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ACP develops three different types of clinical recommendations:

Clinical Practice Guidelines, Clinical Guidance Statements, and Best Practice Advice. ACP's goal is to provide clinicians with recommendations based on the best available evidence; to inform clinicians of when there is no evidence; and finally, to help clinicians deliver the best health care possible.

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Our goal is to help clinicians deliver the best health care possible.

The American College of Physicians (ACP) established its evidence-based clinical practice guidelines program in 1981. The ACP clinical practice guidelines and guidance statements follow a multistep development process that includes a systematic review of the evidence, deliberation of the evidence by the committee, summary recommendations, and evidence and recommendation grading.

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A 59-year-old man is evaluated during a follow-up visit for knee osteoarthritis. He stands for most of the day at work, and his knees are very painful by the afternoon. He reports no joint locking, recent trauma, or twisting injury. Acetaminophen has not improved his symptoms, and as-needed ibuprofen and naproxen cause significant heartburn. History is notable for prediabetes and hypertension treated with combination lisinopril-hydrochlorothiazide.

On physical examination, blood pressure is 144/90 mm Hg, and pulse rate is 76/min. BMI is 30. The right knee is slightly warm with crepitus and mild anterior joint line tenderness. The left knee has crepitus without warmth. There is no laxity, and provocative compression does not produce pain or catching in either knee.

A topical NSAID is prescribed for use on both knees.


Which of the following is the most appropriate additional therapy for this patient?

Intensive exercise plus diet to achieve a 10% weight loss is appropriate for this patient who has knee osteoarthritis and is obese. The 18-month Intensive Diet and Exercise for Arthritis (IDEA) trial demonstrated that an exercise and diet plan to achieve a 10% weight loss in sedentary obese or overweight patients with knee osteoarthritis (age >55 years) improved compressive force, serum interleukin-6 levels, the intensity of pain, and quality of life more than exercise or diet alone. Patients in the exercise-only group lost less weight (1.8 kg [4.0 lb]) than patients in the diet-only group (8.9 kg [19.6 lb]) or the diet plus exercise group (10.6 kg [23.4 lb]). Diet consisted of 800 to 1000 kcal/d, and exercise was 3 hours per week (1 hour x 3 days). Of the participants, 88% completed the study. Although long-term outcomes of diet and weight loss programs are uncertain, this easily understood trial is worth discussing with patients.

Surgical interventions for treatment of osteoarthritis are reserved for patients who have had an inadequate response to pharmacologic and nonpharmacologic treatment. Additionally, arthroscopy with joint lavage has not been shown to be superior to closed joint lavage; the latter may be helpful in selected patients with refractory osteoarthritis. It is therefore an inappropriate treatment for this patient.

The effectiveness of transcutaneous electrical nerve stimulation (TENS) for osteoarthritis has not been established; several small clinical trials have produced conflicting results.

Ultrasound therapy of the joints is intended to heat the deeper connective tissues and possibly increase their extensibility with improvement in joint range of motion and decreased pain associated with degenerative change. However, clinical trials have not demonstrated a benefit, and ultrasound therapy is not recommended as a treatment for osteoarthritis.

Key Point

  • The Intensive Diet and Exercise for Arthritis (IDEA) trial demonstrated that exercise and diet to achieve a 10% weight loss in older, overweight/obese patients with knee osteoarthritis improved measures of pain, inflammatory markers, and quality of life better than exercise or diet alone.
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