Ottawa Panel Evidence-Based Clinical Practice Guidelines for the Management of Osteoarthritis in Adults Who Are Obese or Overweight

Lucie Brosseau, George A. Wells, Peter Tugwell, Mary Egan, Claire-Jehanne Dubouloz, Lynn Casimiro, Nicoleta Bugnariu, Vivian A. Welch, Gino De Angelis, Lilliane Francoeur, Sarah Milne, Laurianne Loew, Jessica McEwan, Steven P. Messier, Eric Doucet, Glen P. Kenny, Denis Prud’homme, Sydney Lineker, Mary Bell, Stéphane Poitras, Jing Xian Li, Hillel M. Finestone, Lucie Laferrière, Angela Haines-Wangda, Marion Russell-Doreleyers, Kim Lambert, Alison D. Marshall, Margot Cartizzone and Adam Teav
Phys Ther. 2011 Jun;91(6):843-61. Epub 2011 Apr 14.

The incidence of osteoarthritis (OA) continues to increase. This may be a result of the aging baby-boomer generation or may also be attributed to the general increase in body mass of the population (For some great data on the obesity epidemic in the United States, I highly recommend visiting the Center for Disease Control and Prevention’s Website – Increases in body mass are disconcerting, particularly because joint compression force is 4 times greater than body mass. This means for every pound of weight gained, there is a 4 pound increase in joint compression force during each step. In addition, increased body mass may be the most modifiable risk factor for developing OA. The large majority of patients who develop OA are overweight or obese and report reduced physical activity because of pain. The reduced activity leads to weight gain and increased pain, and the cycle continues. Therefore, rehabilitation interventions aimed at reducing pain and impairments in patients with OA must also consider body mass, physical inactivity and weakness. The authors of this review paper created evidence-based guidelines for the use of physical activity and diet modifications for the management of patients with OA who were also obese or overweight. Their findings strongly supported the use of physical activity and diet programs to primarily reduce pain and secondarily improve functional status. When they evaluated programs that used diet alone, physical activity alone or physical activity and diet together, the programs that included diet and physical activity components were the optimal approach.

Like many other evidence-based guidelines, the authors graded the existing evidence on a letter grading scale (A, B, C, C+, D, D+ or D-). Outcome variables were given an A if they were part of a randomized controlled trial and were found to be clinically and statistically significant. Psychological well-being (1 study), functional status (3 studies), strength (2 studies), torque/strength (1 study), mobility (3 studies), walking endurance (1 study) self-efficacy during stair climbing (1 study), self-efficacy in walking (1 study), pain relief (3 studies) and body composition (2 studies) were given A grades. Conversely, variables were given the worse grade (D-) if the outcomes favored the control group. In only one study, psychological well-being was given this grade. The authors do a great job devising these evidence-based guidelines. The results from this study support what many may consider common sense (diet and exercise prescriptions should be used for people with OA), but this is not typically the standard of care for patients who are overweight or obese and have knee OA. Despite the positive benefits of diet and physical activity programs, pain reduction, which received the most Grade A scores, was mostly beneficial only in the short term. I wonder if this reflects the fact that patients “fall off the wagon” after the end of the study and resume a their previous diet and more sedentary life, or whether it represents the fact that OA is a progressively degenerative disease, even if some risk factors (activity level and body weight) are reduced. I don’t think that we will ever eliminate the need for total joint replacement with physical interventions, but programs that include physical activity and diet modification prior joint replacement may have an important impact of recovery after joint replacement as well. Reducing body mass, improving cardiac function and improving pre-operative strength may expedite the recovery after surgery, particularly because we know that after knee replacement, patients continue to gain weight. I agree with this panel’s final conclusion: “Reducing weight prior to the implementation of weight-bearing exercise to maintain joint integrity and to avoid joint disease and dysfunction. The Ottawa Panel also recommends the inclusion of diet or physical activity programs in the management of OA among individuals who are obese or overweight.”

Written by: Joseph Zeni, Jr
Reviewed by: Stephen Thomas