A session at the ACR/ARP Annual Meeting on Wednesday, Nov. 13, focused on updated recommendations regarding non-drug interventions included in the 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip and Knee.
The updated guideline recommendations, which are currently still in draft form, will be available online in December and are expected to be published in print in early 2020, according to Sharon Kolasinski, MD, FACP, FACR, who offered an overview of the guideline development and review process.
Dr. Kolasinski is Professor of Clinical Medicine in the Division of Rheumatology at the University of Pennsylvania Perelman School of Medicine, Director of Rheumatology at the Penn Musculoskeletal Center, and principal investigator of the updated guideline.
“The new guideline emphasizes a comprehensive approach to the management of osteoarthritis rather than a stepwise algorithm,” Dr. Kolasinski said. “Clinicians and patients can choose from a varied list of interventions that might be used and reused over time to address the pain and functional compromise caused by osteoarthritis. No specific hierarchy of one option over another is implied other than on the basis of strength of the recommendation.”
Joining Dr. Kolasinski for this session were two members of the guideline development team, who highlighted some of the key recommendation updates and changes from the previous guideline, which was published in 2012.
Carole Dodge, OT, CHT, Clinical Specialist and Supervisor of the Occupational Therapy Hand Therapy Program at the University of Michigan School of Medicine, discussed some of the treatment recommendations for hand OA.
“Regarding recommendations for OA of the hand, there is only one intervention for which there is strong evidence, and that is for exercise, which is strongly recommended for all types of OA,” Dodge said. “And when we talk about OA of the hand, we’re talking about specific joints — primarily the carpometacarpal joint of the thumb, the interphalangeal (IP) joints of the digits, specifically the distal IPs and the proximal IPs where we see the Heberden and Bouchard node formation, and the carpals.”
Recommended interventions, she said, focus on range-of-motion exercises that help the patient gain mobility of these joints, and exercises that strengthen or stabilize the affected joints.
“We want to strengthen those muscles that are in the forearm, the extrinsic muscles of the hand, as well as the intrinsic muscles that lie just within the hand,” she said. “So, we recommend doing a number of different exercises to be sure that we’re strengthening all the muscles that support the joints.”
Among the therapies conditionally recommended for hand OA in the new guideline are kinesiotaping of the carpometacarpal joint, the use of orthotics, and acupuncture.
Daniel White, PT, ScD, MSc, Assistant Professor in the Department of Physical Therapy at the University of Delaware in Newark, reviewed nonpharmacological treatment recommendations for hip and knee OA. He noted there were several important differences between the 2012 guideline and the 2019 guideline.
“First, the voting panel recommended against several treatments for hip and knee osteoarthritis, including pulsed vibration therapy, and transcutaneous electrical stimulation (TENS) based on findings from the literature,” White said. “Second, as with other forms of OA, exercise is strongly recommended as a first-line treatment. In particular, the volume and intensity of aerobic walking, being the most common type of exercise employed by older adults, is discussed in detail in the new guideline as a treatment for osteoarthritis of the knee and hip.”
Other strongly recommended interventions covered in the new guideline include weight loss, self-efficacy and self-management, mind/body interventions, and assistive/supportive devices.
“The bottom line and the strongest message in the new guideline is that people with osteoarthritis should exercise, and if pain gets in the way of doing so, working with a rheumatologist to manage the disease and seeing a physical therapist is likely to help,” White said.