Research Article: A Systematic Critical Appraisal for Non-Pharmacological Management of Osteoarthritis Using the Appraisal of Guidelines Research and Evaluation II Instrument

Date Published: January 10, 2014

Publisher: Public Library of Science

Author(s): Lucie Brosseau, Prinon Rahman, Karine Toupin-April, Stéphane Poitras, Judy King, Gino De Angelis, Laurianne Loew, Lynn Casimiro, Gail Paterson, Jessica McEwan, Adrian V. Hernandez.


Clinical practice CPGs (CPGs) have been developed to summarize evidence related to the management of osteoarthritis (OA). CPGs facilitate uptake of evidence-based knowledge by consumers, health professionals, health administrators and policy makers. The objectives of the present review were: 1) to assess the quality of the CPGs on non-pharmacological management of OA; using a standardized and validated instrument – the Appraisal of Guidelines Research and Evaluation (AGREE II) tool – by three pairs of trained appraisers; and 2) to summarize the recommendations based on only high-quality existing CPGs. Scientific literature databases from 2001 to 2013 were systematically searched for the state of evidence, with 17 CPGs for OA being identified. Most CPGs effectively addressed only a minority of AGREE II domains. Scope and purpose was effectively addressed in 10 CPGs on the management of OA, stakeholder involvement in 12 CPGs, rigour of development in 10 CPGs, clarity/presentation in 17 CPGs, editorial independence in 2 CPGs, and applicability in none of the OA CPGs. The overall quality of the included CPGs, according to the 7-point AGREE II scoring system, is 4.8±0.41 for OA. Therapeutic exercises, patient education, transcutaneous electrical nerve stimulation, acupuncture, orthoses and insoles, heat and cryotherapy, patellar tapping, and weight control are commonly recommended for the non-pharmacological management of OA by the high-quality CPGs. The general clinical management recommendations tended to be similar among high-quality CPGs, although interventions addressed varied. Non-pharmacological management interventions were superficially addressed in more than half of the selected CPGs. For CPGs to be standardized uniform creators should use the AGREE II criteria when developing CPGs. Innovative and effective methods of CPG implementation to users are needed to ultimately enhance the quality of life of arthritic individuals.

Partial Text

Osteoarthritis (OA) is known as a degenerative disorder of the joint cartilage associated with hypertrophic bone changes [1] and it is recognized as the most common chronic joint disease in the world [2]. It is expected that OA will be the fourth leading cause of disability by 2020 and the 6th leading cause of years lived with disability [3]–[4]. The annual absenteeism costs related to OA in North America are $10.3 billion [5]. The management of OA in patients should be comprehensive and should target pain reduction, improvement and maintenance of joint function, a decrease in disability, and education of parents about disease and therapies [6]. While people with severe and persistent OA symptoms may use pharmacological treatments such as nonsteroidal anti-inflammatory drugs (NSAIDs), cyclo-oxygenase-2 (COX 2) inhibitors, and undergo joint arthroplasty [7]–[9], people with mild to moderate OA symptoms should consider conservative management by combining pharmacological and non-pharmacological interventions [7], [10]. Non-pharmacological interventions are essential to the treatment and management of any chronic disease and they are as important as pharmacological interventions [6]. According to Sakalauskiene (2010) [6], most non-pharmacological interventions 1) are low in cost; 2) incorporate self-management performed at home or in the community; and 3) have a substantial public health impact. Non-pharmacological interventions, such as therapeutic exercises and weight control, have been shown to be effective in reducing pain and improving function in OA and are usually safe [6]–[7]. However, their use is often suboptimal, which warrants further knowledge translation to clinicians and patients about their importance in improving health outcomes [11]–[12]. Numerous clinical practice CPGs (CPGs) exist in rheumatology, which are intended to facilitate knowledge translation to clinicians and evidence-based clinical decision making. In order to make optimal and accurate clinical decisions for their arthritic patients, health professionals should use high-quality CPGs. In previous systematic reviews [13]–[16], CPGs that considered non-pharmacological and pharmacological interventions have been appraised. However, the CPGs which targeted only non-pharmacological interventions have never been assessed with the Appraisal of Guidelines Research and Evaluation II (AGREE II) tool [14]–[15]. Our paper focused on the quality assessment of non-pharmacological interventions, especially in terms of rigour of development. Non-pharmacological interventions include electrotherapy (e.g. transcutaneous electrical nerve stimulation), patient education, team approach (e.g. multidisciplinary team approach), therapeutic exercises (e.g. aquatics), weight management and other interventions (e.g. acupuncture assistive devices, etc.) [17]–[18]. This review will provide health care professionals a platform to compare the development of recommendations for non-pharmacological interventions from the AGREE II scoring. It will also help them accept and implement the recommended interventions in their health practice. The objective of this critical appraisal review is to 1) identify the CPGs focusing on non-pharmacological management of OA in all joints of the upper and lower extremities; 2) assess the quality of the CPGs using the updated AGREE II instrument (; and 3) to document the non-pharmacological recommendations and identify the high quality CPGs.

The systematic review of CPGs used the Cochrane Methodology ( to identify, select and analyze the data and the PRISMA statement to guide the reporting of the systematic review [19] (Appendix S1). Ethics approval was not required, as this work was based on a systematic literature review.

This review identified a total of 17 CPGs on the non-pharmacological management of OA in all joints of the upper and lower extremities. Among the 17 CPGs considered, nine of these solely focus on non-pharmacological interventions and the remaining eight comprise a combination of pharmacological and non-pharmacological interventions. According to the AGREE II instrument, ten CPGs [26]–[27], [33]–[41], [44] were recognized as good quality CPGs with high scores for rigor of development and because they effectively targeted four to five domains. Therapeutic exercises, patient education, Transcutaneous Electrical Nerve Stimulation, acupuncture, orthoses and insoles, heat and cryotherapy, patellar tapping and weight control are commonly recommended for the non-pharmacological management of OA by the high-quality CPGs. It was noted that common recommendations were found by the majority of the CPGs; however, the strength of the recommendations varied between the CPGs.

From the total seventeen CPGs included, based on the AGREE II scoring, we found ten good quality CPGs [26]–[27], [33]–[41], [44] where the rigor of development was >60%. There are good-quality CPGs available for health professionals. There was consensus for some of the recommendations, such as therapeutic exercises, patient education, Transcutaneous Electrical Nerve Stimulation, acupuncture, orthoses and insoles, heat and cryotherapy, patellar tapping and weight control for the management of OA.