EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis

Linda Fernandes; Kåre B Hagen; Johannes W J Bijlsma; Oyvor Andreassen; Pia Christensen; Philip G Conaghan; Michael Doherty; Rinie Geenen; Alison Hammond; Ingvild Kjeken; L Stefan Lohmander; Hans Lund; Christian D Mallen; Tiziana Nava; Susan Oliver; Karel Pavelka; Irene Pitsillidou; José Antonio da Silva; Jenny de la Torre; Gustavo Zanoli; Theodora P M Vliet Vlieland

doi:10.1136/annrheumdis-2012-202745

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EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis

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Response: Is (creno)balneotherapy a drug, a surgical procedure or a non-pharmacological treatment?
Thea P Vliet Vlieland
Published on: 31 October 2019
Is (creno)balneotherapy a drug, a surgical procedure or a non-pharmacological treatment?
Romain J FORESTIER
Published on: 31 October 2019

Published on: 31 October 2019
Response: Is (creno)balneotherapy a drug, a surgical procedure or a non-pharmacological treatment?
- Thea P Vliet Vlieland, Prof
- Other Contributors:
  L. Fernandes, J.W. Bijlsma and K.B. Hagen, on behalf of the Task Force on Eular recommendations for the non-pharmacological core management of hip and knee osteoarthritis
Dear editor,
We thank Forestier and Erol for their response on our paper on Eular recommendations for the non-pharmacological core management of hip and knee osteoarthritis (OA). We agree that balneotherapy is a relevant non- pharmacological intervention in hip and knee OA, and has been properly evaluated by means of randomised clinical trials, with the evidence summarized in systematic reviews. The topics to be in...
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Dear editor,
We thank Forestier and Erol for their response on our paper on Eular recommendations for the non-pharmacological core management of hip and knee osteoarthritis (OA). We agree that balneotherapy is a relevant non- pharmacological intervention in hip and knee OA, and has been properly evaluated by means of randomised clinical trials, with the evidence summarized in systematic reviews. The topics to be included in the recommendations were however, in accordance with the standard operating procedures for the development of Eular recommendations [1], determined by the Task Force. Starting with a long list of propositions on a wide range of non-pharmacological interventions, the final set was selected by means of several Delphi rounds. This procedure resulted, apart from the exclusion of balneotherapy, in the omission of several other non- pharmacological interventions which are relevant and for which evidence is available.
The process of development of the recommendations does not include a registration of reasons for selection and exclusion of propositions, however specifically for balneotherapy it could be hypothesized that this intervention is not equally available and/or common in every country.
In general terms, the issue Forestier raises is important from the implementation perspective. It remains to be established to what extent the selection of topics plays a role in the uptake of the recommendations. The exclusion of recommendations on topics which are considered relevant in clinical practice, and likewise the inclusion of recommendations on topics which are not supported by clinicians may play an important role in the implementation. A study on barriers and facilitators for the implementation of recommendations among various groups of stakeholders is needed to further study this aspect. The outcome of such a study may not only influence the content of an update of the current set of recommendations, but probably also the process of guideline development as a whole, with probably larger groups of people in the various stakeholder groups being needed to select the topics to be included in the recommendations.
References
1. Dougados M, Betteridge N, Burmester GR et al. EULAR standardised operating procedures for the elaboration, evaluation, dissemination, and implementation of recommendations endorsed by the EULAR standing committees. Ann Rheum Dis 2004;63:1172-6
Conflict of Interest:
None declared
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Conflict of Interest:
None declared.
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Published on: 31 October 2019
Is (creno)balneotherapy a drug, a surgical procedure or a non-pharmacological treatment?
- Romain J FORESTIER, Rheumatology practitionner
- Other Contributors:
  Fatma B EROL
Dear Editor,
We appreciate that EULAR is preparing a specific recommendation on non-pharmacological treatment of knee osteoarthritis but we are also very surprised to discover that crenobalneotherapy was not even mentionned in the analysed treatments. Crenobalneotherapy (also called balneotherapy or spa therapy) is a very common treatment for knee osteoarthritis in South and Eastern Europe, Middle Asia, Japan, Sou...
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Dear Editor,
We appreciate that EULAR is preparing a specific recommendation on non-pharmacological treatment of knee osteoarthritis but we are also very surprised to discover that crenobalneotherapy was not even mentionned in the analysed treatments. Crenobalneotherapy (also called balneotherapy or spa therapy) is a very common treatment for knee osteoarthritis in South and Eastern Europe, Middle Asia, Japan, South America and North Africa. The common point of crenobalneotherapy procedures is the use of mineral water for the treatment. While, it can sometimes be a passive bath only, more often it is a combined treatment with underwater massages, mud applications, water exercises, baths and showers. We think that crenobalneotherapy is a non- pharmacological treatment.
In 2008, we conducted a systematic review [1] and we concluded that "although the consistency of the results suggests a therapeutic effect of crenobalneotherapy in limb osteoarthritis, available studies are methodologically inadequate and sample sizes too small to allow definitive conclusions". Later, in 2010 we published a multicenter randomized trial on 462 patients suffering from knee osteoarthritis in Annals of Rheumatic Diseases [2]. The results showed a clinically important improvement in pain and function for the balneotherapy group when compared with the control group doing home exercise alone. We suggest that, since crenobalneotherapy is a well evaluated treatment, these non- pharmacological treatment guidelines should also analyse this and some other trials published in this field [3-4].
References
1. R Forestier, A Francon. Crenobalneotherapy for limb osteoarthritis: systematic literature review and methodological analysis. Joint Bone Spine 2008 ;75(2):138-48.
2. Forestier R, Desfour H, Tessier JM, et al. Spa therapy in the treatment of knee osteoarthritis: a large randomised multicentre trial. Ann Rheum Dis. 2010;69(4):660-5.
3. Fioravanti A, Iacoponi F, Bellisai B, et al. Short-and long-term effects of spa therapy in knee osteoarthritis. Am J Phys Med Rehabil 2010;89(2):125-32.
4. Nguyen M, Revel M, Dougados M. Prolonged effects of 3 week therapy in a spa resort on lumbar spine, knee and hip osteoarthritis: follow-up after 6 months. A randomized controlled trial. Br J Rheumatol 1997;36(1):77-81.
Conflict of Interest:
None declared
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Conflict of Interest:
None declared.
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