Table 2

EULAR recommendations for the non-pharmacological core management of hip and knee OA, with levels of evidence (LOE) and level of agreement (LOA). The propositions are ordered by topic

(95% CI)
1In people with hip or knee OA, initial assessments should use a biopsychosocial approach including:Ib, mixed8.6 (7.9 to 9.2)
aphysical status (including pain; fatigue; sleep quality; lower limb joint status (foot, knee, hip); mobility; strength; joint alignment; proprioception and posture; comorbidities; weight)
bactivities of daily living
cparticipation (work/education, leisure, social roles)
ehealth education needs, health beliefs and motivation to self-manage
2Treatment of hip and/or knee OA should be individualised according to the wishes and expectations of the individual, localisation of OA, risk factors (such as age, sex, comorbidity, obesity and adverse mechanical factors), presence of inflammation, severity of structural change, level of pain and restriction of daily activities, societal participation and quality of lifeIb, mixed
Ib, knee
8.7 (8.2 to 9.2)
3All people with knee/hip OA should receive an individualised management plan (a package of care) that includes the core non-pharmacological approaches, specifically:Ib, hip
Ib, knee 
8.7 (8.2 to 9.3)
ainformation and education regarding OA
baddressing maintenance and pacing of activity
caddressing a regular individualised exercise regimen
daddressing weight loss if overweight or obese
e*reduction of adverse mechanical factors (eg, appropriate footwear)
f*consideration of walking aids and assistive technology
4When lifestyle changes are recommended, people with hip or knee OA should receive an individually tailored programme, including long-term and short-term goals, intervention or action plans, and regular evaluation and follow-up with possibilities for adjustment of the programmeIb, mixed
Ib, knee
8.0 (7.1 to 9.0)
5To be effective, information and education for the person with hip or knee OA should:Ia, mixed8.4 (7.7 to 9.1)
a*be individualised according to the person's illness perceptions and educational capability
b*be included in every aspect of management
c†specifically address the nature of OA (a repair process triggered by a range of insults), its causes (especially those pertaining to the individual), its consequences and prognosis
d†be reinforced and developed at subsequent clinical encounters;
e†be supported by written and/or other types of information (eg, DVD, website, group meeting) selected by the individual
f†include partners or carers of the individual, if appropriate
6The mode of delivery of exercise education (eg, individual 1 : 1 sessions, group classes, etc) and use of pools or other facilities should be selected according both to the preference of the person with hip or knee OA and local availability. Important principles of all exercise include:Ia, knee, delivery mode
Ia, mixed, water-based exercise
8.9 (8.5 to 9.3)
a†‘small amounts often’ (pacing, as with other activities)
b†linking exercise regimens to other daily activities (eg, just before morning shower or meals) so they become part of lifestyle rather than additional events
c*starting with levels of exercise that are within the individual's capability, but building up the ‘dose’ sensibly over several months
7People with hip and/or knee OA should be taught a regular individualised (daily) exercise regimen that includes:Ia, hip, overall exercise
Ia, knee, overall exercise
Ia, knee, strength
Ia, knee, aerobic
Ia, mixed, mixed programmes
8.5 (7.7 to 9.3)
astrengthening (sustained isometric) exercise for both legs, including the quadriceps and proximal hip girdle muscles (irrespective of site or number of large joints affected)
baerobic activity and exercise
cadjunctive range of movement/stretching exercises
*Although initial instruction is required, the aim is for people with hip or knee OA to learn to undertake these regularly on their own in their own environment
8Education on weight loss should incorporate individualised strategies that are recognised to effect successful weight loss and maintenance*—for example:III, hip
Ia, knee
9.1 (8.6 to 9.5)
a†regular self-monitoring, recording monthly weight
b†regular support meetings to review/discuss progress
c†increase physical activity
d†follow a structured meal plan that starts with breakfast
e†reduce fat (especially saturated) intake; reduce sugar; limit salt; increase intake of fruit and vegetables (at least ‘5 portions’ a day)
f†limit portion size;
g†addressing eating behaviours and triggers to eating (eg, stress)
h†nutrition education
i†relapse prediction and management (eg, with alternative coping strategies)
9a‡The use of appropriate and comfortable shoes is recommended.Ib, knee.8.7 (8.2 to 9.2)
bRecommendation rejected: a lateral-wedged insole could reduce symptoms in medial knee pain.Ib, knee8.0 (7.0 to 9.1)
10Walking aids, assistive technology and adaptations at home and/or at work should be considered, to reduce pain and increase participation—for example:III, hip
III, knee
8.9 (8.5 to 9.3)
a†a walking stick used on the contralateral side, walking frames and wheeled ‘walkers’
b*increasing the height of chairs, beds and toilet seats
c*hand-rails for stairs
d*replacement of a bath with a walk-in shower
e*change to car with high seat level, easy access and automatic gear change
11People with hip or knee OA at risk of work disability or who want to start/return to work should have rapid access to vocational rehabilitation, including counselling about modifiable work-related factors such as altering work behaviour, changing work tasks or altering work hours, use of assistive technology, workplace modification, commuting to/from work and support from management, colleagues and family towards employmentIII, hip
III, knee
Ib, mixed, sick leave
8.9 (8.3 to 9.5)
  • Recommendations with different LOE within the recommendation are listed below. In the absence of grading of evidence for hip OA populations, the LOE equals IV. LOA was computed as a 0–10 scale, based on 17 votes of agreement with the recommendation.

  • *The specific element was not included in composite interventions and LOE for the inclusion of this specific element could not be graded.

  • †The specific element was included in composite interventions and LOE for the inclusion of this specific element was graded as Ib (ie, no. 5c–f, mixed populations; no. 6a and b, mixed or knee populations; no. 8, knee populations; no. 10a, knee populations).

  • ‡Comparisons between different pairs of comfortable shoes.

  • LOA, level of agreement; LOE, level of evidence; OA, osteoarthritis.

  • Mixed, the evidence is extracted from studies including a mixed population—that is, people with hip and/or knee OA.