Best Practice & Research Clinical Rheumatology 24 (2010) 93–106

Contents lists available at ScienceDirect

Best Practice & Research Clinical

Rheumatology
journal homepage: www.elsevierhealth.com/berh

Non-pharmacological approaches for the treatment

of osteoarthritis
François Rannou, MD, PhD, Professor of Medicine a, b, c, *, Serge Poiraudeau,
MD, PhD, Professor of Medicine a, b, c
a
INSERM, U747, Laboratoire de Pharmacologie, Toxicologie et Signalisation Moléculaire, Paris F-75006, France
b
Université Paris Descartes, Paris F-75006, France
c
AP-HP, Groupe Hospitalier Cochin, Service de rééducation, Paris F-75014, France

Keywords:
For the most part, non-pharmacological approaches are recom-
evidence-based mended for osteoarthritis treatment. This recommendation is
recommendation based mainly on biomechanical observations leading to a modu-
clinical guidelines lation of the symptomatic loading joint. Approaches include
orthoses orthoses, insoles, exercise, diet and patient education. The
insoles approach used for each osteoarthritis site must be adapted for the
exercises individual patient. Here, we use an evidence-based approach,
diet
including the European League Against Rheumatism (EULAR) and
patient education
Osteoarthritis Research Society International (OARSI) recommen-
knee osteoarthritis
hip osteoarthritis dations, to summarise the non-pharmacological treatments avail-
hand osteoarthritis able for knee, hip and hand osteoarthritis and to help the physician
in daily clinical practice.
Ó 2009 Elsevier Ltd. All rights reserved.

Treatment of osteoarthritis (OA) consists of a combination of non-pharmacological and pharma-

cological approaches. Non-pharmacological approaches include orthoses, insoles, exercise, diet and
patient education. For each OA anatomical site, the non-pharmacological approach must be adapted to
the individual patient. Pharmacological treatments, however, are usually the same, whatever the
anatomical site.
Orthoses or braces and insoles are mainly prescribed to modulate mechanical stress on the
symptomatic joint compartment. Besides this mechanical effect, they may have effects on muscle co-
contraction and proprioception [1,2]. Orthoses are external devices used for knee and hand OA. For
knee OA, orthoses are rest orthoses, knee sleeves and unloading knee braces. Orthoses have no use in

* Corresponding author. Service de Rééducation, Hôpital Cochin, 27, Rue du Faubourg Saint-Jacques 75014, Paris, France.
Tel.: þ33 1 58 41 25 35; Fax: þ33 1 58 41 25 45.
E-mail address: francois.rannou@cch.aphp.fr (F. Rannou).

1521-6942/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.berh.2009.08.013
94 Non-pharmacological treatments in OA / Best Practice & Research Clinical Rheumatology 24 (2010) 93–106

hip OA. Insoles are commonly prescribed for knee and hip OA. Foot pronation and cushioning insoles
are largely prescribed for lower-limb OA. Information on the use of orthoses and insoles is elaborated
by the physiotherapist, occupational therapist, podiatrist, prosthetist and orthotist, depending on the
typical use and any professional legislation in each country.
Exercise therapy is widely used for lower-limb and hand OA to improve joint range of motion,
muscle strength, tendon lengthening, aerobic performance and proprioception. The modalities of
exercise are numerous and should be adapted to the joint affected and the health of the patient.
Exercise therapy is delivered mainly by physical and occupational therapists. Even if exercise therapy
is a key treatment modality in OA, the optimal content of this treatment has yet to be precisely
described, so physicians face difficulties in prescribing such treatment for particular OA sites and for
particular patients.
Obesity is a major risk factor for the onset and progression of knee OA, and reducing weight can
alleviate impairment and disability [3,4]. In hip OA, the influence of obesity is less important [5,6].
Surprisingly, obesity is associated with osteoarthritis of the hand, even in non-weight-bearing joints
[7,8]. This observation suggests the existence of systemic pathogenic mechanisms linked to obesity,
besides mechanical factors [9–11]. Because of these mechanical and metabolic apsects, overweight OA
patients should aim to lose weight.
Non-pharmacological treatments must be explained to patients to improve adherence to treatment.
This main goal of patient education, the final step of non-pharmacological approaches to OA treatment,
involves various forms of vehicle information.
Pharmacological treatment of OA involves a combination of acetaminophen, non-steroidal anti-
inflammatory drugs (NSAIDs) and symptomatic slow-acting drugs in OA (SYSADOAs). Depending on
the country, some SYSADOAs are licensed for use as medications and/or nutritional supplements (i.e.,
glucosamine, chondroitin sulphate and avocado/soybean unsaponifiable). We consider SYSADOAs
and nutritional supplements as part of the pharmacological approach, so we do not describe them
here.
Recommendations for treating OA are numerous. They are mainly based on literature analysis to
calculate the effect size of a treatment modality, along with expert opinion. The most important
information for the physician in daily practice is that effect sizes of non-pharmacological treatments
are in the same range (0–1) as those of pharmacological modalities, which favours non-pharmaco-
logical approaches in treating OA. The main international recommendations are from the Osteoarthritis
Research Society International (OARSI) and the European League Against Rheumatism (EULAR).
Besides these international guidelines, national recommendations are adapted to the local health-care
system. As examples, the American College of Rheumatology, the United Kingdom National Institute of
Health and Clinical Excellence and the French Society of Physical Medicine and Rehabilitation have
formulated national clinical guidelines for OA. Recently, Misso et al. listed 18 clinical practice guidelines
devoted to knee OA [12].

Practice points

 The effect sizes of non-pharmacological treatments for OA are similar to those of pharma-
cological treatments, which suggest the importance of the use of non-pharmacological
approaches in treating OA.
 Non-pharmacological approaches for OA include orthoses, insoles, exercise, diet and patient
education.
 Some non-pharmacological modalities can be used whatever the joint affected (aerobic
exercise, diet and patient education), whereas other modalities are specific to the joint
affected (orthoses, insoles and specific exercise).
 The non-pharmacological approach must be adapted to the OA site and clearly explained to
the patient.
 Non-pharmacological treatments in OA / Best Practice & Research Clinical Rheumatology 24 (2010) 93–106 95

Research agenda

 Specific methodology to evaluate non-pharmacological approaches to OA must be used in

future randomised clinical trials.
 The absence of randomised clinical trial for a treatment modality does not mean that the
modality is ineffective.

Non-pharmacological approaches for the treatment of knee OA

Orthosis

For knee OA, orthosis consists of rest orthoses, knee sleeves and unloading knee braces. Rest orthoses are
used for joint immobilisation, which excludes any dynamic effect. Rest orthoses are created by a stiff
composite, by casting or a line. The effectiveness of rest orthoses for lower-limb OA has not been studied in
clinical trials. To date, they cannot be recommended [13]. Knee sleeves are elastic non-adhesive orthoses
associated with various devices aimed at patellar alignment or frontal femoro-tibial stabilisation.
Unloading knee braces are, like knee sleeves, functional devices. They are composed of external stems,
hinges and straps. Their purpose is to decrease compressive loads transmitted to the joint surfaces, either in
the medial or lateral femoro-tibial compartment, depending on the valgus or varus position of the device.
The EULAR recommendation #3 is devoted to the non-pharmacological approach in the treatment of
knee OA [14]. Orthotic devices are recommended mainly on the basis of expert opinion, not evidence.
Only one randomised clinical trial, comparing one group with a knee sleeve, one group with a valgus
brace and a control group without a knee sleeve or a brace, has been described [15]. This study showed
a significant improvement in pain and function for the two intervention groups. In addition, valgus brace
treatment is more effective than the simple knee sleeve. Effect size could not be calculated, but the
strength of the recommendation was moderate (B), which points out the importance of expert opinion
in this recommendation. Cochrane reviews and the OARSI recommendations include one more study,
but the device used was an unloading knee brace, not a knee sleeve [16–18]. The OARSI recommends
a knee brace for patients with knee OA and mild or moderate varus or valgus instability to reduce pain,
improve stability and diminish the risk of falling [18]. For the unloading knee braces, Beaudreuil et al., in
a recent review, found 16 studies [16]. Unfortunately, these studies were of poor quality, and the
recommendation for using an unloading knee brace was again based on the Kirkley study [13,15]. Finally,
Beaudreuil et al. pointed out the potential adverse effects of unloading knee braces, such as venous
thrombo-embolic events [13]. This last point has to be considered in daily medical practice.

Practice points

 Knee sleeves can be used for knee OA to decrease pain and disability.
 Unloading valgus knee braces can be used for medial knee OA to decrease pain and disability.
 Unloading valgus knee braces may be more effective than knee sleeves but have more
adverse effects.

Research agenda

 Randomised clinical trials are needed to determine whether bracing can be effective to
decrease structural damage in knee OA.
96 Non-pharmacological treatments in OA / Best Practice & Research Clinical Rheumatology 24 (2010) 93–106

 Instability, malalignment and the main symptomatic knee compartment (medial, lateral and
patellar) must be evaluated for their importance in the response to bracing treatment.
 Basic research is needed to evaluate the biomechanical and neurological (proprioception)
mechanisms of the bracing effect.

Insoles and footwear

Insoles can be neutral, lateral-wedged or cushioning. The biomechanical concept for the use of
insoles for knee OA has not yet been clearly validated and has been described only for lateral-wedged
insoles. Two different biomechanical theories have been elaborated: adduction moment theory and
kinetic chain theory [19]. The adduction moment theory estimates the loading on the medial knee
compartment by the product of the mechanical axis force and the distance between this axis and the
knee joint centre. With a lateral-wedged insole, the mechanical axis might reach a more upright
position and reduce the distance between the axis and the joint centre, thus decreasing the knee
medial loading (Fig. 1). For the kinetic chain theory, a lateral-wedged insole creates a valgus hind foot
and then a valgus knee joint, as well as a decrease in medial compartment load. Whatever the theory,
lateral-wedged insoles could decrease the load on the knee joint and probably more on the medial
compartment.
The EULAR recommendation #9 describes insoles, without specification, with a strength of
recommendation of B [14]. The calculation of the effect size was not feasible. For the OARSI recom-
mendations, the authors added one more study [18,20]; the effect size not being calculated for the
same reason. Finally, the Cochrane review described a better pain effect with a strapped insole as
compared with an inserted insole but with a poor long-term adherence [16,21–24]. However, strapped
insoles are not disseminated in many countries. In light of the literature and recommendations, lateral-
wedged insoles (Fig. 2) could be of interest to decrease pain and NSAID consumption in patients with
medial knee OA. To date, no evidence suggests a structural or functional impact of insoles [20,25]. No
results from a randomised controlled trial exist to comment on the other sites (lateral and patellar).

Fig. 1. Biomechanical effect of lateral-wedge insole in medial femoro-tibial osteoarthritis: the adduction moment theory. A: in the
absence of a lateral-wedge insole. B: in the presence of a lateral-wedge insole. Adapted from Gelis et al. [19].
 Non-pharmacological treatments in OA / Best Practice & Research Clinical Rheumatology 24 (2010) 93–106 97

Fig. 2. Back view of lateral-wedge insole.

No randomised controlled trial has evaluated footwear and a cushioning insole. The OARSI
recommendations point out an interest to advise patients about appropriate footwear. The optimal
shoes could have a flat or low heel, be flexible and have lateral-wedged soles [26].

Practice points

 A lateral-wedged insole could reduce symptoms in medial knee OA.

 A strapped insole could have a good symptomatic effect.
 A neutral and cushioning insole could be of interest in knee OA, whatever the compartment
affected.

Research agenda

 Medial-wedged insoles should be evaluated for lateral knee OA.

 Randomised controlled trials evaluating footwear are needed.
 The optimal thickness and duration of wear of insoles should be evaluated.

Exercise

Exercise therapy for knee OA should improve joint range of motion, muscle and tendon lengthening,
strength and endurance and decrease pain and loading on the symptomatic compartment. Functional
improvements are expected in walking ability and daily activities, even sport. The possible modalities
of exercise treatments are numerous and depend on the rhythm, duration and type or technique,
conducted individually or in groups and supervised or not by a physiotherapist. Exercise therapy can be
divided into two modalities. The first is aerobic. Aerobic exercise is, by definition, non-specific and aims
to improve general physical performance. The second type is analytic exercise, focusses on the
symptomatic joint and aims to improve joint range of motion, to increase muscle strength and to
decrease loading of the symptomatic joint compartment. Analytic exercise is based on a precise
evaluation of the joint and muscle impairment.
98 Non-pharmacological treatments in OA / Best Practice & Research Clinical Rheumatology 24 (2010) 93–106

Exercise therapy is always recommended in clinical guidelines for managing knee OA. The EULAR
recommendation #3 points out the importance of exercise, although not specified. The range of the
effect size is between 0.57 and 1.00 [14]. The OARSI recommendations are more precise and include
‘‘regular aerobic, muscle strengthening, and range of motion exercises.’’[18] Pooled effect sizes for pain
relief are 0.52 for aerobic exercise and 0.32 for muscle strengthening. A recent Cochrane review of 32
studies concluded that exercise for knee OA has at least a short-term benefit in terms of reduced knee
pain and improved physical function [27]; even if the magnitude of the treatment effect is considered
small, it is comparable to that reported with NSAIDs [27]. Unfortunately, the Cochrane review did not
define ‘exercise therapy’ The MOVE consensus, involving a literature search and a Delphi expert process,
gives more precision regarding the content of exercise therapy. The consensus mainly recommended
aerobic and strengthening exercises to decrease pain and to improve health status [28]. Group and
home exercises are equally effective [28,29], and patients may benefit from referral to a physiotherapist
[18]. Finally, proprioceptive exercise could have the same efficacy as strength training [28,30].
Which muscle to strengthen? To date, responding to this question in terms of the international
recommendations is difficult. The response can only come from expert opinion. Strengthening the
quadriceps may improve joint stability [31] as may hamstring muscle strengthening. To decrease
loading in the medial compartment, strengthening the lateral muscle knee chain would radically open
the medial compartment. By contrast, for lateral knee OA, medial muscle chain strengthening could
decrease the load on the lateral compartment. These last recommendations are based only on the
clinical experience of the authors and need the involvment of a physiotherapist.
Finally, knee flessum is probably important to detect and treat with postural exercise in extension.
This last aspect of the treatment is never defined in international recommendations but may improve
the natural course of knee OA and have better results after total knee replacement.

Practice points

 Aerobic, strengthening, range-of-motion and proprioceptive exercise is recommended to

decrease pain and improve function and quality of life in knee OA.
 Inexpensive aerobic exercise can include sport, walking, swimming, cycling and any physical
activity the patient particularly enjoys (authors’ recommendations).
 Quadriceps and hamstring muscle strengthening may improve joint stability.
 For medial knee OA, strengthening the lateral muscle knee chain may decrease the load on
the medial compartment (authors’ recommendations).
 For lateral knee OA, strengthening the medial muscle knee chain may decrease the load on
the medial compartment (authors’ recommendations).
 Specific postural exercises in extension may guard against flessum (authors’
recommendations).

Research agenda

 Analytic exercise needs to be evaluated in randomised clinical trials.

 Proprioceptive exercise needs to be evaluated in randomised clinical trials.

Diet

Obesity plays a key role in the pathophysiology of OA. The two main factors in this process are
mechanical stress and probably systemic factors contained in fat tissue [10,11,32,33]. The association
 Non-pharmacological treatments in OA / Best Practice & Research Clinical Rheumatology 24 (2010) 93–106 99

between obesity and knee OA is greater for women than for men and for bilateral rather than for unilateral
disease. In addition, alignment disorders increase the risk of knee OA in obese patients. One randomised
clinical trial showed weight loss associated with decreased knee pain and functional improvement,
especially when combined with physical exercise [34]. Weight loss is recommended by the EULAR
recommendation #3 and by the OARSI recommendations without any effect size calculation [14,18].
Weight loss is a difficult process for obese patients. From our experience, defining a weight objective
based on the last weight for which patients experienced no pain is recommended, and the patient
could be told the other metabolic and cardiovascular advantages of losing weight.

Practice points

 Weight loss associated with physical exercise is recommended for knee OA.

Patient education and information

Education and information about non-pharmacological treatment of knee OA is mainly devoted to

encourage adherence to various treatment modalities and is very different from a simple pharmaco-
logical prescription. Education is recommended by the EULAR recommendation #3, with a range of
effect size between 0.28 and 0.35 and a strength of recommendation of A [14]. The OARSI recom-
mendation is more precise [18] and focusses on information and education about the objectives and
the importance of the non-pharmacological treatment. The content of the education and information
process must be delivered by the physician and encouraged by the physical therapist [18]. To improve
the clinical status of the patient, regular phone calls might help [18].

Other modalities

Thermotherapy, transcutaneous electrical nerve stimulation and acupuncture are recommended by

OARSI to decrease pain [18]. These recommendations are mainly based on Cochrane reviews and
independent systematic reviews, showing a slight but significant effect on pain [35–38]. These types of
treatment modalities are not described in the EULAR recommendations [14]. Finally, walking aids –
canes, crutches, frames, wheeled walkers and sticks – are recommended by EULAR and OARSI solely on
the basis of expert opinion.

Practice points

 Canes, crutches, frames, wheeled walkers and sticks are recommended for knee OA.
 For unilateral knee OA, these appliances are held in the contralateral hand.
 For bilateral knee OA, sticks, frames and wheeled walkers can be proposed.
 The physician or physiotherapist should demonstrate these aids: the appliance and the foot of
the affected OA joint must contact the ground at the same time (authors’ recommendations).

Research agenda

 Randomised clinical trials with adapted methodology must be developed to evaluate alter-
native therapy.
100 Non-pharmacological treatments in OA / Best Practice & Research Clinical Rheumatology 24 (2010) 93–106

Non-pharmacological approaches for the treatment of hip OA

Non-pharmacological modalities of treatment for knee OA are widely described in the international
literature. Unfortunately, fewer studies are specifically devoted to hip OA. For this reason, international
recommendations are based more on expert opinion than on literature analysis with effect size
calculations. The other major difference with knee OA is the absence of possibilities for bracing.

Insoles and footwear

The aim of insoles in the treatment of hip OA is to decrease the load applied on the hip. No rand-
omised controlled trials have investigated insoles in hip OA. EULAR recommendations describe insoles
for patients with hip OA solely on the basis of expert opinion [39]. By contrast, no OARSI recom-
mendation describes insoles for hip OA but points out the importance of delivering advice concerning
appropriate footwear for hip OA [18]. This last recommendation is based solely on expert opinion.
The type of insole and precise footwear are not described in international recommendations. These
recommendations can only be based on clinical experience.

Practice points

 Lateral-wedged insoles are not indicated for hip OA.

 Cushioning insoles could be proposed for hip OA (authors’ recommendations).
 Footwear with shock absorbance could be proposed for hip OA (authors’ recommendations).

Research agenda

 Specific randomised clinical trials are needed to test cushioning insoles and footwear with
shock absorbance for hip OA.

Exercises

Exercise therapy for hip OA has the same objective as for knee OA: improving joint range of motion,
muscle and tendon lengthening, strength, endurance and decreasing pain and loading on the symp-
tomatic compartment. Aerobic exercises are by definition non-specific; thus, they are similar to those
recommended for knee OA. Analytic exercise is different because it is devoted to a different joint.
Exercise therapy is always recommended in clinical guidelines for managing hip OA. The EULAR
recommendation #3 points out the importance of exercise, without specification. No specific trial has
been devoted solely to hip OA; effect size calculations are from pooled results of hip and knee OA studies
[39]. The OARSI recommendations are more precise and include ‘‘regular aerobic, muscle strengthening,
and range of motion exercises.’’[18] These are the same recommendations as for knee OA, but for hip OA,
‘‘exercises in water can be effective.’’[18] The content of the exercise programme and the modality of the
deliverance recommended are the same as those described for knee OA but with less evidence for hip
OA [18,28]. Finally, proprioceptive exercise is not recommended, as it is for knee OA.
Which muscles to strengthen? To date, responding to this question in terms of international
recommendations is difficult. The response can only come from expert opinion. Strengthening hip
stabiliser muscles could improve joint stability. To decrease the loading on the hip joint, the pelvi-
trochanterian muscles could be strengthened. These last recommendations are based only on the
clinical experience of the authors and need the involvement of a physiotherapist.
 Non-pharmacological treatments in OA / Best Practice & Research Clinical Rheumatology 24 (2010) 93–106 101

Finally, extension deficit and hip flessum are probably important to detect and to treat with postural
exercise in extension. This last aspect of the treatment is never defined in international recommen-
dations but may improve the natural course of hip OA and have better results after total hip
replacement.

Practice points

 Aerobic, strengthening and range-of-motion exercises are recommended to decrease pain,

improve function and quality of life in hip OA; these exercises can be done on land or in water.
 Inexpensive aerobic exercises can include sport, walking, swimming, cycling and any physical
activity the patient particularly enjoys (authors’ recommendations).
 Strengthening hip stabiliser muscles could improve joint stability (authors’
recommendations).
 Strengthening pelvi-trochanterian muscles could decrease the load on the hip joint (authors’
recommendations).
 Specific postural exercises in extension could guard against extension deficit and flessum
(authors’ recommendations).

Research agenda

 Analytic exercise needs to be evaluated in randomised clinical trials.

Diet

The association between obesity and hip OA is less than in knee OA. Evidence is based only on case-
control studies [18]. Weight loss is recommended by the third EULAR and the OARSI recommendations,
with no effect size calculation [14,18]. Lastly, in a recent prospective population-based study,
Lhomander et al. have clearly shown an association between overweight and the incidence of severe
hip osteoarthritis in men and women [40].
Weight loss is a difficult process for obese patients. From our experience, a weight objective based
on the last weight for which patients experienced no pain could be defined, and the patient could be
told the other metabolic and cardiovascular advantages of losing weight. Finally, obesity is a major risk
factor for total hip replacement, which suggests that patients should lose weight to be in optimal
condition for a safe surgical procedure [41].

Practice points

 Weight loss is recommended for hip OA, to protect the joint and to decrease risk factors if
total hip replacement is needed.

Patient education and information

Education and information given in non-pharmacological treatment of hip OA is the same as for
knee OA. The only difference is that the addition of regular phone calls is solely based on expert opinion
[18].
102 Non-pharmacological treatments in OA / Best Practice & Research Clinical Rheumatology 24 (2010) 93–106

Other modalities

Thermotherapy and transcutaneous electrical nerve stimulation are recommended by OARSI to

decrease pain in hip OA [18]. These recommendations are mainly based on a Cochrane review
showing a slight but significant effect on pain [35,36]. These types of treatment modalities are not
developed in the EULAR recommendations [39]. Finally, walking aids such as canes, crutches, frames,
wheeled walkers and sticks are recommended by EULAR and OARSI solely on the basis of expert
opinion.

Practice points

 Canes, crutches, frames, wheeled walkers and sticks are recommended for hip OA.
 For unilateral hip OA, these appliances are held in the contralateral hand.
 For bilateral hip OA, sticks, frames and wheeled walkers can be proposed.
 The physician or physiotherapist should demonstrate these aids: the appliance and the foot of
the affected OA joint must contact the ground at the same time (authors’ recommendations).

Research agenda

 Randomised clinical trials with adapted methodology must be developed to evaluate alter-
native therapy.

Non-pharmacological approaches for the treatment of hand OA

Hand OA can be divided into two types of clinical evidence, finger OA and base-of-thumb OA. These
two hand OA subtypes probably have different pathophysiological processes. Finger OA is a more
hormonal and systemic disease whereas base-of-thumb OA is a more mechanical disease.
The only international clinical recommendations for hand OA were developed by OARSI [42]. All the
OARSI recommendations devoted to non-pharmacological approaches came from expert opinion, not
from results of randomised clinical trials. Thus, no effect sizes are available to evaluate non-pharma-
cological approaches.

Orthoses

The OARSI recommendation #5 for orthoses is as follows: ‘‘Splints for thumb base OA and orthoses
to prevent/correct lateral angulation and flexion deformity are recommended.’’ At the time of devel-
opment of the recommendation, no results from controlled trials were available. Recently, we showed
good effects on pain and disability not at 1 month but at 12 months in a randomised controlled trial of
splints for base-of-thumb OA [43]. This study confirms the expert opinion and encourages physicians to
prescribe splints to keep the first web open (Fig. 3A–C). The recommendation is for a rest splint, and the
patient must wear it every night [43]. At 12 months, 86% of the intervention group who wore the splint
for more than 5 nights a week showed no adverse effects [43]. For finger OA, stacked or static finger
splints could be used to immobilise and correct distal and/or proximal finger joints (Figs. 4 and 5).
These splints can be used as a rest orthosis or just after a joint injection to immobilise the injected joint
for a few days.
 Non-pharmacological treatments in OA / Best Practice & Research Clinical Rheumatology 24 (2010) 93–106 103

Practice points

 Splints for base-of-thumb OA are recommended to decrease pain and disability.

 Stacked or static finger splints can be used for finger OA.
 Splints for hand OA need to be worn every night.
 Splints for hand OA can be worn just after joint infiltration (authors’ recommendations).

Research agenda

 Randomised clinical trials are needed to determine whether splinting can be effective in
decreasing structural damage in hand OA.

Exercises

Exercise therapy for hand OA is recommended by OARSI [42]. The OARSI recommendations include
‘‘range of motion and strengthening exercises.’’ The experts did not mention aerobic or proprioceptive
exercise.

Practice points

 Strengthening and range-of-motion exercise is recommended.

 Inexpensive aerobic exercise can be recommended: sport, walking, swimming, cycling and
any physical activity that the patient particularly enjoys (authors’ recommendations).
 Strengthening hand-joint stabiliser muscles could improve joint stability (authors’
recommendations).
 Specific postural exercises to open the first web could be of interest (authors’
recommendations).

Research agenda

 Analytic, aerobic and proprioceptive exercise needs to be evaluated in randomised clinical

trials.

Diet

Surprisingly, obesity is associated with finger OA [7]. However, clinical trials have yet to evaluate the
efficacy of weight loss in hand OA. Losing weight is not mentioned in any recommendations for hand
OA [42].

Patient education and information

Patient education and information are recommended by OARSI for hand OA [42]. These recom-
mendations are based only on expert opinion. They point out the interest of educating patients to
104 Non-pharmacological treatments in OA / Best Practice & Research Clinical Rheumatology 24 (2010) 93–106

Fig. 3. A: Base-of-thumb osteoarthritis with a closure of the first web, B: Opponens Splint for base-of-thumb osteoarthritis (palmar
view), C: Opponens Splint for base-of-thumb osteoarthritis (radial view).

protect joints against adverse mechanical factors. To date, no results from basic or clinical research
support this recommendation to protect joints.

Other modalities

Local application of heat to symptomatic joints is recommended, especially before exercise [42].
In summary, non-pharmacological approaches to treat osteoarthritis associate general non-phar-
macological treatment and specific treatment for the affected osteoarthritic joint. Whatever the

Fig. 4. Stack finger splint.

 Non-pharmacological treatments in OA / Best Practice & Research Clinical Rheumatology 24 (2010) 93–106 105

Fig. 5. Static finger splint.

localisation of the osteoarthritis (knee, hip or hand), aerobic, strengthening and range-of-motion
exercise; diet; and patient education should be proposed.
For lower-limb osteoarthritis, cushioning insoles, advice about footwear, canes, crutches, frames,
wheeled walkers, sticks and specific postural exercises in extension could be of interest. For medial
knee osteoarthritis, knee sleeves, unloading valgus knee braces, lateral-wedged insoles and
strengthening the lateral muscle knee chain can be used to decrease impairment. For lateral knee
osteoarthritis, knee sleeves, unloading valrus knee braces and strengthening the medial muscle knee
chain can be used to decrease impairment.
For hand osteoarthritis, local application of heat, strengthening stabiliser joint muscles, range-of-
motion exercise and splinting are recommended. Specific postural exercises to open the first web could
be of interest in base-of-thumb osteoarthritis.
Many recommendations are based on expert opinion. Randomised clinical trials with appropriate
methodology adapted to non-pharmacological treatments are needed.

Acknowledgements

The authors thank Bernard Mazières, Emmanuel Coudeyre, Johann Beaudreuil, Anthony Gelis,
Vincent Tiffreau, Pascal Richette, Yohan Delarue and Franck Chagny.

References

[1] Ramsey DK, Briem K, Axe MJ, Snyder-Mackler L. A mechanical theory for the effectiveness of bracing for medial
compartment osteoarthritis of the knee. J Bone Joint Surg Am 2007;89:2398–407.
[2] Birmingham TB, Kramer JF, Kirkley A, et al. Knee bracing for medial compartment osteoarthritis: effects on proprio-
ception and postural control. Rheumatology (Oxford) 2001;40:285–9.
[3] Felson DT, Goggins J, Niu J, et al. The effect of body weight on progression of knee osteoarthritis is dependent on
alignment. Arthritis Rheum 2004;50:3904–9.
[4] Anderson JJ, Felson DT. Factors associated with osteoarthritis of the knee in the first national Health and Nutrition
Examination Survey (HANES I). Evidence for an association with overweight, race, and physical demands of work. Am J
Epidemiol 1988;128:179–89.
[5] Hochberg MC. Risk factors for the development and progression of hip osteoarthritis. J Rheumatol 2005;32:1135–6.
[6] Lievense AM, Bierma-Zeinstra SM, Verhagen AP, et al. Influence of obesity on the development of osteoarthritis of the
hip: a systematic review. Rheumatology (Oxford) 2002;41:1155–62.
[7] Cicuttini FM, Baker JR, Spector TD. The association of obesity with osteoarthritis of the hand and knee in women: a twin
study. J Rheumatol 1996;23:1221–6.
[8] Sayer AA, Poole J, Cox V, et al. Weight from birth to 53 years: a longitudinal study of the influence on clinical hand
osteoarthritis. Arthritis Rheum 2003;48:1030–3.
[9] Dumond H, Presle N, Terlain B, et al. Evidence for a key role of leptin in osteoarthritis. Arthritis Rheum 2003;48:3118–29.
106 Non-pharmacological treatments in OA / Best Practice & Research Clinical Rheumatology 24 (2010) 93–106

[10] Gosset M, Berenbaum F, Salvat C, et al. Crucial role of visfatin/pre-B cell colony-enhancing factor in matrix degradation and
prostaglandin E2 synthesis in chondrocytes: possible influence on osteoarthritis. Arthritis Rheum 2008;58:1399–409.
[11] Distel E, Cadoudal T, Durant S et al. The infrapatellar fat pad in knee osteoarthritis: an important source of IL-6 and its
soluble receptor. Arthritis Rheum, in press.
[12] Misso ML, Pitt VJ, Jones KM, et al. Quality and consistency of clinical practice guidelines for diagnosis and management of
osteoarthritis of the hip and knee: a descriptive overview of published guidelines. Med J Aust 2008;189:394–9.
[13] Beaudreuil J, Bendaya S, Faucher M, et al. Clinical practice guidelines for rest orthosis, knee sleeves, and unloading knee
braces in knee osteoarthritis. Joint Bone Spine 2009 May 19 [Epub ahead of print].
*[14] Jordan KM, Arden NK, Doherty M, et alStanding Committee for International Clinical Studies Including Therapeutic Trials
ESCISIT. EULAR recommendations 2003: an evidence based approach to the management of knee osteoarthritis: Report
of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT). Ann
Rheum Dis 2003;62:1145–55.
[15] Kirkley A, Webster-Bogaert S, Litchfield R, et al. The effect of bracing on varus gonarthrosis. J Bone Joint Surg 1999;81-A:
539–48.
*[16] Brouwer RW, Jakma TS, Verhagen AP, et al. Braces and orthoses for treating osteoarthritis of the knee. Cochrane Database
Syst Rev 2005 Jan 25 (1):CD004020.
[17] Brouwer RW, van Raaij TM, Verhaar JA, et al. Brace treatment for osteoarthritis of the knee: a prospective randomized
multi-centre trial. Osteoarthr Cartil 2006;14:777–83.
*[18] Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part
II: OARSI evidence-based, expert consensus guidelines. Osteoarthr Cartil 2008;16:137–62.
[19] Gélis A, Coudeyre E, Hudry C, et al. Is there an evidence-based efficacy for the use of foot orthotics in knee and hip
osteoarthritis? Elaboration of French clinical practice guidelines. Joint Bone Spine 2008;75:714–20.
[20] Pham T, Maillefert JF, Hudry C, et al. Laterally elevated wedged insoles in the treatment of medial knee osteoarthritis. A
two-year prospective randomized controlled study. Osteoarthr Cartil 2004;12:46–55.
[21] Toda Y, Segal N, Kato A, et al. Effect of a novel insole on the subtalar joint of patients with medial compartment oste-
oarthritis of the knee. J Rheumatol 2001;28:2705–10.
[22] Toda Y, Segal N. Usefulness of an insole with subtalar strapping for analgesia in patients with medial compartment
osteoarthritis of the knee. Arthritis Rheum 2002;47:468–73.
[23] Toda Y, Tsukimura N. A six-month followup of a randomized trial comparing the efficacy of a lateral-wedge insole with
subtalar strapping and an in-shoe lateral-wedge insole in patients with varus deformity osteoarthritis of the knee.
Arthritis Rheum 2004;50:3129–36.
[24] Toda Y, Tsukimura N. A 2-year follow-up of a study to compare the efficacy of lateral wedged insoles with subtalar
strapping and in-shoe lateral wedged insoles in patients with varus deformity osteoarthritis of the knee. Osteoarthr Cartil
2006;14:231–7.
[25] Maillefert JF, Hudry C, Baron G, et al. Laterally elevated wedged insoles in the treatment of medial knee osteoarthritis:
a prospective randomized controlled study. Osteoarthr Cartil 2001;9:738–45.
*[26] Hinman RS, Bennell KL. Advances in insoles and shoes for knee osteoarthritis. Curr Opin Rheumatol 2009;21:164–70.
*[27] Fransen M, McConnell S, Bell M. Exercise for osteoarthritis of the hip or knee. Cochrane Database Syst Rev 2003 (3):
CD004286.
*[28] Roddy E, Zhang W, Doherty M, et al. Evidence-based recommendations for the role of exercise in the management of
osteoarthritis of the hip or knee–the MOVE consensus. Rheumatology (Oxford) 2005;44:67–73.
[29] Tiffreau V, Mulleman D, Coudeyre E, et al. The value of individual or collective group exercise programs for knee or hip
osteoarthritis. Clinical practice recommendations. Ann Réadapt Méd Phys 2007;50:741–6. 734–40.
[30] Lin DH, Lin CH, Lin YF, Jan MH. Efficacy of 2 non-weight-bearing interventions, proprioception training versus strength
training, for patients with knee osteoarthritis: a randomized clinical trial. J Orthop Sports Phys Ther 2009;39:450–7.
*[31] Felson DT. Clinical practice. Osteoarthritis of the knee. N Engl J Med 2006;354:841–8.
[32] Berenbaum F, Sellam J. Obesity and osteoarthritis: what are the links? Joint Bone Spine 2008;75:667–8.
[33] Gabay O, Hall DJ, Berenbaum F, et al. Osteoarthritis and obesity: experimental models. Joint Bone Spine 2008;75:675–9.
[34] Messier SP, Loeser RF, Miller GD, et al. Exercise and dietary weight loss in overweight and obese older adults with knee
osteoarthritis: the arthritis, diet, and activity promotion trial. Arthritis Rheum 2004;50:1501–10.
[35] Osiri M, Welch V, Brosseau L, et al. Transcutaneous electrical nerve stimulation for knee osteoarthritis. Cochrane Data-
base Syst Rev 2000 (4):CD002823.
[36] Brosseau L, Yonge KA, Robinson V, et al. Thermotherapy for treatment of osteoarthritis. Cochrane Database Syst Rev 2003
(4):CD004522.
[37] Ezzo J, Hadhazy V, Birch S, et al. Acupuncture for osteoarthritis of the knee: a systematic review. Arthritis Rheum 2001;
44:819–25.
[38] Foster NE, Thomas E, Barlas P, et al. Acupuncture as an adjunct to exercise based physiotherapy for osteoarthritis of the
knee: randomised controlled trial. Br Med J 2007;335:436.
*[39] Zhang W, Doherty M, Arden N, et alEULAR Standing Committee for International Clinical Studies Including Therapeutics
(ESCISIT). EULAR evidence based recommendations for the management of hip osteoarthritis: report of a task force of the EULAR
Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis 2005;64:669–81.
[40] Lohmander LS, Gerhardsson de Verdier M, Rollof J, et al. Incidence of severe knee and hip osteoarthritis in relation to
different measures of body mass: a population-based prospective cohort study. Ann Rheum Dis 2009;68:490–6.
[41] Karlson EW, Mandl LA, Aweh GN, et al. Total hip replacement due to osteoarthritis: the importance of age, obesity, and
other modifiable risk factors. Am J Med 2003;114:93–8.
*[42] Zhang W, Doherty M, Leeb BF, et al. EULAR evidence based recommendations for the management of hand osteoarthritis:
report of a Task Force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics
(ESCISIT). Ann Rheum Dis 2007;66:377–88.
*[43] Rannou F, Dimet J, Boutron I, et al. Splint for base-of-thumb osteoarthritis: a randomized trial. Ann Intern Med 2009;150:
661–9.