A SYSTEMATIC REVIEW OF CLINICAL PRACTICE GUIDELINES FOR PHYSICAL THERAPY MANAGEMENT OF OSTEOARTHRITIS OF THE HIP OR KNEE

Purpose (the aim of the study): Clinical practice guidelines (CPGs) consist of systematically developed action statements that guide healthcare providers to deliver high quality care to their patients. This systematic review located, appraised, and synthesized CPGs that outline physical therapy (PT) management of osteoarthritis of hip (HOA) or knee (KOA).
Methods: A medical librarian conducted literature search for PubMed, CINAHL, Cochrane Register for Systematic Reviews, SPORTDiscus, and PsycINFO using pre-defined keywords. Once duplicate citations were removed, two reviewers independently screened remaining citations initially by reviewing their titles and abstract and subsequently by reading the full text. Studies that outlined CPGs for PT management of HOA or KOA were considered for this review, whereas those outlining multidisciplinary team approach or orthopedic management of HOA or KOA were excluded. Two reviewers independently appraised the methodological quality of the studies included in the review using the 23-item Appraisal of Guidelines for Research and Evaluation (AGREE) II tool. This tool examines quality of CPGs across six domains of Scope and Purpose, Stakeholder Involvement, Rigor of Development, Clarity of Presentation, Applicability, Editorial Independence. Quality appraisal scores of 70% or greater for domains 3 (rigor), 5 (applicability) and 6 (editorial independence) were considered as indicative of high-quality CPG. Those with scores between 50% and 70% in any one of these domains were considered moderate quality CPG. Agreement between the reviewers in appraising the quality was examined using intraclass correlation coefficient (ICC), where ICC values of >75% and >90% indicated good and excellent agreement respectively. Lastly, the applicability of each CPG to inform PT practice was examined using Domain 1 of the Recommendation Excellence (AGREE-REX) instrument. The common recommendations across the CPGs were identified.
Results: Of the 725 unique citations captured in literature search, 7 CPG were included in the review. The agreement between the reviewers in completing the appraisals was good (ICC of 0.86; 95% confidence interval of 0.78-0.93). The CPG developed by the Royal Dutch Society for Physical Therapy for HOA and KOA was rated as high quality, whereas the CPG developed by the Academy of Orthopedic Physical Therapy of the American Physical Therapy Association for HOA was rated as moderate quality. The recommendations for exercise interventions (N=7) and patient education (N=5) were the most common across these CPGs for the interventions in people with HOA or KOA. Other less common recommendations included bracing or orthoses (N=3), manual therapy (N=2) and modalities (N=2). For examination, two CPGs discussed using physical tests to diagnose HOA or KOA, whereas all of them (N=7) recommended use of self-reported or physical performance measures to capture impairments. All CPGs (N=7) recommended assessment of joint movement for the affected joint, whereas some recommended assessment of dynamic balance (N=3) and overall endurance (N=3) in people with HOA or KOA.
Conclusions: The most common recommendations of education and exercise interventions found across the CPGs are consistent with the recommendations by the Osteoarthritis Research Society International (OARSI) for non-surgical management of HOA or KOA. Only two CPGs provided recommendations for diagnostic physical tests for HOA or KOA, which is in contrast with purported primary care provider role for PT in many countries. Assessment of joint movement and measures for pain and function were the most common examination approaches recommended by the CPGs, which aligns with OARSI recommendations for capturing these domains. None of the CPGs provided recommendations for using physical functions tests such as 40-meter fast paced walking speed, Timed Up and Go, Step test, or 30-seconds Chair stand test, all of which are highly recommended by the OARSI. The recommendations of these CPGs should be viewed in context of moderate to poor methodological quality for all except one CPG.