EULAR recommendations for the management of knee osteoarthritis. Report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials

doi:10.1016/S1297-319X(01)00271-8

Joint Bone Spine

Volume 68, Issue 3, May 2001, Pages 231-240

https://doi.org/10.1016/S1297-319X(01)00271-8 Get rights and content

Abstract

A task force for the EULAR standing committee for clinical trials determined the methodological and logistical approach required for the development of evidence-based guidelines for treatment of knee osteoarthirits (OA). Methods. The first stage was the selection of treatment modalities to be considered. The second stage comprised a search of the databases of all European-language publications. All of the relevant studies were quality scored. The third stage involved determination of key clinical propositions by expert consensus employing a Delphi approach. The final stage involved ranking of these propositions according to the available evidence. A second set of propositions relating to a future research agenda was determined by expert consensus. Results. Seven hundred and forty-four studies presented outcome data of the effects of specific treatments on knee OA. Quantitative analysis of treatment effect was possible in only 61 studies. Recommendations for the management of knee OA based on currently available data and expert opinion are presented. Proposals for a future research agenda are highlighted. Conclusions. These are the first clinical guidelines on knee OA to combine an evidence-based approach and a consensus approach across a wide range of treatment modalities. It is apparent that only certain clinical propositions are supported by substantial research-based evidence. There is thus an urgent need for future well-designed trials to address key clinical questions.

Section snippets

Recommendations …

Clinical guidelines were defined by the Institute of Medicine in Washington 〚1〛 as “Systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical conditions.” These recommendations appeared about 10 years ago (more than 230 papers on Medline for the January-November 2000 period only). In France, ANAES (Agence Nationale dˈAccréditation et dˈEvaluation en Santé: National Agency for Health Assessment and Accreditation) regularly

…in osteoarthritis

Osteoarthritis (OA) is by far the most common disease to affect synovial joints. It is a major cause of pain and disability. Its cost – estimated in France at more than 6 billion francs in 1993 〚2〛 – poses a community health care problem. With the increasing proportion of elderly people in the population, OA will become an even more important challenge.

OA of the knees is particularly common, with radiographic OA of the tibio-femoral compartment occurring in 5 to 15% of persons aged 35–74 years.

The task force

A task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutic Trials was created in September 1998. It involved a committee of 21 experts in the field of osteoarthritis (rheumatologists and orthopaedic surgeons) representing 13 different European countries together with two experts in the field of guidelines methodology and one pharmacologist (table I).

The objectives of the Committee were: 1) to describe the therapies available for the treatment of knee

Methods

The first step was to produce a comprehensive list of treatment modalities to be included in the review process.

The second step was a systematic search conducted using two databases, Medline Ovid and Bids Embase. All European-language publications in the form of clinical trials and meta-analyses were included. The searches were conducted for the period January–December 1966-1998 and were last performed in July 1999. The methodological quality of each study was scored (from 0 to 28) according to

The list of the 23 treatment modalities

Ten of these modalities are non-pharmacological, nine concern pharmacological tools and four are surgical procedures. Topical (percutaneous) therapy includes NSAIDs and capsaicine or other local analgesics not marketed in France. Vitamins and mineral salts are grouped as ‘nutrients’ (table IV).

Evidence-based approach

Two thousand eight hundred and ninety-two studies were identified by the search strategy; 744 were intervention trials involving knee osteoarthritis. Six hundred and eighty of these trials involved at

Discussion

These are the first clinical guidelines on knee OA to be developed by EULAR. An evidence-based approach was specifically chosen by the Task Force. This was to minimise the potential limitations of ‘expert opinion’ alone 〚50〛 and to permit, wherever possible, calculation of effect sizes and NNT to allow comparison of efficacy between diverse forms of treatment.

Despite the strengths of this method of guideline development a number of caveats deserve emphasis. Although we employed a traditional

References (51)

M Dougados et al.
High molecular weight sodium hyaluronate (hyalectin) in osteoarthritis of the knee: a 1-year placebo-controlled trial
Osteoarthritis Cartilage
(1993)
V Listrat et al.
Arthroscopic evaluation of potential structure modifying activity of hyaluronan (Hyalgan) in osteoarthritis of the knee
Osteoarthritis Cartilage
(1997)
L Bucsi et al.
Efficacy and tolerability of oral chondroitin sulfate as a symptomatic slow-acting drug for osteoarthritis (SYSADOA) in the treatment of knee osteoarthritis
Osteoarthritis Cartilage
(1998)
P Bourgeois et al.
Efficacy and tolerability of chrondroitin sulfate 1200 mg/day vs chondroitin sulfate 3 x 400 mg/day vs placebo
Osteoarthritis Cartilage
(1998)
W Noack et al.
Glucosamine sulfate in osteoarthritis of the knee
Osteoarthritis Cartilage
(1994)
K Pavelka et al.
Glycosaminoglycan polysulfuric acid (GAGPS) in osteoarthritis of the knee
Osteoarthritis Cartilage
(1995)
F.J Keefe et al.
Pain coping skills training in the management of osteoarthritic knee pain: a comparative study
Behav Ther
(1990)
F.J Keefe et al.
Pain coping skills training in the management of osteoarthritic knee pain-II: follow-up results
Behav Ther
(1990)
H Rogind et al.
The effects of a physical training program on patients with osteoarthritis of the knees
Arch Phys Med Rehabil
(1998)
M Doherty et al.
Design of clinical trials in knee osteoarthritis: practical issues for debate
Osteoarthritis
Cart
(1998)

M.J Field et al.

Clinical practice guidelines: directions for a new program

(1990)

E Levy et al.

Les coûts socio-économiques de l'arthrose en France

Rev Rhum 〚Éd Fr〛

(1993)

M.C Hochberg et al.

Guidelines for the medical management of osteoarthritis. Part II. Osteoarthritis of the knee

Arthritis Rheum

(1995)

D.L Scott

Guidelines for the diagnosis, investigation and management of osteoarthritis of the hip and knee. Report of a Joint Working Group of the British Society for Rheumatology and the Research Unit of the Royal College of Physicians

J R Coll Physicians London

(1993)

S.H Downs et al.

The feasibility of creating a checklist for the assessment of the methodological quality both of randomized and non-randomized studies of health care interventions

J Epidemiol Community Health

(1998)

J Cohen

Statistical power analysis for the behavioral sciences

New York: N Y Acad Press

(1977)

A Laupacis et al.

An assessment of clinically useful measures of the consequences of treatment

N Engl J M

(1988)

M Eccles et al.

North of England Evidence Based Guidelines Development Project: methods of developing guidelines for efficient drug use in primary care

BMJ

(1998)

C.L Deal et al.

Treatment of arthritis with topical capsaicin: a double-blind trial

Clin Ther

(1991)

R.L Dreiser et al.

DHEP plasters as a topical treatment of knee osteoarthritis. A double-blind placebo-controlled study

Drugs Exp Clin Res

(1993)

G Kolarz et al.

Hyaluronic acid in the treatment of osteoarthritis of the knee joint: interim results of a comparative clinical study

Eur J Rheumatol Inflamm

(1995)

P Lee et al.

The efficacy of diflunisal in osteoarthritis of the knee. A Canadian Multicenter Study

J Rheumatol

(1985)

P Ravaud et al.

Effects of joint lavage and steroid injection in patients with osteoarthritis of the knee: results of a multicenter, randomized, controlled trial

Arthritis Rheum

(1998)

S.C O'Reilly et al.

Effectiveness of home exercise on pain and disability from osteoarthritis of the knee: a randomized controlled trial

Annal Rheum Dis

(1997)

W.H Ettinger et al.

A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis

The Fitness Arthritis and Seniors Trial (FAST). JAMA

(1997)

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The membership of the American Society of Metabolic and Bariatric Surgery (ASMBS) was asked to submit research questions needed to advance the field of bariatric surgery. An expert panel grouped and collated submitted questions and redistributed them back to the membership to rate their importance on a 5-point Likert scale using a 3-round modified Delphi methodology. The top research questions were determined based on provided rankings.
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Highlight the role of patient education about physical activity and exercise in the treatment of hip and knee osteoarthritis (OA).
Systematic literature review from the Cochrane Library, PubMed and Wiley Online Library databases. A total of 125 items were identified, including 11 recommendations from learned societies interested in OA and 45 randomized controlled trials addressing treatment education and activity/exercise for the treatment of hip and knee osteoarthritis.
In the end, 13 randomized controlled trials and 8 recommendations were reviewed (1b level of evidence). Based on the analysis, it was clear that education, exercise and weight loss are the pillars of non-pharmacological treatments. These treatments have proven to be effective but require changes in patient behaviour that are difficult to obtain. Exercise and weight loss improve function and reduce pain. Education potentiates compliance to exercise and weight loss programs, thereby improving their long-term benefits. Cost efficiency studies have found a reduction in medical visits and healthcare costs after 12 months because of self-management programs.
Among non-surgical treatment options for hip and knee osteoarthritis, the most recent guidelines focus on non-pharmacological treatment. Self-management for general physical activity and exercise has a critical role. Programs must be personalized and adjusted to the patient's phenotype. This development should help every healthcare professional adapt the care they propose to each patient. Registration number for the systematic review: CRD42015032346.
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On the other hand, analgesic intake in the intervention group remained unchanged after the third month, and significantly lower than controls. This is a satisfactory result, since the European League Against Rheumatism (Mazieres et al., 2001) considers that reduction of this type of medication has health benefits in OA treatment. Throughout the six months, the increased paracetamol intake by the control group compared to the intervention group can be explained by a possible pain increased caused by the increasing of 15.4% in KAM peak suffered only by the group which did not wear the Moleca® footwear (within-group).
Efforts have been made to retard the progressive debilitating pain and joint dysfunction in patients with knee osteoarthritis. We aimed to evaluate the therapeutic effect of a low-cost minimalist footwear on pain, function, clinical and gait-biomechanical aspects of elderly women with knee osteoarthritis.
Throughout a randomized, parallel and controlled clinical trial, fifty-six patients with medial knee osteoarthritis were randomly allocated to an intervention (n = 28) or control group (n = 28), and assessed at baseline and after three and six months. The intervention involved wearing Moleca^® footwear for at least 6 h/day, 7 days/week, over 6 months. The pain subscale of the Western Ontario and McMaster Universities Osteoarthritis Index was the primary outcome. The secondary outcomes were the other subscales, Lequesne score, distance walked in 6 min, knee oedema and effusion, knee adduction moment and paracetamol intake. Intention-to-treat analysis was performed using two-way casewise ANOVA (< .05) and Cohen's d coefficient.
Intervention group showed improvement in pain (effect size: 1.41, p < .001), function (effect size: 1.22, p = .001), stiffness (effect size: 0.76, p = .001), Lequesne score (effect size: 1.07, p < .001), and reduction by 21.8% in the knee adduction moment impulse (p = .017) during gait wearing Moleca^®. The analgesic intake was lower in the intervention group.
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Six guidelines can be recommended without modifications.14,17,20,24-26 Eleven guidelines1,5,18,19,21-23,27-30 were recommended with modifications. Forty interventions were identified across the guidelines.
To undertake a systematic critical appraisal of guidelines to provide a summary of recommendations for the physical management of osteoarthritis (OA).
The Cochrane Library, MEDLINE, CINAHL, SPORTDiscus with Full Text, Scopus, ScienceDirect, PEDro, and Google Scholar databases were searched (2000–2013) to identify all guidelines, protocols, and recommendations for the management or treatment of OA. In addition, Internet searches of all relevant arthritis organizations were undertaken. All searches were performed between July 2012 and end of April 2013. Guidelines that included only pharmacological, injection therapy, or surgical interventions were excluded. Guidelines published only in English were retrieved.
OA guidelines developed from evidence-based research, consensus, and/or expert opinion were retrieved. There were no restrictions on severity or site of OA, sex, or age. Nineteen guidelines were identified for evaluation.
The quality of all guidelines was critically appraised using the Appraisal of Guidelines for REsearch and Evaluation II instrument. Each guideline was independently reviewed. All relevant recommendations for the physical management of OA were synthesized, graded, and ranked according to available evidence.
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¹: This paper is a short and commented version of the article from Pendleton A, Arden N, Dougados M, et al. EULAR recommendations for the management of knee osteoarthritis. Ann Rheum Dis 2000 : 59 : 936-44.

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ORIGINAL ARTICLEEULAR recommendations for the management of knee osteoarthritis. Report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials1

Abstract

Section snippets

Recommendations …

…in osteoarthritis

The task force

Methods

The list of the 23 treatment modalities

Evidence-based approach

Discussion

Osteoarthritis Cartilage

Osteoarthritis Cartilage

Osteoarthritis Cartilage

Osteoarthritis Cartilage

Osteoarthritis Cartilage

Osteoarthritis Cartilage

Behav Ther

Behav Ther

Arch Phys Med Rehabil

Cart

Clinical practice guidelines: directions for a new program

Les coûts socio-économiques de l'arthrose en France

Rev Rhum 〚Éd Fr〛

Guidelines for the medical management of osteoarthritis. Part II. Osteoarthritis of the knee

Arthritis Rheum

Guidelines for the diagnosis, investigation and management of osteoarthritis of the hip and knee. Report of a Joint Working Group of the British Society for Rheumatology and the Research Unit of the Royal College of Physicians

J R Coll Physicians London

The feasibility of creating a checklist for the assessment of the methodological quality both of randomized and non-randomized studies of health care interventions

J Epidemiol Community Health

Statistical power analysis for the behavioral sciences

New York: N Y Acad Press

An assessment of clinically useful measures of the consequences of treatment

N Engl J M

North of England Evidence Based Guidelines Development Project: methods of developing guidelines for efficient drug use in primary care

BMJ

Treatment of arthritis with topical capsaicin: a double-blind trial

Clin Ther

DHEP plasters as a topical treatment of knee osteoarthritis. A double-blind placebo-controlled study

Drugs Exp Clin Res

Hyaluronic acid in the treatment of osteoarthritis of the knee joint: interim results of a comparative clinical study

Eur J Rheumatol Inflamm

The efficacy of diflunisal in osteoarthritis of the knee. A Canadian Multicenter Study

J Rheumatol

Effects of joint lavage and steroid injection in patients with osteoarthritis of the knee: results of a multicenter, randomized, controlled trial

Arthritis Rheum

Effectiveness of home exercise on pain and disability from osteoarthritis of the knee: a randomized controlled trial

Annal Rheum Dis

A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis

The Fitness Arthritis and Seniors Trial (FAST). JAMA

ORIGINAL ARTICLE
EULAR recommendations for the management of knee osteoarthritis. Report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials¹