Osteoarthritis Management Guidelines
OSTEOARTHRITIS MANAGEMENT GUIDELINES

Osteoarthritis (OA) is the most common form of arthritis and leading cause of disability among older adults. Knees, hips, and hands are most commonly affected. OA is characterized by pathology involving whole joint, including cartilage degradation, bone remodeling, osteophyte formation, and synovial inflammation leading to pain, stiffness, swelling, and loss of normal joint function. The American College of Rheumatology (ACR) and the Arthritis Foundation have developed in collaboration an evidence-based guideline for the comprehensive management of OA, including educational, behavioral, psychosocial, and physical interventions, as well as pharmacologic therapies (eg, topical, oral, intraarticular medications).

Treatments Hand Knee Hip Notes
NON-PHARMACOLOGIC APPROACHES
Exercise Strongly recommended Strongly recommended Strongly recommended Knee and Hip OA: stronger evidence. Includes walking, strengthening, neuromuscular training, aquatic exercise; no hierarchy of one over another. Associated with better outcomes when supervised.
Self-efficacy and self-management programs Strongly recommended Strongly recommended Strongly recommended Multidisciplinary group-based format combining sessions on skill-building, disease and medication education, joint protection measures, fitness and exercise goals.
Weight loss Strongly recommended Strongly recommended Loss of ≥5% of body weight may be associated with changes in clinical and mechanistic outcomes. Increased benefits with weight loss of 5–10%, 10–20%, and >20% of body weight.
Tai chi Strongly recommended Strongly recommended Focus on strength, balance, fall prevention, depression, and self-efficacy.
Cane Strongly recommended Strongly recommended In patients whom disease in ≥1 joints is causing large impact on ambulation, joint stability, pain.
First carpometacarpal orthosis Strongly recommended Neoprene or rigid orthoses strongly recommended for first CMC joint OA.
Tibiofemoral knee brace Strongly recommended For patients whom disease in ≥1 knee is causing large impact on ambulation, joint stability, or pain.
Other hand orthoses Conditionally recommended Conditionally recommended in joints other than the first CMC joint. Includes digital orthoses, ring splints, and rigid or neoprene orthoses which support specific joints or the entire hand.
Patellofemoral knee brace Conditionally recommended For patients whom disease in ≥1 knee is causing large impact on ambulation, joint stability, or pain. Conditional due to the variable outcomes from published trials and patient’s difficulty in tolerating these braces.
Heat, therapeutic cooling Conditionally recommended Conditionally recommended Conditionally recommended Includes moist heat, diathermy, ultrasound, hot and cold packs. May provide short duration of benefit.
Cognitive behavioral therapy Conditionally recommended Conditionally recommended Conditionally recommended Limited evidence suggests pain reduction in OA. Improved pain, health-related QOL, functional capacity, disability in conditions other than OA.
Acupuncture Conditionally recommended Conditionally recommended Conditionally recommended Efficacy remains controversial.
Kinesiotaping Conditionally recommended Conditionally recommended Permits range of motion of the joint, in contrast to a brace which maintains joint in a fixed position. Limited quality of evidence.
Balance training Conditionally recommended Conditionally recommended Low quality of evidence.
Paraffin Conditionally recommended Additional method of heat therapy.
Yoga Conditionally recommended Lack of available data. Focus on physical postures, breathing techniques, meditation.
Radiofrequency ablation Conditionally recommended Potential analgesic benefits. Lack of long-term safety data.
Iontophoresis Conditionally against Lack of available data.
Manual therapy with/without exercise Conditionally against Conditionally against Includes manual lymphatic drainage, manual traction, massage, mobilization/ manipulation, passive range of motion. Limited data.
Massage therapy Conditionally against Conditionally against Not shown to reduce OA symptoms.
Shoe alterations Conditionally against Conditionally against Modified shoes and/or lateral and medical wedged insoles lack data.
Pulsed vibration therapy Conditionally against Limited data.
Transcutaneous electrical nerve stimulation (TENS) Strongly against Strongly against Low quality of evidence. Studies shown lack of benefit for knee OA.
PHARMACOLOGIC THERAPIES*
Oral NSAIDs Strongly recommended Strongly recommended Strongly recommended Mainstay of pharmacologic management. Use lowest effective dose for shortest duration.
Topical NSAIDs Conditionally recommended Strongly recommended In knee OA, topical NSAIDs should be considered before oral NSAIDs. Frequent hand washing and lack of direct evidence of efficacy in hand OA led to conditional recommendation.
Intraarticular glucocorticoid inj Conditionally recommended Strongly recommended Strongly recommended Hip OA strongly recommended to be ultrasound-guided. Short-term efficacy in knee OA. Lack of evidence in hand OA.
Acetaminophen Conditionally recommended Conditionally recommended Conditionally recommended Few experience important benefit. Monotherapy may be ineffective. May be appropriate for short-term and episodic use in patients with contraindications or intolerance to NSAIDs.
Tramadol Conditionally recommended Conditionally recommended Conditionally recommended May be appropriate if contraindication to NSAIDs, other therapies ineffective, or no available surgical options.
Duloxetine Conditionally recommended Conditionally recommended Conditionally recommended May have efficacy in OA when used alone or in combination with NSAIDs. Concerns regarding tolerability and side effects.
Topical Capsaicin Conditionally against Conditionally recommended Increased risk of contamination of the eye when used for hand OA.
Colchicine Conditionally against Conditionally against Conditionally against Low quality of data.
Non-tramadol opioids Conditionally against Conditionally against Conditionally against With recognition that they may be used in certain circumstances, particularly when no available alternatives.
Fish oil Conditionally against Conditionally against Conditionally against Lack of available data.
Vitamin D Conditionally against Conditionally against Conditionally against Limited evidence of benefit.
Prolotherapy Conditionally against Conditionally against Limited data.
Intraarticular botulinum toxin Conditionally against Conditionally against Studies demonstrate lack of efficacy.
Intraarticular hyaluronic acid inj Conditionally against Conditionally against Strongly against Limited evidence of benefit; used in clinical practice when other alternatives have been exhausted or failed to provide satisfactory benefit. Stronger evidence of lack of benefit in hip OA.
Chondroitin Conditionally recommended Strongly against Strongly against Analgesic efficacy without evidence of harm in hand OA (single trial).
Bisphosphonates Strongly against Strongly against Strongly against No improvement in pain or functional outcomes.
Glucosamine Strongly against Strongly against Strongly against Studies demonstrate lack of efficacy.
Hydroxychloroquine Strongly against Strongly against Strongly against Studies demonstrate lack of efficacy.
Methotrexate Strongly against Strongly against Strongly against Studies demonstrate lack of efficacy.
TNF inhibitors, IL-1 antagonists Strongly against Strongly against Strongly against Studies demonstrate lack of efficacy with increased risks of toxicity.
Platelet-rich plasma Strongly against Strongly against Concerns with heterogeneity and lack of standardization in available preparations and techniques.
Stem cell Strongly against Strongly against Concerns with heterogeneity and lack of standardization in available preparations and techniques.
NOTES

Key: CMC = carpometacarpal; IA = intraarticular; IL-1 = interleukin-1; inj = injection; NSAIDs = nonsteroidal anti-inflammatory drugs; TNF = tumor necrosis factor

* When selecting pharmacologic therapies, initiate treatments with the least systemic exposure or toxicity first.

REFERENCE

Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Care & Research. 2020;0(0):1-14. DOI 10.1002/acr.24131.

Created 2/2021