936 Ann Rheum Dis 2000;59:936–944 Ann Rheum Dis: first published as 10.1136/ard.59.12.936 on 1 December 2000. Downloaded from EXTENDED REPORTS EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT) A Pendleton, N Arden, M Dougados, M Doherty, B Bannwarth, J W J Bijlsma, F Cluzeau, C Cooper, P A Dieppe, K-P Günther, H J Hauselmann, G Herrero-Beaumont, P M Kaklamanis, B Leeb, M Lequesne, S Lohmander, B Mazieres, E-M Mola, K Pavelka, U Serni, B Swoboda, A A Verbruggen, G Weseloh, I Zimmermann-Gorska Abstract Osteoarthritis (OA) is by far the most common disease to Background—Osteoarthritis (OA) is the most com- aVect synovial joints. It is a major cause of musculoskeletal mon joint disease encountered throughout Europe. A pain, the single most important cause of disability and task force for the EULAR Standing Committee for handicap from arthritis, and an important community Clinical Trials met in 1998 to determine the healthcare burden. OA is strongly associated with aging methodological and logistical approach required for and, with the increasing proportion of elderly in Western the development of evidence based guidelines for populations, large joint OA, particularly of the knee, will treatment of knee OA. The guidelines were restricted become an even more important healthcare challenge. to cover all currently available treatments for knee Multiple genetic, constitutional, and environmental fac- OA diagnosed either clinically and/or radiographi- tors may contribute to the development and variable cally aVecting any compartment of the knee. outcome of OA. OA of the knees is particularly common, Methods—The first stage was the selection of treat- with radiographic OA of the tibiofemoral compartment ment modalities to be considered. The second stage occurring in 5–15% of people aged 35–74 years. The con- comprised a search of the electronic databases dition is often associated with pain and disability and Medline and Embase using a combination of subject symptomatic subjects often seek medical advice. Treat- headings and keywords. All European language publi- ment aims at (a) educating the patient about OA, (b) alle- cations in the form of systematic reviews, meta- viating pain, (c) optimising and maintaining function, and analyses, randomised controlled trials, controlled (d) preventing or retarding progression of adverse struc- tural change aVecting the joint tissues (cartilage, bone, trials, and observational studies were included. Dur- http://ard.bmj.com/ ing stage three all the relevant studies were quality ligament, muscle). Current treatments include a wide scored. The summary statistics for validated outcome range of non-pharmacological, pharmacological, and measures, when available, were recorded and, where surgical modalities. Evidence to support the eVectiveness of individual treatments, however, is variable. practical, the numbers needed to treat and the eVect Clinical guidelines were defined in 1995 by the Institute size for each treatment were calculated. In the fourth of Medicine in Washington as “Systematically developed stage key clinical propositions were determined by statements to assist practitioner and patient decisions expert consensus employing a Delphi approach. The about appropriate health care for specific clinical condi- on October 2, 2021 by guest. Protected copyright. final stage ranked these propositions according to the tions.” Using these principles, guidelines on the manage- available evidence. A second set of propositions relat- ment of knee OA have been published by the American ing to a future research agenda was determined by College for Rheumatology1 and the Royal College of Phy- expert consensus using a Delphi approach. sicians.2 However, such guidelines primarily represent Results—Over 2400 English language publications and consensus statements from expert panels. The type and 400 non-English language publications were identi- strength of evidence to support such guidelines remain fied. Seven hundred and forty four studies presented unclear. In 1998 EULAR commissioned a steering outcome data of the eVects of specific treatments on committee to review the available research evidence for knee OA. Quantitative analysis of treatment eVect was treatments of knee OA, to develop guidelines relating to possible in only 61 studies. Recommendations for the clinical issues in OA management, and to indicate clearly management of knee OA based on currently available the level of evidence to support individual statements. It data and expert opinion are presented. Proposals for a was felt that the development of such evidence based future research agenda are highlighted. guidelines for the management of knee OA might lead to Conclusions—These are the first clinical guidelines improvements in patient care and to more uniform on knee OA to combine an evidence based approach treatment approaches throughout Europe. and a consensus approach across a wide range of treatment modalities. It is apparent that certain clinical propositions are supported by substantial Methods research based evidence, while others are not. There MEMBERSHIP OF GUIDELINES STEERING COMMITTEE is thus an urgent need for future well designed trials The initiative endorsed by ESCISIT involved a committee to consider key clinical questions. of 21 experts in the field of osteoarthritis (18 rheumatolo- (Ann Rheum Dis 2000;59:936–944) gists, three orthopaedic surgeons) representing 12 diVerent www.annrheumdis.com EULAR recommendations for the management of knee osteoarthritis 937 Table 1 Interventions selected for assessment in the treatment of knee Table 2 Categories of evidence Ann Rheum Dis: first published as 10.1136/ard.59.12.936 on 1 December 2000. Downloaded from osteoarthritis Category Evidence from: Non-pharmacological Pharmacological Surgical 1A Meta-analysis of randomised controlled trials Patient education NSAIDs* Joint replacement 1B At least one randomised controlled trial Telephone contact Analgesics Osteotomy 2A At least one controlled study without randomisation Exercise Opioids Arthroscopic 2B At least one type of quasi-experimental study debridement 3 Descriptive studies, such as comparative studies, correlation Footwear, including SYSADOA* Lavage studies, or case-control studies insoles 4 Expert committee reports or opinions and/or clinical experience Sticks Psychotropic drugs of respected authorities Spa Sex hormones Patellar tape Topical (periarticular) treatment Table 3 Strength of recommendation Diet Intra-articular steroids Vitamins Intra-articular hyaluronic A Directly based on category 1 evidence acid B Directly based on category 2 evidence or extrapolated Minerals recommendation from category 1 evidence C Directly based on category 3 evidence or extrapolated *NSAIDs = non-steroidal anti-inflammatory drugs; SYSADOA = symptomatic recommendation from category 1 or 2 evidence slow acting drugs for osteoarthritis. D Directly based on category 4 evidence or extrapolated recommendation from category 2 or 3 evidence European countries, together with two experts in the field of guidelines methodology. The objectives of the committee were (a) to describe the fluent in the language of the publication. All quality assess- treatments available for the treatment of knee OA and to ments were collected and recorded centrally. review the current level of evidence for their eVectiveness and (b) to produce recommendations for the management of knee OA based on a combination of current evidence Estimation of treatment eVect Quantitative analysis of treatment e ect was assessed, based and expert opinion. V where possible, by calculating the eVect size (ES)4 and/or the number needed to treat (NNT)5 for validated outcome SCOPE OF THE REVIEW measures of pain and physical function. Before the calcula- During the first meeting the committee produced a tion of these quantitative measures all studies were assessed comprehensive list of treatment modalities to be included for the availability of adequate summary statistics. The in the review process (table 1). To focus the review process mean and distribution of values for the baseline, end point, towards clinically relevant issues, the committee also and diVerence from baseline to end point were tabulated agreed 10 clinically important questions related to the for each of the outcome measures recorded. The Z and T management of OA of the knee. scores and p values were also recorded when available. EVect size calculations were performed with meta-analysis EVIDENCE BASED REVIEW software.6 Pooled variance of baseline values was used as an Search strategy estimation of the pooled variance of the diVerence between A systematic search was devised and conducted using two baseline and end point. The NNT was estimated for 20% databases, Medline Ovid and BIDS Embase. The search reduction in pain outcome measures from baseline. This strategy was designed to be inclusive. All European calculation was performed on continuous data (visual ana- language publications in the form of systematic reviews, logue scale (VAS)) using an assumption that the values for http://ard.bmj.com/ meta-analyses, randomised controlled trials, controlled tri- change displayed a normal distribution about the mean. In als, and observational studies were included. Publications the absence of data allowing direct quantification of the in non-European languages were excluded. Several search treatment eVect,