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
| No. | Recommendation | LOE I–IV | LOA (95% CI) | |
|---|---|---|---|---|
| 1 | In people with hip or knee OA, initial assessments should use a biopsychosocial approach including: | Ib, mixed | 8.6 (7.9 to 9.2) | |
| a | physical status (including pain; fatigue; sleep quality; lower limb joint status (foot, knee, hip); mobility; strength; joint alignment; proprioception and posture; comorbidities; weight) | |||
| b | activities of daily living | |||
| c | participation (work/education, leisure, social roles) | |||
| d | mood | |||
| e | health education needs, health beliefs and motivation to self-manage | |||
| 2 | Treatment 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 life | Ib, mixed Ib, knee | 8.7 (8.2 to 9.2) | |
| 3 | All 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) | |
| a | information and education regarding OA | |||
| b | addressing maintenance and pacing of activity | |||
| c | addressing a regular individualised exercise regimen | |||
| d | addressing weight loss if overweight or obese | |||
| e* | reduction of adverse mechanical factors (eg, appropriate footwear) | |||
| f* | consideration of walking aids and assistive technology | |||
| 4 | When 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 programme | Ib, mixed Ib, knee | 8.0 (7.1 to 9.0) | |
| 5 | To be effective, information and education for the person with hip or knee OA should: | Ia, mixed | 8.4 (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 | |||
| 6 | The 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 | |||
| 7 | People 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) | |
| a | strengthening (sustained isometric) exercise for both legs, including the quadriceps and proximal hip girdle muscles (irrespective of site or number of large joints affected) | |||
| b | aerobic activity and exercise | |||
| c | adjunctive 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 | |||
| 8 | Education 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) | |||
| 9 | a‡ | The use of appropriate and comfortable shoes is recommended. | Ib, knee. | 8.7 (8.2 to 9.2) |
| b | Recommendation rejected: a lateral-wedged insole could reduce symptoms in medial knee pain. | Ib, knee | 8.0 (7.0 to 9.1) | |
| 10 | Walking 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 | |||
| 11 | People 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 employment | III, 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.