MOVE consensus shows OA exercise recommendations still based largely on

The 18 arthritis experts who constituted the MOVE consensus group agreed on 10 propositions about exercise recommendations for patients with osteoarthritis (OA) of the knee or hip, sought evidence to support or refute them, and wound up with 9 recommendations, most of which are based mainly on the opinions of other experts. The report, published in the January 2005 issue of Rheumatology, points to serious gaps in the literature, especially with regard to exercise and hip OA, to contraindications, and to predictors of response, according to lead author Dr Edward Roddy (Nottingham City Hospital, Nottingham UK).

These recommendations tackle many unresolved questions and show us the limited evidence for some of our daily advice,” Dr Johannes WJ Bijlsma (University Medical Center Utrecht, the Netherlands) tells rheumawire. “They show the large gap between evidence and opinion,” says Bijlsma, who coauthored an editorial accompanying the MOVE recommendations.The MOVE consensus highlights gapsRoddy et al used the Delphi method, which involves several cycles of repeated discussion and judgment calls by a group of experts, to settle on 10 testable propositions about exercise and lower-limb OA. These were:1) Both strengthening and aerobic exercise can reduce pain and improve function and health status in patients with knee or hip OA. 2) There are few contraindications to strengthening or aerobic exercise in hip or knee OA. 3) Both aerobic and strengthening exercises are an essential aspect of management for every patient with knee or hip OA. 4) Exercise therapy for hip or knee OA should be individualized. 5) Exercise programs should include advice and education to promote increased physical activity. 6) Group exercise and home exercise are equally effective, so patient preference should be considered. 7) Adherence is the main predictor of long-term outcome from exercise in hip or knee OA. 8) Strategies to improve adherence should be adopted, such as long-term monitoring. 9) The effectiveness of exercise is independent of the severity of radiographic damage. 10) Improvements in muscle strength and proprioception from exercise may reduce OA progression.The reviewers then examined the literature for data pertinent to each proposition. This led to the dropping of recommendation 9, since there was no direct evidence in support and 1 randomized controlled trial showing that patients with less severe loss of medial joint space gained significantly more from exercise. The group included representatives from the British Geriatric Society, British Society for Rheumatology, Chartered Society of Physiotherapy, and Primary Care Rheumatology Society.The first round of the Delphi process produced 123 propositions, but this was reduced to 10 after 4 rounds. The propositions all relate to aerobic and strengthening exercise, group vs home exercise, adherence, contraindications, and predictors of response. The literature search identified 910 articles; 57 intervention trials relating to knee OA, 9 to hip OA, and 73 to adherence. The researchers then weighed the methodological quality of each publication. Moreover, outcome data were abstracted and effect sizes calculated. The evidence for each recommendation was assessed and expert consensus highlighted by the allocation of strength of evidence and strength of recommendation.The group found that there are few contraindications to the prescription of strengthening or aerobic exercise in patients with hip or knee OA. However, the authors point out that there is no direct evidence concerning contraindications to exercise among OA patients, except for 11 studies that suggest a history of cardiac disease as an exclusion criterion in OA patients.The recommendations suggest that exercise for hip and knee OA should be individualized and patient-centered, taking into account factors such as age, comorbidity, and overall mobility. The authors point out that this proposition has not been assessed by clinical trials, which tend to focus on homogenous populations who receive a standardized intervention. They accept it based on “clear face validity.” Exercise programs should also include advice and education to promote a positive lifestyle change with an increase in physical activity, although this has not been looked at specifically in OA, they write.Adherence issues contemplatedGroup exercise and home exercise can be equally effective, Roddy et al write. As a result, patient preference should be considered.Strategies to improve and maintain adherence should be adopted, including long-term monitoring, review, and inclusion of partner and/or family in the exercise program, according to 1 of the recommendations. But again, the authors note that this is extrapolated from the general exercise literature and that few studies of lower-limb OA have addressed this issue. (Source: Rheumatology: Rheumawire: January 2005.)