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Arthritis Care Res (Hoboken). Author manuscript; available in PMC 2024 October 18.
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Published in final edited form as:

Arthritis Care Res (Hoboken). 2020 February ; 72(2): 149–162. doi:10.1002/acr.24131.

2019 American College of Rheumatology/Arthritis Foundation

Guideline for the Management of Osteoarthritis of the Hand, Hip,
and Knee
Sharon L. Kolasinski1, Tuhina Neogi2, Marc C. Hochberg3, Carol Oatis4, Gordon Guyatt5,
Joel Block6, Leigh Callahan7, Cindy Copenhaver8, Carole Dodge9, David Felson2, Kathleen
Gellar10, William F. Harvey11, Gillian Hawker12, Edward Herzig13, C. Kent Kwoh14, Amanda
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E. Nelson7, Jonathan Samuels15, Carla Scanzello1, Daniel White16, Barton Wise17, Roy D.
Altman18, Dana DiRenzo19, Joann Fontanarosa20, Gina Giradi20, Mariko Ishimori21, Devyani
Misra2, Amit Aakash Shah22, Anna K. Shmagel23, Louise M. Thoma7, Marat Turgunbaev22,
Amy S. Turner22, James Reston20
1Sharon L. Kolasinski, MD, FACP, FACR, Carla Scanzello, MD: University of Pennsylvania School
of Medicine, Philadelphia
2Tuhina Neogi, MD, PhD, FRCPC, David Felson, MD, MPH, Devyani Misra, MD, MSc: Boston
University School of Medicine, Boston, Massachusetts
3Marc C. Hochberg, MD, MPH, MACP, MACR: University of Maryland School of Medicine and
Veterans Affairs Maryland Health Care System, Baltimore
4Carol Oatis, PT, PhD: Arcadia University, Glenside, Pennsylvania
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5Gordon Guyatt, MD, MSc: McMaster University, Hamilton, Ontario, Canada

6Joel Block, MD: Rush University Medical Center, Chicago, Illinois
7LeighCallahan, PhD, Amanda E. Nelson, MD, MSCR, RhMSUS, Louise M. Thoma, PT, DPT,
PhD: University of North Carolina School of Medicine, Chapel Hill
8Cindy Copenhaver, LMT: South Holland Recreational Services, University of Chicago, and
Ingalls Memorial Hospital, Thornton, Illinois
9Carole Dodge, OT, CHT: University of Michigan Medical Center, Ann Arbor
10Kathleen Gellar: Watchung, New Jersey
11William F. Harvey, MD, MSc, FACR: Tufts Medical Center, Boston, Massachusetts
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12Gillian Hawker, MD, MSc: University of Toronto, Toronto, Ontario, Canada

13Edward Herzig, MD: Fairfield, Ohio
14C. Kent Kwoh, MD: University of Arizona College of Medicine, Tucson
15Jonathan Samuels, MD: New York University Langone Medical Center, New York, New York

Address correspondence to Sharon L. Kolasinski, MD, FACP, FACR, University of Pennsylvania, Perelman School of Medicine,
Division of Rheumatology, 3737 Market Street, Philadelphia, PA 19104. [Link]@[Link].
 Kolasinski et al. Page 2

16Daniel White, PT, ScD: University of Delaware, Newark

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17Barton Wise, MD, PhD: University of California, Davis

18Roy D. Altman, MD: Ronald Reagan UCLA Medical Center, Los Angeles, California
19Dana DiRenzo, MD: Johns Hopkins University School of Medicine, Baltimore, Maryland
20Joann Fontanarosa, PhD, Gina Giradi, James Reston, PhD, MPH: ECRI Institute, Plymouth
Meeting, Pennsylvania
21Mariko Ishimori, MD: Cedars Sinai Medical Center, Los Angeles, California
22AmitAakash Shah, MD, MPH, Marat Turgunbaev, MD, MPH, Amy S. Turner: American College
of Rheumatology, Atlanta, Georgia
23Anna K. Shmagel, MD, MS: University of Minnesota, Minneapolis
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Abstract
Objective.—To develop an evidence-based guideline for the comprehensive management of
osteoarthritis (OA) as a collaboration between the American College of Rheumatology (ACR) and
the Arthritis Foundation, updating the 2012 ACR recommendations for the management of hand,
hip, and knee OA.

Methods.—We identified clinically relevant population, intervention, comparator, outcomes

questions and critical outcomes in OA. A Literature Review Team performed a systematic
literature review to summarize evidence supporting the benefits and harms of available
educational, behavioral, psychosocial, physical, mind-body, and pharmacologic therapies for OA.
Grading of Recommendations Assessment, Development and Evaluation methodology was used to
rate the quality of the evidence. A Voting Panel, including rheumatologists, an internist, physical
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and occupational therapists, and patients, achieved consensus on the recommendations.

Results.—Based on the available evidence, either strong or conditional recommendations were

made for or against the approaches evaluated. Strong recommendations were made for exercise,
weight loss in patients with knee and/or hip OA who are overweight or obese, self-efficacy and
self-management programs, tai chi, cane use, hand orthoses for first carpometacarpal (CMC)
joint OA, tibiofemoral bracing for tibiofemoral knee OA, topical nonsteroidal antiinflammatory
drugs (NSAIDs) for knee OA, oral NSAIDs, and intraarticular glucocorticoid injections for knee
OA. Conditional recommendations were made for balance exercises, yoga, cognitive behavioral
therapy, kinesiotaping for first CMC OA, orthoses for hand joints other than the first CMC
joint, patellofemoral bracing for patellofemoral knee OA, acupuncture, thermal modalities,
radiofrequency ablation for knee OA, topical NSAIDs, intraarticular steroid injections and
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chondroitin sulfate for hand OA, topical capsaicin for knee OA, acetaminophen, duloxetine, and
tramadol.

Conclusion.—This guideline provides direction for clinicians and patients making treatment
decisions for the management of OA. Clinicians and patients should engage in shared decision-
making that accounts for patients’ values, preferences, and comorbidities. These recommendations
should not be used to limit or deny access to therapies.

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INTRODUCTION
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Osteoarthritis (OA) is the most common form of arthritis, affecting an estimated 302 million
people worldwide (1–5), and is a leading cause of disability among older adults. The knees,
hips, and hands are the most commonly affected appendicular joints. OA is characterized
by pathology involving the whole joint, including cartilage degradation, bone remodeling,
osteophyte formation, and synovial inflammation, leading to pain, stiffness, swelling, and
loss of normal joint function.

As OA spans decades of a patient’s life, patients with OA are likely to be treated

with a number of different pharmaceutical and nonpharmaceutical interventions, often in
combination. This report provides recommendations to guide patients and clinicians in
choosing among the available treatments. Certain principles of management apply to all
patients with OA (see Comprehensive Management of OA below and Figure 1). Some
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recommendations are specific to a particular joint (e.g., hip, knee, patellofemoral joint, first
carpometacarpal joint [CMC]) or particular patient populations (e.g., those with erosive
OA).

METHODS
This guideline, from the American College of Rheumatology (ACR) and
the Arthritis Foundation (AF), follows the ACR guideline development
process ([Link]
Guidelines), using the Grading of Recommendations Assessment, Development and
Evaluation (GRADE) methodology to rate the quality of the available evidence and
to develop the recommendations (6). ACR policy guided management of conflicts of
interest and disclosures ([Link]
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Clinical-Practice-Guidelines/Osteoarthritis). A full description of the methods is presented

in Supplementary Appendix 1 (on the Arthritis Care & Research web site at http://
[Link]/doi/10.1002/acr.24131/abstract).

Briefly, this work involved 5 teams: 1) a Core Leadership Team that supervised and
coordinated the project and drafted the clinical/population, intervention, comparator,
outcomes (PICO) questions that served as the basis for the evidence report and
manuscript; 2) a Literature Review Team that completed the literature screening
and data abstraction and produced the Evidence Report (Supplementary Appendix
2, [Link] 3) an Expert Panel that
had input into scoping and clinical/PICO question development; 4) a Patient Panel;
and 5) an interprofessional Voting Panel that included rheumatologists, an internist,
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physical and occupational therapists, and patients (Supplementary Appendix 3, http://

[Link]/doi/10.1002/acr.24131/abstract).

This guideline included an initial literature review limited to English-language publications

from inception of the databases to October 15, 2017, with updated searches conducted
on August 1, 2018 and relevant papers included. Studies published after August
1, 2018 were not evaluated for this guideline. Supplementary Appendix 4 (http://

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[Link]/doi/10.1002/acr.24131/abstract) shows search terms used and

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databases reviewed, and Supplementary Appendix 5 ([Link]

10.1002/acr.24131/abstract) highlights the study selection process. The guideline evidence
base results from our own systematic review of randomized controlled trials (RCTs), rather
than focusing on systematic reviews and meta-analyses published by others, as was done
for the 2012 ACR recommendations for the use of nonpharmacologic and pharmacologic
therapies in hand, hip, and knee OA (7). Systematic reviews of observational studies
published by others were included if, in the opinion of the Voting Panel, they added critical
information for the formulation of a recommendation: for example, related to adverse effects
that may not be seen in shorter-duration RCTs. Subsequent updates of this guideline will
consider studies included here and new RCTs published since completion of the literature
review for the current publication.

Although RCTs are considered the gold standard for evaluation, a number of limitations
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of RCTs proved particularly important in the formulation of the final recommendations:

possible publication bias (favoring publication of positive results), inadequate blinding,
and inadequate provision of active comparators and appropriate sham alternatives. Further,
short-duration RCTs cannot provide adequate prognostic information when applied to a
complex disease such as OA, in which pathophysiologic processes are slowly progressive
over decades.

We focused on management options that are available in the US and, for pharmacologic
therapies, we additionally focused on agents that are available in pharmaceutical-grade
formulations, thus eliminating most nutraceuticals. We limited our review to the English-
language literature. We reviewed [Link] to identify phase 2 and 3 trials that
may be far enough along to be US Food and Drug Administration (FDA)–approved and
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available by the time this guideline was published.

A hierarchy of outcome measures assessing pain and function in OA was developed based
on the published literature (8,9). This hierarchy is detailed in Supplementary Appendix 1
([Link]

Using GRADE, a recommendation can be either in favor of or against the proposed

intervention and either strong or conditional (10,11). The strength of the recommendation
is based on a 70% consensus among the Voting Panel members. Much of the evidence
proved indirect (did not specifically address the PICO question as written) and of low-to-
moderate quality (12,13). The Voting Panel made strong recommendations when it inferred
compelling evidence of efficacy and that benefits clearly outweighed harms and burdens.
Thus, a strong recommendation means that the Voting Panel was confident that the desirable
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effects of following the recommendation outweigh potential undesirable effects (or vice
versa), so the course of action would apply to all or almost all patients, and only a small
proportion of patients would not want to follow the recommendation.

The Voting Panel made conditional recommendations when the quality of the evidence
proved low or very low and/or the balance of benefits versus harms and burdens was
sufficiently close that shared decision-making between the patient and the clinician would

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be particularly important. Conditional recommendations are those for which the majority
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of informed patients would choose to follow the recommended course of action, but
some would not (14,15). Thus, conditional recommendations are particularly value- and
preference-sensitive and always warrant a full shared decision-making approach involving a
complete and clear explication of benefits, harms, and burdens in language and in a context
that patients understand (16). Where recommendations are made regarding a particular
approach, details and references regarding that approach can be found in the Evidence
Report (Supplementary Appendix 2, [Link]
abstract).

RESULTS/RECOMMENDATIONS
Comprehensive management of OA
A comprehensive plan for the management of OA in an individual patient may include
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educational, behavioral, psychosocial, and physical interventions, as well as topical,

oral, and intraarticular medications. Recommendations assume appropriate application of
physical, psychological, and/or pharmacologic therapies by an appropriate provider. Goals
of management and principles for implementing those goals have broad applicability across
patients. However, for some patients at some time points, a single physical, psychosocial,
mind-body, or pharmacologic intervention may be adequate to control symptoms; for others,
multiple interventions may be used in sequence or in combination. Which interventions and
the order in which interventions are used will vary among patients. An overview of a general
approach to management of OA is outlined in Figure 1 for recommended options, but no
specific hierarchy of one option over another is implied other than on the basis of strength of
the recommendation. Figure 2 summarizes the approaches that were not recommended.
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Treatment decisions should take the personal beliefs and preferences of the patient, as
well as the patient’s medical status, into consideration. This guideline applies to patients
with OA with no specific contraindications to the recommended therapies. However, each
patient should be assessed for the presence of medical conditions, such as hypertension,
cardiovascular disease, heart failure, gastrointestinal bleeding risk, chronic kidney disease,
or other comorbidities, that might have an impact on their risk of side effects from certain
pharmacologic agents, as well as injuries, disease severity, surgical history, and access to
and availability of services (transportation, distance, ability to take time off work, cost,
insurance coverage) that might have an impact on the choice of physical, psychological, and
mind-body approaches. It is assumed that such an assessment will be performed prior to
finalization of an individual treatment plan. When choosing among pharmacologic therapies,
management should begin with treatments with the least systemic exposure or toxicity.
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Patients may experience a variety of additional symptoms as a result of the pain and
functional limitations arising from OA and/or comorbidities. These include mood disorders,
such as depression and anxiety, altered sleep, chronic widespread pain, and impaired coping
skills. The Patient Panel noted that the broader impact of OA on these comorbidities is
of particular importance when choosing among treatment options and best addressed by a
multimodal treatment plan, rather than one that is limited to the prescription of a single
medication. Measures aimed at improving mood, reducing stress, addressing insomnia,

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managing weight, and enhancing fitness may improve the patient’s overall well-being and
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OA treatment success. Indeed, interventions that have proven beneficial in the management
of chronic pain may prove useful in OA (17) even when data specific to patients with OA are
limited.

Unless otherwise specified, recommendations regarding physical, psychosocial, and mind-

body approaches assume that the patient will be adding the intervention to usual care. For
the purposes of this guideline, usual care includes the use of maximally recommended
or safely tolerated doses of over-the counter oral nonsteroidal antiinflammatory drugs
(NSAIDs) and/or acetaminophen, as has generally been explicitly permitted in clinical trials
of nonpharmacologic interventions.

Physical, psychosocial, and mind-body approaches (Table 1)

During the GRADE analysis, clinical trials involving physical modalities and mind-body
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approaches were often designated as yielding low-quality evidence because blinding with
regard to the active treatment was not always possible. This contributed to a preponderance
of conditional recommendations for physical modalities and mind-body approaches. The
delivery of instruction by physical and occupational therapists is helpful, and often essential,
for the appropriate initiation and maintenance of exercise as a part of OA management. In
addition to exercise, physical and occupational therapists often incorporate self-efficacy and
self-management training, thermal therapies, and instruction in use of and fitting of splints
and braces in their practices. Most patients with OA are likely to experience benefit from
referral to physical therapy and/or occupational therapy at various times during the course of
their disease.

Exercise is strongly recommended for patients with knee, hip, and/or hand
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OA.—Though exercise is strongly recommended for all OA patients, there is considerably

more evidence for the use of exercise in the treatment of knee and hip OA than for hand
OA, and the variety of exercise options studied is far greater. While patients and providers
seek recommendations on the “best” exercise and the ideal dosage (duration, intensity, and
frequency), current evidence is insufficient to recommend specific exercise prescriptions.
Broad recommendations suggesting one form of exercise over another are based largely
on expert opinion. A substantial body of literature (see Evidence Report, Supplementary
Appendix 2 [[Link] supports a wide
range of appropriate exercise options and suggests that the vast majority of OA patients can
participate in, and benefit from with regard to pain and function, some form of exercise.
Exercise recommendations to patients should focus on the patient’s preferences and access,
both of which may be important barriers to participation. If a patient does not find a certain
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form of exercise acceptable or cannot afford to participate or arrange transportation to

participate, he or she is not likely to get any benefit from the suggestion to pursue that
exercise.

In the majority of studies that assessed the role of aerobic exercise in the management of
OA, walking was the most common form of exercise evaluated, either on a treadmill or as
supervised, community-based, indoor fitness walking. Other studies used supervised group

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cycling on stationary bicycles. Strengthening exercises have included the use of isokinetic
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weight machines, resistance exercise training with and without props such as elastic bands,
and isometric exercise. Neuromuscular training has been developed to address muscle
weakness, reduced sensorimotor control, and functional instability specifically seen with
knee OA, with a series of dynamic maneuvers of increased complexity. Aquatic exercise
often encompasses aspects of aerobic fitness exercises and exercises for enhancing joint
range of motion, in a low-impact environment.

A specific hierarchy of these various forms of exercise could not be discerned from the
literature. Patient participants on the Patient and Voting Panels raised the concern that
patients who are in pain might be hesitant to participate in exercise. There is no uniformly
accepted level of pain at which a patient should or should not exercise, and a common-sense
approach of shared decision-making between the treating clinician and the patient regarding
when to initiate an exercise program is advisable. However, clinical trials of exercise for
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OA include patients with pain and functional limitations due to OA, and improvements in
OA-specific outcomes have been demonstrated; thus, results are likely to be generalizable to
most patients with pain due to OA.

Although there is currently insufficient evidence to recommend one form of exercise over
another, patients will likely benefit from advice that is as specific as possible, rather
than simple encouragement to exercise. Given the wide range of evidence-based exercise
interventions shown to effectively improve pain and function in OA, all patients should
be encouraged to consider some form of exercise as a central part of their treatment plan.
Individual preferences, access, and affordability are likely to play a role in what works best
for an individual patient. Overall, exercise programs are more effective if supervised, often
by physical therapists and sometimes in a class setting, rather than when performed by the
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individual at home. They also tend to be more effective when combined with self-efficacy
and self-management interventions or weight loss programs.

Few studies have employed monitoring devices or pre- and postintervention assessment of
cardiovascular or musculoskeletal fitness, so targets using these devices or assessments are
not available. Future research is essential to establish specific exercise guidelines that will
direct the patient and provider toward more individualized exercise prescriptions.

Balance exercises are conditionally recommended for patients with knee

and/or hip OA.—Balance exercises include those that improve the ability to control
and stabilize body position (American Physical Therapy Association: [Link]
BalanceFalls/). Although one might expect balance exercises to help reduce the risk of falls
in patients with OA, RCTs to date have not addressed this outcome in this population,
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and the low quality of evidence addressing the use of balance exercises necessitates only a
conditional recommendation for balance exercises.

Weight loss is strongly recommended for patients with knee and/or hip OA
who are overweight or obese.—A dose-response has been noted with regard to the
amount of weight loss that will result in symptom or functional improvement in patients
with OA (18). A loss of ≥5% of body weight can be associated with changes in clinical and

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mechanistic outcomes. Furthermore, clinically important benefits continue to increase with

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weight loss of 5–10%, 10–20%, and >20% of body weight. The efficacy of weight loss for
OA symptom management is enhanced by use of a concomitant exercise program.

Self-efficacy and self-management programs are strongly recommended for

patients with knee, hip, and/or hand OA.—Although effect sizes are generally
small, the benefits of participation in self-efficacy and self-management programs are
consistent across studies, and risks are minimal. These programs use a multidisciplinary
group–based format combining sessions on skill-building (goal-setting, problem-solving,
positive thinking), education about the disease and about medication effects and side effects,
joint protection measures, and fitness and exercise goals and approaches. Health educators,
National Commission for Certification Services–certified fitness instructors, nurses, physical
therapists, occupational therapists, physicians, and patient peers may lead the sessions,
which can be held in person or online. In the studies reviewed, sessions generally occurred 3
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times weekly, but varied from 2 to 6 times weekly.

Tai chi is strongly recommended for patients with knee and/or hip OA.—Tai
chi is a traditional Chinese mind-body practice that combines meditation with slow, gentle,
graceful movements, deep diaphragmatic breathing, and relaxation. The efficacy of tai chi
may reflect the holistic impact of this mind-body practice on strength, balance, and fall
prevention, as well as on depression and self-efficacy.

Yoga is conditionally recommended for patients with knee OA.—Yoga is a

mind-body practice with origins in ancient Indian philosophy and typically combines
physical postures, breathing techniques, and meditation or relaxation (National Center
for Complementary and Integrative Health [NCCIH]: [Link]
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Though far less well studied than tai chi, yoga may be helpful in OA through a similar
blend of physical and psychosocial factors. Due to lack of data, no recommendation can
be made regarding use of yoga to help manage symptoms of hip OA. Other mind-body
practices could not be assessed due to insufficient evidence, as well as a lack of standard
definitions of certain interventions (hypnosis, qi gong).

Cognitive behavioral therapy (CBT) is conditionally recommended for patients

with knee, hip, and/or hand OA.—There is a well-established body of literature (19,20)
supporting the use of CBT in chronic pain conditions, and CBT may have relevance for the
management of OA. Trials have demonstrated improvement in pain, health-related quality of
life, negative mood, fatigue, functional capacity, and disability in conditions other than OA.
In OA, limited evidence suggests that CBT may reduce pain (21). Further research is needed
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to establish whether or not benefits in OA are related to alteration in mood, sleep, coping, or
other factors that may co-occur with, result from, or be a part of the experience of OA (22).

Cane use is strongly recommended for patients with knee and/or hip OA in whom disease in
1 or more joints is causing a sufficiently large impact on ambulation, joint stability, or pain
to warrant use of an assistive device.

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Tibiofemoral knee braces are strongly recommended for patients with knee OA in whom
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disease in 1 or both knees is causing a sufficiently large impact on ambulation, joint stability,
or pain to warrant use of an assistive device, and who are able to tolerate the associated
inconvenience and burden associated with bracing.

Patellofemoral braces are conditionally recommended for patients with

patellofemoral knee OA in whom disease in 1 or both knees is causing a
sufficiently large impact on ambulation, joint stability, or pain to warrant use
of an assistive device.—The recommendation is conditional due to the variability in
results across published trials and the difficulty some patients will have in tolerating the
inconvenience and burden of these braces. Optimal management with knee bracing is
likely to require that clinicians are familiar with the various types of braces and where
they are available and have expertise in fitting the braces. Patient Voting Panel members
strongly emphasized the importance of coordination of care between primary care providers,
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specialists, and providers of braces.

Kinesiotaping is conditionally recommended for patients with knee and/or

first CMC joint OA.—Kinesiotaping permits range of motion of the joint to which it is
applied, in contrast to a brace, which maintains the joint in a fixed position. Published
studies have examined various products and methods of application, and blinding with
regard to use is not possible, thereby limiting the quality of the evidence.

Hand orthoses are strongly recommended for patients with first CMC joint OA.
Hand orthoses are conditionally recommended for patients with OA in other
joints of the hand.—A variety of mechanical supports are available, including digital
orthoses, ring splints, and rigid or neoprene orthoses, some of which are intended for
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specifically affected joints (e.g., first CMC joint, individual digits, wrist) and some of which
support the entire hand. In addition, gloves may offer benefit by providing warmth and
compression to the joints of the hand. Data are insufficient to recommend one type of
orthosis over another for use in the hand. Patients considering these interventions will likely
benefit from evaluation by an occupational therapist.

Modified shoes are conditionally recommended against in patients with knee and/or hip
OA.
Modifications to shoes can be intended to alter the biomechanics of the lower extremities
and the gait. While optimal footwear is likely to be of considerable importance for those
with knee and/or hip OA, the available studies do not define the best type of footwear to
improve specific outcomes for knee or hip OA.
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Lateral and medial wedged insoles are conditionally recommended against in patients with
knee and/or hip OA.
The currently available literature does not demonstrate clear efficacy of lateral or medial
wedged insoles.

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Acupuncture is conditionally recommended for patients with knee, hip, and/or hand OA.
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Although a large number of trials have addressed the use of acupuncture for OA, its efficacy
remains a subject of controversy. Issues related to the use of appropriate blinding, the
validity of sham controls, sample size, effect size, and prior expectations have arisen with
regard to this literature. Variability in the results of RCTs and meta-analyses is likely driven,
in part, by differences in the type of controls and the intensity of the control interventions
used. In addition, the benefits of acupuncture result from the large contextual effect plus
small differences in outcomes between “true” and “sham” acupuncture. The latter is of
the same magnitude as the effect of full-dose acetaminophen versus placebo. The greatest
number of positive trials with the largest effect sizes have been carried out in knee OA.
Positive trials and meta-analyses have also been published in a variety of other painful
conditions and have indicated that acupuncture is effective for analgesia. While the “true”
magnitude of effect is difficult to discern, the risk of harm is minor, resulting in the Voting
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Panel providing a conditional recommendation.

Thermal interventions (locally applied heat or cold) are conditionally recommended for
patients with knee, hip, and/or hand OA.
The method of delivery of thermal interventions varies considerably in published reports,
including moist heat, diathermy (electrically delivered heat), ultrasound, and hot and cold
packs. Studies using diathermy or ultrasound were more likely to be sham controlled
than those using other heat delivery modalities. The heterogeneity of modalities and short
duration of benefit for these interventions led to the conditional recommendation.

Paraffin, an additional method of heat therapy for the hands, is conditionally

recommended for patients with hand OA.
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Radiofrequency ablation is conditionally recommended for patients with knee

OA.—A number of studies have demonstrated potential analgesic benefits with various
ablation techniques but, because of the heterogeneity of techniques and controls used and
lack of long-term safety data, this recommendation is conditional.

Massage therapy is conditionally recommended against in patients with knee and/or hip
OA.
Massage therapy encompasses a number of techniques aimed at affecting muscle and other
soft tissue (NCCIH: [Link]
Studies addressing massage have suffered from high risk of bias, have included small
numbers of patients, and have not demonstrated benefit for OA-specific outcomes. Patient
participants on the Patient and Voting Panels noted that some studies have shown positive
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outcomes and minimal risk and felt strongly that massage therapy was beneficial for
symptom management (23). However, based on the available evidence regarding OA
specifically, a conditional recommendation against the use of massage for reduction of OA
symptoms is made, though the Voting Panel acknowledged that massage may have other
benefits.

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Manual therapy with exercise is conditionally recommended against over exercise alone in
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patients with knee and/or hip OA.

Manual therapy techniques may include manual lymphatic drainage, manual traction,
massage, mobilization/manipulation, and passive range of motion and are always used
in conjunction with exercise ([Link] A
limited number of studies have addressed manual therapy added to exercise versus exercise
alone in hip and knee OA. Although manual therapy can be of benefit for certain conditions,
such as chronic low back pain, limited data in OA show little additional benefit over exercise
alone for managing OA symptoms.

Iontophoresis is conditionally recommended against in patients with first CMC joint OA.
There are no published RCTs evaluating iontophoresis for OA in any anatomic location.
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Pulsed vibration therapy is conditionally recommended against in patients with knee OA.
Few trials have addressed pulsed vibration therapy, and in the absence of adequate data, we
conditionally recommend against its use.

Transcutaneous electrical stimulation (TENS) is strongly recommended against in patients

with knee and/or hip OA.
Studies examining the use of TENS have been of low quality with small size and variable
controls, making comparisons across trials difficult. Studies have demonstrated a lack of
benefit for knee OA.

Pharmacologic management (Table 2)

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RCTs of pharmacologic agents may be subject to a variety of limitations, including

generalizability of their findings across patients. Publication bias may reduce the likelihood
that negative trials will become part of the published literature. Statistically significant
findings may represent benefits so small that they are not clinically important to patients. We
have highlighted these considerations where relevant.

Topical NSAIDs are strongly recommended for patients with knee OA and conditionally
recommended for patients with hand OA.
In keeping with the principle that medications with the least systemic exposure (i.e., local
therapy) are preferable, topical NSAIDs should be considered prior to use of oral NSAIDs
(24). Practical considerations (e.g., frequent hand washing) and the lack of direct evidence
of efficacy in the hand lead to a conditional recommendation for use of topical NSAIDs in
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hand OA. In hip OA, the depth of the joint beneath the skin surface suggests that topical
NSAIDs are unlikely to confer benefit, and thus, the Voting Panel did not examine use in hip
OA.

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Topical capsaicin is conditionally recommended for patients with knee OA and

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conditionally recommended against in patients with hand OA.

Topical capsaicin is conditionally recommended for treatment of knee OA due to small
effect sizes and wide confidence intervals in the available literature. We conditionally
recommend against the use of topical capsaicin in hand OA because of a lack of direct
evidence to support use, as well as a potentially increased risk of contamination of the eye
with use of topical capsaicin to treat hand OA. In hip OA, the depth of the joint beneath the
skin surface suggests that topical capsaicin is unlikely to have a meaningful effect, and thus,
the Voting Panel did not examine use of topical capsaicin in hip OA. Insufficient data exists
to make recommendations about the use of topical lidocaine preparations in OA.

Oral NSAIDs are strongly recommended for patients with knee, hip, and/or hand OA.
Oral NSAIDs remain the mainstay of the pharmacologic management of OA, and their use
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is strongly recommended. A large number of trials have established their short-term efficacy.
Oral NSAIDs are the initial oral medication of choice in the treatment of OA, regardless of
anatomic location, and are recommended over all other available oral medications.

While this guideline did not address the relative merits of different NSAIDs, there is
evidence suggesting that certain agents may have more favorable side effect profiles
than others (25–27). Clinical considerations aimed at risk mitigation for the safe use of
NSAIDs, such as appropriate patient selection, regular monitoring for the development of
potential adverse gastrointestinal, cardiovascular, and renal side effects and potential drug
interactions, were not specifically included in the GRADE process for the formulation of
recommendations. Doses should be as low as possible, and NSAID treatment should be
continued for as short a time as possible.
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Intraarticular glucocorticoid injections are strongly recommended for patients with knee
and/or hip OA and conditionally recommended for patients with hand OA.
Trials of intraarticular glucocorticoid injections have demonstrated short-term efficacy
in knee OA. Intraarticular glucocorticoid injection is conditionally, rather than strongly,
recommended for hand OA given the lack of evidence specific to this anatomic location.
There are insufficient data to judge the choice of short-acting over long-acting preparations
or the use of low rather than high doses. A recent report (28) raised the possibility that
specific steroid preparations or a certain frequency of steroid injections may contribute to
cartilage loss, but the Voting Panel was uncertain of the clinical significance of this finding,
particularly since change in cartilage thickness was not associated with a worsening in pain,
functioning, or other radiographic features.
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Ultrasound guidance for intraarticular glucocorticoid injection is strongly recommended

for injection into hip joints.
When available, ultrasound guidance for steroid injection may help ensure accurate drug
delivery into the joint, but is not required for knee and hand joints. However, imaging
guidance for injection into hip joints is strongly recommended.

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 Kolasinski et al. Page 13

Intraarticular glucocorticoid injections versus other injections are conditionally

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recommended for patients with knee, hip, and/or hand OA.

In OA generally, intraarticular glucocorticoid injection is conditionally recommended over
other forms of intraarticular injection, including hyaluronic acid preparations. Head-to-head
comparisons are few, but the evidence for efficacy of glucocorticoid injections is of
considerably higher quality than that for other agents.

Acetaminophen is conditionally recommended for patients with knee, hip, and/or hand OA.
In clinical trials, the effect sizes for acetaminophen are very small, suggesting that few
of those treated experience important benefit, and meta-analysis has suggested that use of
acetaminophen as monotherapy may be ineffective (29). Longer-term treatment is no better
than treatment with placebo for most individuals. Members of the Patient Panel noted that,
for most individuals, acetaminophen is ineffective. For those with limited pharmacologic
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options due to intolerance of or contraindications to the use of NSAIDs, acetaminophen

may be appropriate for short-term and episodic use. Regular monitoring for hepatotoxicity
is required for patients who receive acetaminophen on a regular basis, particularly at the
recommended maximum dosage of 3 gm daily in divided doses.

Duloxetine is conditionally recommended for patients with knee, hip, and/or hand OA.
While studied primarily in the knee, the effects of duloxetine may plausibly be expected
to be similar for OA of the hip or hand. While a variety of centrally acting agents (e.g.,
pregabalin, gabapentin, selective serotonin reuptake inhibitors, serotonin norepinephrine
reuptake inhibitors, and tricyclic antidepressants) have been used in the management of
chronic pain, only duloxetine has adequate evidence on which to base recommendations
for use in OA. However, in considering all the ways in which OA may be affecting
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an individual patient, shared decision-making between the physician and patient may
include consideration of any of these agents. Considering the utility of these agents in
pain management generally, their use may be an appropriate target of future investigations
specific to OA. Evidence suggests that duloxetine has efficacy in the treatment of OA when
used alone or in combination with NSAIDs; however, there are issues regarding tolerability
and side effects. No recommendations were made for the other centrally acting agents due to
lack of direct studies of relevance in OA.

Tramadol is conditionally recommended for patients with knee, hip, and/or OA.
Recent work has highlighted the very modest level of beneficial effects in the long-term (3
months to 1 year) management of non-cancer pain with opioids (30). Nonetheless, there are
circumstances in which tramadol or other opioids may be appropriate in the treatment of
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OA, including when patients may have contraindications to NSAIDs, find other therapies
ineffective, or have no available surgical options. Patient Panel input demonstrated a high
level of understanding concerning addiction potential, but also included an appreciation
for the role of these agents when other pharmacologic and physical options have been
ineffective. However, RCT evidence addressing the use of tramadol and other opioids
for periods longer than 1 year is not available. Clinical trials have demonstrated some
symptomatic efficacy, though concerns regarding potential adverse effects remain. If an

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 Kolasinski et al. Page 14

opioid is being considered, tramadol is conditionally recommended over non-tramadol

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opioids.

Non-tramadol opioids are conditionally recommended against in patients with knee, hand,
and/or hip OA with the recognition that they may be used under certain circumstances,
particularly when alternatives have been exhausted.
As noted above, evidence suggests very modest benefits of long-term opioid therapy and
a high risk of toxicity and dependence. Use of the lowest possible doses for the shortest
possible length of time is prudent, particularly since a recent systematic review and meta-
analysis suggests that less pain relief occurs during longer trials in the treatment of non-
cancer chronic pain (30).

Colchicine is conditionally recommended against in patients with knee, hip, and/or hand
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OA.
Two very small studies have suggested analgesic benefit of colchicine in OA, but the quality
of the data was low. In addition, potential adverse effects, as well as drug interactions, may
occur with use of colchicine.

Fish oil is conditionally recommended against in patients with knee, hip, and/or hand OA.
Fish oil is the most commonly used dietary supplement in the US (31). Despite its
popularity, only 1 published trial has addressed its potential role in OA. This study failed to
show efficacy of a higher dose of fish oil over a lower dose.

Vitamin D is conditionally recommended against in patients with knee, hip, and/or hand
OA.
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A number of trials in OA demonstrated small effect sizes with vitamin D treatment, while
others have shown no benefit and pooling data across studies yielded null results. In
addition, limited and questionable health benefits from vitamin D supplementation have
been suggested in other contexts (32,33).

Bisphosphonates are strongly recommended against in patients with knee, hip, and/or
hand OA.
Though a single small study of an oral bisphosphonate suggested a potential analgesic
benefit in OA, the preponderance of data shows no improvement in pain or functional
outcomes.

Glucosamine is strongly recommended against in patients with knee, hip, and/or hand OA.
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Pharmaceutical-grade preparations of glucosamine are available and have been studied in

multiple trials. However, discrepancies in efficacy reported in studies that were industry
sponsored as opposed to publicly funded have raised serious concerns about publication bias
(34,35). In addition, there is a lack of a clear biologic understanding of how efficacy would
vary with the type of salt studied. The data that were deemed to have the lowest risk of bias
fail to show any important benefits over placebo. These recommendations represent a change
from the prior conditional recommendation against the use of glucosamine. The weight of

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 Kolasinski et al. Page 15

the evidence indicates a lack of efficacy and large placebo effects. Nonetheless, glucosamine
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remains among the most commonly used dietary supplements in the US (31), and clinicians
should be aware that many patients perceive that glucosamine is efficacious. Patients also
often perceive that different glucosamine formulas are associated with different degrees of
efficacy and seek advice on brands and manufacturers. The potential toxicity of glucosamine
is low, though some patients exposed to glucosamine may show elevations in serum glucose
levels (36).

Chondroitin sulfate is strongly recommended against in patients with knee and/or hip
OA as are combination products that include glucosamine and chondroitin sulfate, but is
conditionally recommended for patients with hand OA.
A single trial suggested analgesic efficacy of chondroitin sulfate, without evidence of harm,
in hand OA.
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Hydroxychloroquine is strongly recommended against in patients with knee, hip, and/or

hand OA.
Well-designed RCTs of hydroxychloroquine, conducted in the subset of patients with erosive
hand OA, have demonstrated no efficacy.

Methotrexate is strongly recommended against in patients with knee, hip, and/or hand OA.
Well-designed RCTs of methotrexate, conducted in the subset of patients with erosive hand
OA, have demonstrated no efficacy.

Intraarticular hyaluronic acid injections are conditionally recommended against in patients

with knee and/or first CMC joint OA and strongly recommended against in patients with hip
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OA.
In prior systematic reviews, apparent benefits of hyaluronic acid injections in OA have
been reported. These reviews have not, however, taken into account the risk of bias of the
individual primary studies. Our review showed that benefit was restricted to the studies with
higher risk of bias: when limited to trials with low risk of bias, meta-analysis has shown
that the effect size of hyaluronic acid injections compared to saline injections approaches
zero (37). The finding that best evidence fails to establish a benefit, and that harm may be
associated with these injections, motivated the recommendation against use of this treatment.

Many providers want the option of using hyaluronic acid injections when glucocorticoid
injections or other interventions fail to adequately control local joint symptoms. In clinical
practice, the choice to use hyaluronic acid injections in the knee OA patient who has
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had an inadequate response to nonpharmacologic therapies, topical and oral NSAIDs,

and intraarticular steroids may be viewed more favorably than offering no intervention,
particularly given the impact of the contextual effects of intraarticular hyaluronic acid
injections (38). The conditional recommendation against is consistent with the use of
hyaluronic acid injections, in the context of shared decision-making that recognizes the
limited evidence of benefit of this treatment, when other alternatives have been exhausted
or failed to provide satisfactory benefit. The conditional recommendation against is not
intended to influence insurance coverage decisions.

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 Kolasinski et al. Page 16

In contrast, the evidence of lack of benefit is of higher quality with respect to hyaluronic
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acid injection in the hip. We therefore strongly recommend against hyaluronic acid
injections in hip OA.

Intraarticular botulinum toxin injections are conditionally recommended against in patients

with knee and/or hip OA.
The small number of trials of intraarticular botulinum toxin treatment in knee or hip OA
suggest a lack of efficacy. This treatment has not been evaluated in hand OA and, therefore,
no recommendation is made with regard to OA of the hand.

Prolotherapy is conditionally recommended against in patients with knee and/or hip OA.
A limited number of trials involving a small number of participants have shown small effect
sizes of prolotherapy in knee or hip OA. However, injection schedules, injection sites, and
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comparators have varied substantially between trials. This treatment has not been evaluated
in hand OA and, therefore, no recommendation is made with regard to OA of the hand.

Platelet-rich plasma treatment is strongly recommended against in patients with knee

and/or hip OA.
In contrast to intraarticular therapies discussed above, there is concern regarding the
heterogeneity and lack of standardization in available preparations of platelet-rich plasma, as
well as techniques used, making it difficult to identify exactly what is being injected. This
treatment has not been evaluated in hand OA and, therefore, no recommendation is made
with regard to OA of the hand.

Stem cell injections are strongly recommended against in patients with knee and/or hip
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OA.
There is concern regarding the heterogeneity and lack of standardization in available
preparations of stem cell injections, as well as techniques used. This treatment has not
been evaluated in hand OA and, therefore, no recommendation is made with regard to OA of
the hand.

Tumor necrosis factor inhibitors and interleukin-1 receptor antagonists are strongly
recommended against in patients with knee, hip, and/or hand OA.
Tumor necrosis factor inhibitors and interleukin-1 receptor antagonists have been studied in
trials using both subcutaneous and intraarticular routes of administration. Efficacy has not
been demonstrated, including in erosive hand OA. Therefore, given their known risks of
toxicity, we strongly recommended against their use for any form of OA.
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Initial observations addressing the use of anti–nerve growth factor (anti-NGF) agents
suggest that significant analgesic benefits may occur but that incompletely explained
important safety issues may arise. A small subset of patients treated with these agents
had rapid joint destruction leading to early joint replacement. The FDA temporarily halted
clinical trials of anti-NGF as a result, but trials have since resumed, with ongoing collection
of longer-term efficacy and safety data. As none of these agents were approved for use by
the FDA and the longer-term data were not available at the time of the literature review

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 Kolasinski et al. Page 17

and Voting Panel meeting, we are unable to make recommendations regarding the use of
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anti-NGF therapy.

DISCUSSION
These 2019 ACR/AF recommendations for the management of OA are based on the
best available evidence of benefit, safety, and tolerability of physical, educational,
behavioral, psychosocial, mind-body, and pharmacologic interventions, as well as the
consensus judgment of clinical experts. The GRADE approach used provided a
comprehensive, explicit, and transparent methodology for developing recommendations for
OA management. The choice of any single or group of interventions may vary over the
course of the disease or with patient and provider preferences, and is optimally arrived at
through shared decision-making.
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The Voting Panel made strong recommendations for patients to participate in a regular,
ongoing exercise program. The literature provides support for choice from a broad menu of
exercises for patients with OA. The effectiveness of an exercise program is enhanced when
patient preferences and access to exercise programs are considered, as well as when they
are supervised or coupled with self-efficacy, self-management, and weight loss programs.
Strong recommendations were also made for weight loss in patients with knee and/or hip
OA who are overweight or obese, self-efficacy and self-management programs, tai chi,
cane use, first CMC joint orthoses, tibiofemoral bracing, topical NSAIDs for knee OA and
oral NSAIDs for hand, knee, and/or hip OA, and intraarticular glucocorticoid injections
for knee and/or hip OA. The Voting Panel made conditional recommendations for balance
exercises, yoga, CBT, kinesiotaping, orthoses for hand joints other than the first CMC,
patellofemoral bracing, acupuncture, thermal modalities, radiofrequency ablation, topical
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NSAIDs, intraarticular steroid injections and chondroitin sulfate for hand OA, topical
capsaicin for knee OA, acetaminophen, duloxetine, and tramadol. The recommendations
provide an array of options for a comprehensive approach for optimal management of OA
encompassing the use of educational, physical, behavioral, psychosocial, mind-body, and
pharmacologic interventions. The availability, accessibility, and affordability of some of
these interventions vary, but in many communities the AF, as well as local hospitals and
other health-related agencies, offer free self-efficacy and self-management programs.

For some patients with more limited disease in whom medication is required, topical
NSAIDs represent an appropriate first choice. For others, particularly with hip OA or
polyarticular involvement, oral NSAIDs are more appropriate. The appropriate use of other
oral agents, particularly acetaminophen and opioids, will continue to evolve (39–41).
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Despite the many options available, some patients may continue to experience inadequate
symptom control; others will experience adverse effects from the available interventions.
Clinicians treating patients in these circumstances should choose interventions with a low
risk of harm, but both clinicians and patients may be dissatisfied with the options and
unsure of how to choose among them. There are controversies in interpretation of the
evidence, particularly with regard to the use of glucosamine and chondroitin, acupuncture,
and intraarticular hyaluronic acid injections. Nonetheless, the process of updating treatment

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 Kolasinski et al. Page 18

guidelines permits scrutiny of the state of the literature and identification of critical gaps in
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our knowledge about best practices. Further, it highlights the need for ongoing, appropriately
funded, high-quality clinical research, as well as development of new treatment modalities,
to address the human and economic impact of the most common form of arthritis.

No effective disease-modifying agents for OA have yet been identified though phase 2
and 3 trials are underway, and, for the time being, preventive strategies focus on weight
management and injury prevention. Development of more effective therapies that permit
a sophisticated and individualized approach to the patient with OA await the outcome of
future investigation. Important directions for research include gaining a more comprehensive
understanding of the optimal types of exercises and the modifications that should be used
based on disease location and severity, study of the intensity of exercise that would be
optimal for a given individual ([Link]
defining optimal footwear for patients with knee and hip OA and understanding the
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interaction between footwear and exercise, conducting rigorous RCTs for physical modality
options in hand OA, assessing a broader array of outcomes, including fall prevention,
assessing optimal use of oral, topical, and injectable agents alone and in combination,
obtaining a better understanding of the role of integrative medicine, including massage,
herbal products, medical marijuana, and additional mind-body interventions, and exploring
agents with novel mechanisms of action for prevention and treatment.

In conclusion, optimal management requires a comprehensive, multimodal approach to

treating patients with hand, hip, and/or knee OA offered in the context of shared decision-
making with patients, to choose the safest and most effective treatment possible. A large
research agenda remains to be addressed, with a need for more options with greater efficacy
for the millions of people worldwide with osteoarthritis.
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Addendum.
Therapies that were approved after the original systematic literature review are not included
in these recommendations.

Supplementary Material
Refer to Web version on PubMed Central for supplementary material.

ACKNOWLEDGMENTS
We thank Nancy Baker, ScD, MPH, OTR/l, Yvonne Golightly, PT, MS, PhD, Thomas Schnitzer, MD, PhD, and
ChenChen Wang, MD, MSc for serving (along with authors Joel Block, MD, Leigh Callahan, PhD, Carole Dodge,
OT, CHT, David Felson, MD, MPH, William F. Harvey, MD, MSc, Edward Herzig, MD, Marc C. Hochberg, MD,
Author Manuscript

MPH, Sharon L. Kolasinski, MD, C. Kent Kwoh, MD, Amanda E. Nelson, MD, Tuhina Neogi, MD, PhD, Carol
Oatis, PT, PhD, Jonathan Samuels, MD, Daniel White, PT, ScD, and Barton Wise, MD, PhD) on the Expert Panel.
We thank Suzanne Schrandt, Angie Botto-van Bemden, and Jaffe Marie with the Arthritis Foundation for their
involvement throughout the guideline development process. We thank the patients who (along with author Kathleen
Gellar) participated in the Patient Panel meeting: Cindy Copenhaver, LMT, Donna Dernier, Fletcher Johnson,
Nancy J. Maier, Travis Salmon, Elise Sargent, and Linda Walls. We thank the ACR staff, including Regina Parker
for assistance in organizing the face-to-face meeting and coordinating the administrative aspects of the project and
Robin Lane for assistance in manuscript preparation. We thank Janet Waters for help in developing the literature
search strategy and performing the literature search and updates, and Janet Joyce for peer-reviewing the literature
search strategy.

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Supported by the American College of Rheumatology and the Arthritis Foundation.

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Dr. Neogi has received consulting fees from Pfizer, Regeneron, EMD Merck Serono, and Novartis (less than
$10,000 each). Dr. Hochberg has received consulting fees, speaking fees, and/or honoraria from Bone Therapeutics,
Bristol-Myers Squibb, EMD Serono, IBSA, and Theralogix LLC (less than $10,000 each) and from Eli Lilly,
Novartis Pharma AG, Pfizer, and Samumed LLC (more than $10,000 each), royalties from Wolters Kluwer for
UpToDate, owns stock or stock options in BriOri BioTech and Theralogix LLC, and is President of Rheumcon, Inc.
Dr. Block has received consulting fees, speaking fees, and/or honoraria from Zynerba Pharma, GlaxoSmithKline,
and Medivir (less than $10,000 each) and royalties from Agios, GlaxoSmithKline, Omeros, and Daiichi Sankyo for
human chondrosarcoma cell lines. Dr. Callahan has received consulting fees, speaking fees, and/or honoraria from
AbbVie (less than $10,000.) Dr. Kwoh has received consulting fees, speaking fees, and/or honoraria from Astellas,
Fidia, GlaxoSmithKline, Kolon TissueGene, Regeneron, Regulus, Taiwan Liposome Company, and Thusane (less
than 10,000 each) and from EMD Serono, and Express Scripts (more than $10,000 each). Dr. Nelson has received
consulting fees and/or honoraria from Flexion, GlaxoSmithKline, and Medscape (less than $10,000 each). Dr.
Samuels has received consulting fees, speaking fees, and/or honoraria from Dinora, Inc. (less than $10,000). Dr.
Altman has received consulting fees, speaking fees, and/or honoraria from Flexion, GlaxoSmithKline, Novartis,
Olatec, Pfizer, Sorrento Therapeutics, and Teva Pharmaceutical Industries (less than $10,000 each). No other
disclosures relevant to this article were reported.
Author Manuscript

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Guidelines and recommendations developed and/or endorsed by the American College

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of Rheumatology (ACR) are intended to provide guidance for patterns of practice and
not to dictate the care of a particular patient. The ACR considers adherence to the
recommendations within this guideline to be voluntary, with the ultimate determination
regarding their application to be made by the clinician in light of each patient’s individual
circumstances. Guidelines and recommendations are intended to promote beneficial
or desirable outcomes, but cannot guarantee any specific outcome. Guidelines and
recommendations developed and endorsed by the ACR are subject to periodic revision,
as warranted by the evolution of medical knowledge, technology, and practice. ACR
recommendations are not intended to dictate payment or insurance decisions. These
recommendations cannot adequately convey all uncertainties and nuances of patient care.

The American College of Rheumatology is an independent, professional, medical and

scientific society that does not guarantee, warrant, or endorse any commercial product or
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service.
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 Kolasinski et al. Page 23
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Figure 1.
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Recommended therapies for the management of osteoarthritis (OA). Strongly and

conditionally recommended approaches to management of hand, knee, and/or hip OA are
shown. No hierarchy within categories is implied in the figure, with the recognition that
the various options may be used (and reused) at various times during the course of a
particular patient’s disease. * = Exercise for knee and hip OA could include walking,
strengthening, neuromuscular training, and aquatic exercise, with no hierarchy of one
over another. Exercise is associated with better outcomes when supervised. ** = Knee

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 Kolasinski et al. Page 24

brace recommendations: tibiofemoral (TF) brace for TF OA (strongly recommended),

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patellofemoral (PF) brace for PF OA (conditionally recommended). *** = Hand orthosis

recommendations: first carpometacarpal (CMC) joint neoprene or rigid orthoses for first
CMC joint OA (strongly recommended), orthoses for joints of the hand other than the
first CMC joint (conditionally recommended). RFA = radiofrequency ablation; NSAIDs =
nonsteroidal antiinflammatory drugs; IA = intraarticular.
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 Kolasinski et al. Page 25
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Figure 2.
Therapies recommended against (physical, psychosocial, and mind-body approaches [A] and
pharmacologic approaches [B]) in the management of hand, knee, and/or hip osteoarthritis.
No hierarchy within categories is implied in the figure. TENS = transcutaneous electrical
nerve stimulation; TNF = tumor necrosis factor; IL-1 = interleukin-1; PRP = platelet-rich
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plasma; IA = intraarticular.
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Table 1.

Recommendations for physical, psychosocial, and mind-body approaches for the management of osteoarthritis of the hand, knee, and hip

Joint
Intervention
Hand Knee Hip
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Exercise

Balance training

Weight loss

Self-efficacy and self-management programs

Tai chi

Yoga

Cognitive behavioral therapy

Cane

Tibiofemoral knee braces (Tibiofemoral)

Patellofemoral braces (Patellofemoral)

Kinesiotaping (First carpometacarpal)

Hand orthosis (First carpometacarpal)

Hand orthosis (Other joints)

Modified shoes

Lateral and medial wedged insoles

Acupuncture

Thermal interventions

Paraffin

Radiofrequency ablation

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Massage therapy

Manual therapy with/without exercise

Iontophoresis (First carpometacarpal)

Pulsed vibration therapy

Transcutaneous electrical nerve stimulation

Strongly recommended
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Conditionally recommended against

Strongly recommended against
Conditionally recommended
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No recommendation
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Table 2.

Recommendations for the pharmacologic management of osteoarthritis of the hand, knee, and hip

Joint
Intervention
Hand Knee Hip
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Topical nonsteroidal antiinflammatory drugs

Topical capsaicin

Oral nonsteroidal antiinflammatory drugs

Intraarticular glucocorticoid injection

Ultrasound-guided intraarticular glucocorticoid injection

Intraarticular glucocorticoid injection compared to other injections

Acetaminophen

Duloxetine

Tramadol

Non-tramadol opioids

Colchicine

Fish oil

Vitamin D

Bisphosphonates

Glucosamine

Chondroitin sulfate

Hydroxychloroquine

Methotrexate

Intraarticular hyaluronic acid injection (First carpometacarpal)

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Intraarticular botulinum toxin

Prolotherapy

Platelet-rich plasma

Stem cell injection

Biologics (tumor necrosis factor inhibitors, interleukin-1 receptor antagonists)

Strongly recommended
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Conditionally recommended against

Strongly recommended against
Conditionally recommended
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No recommendation
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