A systematic review of recommendations and guidelines for the management of osteoarthritis: The Chronic Osteoarthritis Management Initiative of the U.S. Bone and Joint Initiative

Abstract

Purpose

Although a number of osteoarthritis (OA) management guidelines exist, uptake has been suboptimal. Our aim was to review and critically evaluate existing OA management guidelines to better understand potential issues and barriers.

Methods

A systematic review of the literature in MEDLINE published from January 1, 2000 to April 1, 2013 was performed and supplemented by bibliographic reviews, following PRISMA guidelines and a written protocol. Following initial title and abstract screening, 2 authors independently reviewed full-text articles; a third settled disagreements. Two independent reviewers extracted data into a standardized form. Two authors independently assessed guideline quality using the AGREE II instrument; three generated summary recommendations based on the extracted guideline data.

Results

Overall, 16 articles were included in the final review. There was broad agreement on recommendations by the various organizations. For non-pharmacologic modalities, education/self-management, exercise, weight loss if overweight, walking aids as indicated, and thermal modalities were widely recommended. For appropriate patients, joint replacement was recommended; arthroscopy with debridement was not recommended for symptomatic knee OA. Pharmacologic modalities most recommended included acetaminophen/paracetamol (first line) and NSAIDs (topical or oral, second line). Intra-articular corticosteroids were generally recommended for hip and knee OA. Controversy remains about the use of acupuncture, knee braces, heel wedges, intra-articular hyaluronans, and glucosamine/chondroitin.

Conclusions

The relative agreement on many OA management recommendations across organizations indicates a problem with dissemination and implementation rather than a lack of quality guidelines. Future efforts should focus on optimizing implementation in primary care settings, where the majority of OA care occurs.

Introduction

Arthritis, rheumatism, and back/spine problems were the leading causes of disability in the U.S. in 2005, resulting in more cases of disability than the next 8 causes combined [1]. In 2008, 13% of adults over 18 years of age had self-reported arthritis-attributable activity limitations, up from less than 9% in 2003–2005 [2]. Osteoarthritis (OA) is the most common form of arthritis, affecting more than 27 million people in the U.S. [3]. OA is one of several chronic conditions that are becoming more prevalent with the aging of the population and increasing prevalence of obesity. Data from the 2009 Behavioral Risk Factor Surveillance System indicated that the top 2 most prevalent conditions in those over 50 years of age were hypertension (36.5% for age 50–59 years, increasing to 60.7% for those over the age of 70 years) and arthritis (35% for age 50–59 years, increasing to more than 55% over the age of 70 years); the average number of conditions increased with age and was associated with a higher prevalence of activity limitations [4], highlighting the potential future burden of OA and other chronic diseases [5]. Gadermann et al. used U.S. National Comorbidity Survey Replication data to assess disease burden and comorbidities, finding that arthritis was the second most common reported disorder (prevalence 27%). More importantly, 88% of those reporting arthritis had at least one other physical or mental comorbidity (mean of 2.4 disorders) [6]. The importance of OA management as part of the care of individuals with multiple chronic conditions cannot be overlooked, given its impact on disability and functional limitation, as well as management of other chronic health conditions.

Numerous guidelines for OA management exist, but despite their many commonalities, and general agreement with these published recommendations among providers, there remains poor implementation in clinical practice [7], [8]. With the goal of improving the current approach to OA management, the Chronic Osteoarthritis Management Initiative (COAMI) Work Group was convened by the U.S. Bone and Joint Initiative in May 2012. This work group includes orthopedic nurses and surgeons, rheumatologists, rehabilitation and sports medicine providers, primary care and osteopathic physicians, physical therapists, athletic trainers, and patients. COAMI issued a Call to Action in September 2012, which mentions several priority actions, including convening an OA management conference, including other partners (U.S. Preventative Services Task Force, other federal agencies, other chronic disease and professional advocacy groups, and researchers and practitioners) in ongoing efforts, exploring standardized screening tools and indicators of OA, supporting advocacy endeavors, and developing and supporting an OA-specific research agenda [9]. This systematic review is one of the recommended outcomes of the first COAMI meeting and will serve as part of the background to support these initiatives by identifying, evaluating, and summarizing existing guidelines for management of symptomatic OA at the hip, knee, or hand, with the goal of determining commonalities more directly translatable to clinical practice.