Although therapies abound, determining what works best and doesn’t can be challenging for patients and doctors alike. To help make decisions about what treatments may be most effective, the American College of Rheumatology (ACR) and the Arthritis Foundation have been updating their intervention guidelines for hip, knee, and hand osteoarthritis. A total of 34 physicians, occupational therapists, physical therapists, and researchers participated in the process, along with seven patients. RELATED: Low-Dose Steroid Reduces Hand Osteoarthritis Inflammation The updated draft was previewed at the 2019 ACR/Association of Rheumatology Professionals (ARP) Annual Meeting in November. The ACR stresses that the official recommendations have not yet been finalized or published, but the draft gives a good idea of what to expect when the guideline is officially released in 2020.

Exercise May Be the Most Vital Therapy for Osteoarthritis

Since that last guideline from the ACR was published, seven years ago, many scientific studies have altered the landscape for arthritis care. But exercise has remained one of the most important forms of recommended therapy. The current draft spotlights physical activity as the single intervention that should be considered for all patients who have osteoarthritis — whether it be in the hand, knee, or hip. RELATED: Arthritis-Friendly Water Exercises “The strongest research supports the use of exercise in osteoarthritis patients,” says the lead author for the guideline update, Sharon Kolasinski, MD, with the division of rheumatology at the Perlman School of Medicine at the University of Pennsylvania in Philadelphia. “But in addition, a long list of things may be helpful for patients as their osteoarthritis evolves over time. There is a large menu of choices that people should be familiar with.” RELATED: Restless Sleep and Knee Osteoarthritis

The new guideline presents recommendations that are either “strong” (clear evidence supports them) or “conditional” (evidence is not strong enough to fully support them but the clinician and patient may consider them on a case-by-case basis). RELATED: How to Stretch When You’re in Pain Several former conditional recommendations now have been elevated to strong recommendations, including:

Self-efficacy or self-management programsUse of tai chi for knee and hip OATopical NSAIDs for knee and hand OAOral NSAIDs (such as aspirin and ibuprofen) and intra-articular steroids (injected directly into the joint) for knee and hip OA

The update also suggests conditional recommendations for:

Balance exercises for knee and hip OADuloxetine (Cymbalta) for knee OAYogaCognitive behavioral therapy (CBT)Radiofrequency ablationKinesiotaping for first carpometacarpal and knee OATopical capsaicin for knee OA

Matthew Hepinstall, MD, an associate director of the Center for Joint Preservation and Reconstruction at Lenox Hill Hospital in New York City, says that many of these options “belong in your arsenal to use on a case-by-case basis.” RELATED: Tai Chi Beats Stretching and Conventional Exercise in Reducing Fall Risk for the Elderly Dr. Hepinstall, who was not involved in the new guideline update, supports approaches where the patient owns his or her treatment, but points out that self-management can be difficult to define. “Embracing things like tai chi and yoga is an important part of living with arthritis,” he says. “We shouldn’t be seeking pharmaceutical interventions for low-level arthritis that can be managed independently. Giving patients options to feel better is a powerful tool. The challenge is how to figure out which of these treatments are right for which patient.” Hepinstall recognizes that pharmaceuticals can be part of the treatment picture. NSAIDs can make patients feel well enough so they can exercise. Pain can feed depression, according to Hepinstall, so an antidepressant like Cymbalta (duloxetine) may benefit an arthritis patient.

Therapies That Empower and Enable People With OA

The right combination of tools can feed a “virtuous cycle” rather than a vicious one, according to Hepinstall. Pain relief can enable more normal activity, which can improve strength and coordination, which can provide further pain relief. Dr. Kolasinski adds that treatment has to take into account related factors that people experience when they have chronic pain, such as depression, insomnia, and poor coping.

“You have to think about tools that are not from the field of osteoarthritis that have been found to be useful in other pain-related conditions,” she says. “Cognitive behavioral therapy is one of those. It is widely used for a lot of pain conditions. There is some data to support its use in osteoarthritis, and there is very little harm associated with it.” RELATED: The Difference Between Rheumatoid Arthritis Joint Pain and Osteoarthritis Joint Pain

Therapies That Might Not Be Helpful for Osteoarthritis

Some of the recommendations in the new guideline advise against certain treatments that patients may have tried for relief but that further study has not proven effective. For example, the guideline draft recommends against the use of transcutaneous (applied across the skin) electric nerve stimulation (TENS) for knee and hip OA. “The procedure was popular in physical therapy for a long time, but really there is virtually no evidence for its use in treating osteoarthritis,” says Kolasinski.

Supplements That Might Not Be Useful for OA

Practitioners are also advised not to use the supplements glucosamine or chondroitin in patients with knee and hip OA. “The accumulated data over time suggests that there really is no convincing demonstrated benefit from these supplements,” says Kolasinski. While hyaluronic acid injections for first carpometacarpal and knee OA were conditionally recommended, these injections were strongly recommended against for hip OA. Hyaluronic acid is a naturally occurring substance in the skin known for holding moisture, but meta-analysis of related studies found that these injections were not more effective than placebo saline injections. Hepinstall, however, still recommends it for some patients. “Hyaluronic acid is a very common treatment for osteoarthritis,” he says. “For decades, we have injected hyaluronic acid into knees with the idea that it would improve the lubrication of the joint. My anecdotal experience is that I’ve had patients who get a series of hyaluronic acid injections and they feel better.”

Drugs That Are Not Encouraged for People With Osteoarthritis

The guideline team also made recommendations against the use of bisphosphonates, hydroxychloroquine, methotrexate, platelet-rich plasma (PRP) injections (in hip and knee OA), stem cell injections (in hip and knee OA), tumor necrosis factor inhibitors, and interleukin-1 receptor antagonists. Many of these therapies have been shown to be effective in treating rheumatoid arthritis (RA). But the guideline update suggests that the application of antirheumatic agents to osteoarthritis does not seem to be effective. “If we know something works in one disease, we will sometimes try an available drug in another disease,” says Kolasinski. “Sometimes we hit a home run and sometimes we do not. We wanted it to be clear that some of these therapies are not ready for prime time. We need much better studies to assess them.”