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Systematic Review of Guidelines for the Physical Management of Osteoarthritis

Published:November 04, 2013DOI:https://doi.org/10.1016/j.apmr.2013.10.011

      Abstract

      Objective

      To undertake a systematic critical appraisal of guidelines to provide a summary of recommendations for the physical management of osteoarthritis (OA).

      Data Sources

      The Cochrane Library, MEDLINE, CINAHL, SPORTDiscus with Full Text, Scopus, ScienceDirect, PEDro, and Google Scholar databases were searched (2000–2013) to identify all guidelines, protocols, and recommendations for the management or treatment of OA. In addition, Internet searches of all relevant arthritis organizations were undertaken. All searches were performed between July 2012 and end of April 2013. Guidelines that included only pharmacological, injection therapy, or surgical interventions were excluded. Guidelines published only in English were retrieved.

      Study Selection

      OA guidelines developed from evidence-based research, consensus, and/or expert opinion were retrieved. There were no restrictions on severity or site of OA, sex, or age. Nineteen guidelines were identified for evaluation.

      Data Extraction

      The quality of all guidelines was critically appraised using the Appraisal of Guidelines for REsearch and Evaluation II instrument. Each guideline was independently reviewed. All relevant recommendations for the physical management of OA were synthesized, graded, and ranked according to available evidence.

      Data Synthesis

      Seventeen guidelines with recommendations on the physical management of OA met the inclusion criteria and underwent a full critical appraisal. There were variations in the interventions, levels of evidence, and strength of recommendations across the guidelines. Forty different interventions were identified. Recommendations were graded from “strongly recommended” to “unsupported.” Exercise and education were found to be strongly recommended by most guidelines.

      Conclusions

      Exercise and education were key recommendations supporting the importance of rehabilitation in the physical management of OA. This critical appraisal can assist health care providers who are involved in the management of people with OA.

      Keywords

      List of abbreviations:

      AGREE II (Appraisal of Guidelines for REsearch and Evaluation II), LOE (level of evidence), MA (meta-analysis), NICE (National Institute of Clinical Excellence), OA (osteoarthritis), RCT (randomized controlled trial), SOR (strength of recommendation)
      Osteoarthritis (OA) is the most common form of arthritis and is identified as one of the leading causes of pain and disability worldwide.

      National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults: Royal College of Physicians. 2008. Available at: http://www.nice.org.uk/CG059. Accessed November 26, 2012.

      • Vos T.
      • Flaxman A.D.
      • Naghavi M.
      • et al.
      Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010.
      By the year 2020, the prevalence of OA is expected to double.
      • Gupta S.
      • Hawker G.A.
      • Laporte A.
      • Croxford R.
      • Coyte P.C.
      The economic burden of disabling hip and knee osteoarthritis (OA) from the perspective of individuals living with this condition.
      The risk factors associated with OA include age, sex, genetics, occupation, past injuries, and obesity.
      • Symmons D.
      • Mathers C.
      • Pleger B.
      Global burden of osteoarthritis in the year 2000.
      Hip and knee pain associated with OA often leads to inactivity and loss of mobility, resulting in deconditioning, weight gain, loss of independence, and decreased quality of life.
      • Loew L.
      • Brosseau L.
      • Wells G.A.
      • et al.
      Ottawa panel evidence-based clinical practice guidelines for aerobic walking programs in the management of osteoarthritis.
      There are substantial personal and societal costs associated with OA.

      National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults: Royal College of Physicians. 2008. Available at: http://www.nice.org.uk/CG059. Accessed November 26, 2012.

      Personal costs may include the inability to participate in work, sport, hobbies, or caring for others because of pain. Societal costs may include visits to the doctor, medication costs, and assistance equipment. Joint replacement is an effective intervention to alleviate pain and improve quality of life for those with advanced OA. However, despite a growing number of joint replacements undertaken each year, many people are still placed on a waiting list often for a considerable time.
      • Williams J.I.
      • Llewellyn Thomas H.
      • Arshinoff R.
      • Young N.
      • Naylor C.D.
      The burden of waiting for hip and knee replacements in Ontario. Ontario Hip and Knee Replacement Project Team.
      • Ackerman I.N.
      • Bennell K.L.
      • Osborne R.H.
      Decline in health-related quality of life reported by more than half of those waiting for joint replacement surgery: a prospective cohort study.
      To reduce the burden of OA, safe and effective health services, involving a range of nonsurgical treatments options, are required. These services must be effective with respect to intervention and cost as well as meet the affected person's needs.
      Evidence-based clinical guidelines are developed to assist the practitioner, patient, and/or policymaker to make informed clinical decisions.
      • Guyatt G.H.
      • Haynes R.B.
      • Jaeschke R.Z.
      • et al.
      Users' Guides to the Medical Literature: XXV. Evidence-based medicine: principles for applying the Users' Guides to patient care.
      Guidelines are valuable resources that play an integral role in improving treatment and management of various health conditions. They can be used by health practitioners and people suffering with OA seeking information to determine how their disease can best be managed. A preliminary search of the literature identified many international guidelines developed for the management of OA. The preliminary search identified that the guidelines included evidence and recommendations for a number of interventions including pharmacological, nonpharmacological, surgical, and injection therapies, physical management, and lifestyle changes for the management of OA. However, because of adverse effects, patients and health care providers may pursue physical management options rather than surgery, pharmacology, or injection-based therapy. A number of guidelines highly recommend exercise as an intervention for OA. However, Gill and McBurney
      • Gill S.D.
      • McBurney H.
      Does exercise reduce pain and improve physical function before hip or knee replacement surgery? A systematic review and meta-analysis of randomized controlled trials.
      in a recent systematic review concluded that while exercise interventions were beneficial for those people awaiting hip replacement, this was not the case for those awaiting knee replacement. It was also noted that there were variations across the guidelines in the recommendations made. Currently, there is no critical appraisal of international guidelines that has synthesized, graded, and comprehensively presented all the relevant recommendations for the physical management of OA. Therefore, a systematic critical appraisal of international OA guidelines was undertaken to comprehensively present all the relevant evidence-based recommendations on the physical management of OA.

      Methods

       Electronic database searches

      A systematic literature search was performed. The Cochrane Library, MEDLINE, CINAHL, SPORTDiscus with Full Text, Scopus, ScienceDirect, PEDro, and Google Scholar databases were searched (2000–2013) to identify all guidelines, protocols, and recommendations for the management or treatment of OA. An experienced health science librarian assisted with the development of the search strategy. MEDLINE, CINAHL, and SPORTDiscus with Full Text databases were searched using key word proximity searches to identify guidelines or recommendations for the management of OA ([osteoarthrit* N5 guideline*] OR [osteoarthrit* N5 evidence*] OR [osteoarthrit* N5 recommend] OR [osteoarthrit* N5 best*]). Scopus and ScienceDirect databases used the same proximity search logic but with the appropriate syntax. PEDro and The Cochrane Libraries were searched using ([osteoarthriti* and guideline] AND [osteoarthriti* and protocol]). A manual search was conducted on reference lists found in relevant guidelines, systematic reviews, and meta-analysis (MA), which returned additional resources.

       Internet searches

      A thorough Internet search was conducted to identify international arthritis organizations and guideline clearinghouses. The names of organizations were also found during the process of reviewing guidelines and recommendations identified during the electronic database searches. The websites of these organizations were reviewed, and any relevant guidelines were included. A list of these organizations is given in appendix 1.

       Eligibility criteria

      The primary source of literature for this review was recommended guidelines developed from evidence-based research, consensus, and/or expert opinion. Guidelines that included only pharmacological therapy, injection therapy, or surgical interventions were excluded. There were no restrictions on severity or site of OA, sex, or age. The search was confined to articles published in English and available electronically between the period of 2000 and end of April 2013. Animal-based studies were not included. If there had been updates to guidelines, only the latest version of the guideline was reviewed.

       Selection of guidelines

      All titles and/or abstracts were reviewed to determine whether they met the eligibility criteria of this critical appraisal. When citations met the criteria, the full-text articles were retrieved and reviewed. Nineteen guidelines were identified for evaluation. The details of results returned are illustrated in figure 1.
      Figure thumbnail gr1
      Fig 1Results of the search strategy for international guidelines that contain recommendations for the physical management of OA.

       Quality appraisal

      The Appraisal of Guidelines for REsearch and Evaluation II (AGREE II) tool was used to critique the guidelines.

      AGREE. Appraisal of Guidelines for REsearch & Evaluation II: AGREEII instrument 2009. Available at: http://www.agreetrust.org/. Accessed January 14, 2013.

      AGREE II is a guideline quality appraisal tool that has been found to have high construct validity.
      • Brouwers M.
      • Kho M.
      • Browman G.
      • et al.
      AGREE II: advancing guideline development, reporting and evaluation in health care.
      It consists of 23 items arranged into 6 domains: scope and purpose (3 items), stakeholder involvement (3 items), rigor of development (8 items), clarity of presentation (3 items), applicability (4 items), and editorial independence (2 items). Each item is scored between strongly agree (4) and strongly disagree (1). The items scores within a domain were then added and calculated as a percentage. A domain was determined to be effectively addressed if its score was ≥60%, as has been used in other critical appraisals of arthritis guidelines.
      • Poitras S.
      • Avouac J.
      • Rossignol M.
      • et al.
      A critical appraisal of guidelines for the management of knee osteoarthritis using Appraisal of Guidelines REsearch and Evaluation criteria.
      • Hurkmans E.J.
      • Jones A.
      • Li L.C.
      • Vliet Vlieland T.P.M.
      Quality appraisal of clinical practice guidelines on the use of physiotherapy in rheumatoid arthritis: a systematic review.
      Before a full critique of the guidelines, all members of the research team undertook a training review process to ensure consistency and reliability in grading. All guidelines were then reviewed independently to ensure sufficient reliability as suggested by previous authors.
      • Brouwers M.
      • Kho M.
      • Browman G.
      • et al.
      AGREE II: advancing guideline development, reporting and evaluation in health care.
      Differences in scoring were resolved through discussions and consensus between all 4 authors. Where guidelines were not clear, the identified author was contacted for clarification if possible. Finally, based on their overall domain scores, the guidelines received an overall assessment from the research team of “recommended,” “recommended with modifications,” or “not recommended.”

      AGREE. Appraisal of Guidelines for REsearch & Evaluation II: AGREEII instrument 2009. Available at: http://www.agreetrust.org/. Accessed January 14, 2013.

       Synthesis of recommendations

      Following the AGREE II appraisal of the guidelines, recommendations that were specific to the physical management of OA were identified for data extraction. This analysis involved categorizing recommendations by intervention (eg, exercise, education) with their associated level of evidence (LOE) and strength of recommendation (SOR). For the purposes of this review, the interventions have been grouped for similarity into 12 interventions. For each guideline recommendation, the associated interventions were scored on an individual weighting scale from +4 to −4 (table 1) on the basis of their LOE and SOR values. The levels of the scale were derived from LOE and SOR values found in each guideline. There was variation in how individual guidelines provided grading scales for both LOE and SOR. A list of individual guideline scales is provided in appendix 2. Guidelines based on MA, systematic reviews, and definitive randomized controlled trials (RCTs) that were strongly recommended were weighted highest (individual weighting=4), whereas expert opinion with a weak SOR was weighted low (individual weighting=1). Where a guideline provided a recommendation against an intervention, this was weighted negatively (individual weighting=−1 to −4). There were 2 exceptions to this process. First, the recommendations from the National Health and Medical Research Council guideline

      Brand C, Buchbinder R, Wluka A, et al. Guideline for the nonsurgical management of hip and knee osteoarthritis 2009. Available at: http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.

      were already graded on a 4-point scale on the basis of LOE and SOR. Second, the National Institute of Clinical Excellence (NICE) guideline

      National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults: Royal College of Physicians. 2008. Available at: http://www.nice.org.uk/CG059. Accessed November 26, 2012.

      provided extensive level I evidence (MA, systematic review, RCTs) throughout the article. However, it did not present recommendations with an LOE or SOR. Because of the support of a high LOE, we have graded each of the NICE recommendations with a weighting of 4.
      Table 1Weightings of individual guideline interventions
      LOE
      A full list of individual guideline grading systems for LOE and SORs is provided in appendix 2.
      SOR
      A full list of individual guideline grading systems for LOE and SORs is provided in appendix 2.
      Individual Weighting
      High: I, II, 1++, 1+, 1−, Ia, Ib, IIaHigh: Strong, A, B, 60%–100%4
      High: I, II, 1++, 1+, 1−, Ia, Ib, IIaLow or multiple SOR within 1 recommendation: Weak, C, D, inconclusive, <60%, not stated3
      Low: III-1, III-2, III-3, IV, 2++, 2+, 2−, 3, 4, IIb, III, IV, not statedHigh: Strong, A, B, 60%–100%2
      Low: III-1, III-2, III-3, IV, V, 2++, 2+, 2−, 3, 4, IIb, III, IV, not statedLow: Weak, C, D, inconclusive, <60%, not stated1
      High to low
      Where there was an LOE or SOR against an intervention, a negative score was given.
      High to low
      Where there was an LOE or SOR against an intervention, a negative score was given.
      −1 to −4
      Where there was an LOE or SOR against an intervention, a negative score was given.
      NOTE. Because of the variability in LOE scales throughout the guidelines, we have standardized LOE to Roman numerals wherever possible.
      A full list of individual guideline grading systems for LOE and SORs is provided in appendix 2.
      Where there was an LOE or SOR against an intervention, a negative score was given.
      Overall recommendation scores of interventions were determined by the median value of the specific intervention's individual weightings. Table 2 illustrates how the overall intervention recommendations were then grouped on the basis of their median score into strongly recommended, recommended, recommended with caution, and unsupported. For example, knee bracing is recommended by 5 guidelines with weighted scores of 4, 3, 4, 4, and 2, resulting in a median score of 4 and grading of strongly recommended.
      Table 2Overall median value of interventions and related recommendation levels
      Median Value of InterventionOverall Recommendation Level
      3–4Strongly recommended
      2–2.9Recommended
      1.1–1.9Recommended with caution
      0–1Unsupported
      (−1 to −4) to 0Not recommended

      Results

      The systematic literature search yielded 19 guidelines. One
      • Brighton S.
      • Mody G.M.
      • Tikly M.
      • Bouwer D.
      Osteoarthritis: clinical guideline 2003.
      was excluded because there were no stated methods for evidence gathering or developing recommendations, recommendations were not clear, and no method for grading recommendations was stated. One

      Izquierdo R, Voloshin I, Edwards S, et al. The treatment of glenohumeral joint osteoarthritis: guideline and evidence report. Rosemont: American Academy of Orthopaedic Surgeons; 2009. Available at: http://www.aaos.org/research/guidelines/gloguideline.pdf. Accessed January 14, 2013.

      was excluded because no conclusive recommendations were provided for the physical management of glenohumeral joint OA. This resulted in 17 guidelines available for full data extraction.

       AGREE II appraisal results

      Table 3 lists the 17 guidelines' AGREE II domain scores with an overall quality assessment rating and a comment on weaknesses of the specific guideline. There was variability in the domains that were effectively addressed by the guidelines. Of the 17 guidelines, 2 effectively addressed 4 of the 6 AGREE II domains,

      Brand C, Buchbinder R, Wluka A, et al. Guideline for the nonsurgical management of hip and knee osteoarthritis 2009. Available at: http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.

      Richmond J, Hunter D, Irrgang J, et al. Treatment of osteoarthritis of the knee (non-arthroplasty): full guideline. Rosemont: American Academy of Orthopaedic Surgeons; 2008. Available at: http://www.aaos.org/research/guidelines/oakguideline.pdf. Accessed January 14, 2013.

      9 effectively addressed 3 domains,
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for the management of osteoarthritis in adults who are obese or overweight.
      • Hochberg M.C.
      • Altman R.D.
      • April K.T.
      • et al.
      American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee.
      • Jordan K.M.
      • Arden N.K.
      • Doherty M.
      • et al.
      EULAR recommendations 2003: an evidence based approach to the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT).
      • Roddy E.
      • Zhang W.
      • Doherty M.
      • et al.
      Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or knee—the MOVE consensus.
      • Tuncer T.
      • Çay H.F.
      • Kaçar C.
      • et al.
      Evidence-based recommendations for the management of knee osteoarthritis: a consensus report of the Turkish League Against Rheumatism.
      • Zhang W.
      • Doherty M.
      • Arden N.
      • et al.
      EULAR evidence based recommendations for the management of hip osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).
      • Zhang W.
      • Doherty M.
      • Leeb B.F.
      • et al.
      EULAR evidence based recommendations for the management of hand osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).
      • Zhang W.
      • Moskowitz R.W.
      • Nuki G.
      • et al.
      OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines.
      • Fernandes L.
      • Hagen K.B.
      • Bijlsma J.W.
      • et al.
      EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis.
      and 6 effectively addressed at least 2 domains.

      National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults: Royal College of Physicians. 2008. Available at: http://www.nice.org.uk/CG059. Accessed November 26, 2012.

      • Loew L.
      • Brosseau L.
      • Wells G.A.
      • et al.
      Ottawa panel evidence-based clinical practice guidelines for aerobic walking programs in the management of osteoarthritis.
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for patient education programmes in the management of osteoarthritis.
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for therapeutic exercises and manual therapy in the management of osteoarthritis.
      • Mazières B.
      • Bannwarth B.
      • Dougados M.
      • Lequesne M.
      EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials.
      • Peter W.F.H.
      • Jansen M.J.
      • Hurkmans E.J.
      • et al.
      Physiotherapy in hip and knee osteoarthritis: development of a practice guideline concerning initial assessment, treatment and evaluation.
      Stakeholder involvement was effectively addressed by 6 guidelines,

      National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults: Royal College of Physicians. 2008. Available at: http://www.nice.org.uk/CG059. Accessed November 26, 2012.

      Brand C, Buchbinder R, Wluka A, et al. Guideline for the nonsurgical management of hip and knee osteoarthritis 2009. Available at: http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.

      Richmond J, Hunter D, Irrgang J, et al. Treatment of osteoarthritis of the knee (non-arthroplasty): full guideline. Rosemont: American Academy of Orthopaedic Surgeons; 2008. Available at: http://www.aaos.org/research/guidelines/oakguideline.pdf. Accessed January 14, 2013.

      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for the management of osteoarthritis in adults who are obese or overweight.
      • Fernandes L.
      • Hagen K.B.
      • Bijlsma J.W.
      • et al.
      EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis.
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for therapeutic exercises and manual therapy in the management of osteoarthritis.
      editorial independence was effectively addressed by 1 guideline,
      • Tuncer T.
      • Çay H.F.
      • Kaçar C.
      • et al.
      Evidence-based recommendations for the management of knee osteoarthritis: a consensus report of the Turkish League Against Rheumatism.
      and applicability was not effectively addressed in any guideline. Six guidelines can be recommended without modifications.

      Brand C, Buchbinder R, Wluka A, et al. Guideline for the nonsurgical management of hip and knee osteoarthritis 2009. Available at: http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.

      Richmond J, Hunter D, Irrgang J, et al. Treatment of osteoarthritis of the knee (non-arthroplasty): full guideline. Rosemont: American Academy of Orthopaedic Surgeons; 2008. Available at: http://www.aaos.org/research/guidelines/oakguideline.pdf. Accessed January 14, 2013.

      • Jordan K.M.
      • Arden N.K.
      • Doherty M.
      • et al.
      EULAR recommendations 2003: an evidence based approach to the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT).
      • Zhang W.
      • Doherty M.
      • Leeb B.F.
      • et al.
      EULAR evidence based recommendations for the management of hand osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).
      • Zhang W.
      • Moskowitz R.W.
      • Nuki G.
      • et al.
      OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines.
      • Fernandes L.
      • Hagen K.B.
      • Bijlsma J.W.
      • et al.
      EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis.
      Eleven guidelines

      National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults: Royal College of Physicians. 2008. Available at: http://www.nice.org.uk/CG059. Accessed November 26, 2012.

      • Loew L.
      • Brosseau L.
      • Wells G.A.
      • et al.
      Ottawa panel evidence-based clinical practice guidelines for aerobic walking programs in the management of osteoarthritis.
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for the management of osteoarthritis in adults who are obese or overweight.
      • Hochberg M.C.
      • Altman R.D.
      • April K.T.
      • et al.
      American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee.
      • Roddy E.
      • Zhang W.
      • Doherty M.
      • et al.
      Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or knee—the MOVE consensus.
      • Tuncer T.
      • Çay H.F.
      • Kaçar C.
      • et al.
      Evidence-based recommendations for the management of knee osteoarthritis: a consensus report of the Turkish League Against Rheumatism.
      • Zhang W.
      • Doherty M.
      • Arden N.
      • et al.
      EULAR evidence based recommendations for the management of hip osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for patient education programmes in the management of osteoarthritis.
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for therapeutic exercises and manual therapy in the management of osteoarthritis.
      • Mazières B.
      • Bannwarth B.
      • Dougados M.
      • Lequesne M.
      EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials.
      • Peter W.F.H.
      • Jansen M.J.
      • Hurkmans E.J.
      • et al.
      Physiotherapy in hip and knee osteoarthritis: development of a practice guideline concerning initial assessment, treatment and evaluation.
      were recommended with modifications.
      Table 3AGREE II domain scores and overall quality assessment rating of guidelines
      Organization (Year)Scope and PurposeStakeholder InvolvementRigor of DevelopmentClarity of PresentationApplicabilityEditorial IndependenceOverall Quality Assessment Rating

      • Comment
      AAOS

      Richmond J, Hunter D, Irrgang J, et al. Treatment of osteoarthritis of the knee (non-arthroplasty): full guideline. Rosemont: American Academy of Orthopaedic Surgeons; 2008. Available at: http://www.aaos.org/research/guidelines/oakguideline.pdf. Accessed January 14, 2013.

      (2008)
      946796100058Recommended
      ACR
      • Hochberg M.C.
      • Altman R.D.
      • April K.T.
      • et al.
      American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee.
      (2012)
      8956798348Recommended with modifications
      • Recommendations need to be more specific
      BSR
      • Roddy E.
      • Zhang W.
      • Doherty M.
      • et al.
      Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or knee—the MOVE consensus.
      (2005)
      83446367058Recommended with modifications
      • Recommendations need to be more specific
      EULAR
      • Fernandes L.
      • Hagen K.B.
      • Bijlsma J.W.
      • et al.
      EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis.
      (2013)
      898356100858Recommended
      EULAR
      • Zhang W.
      • Doherty M.
      • Leeb B.F.
      • et al.
      EULAR evidence based recommendations for the management of hand osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).
      (2007)
      78336078218Recommended
      EULAR
      • Zhang W.
      • Doherty M.
      • Arden N.
      • et al.
      EULAR evidence based recommendations for the management of hip osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).
      (2005)
      836737208Recommended with modifications
      • Wider input required on expert panel
      EULAR
      • Jordan K.M.
      • Arden N.K.
      • Doherty M.
      • et al.
      EULAR recommendations 2003: an evidence based approach to the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT).
      (2003)
      8328678348Recommended
      EULAR
      • Mazières B.
      • Bannwarth B.
      • Dougados M.
      • Lequesne M.
      EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials.
      (2001)
      8339568348Recommended with modifications
      • Methodology requires better description, and recommendations need to be more succinct
      NHMRC

      Brand C, Buchbinder R, Wluka A, et al. Guideline for the nonsurgical management of hip and knee osteoarthritis 2009. Available at: http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.

      (2009)
      1006188832958Recommended
      NICE

      National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults: Royal College of Physicians. 2008. Available at: http://www.nice.org.uk/CG059. Accessed November 26, 2012.

      (2008)
      7210054504233Recommended with modifications
      • Recommendations need to be more specific
      OARSI
      • Zhang W.
      • Moskowitz R.W.
      • Nuki G.
      • et al.
      OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines.
      (2008)
      895694892158Recommended
      Ottawa
      • Loew L.
      • Brosseau L.
      • Wells G.A.
      • et al.
      Ottawa panel evidence-based clinical practice guidelines for aerobic walking programs in the management of osteoarthritis.
      (2012)
      835071392550Recommended with modifications
      • Recommendations need to be more specific
      Ottawa
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for patient education programmes in the management of osteoarthritis.
      (2011)
      9467655608Recommended with modifications
      • Recommendations need to be more specific
      Ottawa
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for the management of osteoarthritis in adults who are obese or overweight.
      (2011)
      9450673980Recommended with modifications
      • Recommendations need to be more specific
      Ottawa
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for therapeutic exercises and manual therapy in the management of osteoarthritis.
      (2005)
      8361524408Recommended with modifications
      • Recommendations need to be more specific
      KNGF
      • Peter W.F.H.
      • Jansen M.J.
      • Hurkmans E.J.
      • et al.
      Physiotherapy in hip and knee osteoarthritis: development of a practice guideline concerning initial assessment, treatment and evaluation.
      (2011)
      8933508348Recommended with modifications
      • Methods need to be described and patient population involved
      TLAR
      • Tuncer T.
      • Çay H.F.
      • Kaçar C.
      • et al.
      Evidence-based recommendations for the management of knee osteoarthritis: a consensus report of the Turkish League Against Rheumatism.
      (2012)
      893958830100Recommended with modifications
      • Methodology quality needs improvement, and recommendations need to be more specific
      NOTE. Values represent %.
      Abbreviations: AAOS, American Academy of Orthopaedic Surgeons; ACR, American College of Rheumatology; BSR, British Society for Rheumatology; EULAR, European League Against Rheumatism; KNGF, Royal Dutch Society for Physical Therapy; NHMRC, National Health and Medical Research Council; OARSI, Osteoarthritis Research Society International; Ottawa, Ottawa Panel; TLAR, Turkish League Against Rheumatism.

       Interventions

      Forty interventions were identified across the guidelines. Table 4 lists the grouped interventions covered by the 17 guidelines. The grouped interventions are listed in descending order with the number of guidelines that recommended them: exercise (16 guidelines), education (13 guidelines), equipment (11 guidelines), weight loss/diet (11 guidelines), taping, heat/ice (9 guidelines), electrical-based therapy (7 guidelines), self-management (7 guidelines), acupuncture (5 guidelines), manual therapy (5 guidelines), psychosocial interventions (5 guidelines), and balneotherapy/spa therapy (2 guidelines).
      Table 4Grouped interventions within guidelines
      GuidelineGrouped Interventions
      Organization: (Date)ExerciseEducationEquipmentWeight Loss/DietTaping, Heat/IceElectrical-Based TherapySelf- ManagementAcupunctureManual TherapyPsychosocial InterventionsBalneotherapy/Spa
      AAOS

      Richmond J, Hunter D, Irrgang J, et al. Treatment of osteoarthritis of the knee (non-arthroplasty): full guideline. Rosemont: American Academy of Orthopaedic Surgeons; 2008. Available at: http://www.aaos.org/research/guidelines/oakguideline.pdf. Accessed January 14, 2013.

      (2008)
      XXXXXX
      ACR
      • Hochberg M.C.
      • Altman R.D.
      • April K.T.
      • et al.
      American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee.
      (2012)
      XXXXXXXXXX
      BSR
      • Roddy E.
      • Zhang W.
      • Doherty M.
      • et al.
      Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or knee—the MOVE consensus.
      (2005)
      XXX
      EULAR
      • Fernandes L.
      • Hagen K.B.
      • Bijlsma J.W.
      • et al.
      EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis.
      (2013)
      XXXXX
      EULAR
      • Zhang W.
      • Doherty M.
      • Leeb B.F.
      • et al.
      EULAR evidence based recommendations for the management of hand osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).
      (2007)
      XXXXX
      EULAR
      • Zhang W.
      • Doherty M.
      • Arden N.
      • et al.
      EULAR evidence based recommendations for the management of hip osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).
      (2005)
      XXXX
      EULAR
      • Jordan K.M.
      • Arden N.K.
      • Doherty M.
      • et al.
      EULAR recommendations 2003: an evidence based approach to the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT).
      (2003)
      XXXX
      EULAR
      • Mazières B.
      • Bannwarth B.
      • Dougados M.
      • Lequesne M.
      EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials.
      (2001)
      XXXXXXX
      NHMRC

      Brand C, Buchbinder R, Wluka A, et al. Guideline for the nonsurgical management of hip and knee osteoarthritis 2009. Available at: http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.

      (2009)
      XXXXXXXXX
      NICE

      National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults: Royal College of Physicians. 2008. Available at: http://www.nice.org.uk/CG059. Accessed November 26, 2012.

      (2008)
      XXXXXXXXX
      OARSI
      • Zhang W.
      • Moskowitz R.W.
      • Nuki G.
      • et al.
      OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines.
      (2008)
      XXXXXXXXX
      Ottawa
      • Loew L.
      • Brosseau L.
      • Wells G.A.
      • et al.
      Ottawa panel evidence-based clinical practice guidelines for aerobic walking programs in the management of osteoarthritis.
      (2012)
      X
      Ottawa
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for patient education programmes in the management of osteoarthritis.
      (2011)
      XX
      Ottawa
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for the management of osteoarthritis in adults who are obese or overweight.
      (2011)
      X
      Ottawa
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for therapeutic exercises and manual therapy in the management of osteoarthritis.
      (2005)
      XX
      KNGF
      • Peter W.F.H.
      • Jansen M.J.
      • Hurkmans E.J.
      • et al.
      Physiotherapy in hip and knee osteoarthritis: development of a practice guideline concerning initial assessment, treatment and evaluation.
      (2011)
      XXXXXX
      TLAR
      • Tuncer T.
      • Çay H.F.
      • Kaçar C.
      • et al.
      Evidence-based recommendations for the management of knee osteoarthritis: a consensus report of the Turkish League Against Rheumatism.
      (2012)
      XXXXXXXX
      Abbreviations: AAOS, American Academy of Orthopaedic Surgeons; ACR, American College of Rheumatology; BSR, British Society for Rheumatology; EULAR, European League Against Rheumatism; KNGF, Royal Dutch Society for Physical Therapy; NHMRC, National Health and Medical Research Council; OARSI, Osteoarthritis Research Society International; Ottawa, Ottawa Panel; TLAR, Turkish League Against Rheumatism.
      Balneotherapy refers to the passive relaxation in mineral or thermal water, whereas hydrotherapy refers to therapeutic methods (eg, exercise) that take advantage of the physical properties of water. All guidelines except the NICE guideline stated grading scales for their recommendations, using either LOE or SOR or both. The grading criteria used by guideline developers varied among guidelines.

       Guideline intervention recommendations

      The median weighting of the specific interventions across guidelines was calculated and then given an overall recommendation. These are presented as strongly recommended (table 5), recommended (table 6), recommended with caution (table 7), unsupported (table 8), and not recommended (table 9).
      Table 5Interventions strongly recommended
      InterventionGuideline (Date)LOE
      A full list of individual guideline grading systems for LOE and SORs is provided in appendix 2.
      SOR
      A full list of individual guideline grading systems for LOE and SORs is provided in appendix 2.
      Individual WeightingMedian (Overall Recommendation)
      Exercise
       Combined exercise or unspecified typeAAOS

      Richmond J, Hunter D, Irrgang J, et al. Treatment of osteoarthritis of the knee (non-arthroplasty): full guideline. Rosemont: American Academy of Orthopaedic Surgeons; 2008. Available at: http://www.aaos.org/research/guidelines/oakguideline.pdf. Accessed January 14, 2013.

      (2008)
      VC13 (strongly recommended)
      BSR
      • Roddy E.
      • Zhang W.
      • Doherty M.
      • et al.
      Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or knee—the MOVE consensus.
      (2005)
      IVD1
      EULAR
      • Fernandes L.
      • Hagen K.B.
      • Bijlsma J.W.
      • et al.
      EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis.
      (2013)
      Ia89%4
      EULAR
      • Zhang W.
      • Doherty M.
      • Arden N.
      • et al.
      EULAR evidence based recommendations for the management of hip osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).
      (2005)
      NS72%2
      EULAR
      • Jordan K.M.
      • Arden N.K.
      • Doherty M.
      • et al.
      EULAR recommendations 2003: an evidence based approach to the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT).
      (2003)
      1BA4
      EULAR
      • Mazières B.
      • Bannwarth B.
      • Dougados M.
      • Lequesne M.
      EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials.
      (2001)
      IBA4
      Ottawa
      • Loew L.
      • Brosseau L.
      • Wells G.A.
      • et al.
      Ottawa panel evidence-based clinical practice guidelines for aerobic walking programs in the management of osteoarthritis.
      (2012)
      1A–D3
      Ottawa
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for patient education programmes in the management of osteoarthritis.
      (2011)
      1A–D3
      Ottawa
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for therapeutic exercises and manual therapy in the management of osteoarthritis.
      (2005)
      1A–C3
      KNGF
      • Peter W.F.H.
      • Jansen M.J.
      • Hurkmans E.J.
      • et al.
      Physiotherapy in hip and knee osteoarthritis: development of a practice guideline concerning initial assessment, treatment and evaluation.
      (2011)
      I–IINS3
      TLAR
      • Tuncer T.
      • Çay H.F.
      • Kaçar C.
      • et al.
      Evidence-based recommendations for the management of knee osteoarthritis: a consensus report of the Turkish League Against Rheumatism.
      (2012)
      1a, 1b97%4
       AerobicAAOS

      Richmond J, Hunter D, Irrgang J, et al. Treatment of osteoarthritis of the knee (non-arthroplasty): full guideline. Rosemont: American Academy of Orthopaedic Surgeons; 2008. Available at: http://www.aaos.org/research/guidelines/oakguideline.pdf. Accessed January 14, 2013.

      (2008)
      IA43 (strongly recommended)
      ACR
      • Hochberg M.C.
      • Altman R.D.
      • April K.T.
      • et al.
      American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee.
      (2012)
      NSStrongly recommended2
      BSR
      • Roddy E.
      • Zhang W.
      • Doherty M.
      • et al.
      Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or knee—the MOVE consensus.
      (2005)
      Ib–IVA–C4, 1
      EULAR
      • Fernandes L.
      • Hagen K.B.
      • Bijlsma J.W.
      • et al.
      EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis.
      (2013)
      IaNS3
      NICE

      National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults: Royal College of Physicians. 2008. Available at: http://www.nice.org.uk/CG059. Accessed November 26, 2012.

      (2008)
      NSNS4
      OARSI
      • Zhang W.
      • Moskowitz R.W.
      • Nuki G.
      • et al.
      OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines.
      (2008)
      Ia–IV96%4, 2
      Ottawa
      • Loew L.
      • Brosseau L.
      • Wells G.A.
      • et al.
      Ottawa panel evidence-based clinical practice guidelines for aerobic walking programs in the management of osteoarthritis.
      (2012)
      1A–C3
      Ottawa
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for therapeutic exercises and manual therapy in the management of osteoarthritis.
      (2005)
      1A–C3
       StrengtheningAAOS

      Richmond J, Hunter D, Irrgang J, et al. Treatment of osteoarthritis of the knee (non-arthroplasty): full guideline. Rosemont: American Academy of Orthopaedic Surgeons; 2008. Available at: http://www.aaos.org/research/guidelines/oakguideline.pdf. Accessed January 14, 2013.

      (2008)
      IIB43 (strongly recommended)
      ACR
      • Hochberg M.C.
      • Altman R.D.
      • April K.T.
      • et al.
      American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee.
      (2012)
      NSStrongly recommended2
      BSR
      • Roddy E.
      • Zhang W.
      • Doherty M.
      • et al.
      Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or knee—the MOVE consensus.
      (2005)
      Ib–IVA–C4, 1
      EULAR
      • Fernandes L.
      • Hagen K.B.
      • Bijlsma J.W.
      • et al.
      EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis.
      (2013)
      IaNS3
      EULAR
      • Zhang W.
      • Doherty M.
      • Leeb B.F.
      • et al.
      EULAR evidence based recommendations for the management of hand osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).
      (2007)
      IVC1
      EULAR
      • Mazières B.
      • Bannwarth B.
      • Dougados M.
      • Lequesne M.
      EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials.
      (2001)
      IBA4
      NICE

      National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults: Royal College of Physicians. 2008. Available at: http://www.nice.org.uk/CG059. Accessed November 26, 2012.

      (2008)
      NSNS4
      OARSI
      • Zhang W.
      • Moskowitz R.W.
      • Nuki G.
      • et al.
      OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines.
      (2008)
      Ia–IV96%4, 2
      Ottawa
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for therapeutic exercises and manual therapy in the management of osteoarthritis.
      (2005)
      1A–C3
       Aquatic/hydrotherapyACR
      • Hochberg M.C.
      • Altman R.D.
      • April K.T.
      • et al.
      American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee.
      (2012)
      NSStrongly recommended23 (strongly recommended)
      NHMRC

      Brand C, Buchbinder R, Wluka A, et al. Guideline for the nonsurgical management of hip and knee osteoarthritis 2009. Available at: http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.

      (2009)
      NSC2
      NICE

      National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults: Royal College of Physicians. 2008. Available at: http://www.nice.org.uk/CG059. Accessed November 26, 2012.

      (2008)
      NSNS4
      OARSI
      • Zhang W.
      • Moskowitz R.W.
      • Nuki G.
      • et al.
      OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines.
      (2008)
      Ib96%4
      Ottawa
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for therapeutic exercises and manual therapy in the management of osteoarthritis.
      (2005)
      1A–C3
      KNGF
      • Peter W.F.H.
      • Jansen M.J.
      • Hurkmans E.J.
      • et al.
      Physiotherapy in hip and knee osteoarthritis: development of a practice guideline concerning initial assessment, treatment and evaluation.
      (2011)
      INS3
       Land-basedNHMRC

      Brand C, Buchbinder R, Wluka A, et al. Guideline for the nonsurgical management of hip and knee osteoarthritis 2009. Available at: http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.

      (2009)
      NSB33 (strongly recommended)
       YogaOttawa
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for therapeutic exercises and manual therapy in the management of osteoarthritis.
      (2005)
      1A–C33 (strongly recommended)
      Electrical-based therapy
       Transcutaneous electrical nerve stimulationACR
      • Hochberg M.C.
      • Altman R.D.
      • April K.T.
      • et al.
      American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee.
      (2012)
      NSConditionally recommended13 (strongly recommended)
      NHMRC

      Brand C, Buchbinder R, Wluka A, et al. Guideline for the nonsurgical management of hip and knee osteoarthritis 2009. Available at: http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.

      (2009)
      NSC2
      NICE

      National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults: Royal College of Physicians. 2008. Available at: http://www.nice.org.uk/CG059. Accessed November 26, 2012.

      (2008)
      NSNS4
      OARSI
      • Zhang W.
      • Moskowitz R.W.
      • Nuki G.
      • et al.
      OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines.
      (2008)
      1a58%4
      KNGF
      • Peter W.F.H.
      • Jansen M.J.
      • Hurkmans E.J.
      • et al.
      Physiotherapy in hip and knee osteoarthritis: development of a practice guideline concerning initial assessment, treatment and evaluation.
      (2011)
      IVNS1
      TLAR
      • Tuncer T.
      • Çay H.F.
      • Kaçar C.
      • et al.
      Evidence-based recommendations for the management of knee osteoarthritis: a consensus report of the Turkish League Against Rheumatism.
      (2012)
      Ib96%4
      Equipment Knee bracingEULAR
      • Jordan K.M.
      • Arden N.K.
      • Doherty M.
      • et al.
      EULAR recommendations 2003: an evidence based approach to the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT).
      (2003)
      1BB44 (strongly recommended)
      NHMRC

      Brand C, Buchbinder R, Wluka A, et al. Guideline for the nonsurgical management of hip and knee osteoarthritis 2009. Available at: http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.

      (2009)
      NSB3
      NICE

      National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults: Royal College of Physicians. 2008. Available at: http://www.nice.org.uk/CG059. Accessed November 26, 2012.

      (2008)
      NSNS4
      OARSI
      • Zhang W.
      • Moskowitz R.W.
      • Nuki G.
      • et al.
      OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines.
      (2008)
      Ia76%4
      TLAR
      • Tuncer T.
      • Çay H.F.
      • Kaçar C.
      • et al.
      Evidence-based recommendations for the management of knee osteoarthritis: a consensus report of the Turkish League Against Rheumatism.
      (2012)
      III, Ia86%2
       Appropriate footwearEULAR
      • Fernandes L.
      • Hagen K.B.
      • Bijlsma J.W.
      • et al.
      EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis.
      (2013)
      Ib87%43 (strongly recommended)
      NICE

      National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults: Royal College of Physicians. 2008. Available at: http://www.nice.org.uk/CG059. Accessed November 26, 2012.

      (2008)
      NSNS4
      OARSI
      • Zhang W.
      • Moskowitz R.W.
      • Nuki G.
      • et al.
      OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines.
      (2008)
      IV77%2
      TLAR
      • Tuncer T.
      • Çay H.F.
      • Kaçar C.
      • et al.
      Evidence-based recommendations for the management of knee osteoarthritis: a consensus report of the Turkish League Against Rheumatism.
      (2012)
      IV86%2
       Wedged insolesAAOS

      Richmond J, Hunter D, Irrgang J, et al. Treatment of osteoarthritis of the knee (non-arthroplasty): full guideline. Rosemont: American Academy of Orthopaedic Surgeons; 2008. Available at: http://www.aaos.org/research/guidelines/oakguideline.pdf. Accessed January 14, 2013.

      (2008)
      IIB44 (strongly recommended)
      ACR
      • Hochberg M.C.
      • Altman R.D.
      • April K.T.
      • et al.
      American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee.
      (2012)
      NSConditionally recommended1
      EULAR
      • Fernandes L.
      • Hagen K.B.
      • Bijlsma J.W.
      • et al.
      EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis.
      (2013)
      Ib80%−4
      EULAR
      • Zhang W.
      • Doherty M.
      • Arden N.
      • et al.
      EULAR evidence based recommendations for the management of hip osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).
      (2005)
      IV61.7%2
      EULAR
      • Jordan K.M.
      • Arden N.K.
      • Doherty M.
      • et al.
      EULAR recommendations 2003: an evidence based approach to the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT).
      (2003)
      1BB4
      EULAR
      • Mazières B.
      • Bannwarth B.
      • Dougados M.
      • Lequesne M.
      EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials.
      (2001)
      IIAB4
      NHMRC

      Brand C, Buchbinder R, Wluka A, et al. Guideline for the nonsurgical management of hip and knee osteoarthritis 2009. Available at: http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.

      (2009)
      NSB3
      NICE

      National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults: Royal College of Physicians. 2008. Available at: http://www.nice.org.uk/CG059. Accessed November 26, 2012.

      (2008)
      NSNS4
      OARSI
      • Zhang W.
      • Moskowitz R.W.
      • Nuki G.
      • et al.
      OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines.
      (2008)
      Ia77%4
      TLAR
      • Tuncer T.
      • Çay H.F.
      • Kaçar C.
      • et al.
      Evidence-based recommendations for the management of knee osteoarthritis: a consensus report of the Turkish League Against Rheumatism.
      (2012)
      Ib86%4
      Education
       Education type unspecifiedAAOS

      Richmond J, Hunter D, Irrgang J, et al. Treatment of osteoarthritis of the knee (non-arthroplasty): full guideline. Rosemont: American Academy of Orthopaedic Surgeons; 2008. Available at: http://www.aaos.org/research/guidelines/oakguideline.pdf. Accessed January 14, 2013.

      (2008)
      IIB44 (strongly recommended)
      ACR
      • Hochberg M.C.
      • Altman R.D.
      • April K.T.
      • et al.
      American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee.
      (2012)
      NSConditionally recommended1
      BSR
      • Roddy E.
      • Zhang W.
      • Doherty M.
      • et al.
      Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or knee—the MOVE consensus.
      (2005)
      IVD1
      EULAR
      • Zhang W.
      • Doherty M.
      • Leeb B.F.
      • et al.
      EULAR evidence based recommendations for the management of hand osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).
      (2007)
      IV59%1
      EULAR
      • Zhang W.
      • Doherty M.
      • Arden N.
      • et al.
      EULAR evidence based recommendations for the management of hip osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).
      (2005)
      Ib72%4
      EULAR
      • Jordan K.M.
      • Arden N.K.
      • Doherty M.
      • et al.
      EULAR recommendations 2003: an evidence based approach to the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT).
      (2003)
      1AA4
      EULAR
      • Mazières B.
      • Bannwarth B.
      • Dougados M.
      • Lequesne M.
      EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials.
      (2001)
      IAA4
      NICE

      National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults: Royal College of Physicians. 2008. Available at: http://www.nice.org.uk/CG059. Accessed November 26, 2012.

      (2008)
      NSNS4
      OARSI
      • Zhang W.
      • Moskowitz R.W.
      • Nuki G.
      • et al.
      OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines.
      (2008)
      Ia97%4
      KNGF
      • Peter W.F.H.
      • Jansen M.J.
      • Hurkmans E.J.
      • et al.
      Physiotherapy in hip and knee osteoarthritis: development of a practice guideline concerning initial assessment, treatment and evaluation.
      (2011)
      IINS3
      TLAR
      • Tuncer T.
      • Çay H.F.
      • Kaçar C.
      • et al.
      Evidence-based recommendations for the management of knee osteoarthritis: a consensus report of the Turkish League Against Rheumatism.
      (2012)
      Ib, III, IV96%, 94%4
       Pain management programOttawa
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for the management of osteoarthritis in adults who are obese or overweight.
      (2011)
      1A–D33 (strongly recommended)
       Individual educationEULAR
      • Fernandes L.
      • Hagen K.B.
      • Bijlsma J.W.
      • et al.
      EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis.
      (2013)
      Ia84%43.5 (strongly recommended)
      Ottawa
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for the management of osteoarthritis in adults who are obese or overweight.
      (2011)
      1A–D3
       Group educationOttawa
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for the management of osteoarthritis in adults who are obese or overweight.
      (2011)
      1A–D33 (strongly recommended)
       Preoperative educationOttawa
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for the management of osteoarthritis in adults who are obese or overweight.
      (2011)
      1A–D33 (strongly recommended)
       Collective informationOttawa
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for the management of osteoarthritis in adults who are obese or overweight.
      (2011)
      1A–D33 (strongly recommended)
      Manual therapy
       Manual therapy with supervised exerciseACR
      • Hochberg M.C.
      • Altman R.D.
      • April K.T.
      • et al.
      American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee.
      (2012)
      NSConditionally recommended13 (strongly recommended)
      Ottawa
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for therapeutic exercises and manual therapy in the management of osteoarthritis.
      (2005)
      IA–C3
      KNGF
      • Peter W.F.H.
      • Jansen M.J.
      • Hurkmans E.J.
      • et al.
      Physiotherapy in hip and knee osteoarthritis: development of a practice guideline concerning initial assessment, treatment and evaluation.
      (2011)
      IINS3
       Manipulation and stretchingNICE

      National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults: Royal College of Physicians. 2008. Available at: http://www.nice.org.uk/CG059. Accessed November 26, 2012.

      (2008)
      NSNS44 (strongly recommended)
      Diet and weight loss
       Weight lossAAOS

      Richmond J, Hunter D, Irrgang J, et al. Treatment of osteoarthritis of the knee (non-arthroplasty): full guideline. Rosemont: American Academy of Orthopaedic Surgeons; 2008. Available at: http://www.aaos.org/research/guidelines/oakguideline.pdf. Accessed January 14, 2013.

      (2008)
      IA44 (strongly recommended)
      ACR
      • Hochberg M.C.
      • Altman R.D.
      • April K.T.
      • et al.
      American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee.
      (2012)
      NSStrongly recommended2
      EULAR
      • Fernandes L.
      • Hagen K.B.
      • Bijlsma J.W.
      • et al.
      EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis.
      (2013)
      Ia–III98%4–2
      EULAR
      • Zhang W.
      • Doherty M.
      • Arden N.
      • et al.
      EULAR evidence based recommendations for the management of hip osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).
      (2005)
      III68%2
      EULAR
      • Jordan K.M.
      • Arden N.K.
      • Doherty M.
      • et al.
      EULAR recommendations 2003: an evidence based approach to the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT).
      (2003)
      1BB4
      EULAR
      • Mazières B.
      • Bannwarth B.
      • Dougados M.
      • Lequesne M.
      EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials.
      (2001)
      IBB4
      NHMRC

      Brand C, Buchbinder R, Wluka A, et al. Guideline for the nonsurgical management of hip and knee osteoarthritis 2009. Available at: http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.

      (2009)
      NSB3
      NICE

      National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults: Royal College of Physicians. 2008. Available at: http://www.nice.org.uk/CG059. Accessed November 26, 2012.

      (2008)
      NSNS4
      OARSI
      • Zhang W.
      • Moskowitz R.W.
      • Nuki G.
      • et al.
      OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines.
      (2008)
      Ia96%4
      TLAR
      • Tuncer T.
      • Çay H.F.
      • Kaçar C.
      • et al.
      Evidence-based recommendations for the management of knee osteoarthritis: a consensus report of the Turkish League Against Rheumatism.
      (2012)
      IIINS1
       DietOttawa
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for patient education programmes in the management of osteoarthritis.
      (2011)
      IA–D33 (strongly recommended)
       Combinations of diet, physical activity, and social cognitive theoryOttawa
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for patient education programmes in the management of osteoarthritis.
      (2011)
      IA–D33 (strongly recommended)
      Self-management and psychosocial-based therapy
       Self-managementAAOS

      Richmond J, Hunter D, Irrgang J, et al. Treatment of osteoarthritis of the knee (non-arthroplasty): full guideline. Rosemont: American Academy of Orthopaedic Surgeons; 2008. Available at: http://www.aaos.org/research/guidelines/oakguideline.pdf. Accessed January 14, 2013.

      (2008)
      IIB43 (strongly recommended)
      ACR
      • Hochberg M.C.
      • Altman R.D.
      • April K.T.
      • et al.
      American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee.
      (2012)
      NSConditionally recommended1
      NHMRC

      Brand C, Buchbinder R, Wluka A, et al. Guideline for the nonsurgical management of hip and knee osteoarthritis 2009. Available at: http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.

      (2009)
      NSC1
      NICE

      National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults: Royal College of Physicians. 2008. Available at: http://www.nice.org.uk/CG059. Accessed November 26, 2012.

      (2008)
      NSN/S4
      OARSI
      • Zhang W.
      • Moskowitz R.W.
      • Nuki G.
      • et al.
      OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines.
      (2008)
      IV97%2
      Ottawa
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for the management of osteoarthritis in adults who are obese or overweight.
      (2011)
      IC–D3
      KNGF
      • Peter W.F.H.
      • Jansen M.J.
      • Hurkmans E.J.
      • et al.
      Physiotherapy in hip and knee osteoarthritis: development of a practice guideline concerning initial assessment, treatment and evaluation.
      (2011)
      IINS3
      Balneotherapy/spa
       BalneotherapyTLAR
      • Tuncer T.
      • Çay H.F.
      • Kaçar C.
      • et al.
      Evidence-based recommendations for the management of knee osteoarthritis: a consensus report of the Turkish League Against Rheumatism.
      (2012)
      Ia, Ib, III91%44 (strongly recommended)
       SpaEULAR
      • Mazières B.
      • Bannwarth B.
      • Dougados M.
      • Lequesne M.
      EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials.
      (2001)
      IBC33 (strongly recommended)
      Abbreviations: AAOS, American Academy of Orthopaedic Surgeons; ACR, American College of Rheumatology; BSR, British Society for Rheumatology; EULAR, European League Against Rheumatism; KNGF, Royal Dutch Society for Physical Therapy; NHMRC, National Health and Medical Research Council; NS, not stated; OARSI, Osteoarthritis Research Society International; TLAR, Turkish League Against Rheumatism.
      A full list of individual guideline grading systems for LOE and SORs is provided in appendix 2.
      Table 6Interventions recommended
      InterventionGuideline (Date)LOE
      A full list of individual guideline grading systems for LOE and SORs is provided in appendix 2.
      SOR
      A full list of individual guideline grading systems for LOE and SORs is provided in appendix 2.
      Individual WeightingMedian (Overall Recommendation)
      Exercise
       Tai chiACR
      • Hochberg M.C.
      • Altman R.D.
      • April K.T.
      • et al.
      American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee.
      (2012)
      NSConditionally recommended12 (recommended)
      NHMRC

      Brand C, Buchbinder R, Wluka A, et al. Guideline for the nonsurgical management of hip and knee osteoarthritis 2009. Available at: http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.

      (2009)
      NSC2
      Ottawa
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for therapeutic exercises and manual therapy in the management of osteoarthritis.
      (2005)
      IA–C3
      Electrical-based therapy
       Electrical stimulationNHMRC

      Brand C, Buchbinder R, Wluka A, et al. Guideline for the nonsurgical management of hip and knee osteoarthritis 2009. Available at: http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.

      (2009)
      NSB32 (recommended)
      KNGF
      • Peter W.F.H.
      • Jansen M.J.
      • Hurkmans E.J.
      • et al.
      Physiotherapy in hip and knee osteoarthritis: development of a practice guideline concerning initial assessment, treatment and evaluation.
      (2011)
      IIINS−1
      TLAR
      • Tuncer T.
      • Çay H.F.
      • Kaçar C.
      • et al.
      Evidence-based recommendations for the management of knee osteoarthritis: a consensus report of the Turkish League Against Rheumatism.
      (2012)
      NS88%2
      Equipment
       Devices to assist with activities of daily livingACR
      • Hochberg M.C.
      • Altman R.D.
      • April K.T.
      • et al.
      American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee.
      (2012)
      NSConditionally recommended12.5 (recommended)
      NICE

      National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults: Royal College of Physicians. 2008. Available at: http://www.nice.org.uk/CG059. Accessed November 26, 2012.

      (2008)
      NSNS4
       Walking aidsACR
      • Hochberg M.C.
      • Altman R.D.
      • April K.T.
      • et al.
      American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee.
      (2012)
      NSConditionally recommended12 (recommended)
      EULAR
      • Fernandes L.
      • Hagen K.B.
      • Bijlsma J.W.
      • et al.
      EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis.
      (2013)
      III89%2
      EULAR
      • Zhang W.
      • Doherty M.
      • Arden N.
      • et al.
      EULAR evidence based recommendations for the management of hip osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).
      (2005)
      IV61%2
      NICE

      National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults: Royal College of Physicians. 2008. Available at: http://www.nice.org.uk/CG059. Accessed November 26, 2012.

      (2008)
      NSNS4
      OARSI
      • Zhang W.
      • Moskowitz R.W.
      • Nuki G.
      • et al.
      OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines.
      (2008)
      IV90%2
      TLAR
      • Tuncer T.
      • Çay H.F.
      • Kaçar C.
      • et al.
      Evidence-based recommendations for the management of knee osteoarthritis: a consensus report of the Turkish League Against Rheumatism.
      (2012)
      Ib96%4
      AcupunctureNHMRC

      Brand C, Buchbinder R, Wluka A, et al. Guideline for the nonsurgical management of hip and knee osteoarthritis 2009. Available at: http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.

      (2009)
      NSC22 (recommended)
      OARSI
      • Zhang W.
      • Moskowitz R.W.
      • Nuki G.
      • et al.
      OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines.
      (2008)
      Ia59%3
      TLAR
      • Tuncer T.
      • Çay H.F.
      • Kaçar C.
      • et al.
      Evidence-based recommendations for the management of knee osteoarthritis: a consensus report of the Turkish League Against Rheumatism.
      (2012)
      NS93%2
      Manual therapy
       Multimodal physical therapyNHMRC

      Brand C, Buchbinder R, Wluka A, et al. Guideline for the nonsurgical management of hip and knee osteoarthritis 2009. Available at: http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.

      (2009)
      NSC22 (recommended)
      TapingAAOS

      Richmond J, Hunter D, Irrgang J, et al. Treatment of osteoarthritis of the knee (non-arthroplasty): full guideline. Rosemont: American Academy of Orthopaedic Surgeons; 2008. Available at: http://www.aaos.org/research/guidelines/oakguideline.pdf. Accessed January 14, 2013.

      (2008)
      IIB42.5 (recommended)
      ACR
      • Hochberg M.C.
      • Altman R.D.
      • April K.T.
      • et al.
      American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee.
      (2012)
      NSConditionally recommended1
      EULAR
      • Mazières B.
      • Bannwarth B.
      • Dougados M.
      • Lequesne M.
      EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials.
      (2001)
      IbB4
      NHMRC

      Brand C, Buchbinder R, Wluka A, et al. Guideline for the nonsurgical management of hip and knee osteoarthritis 2009. Available at: http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.

      (2009)
      NSD1
      KNGF
      • Peter W.F.H.
      • Jansen M.J.
      • Hurkmans E.J.
      • et al.
      Physiotherapy in hip and knee osteoarthritis: development of a practice guideline concerning initial assessment, treatment and evaluation.
      (2011)
      IINS3
      TLAR
      • Tuncer T.
      • Çay H.F.
      • Kaçar C.
      • et al.
      Evidence-based recommendations for the management of knee osteoarthritis: a consensus report of the Turkish League Against Rheumatism.
      (2012)
      III86%2
      Thermal-based therapyACR
      • Hochberg M.C.
      • Altman R.D.
      • April K.T.
      • et al.
      American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee.
      (2012)
      NSConditionally recommended12 (recommended)
      EULAR
      • Zhang W.
      • Doherty M.
      • Leeb B.F.
      • et al.
      EULAR evidence based recommendations for the management of hand osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).
      (2007)
      IV77%2
      NHMRC

      Brand C, Buchbinder R, Wluka A, et al. Guideline for the nonsurgical management of hip and knee osteoarthritis 2009. Available at: http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.

      (2009)
      NSC2
      NICE

      National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults: Royal College of Physicians. 2008. Available at: http://www.nice.org.uk/CG059. Accessed November 26, 2012.

      (2008)
      NSNS4
      OARSI
      • Zhang W.
      • Moskowitz R.W.
      • Nuki G.
      • et al.
      OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines.
      (2008)
      Ia64%4
      KNGF
      • Peter W.F.H.
      • Jansen M.J.
      • Hurkmans E.J.
      • et al.
      Physiotherapy in hip and knee osteoarthritis: development of a practice guideline concerning initial assessment, treatment and evaluation.
      (2011)
      IVNS1
      TLAR
      • Tuncer T.
      • Çay H.F.
      • Kaçar C.
      • et al.
      Evidence-based recommendations for the management of knee osteoarthritis: a consensus report of the Turkish League Against Rheumatism.
      (2012)
      Ib86%4
      Self-management and psychosocial-based therapy
       Adherence strategiesBSR
      • Roddy E.
      • Zhang W.
      • Doherty M.
      • et al.
      Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or knee—the MOVE consensus.
      (2005)
      IVD12.5 (recommended)
      OARSI
      • Zhang W.
      • Moskowitz R.W.
      • Nuki G.
      • et al.
      OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines.
      (2008)
      Ib97%4
       Telephone supportAAOS

      Richmond J, Hunter D, Irrgang J, et al. Treatment of osteoarthritis of the knee (non-arthroplasty): full guideline. Rosemont: American Academy of Orthopaedic Surgeons; 2008. Available at: http://www.aaos.org/research/guidelines/oakguideline.pdf. Accessed January 14, 2013.

      (2008)
      IVC12.5 (recommended)
      EULAR
      • Mazières B.
      • Bannwarth B.
      • Dougados M.
      • Lequesne M.
      EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials.
      (2001)
      IbB4
      NHMRC

      Brand C, Buchbinder R, Wluka A, et al. Guideline for the nonsurgical management of hip and knee osteoarthritis 2009. Available at: http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.

      (2009)
      NSD1
      OARSI
      • Zhang W.
      • Moskowitz R.W.
      • Nuki G.
      • et al.
      OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines.
      (2008)
      Ia, IV66%, 66%4, 2
      Ottawa
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for the management of osteoarthritis in adults who are obese or overweight.
      (2011)
      IC–D3
      Abbreviations: AAOS, American Academy of Orthopaedic Surgeons; ACR, American College of Rheumatology; BSR, British Society for Rheumatology; EULAR, European League Against Rheumatism; KNGF, Royal Dutch Society for Physical Therapy; NHMRC, National Health and Medical Research Council; NS, not stated; OARSI, Osteoarthritis Research Society International; TLAR, Turkish League Against Rheumatism.
      A full list of individual guideline grading systems for LOE and SORs is provided in appendix 2.
      Table 7Interventions recommended with caution
      InterventionGuideline (Date)LOE
      A full list of individual guideline grading systems for LOE and SORs is provided in appendix 2.
      SOR
      A full list of individual guideline grading systems for LOE and SORs is provided in appendix 2.
      Individual WeightingMedian (Overall Recommendation)
      Electrical-based therapy
       UltrasoundEULAR
      • Zhang W.
      • Doherty M.
      • Leeb B.F.
      • et al.
      EULAR evidence based recommendations for the management of hand osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).
      (2007)
      IV25%11.5 (recommended with caution)
      NHMRC

      Brand C, Buchbinder R, Wluka A, et al. Guideline for the nonsurgical management of hip and knee osteoarthritis 2009. Available at: http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.

      (2009)
      NSC2
      KNGF
      • Peter W.F.H.
      • Jansen M.J.
      • Hurkmans E.J.
      • et al.
      Physiotherapy in hip and knee osteoarthritis: development of a practice guideline concerning initial assessment, treatment and evaluation.
      (2011)
      IINS−3
      TLAR
      • Tuncer T.
      • Çay H.F.
      • Kaçar C.
      • et al.
      Evidence-based recommendations for the management of knee osteoarthritis: a consensus report of the Turkish League Against Rheumatism.
      (2012)
      Ia, Ib, III95%4
      Equipment
       Hand splintsACR
      • Hochberg M.C.
      • Altman R.D.
      • April K.T.
      • et al.
      American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee.
      (2012)
      NSConditionally recommended11.5 (recommended with caution)
      EULAR
      • Zhang W.
      • Doherty M.
      • Leeb B.F.
      • et al.
      EULAR evidence based recommendations for the management of hand osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).
      (2007)
      IV67%2
      Abbreviations: ACR, American College of Rheumatology; EULAR, European League Against Rheumatism; KNGF, Royal Dutch Society for Physical Therapy; NHMRC, National Health and Medical Research Council; NS, not stated; TLAR, Turkish League Against Rheumatism.
      A full list of individual guideline grading systems for LOE and SORs is provided in appendix 2.
      Table 8Interventions unsupported
      InterventionGuideline (Date)LOE
      A full list of individual guideline grading systems for LOE and SORs is provided in appendix 2.
      SOR
      A full list of individual guideline grading systems for LOE and SORs is provided in appendix 2.
      Individual WeightingMedian (Overall Recommendation)
      Electrical-based therapy
       Laser therapyNHMRC

      Brand C, Buchbinder R, Wluka A, et al. Guideline for the nonsurgical management of hip and knee osteoarthritis 2009. Available at: http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.

      (2009)
      NSD10 (unsupported)
      KNGF
      • Peter W.F.H.
      • Jansen M.J.
      • Hurkmans E.J.
      • et al.
      Physiotherapy in hip and knee osteoarthritis: development of a practice guideline concerning initial assessment, treatment and evaluation.
      (2011)
      IVNS−1
      Equipment
       Magnetic braceletsNHMRC

      Brand C, Buchbinder R, Wluka A, et al. Guideline for the nonsurgical management of hip and knee osteoarthritis 2009. Available at: http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.

      (2009)
      NSD11 (unsupported)
      Acupuncture
       Chinese acupunctureACR
      • Hochberg M.C.
      • Altman R.D.
      • April K.T.
      • et al.
      American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee.
      (2012)
      NSConditionally recommended11 (unsupported)
      Manual therapy
       Massage therapyNHMRC

      Brand C, Buchbinder R, Wluka A, et al. Guideline for the nonsurgical management of hip and knee osteoarthritis 2009. Available at: http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.

      (2009)
      NSD10 (unsupported)
      KNGF
      • Peter W.F.H.
      • Jansen M.J.
      • Hurkmans E.J.
      • et al.
      Physiotherapy in hip and knee osteoarthritis: development of a practice guideline concerning initial assessment, treatment and evaluation.
      (2011)
      IINS−1
      Self-management and psychosocial-based therapy
       Psychosocial interventionsACR
      • Hochberg M.C.
      • Altman R.D.
      • April K.T.
      • et al.
      American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee.
      (2012)
      NSConditionally recommended11 (unsupported)
       Cognitive behavior therapy (CBT)NHMRC

      Brand C, Buchbinder R, Wluka A, et al. Guideline for the nonsurgical management of hip and knee osteoarthritis 2009. Available at: http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.

      (2009)
      NSD11 (unsupported)
      Abbreviations: ACR, American College of Rheumatology; KNGF, Royal Dutch Society for Physical Therapy; NHMRC, National Health and Medical Research Council; NS, not stated.
      A full list of individual guideline grading systems for LOE and SORs is provided in appendix 2.
      Table 9Interventions not recommended
      InterventionGuideline (Date)LOESORIndividual WeightingMedian (Overall Recommendation)
      Acupuncture
       ElectroacupunctureNICE

      National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults: Royal College of Physicians. 2008. Available at: http://www.nice.org.uk/CG059. Accessed November 26, 2012.

      (2008)
      NSNS−4−4 (not recommended)
      Abbreviation: NS, not stated.
      Strongly recommended interventions included unspecified types of education (n=11, where n=recommended by number of guidelines), combined modalities of exercise or exercise of an unspecified type (n=11), wedged insoles for knee OA (n=10), weight loss (n=10), strengthening exercise (n=9), aerobic exercise (n=8), self-management (n=7), aquatic therapy/hydrotherapy (n=6), transcutaneous electrical nerve stimulation (n=6), knee bracing for knee OA (n=5), and appropriate footwear (n=4). Yoga, manual therapy with supervised exercise, manipulation and stretching, land-based exercise, and balneotherapy/spa therapies were also graded as strongly recommended interventions. However, only 3 or fewer guidelines provided recommendations for each of these interventions. Extensive research in regard to specific forms of education and diet strategies was described by 2 of the Ottawa Panel guidelines,
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for the management of osteoarthritis in adults who are obese or overweight.
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for patient education programmes in the management of osteoarthritis.
      warranting their interventions to be strongly recommended. With respect to exercise, there were few studies that investigated individualized or tailored exercise; however, 9 guidelines

      National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults: Royal College of Physicians. 2008. Available at: http://www.nice.org.uk/CG059. Accessed November 26, 2012.

      Brand C, Buchbinder R, Wluka A, et al. Guideline for the nonsurgical management of hip and knee osteoarthritis 2009. Available at: http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.

      • Jordan K.M.
      • Arden N.K.
      • Doherty M.
      • et al.
      EULAR recommendations 2003: an evidence based approach to the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT).
      • Roddy E.
      • Zhang W.
      • Doherty M.
      • et al.
      Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or knee—the MOVE consensus.
      • Tuncer T.
      • Çay H.F.
      • Kaçar C.
      • et al.
      Evidence-based recommendations for the management of knee osteoarthritis: a consensus report of the Turkish League Against Rheumatism.
      • Zhang W.
      • Doherty M.
      • Arden N.
      • et al.
      EULAR evidence based recommendations for the management of hip osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).
      • Zhang W.
      • Doherty M.
      • Leeb B.F.
      • et al.
      EULAR evidence based recommendations for the management of hand osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).
      • Fernandes L.
      • Hagen K.B.
      • Bijlsma J.W.
      • et al.
      EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis.
      • Mazières B.
      • Bannwarth B.
      • Dougados M.
      • Lequesne M.
      EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials.
      indicated that this should be an important consideration when prescribing exercise.
      Recommended interventions included thermal-based therapy (n=7), taping (n=6), walking aids (n=6), and telephone support (n=5). Tai chi, electrical stimulation, devices to assist with activities of daily living, acupuncture, multimodal physical therapy, and adherence strategies were also graded as recommended interventions. However, only 3 or fewer guidelines provided recommendations for each of these interventions.
      Two interventions—ultrasound and hand splints—were recommended with caution.
      Interventions reported as unsupported recommendations were laser therapy, magnetic bracelets, Chinese acupuncture, massage therapy, psychosocial interventions, and cognitive behavioral therapy.
      One intervention, electro acupuncture, was explicitly not recommended by 1 guideline

      National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults: Royal College of Physicians. 2008. Available at: http://www.nice.org.uk/CG059. Accessed November 26, 2012.

      (see table 9). While there were a number of interventions that were either unsupported or not recommended by their authors, there were no interventions that were specified as harmful.

      Discussion

      This review is the first published critical appraisal of guidelines for the physical management of OA. Of the 19 guidelines that we identified, 2 were excluded. First, the South Africa Arthritis Foundation guideline
      • Brighton S.
      • Mody G.M.
      • Tikly M.
      • Bouwer D.
      Osteoarthritis: clinical guideline 2003.
      was not included because recommendations were not clearly stated. Second, the recommendations from the American Academy of Orthopaedic Surgeons glenohumeral OA guideline

      Izquierdo R, Voloshin I, Edwards S, et al. The treatment of glenohumeral joint osteoarthritis: guideline and evidence report. Rosemont: American Academy of Orthopaedic Surgeons; 2009. Available at: http://www.aaos.org/research/guidelines/gloguideline.pdf. Accessed January 14, 2013.

      were not included because the focus of the guideline was surgical and pharmacological, with no conclusive recommendations provided for the physical management of OA. It was also noted that there were no allied health members (physiotherapists or occupational therapists) on the guideline development group. The group consisted entirely of medical doctors. In the future, patients with glenohumeral OA may be better served if the working group included individuals from all relevant health professional groups.
      The AGREE II instrument was used to assess the methodological quality of the remaining 17 guidelines. When reviewing the AGREE II domain scores, the authors chose to use 60% as the value that represented adequate coverage of the criteria in a particular domain. The same approach was also used in other critical appraisals of arthritis guidelines.
      • Poitras S.
      • Avouac J.
      • Rossignol M.
      • et al.
      A critical appraisal of guidelines for the management of knee osteoarthritis using Appraisal of Guidelines REsearch and Evaluation criteria.
      • Hurkmans E.J.
      • Jones A.
      • Li L.C.
      • Vliet Vlieland T.P.M.
      Quality appraisal of clinical practice guidelines on the use of physiotherapy in rheumatoid arthritis: a systematic review.
      This allowed comparisons of the domains among the 17 guidelines and recommendations to be made on the areas that could be improved in the future development of guidelines. In this appraisal, the domains of scope and purpose, rigor of development, and clarity of presentation were addressed effectively by the majority of the guidelines. However, there were 3 domains that were consistently weak or unfulfilled by most guidelines: stakeholder involvement, applicability, and editorial independence. On reviewing previous appraisals on clinical practice guidelines, it became apparent that the same 3 domains have consistently scored poorly.
      • Poitras S.
      • Avouac J.
      • Rossignol M.
      • et al.
      A critical appraisal of guidelines for the management of knee osteoarthritis using Appraisal of Guidelines REsearch and Evaluation criteria.
      • Pencharz J.N.
      • Grigoriadis E.
      • Jansz G.F.
      • Bombardier C.
      A critical appraisal of clinical practice guidelines for the treatment of lower-limb osteoarthritis.
      • Alonso-Coello P.
      • Irfan A.
      • Sola I.
      • et al.
      The quality of clinical practice guidelines over the last two decades: a systematic review of guideline appraisal studies.
      While AGREE II scores have no bearing on the actual content of the recommendations, strong AGREE II scores add to the credibility of the recommendations.
      Stakeholder involvement was adequately addressed by only 6 of the 17 guidelines, and improvement is needed within this domain. It requires the inclusion of all relevant information pertaining to the authors involved, target users clearly identified, and the views of the target population considered when developing guidelines. Guyatt and Rennie
      • Guyatt G.H.
      • Rennie D.
      Users' guides to the medical literature: essentials of evidence-based clinical practice.
      reported that the patient's values need to be considered when developing evidence-based literature. A failure in doing so is likely to overlook the person's lived experience of OA and what is important to him/her. The applicability domain addresses resource implications, facilitators, and barriers as well as advice on the implementation of the recommendation. None of the guidelines fulfilled the criteria for this domain. These elements play a role in decision making for the consumer, and these should be addressed within the guideline. Editorial independence adds to the rigor of the guideline. Only 1 guideline fulfilled this criterion. Guideline developers are required to declare the funding body and any competing interests. However, it is important that authors not only declare the funding body and competing interests but also clearly state editorial independence. When this is omitted, the reader is unsure whether there is actually a conflict of interest or whether it was simply not mentioned. While this may be taken for granted, it is an important statement that adds to the rigor of the guideline. Improving all these areas of guideline development will allow the consumer to have more confidence in the recommendations made within the guideline.
      The method used to determine our overall combined intervention recommendations is novel and untested. We calculated a median score in an attempt to provide a balance on individual guideline's LOE and SOR. The variability across guidelines made any attempt at aggregating recommendations difficult. It is also important to note that while some interventions were strongly recommended, some were based on only 1 or 2 guidelines. Balneotherapy was based on 2 guidelines,
      • Tuncer T.
      • Çay H.F.
      • Kaçar C.
      • et al.
      Evidence-based recommendations for the management of knee osteoarthritis: a consensus report of the Turkish League Against Rheumatism.
      • Mazières B.
      • Bannwarth B.
      • Dougados M.
      • Lequesne M.
      EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials.
      while land-based exercise,

      Brand C, Buchbinder R, Wluka A, et al. Guideline for the nonsurgical management of hip and knee osteoarthritis 2009. Available at: http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.

      yoga,
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for therapeutic exercises and manual therapy in the management of osteoarthritis.
      and diet
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for the management of osteoarthritis in adults who are obese or overweight.
      were based on only 1 guideline. In comparison, other intervention recommendations were supported by many guidelines and therefore provide greater confidence in recommending that intervention.
      There were some inconsistencies found among the guidelines. Peter et al
      • Peter W.F.H.
      • Jansen M.J.
      • Hurkmans E.J.
      • et al.
      Physiotherapy in hip and knee osteoarthritis: development of a practice guideline concerning initial assessment, treatment and evaluation.
      specifically recommended not to use massage therapy, electrical stimulation, laser therapy, and ultrasound, while ultrasound was recommended by Brand,

      Brand C, Buchbinder R, Wluka A, et al. Guideline for the nonsurgical management of hip and knee osteoarthritis 2009. Available at: http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.

      Tuncer,
      • Tuncer T.
      • Çay H.F.
      • Kaçar C.
      • et al.
      Evidence-based recommendations for the management of knee osteoarthritis: a consensus report of the Turkish League Against Rheumatism.
      Zhang
      • Zhang W.
      • Doherty M.
      • Leeb B.F.
      • et al.
      EULAR evidence based recommendations for the management of hand osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).
      and colleagues. Electrical stimulation was recommended by Brand

      Brand C, Buchbinder R, Wluka A, et al. Guideline for the nonsurgical management of hip and knee osteoarthritis 2009. Available at: http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.

      and Tuncer,
      • Tuncer T.
      • Çay H.F.
      • Kaçar C.
      • et al.
      Evidence-based recommendations for the management of knee osteoarthritis: a consensus report of the Turkish League Against Rheumatism.
      and massage therapy and laser therapy received a recommendation based on expert opinion.

      Brand C, Buchbinder R, Wluka A, et al. Guideline for the nonsurgical management of hip and knee osteoarthritis 2009. Available at: http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.

      Consumers of evidence-based literature should be aware that there may be conflicting evidence among the research. This critical appraisal has assisted the user by identifying these inconsistencies and by providing a balanced interpretation.
      The Ottawa group's 4 guidelines,
      • Loew L.
      • Brosseau L.
      • Wells G.A.
      • et al.
      Ottawa panel evidence-based clinical practice guidelines for aerobic walking programs in the management of osteoarthritis.
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for the management of osteoarthritis in adults who are obese or overweight.
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for patient education programmes in the management of osteoarthritis.
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for therapeutic exercises and manual therapy in the management of osteoarthritis.
      while very comprehensive, failed to provide specific recommendations for the management of OA. The group provided extensive evidence of the research. However, the articles were presented in a population, intervention, comparator, outcome, and time frame format for different comparisons of interventions, making it difficult for consumers to take recommendations from the article. The Ottawa panel was contacted and responded to questions surrounding the usability of the recommendations. The panel replied that a Cochrane Collaboration methodology was used and directed us to an Arthritis Society of Canada website. The Ottawa group report on highly relevant information concerning the physical management of OA. However, it would assist the guideline user if the group synthesized the data and presented key recommendations in an easily identifiable summarized box or grouped together in 1 section.
      The NICE guidelines are very comprehensive, with extensive evidence supporting the use of nonpharmacological interventions. The 3 core recommendations from the guidelines were for strength and aerobic fitness, education, and weight loss if overweight. However, there are several user issues with the NICE guidelines. The guidelines provided evidence statements in tables throughout the guidelines. However, it did not grade the evidence; instead, it referred the reader to an online link. Unfortunately, the webpage was no longer available. After corresponding with the author, we were informed that their recommendations were no longer graded and we were advised to use the language in the recommendation as a guide. Although they provided strong evidence, without grading the LOEs and SORs it was difficult to interpret the recommendations. The authors have endeavored to use a consistent methodology when grading the NICE guideline recommendations. While it is not mandatory to use a grading system for the SORs, it provides the reader with valuable information. Finally, the layout of the NICE recommendations was very difficult to follow. The guidelines provided 36 recommendations (18 nonpharmacological recommendations). These were dispersed throughout the document, making it difficult to locate all the recommendations. It would assist the reader if the recommendations were presented in an easily identifiable box summarizing the recommendations or presenting them grouped together at the beginning of the document.
      Exercise and education were found to be among the strongest interventions recommended throughout the guidelines. While the exercise recommendations ranged from very specific (aerobic, strength training, hydrotherapy) to very general (exercise of unspecified type), the message was clear that exercise in all its forms is strongly recommended for OA, most specifically for knee OA. The important benefits of exercise include an improvement in pain and function, which are the main complaints reported by OA sufferers. Exercise is a low-cost option in the management of OA, which makes it accessible to all OA sufferers. Education was also considered a strong recommendation. Education was found to reduce pain, increase coping skills, and result in fewer visits to primary care practitioners in knee OA.
      • Loew L.
      • Brosseau L.
      • Wells G.A.
      • et al.
      Ottawa panel evidence-based clinical practice guidelines for aerobic walking programs in the management of osteoarthritis.
      • Jordan K.M.
      • Arden N.K.
      • Doherty M.
      • et al.
      EULAR recommendations 2003: an evidence based approach to the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT).
      • Mazières B.
      • Bannwarth B.
      • Dougados M.
      • Lequesne M.
      EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials.
      In addition, although the supporting evidence concerning tailored exercises was sparse, the consensus from 9 guidelines recommended prescribing individualized patient exercise and education and these are key components of rehabilitation.

       Study limitations

      This critical appraisal has 2 key limitations. First, a new grading scale to grade the overall strength of each recommendation was developed. This was a nonstandardized grading system and requires further testing. Second, guidelines published only in English were reviewed, leading to a potential publication bias. This criterion may misrepresent the amount of research that has been conducted on the physical management of OA globally.

      Conclusions

      The objective of this appraisal was to review the available guidelines and present the treatment recommendations for the physical management of OA in a format that was useful to the user. Throughout the research, there is strong evidence to support aspects of the use of exercise, electrical-based therapy, equipment, education, diet and weight loss, manual therapy, and self-management. Laser therapy, magnetic bracelets, Chinese acupuncture, massage therapy, aspects of psychosocial-based therapy, and electroacupuncture were either unsupported or not recommended. With the prevalence of OA expected to double by 2020 and the personal and societal costs associated with OA being substantial, it is important to establish the best strategy to manage and treat OA. Because exercise and education were found to be among the strongest recommendations within the guidelines and can be relatively cost-effective to provide, there is an opportunity for those engaged in rehabilitation to move into a leading role in the management of OA.
      In this critical appraisal we have taken a unique approach. Not only have we appraised the quality of the guidelines but also synthesized, graded, and comprehensively presented all the relevant recommendations for the physical management of OA. It is hoped that this will inform health care providers on the best evidence interventions available for the physical management of OA.
      Appendix 1Arthritis-related organizations
      Organization Name
      3e Initiative in Rheumatology
      African League of Associations for Rheumatology
      American Academy of Orthopaedic Surgeons
      American College of Rheumatology
      American Geriatrics Society
      American Pain Society
      Arthritis.com
      Arthritis New Zealand
      Arthritis Research UK
      Arthritis Society—Canada
      Asia Pacific League of Associations for Rheumatology
      Assessment of SpondyloArthritis International Society
      Brazilian Society of Rheumatology
      British Paediatric Rheumatology Group
      British Society for Rheumatology
      Canadian Medical Association Clinical Guidelines
      Canadian Rheumatology Association
      Centers for Disease Control and Prevention Guidelines
      Cochrane Review—Osteoarthritis
      European League Against Rheumatism
      Group for Research in Psoriasis and Psoriatic Arthritis
      Hong Kong Society of Rheumatology
      Institute for Clinical Systems Improvement
      International League of Association for Rheumatology
      Italian Society of Rheumatology
      Medical Journal of Australia Clinical Guidelines
      National Guidelines Clearinghouse
      National Health and Medical Research Council
      National Institute for Health and Care Excellence
      New South Wales Therapeutic Assessment Group
      New Zealand Guidelines Group (completed voluntary liquidation mid-2012)
      Orthopedic Research Society
      Osteoarthritis Research Society International
      Ottawa Panel Evidence
      Pan-American League of Associations for Rheumatology
      Queensland University Clinical Practice Guidelines
      Royal Dutch Society for Physical Therapy
      Scottish Intercollegiate Guidelines Network
      South Africa Arthritis Foundation
      Therapeutic Goods Administration
      Therapeutic Guidelines
      Turkish League Against Rheumatism
      U.S. Agency for Healthcare Research & Quality
      Appendix 2LOE and SOR scales
      Author

      Criteria for LOEs/Recommending Grading
      AAOS

      Richmond J, Hunter D, Irrgang J, et al. Treatment of osteoarthritis of the knee (non-arthroplasty): full guideline. Rosemont: American Academy of Orthopaedic Surgeons; 2008. Available at: http://www.aaos.org/research/guidelines/oakguideline.pdf. Accessed January 14, 2013.

       Grading the recommendations
      AGood evidence (level I studies with consistent finding) for or against recommending intervention
      BFair evidence (level II or III studies with consistent findings) for or against recommending intervention
      CPoor-quality evidence (level IV or V) for or against recommending intervention
      IInsufficient or conflicting evidence not allowing a recommendation for or against intervention
       LOEStudy type
      Level ISystematic reviews, high-quality RCTs
      Level II or IIIPoor-quality RCTs, prospective or retrospective comparative studies, case-control
      Level IV or VCase series, expert opinion
      None or conflicting
      ACR
      • Hochberg M.C.
      • Altman R.D.
      • April K.T.
      • et al.
      American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee.
       Strong recommendation to use
       Weak (or conditional) recommendation to use
       No recommendation
       Weak (or conditional) recommendation not to use
       Strong recommendation not to use
      Strong recommendations mean that most informed patients would choose the recommended management and that clinicians can structure their interactions with patients accordingly.
      Conditional recommendations mean that the majority of informed patients would choose the recommended management but many would not, and so clinicians must ensure that patients’ care is in keeping with their values and preferences.
      BSR
      • Roddy E.
      • Zhang W.
      • Doherty M.
      • et al.
      Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or knee—the MOVE consensus.
       SOR
      ADirectly based on category I evidence
      BDirectly based on category II evidence or extrapolated recommendation from category I evidence
      CDirectly based on category III evidence or extrapolated recommendation from category I or II evidence
      DDirectly based on category IV evidence or extrapolated recommendation from category I, II, or III evidence
       Categories of evidence
      IaMA of RCT
      IbAt least 1 RCT
      IIaAt least 1 controlled study without randomization
      IIbAt least 1 type of quasi-experimental study
      IIIDescriptive studies (comparative, correlation, case-control)
      IVExpert committee reports/opinions and/or clinical opinion of respected authorities
      EULAR
      • Jordan K.M.
      • Arden N.K.
      • Doherty M.
      • et al.
      EULAR recommendations 2003: an evidence based approach to the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT).
      • Zhang W.
      • Doherty M.
      • Arden N.
      • et al.
      EULAR evidence based recommendations for the management of hip osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).
      • Zhang W.
      • Doherty M.
      • Leeb B.F.
      • et al.
      EULAR evidence based recommendations for the management of hand osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).
      • Fernandes L.
      • Hagen K.B.
      • Bijlsma J.W.
      • et al.
      EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis.
      • Mazières B.
      • Bannwarth B.
      • Dougados M.
      • Lequesne M.
      EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials.
       SOR
      ACategory I evidence
      BCategory II evidence or extrapolated recommendation from category I evidence
      CCategory III evidence or extrapolated recommendation from category I or II evidence
      DCategory IV evidence or extrapolated recommendation from category II or III evidence
       Categories of evidence
      IaMA or RCTs
      IbAt least 1 RCT
      IIaAt least 1 controlled study without randomization
      IIbAt least 1 quasi-experimental study
      IIIDescriptive studies, such as comparative, correlation, or case-control studies
      IVExpert committee reports or opinions and/or clinical experience of respected authorities
      NHMRC

      Brand C, Buchbinder R, Wluka A, et al. Guideline for the nonsurgical management of hip and knee osteoarthritis 2009. Available at: http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.

       Grade of recommendations
      ABody of evidence can be trusted to guide practice
      BBody of evidence can be trusted to guide practice in most situations
      CBody of evidence provides some support for recommendation(s), but care should be taken in its application
      DBody of evidence is weak, and recommendation must be applied with caution
      Note: A recommendation cannot be graded A or B unless the volume and consistency of evidence components are both graded either A or B
       LOE
      IEvidence obtained from a systematic review of all relevant RCTs
      IIEvidence obtained from at least 1 properly designed RCT
      III-1Evidence obtained from well-designed pseudo RCTs (alternate allocation or some other method)
      III-2Evidence obtained from comparative studies with concurrent controls and allocation not randomized (cohort studies), case-control studies, or interrupted time series with a control group
      III-3Evidence obtained from comparative studies with historical control, 2 or more single-arm studies, or interrupted time series without a parallel control group
      IVEvidence obtained from case series, either posttest or pretest and posttest
      NICE

      National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults: Royal College of Physicians. 2008. Available at: http://www.nice.org.uk/CG059. Accessed November 26, 2012.

       Grading the evidence statements
      1++High-quality MAs, systematic reviews of RCTs, or RCTs with a very low risk of bias
      1+Well-conducted MAs, systematic reviews of RCTs, or RCTs with a low risk of bias
      1–MAs, systematic reviews of RCTs, or RCTs with a high risk of bias
      Studies with an LOE ‘–’ are not used as a basis for making a recommendation.
      2++High-quality systematic reviews of case-control or cohort studies
      2+High-quality case-control or cohort studies with a very low risk of confounding, bias, or chance and a high probability that the relation is causal
      2−Well-conducted case-control or cohort studies with a low risk of confounding, bias, or chance and a moderate probability that the relation is causal
      3Case-control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the relation is not causal
      Studies with an LOE ‘–’ are not used as a basis for making a recommendation.
      4Nonanalytic studies (eg, case reports, case series)

      Expert opinion, formal consensus
      OARSI
      • Tuncer T.
      • Çay H.F.
      • Kaçar C.
      • et al.
      Evidence-based recommendations for the management of knee osteoarthritis: a consensus report of the Turkish League Against Rheumatism.
      • Zhang W.
      • Moskowitz R.W.
      • Nuki G.
      • et al.
      OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines.
       SOR: VAS (0%–100%)
       Evidence hierarchy
      IaMA of RCTs
      IbAt least 1 RCT
      IIaAt least 1 well-designed controlled study, but without randomization
      IIbAt least 1 well-designed quasi-experimental study
      IIIAt least 1 nonexperimental descriptive study (comparative, correlation, or case-controlled study)
      IVExpert committee reports, opinions, and/or experience of respected authorities
      Ottawa Panel
      • Loew L.
      • Brosseau L.
      • Wells G.A.
      • et al.
      Ottawa panel evidence-based clinical practice guidelines for aerobic walking programs in the management of osteoarthritis.
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for the management of osteoarthritis in adults who are obese or overweight.
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for patient education programmes in the management of osteoarthritis.
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for therapeutic exercises and manual therapy in the management of osteoarthritis.
      GradeClinical Importance (%)Statistical SignificanceStudy Design
      A (strongly recommended)≥15<.05RCT (single or meta-analysis)
      B (recommended)≥15<.05CCT or observational (single or meta-analysis)
      C+ (suggested used)≥15Not significantRCT/CCT or observational (single or meta-analysis)
      C (neutral)<15Not significantAny study design
      D (neutral)<15 (favors control)Not significantAny study design
      D+ (suggested no use)<15 (favors control)Not significantRCT/CCT or observational (single or meta-analysis)
      D− (strongly not recommended)≤15 (favors control)<.05 (favors control)Well-designed RCT with >100 patients (if <100 patients, becomes grade D)
      KNGF
      • Peter W.F.H.
      • Jansen M.J.
      • Hurkmans E.J.
      • et al.
      Physiotherapy in hip and knee osteoarthritis: development of a practice guideline concerning initial assessment, treatment and evaluation.
      LOE
       IOne A1 study or at least 2 A2 studies
       IIOne A2 study or at least 2 B studies
       II1 B or multiple C studies
       IVExpert opinion
      Grades of recommendation
       A1MA (systematic reviews) that includes at least 2 RCTs at quality level A2 that show consistent results between studies
       A2RCTs of a good methodological quality (randomized double-blind controlled studies) with sufficient power and consistency
       BRCT of a moderate methodological quality of insufficient power, or nonrandomized, cohort of patient-control group study involving intergroup comparisons
       CPatient series
       DExpert opinion
      Abbreviations: AAOS, American Academy of Orthopaedic Surgeons; ACR, American College of Rheumatology; BSR, British Society for Rheumatology; CCT, controlled clinical trial; EULAR, European League Against Rheumatism; KNGF, Royal Dutch Society for Physical Therapy; NHMRC, National Health and Medical Research Council; OARSI, Osteoarthritis Research Society International; TLAR, Turkish League Against Rheumatism; VAS, visual analog scale.
      Studies with an LOE ‘–’ are not used as a basis for making a recommendation.

      Acknowledgments

      We thank Andrew South, MSocSci (Hons), GradDipLib, a library technician at the Auckland University of Technology, for his assistance with designing the literature search criteria.

      References

      1. National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults: Royal College of Physicians. 2008. Available at: http://www.nice.org.uk/CG059. Accessed November 26, 2012.

        • Vos T.
        • Flaxman A.D.
        • Naghavi M.
        • et al.
        Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010.
        Lancet. 2012; 380: 2163-2196
        • Gupta S.
        • Hawker G.A.
        • Laporte A.
        • Croxford R.
        • Coyte P.C.
        The economic burden of disabling hip and knee osteoarthritis (OA) from the perspective of individuals living with this condition.
        Rheumatology (Oxford). 2005; 44: 1531-1537
        • Symmons D.
        • Mathers C.
        • Pleger B.
        Global burden of osteoarthritis in the year 2000.
        World Health Organization, Geneva2003
        • Loew L.
        • Brosseau L.
        • Wells G.A.
        • et al.
        Ottawa panel evidence-based clinical practice guidelines for aerobic walking programs in the management of osteoarthritis.
        Arch Phys Med Rehabil. 2012; 93: 1269-1285
        • Williams J.I.
        • Llewellyn Thomas H.
        • Arshinoff R.
        • Young N.
        • Naylor C.D.
        The burden of waiting for hip and knee replacements in Ontario. Ontario Hip and Knee Replacement Project Team.
        J Eval Clin Pract. 1997; 3: 59-68
        • Ackerman I.N.
        • Bennell K.L.
        • Osborne R.H.
        Decline in health-related quality of life reported by more than half of those waiting for joint replacement surgery: a prospective cohort study.
        BMC Musculoskelet Disord. 2011; 12: 108-116
        • Guyatt G.H.
        • Haynes R.B.
        • Jaeschke R.Z.
        • et al.
        Users' Guides to the Medical Literature: XXV. Evidence-based medicine: principles for applying the Users' Guides to patient care.
        JAMA. 2000; 284: 1290-1296
        • Gill S.D.
        • McBurney H.
        Does exercise reduce pain and improve physical function before hip or knee replacement surgery? A systematic review and meta-analysis of randomized controlled trials.
        Arch Phys Med Rehabil. 2013; 94: 164-176
      2. AGREE. Appraisal of Guidelines for REsearch & Evaluation II: AGREEII instrument 2009. Available at: http://www.agreetrust.org/. Accessed January 14, 2013.

        • Brouwers M.
        • Kho M.
        • Browman G.
        • et al.
        AGREE II: advancing guideline development, reporting and evaluation in health care.
        Can Med Assoc J. 2010; 182: E839-E842
        • Poitras S.
        • Avouac J.
        • Rossignol M.
        • et al.
        A critical appraisal of guidelines for the management of knee osteoarthritis using Appraisal of Guidelines REsearch and Evaluation criteria.
        Arthritis Res Ther. 2007; 9: R126
        • Hurkmans E.J.
        • Jones A.
        • Li L.C.
        • Vliet Vlieland T.P.M.
        Quality appraisal of clinical practice guidelines on the use of physiotherapy in rheumatoid arthritis: a systematic review.
        Rheumatology (Oxford). 2011; 50: 1879-1888
      3. Brand C, Buchbinder R, Wluka A, et al. Guideline for the nonsurgical management of hip and knee osteoarthritis 2009. Available at: http://www.nhmrc.gov.au/guidelines/. Accessed January 14, 2013.

        • Brighton S.
        • Mody G.M.
        • Tikly M.
        • Bouwer D.
        Osteoarthritis: clinical guideline 2003.
        S Afr Med J. 2003; 93: 972-990
      4. Izquierdo R, Voloshin I, Edwards S, et al. The treatment of glenohumeral joint osteoarthritis: guideline and evidence report. Rosemont: American Academy of Orthopaedic Surgeons; 2009. Available at: http://www.aaos.org/research/guidelines/gloguideline.pdf. Accessed January 14, 2013.

      5. Richmond J, Hunter D, Irrgang J, et al. Treatment of osteoarthritis of the knee (non-arthroplasty): full guideline. Rosemont: American Academy of Orthopaedic Surgeons; 2008. Available at: http://www.aaos.org/research/guidelines/oakguideline.pdf. Accessed January 14, 2013.

        • Brosseau L.
        • Wells G.A.
        • Tugwell P.
        • et al.
        Ottawa Panel evidence-based clinical practice guidelines for the management of osteoarthritis in adults who are obese or overweight.
        Phys Ther. 2011; 91: 843-861
        • Hochberg M.C.
        • Altman R.D.
        • April K.T.
        • et al.
        American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee.
        Arthritis Care Res. 2012; 64: 465-474
        • Jordan K.M.
        • Arden N.K.
        • Doherty M.
        • et al.
        EULAR recommendations 2003: an evidence based approach to the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT).
        Ann Rheum Dis. 2003; 62: 1145-1155
        • Roddy E.
        • Zhang W.
        • Doherty M.
        • et al.
        Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or knee—the MOVE consensus.
        Rheumatology (Oxford). 2005; 44: 67-73
        • Tuncer T.
        • Çay H.F.
        • Kaçar C.
        • et al.
        Evidence-based recommendations for the management of knee osteoarthritis: a consensus report of the Turkish League Against Rheumatism.
        Turkish J Rheumatol. 2012; 27: 1-17
        • Zhang W.
        • Doherty M.
        • Arden N.
        • et al.
        EULAR evidence based recommendations for the management of hip osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).
        Ann Rheum Dis. 2005; 64: 669-681
        • Zhang W.
        • Doherty M.
        • Leeb B.F.
        • et al.
        EULAR evidence based recommendations for the management of hand osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).
        Ann Rheum Dis. 2007; 66: 377-388
        • Zhang W.
        • Moskowitz R.W.
        • Nuki G.
        • et al.
        OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines.
        Osteoarthritis Cartilage. 2008; 16: 137-162
        • Fernandes L.
        • Hagen K.B.
        • Bijlsma J.W.
        • et al.
        EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis.
        Ann Rheum Dis. 2013; 72: 1125-1135
        • Brosseau L.
        • Wells G.A.
        • Tugwell P.
        • et al.
        Ottawa Panel evidence-based clinical practice guidelines for patient education programmes in the management of osteoarthritis.
        Health Educ J. 2011; 70: 318-358
        • Brosseau L.
        • Wells G.A.
        • Tugwell P.
        • et al.
        Ottawa Panel evidence-based clinical practice guidelines for therapeutic exercises and manual therapy in the management of osteoarthritis.
        Phys Ther. 2005; 85: 907-971
        • Mazières B.
        • Bannwarth B.
        • Dougados M.
        • Lequesne M.
        EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials.
        Joint Bone Spine. 2001; 68: 231-240
        • Peter W.F.H.
        • Jansen M.J.
        • Hurkmans E.J.
        • et al.
        Physiotherapy in hip and knee osteoarthritis: development of a practice guideline concerning initial assessment, treatment and evaluation.
        Acta Reumatológica Portuguesa. 2011; 36: 268-281
        • Pencharz J.N.
        • Grigoriadis E.
        • Jansz G.F.
        • Bombardier C.
        A critical appraisal of clinical practice guidelines for the treatment of lower-limb osteoarthritis.
        Arthritis Res. 2002; 4: 36-44
        • Alonso-Coello P.
        • Irfan A.
        • Sola I.
        • et al.
        The quality of clinical practice guidelines over the last two decades: a systematic review of guideline appraisal studies.
        Qual Saf Health Care. 2010; 19: e58
        • Guyatt G.H.
        • Rennie D.
        Users' guides to the medical literature: essentials of evidence-based clinical practice.
        AMA Press, Chicago2002