Hochberg MC, Altman RD, April KT, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken) 64: 465

Division of Rheumatology, University of Maryland School of Medicine, 10 South Pine Street, MSTF 8-34, Baltimore, MD 21201, USA.
Arthritis care & research 04/2012; 64(4):465-74. DOI: 10.1002/acr.21596
Source: PubMed


To update the American College of Rheumatology (ACR) 2000 recommendations for hip and knee osteoarthritis (OA) and develop new recommendations for hand OA.
A list of pharmacologic and nonpharmacologic modalities commonly used to manage knee, hip, and hand OA as well as clinical scenarios representing patients with symptomatic hand, hip, and knee OA were generated. Systematic evidence-based literature reviews were conducted by a working group at the Institute of Population Health, University of Ottawa, and updated by ACR staff to include additions to bibliographic databases through December 31, 2010. The Grading of Recommendations Assessment, Development and Evaluation approach, a formal process to rate scientific evidence and to develop recommendations that are as evidence based as possible, was used by a Technical Expert Panel comprised of various stakeholders to formulate the recommendations for the use of nonpharmacologic and pharmacologic modalities for OA of the hand, hip, and knee.
Both “strong” and “conditional” recommendations were made for OA management. Modalities conditionally recommended for the management of hand OA include instruction in joint protection techniques, provision of assistive devices, use of thermal modalities and trapeziometacarpal joint splints, and use of oral and topical nonsteroidal antiinflammatory drugs (NSAIDs), tramadol, and topical capsaicin. Nonpharmacologic modalities strongly recommended for the management of knee OA were aerobic, aquatic, and/or resistance exercises as well as weight loss for overweight patients. Nonpharmacologic modalities conditionally recommended for knee OA included medial wedge insoles for valgus knee OA, subtalar strapped lateral insoles for varus knee OA, medially directed patellar taping, manual therapy, walking aids, thermal agents, tai chi, self management programs, and psychosocial interventions. Pharmacologic modalities conditionally recommended for the initial management of patients with knee OA included acetaminophen, oral and topical NSAIDs, tramadol, and intraarticular corticosteroid injections; intraarticular hyaluronate injections, duloxetine, and opioids were conditionally recommended in patients who had an inadequate response to initial therapy. Opioid analgesics were strongly recommended in patients who were either not willing to undergo or had contraindications for total joint arthroplasty after having failed medical therapy. Recommendations for hip OA were similar to those for the management of knee OA.
These recommendations are based on the consensus judgment of clinical experts from a wide range of disciplines, informed by available evidence, balancing the benefits and harms of both nonpharmacologic and pharmacologic modalities, and incorporating their preferences and values. It is hoped that these recommendations will be utilized by health care providers involved in the management of patients with OA.

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Available from: Karine Toupin April, Oct 28, 2015
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    • "In thumb OA, corticosteroid injections are recommended, and hyaluronic acid injections may be useful, according to the EULAR experts [5]. However, both of these injection modalities are not recommended by the ACR experts [4]. The objective of the present study was to assess short-term and medium-term efficacy on pain, functional capacity and pulp pinch force of intra-articular injections of corticosteroids or hyaluronic acid in patients with thumb OA in controlled trials, by performing a meta-analysis of published articles. "
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    ABSTRACT: The objective was to assess the efficacy of intra-articular injections of corticosteroids or hyaluronic acid in thumb osteoarthritis. A systematic review of the literature was performed until August 2014. All controlled trials reporting the efficacy on pain, functional capacity and pulp pinch force of hyaluronic acid or corticosteroids in thumb osteoarthritis were selected. Pooled standardized response means (SRMs) were assessed by meta-analysis. Six trials were included and contributed to 3 meta-analyses (hyaluronic acid versus placebo, corticosteroids vs. placebo and hyaluronic acid vs. corticosteroids). Among the 428 patients included, 169 were treated with hyaluronic acid, 147 with corticosteroids and 74 with placebo. Versus placebo at week 12, hyaluronic acid (2 trials, 148 patients) lead to better functional capacity (SRM -1.14 [-1.69; -0.60]) with no difference on pain; corticosteroids (2 trials, 164 patients) lead to no difference on pain or function. When comparing hyaluronic acid vs. corticosteroids (4 trials, 304 patients), no difference was evidenced until week 12. At week 24, pain was significantly lower in the corticosteroids group (SRM 1.44 [0.14; 2.74]) and pulp pinch force higher in the hyaluronic acid group (SRM -0.75 [-3.87; -1.97]). This meta-analysis shows great heterogeneity. Hyaluronic acid may be useful to increase functional capacity and corticosteroids to decrease pain in thumb osteoarthritis at week 24. Copyright © 2015. Published by Elsevier SAS.
    Full-text · Article · Mar 2015 · Joint, bone, spine: revue du rhumatisme
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    • "The medial compartment of the knee is the most common site affected by OA (Lawrence et al., 2008) and has attracted much attention for treatment and symptom alleviation. Aerobic exercise is one of the more effective nonpharmacologic treatment options for OA (Hochberg et al., 2012a, 2012b; Jordan et al., 2003; Wortley et al., 2013; Zhang, 2013; Zhang et al., 2008); however, weight-bearing activities may increase joint loading and pain, which could ultimately prohibit continued participation . To address this issue, exercises such as cycling that are intended to reduce joint loading compared to weight-bearing activities are commonly recommended by prominent health organizations (AAOS, 2014; Westby, 2012; Winters). "
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    ABSTRACT: Background: Cycling is commonly prescribed for knee osteoarthritis, but previous literature on biomechanics during cycling and the effects of acute intervention on osteoarthritis patients does not exist. Due to their altered knee kinematics, osteoarthritis patients may be at greater risk of osteoarthritis progression or other knee injuries during cycling. This study investigated the effects of reduced foot progression (toe-in) angles on knee joint biomechanics in subjects with medial compartment knee osteoarthritis. Methods: Thirteen osteoarthritis and 11 healthy subjects participated in this study. A motion analysis system and custom instrumented pedal was used to collect 5 pedal cycles of kinematic and kinetic data in 1 neutral and 2 toe-in conditions (5° and 10°) at 60 RPM and 80W. Findings: For peak knee adduction angle, there was a 61% (2.7°) and a 73% (3.2°) decrease in the 5° and 10° toe-in conditions compared to neutral in the osteoarthritis group and a 77% (1.7°) and 109% (2.4°) decrease in the healthy group for the 5° and 10° conditions, respectively. This finding was not accompanied by a decrease in pain or peak knee abduction moment. A simple linear regression showed a positive correlation between Kelgren-Lawrence score and both peak knee adduction angle and abduction moment. Interpretation: For individuals who cycle with increased knee adduction angles, decreasing the foot progression angle may be beneficial for reducing the risk of overuse knee injuries during cycling by resulting in a frontal plane knee alignment closer to a neutral position.
    Full-text · Article · Jan 2015 · Clinical Biomechanics
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    • "The well-known pharmacological approach for symptomatic treatment includes oral administration of paracetamol, NSAIDs, opioids, and intra-articular corticosteroid injections [3] [4]. Although paracetamol should be prescribed as the preferred oral analgesic [5], it has been reported that the majority of patients with OA would prefer NSAIDs to paracetamol [6] [7]. However, NSAIDs should be used with caution in patients with peptic ulcer disease, renal insufficiency, or cardiovascular risk [8] [9]. "
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    ABSTRACT: The aim of this study was to verify the clinical responses to Thai massage (TM) and Thai herbal compression (THC) for treating osteoarthritis (OA) of the knee in comparison to oral ibuprofen. This study was a randomized, evaluator-blind, controlled trial. Sixty patients with OA of the knee were randomly assigned to receive either a one-hour session of TM or THC (three times weekly) or oral ibuprofen (three times daily). The duration of treatment was three weeks. The clinical assessments included visual analog scale assessing pain and stiffness, Lequesne's functional index, time for climbing up ten steps, and physician's and patient's overall opinions on improvement. In a within-group comparison, each treatment modality caused a significant improvement of all variables determined for outcome assessments. In an among group comparison, all modalities provided nearly comparable clinical efficacy after a three-week symptomatic treatment of OA of the knee, in which a trend toward greatest improvement was likely to be found in THC group. In conclusion, TM and THC generally provided comparable clinical efficacy to oral ibuprofen after three weeks of treatment and could be considered as complementary and alternative treatments for OA of the knee.
    Full-text · Article · Sep 2014 · BioMed Research International
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