OARSI Releases Evidence-Based Exercise Recommendations for Patients With Knee, Hip OA

The Osteoarthritis Research Society International (OARSI) Rehabilitation Discussion Group has developed evidence-based recommendations for the delivery of therapeutic exercise for patients with knee and/or hip osteoarthritis (OA). The full recommendations were published in Osteoarthritis and Cartilage.

As a leading cause of disability, osteoarthritis is a burden on individuals and the health care system. Despite the importance of exercise as a treatment for people with knee and/or hip OA, there is little guidance for health care and exercise professionals to prescribe and monitor physical activity.

A taskforce including 17 OA experts performed a literature review to identify existing recommendations. They used electronic snowball sampling to establish an international multidisciplinary panel. After reviewing the findings of the literature search, panel members submitted proposition statements, which the taskforce grouped into domains and refined for the consensus process.

Three rounds of electronic Delphi surveys were used to identify the most important proposition statements. In each round, panel members rated the statements. To reduce the number of statements that each panel member had to review, the panel was divided into 3 groups. Only the highest-rated statements that achieved a consensus of at least 80% passed to the next round. The statements remaining after the third round were then analyzed, refined, and merged into unique domains.

Of 319 proposition statements that entered round 1, the final set of recommendations included 54 statements across 11 domains.

1. The taskforce recommended the use of an evidence-based approach while providing patients with guidance on exercise.
2. Exercise in the context of living with OA and pain should be considered.The taskforce recommended that patients be encouraged to get the knowledge and skills to self-manage their OA and pain, including strategies to manage short-term increases in pain during and after exercise and a plan to modify their exercise regimen in response to an OA flare.
3. The taskforce also noted that health care providers perform a comprehensive baseline assessment with follow-up.The baseline assessment may take into consideration overall health of the patient, reported difficulties, physical limitations, functional restrictions, relevant psychosocial factors, and contraindications to exercise. Providers may use baseline measurements to set targets and monitor progress over time.
4. One of the recommendations was collaborative goal-setting. Health care providers and patients should discuss mutually agreeable exercise goals, including functional goals that promote participation in daily activities. The taskforce emphasized that goals be clearly communicated and that patients have realistic expectations about the outcomes of exercise.
5. Health care providers should consider the type of physical activity that they recommend to patients. Exercise options must consider the patient’s impairments or functional limitations. The exercise must also be simple and easily reproducible at home.
6. The taskforce recommended that the dose of the exercise be considered. Dosing should provide physiologic benefits consistent with the patient’s goals, based on which an appropriate starting dose should be recommended. Patients must be encouraged to take part in exercise 2 or more times per week, with providers considering a “long-term” rather than “episodic” approach.
7. Health care providers should progress and modify physical activity based on the patient’s response to it. Gradual progression may be recommended.
8. The taskforce recommended that exercise be tailored to the individual, based on assessment findings, as well as comorbidities, pain severity, physical and cognitive ability to participate in exercise, and the ability to perform exercise independently. “Focus on the whole person, not just the joint,” the taskforce added.
9. The delivery of exercise should be optimized by health care providers. The taskforce recommended that patients receive instructions that are easy to follow, understand the exercises, and have confidence in their ability to participate in the program. Health care providers should aim to build trust and encourage dialogue and questions by patients.
10. The taskforce recommended that providers focus on exercise adherence, by,providing motivation and feedback and addressing barriers and facilitators to exercise. Exercise programs must be developed in way that is achievable and modified as necessary. Providers are also recommended to provide suggestions for continuing exercise after the completion of treatment.
11. Lastly, the taskforce recommended providers educate patients about OA, the benefits and safety of exercise, and the difference between OA flare pain and pain related to exercise, including muscle soreness. Addressing any fears or misconceptions may also be beneficial.

Limitations of the consensus study included potential bias due to the fact that the panel was split into 3 groups; the lack of diversity among panel members; and the electronic format of the study.

Research Conclusions

The authors of the paper concluded, “The breadth of issues deemed important by our panel of experts highlights that therapeutic exercise prescription for OA is multi-dimensional and complex. The recommendations developed in this study will be used to directly inform the development of an online toolbox and associated implementation strategy to support health care professionals deliver best practice therapeutic exercise for patients with knee and/or hip OA.”