— Panel leader talks exercise, supplements, “mind-body interventions
by Scott Harris, Contributing Writer, MedPage Today March 24, 2020

This article is a collaboration between MedPage Today and:

Sharon Kolasinski, MD, is a rheumatologist with Penn Medicine and the University of Pennsylvania School of Medicine. She recently led the panel that developed the 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. The guideline has been published in Arthritis & Rheumatology.

The document was a collaboration between the American College of Rheumatology and the Arthritis Foundation, updating the 2012 version of the guideline. Many of the nearly 50 recommendations are new or revised: the updated guideline generally emphasizes a more flexible, comprehensive approach to osteoarthritis (OA) care.

Kolasinski recently discussed the guideline with MedPage Today.

Exercise is a critical and evolving area in managing OA, and it’s a big point of emphasis in the new guideline. How would you summarize what you found?

Kolasinski: One of the important takeaways to me is that the type of exercise a patient might do, can, for several reasons, vary over time. Flexibility about exercise is important for both patients and clinicians.

Presenting and discussing choices — like aquatic exercise, walking, exercise bikes, chair yoga, tai chi, and so on — can let patients know that their preferences matter. One of the most important aspects of integrating exercise into the management plan for someone with OA is that many different kinds of exercise can be effective. In other words, if a person with OA dislikes being in a pool, they do not have to take up swimming!

You have several “mind-body” recommendations in the guideline, including tai chi, acupuncture, and yoga. Do you believe rheumatologists and OA patients should consider these sorts of options more strongly?

Kolasinski: Absolutely. Tai chi provides another option that patients or clinicians may not have thought of as being helpful for OA, and the guideline helps to highlight this information.

We also made conditional recommendations for yoga and acupuncture, but at the same time conditionally recommended against fish oil and vitamin D. For all their popularity, particularly as supplements, studies to date are scant and have not clearly demonstrated their effectiveness.

There is controversy around some OA therapies, including glucosamine and chondroitin and intra-articular hyaluronic acid injections. What was determined there?

Kolasinski: It has become increasingly obvious that the effect of glucosamine and chondroitin is close to placebo. While these supplements have been incredibly popular around the world for decades, their effectiveness is minimal when the most well-designed trials are examined. That is why we chose to strongly recommend against their use in this population.

Some clinicians may be surprised by the conditional recommendation we made against hyaluronic acid injections. This was previously conditionally recommended for use in knee OA. However, the best evidence suggests hyaluronic acid injections are equivalent to saline injections in efficacy.

These injections have been popular, in part, because they provide a therapeutic option for patients who stopped responding to first-line interventions and are wary of opioids or surgery. This, unfortunately, remains a common clinical scenario and requires discussion and shared decision making between patients and clinicians.

Is there anything else you would like rheumatologists to know regarding the recommendations or their incorporation into practice?

Kolasinski: OA is the most common form of arthritis and most rheumatologists see patients with OA every day, regardless of the scope of their practice. But OA management is also important because people with rheumatoid arthritis, lupus, and other conditions also get OA. We need to appreciate the impact of OA on a person’s life and work, and recognize there are many effective options we can offer our patients to meet the challenge of dealing with OA.

You can read expert commentary about the clinical implications of the new guideline here and an abstract of the guideline here.