Effectiveness of Nonpharmacological and Nonsurgical Interventions for Hip Osteoarthritis: An...

Effectiveness of Nonpharmacologicaland Nonsurgical Interventions for HipOsteoarthritis: An Umbrella Review ofHigh-Quality Systematic ReviewsRikke H Moe, Espen A Haavardsholm, Anne Christie, Gro Jamtvedt,Kristin Thuve Dahm, Kåre Birger Hagen

An increasing number of systematic reviews are available regarding nonpharmaco-logical and nonsurgical interventions for hip osteoarthritis (OA). The objectives ofthis article are to identify high-quality systematic reviews on the effect of nonphar-macological and nonsurgical interventions for hip OA and to summarize availablehigh-quality evidence for these treatment approaches. The authors identified andscreened 204 reviews. Two independent reviewers using a previously pilot-testedquality assessment form assessed the full text of 58 reviews. Six reviews were ofsufficient high quality and could be included for further analyses. There wasmoderate-quality evidence that acupuncture and diacerein have no effect on pain andfunction. There was low-quality evidence that strengthening exercises and avocado/soybean unsaponifiables reduce pain and that diacerein decreases radiographic OAprogression. There was insufficient high-quality evidence regarding nonpharmaco-logical and nonsurgical interventions for hip OA, and further primary studies andreviews are needed.

RH Moe, PT, is Research Fellow,National Resource Centre for Re-habilitation in Rheumatology, Dia-konhjemmet Hospital, PO Box 23Vindern, 0319 Oslo, Norway. Ad-dress all correspondence to DrMoe at: [email protected].

EA Haavardsholm, MD, is ResearchFellow, Department of Rheuma-tology, Diakonhjemmet Hospital.

A Christie, PT, MSc, is ResearchFellow, National Resource Centrefor Rehabilitation in Rheumatol-ogy, Diakonhjemmet Hospital.

G Jamtvedt, PT, MPH, is Re-searcher, Norwegian KnowledgeCentre for the Health Services, StOlavs Plass, 0103 Oslo, Norway.

KT Dahm, PT, MSc, is ResearchAssistant, Norwegian KnowledgeCentre for the Health Services.

KB Hagen, PT, PhD, is Researcher,National Resource Centre for Re-habilitation in Rheumatology, Dia-konhjemmet Hospital.

[Moe RH, Haavardsholm EA,Christie A, et al. Effectiveness ofnonpharmacological and nonsur-gical interventions for hip osteoar-thritis: an umbrella review of high-quality systematic reviews. PhysTher. 2007;87:1716–1727.]

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1716 f Physical Therapy Volume 87 Number 12 December 2007

Osteoarthritis (OA) is a chronicjoint condition, characterizedby pain, disability, and im-

pairment. The prevalence of hip OAin Western populations over 35years of age ranges from 3% to 11%.1

The hip is considered one of themost common weight-bearing jointsaffected by OA.2–4 Main treatmentgoals are improved function, symp-tomatic relief, slowing disease progres-sion, and improving quality of life.5

Treatment for OA may vary dependingon various factors,1 and guidelines onthe management of OA recommendboth pharmacological and nonphar-macological approaches.1 There is lim-ited availability of disease-modifyingdrugs, and many patients use comple-mentary and alternative medicines andtherapies. An increasing number ofsystematic reviews are available re-garding nonpharmacological and non-surgical interventions, and in this um-brella review we summarize and gradethe quality of the available evidencefor these treatment approaches.

Decisions on the provision of healthcare are increasingly based on theavailable evidence. Patients, healthcare professionals, and researchersneed information about the effective-ness of interventions in order to im-prove self-management strategies,to improve clinical practice, and toset priorities for research, respec-tively. Decisions on the reimburse-ment of health care are increasinglyevidence-based. Thus, purchasing or-ganizations and policymakers inhealth care are in need of reliableinformation on the effectiveness ofinterventions.

Summarizing systematic reviews canfacilitate decision making aboutappropriate health care, promoteevidence-based treatment, and iden-tify areas for future research inhealth care. Conclusions based on asystematic review of randomizedcontrolled trials are considered toprovide the highest level of evidence

about the effectiveness of anintervention.

Based on a review of literature before2001, Chard and Dieppe concluded,“Nonpharmaceutical therapies forOA have not been researched enoughfor us to understand their potentialbenefit.”6(p256) There is, to our knowl-edge, no updated overview availableon the effectiveness of nonpharmaco-logical and nonsurgical interventionsfor hip OA. The aim of this overview isto summarize the available evidencefrom systematic reviews on the effec-tiveness of nonpharmacological andnonsurgical interventions for patientswith hip OA.

MethodCriteria for Including ReviewsWe included systematic reviews withthe primary aim of investigating theeffects of nonpharmacological andnonsurgical interventions for hip OApublished in the English, Dutch, orScandinavian language. More specifi-cally, the following inclusion criteriawere used:

• People with OA: Diagnosis accord-ing to the American College ofRheumatology criteria7 or other ac-ceptable criteria.8 Reviews includ-ing people with various rheumaticdiagnoses were accepted only if re-sults for OA could be extractedseparately.

• Interventions: All types of non-pharmacological and nonsurgicalinterventions. Excluded were in-terventions such as gene therapy,all types of invasive interventions(ie, injections or arthroscopy),therapeutic apheresis or interven-tions related to pharmacological orsurgical interventions (eg, thera-peutic exercises after total jointreplacement).

• Outcomes: For the purposes of thisoverview, the primary outcomemeasures were function, pain, andstiffness. The concept of “function”is based on the International Clas-

sification of Functioning, Disabil-ity and Health9 (ICF) definition,where “function” is an umbrellaterm for body function, body struc-ture, activities, and participation.

Search StrategyWe searched the Cochrane Library(Cochrane Database of SystematicReviews and DARE), MEDLINE,EMBASE, PEDro, PsychINFO, andCINAHL from 2000 to January 2007for “hip osteoarthritis/-arthrosis orOA.” A broad computerized searchstrategy was developed (Appendix1). Reference lists from retrieved re-views were examined.

Retrieved hits were assessed by 2of the authors (EAH, RHM), whoscreened the titles and abstracts toidentify relevant studies. If doubt oc-curred, one of the other authors(KBH) was consulted. Potential rele-vant full-text articles were read by 2authors (EAH, RHM).

Assessment ofMethodological QualityTwo authors (EAH, RHM) indepen-dently assessed the methodologicalquality of the reviews. Disagreementwas resolved by discussion. Nine cri-teria were rated as “met,” “unclear/partly met,” or “not met” accordingto a criteria list modified from theEffective Practice and Organisationof Care (EPOC) group within theCochrane Collaboration (Appendix2).10 Based on a summary of these 9criteria, an overall scientific qualitywas applied to each review, as fol-lows: “minor limitations” (at least 7of the criteria were met), “moderatelimitations” (4–6 of the criteria weremet), and “major limitations” (fewerthan 4 of the criteria were met). Re-views with major limitations wereexcluded. The quality assessments ofprimary studies included in the orig-inal reviews are reported in Table 1.

Principles from Grading of Recom-mendations Assessment, Develop-

Effectiveness of Nonpharmacological and Nonsurgical Interventions for Hip OA

December 2007 Volume 87 Number 12 Physical Therapy f 1717

Table 1.Findings From Included Reviewsa

Reference QR/QPS IncludedPrimaryStudies

Intervention/Control

Outcome Data Analyses/Pooling

Findings

Acupuncture

Acupuncturefor peripheraljoint osteo-arthritis(Kwonet al)13

QR: minorlimitations(7/9)

QPS: meanJadad scalescore�5

1 study(N�67)

Acupuncture/sham treatment

VAS pain score(WOMAC)

Meta-analysis,1 study

Mean pain reduction:intervention group,14.43 (SD�25.07);sham treatment group,15.31 (SD�25.03);CI��0.52–0.45

Point estimate of effectsize: SMD�0.03

No intergroup difference;there is no evidencethat acupuncture isbeneficial for hip OA

Authors’ conclusion:“Further studies arerequired.”

1 study(N�67)

Acupuncture/sham treatment

Functional impairment Based on 1 study No intergroup difference

1 study(N�45)

A. acupunctureB. hydrotherapyC. education

VAS pain score Open study, notincluded in meta-analysis

Descriptive summary—authors’ conclusion: nointergroup differences

1 study(N�45)


Daytime VAS painscore

Based on 1 study Descriptive summary—authors’ conclusion:change in A and Bcompared withbaseline (P�.05)

1 study(N�45)


Nighttime VAS painscore

Based on 1 study Descriptive summary—authors’ conclusion:change in A and Bcompared withbaseline (P�.01)

1 study(N�32)


WOMAC scorePainStiffnessPhysical function

Open study, notincluded in meta-analysis

Our interpretation: low-quality primary study,open study design, nosham treatment

Intergroup difference:P�.02

Authors’ conclusion:“One of 3 studiesshowed results on . . .”

(Continued)



Table 1.Continued

Reference QR/QPS IncludedPrimaryStudies



Findings

ASU

Herbal therapy fortreatingosteoarthritis(Little et al)14

QR: minorlimitations (9/9)

QPS: mean Jadadscale score�4.5

1 study onhip OA(N�62)

ASU/placebo VAS pain score Based on 1 study Current available data onASU suggests that itmay provide possiblebeneficial effects onchronic but stabile OAof the hip

Evidence is based on 1study

Authors write thatevidence for beneficialeffects of ASU on OA isconvincing

Point estimate of effectsize: WMD��13.80(CI��25.22–2.38,P�.02)

Diacerein

Diacerein forosteoarthritis(Fidelix et al)15




Diacerein/placebo

Radiographic OAprogression

Meta-analysis In hip OA, there was astatistically significantslowing of radiographicOA progression ondiacerein vs placebo(�0.50 mm during 3 y)

Point estimate of effectsize: relative risk�0.84(CI�0.71–0.99),NNT�11 (CI�6–167)


Diacerein/placebo

Total hipreplacement

Meta-analysis Not statistically significantPoint estimate of effect

size: relative risk�0.73(CI�0.5–1.08)

2 studies onhip OA(N�653)

Diacerein/placebo

VAS pain score Meta-analysis Not statistically significantPoint estimate of effect

size: WMD��3.37(CI��11.12–4.37)


Diacerein/placebo

LequesneFunctionalIndex

Meta-analysis Not statistically significantPoint estimate of effect

size: WMD��0.21(CI��0.82–0.40)


Diacerein/NSAIDs

VAS pain score Meta-analysis Favors NSAIDs, notstatistically significant

Point estimate of effectsize: WMD�2.0(CI��6.48–10.48)

A meta-analysis ofcontrolledclinical studieswith diacereinin thetreatment ofosteoarthritis(Rintelen et al)16




Diacerein/placebo

VAS pain score,LequesneFunctionalIndex

Meta-analysis Effect on pain andfunction

No separate quantitativepooling for hip OA

(Continued)



ment, and Evaluation (GRADE)were used for an overall assessmentof the quality of evidence for eachintervention.10–12 The GRADE con-cept is based on an assessment of thefollowing criteria: quality of primarystudies, design of primary studies,consistency, and directness. An over-

all assessment of the quality of evi-dence was based on a summary ofthese 4 criteria, as presented inTable 2.

Data Extraction and SynthesisData on effectiveness were extractedfrom the identified high-quality re-

views by 2 of the authors (EAH,RHM); if doubt occurred, one of theother authors (KBH) was consulted.The following criteria were appliedwhen data on effects were extracted:

• Adequate quantitative pooling ofdata in reviews was regarded as

Table 1.Continued

Reference QR/QPS Included PrimaryStudies



Findings

Exercise

Evidence-basedrecommendationsfor the role ofexercise in themanagement ofosteoarthritis ofthe hip or knee:the MOVEconsensus (Roddyet al)18


QPS: 20–23/28(Downs,1998)b

2 positive studies,no negative(N�306)

Strengtheningexercise/control(generalpractitionerfollow-up)

Pain Based on 2positive studies

There might possibly bea beneficial effect ofstrengtheningexercises on hip OA

Point estimate of effectsize�0.22 and 0.73

There is some evidencethat strengtheningexercises may bebeneficial for hip OA

1 negative study(N�201), hipand knee

Strengtheningexercise

Disability Based on 1 study Not possible to extractdata on hip OA

0 studies included Strengtheningexercise, N/A

Health status

0 positive studies,2 negativestudies (N�419),mixed inclusion

Aerobic exercise Pain Based on 2 studies Not possible to extractdata on hip OA


Aerobic exercise Disability Based on 2 studies Not possible to extractdata on hip OA


Aerobic exercise Health status Based on 2 studies Not possible to extractdata on hip OA

Exercise for osteo-arthritis of thehip or knee(Fransen et al)17


QPS: meanJadad scalescore�2.5

2 studies on hipOA (N�100)included

Exercise/controlgroup follow-up

N/A N/A There were notenough studies toevaluate land-basedtherapeutic exercisefor people with OAof the hip

Optimal exercise typeand dosage couldnot be extrapolatedfrom this review

a WOMAC�Western Ontario and McMaster Universities Osteoarthritis Index, QR�quality of review, QPS�quality of studies, VAS�visual analog scale,SMD�standardized mean difference, CI�confidence interval, NNT�number needed to treat, WMD�weighted mean difference, ASU�avocado/soybeanunsaponifiables, OA�osteoarthritis, NSAID�nonsteroidal anti-inflammatory drug, N/A�not available.b Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomisedstudies of healthcare interventions. J Epidemiol Community Health. 1998;52:377–384.



more valid than a qualitative datasynthesis approach.

• If no direct comparisons betweentreatments were undertaken or noquantitative pooling of data wasdone, the results are reported as“no quantitative pooling,” and theauthors’ statements were reported.

• When we found that the resultswere reported inconsistently in dif-ferent sections of the review, theeffects were extracted from themain result section.

ResultsStudy SelectionThe literature search identified 204reviews on hip OA. One hundredsixty-four articles were clearly notrelevant based on information fromthe abstract. For 58 reviews, the fulltext was retrieved (Tab. 3) and as-sessed, and 52 reviews were ex-cluded for various reasons (Figure).In the end, we included 6 high-qualitysystematic reviews, which formed thebasis of this umbrella review (Tab. 1).Generally, the methodological qualityof the primary studies was low to mod-erate, often presenting conflicting re-sults (Tab. 4).

Quality of FindingsAcupuncture. One high-qualitysystematic review13 assessed the ef-fect of acupuncture on peripheraljoint OA. The conclusions werebased on 3 primary studies. On thebasis of the meta-analysis, therewere no statistically significant re-sults, and thus there was no evi-dence that acupuncture is beneficialfor reducing OA pain. Mean pain re-duction was 14.43 (on a 0–100 vi-sual analog scale [VAS]) for the inter-vention group and 15.31 for thesham treatment group (mean differ-ence of �0.03, 95% confidence in-terval [CI]��0.52–0.45).

Avocado/soybean unsaponifiables(ASU). Avocado/soybean unsaponi-fiables may reduce pain in peoplewith chronic hip OA. The authors’

conclusion is that the evidence forthe beneficial effects of ASU on OA isconvincing.14 Evidence extractedfrom the review was based on oneprimary study that compared ASUwith a placebo on VAS pain scores.The mean difference was �13.80(95% CI��25.2 to �2.38, P�.02)(on a 0–100 scale) in favor of ASU.In our opinion, current available dataon ASU suggest that it may providepossible beneficial effects on OA ofthe hip, but there is still insufficientevidence to draw firm conclusions.These data suggest that there islow-quality evidence that ASU reducespain (based on VAS scores) in hip OA.

Diacerein. Diacerein is a symp-tomatic, slow-acting herbal therapyfor OA. It is a registered medica-tion in the United States, but it isconsidered a herbal therapy in mostother countries; therefore, it wasincluded in this umbrella review. Weincluded 2 reviews on the effect ofdiacerein.15,16 The conclusions fromthese reviews on the effect ofdiacerein on hip OA were based on 7primary studies; however, evidenceon radiographic OA progression wasbased on the results of one primarystudy. There was a statistically signif-icant slowing of radiographic OAprogression on diacerein versus a

placebo (�0.50 mm during 3 years,relative risk�0.84 [95% CI�0.71–0.99], number needed to treat�11[95% CI�6–167]). However, the ad-verse effect of diarrhea (42%) wasquite common15 and, in our opinion,should not be ignored in clinicalpractice and further research. Thereis low-quality evidence that treat-ment with diacerein reduces radio-graphic OA progression andmoderate-quality evidence that it hasno effect on pain, impairment, orincidence of total hip replacement.15

Exercises. Two high-quality re-views reported on the effects of ex-ercise on hip OA.17,18 Fransen et al17

concluded that no optimal exercisetype or dosage could be extrapolatedfrom the review due to little avail-able scientific evidence. Roddy etal18 concluded that there is some ev-idence that strengthening exercisemay be beneficial in reducing pain inpeople with hip OA, but that there isnot enough evidence to make con-clusions on the effect on disability.There also is not enough evidence tomake conclusions about the effect ofaerobic exercise on pain, disability,or health status.18

Other interventions. It was notpossible to extract data on hip OA

Table 2.Grading Quality of Evidence

Level Criteria

High-quality evidence One or more updated, high-quality systematic review that arebased on at least 2 high-quality primary studies withconsistent results

Moderate-quality evidence One or more updated systematic reviews of high ormoderate quality

• Based on at least 1 high-quality primary study• Based on at least 2 primary studies of moderate quality

with consistent results

Low-quality evidence One or more systematic reviews of variable quality• Based on primary studies of moderate quality• Based on inconsistent results in the reviews• Based on inconsistent results in primary studies

Very low-quality evidence No high-quality systematic review was identified on thistopic



Table 3.Overview of Full-Text Reviews Assessed (Status Included/Excluded)

Review Status

Adebajo AO. Osteoarthritis. Baillieres Clin Rheumatol. 1995;9: 65–74. Excluded due to publication date

Angermann P. [Avocado/soybean unsaponifiables in the treatment of knee and hiposteoarthritis.] Ugeskr Laeger. 2005:167:3023–3025.

Excluded, methodologically major limitations

Barthels EM, Lund H, Hagen KB, et al. Aquatic exercise for the treatment of kneeand hip osteoarthritis. Cochrane Database Syst Rev. Protocol stage.

Excluded, not yet published, still in protocol

Bennell K, Hinman R. Exercise as a treatment for osteoarthritis. Curr OpinRheumatol. 2005;17:634–640.


Bland JH. The reversibility of osteoarthritis: a review. Am J Med. 1983;74:16–26. Excluded due to publication date

Bischoff HA, Roos EM. Effectiveness and safety of strengthening, aerobic, andcoordination exercises for patients with osteoarthritis. Curr Opin Rheumatol.2003;15:141–144.


Brosseau L, Gam A, Harman K, et al. Low level laser therapy (classes I, II and III)for treating osteoarthritis. Cochrane Database Syst Rev. 2004;(3):CD002046.

Excluded, no studies on hip OA included in thereview

Brosseau L, MacLeay L, Robinson V, et al. Intensity of exercise for the treatmentof osteoarthritis. Cochrane Database Syst Rev. 2003;(2):CD004259.


Brosseau L, Yonge KA, Marchand S, et al. Thermotherapy for treatment ofosteoarthritis. Cochrane Database Syst Rev. 2003;(4):CD00452.


Chard J, Dieppe P. The case for nonpharmacologic therapy of osteoarthritis. CurrRheumatol Rep. 2001;3:251–257.


Chodosh J, Morton SC, Mojica W, et al. Chronic disease self-managementprograms for older adults. Ann Intern Med. 2005;143:427–438.

Excluded, impossible to extract data on hip OA

Ernst E. Complimentary medicine. Curr Opin Rheumatol. 2003;15:151–155. Excluded, methodologically major limitations

Felson DT, Chaisson CE. Understanding the relationship between body weightand osteoarthritis. Baillieres Clin Rheumatol. 1997;11:671–681.

Excluded due to publication date

Felson DT. Does excess weight cause osteoarthritis and, if so, why? Ann RheumDis. 1996;55:668–670.


Felson DT. Preventing knee and hip osteoarthritis. Bull Rheum Dis. 1998;47:1–4. Excluded due to publication date

Felson DT. Weight and osteoarthritis. Am J Clin Nutr. 1996;63(suppl):430S–432S. Excluded due to publication date

Fransen M, Crosbie J, Edmonds J. Exercise for osteoarthritis of the hip or knee.J Rheumatol. 2001;28:156–164.

Excluded, included in Cochrane review below

Fransen M, McConnell S, Bell M, Exercise for osteoarthritis of the hip or knee.Cochrane Database Syst Rev. 2001;(2):CD004376.

Included, methodologically minor limitations

Fransen M, McConnell S, Bell M, Therapeutic exercise for people withosteoarthritis of the hip or knee: a systematic review. J Rheumatol. 2002;29:1737–1745.

Excluded, no separate analyses for hip OA

Fidelix TS, Soares BG, Trevisani VF. Diacerein for osteoarthritis. CochraneDatabase Syst Rev. 2006;(1):CD005117.


Grassi W, Filipucci E, Farina A. Ultrasonography in osteoarthritis. Semin ArthritisRheum. 2004;34(2 suppl):9–23.

Excluded, not a systematic review

Hochberg MC, Berman B, Birch S, et al. Acupuncture for osteoarthritis. CochraneDatabase Syst Rev. Protocol stage.


Hoving JL, van der Heijden GJ. Fysiotherapie bij heupklachten: systematischereview van klinisch effectonderzoek. Ned Tijdschr Fysiother. 1997;107:2–7.

Excluded, searched primary studies only up to1994

Hulme JM, DeBie R, Robinson VA, et al. Electromagnetic fields for the treatmentof osteoarthritis. Cochrane Database Syst Rev. 2002;(1):CD003523.

Excluded, no studies on hip OA included inreview

(Continued)



Table 3.Continued

Review Status

Hunter DJ, Felson DT. Clinical review: Osteoarthritis. BMJ. 2006;332:639–642. Excluded, no studies on hip OA included inreview

Kalb RL. Evaluation and treatment of hip pain. Hosp Pract (Minneap). 1998;33:131–132.


Kettunen JA, Kujala UM. Exercise therapy for people with rheumatoid arthritisand osteoarthritis. Scand J Med Sci Sports. 2004;14:138–142.


Kwon YD, Pittler MH, Ernst E. Acupuncture for pheripheral joint osteoarthritis.Rheumatology (Oxford). 2006:27;1331–1337.


Lane NE, Buckwalter JA. Exercise and osteoarthritis. Curr Opin. Rheumatol. 1999;11:413–416.


Latham N, Anderson C, Bennett D, Stretton C. Progressive resistance strengthtraining for physical disability in older people. Cochrane Database Syst Rev.2003;(2):CD002759.

Excluded, no studies on hip OA included inreview

Little CV, Parsons TJ, Logan S. Herbal therapy for treating osteoarthritis. CochraneDatabase Syst Rev. 2000;(4):CD002947.


Livense AM, Bierma-Zeinstra SMA, Verhagen AP, et al. Influence of obesity on thedevelopment of osteoarthritis of the hip: a systematic review. Rheumatology(Oxford). 2002;41:1155–1162.

Excluded, risk factors

Long L, Soeken K, Ernst E. Herbal medicines for the treatment of osteoarthritis: asystematic review. Rheumatology (Oxford). 2001;40:779–793.


McAlindon TE, LaValley MP, Gulin JP, Felson DT. Glucosamine and chondroitinfor treatment of osteoarthritis: a systematic quality assessment and meta-analysis.JAMA. 2000;283:1469–1475.


McGuire JB. Arthritis and related diseases of the foot and ankle: rehabilitation andbiomechanical considerations. Clin Podiatr Med Surg. 2003;20:469–485.


Marks R, Allegrante JP. Effectiveness of psychoeducational interventions inosteoarthritis. Clin Rev Phys Rehabil Med. 2002;14:173–195.


Mazieres B, Jamard B, Verrouil E, et al. The therapeutic approach to osteoarthritis.Aging Clin Exp Res. 2003;15:405–412.


Minor MA. Exercise in the treatment of osteoarthritis. Rheum Dis Clin North Am.1999;25:397–433.


Neame RL, Doherty M. Managing hip osteoarthritis. Practitioner. 2000;244(1616):964–968, 971–972.


O’Reilly S, Doherty M. Lifestyle changes in the management of osteoarthritis. BestPract Res Clin Rheumatol. 2001;15:559–568.


Pelland L, Brosseau L, Wells G, et al. Efficacy of strengthening exercises onosteoarthritis: a meta-analysis. Phys Ther Rev. 2004;9:77–108.


Pencharz JN, Grigoriadis E, Jansz GF, Bombardier C. A critical appraisal of clinicalpractice guidelines for the treatment of lower-limb osteoarthritis. Arthritis Res.2002;4:36–44.

Excluded, review of guidelines

Perkins PJ, Doherty M. Nonpharmacologic therapy of osteoarthritis. CurrRheumatol Rep. 1999;1:48–53.


Pham T, Van Der Heijde D, Lassere M, et al. OMERACT-OARSI outcome variablesfor osteoarthritis clinical trials: the OMERACT-OARSI set of responder criteria.J Rheumatol. 2003;30:1648–1654.

Excluded, includes only medication astreatment

Puett DW, Griffin M. Published trials of nonmedicinal and noninvasive therapiesfor hip and knee osteoarthritis. Ann Intern Med. 1994;121:133–140.


Riemsma RP, Kirwan JA, Taal E, Rasker JJ. Patient education for osteoarthritis.Cochrane Database Syst Rev. Protocol stage.


(Continued)



for chondroitin, glucosamine, orherbal therapies such as Reumalex,*capsaicin, and tipi tea. No relevanthigh-quality reviews were located onweight loss, thermotherapy, patienteducation, lifestyle changes, electro-therapy, manual therapy, or jointtraction or distraction.

DiscussionThis overview (umbrella review) ofsystematic reviews examining the ef-fectiveness of nonpharmacologicaland nonsurgical interventions for hipOA is based on an extensive litera-ture search, combined with assess-ment of study quality and synthesisof findings. We identified 204 poten-

tially relevant manuscripts, but in theend were able to include only 6 high-quality reviews. We found that there ismoderate-quality evidence that acu-puncture and diacerein have no effecton pain and function. There is low-quality evidence that strengtheningexercises and ASU reduce pain andthat diacerein decreases radiographicOA progression. Several primary stud-ies might have been published afterthe reviews included in this overview,and thus their results were not cap-tured. Further updating of reviews andmore primary research might confirmour findings and upgrade the evi-dence. For other interventions andoutcomes, the quality of evidence wasassessed as low or very low, and newprimary studies are needed. For sev-

eral interventions for hip OA (ie,aquatic exercise; electrotherapy; glu-cosamine; herbal therapies such asReumalex, capsaicin, and tipi tea;joint traction and distraction; lifestylechanges; manual therapy; patient edu-cation; thermotherapy; and weightloss), no systematic review was iden-tified. Our conclusions were made onbasis of statistically significant changesand not clinically relevant differences.Clinical evidence-based advice per-haps instead should be founded onclinically relevant change (eg, painreduction).

To our knowledge, no such over-view has been published on hip OAuntil now. Umbrella reviewspresent a synthesis of the highest-* Gerard House Ltd, 375 Capability Green, Lu-

ton, United Kingdom.

Table 3.Continued

Review Status

Rintelen B, Neumann K, Leeb BF. A meta-analysis of controlled clinical studieswith diacerein in the treatment of osteoarthritis. Arch Intern Med. 2006;166:1899–1906.

Included; minor limitations

Roberts WN, Williams RB. Hip pain. Prim Care. 1988;15:783–793. Excluded due to publication date

Roddy E, Zhang W, Doherty M, et al. Evidence-based recommendations for therole of exercise in the management of osteoarthritis of the hip or knee: theMOVE consensus. Rheumatology (Oxford). 2005;44:67–73.


Sharma L. Local factors in osteoarthritis. Curr Opin Rheumatol. 2001;13:441–446. Excluded, methodologically major limitations

Sims K. The development of hip osteoarthritis: implications for conservativemanagement. Man Ther. 1999;4:127–135.


Singh JA, Wilt TJ, Mcdonald R. Chondroitin for osteoarthritis. Cochrane DatabaseSyst Rev. Protocol stage.


Smidt N, de Vet HC, Bouter LM, et al; Exercise Therapy Group. Effectiveness ofexercise therapy: a best-evidence summary of systematic reviews. Aust JPhysiother. 2005;51:71–85.

Excluded, overview of overviews

Towheed TE, Maxwell L, Anastassiades TP, et al. Glucosamine therapy for treatingosteoarthritis. Cochrane Database Syst Rev. 2005;(2):CD002946.

Excluded, not possible to extract data on hipOA

Van Baar ME, Assendelft WJ, Dekker J, et al. Effectiveness of exercise inosteoarthritis of the hip or knee: a systematic review of randomised clinicaltrials. Arthritis Rheum. 1999;42:1361–1369.


Ytterberg SR, Mahowald ML, Krug HE. Exercise for arthritis. Baillieres ClinRheumatol. 1994;8:161–189.


Zacher J, Gursche A. Regional musculoskeletal conditions: hip pain. Best PractRes Clin Rheumatol. 2003;17:71–85.


Zhang W, Doherty M, Arden N, et al. Eular recommendations for hiposteoarthritis: report of a task force of the EULAR Standing Committee forInternational Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis.2005;64:669–681.

Excluded, recommendations



quality research evidence availablein a condensed format, simply ac-cessible for clinicians and policy-makers. There are important limita-tions in summarizing evidencefrom systematic reviews only. Forevery review, primary studies willbe missed. Even though reviewsshould be updated regularly, newstudies are published all the time,and most reviews are seldom ornever updated. Another issue isthat all types of interventions maynot be covered by a review, andthus important high-quality pri-mary studies might be overlooked.As the number of published system-atic reviews increases, a commonfinding is that more than one sys-tematic review addresses the sameinterventions, and conflicts amongreviews are emerging.19 Such dis-cordance might cause difficulties

Table 4.Summary of Findings From Included Reviewsa

Quality ofEvidence

Intervention Comparison Results

High N/A N/A None identified

Moderate Acupuncture Sham No difference on pain and function

Diacerein Placebo No difference on pain and function

Low Aerobic exercise ROM No difference on pain, disability,and health status

Avocado/soybean unsaponifiables Placebo Reduces pain

Diacerein Placebo Reduces radiographic OAprogression

No difference in number of totalhip replacements

Strengthening exercises Control Reduces pain

Very low Aquatic exerciseElectrotherapyChondroitinGlucosamineJoint tractionLifestyle changesManual therapyPatient educationReumalex, capsaicin, tipi tea (herbal

therapies)ThermotherapyWeight loss

No high-quality reviews identified

N/A�not available, ROM�range of motion, OA�osteoarthritis.

146 reviews excluded based on abstract

58 full-text reviews retrieved

52 reviews excluded based on:low quality, same review published indifferent journals, reviews with updates, not possible to extract data on hip osteoarthritis

6 reviews included in umbrella review

204 potentially relevant reviews identified and screened for retrieval

Figure.Flow chart.



for decision makers (including cli-nicians, policymakers, researchers,and patients) who rely on reviewsto help them make choices amongdifferent health care interventions.

Grading quality on nonpharmaco-logical treatment approaches for OAis challenging. Nonpharmacologicalevidence is systematically gradedsignificantly lower methodologicallythan pharmacological evidence.20 Thissuggests that it is even more difficultto include nonpharmacological stud-ies and reviews when applying highstandards for quality assessments. Thetype of methodological quality assess-ment applied determines which stud-ies are included in the review. Thenumber of good primary studies avail-able at the time of the review influ-ences the methodological quality rat-ing, and high-quality primary studiesnot included in the reviews are not apart of our results.

Depending on the total qualityscore, we included or excluded re-views for this umbrella review. To-tal quality scores are presented as aresult of summing all 9 qualityscore items.12 The cutoff point of 4out of a total of 9 satisfactory items9

might be considered strict and isdebatable. High-quality primarystudies are warranted in order todraw substantive conclusions re-garding the effectiveness of inter-ventions. The studies should berandomized, double-blind (or atleast assessor blinded), and pla-cebo controlled. The duration ofthe intervention should be of ade-quate length, and examinationsshould be frequent enough to de-tect a difference in outcome mea-sures. The follow-up period shouldbe of sufficient length to assesslong-term effects. Outcome mea-sures also should be standardized,feasible, valid, reliable, and sensi-tive to change.

The major finding of this umbrellareview is that there is insufficienthigh-quality evidence regarding non-pharmacological and nonsurgical in-terventions for hip OA. For knee OA,this seems to be a completely differ-ent issue, as there is substantiallymore available evidence for differenttreatment approaches for this joint.Many reviews include both knee andhip OA and merge the results. It isbeyond the scope of this article toaddress interventions that have someevidence of effectiveness for kneeOA but that have not been tested todate for hip OA. We found it difficultto extract data for hip OA only inmost reviews. One may not directlyapply findings and evidence fromstudies of knee OA and extrapolatethem to hip OA, as the effectivenessof different therapies may be differ-ent for these joints. Thus, our lack offindings for hip OA warrants furtherprimary studies and reviews regard-ing nonpharmacological and nonsur-gical interventions in this area.

ConclusionThere is insufficient high-quality evi-dence regarding nonpharmacologi-cal and nonsurgical interventions forhip OA, and further primary studiesand reviews are needed.

Ms Moe and Dr Hagen provided concept/idea/project design. All authors providedwriting. Ms Moe, Dr Haavardsholm, MsChristie, and Ms Dahm provided data collec-tion. Ms Moe, Dr Haavardsholm, MsChristie, Ms Jamtvedt, and Ms Dahm pro-vided data analysis. Ms Moe and Dr Haa-vardsholm provided project management.Ms Jamtvedt and Dr Hagen provided consul-tation (including review of manuscript be-fore submission).

This work was inspired and facilitated bythe CARE III and CARE IV InternationalConferences.

This article was submitted February 1, 2007,and was accepted July 5, 2007.

DOI: 10.2522/ptj.20070042

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recommendations for hip osteoarthritis:report of a task force of the EULAR Stand-ing Committee for International ClinicalStudies Including Therapeutics (ESCISIT).Ann Rheum Dis. 2005;64:669–681.

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Appendix 1.Search Strategy

The following databases were searched:

MEDLINE, 1996–2007, week 2; CI-NAHL, 1982–2007, week 2; AMED,1985–2007, week 2; EMBASE,1996–2007, week 2; PsycINFO, 1996–2007, week 2; The Cochrane Libraryand PEDro, 2000–2007, week 2.

The search strategy has been formulatedin Ovid (MEDLINE, CINAHL, EMBASE,and AMED). A broad computerized searchstrategy was developed to identify the fol-lowing components:

(A) Study type: systematic reviews

Search strategy: (1) controlled.ab.(ab.�all searchable words from the ab-stract); (2) design.ab.; (3) evidence.ab.;(4) extraction.ab.; (5) randomized con-trolled trials/[MESH]; (6) meta-analysis.pt. (pt.�publication type); (7) review.pt.;(8) sources.ab.; (9) studies.ab.; (10) OR/1–9; (11) letter.pt.; (12) comment.pt.;(13) editorial.pt.; (14) OR/11–13; and(15) 10 NOT 14

(B) Participants: Hip[MeSH], osteo-arthritis[MeSH], OR osteoarthrosis-[MeSH]

(C) Interventions: nonpharmacologicaland nonsurgical exp “behavior and be-havior mechanisms”/OR exp “psycho-logical phenomena and processes”/ORexp “mental disorders”/OR exp “behav-ioural disciplines and activities”/

In addition, the following free-textwords were used: hip osteothritis ORosteoarthrosis AND modalities/ORheat/OR cold/OR cryotherapy/ORTENS/OR thermotherapy/OR acupunc-ture/OR copper/OR bracelet/OR mag-net/OR exercise/OR flexibility/ORstrengthening/OR aerobic/OR Felden-krais/OR aquatic/OR hydrotherapy/ORpool exercise/OR glucosamine/ORherbal/OR laser/OR ultrasound/OR ul-trasonography/OR nonmedical/OR non-medicinal/OR noninvasive/OR brac-es/OR orthoses/OR physiotherapy/ORphysical therapy/OR education/ORschool/OR management/OR treatment/OR recommendations/OR distraction/ORtraction/OR conservative/OR NOT sur-gery NOT pharmacological NOT pharma-cotherapy

The following MESH terms and floatingsubheadings were excluded from thesearch result with NOT: exp “Special-ties, Surgical”/OR su.fs (Surgery as float-ing subheading to a MESH term) exp“inorganic chemicals”/OR exp “organicchemicals”/OR exp “heterocyclic com-pounds”/OR exp “polycyclic com-pounds”/OR exp macromolecular sub-stances/OR exp “hormones, hormonesubstitutes, and hormone antago-nists”/OR exp “enzymes and coen-zymes”/OR exp “carbohydrates/ OR exp“lipids”/OR exp “amino acids, peptides,and proteins”/OR exp “nucleic acids, nu-cleotides, and nucleosides”/OR exp “com-plex mixtures”/OR exp “biological fac-tors”/OR exp “biomedical and dentalmaterials”/OR exp “pharmaceutical prep-arations”/OR exp “chemical actions anduses”/

(D) Language restrictions: English, Dutch,or Scandinavian language

(E) Publication year from 2000 to week 2of January 2007

Additionally, The Cochrane Library wasmanually explored title by title for possi-ble relevant reviews.

Appendix 2.Criteria for the Assessment of the Quality of the Systematic Reviews10

The following 9 criteria were rated as“met,” “unclear/partly met,” or “notmet” according to a criteria list modifiedfrom the Effective Practice and Organi-sation of Care (EPOC) group within theCochrane Collaboration:

1. Is the search strategy described inenough detail for the search to bereproducible?

2. Was the search for evidence reason-ably comprehensive?

3. Were the criteria used for decidingwhich studies to include in the re-view reported?

4. Was bias in the selection of articlesavoided?

5. Were the criteria used for assessingthe validity of the studies that werereviewed reported?

6. Was the validity of all of the studiesreferred to in the text assessed usingappropriate criteria in analyzing thestudies that are cited?

7. Were the methods used to combinethe findings of the relevant studies(to reach a conclusion) reported?

8. Were the findings of the relevantstudies combined (or not combined)and analyzed appropriately relativeto the primary question the reviewaddresses and the available data?

9. Were the conclusions made by theauthor(s) supported by the data orthe analysis reported in the review?



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