported by more than half of those waiting for joint replacement surgery: a prospective
420
cohort study. BMC Musculoskelet Disord. 2011;12(1):108-16.
421
8.
422
guides to the medical literature: XXV. Evidence-based medicine: Principles for applying the
423
Users' Guides to patient care. JAMA: Journal of the American Medical Association.
424
2000;284(10):1290-6.
SC
RI PT
Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, et al. Years lived
M AN U
Gupta S, Hawker GA, Laporte A, Croxford R, Coyte PC. The economic burden of
Symmons D, Mathers C, Pleger B. Global burden of osteoarthritis in the year 2000.
TE D
Loew L, Brosseau L, Wells GA, Tugwell P, Kenny GP, Reid R, et al. Ottawa panel
EP
Williams JI, Llewellyn Thomas H, Arshinoff R, Young N, Naylor CD. The burden of
AC C
Ackerman IN, Bennell KL, Osborne RH. Decline in Health-Related Quality of Life
Guyatt GH, Haynes RB, Jaeschke RZ, Cook DJ, Green L, Naylor CD, et al. Users'
18
ACCEPTED MANUSCRIPT
425
9.
Gill SD, McBurney H. Does exercise reduce pain and improve physical function
426
before hip or knee replacement surgery? A systematic review and meta-analysis of
427
randomized controlled trials. Arch Phys Med Rehabil. 2013;94(1):164-76.
428
10.
429
2009. Available from: http://www.agreetrust.org/. Accessed January 14, 2013.
430
11.
431
Advancing guideline development, reporting and evaluation in health care. Can Med Assoc J.
432
2010;182(18):E839-E42.
433
12.
434
appraisal of guidelines for the management of knee osteoarthritis using Appraisal of
435
Guidelines Research and Evaluation criteria. Arthritis Research & Therapy. 2007;9(6):R126.
436
13.
437
practice guidelines on the use of physiotherapy in rheumatoid arthritis: a systematic review.
438
Rheumatology (Oxford). 2011;50(10):1879-88.
439
14.
440
the nonsurgical management of hip and knee osteoarthritis 2009. Available from:
441
http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.
442
15.
443
Afr Med J. 2003;93(12, Pt. 2):972-90.
444
16.
445
treatment of glenohumeral joint osteoarthritis: Guideline and evidence report. Rosemont, IL:
446
American Academy of Orthopaedic Surgeons; 2009. Available from:
447
http://www.aaos.org/research/guidelines/gloguideline.pdf.
448
17.
449
Treatment of osteoarthritis of the knee (non-arthroplasty): Full guideline. Rosemont, IL:
RI PT
AGREE. Appraisal of Guidelines for REsearch & Evaluation II: AGREEII instrument
SC
Brouwers M, Kho M, Browman G, Burgers J, Cluzeau F, Feder G, et al. AGREE II:
M AN U
Poitras S, Avouac J, Rossignol M, Avouac B, Cedraschi C, Nordin M, et al. A critical
TE D
Hurkmans EJ, Jones A, Li LC, Vliet Vlieland TPM. Quality appraisal of clinical
EP
Brand C, Buchbinder R, Wluka A, Ruth D, McKenzie S, Jones K, et al. Guideline for
AC C
Brighton S, Mody GM, Tikly M, Bouwer D. Osteoarthritis: Clinical guideline 2003. S
Izquierdo R, Voloshin I, Edwards S, Freehill MQ, Stanwood W, Wiater JM, et al. The
Richmond J, Hunter D, Irrgang J, Jones MH, Snyder-Mackler L, Van Durme D, et al.
19
ACCEPTED MANUSCRIPT
450
American Academy of Orthopaedic Surgeons; 2008. Available from:
451
http://www.aaos.org/research/guidelines/oakguideline.pdf.
452
18.
453
Panel evidence-based clinical practice guidelines for the management of osteoarthritis in
454
adults who are obese or overweight. Phys Ther. 2011;91(6):843-61.
455
19.
456
American College of Rheumatology 2012 recommendations for the use of nonpharmacologic
457
and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res.
458
2012;64(4):465-74.
459
20.
460
EULAR recommendations 2003: An evidence based approach to the management of knee
461
osteoarthritis: Report of a task force of the Standing Committee for International Clinical
462
Studies Including Therapeutic Trials (ESCISIT). Ann Rheum Dis. 2003;62(12):1145-55.
463
21.
464
recommendations for the role of exercise in the management of osteoarthritis of the hip or
465
knee - The MOVE consensus. Rheumatology (Oxford). 2005;44(1):67-73.
466
22.
467
recommendations for the management of knee osteoarthritis: A consensus report of the
468
Turkish League Against Rheumatism. Turkish Journal of Rheumatology. 2012;27(1):1-17.
469
23.
470
evidence based recommendations for the management of hip osteoarthritis: Report of a task
471
force of the EULAR Standing Committee for International Clinical Studies Including
472
Therapeutics (ESCISIT). Ann Rheum Dis. 2005;64(5):669-81.
473
24.
474
evidence based recommendations for the management of hand osteoarthritis: Report of a task
RI PT
Brosseau L, Wells GA, Tugwell P, Egan M, Dubouloz C-J, Casimiro L, et al. Ottawa
M AN U
SC
Hochberg MC, Altman RD, April KT, Benkhalti M, Guyatt G, McGowan J, et al.
Jordan KM, Arden NK, Doherty M, Bannwarth B, Bijlsma JWJ, Dieppe P, et al.
TE D
Roddy E, Zhang W, Doherty M, Arden NK, Barlow J, Birrell F, et al. Evidence-based
AC C
EP
Tuncer T, Çay HF, Kaçar C, Altan L, Atik OS, Aydin AT, et al. Evidence-based
Zhang W, Doherty M, Arden N, Bannwarth B, Bijlsma J, Gunther KP, et al. EULAR
Zhang W, Doherty M, Leeb BF, Alekseeva L, Arden NK, Bijlsma JW, et al. EULAR
20
ACCEPTED MANUSCRIPT
475
force of the EULAR Standing Committee for International Clinical Studies Including
476
Therapeutics (ESCISIT). Ann Rheum Dis. 2007;66(3):377-88.
477
25.
478
recommendations for the management of hip and knee osteoarthritis, Part II: OARSI
479
evidence-based, expert consensus guidelines. Osteoarthritis and Cartilage. 2008;16(2):137-
480
62.
481
26.
482
al. EULAR recommendations for the non-pharmacological core management of hip and knee
483
osteoarthritis. Ann Rheum Dis. 2013;72:1125-35.
484
27.
485
Panel evidence-based clinical practice guidelines for patient education programmes in the
486
management of osteoarthritis. Health Educ J. 2011;70(3):318-58.
487
28.
488
Panel evidence-based clinical practice guidelines for therapeutic exercises and manual
489
therapy in the management of osteoarthritis. Phys Ther. 2005;85(9):907-71.
490
29.
491
the management of knee osteoarthritis. Report of a task force of the Standing Committee for
492
International Clinical Studies Including Therapeutic Trials. Joint Bone Spine.
493
2001;68(3):231-40.
494
30.
495
Physiotherapy in hip and knee osteoarthritis: Development of a practice guideline concerning
496
initial assessment, treatment and evaluation. Acta Reumatológica Portuguesa.
497
2011;36(3):268-81.
RI PT
Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N, et al. OARSI
M AN U
SC
Fernandes L, Hagen KB, Bijlsma JW, Andreassen O, Christensen P, Conaghan PG, et
Brosseau L, Wells GA, Tugwell P, Egan M, Dubouloz C-J, Casimiro L, et al. Ottawa
TE D
Brosseau L, Wells GA, Tugwell P, Egan M, Dubouloz C-J, Casimiro L, et al. Ottawa
AC C
EP
Mazières B, Bannwarth B, Dougados M, Lequesne M. EULAR recommendations for
Peter WFH, Jansen MJ, Hurkmans EJ, Bloo H, Dekker J, Dilling RG, et al.
21
ACCEPTED MANUSCRIPT
498
31.
Pencharz JN, Grigoriadis E, Jansz GF, Bombardier C. A critical appraisal of clinical
499
practice guidelines for the treatment of lower-limb osteoarthritis. Arthritis Research.
500
2002;4(1):36-44.
501
32.
502
quality of clinical practice guidelines over the last two decades: A systematic review of
503
guideline appraisal studies. Qual Saf Health Care. 2010;19(6):e58.
504
33.
505
based clinical practice. Chicago, IL: AMA Press; 2002.
RI PT
Alonso-Coello P, Irfan A, Sola I, Gich I, Delgado-Noguera M, Rigau D, et al. The
M AN U
506
SC
Guyatt GH, Rennie D. Users' guides to the medical literature: Essentials of evidence-
AC C
EP
TE D
507
22
ACCEPTED MANUSCRIPT
Appendix 1 Arthritis related organisations
RI PT
Organisation name 3e Initiative in Rheumatology African League of Associations for Rheumatology American Academy of Orthopaedic Surgeons
SC
American College of Rheumatology American Geriatrics Society
M AN U
American Pain Society Arthritis New Zealand Arthritis Research UK Arthritis Society - Canada
TE D
Arthritis.com
Asia Pacific League of Associations for Rheumatology Assessment of SpondyloArthritis International Society
EP
Brazilian Society of Rheumatology
British Paediatric Rheumatology Group
AC C
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
ACCEPTED MANUSCRIPT
Hong Kong Society of Rheumatology Institute for Clinical Systems Improvement International League of Association for Rheumatology
RI PT
Italian Society of Rheumatology Medical Journal of Australia Clinical Guidelines National Guidelines Clearinghouse
National Institute of Clinical Excellence
M AN U
New South Wales Therapeutic Assessment Group
SC
National Health and Medical Research Council
New Zealand Guidelines Group (completed voluntary liquidation mid-2012) Orthopedic Research Society
Osteoarthritis Research Society International Ottawa Panel Evidence
TE D
Panamerican League of Associations for Rheumatology Queensland University Clinical Practice Guidelines Royal Dutch Society for Physical Therapy
EP
Scottish Intercollegiate Guidelines Network South Africa Arthritis Foundation
AC C
Therapeutic Goods Administration Therapeutic Guidelines
Turkish League Against Rheumatism U.S. Agency for Healthcare Research & Quality
ACCEPTED MANUSCRIPT
Appendix 2
RI PT
Levels of evidence and strengths of recommendation scales Author. Criteria for levels of evidence/recommending grading AAOS(17)
ACR(19) Strong recommendation to use Weak (or conditional) recommendation to use No recommendation Weak (or conditional) recommendation not to use Strong recommendation not to use.
TE D
Study Type: Systematic reviews, high quality RCTs Poor quality RCTs, prospective or retrospective comparative studies, case control Case series, expert opinion
EP
Level of Evidence: Level I Level II or III Level IV or V None or Conflicting
M AN U
SC
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 There is insufficient or conflicting evidence not allowing a recommendation for or against intervention.
AC C
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, so clinicians must ensure that patients’ care is in keeping with their values and preferences. BSR(21) Strength of recommendation: A Directly based on category 1 evidence B Directly based on category 2 evidence or extrapolated recommendation from category 1 evidence C Directly based on category 3 evidence or extrapolated recommendation from category 1 or 2 evidence
ACCEPTED MANUSCRIPT
M AN U
EULAR(20, 23, 24, 26, 29) Strength of recommendation: Category 1 evidence A B Category 2 evidence or extrapolated recommendation from category 1 evidence C Category 3 evidence or extrapolated recommendation from category 1 or 2 evidence D Category 4 evidence or extrapolated recommendation from category 2 or 3 evidence
SC
Categories of evidence: Ia Meta-analysis of RCT Ib At least one RCT IIa At least one CT without randomization IIb At least one type of quasi-experimental study III Descriptive studies (comparative, correlation, case–control) IV Expert committee reports/opinions and/or clinical opinion of respected authorities
RI PT
Author. Criteria for levels of evidence/recommending grading D Directly based on category 4 evidence or extrapolated recommendation from category 1, 2 or 3 evidence
TE D
Categories of evidence: Ia Meta-analysis or RCT's Ib At least one RCT IIa At least one controlled study without randomisation IIb At least one 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
AC C
EP
NHMRC(14) 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. Levels of evidence: I Evidence obtained from a systematic review of all relevant randomised controlled trials. II Evidence obtained from at least one properly designed randomised controlled trial.
ACCEPTED MANUSCRIPT
RI PT
Author. Criteria for levels of evidence/recommending grading III-1 Evidence obtained from well designed pseudo randomised controlled trials (alternate allocation or some other method). III-2 Evidence obtained from comparative studies with concurrent controls and allocation not randomised (cohort studies), case control studies, or interrupted time series with a control group. III-3 Evidence obtained from comparative studies with historical control, two or more single arm studies, or interrupted time series without a parallel control group. IV Evidence obtained from case series, either post-test or pre-test and post-test.
M AN U
SC
NICE(1) Grading the evidence statements: High-quality meta-analyses (MA), systematic reviews of RCTs, or RCTs with a very low risk of bias. 1++ 1+ Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias. 1– Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias.* 2++ High-quality systematic reviews of case-control or cohort studies. High-quality case-control or cohort studies with a very low risk of confounding, bias or chance and a high probability that the relationship 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 relationship is causal. 2Case-control or cohort studies with a high risk of confounding, bias or chance and a significant risk that the relationship is not causal.* 3 Non-analytic studies (for example case reports, case series). 4 Expert opinion, formal consensus.
TE D
*Studies with a level of evidence ‘–’ are not used as a basis for making a recommendation OARSI (22, 25) Strength of Recommendation: VAS Scale (0-100%)
Ottawa Panel(5, 18, 27, 28) Grade: A (strongly recommended) B (recommended)
AC C
EP
Evidence hierarchy: Ia Meta-analysis of randomized controlled trials Ib At least one randomized controlled trial At least one well-designed controlled study, but without randomisation IIa IIb At least one well-designed quasi-experimental study III At least one non-experimental descriptive study (comparative, correlation or case-controlled study) IV Expert committee reports, opinions and/or experience of respected authorities
Clinical Importance (%): >=15 >=15
Statistical Significance:
