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// 12 steps, // 12 traditions, // tools of recovery, // oa groups, // intergroup, // region 10, // oa world service office.

The Twelve Steps are the heart of the OA recovery program. They offer a new way of life that enables the compulsive overeater to live without the need for excess food. The ideas expressed in the Twelve Steps, which originated in Alcoholics Anonymous, reflect practical experience and application of spiritual insights recorded by thinkers throughout the ages. Their greatest importance lies in the fact that they work! They enable compulsive overeaters and millions of other Twelve-Steppers to lead happy, productive lives. They represent the foundation upon which OA is built.

The Twelve Steps of Overeaters Anonymous

We admitted we were powerless over food – that our lives had become unmanageable.

Came to believe that a Power greater than ourselves could restore us to sanity.

Made a decision to turn our will and our lives over to the care of God as we understood Him.

Made a searching and fearless moral inventory of ourselves.

Admitted to God, to ourselves and to another human being the exact nature of our wrongs.

Were entirely ready to have God remove all these defects of character.

Humbly asked Him to remove our shortcomings.

Made a list of all persons we had harmed and became willing to make amends to them all.

Made direct amends to such people wherever possible, except when to do so would injure them or others.

Continued to take personal inventory and when we were wrong, promptly admitted it.

Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.

Having had a spiritual awakening as the result of these Steps, we tried to carry this message to compulsive overeaters and to practice these principles in all our affairs.

Permission to use the Twelve Steps of Alcoholics Anonymous for adaptation granted by AA World Services, Inc.

12 Traditions

The Twelve Traditions are the means by which OA remains unified in a common cause. These Twelve Traditions are to the groups what the Twelve Steps are to the individual. They are suggested principles to ensure the survival and growth of the many groups that compose Overeaters Anonymous.

Like the Twelve Steps, the Twelve Traditions have their origins in Alcoholics Anonymous. These Traditions describe attitudes which those early members believed were important to group survival.

The Twelve Traditions of Overeaters Anonymous

Our common welfare should come first; personal recovery depends upon OA unity

For our group purpose there is but one ultimate authority – a loving God as He may express Himself in our group conscience. Our leaders are but trusted servants; they do not govern.

The only requirement for OA membership is a desire to stop eating compulsively.

Each group should be autonomous except in matters affecting other groups or OA as a whole.

Each group has but one primary purpose – to carry its message to the compulsive overeater who still suffers.

An OA group ought never endorse, finance or lend the OA name to any related facility or outside enterprise, lest problems of money, property and prestige divert us from our primary purpose.

Every OA group ought to be fully self-supporting, declining outside contributions.

Overeaters Anonymous should remain forever non-professional, but our service centers may employ special workers.

OA, as such, ought never be organised; but we may create service boards or committees directly responsible to those they serve.

Overeaters Anonymous has no opinion on outside issues; hence the OA name ought never be drawn into public controversy.

Our public relations policy is based on attraction rather than promotion; we need always maintain personal anonymity at the level of press, radio, films, television and other public media of communication.

Anonymity is the spiritual foundation of all these Traditions, ever reminding us to place principles before personalities.

Permission to use the Twelve Traditions of Alcoholics Anonymous for adaptation granted by AA World Services, Inc.

Tools of recovery

In Overeaters Anonymous (OA), abstinence is ‘the action of refraining from compulsive eating and compulsive food behaviours.’ Many of us have found that we cannot abstain from compulsive eating unless we use some or all of OA’s nine tools of recovery.

A Plan of Eating

As a tool, a plan of eating helps us to abstain from eating compulsively. Having a personal plan of eating guides us in our dietary decisions, as well as defines what, when, how, where and why we eat. It is our experience that sharing this plan with a sponsor or another OA member is important.

There are no specific requirements for a plan of eating; OA does not endorse or recommend any specific plan of eating, nor does it exclude the personal use of one. (See the pamphlets Dignity of Choice and A Plan of Eating for more information). For specific dietary or nutritional guidance, OA suggests consulting a qualified health care professional, such as a physician or dietician. Each of us develops a personal plan of eating based on an honest appraisal of his or her own past experience; we also have come to identify our current individual needs, as well as those things which we should avoid.

Although individual plans of eating are as varied as our members, most OA members agree that some plan – no matter how flexible or structured – is necessary.

This tool helps us deal with the physical aspects of our disease and helps us achieve physical recovery. From this vantage point, we can more effectively follow OA’s Twelve-Step program of recovery and move beyond the food to a happier, healthier and more spiritual living experience

Sponsorship

Sponsors are OA members who are living the Twelve Steps and Twelve Traditions to the best of their ability. They are willing to share their recovery with other members of the Fellowship and are committed to abstinence.

We ask a sponsor to help us through our program of recovery on all three levels: physical, emotional and spiritual. By working with other members of OA and sharing their experience, strength and hope, sponsors continually renew and reaffirm their own recovery. Sponsors share their program up to the level of their own experience.

Ours is a program of attraction: find a sponsor who has what you want, and ask that person how he or she is achieving it. A member may work with more than one sponsor and may change sponsors at will.

Meetings are gatherings of two or more compulsive overeaters who come together to share their personal experience, and the strength and hope OA has given them. Though there are many types of meetings, fellowship with other compulsive overeaters is the basis of them all. Meetings give us an opportunity to identify and confirm our common problem and to share the gifts we receive through this program

The telephone helps us share one-to-one and avoid the isolation which is so common among us. Many members call other OA members and their own sponsors daily. As a part of the surrender process, it is a tool with which we learn to reach out, ask for help and extend help to others. The telephone also provides an immediate outlet for those hard-to-handle highs and lows we may experience.

In addition to writing our inventories and the list of people we have harmed, most of us have found that writing has been an indispensable tool for working the Steps. Further, putting our thoughts and feelings down on paper, or describing a troubling incident, helps us to better understand our actions and reactions in a way that is often not revealed to us by simply thinking or talking about them. In the past, compulsive eating was our most common reaction to life. When we put our difficulties down on paper, it becomes easier to see situations more clearly and perhaps better discern any necessary action.

We study and read OA-approved pamphlets; OA-approved books, such as Overeaters Anonymous, Second Edition, The Twelve Steps and Twelve Traditions of Overeaters Anonymous and For Today; and we read Lifeline, our monthly magazine on recovery. We also study the book Alcoholics Anonymous, referred to as the ‘Big Book,’ to understand and reinforce our program. Many OA members find that when read daily, the literature further reinforces how to live the Twelve Steps. Our OA literature and the AA ‘Big Book’ are ever-available tools which provide insight into our problem of eating compulsively, strength to deal with it, and the very real hope that there is a solution for us.

Anonymity, referred to in Traditions Eleven and Twelve, is a tool that guarantees that we will place principles before personalities. The protection anonymity provides offers each of us freedom of expression and safeguards us from gossip. Anonymity assures us that only we, as individual OA members, have the right to make our membership known within our community. Anonymity at the level of press, radio, films and television means that we never allow our faces or last names to be used once we identify ourselves as OA members. This protects both the individual and the Fellowship.

Within the Fellowship, anonymity means that whatever we share with another OA member will be held in respect and confidence. What we hear at meetings should remain there. However, anonymity must not be used to limit our effectiveness within the Fellowship. It is not a break of anonymity to use our full names within our group or OA service bodies. Also, it is not a break of anonymity to enlist Twelfth-Step help for group members in trouble, provided we refrain from discussing specific personal information.

Another aspect of anonymity is that we are all equal in the Fellowship, whether we are newcomers or seasoned long-timers. And our outside status makes no difference in OA; we have no stars or VIPs. We come together simply as compulsive overeaters.

In keeping with OA’s tradition of anonymity no OA members are pictured on this site.

Carrying the message to the compulsive overeater who still suffers is the basic purpose of our Fellowship; therefore, it is the most fundamental form of service. Any form of service-no matter how small-which helps reach a fellow sufferer adds to the quality of our own recovery. Getting to meetings, putting away chairs, putting out literature, talking to newcomers, doing whatever needs to be done in a group or for OA as a whole are ways in which we give back what we have so generously been given. We are encouraged to do what we can when we can. ‘A life of sane and happy usefulness’ is what we are promised as the result of working the Twelve Steps. Service helps to fulfill that promise.

Action Plan

The delegates at OA’s World Service Business Conference 2010 adopted a motion that created a ninth tool called “Action Plan.” The Conference Literature Committee is working on a definition that will be presented for adoption to WSBC 2011. Until that time, OA members are free to interpret “Action Plan” as they wish.

As OA’s responsibility pledge states: ‘Always to extend the hand and heart of OA to all who share my compulsion; for this I am responsible.’

Tools of Recovery © 1996 Overeaters Anonymous, Inc. All rights reserved

A group consists of two or more people. Each group practices the Twelve Steps and Twelve Traditions of OA. No member of a group is required to practice any actions to remain an OA member or to have a voice at a meeting. Any new groups who wish to carry the OA name must register the meeting online at the World Service Office website.

Two or more groups can form an intergroup (IG). The intergroup provides services to existing groups within its geographical area and spreads the OA message of recovery to those who still suffer. Melbourne Intergroup, including Regional Victoria and Tasmania meets on the second Saturday of the month (except January) from 8.00am to 10.00am virtually via Zoom.

OA has 10 regions worldwide that maintain direct communication with groups and intergroups. Regions sponsor local conventions and assemblies. Regional assemblies also nominate trustee candidates to serve on OA’s Board of Trustees (BOT), whose members are elected at the World Service Business Conference (WSBC). Australia is considered to be in Region 10, along with New Zealand, Japan, China, South Korea, South East Asia, and the Pacific Islands.

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Overeaters Anonymous in Australia, New Zealand, Far East, South East Asia and the Pacific

Overeaters Anonymous Region Ten

Overeaters anonymous is a fellowship of individuals recovering from compulsive overeating.

Overeaters Anonymous is a fellowship of men and women who, through shared experience, strength and hope, are recovering from compulsive overeating. We welcome everyone who wants to stop eating compulsively.

There are no dues or fees for members; we are self-supporting through our own contributions, neither soliciting nor accepting outside donations. OA is not affiliated with any public or private organization, political movement, ideology or religious doctrine; we take no position on outside issues.

Our primary purpose is to abstain from compulsive eating and compulsive food behaviours and to carry the message of recovery through the Twelve Steps of OA to those who still suffer

What is Region Ten?

Region Ten consists of Overeaters Anonymous meetings and intergroups from the following geographical locations: Australia, New Zealand, Japan, China, South Korea, South East Asia, and the Pacific Islands.

Region Ten is one of the ten geographical regions – each organised to serve communication between groups, intergroups and service boards within its area. The Virtual Region supports virtual meetings and virtual service bodies of OA worldwide.

Where does Region Ten Fit in? (PDF, 1.8MB)

What is the Purpose of Region Ten?

Region Ten′s purpose is to practice and safe guard the Twelve Steps, Twelve Traditions, and Twelve Concepts of Service of Overeaters Anonymous.

• Maintain direct communication with and support groups, intergroups and service boards
• Sponsor an annual convention & assembly
• Support Officers’ expenses
• Offer support and suggestions to intergroups and unaffiliated groups with difficult situations involving the Twelve Traditions.

Visit the oa.org website for more information about Overeaters Anonymous

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When I attended a recent Region Nine assembly, the trustee asked us to write about how OA literature has been useful on our OA journey. “Write a note to a fictitious OA member explaining how you found OA, which piece of OA-approved literature helped you work all Twelve Steps of OA , what piece of OA literature is your favorite and why, and which literature you feel is useful in carrying the message of OA.” Here goes . . .

I came into OA when I was in my twenties. A friend had given me a meetings list and said OA might help me. I put the list on my fridge. Six months later, after a blitz of bingeing and gaining weight, I went to my first meeting. I hated it and fled at the end. After another week of overeating, I went to a second, different meeting, where a woman with one year of abstinence came up to me and asked if I had a sponsor. When I said no, she said to call her at 6:10 the next morning. I have never binged since!

She had me purchase Alcoholics Anonymous and AA’s Twelve Steps and Twelve Traditions . Starting that day, I was given reading assignments from them both, and these two books continue to be my primary literature. That’s where my directions are, which I refer to on a daily basis and use for sponsoring. Other OA-approved literature supplements them but does not replace them, since the fundamental directions for how to work the Twelve Steps are in these two books.

I’ve had a lifetime subscription to Lifeline , which I’ve read monthly and written for regularly. It’s a good size. It fits easily in a pocket or bag and is good to have on hand to give to someone when giving Twelfth Step Within service. I write my contact info on the cover.

I also like the coins. I keep them in my coin purse and give them to newcomers. My abstinence date is engraved on one coin to remind me of how precious my abstinence is and how I don’t want to change it.

I also use Dignity of Choice when starting with a new sponsee to help them choose a safe food plan. Dignity of Choice  gives several options, including my first food plan, which has remained basically the same for thirty-seven years.

I love For Today , a nugget of recovery whenever I want it!

My favorite book has been Overeaters Anonymous, Third Edition , which offers great stories of genuine recovery from compulsive overeating. I’ve listened to the CDs at least ten times. They are my traveling companions in my car and always a source of inspiration and assurance that it is possible for me to be abstinent one more day.

— Anonymous

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Overeaters Anonymous is a Fellowship of individuals who, through shared experience, strength, and hope, are recovering from compulsive overeating. We welcome everyone who wants to stop eating compulsively. There are no dues or fees for members; we are self-supporting through our own contributions, neither soliciting nor accepting outside donations. OA is not affiliated with any public or private organization, political movement, ideology, or religious doctrine; we take no position on outside issues. Our primary purpose is to abstain from compulsive eating and compulsive food behaviors and to carry the message of recovery through the Twelve Steps of OA to those who still suffer.

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It is helpful to carefully review the regularly updated contents of this website and other OA websites , and to read through the information found under the Get Started menu tab.

Additionally, we invite you to familiarize yourself with some of our OA literature.

Expressly for the Family & Friends of compulsive eaters:

• To the Family of the Compulsive Eater: Family Involvement Is an Individual Choice…
• To Parents and Concerned Adults

This is a list of OA-approved literature expressly for the compulsive eater and for those interested in helping them (for the most up-to-date list, please visit the OA online bookstore ):

• Where Do I Start?: Everything a Newcomer Needs to Know
• To the Newcomer: You’re not Alone Anymore…
• To the Young Person
• Pocket Reference for OA Members
• Anonymity: The Meaning and Application of Traditions Eleven and Twelve
• Overeaters Anonymous, Third Edition
• The Twelve-Step Workbook of Overeaters Anonymous
• For Today Workbook
• Voices of Recovery Workbook
• Just For Today Wallet Card
• Alcoholics Anonymous, Fourth Edition – our basic textbook for Twelve Step recovery
• Abstinence, Second Edition
• Beyond Our Wildest Dreams: A History of Overeaters Anonymous as Seen by the Founder
• Body Image, Relationships, and Sexuality: Personal Journeys to Recovery in Overeaters Anonymous
• A New Beginning: Stories of Recovery from Relapse
• Seeking the Spiritual Path: A Collection from Lifeline
• Taste of Lifeline
• Lifeline Sampler
• A Common Solution: Diversity and Recovery
• Black OA Members Share Their Experience, Strength, and Hope
• To the Man Who Wants to Stop Compulsive Overeating, Welcome
• Strong Abstinence Checklist and Writing Exercises Wallet Card
• Twelve Stepping a Problem Wallet Card
• Carrying the Message Wallet Card

By attending in-person meetings wherever available, you and your loved one may receive various informative OA pamphlets as well as the meeting guide at no cost.

During this pandemic, given the vast majority of meetings have moved online, we are encouraging those seeking literature to visit the online bookstore. To do so, please click here!

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Sweet potatoes to faster passports: things you might have missed among 7,200 pages of budget papers

Not every measure makes the headlines, here we look at some of them – from a French re-connection to milk mix-ups in this year’s budget

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The 2024 federal budget was delivered to the nation’s journalists in the form of 7,265 pages, including four main papers, 38 media releases, 20 portfolio budget statements and 12 portfolio budget supplements.

It is a dense, arduous reading experience – and it’s easy to miss some things.

You know about the budget’s tax cut promises, energy bill relief and new housing investments. But did you know about changes to the sweet potato market? Or the good news for procrastinators in need of last-minute passport renewal? Or Australia’s soft-power diplomatic relationship with France? I didn’t think so.

Here are 11 really specific things that snuck into this year’s budget:

1. Hyperlocal improvements to data on a train line

If you happen to catch the Hornsby to Wyong train in northern Sydney, it’s your lucky day! Because funding is going to improving your mobile and internet connectivity – weirdly specific but, I’m told by my dear colleagues, necessary as that line has been “stuffed” and “a black spot for years”.

2. FNQ insurance finder

Homeowners in far north Queensland have been hit by a series of cyclones and floods but have also caught the benevolent eye of the federal treasurer and fellow Queenslander, Jim Chalmers, because $1m is going to the maintenance of a home insurance comparison website to help with rising insurance premiums .

3. Orange is the new snack

Cheaper sweet potatoes may be on the menu as the levy rate (usually applied across an industry for marketing or development) is being decreased from 1.5% to 0.5% from 1 July this year, at the request of Australian Sweetpotato Growers Inc.

4. Museum mania

The Australian Orphanage Museum will get $1m over three years. Qtopia (the heritage-listed Darlinghurst police station that is now home to Australia’s first queer history museum) will also be supported by $1.5m this year.

5. Sheep to shore

$107m is being spent over five years to support the phasing out of live sheep exports by sea, preparing businesses and communities for the end of the trade.

6. Pitch perfect

Income tax exemptions will be provided for World Rugby, for income made from the 2027 men’s World Cup and the 2029 women’s World Cup.

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7. Consultant non grata

The government is keen to further slash the number of consultants engaged by the public service and bring skills back in-house. The reduced spending on consultants, contractors and labour hire is estimated to save $1bn over four years from 2024, on top of $4bn saved from 2022.

8. Cow or not cow?

There’s $1.5m over two years for “accurate and clear” labelling of plant-based protein products. Just in case anyone was in danger of accidentally buying almond milk.

9. Bon amis! Australia and France patch up the friendship

It seems Anthony Albanese and Emmanuel Macron have made up after a soured submarine deal, because the “Australia-France Roadmap” is costing $20.7m to roll out “a new agenda for bilateral cooperation” over five years from 2023 (and $3.9m a year ongoing). This includes introducing a few specialist centres, award programs and “enhanced Australian cultural promotion in France”.

10. Drop some cash to get your passport in a dash

A new fast-track processing of passports will commence on 1 July this year, which will see applications processed in five business days for a $100 fee. So if you have booked a trip to Bali and forgotten to renew your passport, you might be in luck.

11. APS gets an AI boost

The Australian Public Service will be given $2.2m for AI projects “including AI integration” and enhancing the quality of data that informs policy analysis. But given elsewhere in the budget the government has flagged changing the law to allow the ATO to stop chasing historical tax debts , and given the robodebt disaster , it might be a good idea to put a human decision-maker in there too.

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• Irene A Pitsillidou 20 ,
• Margaret P Rayman 21 ,
• Anne Therese Tveter 1 ,
• http://orcid.org/0000-0003-4783-8663 Johanna E Vriezekolk 22 ,
• Dieter Wiek 23 ,
• Gustavo Zanoli 24 ,
• http://orcid.org/0000-0001-8602-342X Nina Østerås 1
• 1 Center for treatment of Rheumatic and Musculoskeletal Diseases (REMEDY) , Diakonhjemmet Hospital , Oslo , Norway
• 2 Department of Orthopaedics, Rehabilitation and Physical Therapy , Leiden University Medical Center (LUMC) , Leiden , Netherlands
• 3 University of Genoa Department of Neuroscience Ophthalmological Rehabilitation Genetics and Mother and Child Health , Genova , Italy
• 4 Rehabilitation Research Department , Vrije Universiteit Brussel , Brussel , Belgium
• 5 UMHAT “St. Iv. Rilski” Clinic of Rheumatology, Medical University Sofia , Sofia , Bulgaria
• 6 Leeds Institute of Rheumatic and Musculoskeletal Medicine , University of Leeds and NIHR Leeds Biomechanical Reserch Centre , Leeds , UK
• 7 Comprehensive Health Research Center (CHRC) , Universidade Nova de Lisboa , Lisboa , Portugal
• 8 Department of Academic Rheumatology , University of Nottingham , Nottingham , UK
• 9 Research Institute for Primary Care and Health Sciences , Keele University School of Medicine , Keele , UK
• 10 School of Nursing and Midwifery , Keele University , Keele , UK
• 11 Clinic of Rheumatology, University Hospital St. Marina, First Department of Internal Medicine , Medical University Varna , Varna , Bulgaria
• 12 Positivamente Centro de Psicología , Madrid , Spain
• 13 School of Allied Health, Faculty of Education and Health Sciences and Health Research Institute , University of Limerick , Limerick , Ireland
• 14 Department of Rheumatology , Leiden University Medical Center (LUMC) , Leiden , The Netherlands
• 15 Department of Rheumatology , Zuyderland Medical Centre Heerlen , Heerlen , The Netherlands
• 16 Department of Clinical Sciences Lund, Orthopaedics , Lund University , Lund , Sweden
• 17 Centre for Evidence-Based Practice , Western Norway University of Applied Sciences , Bergen , Norway
• 18 Keele University School of Medicine , Keele , UK
• 19 Institute of Rheumatology, Department of Rheumatology , Charles University First Faculty of Medicine , Praha , Czech Republic
• 20 EULAR Patient Research Partner , Cyprus League Against Rheumatism , Nicosia , Cyprus
• 21 Department of Nutritional Sciences , University of Surrey Faculty of Health and Medical Sciences , Guildford , UK
• 22 Research & Innovation , Sint Maartenskliniek , Nijmegen , The Netherlands
• 23 EULAR Patient Research Partner , Deutsche Rheuma-Liga , Bonn , Germany
• 24 Orthopaedic Ward , Casa di Cura Santa Maria Maddalena , Novara , Italy
• Correspondence to Dr Tuva Moseng, Center for treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway; tuva.moseng{at}diakonsyk.no

Introduction Hip and knee osteoarthritis (OA) are increasingly common with a significant impact on individuals and society. Non-pharmacological treatments are considered essential to reduce pain and improve function and quality of life. EULAR recommendations for the non-pharmacological core management of hip and knee OA were published in 2013. Given the large number of subsequent studies, an update is needed.

Methods The Standardised Operating Procedures for EULAR recommendations were followed. A multidisciplinary Task Force with 25 members representing 14 European countries was established. The Task Force agreed on an updated search strategy of 11 research questions. The systematic literature review encompassed dates from 1 January 2012 to 27 May 2022. Retrieved evidence was discussed, updated recommendations were formulated, and research and educational agendas were developed.

Results The revised recommendations include two overarching principles and eight evidence-based recommendations including (1) an individualised, multicomponent management plan; (2) information, education and self-management; (3) exercise with adequate tailoring of dosage and progression; (4) mode of exercise delivery; (5) maintenance of healthy weight and weight loss; (6) footwear, walking aids and assistive devices; (7) work-related advice and (8) behaviour change techniques to improve lifestyle. The mean level of agreement on the recommendations ranged between 9.2 and 9.8 (0–10 scale, 10=total agreement). The research agenda highlighted areas related to these interventions including adherence, uptake and impact on work.

Conclusions The 2023 updated recommendations were formulated based on research evidence and expert opinion to guide the optimal management of hip and knee OA.

• Osteoarthritis, Knee
• Osteoarthritis
• Rehabilitation
• Physical Therapy Modalities
• Therapeutics

This is an open access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0). See: http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/ard-2023-225041

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Introduction

Osteoarthritis (OA) is the most common joint disease worldwide, 1 with an increasing global burden of disability and healthcare utilisation. 2 The number of people with OA globally rose by 28% from 2010 to 2019, affecting over 500 million people, and about 6%, worldwide. 3 Due to an ageing population, increasing obesity and sport-related joint injuries, the disease will become even more prevalent in the forthcoming years. 2 In 2019, OA was the 15th highest-ranked cause of years lived with disability (YLDs) worldwide and was responsible for 2% of the total global YLDs. 3 OA is regarded as a severe disease, and serious condition and people with OA commonly experience pain, stiffness and associated functional loss. 4 Optimal management of hip and knee OA has important implications for the individual and society through the potential for improving individual health, work participation and utilisation of healthcare services. However, most people with OA do not receive optimal management. 5 6 In order to reduce the evidence-to-practice gap and the future burden 7 of this disease, the healthcare services’, policy-makers’ and the population awareness of the importance and benefits of evidence-based management of OA must be improved.

EULAR recommendations, including priorities for implementation and future research, can play a role in increasing awareness and uptake of best evidence care. In 2013, an EULAR Task Force (TF) developed recommendations for the non-pharmacological core management of hip and knee OA. 8 Since then there remains no cure in sight for OA, and effective disease-modifying drugs are lacking. 2 Therefore, non-pharmacological approaches are still considered a core treatment for people with hip and knee OA, aiming to alleviate symptoms and improve or maintain physical function. Since the publication of the 2013 recommendations, a large number of studies on the effectiveness of core non-pharmacological treatment modalities and new methods for delivery and follow-up of such treatments have been published. An update of these recommendations would potentially have implications for the level of evidence (LoE) categories and could lead to revisions of the recommendations and formulation of new recommendations with important implications for OA management.

The main aim of this TF process was to update the 2013 evidence-based recommendations for non-pharmacological core management, provide additional details on effectiveness, safety and cost-effectiveness, and formulate research and educational agendas and priorities for implementation activities. The target groups for the updated recommendations are people with hip or knee OA, all healthcare providers involved in the delivery of non-pharmacological interventions in OA care, researchers in the field of OA, officials in healthcare governance and reimbursement agencies and policy-makers.

The Standardised Operating Procedures for EULAR-endorsed Recommendations 9 were used as a framework for this project. The structure of the manuscript is guided by the Appraisal of Guidelines, Research and Evaluation instrument. 10

To pursue the task of updating the 2013 recommendations, a multidisciplinary TF with in-depth knowledge of non-pharmacological OA care was established. The TF consisted of 25 members from 14 European countries and included 9 physiotherapists, 6 rheumatologists, 2 orthopaedic surgeons, 2 psychologists, 2 patient research partners, 1 occupational therapist, 1 nurse, 1 general practitioner and 1 nutrition expert. A steering group, including a convenor (NØ), a methodologist (TPMVV) and a research fellow (TM), managed the process.

During the first digital TF meeting, the rationale for the update of the recommendations was presented, and the definition of core non-pharmacological management was clarified. The TF agreed on 11 research questions based on the research propositions from the 2013 recommendation. For the subsequent systematic literature review (SLR), the research questions were organised according to the population, intervention, control and outcome (PICO) format with associated search terms ( online supplemental file 1 ). The new search terms added to the previous search strategy were related to the following topics: remote care, shared decision-making, psychological interventions/cognitive behaviour therapy (CBT)-based interventions and specific exercise modalities (eg, strength training and aerobic exercise). Due to the expected large body of published literature since the previous literature review from 2012, combined with the available resources and strict timeline for this update, it was decided that this SLR should primarily focus on evidence from systematic reviews (SRs) and meta-analyses of randomised controlled trials (RCTs) and secondarily on evidence from single RCTs. As this SLR was an update of a previously unpublished SLR, along with its pragmatic approach, it was decided that the details were best presented as online supplemental file 1 rather than a publication of its own.

Supplemental material

The SLR was conducted by the fellow and convenor in close collaboration with an experienced librarian (HIF) and with support from the methodologist. Three main literature searches were conducted in the databases Medline (Ovid), Embase (Ovid), AMED (Ovid), Cochrane Library (Cochrane TRIALS), CINAHL (Ebsco) and Epistemonikos (SR search only).

The primary literature search aimed at identifying relevant SRs of RCTs investigating the effectiveness of core non-pharmacological management strategies as specified in the PICOs. The search was conducted from 2012 (the end year of the previous search) until 17 February 2022 and later updated until 27 May 2022 ( online supplemental file 1 ). Based on the PICOs, two authors (TM and NØ) independently screened titles and abstracts. Potentially relevant studies were read and evaluated in full text. Studies were included if they were SRs, including a meta-analysis of two or more RCTs on people diagnosed with hip or knee OA or with persisting knee pain in people 45 years or older and investigating non-pharmacological core management strategies. Relevant comparisons were no intervention, usual care or any other intervention. Relevant outcomes were pain, physical function, quality of life (QoL), patient global assessment of target joint, adverse effects or cost-effectiveness. The included studies were categorised under the 11 research questions. If relevant, one study could inform multiple research questions. The quality of the included SRs was evaluated with A MeaSurement Tool to Assess systematic Reviews (AMSTAR II). 11 The assessments were conducted independently by three assessors (GS, EAB and IS), working in pairs independent of the TF, with experience in quality assessment of SRs and RCTs. Disagreements between the assessors were resolved through discussion.

A second literature search with a comparable search strategy was conducted to identify newer RCTs not included in the latest published SR on the same topic, or relevant RCTs not included in any SRs, or RCTs on research questions for which no relevant SRs were identified. To identify such RCTs published in the past four to 5 years, the search was conducted from 1 January 2018 to 27 May 2022.

A third literature search was conducted with a similar search strategy from 1 January 2012 to 31 December 2017, aiming to identify relevant RCTs specifically on the research questions for which no relevant SRs had been identified. The two last searches were screened independently by the same two authors, and relevant studies were read and evaluated in full text. Studies were included if they were RCTs relevant to the PICOs. The quality of the included RCTs was assessed with the Cochrane Risk of Bias tool 2 (RoB2) 12 independently by two researchers (EAB and IS) independent of the TF. Disagreements between the assessors were resolved through discussion.

In the period before the second TF meeting, five digital subgroup meetings were arranged. Groups of 4–5 TF members and the steering group participated in each meeting. The purpose of the subgroup meetings was to go through the relevant results from the SLR and to discuss and prepare preliminary suggestions for revisions and updates of the recommendations to guide the discussion at the second TF meeting. The group discussed between 1 and 3 of the previous 11 recommendations in each subgroup meeting. This method was implemented to allow all TF members to express their opinions in smaller forums and potentially to reduce the workload of the second TF meeting.

During the second digital TF meeting, the results from the SLR, along with the proposed updates from the subgroups, were presented to the whole TF. The previous recommendations and the proposed updates were then discussed in light of the SLR and the expertise of the group. After the discussions and revisions, the TF members voted for consensus on each revised overarching principle and recommendation (defined as 75% or more in favour of the suggested updates). After the meeting, the updated list of recommendations was collated and emailed to the TF members in a digital survey to rate the level of agreement (LoA) on a 0–10 point scale (0=totally disagree, 10=totally agree). Further, the TF voted on the prioritised order of the recommendations for implementation activities. The TF also formulated a research agenda based on identified gaps in the evidence. The steering group defined the LoE and strength of each recommendation in accordance with the Oxford Levels of Evidence. 13 The steering group also formulated the educational agenda on behalf of the TF.

The three systematic literature searches yielded a total of 6816 references after the removal of duplicates ( figure 1 ). From these, 67 SRs and 31 RCTs were initially considered relevant for the SLR. However, we chose to extract data from 36 of the SRs due to reasons elaborated in online supplemental file 1, p.49 ,. The most frequent reason was that the interventions under study were not considered relevant for this review. The quality of the included SRs was generally poor, with 35 of 36 studies being rated with an overall low or critically low quality by the AMSTAR II tool ( online supplemental file 1 ). The critical items that most often contributed to the overall low quality of the studies were: the lack of an explicit statement that the review methods were established prior to the conduct of the review; the lack of the use of a comprehensive literature search strategy; and lack of a list of excluded studies with reasons for exclusion. There was large variation in the overall quality of the included RCTs as assessed by the RoB2 tool ( online supplemental file 1 ). Most studies with a low risk of bias were on exercise interventions and delivery, whereas there were higher concerns related to the studies on, for example, lifestyle-related interventions. Most commonly, these concerns were related to the elements of measurement of the outcome (eg, the lack of a blinded outcome assessor).

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PRISMA flow diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

The main updates to the recommendations are summarised in box 1 . The TF agreed to rephrase and change two previous recommendations into overarching principles. These were the recommendations on: (1) the use of a biopsychosocial approach in the initial assessment and (2) the recommendation on individualisation of treatment. It was decided that these were generic statements used to inform the basis for management rather than specific treatment recommendations. Inherent to the nature of these statements, relevant studies were absent from the SLR. 14

What is new?

The updated recommendations have been reorganised into two overarching principles and eight treatment recommendations.

The wording of each recommendation is condensed.

The level of agreement is above 9 for all recommendations.

The level of evidence is 1a/1b for seven of the eight recommendations.

It was further decided to revise the nine previous recommendations into eight updated recommendations by merging the recommendations on footwear and walking aids, other assistive devices and adaptations. Moreover, to improve readability the previous recommendations were shortened, and subsections were rewritten and moved to the explanatory text. In addition, the TF also discussed the order for the presentation of the recommendations and decided to change this into a more logical sequence.

High LoAs were achieved for all eight recommendations, and seven recommendations were graded with LoE 1a/1b and strength level A. Recommendation 2—on delivery of information, patient education and self-management—was ranked by the TF as having the highest priority for implementation. Table 1 summarises the updated overarching principles, recommendations, LoA, LoE, strength of recommendation and priority for implementation.

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Overarching principles and specific recommendations for the non-pharmacological core management of hip and knee osteoarthritis

Recommendation 1

People with hip or knee OA should be offered an individualised, multicomponent management plan that includes the recommended core non-pharmacological approaches.

This recommendation deals with the provision of an integrated package of care rather than single treatments alone or in succession. The majority of new, relevant SRs and RCTs informing this recommendation investigated the effectiveness of the combination of patient education and exercise or the combination of patient education, exercise and diet or the combination of behaviour change techniques/pain-coping skills training and exercise, compared with information or one of the treatments alone. 15–18 The updated evidence shows that combining treatments leads to larger effects on pain and function compared with providing the treatments separately, thereby providing a rationale for combining different treatment modalities. The combination of education, exercise and dietary weight management was also considered cost-effective compared with physician-delivered usual care investigated in five healthcare systems. 19 The TF discussed that, although not all potential combinations of treatments are investigated in meta-analyses or newer RCTs, the results of available studies are likely to be generalisable to different combinations. Thus, the TF agreed on the general consideration of multicomponent treatments from a broader spectrum of potential combinations based on an assessment of a patient’s individual needs and preferences.

Through the SLR, no specific evidence was retrieved with regard to the effects of pacing and maintenance of activity. This specific element was therefore removed from the recommendation.

Recommendation 2

People with hip or knee OA should be offered information, education and advice on self-management strategies (considering available modes of delivery) and these should be included and reinforced at subsequent clinical encounters.

Recommendation 2 concerns the delivery of information, education and advice on self-management strategies. New evidence from the SLR showed zero to small significant effects on pain and function from patient education as a single intervention in the short term, which is in line with the previous recommendation. 15 20 In 2013, this recommendation focused on how education and information should be delivered in terms of being individualised, being included in every aspect of management, and specifically addressing the nature, causes, consequences and prognosis of OA. Moreover, it was stated that this should be reinforced and developed, supported by written or other types of material, including partners or carers of the individual, if relevant. The current TF acknowledged the importance of these aspects to ensure the effective delivery of information and education for people with hip and knee OA. However, none of the studies from the SLR could provide specific evidence for any of these aspects, except with regard to delivery method. One SR reported the effects of patient education delivered through telephone when compared with usual care, but the results were not significant for pain or disability. 20 The TF further chose to add self-management to the updated recommendation. Evidence from two SRs, including seven RCTs, compared structured self-management programmes against a large range of control interventions. Zero to small favourable effects were found for self-management, delivered face to face or digitally, compared with routine/usual care. 21 22 Despite the limited effects reported in the literature, the TF agreed that self-management is a concept closely related both to the delivery of information and education in a clinical setting and to the uptake of other relevant treatment modalities.

Recommendation 3

All people with hip or knee OA should be offered an exercise programme (eg, strength, aerobic, flexibility or neuromotor) of adequate dosage with progression tailored to their physical function, preferences and available services.

The body of literature investigating the effects of different types of exercise regimes was already large when the 2013 recommendations were published. Aiming to progress the knowledge on the effects of exercise for hip and knee OA, the current SLR did not focus on studies investigating the effects of general exercise on hip and knee OA as these effects were well established previously. 23 24 The aim was rather to identify studies investigating the effects of well-defined exercise modalities, as well as studies looking more specifically into exercise dosage.

For hip OA, one SR summarised the effects of supervised, progressive resistance training, which reported beneficial effects on pain, function and QoL. The effect sizes, however, were small with large CIs. 25

For knee OA, four SRs and five additional RCTs were identified on the exercise 26–28 modalities Tai Chi, yoga, stationary cycling, proprioceptive training, weight-bearing and non-weight bearing exercise, and neuromuscular exercise combined with strength training. 29–33 Overall, the results showed small to moderate positive effects on pain and function for all these exercise modalities compared with no-exercise control (no intervention, waiting list or non-exercise interventions). Still, the results were less clear in head-to-head comparisons of different exercise types, modalities or doses.

In summary, results showed that a variety of exercise modalities might lead to improved pain and function for people with hip or knee OA, making it difficult to recommend one type of exercise over another. The optimal exercise dosage is also difficult to establish, with evidence from 1 SR on hip OA (including 12 RCTs) and 1 SR on knee OA (including 45 RCTs) providing some evidence that exercise in line with dose recommendations from the American College of Sports Medicine provided larger improvements in pain compared with non-compliant exercise programmes. 34–36 The differences, however, were small, and the clinical relevance is debatable. Two newer RCTs on knee OA, comparing high-intensity to low-intensity resistance training or no-exercise control, found no or only small between-group differences with regard to pain and function, 37 38 thus making it difficult to make explicit recommendations on exercise dosage.

With respect to safety, adverse events in exercise studies for hip and knee OA were investigated in two SRs. 39 40 The two studies concluded that, although the report of adverse events in exercise studies was inconsistent and some patient drop-outs were potentially misclassified, adverse events were generally uncommon and non-serious, and that exercise seemed to be associated with minimal risk of harm. Concerning the economic aspects of exercise, one SR on cost-effectiveness found that in the majority of the 12 included studies, exercise for hip and knee OA showed cost-effectiveness at conventional willingness-to-pay thresholds. 19

The TF chose to update this recommendation, highlighting that the choice of exercise should be based on individual function, patient preferences and available services. 41 Overall, exercise is by far the most studied and strongly recognised non-pharmacological core management treatment option and this recommendation has the strongest evidence base. The TF also expressed the importance of maintaining exercise over time for the positive effects to persist.

Recommendation 4

The mode of delivery of exercises (eg, individual or group sessions, supervised or unsupervised, face to face or by using digital technology, land-based or aquatic exercise) should be selected according to local availability and patient preferences. The exercises preferably should be embedded in an individual plan for physical activity.

As established in the description of recommendation 3, there is convincing evidence for the effectiveness of various exercise modalities on pain and function in hip and knee OA. However, the delivery method of exercise programmes varies largely across studies and may influence study outcomes.

One SR found superior effects from technology-supported exercise compared with control with non-technological or no care services on pain, function and QoL, 42 whereas another SR found superior effects from telehealth-based exercise compared with no-telehealth exercise control for pain but not for function or QoL. 43 The reported effect sizes were small. One additional RCT found a small, significant effect on function at 6 months follow-up for an education combined with strengthening exercise follow-up through telephone calls compared with education alone, but no other between-group differences in pain and function were detected after 6 and 12 months. 44 Another RCT comparing access to an educational website combined with exercise supported by automated behaviour change text messages to access to the educational website alone found significant superior effects of the combined first intervention on pain and function after 24 weeks. 45 For aquatic exercise, one SR reported small short-term beneficial effects for pain and function compared with no intervention or usual care. However, another SR comparing aquatic exercise to land-based exercise did not find any of these modes superior to the other. 46 47 One RCT of a three-stage stepped care exercise programme compared with educational materials found beneficial, although not clinically relevant, effects of the stepped care programme on pain and function at 3 and 9 months, but not at 6 months. 48 Analyses of the cost-effectiveness of the same stepped-care intervention concluded that there is a high probability of short-term cost-effectiveness. 49

The new evidence adds information on technology-supported delivery of exercise, aquatic exercise and a stepped care strategy for exercise delivery. The results from these studies show a wide variety of potentially effective delivery methods for exercise, which in clinical practice should be aligned with patient preferences and the availability of local services. The TF also underlined the importance of the exercise programme being embedded in an individual plan for physical activity. Such plans should be set up in accordance with well-recognised recommendations for physical activity, such as from the WHO or EULAR. 41 50 General physical activity has multiple health benefits and is also important for the management of common comorbidities associated with OA, such as cardiovascular disease and diabetes. 51 52

Recommendation 5

People with hip or knee OA should be offered education on the importance of maintaining a healthy weight. Those overweight or obese should be offered support to achieve and maintain weight loss.

In the updated SLR, three SRs were identified, including one network meta-analysis investigating the effects of weight loss interventions. Two were on studies of knee OA, 19 53 whereas the third included studies of both hip and knee OA, although only 2 of the 19 trials included in that study were conducted on a mixed hip and knee OA population. 54 The results from this SR showed beneficial effects, compared with minimal care, of both diet and multifocused weight-loss interventions (combining diets, telephone coaching, psychological pain-coping interventions/CBT, specialist referral education and exercise) on pain and disability, with the largest effect size on pain for multifocused interventions. Further, it was reported that when comparing weight-loss-focused interventions (diets) to exercise, no between-group differences were detected for pain or disability. When comparing combined interventions of dietary weight loss and exercise to dietary weight loss or exercise alone, small effects were found in favour of the combined intervention.

In the network meta-analysis, bariatric surgery was the most effective pain-reducing intervention, followed by a low-calorie diet combined with exercise intervention. 53 The last SR on knee OA used cost-effectiveness as an outcome and reported that an intensive 18-month diet and exercise intervention with the goal of 5% weigth loss was likely to be an efficient use of healthcare resources compared with a healthy lifestyle control. 19

The above-mentioned studies made it clear that there is increasing evidence supporting multifocused weight loss interventions as beneficial for OA pain and disability. Therefore, the TF recommended that people with overweight or obesity and OA should be offered support to achieve and maintain weight loss. The TF notes that the amount of evidence mainly stems from studies on knee OA. As overweight and obesity are strong risk factors for the development and progression of OA, and in particular knee OA, 2 the TF also wanted to add to the recommendation the importance of education on the benefits of maintaining a healthy weight.

Recommendation 6

For people with hip or knee OA, consider walking aids, appropriate footwear, assistive devices and adaptations at home and at work to reduce pain and increase participation.

Through the SLR, four SRs investigating the effects on knee OA of lateral wedge insoles compared with other types of insoles, including flat/neutral insoles or knee braces, were retrieved. These studies did not report any between-group differences for any comparisons on pain or function. 55–58 On the other hand, one RCT reported a small between-group difference in favour of lateral wedge insoles compared with neutral insoles on a single pain scale in people prescreened to knee adduction moment improvements (but not on other pain scales, function or QoL). 59 For footwear, one RCT found positive effects of biomechanical footwear with individually adjustable external convex pods attached to the outsole compared with control footwear. 60 Another RCT found small effects after 6 months on pain, but not on function, from wearing stable, supportive shoes over flat flexible shoes for at least 6 hours per day. 61

Summarised, most evidence did not support the use of any lateral wedged or other insoles to affect pain or function in knee OA. The results from one RCT provided some support for the use of stable, supportive shoes. The TF wanted to add that from a clinical perspective, the use of comfortable shoes, big enough to give ample space for the toes when weight-bearing, is still a general recommendation for people with hip and knee OA.

For other types of assistive aids and devices, two RCTs comparing the use of canes to the non-use of auxiliary gait devices were identified. The results were contradictory, and conclusions on the effect of cane were difficult to draw from the available evidence. 62 63 No studies were retrieved for other types of assistive devices or home adaptations. Based on the expert knowledge of the group, it was argued that such devices could still be useful to some people with hip or knee OA in terms of reducing pain, undertaking daily activities and improving participation. The TF wanted to emphasise that improving participation is an important aspect underpinning this specific recommendation. Assistive devices may serve as means to reduce pain and improve participation both at home and at work and should, therefore, be considered in that context. Examples of such devices might be devices to aid dressing, height-adjustable chairs, raised toilet seats, handrails in staircases or the use of appropriate walking aids.

Recommendation 7

People with hip or knee OA with or at risk of work disability should be offered timely advice on modifiable work-related factors and, where appropriate, referral for expert advice.

OA is one of the leading causes of reduced work participation, and the disease may critically affect the number of sick days and, ultimately, the extension of a person’s work career. 64 Although there are well-known occupational risk factors, such as heavy lifting and knee straining activities associated with the development of knee OA, 65 it was noted that there is a lack of studies on vocational rehabilitation for people with hip or knee OA. In the current update, only one relevant RCT was retrieved. This study used workability as an outcome, whereas the study intervention in both groups focused on self-management with the addition of an activity tracker in the intervention group. In this study, no between-group differences were reported for workability. 66

Although little research has been conducted, the TF considered that appropriate interventions to increase work participation for people with hip and knee OA are highly relevant. A proper assessment of the individual work situation may have a large impact and should receive attention during consultations. 67 Health professionals, in cooperation with the employer, should be able to offer timely advice on modifiable work-related factors such as working from home, the use of height-adjustable desks and office chairs, the possibility of changing work tasks, commuting to/from work, use of assistive technology, and receiving support from management, colleagues and family towards employment. The TF also noted that adaptations to improve workability might be considered and applied not only at the workplace but also in the home.

Recommendation 8

Consider employing elements of behaviour change techniques when lifestyle modifications are needed (eg, physical activity, weight loss) for people with hip or knee OA.

This recommendation concerns the potential need for lifestyle change in people with hip and knee OA. It focuses specifically on physical activity and weight loss as part of a healthy lifestyle since these aspects are specifically relevant for people with hip or knee OA. One SR and eight additional RCTs were identified on various interventions to enhance a healthy lifestyle, mainly through maintaining physical activity over time. The SR reported small to moderate effects of adding booster sessions to exercise programmes to improve mid-term to long-term adherence to exercise. 68 Furthermore, one RCT reported statistically significant improvements in pain and function from a combined programme of pain coping skills training and lifestyle behavioural weight management lasting 24 weeks compared with these interventions alone or standard care. 69 Interventions from the other RCTs aiming to support people with OA to improve their lifestyle and sustain such changes over time, included interventions of behaviour-graded activity, improving exercise adherence with telephone counselling, an app to enhance a healthy lifestyle, physical activity with telephone follow-up and a self-management lifestyle intervention. 70–72 However, when the effects on pain and function of these interventions were compared with standard care or other minimal interventions, none to very small between-group differences were observed for the comparisons. The TF wanted to enhance the importance of long-term follow-up on health behaviour change and not just recommend lifestyle change as a single intervention. The TF also discussed that the EULAR recommendation on core competencies for health professionals in rheumatology underlines that health professionals should be able to provide the principles of behaviour change techniques in the management of people with rheumatic and musculoskeletal disorders. 73

Research and educational agendas

The proposed research agenda ( table 2 ) was based on gaps identified in the literature and on topics which emerged during discussions among the TF members.

Research agenda for the non-pharmacological core management of people with hip and knee osteoarthritis

The education agenda ( table 3 ) highlights activities relevant to promote appropriate management of people with hip and knee OA.

Educational agenda for the non-pharmacological core management of people with hip and knee OA

Through this update, the recommendations for the non-pharmacological core management of hip and knee OA have been revised into two overarching principles and eight treatment recommendations. The revisions are based on research evidence, expert discussions and consensus. Since the publication of the 2013 recommendations, a number of new studies have been published on non-pharmacological treatment modalities and their methods of delivery. The updates to the recommendations are thus well anchored in evidence from research and the perspectives of the TF members, representing different professional, cultural and personal backgrounds, including the perspective of people with OA. The process led to a broad consensus within the TF on the updated principles and recommendations, reflected by the high LoA for all the revised recommendations. Such strong consensus gives reason to believe that the recommendations are suitable for use and implementation across European healthcare systems. These recommendations are also in line with recently published treatment recommendations for hip and knee OA by other societies. 74–76

The number of relevant SRs and RCTs retrieved through the SLR was high, especially for the research questions concerning exercise and delivery of exercise, with data drawn from a total of 15 SRs and 11 additional RCTs. The number of new studies led to an upgrade of the LoE for most of the recommendations, and seven of eight recommendations are now supported by level 1a or 1b evidence. However, it should be noted that the stated LoE does not necessarily involve all aspects of every recommendation and does not distinguish between hip and knee OA. The number of studies on hip OA was markedly lower than those on knee OA for all the treatment modalities. Therefore, the recommendations are generally weaker for hip OA than knee OA. There is an increasing recognition of differences between hip and knee OA, which heightens the need for more hip OA-specific studies to improve outcomes for this group specifically. 77 This is also highlighted in the proposed research agenda ( table 2 ). Further, as the aim was to address relevant non-pharmacological core management strategies, the recommendations do not specifically advise the management of subgroups of the OA population, for instance, younger adults or adults with a high burden of comorbidities. The authors are also aware of a number of ongoing studies addressing a range of innovative digital programmes in OA care. Such approaches will likely receive further attention in future updates of these recommendations. 78–81

With regard to outcomes, most of the included studies reported effects primarily on pain and physical function. To follow the recommendations on prioritised outcomes in OA research, 82 more studies investigating the effects of interventions on QoL and patients’ global assessment of the target joint may have provided additional relevant information. Workability and cost-effectiveness are two other outcomes of increasing interest when investigating the effect of interventions from a broader perspective. This SLR identified some studies including these outcomes, thus adding new and important knowledge to the recommendations. Nevertheless, additional studies with a focus on interventions to prevent the decline in workability and studies examining cost-effectiveness are still needed as such knowledge is important for healthcare governance and policy-makers when planning and prioritising effective OA care. Another relevant aspect of this update is the inclusion of studies investigating potential harm or adverse events from the interventions under study. Only two SRs specifically looking into this subject were identified. Still, the results add new knowledge to this important, although understudied, aspect of non-pharmacological interventions. 83

The challenges of implementing recommended care for people with hip and knee OA are well documented. 84 It is also apparent that developing recommendations is not sufficient on its own to influence practice. 85 Therefore, efforts have been made to address the impact and to develop strategies for the implementation of treatment recommendations. For future implementation, collaboration with other organisations focusing on OA care, such as The Osteoarthritis Research Society International, must be considered. EULAR highlights that implementing all recommendations at once is probably not feasible in practice. 86 The TF voted that the recommendation on information, education and self-management was ranked as the recommendation with the highest priority for implementation. This recommendation may play an important role as a basis for all other management and may improve people’s ability to live a good life with OA, as well as being an enabler of, aspects such as physical activity. 87 The prioritisation of the recommendations for implementation activities is also important with respect to the effective utilisation of healthcare services. As the OA population is growing, the need for effective healthcare utilisation and sustainable management strategies to improve outcomes will be vital to minimising the burden of OA at an individual and a societal level. 88

To conclude, the TF reached a broad consensus on the updated recommendation for non-pharmacological core OA management as well as on a research agenda highlighting the current evidence gaps, on an educational agenda and on the priority of the recommendations to support implementation activities.

Ethics statements

Patient consent for publication.

Not applicable.

Acknowledgments

We thank the librarian Hilde Iren Flaatten, University of Oslo, Norway, for supporting the literature searches and Emilie Andrea Bakke, Ingrid Skaalvik and Geir Smedslund, Diakonhjemmet Hospital, Center for treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Norwegian National Advisory Unit on Rehabilitation in Rheumatology, Oslo, Norway, for their thorough work in the AMSTAR II and Cochrane risk of bias assessments of the included studies.

PGC is funded in part by the National Institute for Health and Care Research (NIHR) through the Leeds Biomedical Research Centre.

• EULAR RheumaMap
• Hunter DJ ,
• Bierma-Zeinstra S
• Global Burden of Disease Collaborative Network
• Basedow M ,
• Smedslund G ,
• Østerås N , et al
• Kolahi A-A ,
• Smith E , et al
• Fernandes L ,
• Bijlsma JW , et al
• van der Heijde D ,
• Aletaha D ,
• Carmona L , et al
• Brouwers MC ,
• Browman GP , et al
• Reeves BC ,
• Wells G , et al
• Higgins JPT SJ ,
• Elbers RG , et al
• OCEBM Levels of Evidence Working Group*
• de Rooij M ,
• van der Leeden M ,
• Cheung J , et al
• De Oliveira Silva D ,
• Merolli M , et al
• Alrushud AS ,
• Rushton AB ,
• Kanavaki AM , et al
• Castelein B ,
• Wittoek R , et al
• Pitsillides A ,
• Stasinopoulos D ,
• Giannakou K
• Mazzei DR ,
• Ademola A ,
• Abbott JH , et al
• O’Brien KM ,
• Hodder RK ,
• Wiggers J , et al
• Zhu Y , et al
• Jackson J ,
• Sheffield D
• Uthman OA ,
• van der Windt DA ,
• Jordan JL , et al
• Verhagen AP ,
• Ferreira M ,
• Reijneveld-van de Vendel EAE , et al
• Mikkelsen LR ,
• Overgaard S , et al
• Bennell KL ,
• Nelligan RK ,
• Kimp AJ , et al
• Yen H-Y , et al
• Schrøder HM ,
• Wernbom M , et al
• Liu X , et al
• Pranata A , et al
• El-Ansary D ,
• Adams R , et al
• Chen Z , et al
• Garber CE ,
• Blissmer B ,
• Deschenes MR , et al
• Dagfinrud H ,
• Smedslund G , et al
• Bartholdy C ,
• Christensen R , et al
• de Zwart AH ,
• Roorda LD , et al
• Messier SP ,
• Mihalko SL ,
• Beavers DP , et al
• von Heideken J ,
• Chowdhry S ,
• Borg J , et al
• Rausch Osthoff A-K ,
• Niedermann K ,
• Braun J , et al
• Cai Y , et al
• Hinman RS ,
• Campbell PK ,
• Lawford BJ , et al
• Kasza J , et al
• Xu S , et al
• Zhou P , et al
• Woolson S ,
• Hoenig HM , et al
• Kaufman BG ,
• Coffman CJ , et al
• World Health Organization
• Williams MF ,
• London DA ,
• Husni EM , et al
• Mamas MA , et al
• Panunzi S ,
• Maltese S ,
• De Gaetano A , et al
• Robson EK ,
• Kamper SJ , et al
• Khosravi M ,
• Daryabor A , et al
• Yang J , et al
• Liang L , et al
• Felson DT ,
• Carter S , et al
• Reichenbach S ,
• Hincapié CA , et al
• Paterson KL ,
• Campbell PK , et al
• Silva AC , et al
• Van Ginckel A ,
• Wrigley TV , et al
• Viikari-Juntura E ,
• Solovieva S
• McWilliams DF ,
• Muthuri SG , et al
• Östlind E ,
• Stigmar K , et al
• Gwinnutt JM ,
• Wieczorek M ,
• Balanescu A , et al
• Nicolson PJA ,
• Dobson FL , et al
• Somers TJ ,
• Blumenthal JA ,
• Guilak F , et al
• Bendrik R ,
• Kallings LV ,
• Bröms K , et al
• LaValley MP ,
• Brown C , et al
• Lombard C ,
• Hussain SM , et al
• Edelaar L ,
• Nikiphorou E ,
• Fragoulis GE , et al
• National Institute for Health and Care Excellence: Guidelines
• Kolasinski SL ,
• Hochberg MC , et al
• Bannuru RR ,
• Vaysbrot EE , et al
• van der Esch M ,
• Hinman RS , et al
• Knox G , et al
• de Almeida AC ,
• de Noronha M , et al
• Groves-Williams D ,
• McHugh GA ,
• Bennell KL , et al
• Hawker GA ,
• Hunter DJ , et al
• Boutron I ,
• Baron G , et al
• Golightly YM ,
• Dziedzic KS ,
• EULAR European alliance of Associatons for rheumatology
• Kanavaki AM ,
• Rushton A ,
• Efstathiou N , et al
• Turkiewicz A ,
• Petersson IF ,
• Björk J , et al

Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

• Data supplement 1

Handling editor Josef S Smolen

X @DrS_Battista

Contributors TM was the research fellow for the project, undertaking the SLR in cooperation with NØ. The fellow was supervised by the steering group consisting of NØ (convenor) and TPMVV (methodologist). NØ and TPMVV supervised the process of the SLR. NØ organised and chaired the TF meetings. TM drafted the manuscript with advice from NØ and TPMVV. All authors have contributed to the recommendations by participating in the TF meetings; during discussion and agreement on the recommendations; revising and approving the manuscript for publication.

Funding This study was funded by European League Against Rheumatism (HPR055).

Disclaimer The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Competing interests TPMVV was the Vice president EULAR health professionals 2020–2022 and is part of the EULAR Advocacy Committee 2020–present. MG holds a leadership position in OpenReuma/Spanish Association of Health Professionals in Rheumatology (unpaid). CDM received Grants from Versus Arthritis, MRC, NIHR (paid to Keele University) and is the director of the NIHR School for Primary Care Research. SL received payment as scientific consultant from Arthro Therapeutics AB and received payment from AstraZeneca as a member of DSMB. DC received grants from Fundação para a Ciência e Tecnologia SFRH/BD/148420/2019 and Pfizer (ID 64165707). GZ received payment for expert testimony from Casa di Cura San Francesco, Verona and Support for attending meetings and/or travel from Orthotech and Jtech, payment for participation on a Data Safety Monitoring Board or Advisory Board from VIVENKO for Gruenenthal and Ethos for Angelini and holds other financial interests related to clinical practice as an orthopedic surgeon (performing total joint replacement, arthroscopies and other types of surgeries), either directly from private patients or indirectly from the health system or insurances acting as a private consultant. JEV has received payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Lilly Netherlands BV. TG has received paid honoraria for lectures by Abbvie, Novartis, Boehringer Ingelheim, UCB, Berlin-Chemie/A. Menarini Bulgaria, Sandoz and received support for attending meetings by Abbvie, Pfizer and UCB. DW is an International Advisory Board Member of DRFZ (Germany) 2019–current and was the EULAR PARE Chair 2015–2017and an EULAR Vice President representing PARE 2017–2021.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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