OARSI guidelines for the non-surgical management of knee osteoarthritis.
OBJECTIVE
To develop concise, up-to-date, patient-focused, evidence-based, expert consensus guidelines for the management of knee osteoarthritis (OA), intended to inform patients, physicians, and allied healthcare professionals worldwide.


METHODS
Thirteen experts from relevant medical disciplines (primary care, rheumatology, orthopedics, physical therapy, physical medicine and rehabilitation, and evidence-based medicine), three continents and ten countries (USA, UK, France, Netherlands, Belgium, Sweden, Denmark, Australia, Japan, and Canada) and a patient representative comprised the Osteoarthritis Guidelines Development Group (OAGDG). Based on previous OA guidelines and a systematic review of the OA literature, 29 treatment modalities were considered for recommendation. Evidence published subsequent to the 2010 OARSI guidelines was based on a systematic review conducted by the OA Research Society International (OARSI) evidence team at Tufts Medical Center, Boston, USA. Medline, EMBASE, Google Scholar, Web of Science, and the Cochrane Central Register of Controlled Trials were initially searched in first quarter 2012 and last searched in March 2013. Included evidence was assessed for quality using Assessment of Multiple Systematic Reviews (AMSTAR) criteria, and published criticism of included evidence was also considered. To provide recommendations for individuals with a range of health profiles and OA burden, treatment recommendations were stratified into four clinical sub-phenotypes. Consensus recommendations were produced using the RAND/UCLA Appropriateness Method and Delphi voting process. Treatments were recommended as Appropriate, Uncertain, or Not Appropriate, for each of four clinical sub-phenotypes and accompanied by 1-10 risk and benefit scores.


RESULTS
Appropriate treatment modalities for all individuals with knee OA included biomechanical interventions, intra-articular corticosteroids, exercise (land-based and water-based), self-management and education, strength training, and weight management. Treatments appropriate for specific clinical sub-phenotypes included acetaminophen (paracetamol), balneotherapy, capsaicin, cane (walking stick), duloxetine, oral non-steroidal anti-inflammatory drugs (NSAIDs; COX-2 selective and non-selective), and topical NSAIDs. Treatments of uncertain appropriateness for specific clinical sub-phenotypes included acupuncture, avocado soybean unsaponfiables, chondroitin, crutches, diacerein, glucosamine, intra-articular hyaluronic acid, opioids (oral and transdermal), rosehip, transcutaneous electrical nerve stimulation, and ultrasound. Treatments voted not appropriate included risedronate and electrotherapy (neuromuscular electrical stimulation).


CONCLUSIONS
These evidence-based consensus recommendations provide guidance to patients and practitioners on treatments applicable to all individuals with knee OA, as well as therapies that can be considered according to individualized patient needs and preferences.
Division of Rheumatology, Tufts Medical Center, Boston, MA, USA. Electronic address: tmcalindon@tuftsmedicalcenter.org.
T E
TE
McAlindon
Division of Rheumatology, Tufts Medical Center, Boston, MA, USA.
R R
RR
Bannuru
Division of Rheumatology, Tufts Medical Center, Boston, MA, USA.
M C
MC
Sullivan
NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, UK. Electronic address: nigel.arden@ndorms.ox.ac.uk.
N K
NK
Arden
Pierre and Marie Curie University Paris 06, France; AP-HP, Saint-Antoine Hospital, Paris, France. Electronic address: francis.berenbaum@sat.aphp.fr.
F
F
Berenbaum
Department of General Practice, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands. Electronic address: s.bierma-zeinstra@erasmusmc.nl.
S M
SM
Bierma-Zeinstra
Department of Medicine, Women's College Hospital, Institute for Clinical Evaluative Sciences, Ontario, Canada. Electronic address: gillian.hawker@wchospital.ca.
G A
GA
Hawker
Bone and Cartilage Research Unit, University of Liège, Liège, Belgium; Dept of Physical Therapy and Rehabilitation, Princess Paola Hospital, Marche-en-Famenne, Belgium. Electronic address: yhenrotin@ulg.ac.be.
Y
Y
Henrotin
Rheumatology Department, Royal North Shore Hospital and Northern Clinical School, University of Sydney, NSW, Australia. Electronic address: david.hunter@sydney.edu.au.
D J
DJ
Hunter
Sensory & Motor System Medicine, Faculty of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan. Electronic address: kawaguchi-ort@h.u-tokyo.ac.jp.
H
H
Kawaguchi
Division of Rheumatology and Clinical Immunology, University of Arizona Arthritis Center of Excellence, USA. Electronic address: kwoh@arthritis.arizona.edu.
K
K
Kwoh
Department of Orthopaedics, Clinical Sciences Lund, Lund University, Lund, Sweden. Electronic address: stefan.lohmander@med.lu.se.
S
S
Lohmander
Université Paris Descartes, Sorbonne Paris Cité, Paris, France. Electronic address: francois.rannou@cch.aphp.fr.
F
F
Rannou
Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark. Electronic address: eroos@health.sdu.dk.
E M
EM
Roos
Warwick Clinical Trials Unit, Coventry, UK. Electronic address: m.underwood@warwick.ac.uk.
M
M
Underwood
D032921:Consensus; D019317:Evidence-Based Medicine; D006801:Humans; D007391:International Cooperation; D015201:Meta-Analysis as Topic; D020370:Osteoarthritis, Knee / Q000628:therapy*; D018802:Patient-Centered Care; D012196:Review Literature as Topic; D016896:Treatment Outcome
Knee osteoarthritis; OARSI; Treatment guidelines