Rheumatology 2005 44:67���73 doi:10.1093/rheumatology/keh399 Advance Access publication 7 September 2004 Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or knee���the MOVE consensus E. Roddy, W. Zhang, M. Doherty, N. K. Arden1, J. Barlow2, F. Birrell3, A. Carr, K. Chakravarty4, J. Dickson5, E. Hay6, G. Hosie7, M. Hurley8, K. M. Jordan1, C. McCarthy9, M. McMurdo10, S. Mockett11, S. O���Reilly12, G. Peat6, A. Pendleton13 and S. Richards14 Objectives. Exercise is an effective and commonly prescribed intervention for lower limb osteoarthritis (OA). Many unanswered questions remain, however, concerning the practical delivery of exercise therapy. We have produced evidence-based recom- mendations to guide health-care practitioners. Methods. A multidisciplinary guideline development group was formed from representatives of professional bodies to which OA is of relevance and other interested parties. Each participant contributed up to 10 propositions describing key clinical points regarding exercise therapy for OA of the hip or knee. Ten final recommendations were agreed by the Delphi technique. The research evidence for each was determined. A literature search was undertaken in the Medline, PubMed, EMBASE, PEDro, CINAHL and Cochrane databases. The methodological quality of each retrieved publication was assessed. Outcome data were abstracted and effect sizes calculated. The evidence for each recommendation was assessed and expert consensus highlighted by the allocation of two categories: (1) strength of evidence and (2) strength of recommendation. Results. The first round of the Delphi process produced 123 propositions. This was reduced to 10 after four rounds. These related to aerobic and strengthening exercise, group versus home exercise, adherence, contraindications and predictors of response. The literature search identified 910 articles 57 intervention trials relating to knee OA, 9 to hip OA and 73 to adherence. The evidence to support each proposition is presented. Conclusion. These are the first recommendations for exercise in hip and knee OA to clearly differentiate research evidence and expert opinion. Gaps in the literature are identified and issues requiring further study highlighted. KEY WORDS: Knee osteoarthritis, Hip osteoarthritis, Exercise, Aerobic exercise, Strengthening exercise, Evidence-based recommendations. Osteoarthritis (OA) is the most common cause of musculo- skeletal pain and disability. Exercise is a commonly prescribed and effective treatment for patients with lower limb OA. Many questions remain, however, regarding the type and format of exercise that should be prescribed, predictors of response and adherence. The American Institute of Medicine has defined clinical guide- lines as ���systematically developed statements to assist practi- tioner and patient decisions about appropriate health care for specific clinical conditions��� [1]. Guidelines for the management of OA of the knee and hip [2���4] recommend exercise therapy without addressing the issues described above. Existing guidelines for exercise in OA [5] are not site-specific and do not provide estimates of treatment effect or differentiate between expert opinion and evidence-based recommendations. Our objectives were to produce evidence-based recom- mendations for the role of exercise in the management of hip and knee OA, differentiating research-based evidence from Correspondence to: E. Roddy, Academic Rheumatology, Clinical Sciences Building, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, UK. E-mail: edward.roddy@nottingham.ac.uk Academic Rheumatology, Clinical Sciences Building, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, 1MRC Epidemiology Resource Centre, Southampton General Hospital, Tremona Road, Southampton, Hampshire SO16 6YD, 2Interdisciplinary Research Centre in Health, School of Health and Social Sciences, Coventry University, Priory St, Coventry CV1 5FB, 3Musculoskeletal Research Group, 4th Floor Cookson Building, Framlington Place, University of Newcastle upon Tyne, Newcastle upon Tyne, NE2 4HH, 4Haroldwood Hospital, Gubbins Lane, Romford, Essex RM3 OBE, 5Langbaurgh PCT, Langbaurgh House, Bow Street, Guisborough, Cleveland TS14 7AA, 6Primary Care Sciences Research Centre, Keele University, Staffordshire ST5 5BG, 7Primary Care Rheumatology Society, Northallerton, North Yorkshire DL7 8YG, 8King���s College London, Rehabilitation Research Unit, Dulwich Hospital, East Dulwich Grove, London SE22 8PT, 9The Centre for Rehabilitation Science, University of Manchester, Oxford Road, Manchester M13 9WL, 10Department of Medicine, University of Dundee, Ninewells Hospital, Dundee DD1 9SY, 11Division of Physiotherapy Education, School of Community Health Sciences, University of Nottingham, Nottingham City Hospital, Hucknall Rd, Nottingham NG5 1PB, 12Derbyshire Royal Infirmary, London Rd, Derby DE1 2QY, 13Craigavon Area Hospital, 68 Lurgan Rd, Portadown, Co Armagh BT63 5QQ, 14Poole Hospital, Longfleet Road, Poole BH15 2JB, UK. Submitted 25 July 2004 revised version accepted 6 August 2004. Rheumatology Vol. 44. No. 1 �� British Society for Rheumatology 2004 all rights reserved 67

expert opinion, to guide health-care practitioners caring for patients with OA. Methods The guideline development group Professional bodies to which knee and hip OA are of relevance were invited to participate in a multidisciplinary guideline development group concerning exercise therapy and OA of the hip and knee. Representatives suggested by the British Geriatric Society, British Society for Rheumatology, Chartered Society of Physiotherapy and Primary Care Rheumatology Society agreed to take part in addition to other interested parties. A committee was formed con- sisting of 20 experts in the field of OA (10 rheumatologists, four physiotherapists, two general practitioners, two experts from the field of evidence-based medicine, one medicine for the elderly physician and one health psychologist). Opinion of the expert committee Each committee member was asked to contribute up to 10 pro- positions describing key clinical points regarding the role of exercise as a therapy for OA of the hip or knee. The propositions from all experts were then collated and consensus regarding the propositions reached by the Delphi technique [6]. The propositions were returned to the participants who were asked to select the 10 most important propositions. These were collated and similar propositions combined. The procedure was repeated until 10 recommendations were agreed. Propositions were accepted auto- matically if selected by over two-thirds of participants in one Delphi round. After the third round, propositions that were selected by fewer than 25% of participants were rejected. The evidence-base to support each recommendation was then determined. Literature search A systematic literature search was undertaken in the Medline, PubMed, EMBASE, PEDro, CINAHL and Cochrane databases covering the period 1966 to November 2003. Search terms used were ���exercise��� and ���exercise therapy��� combined with ���osteo- arthritis, knee���, ���osteoarthritis, hip��� or ���adherence���. Search terms were exploded. Reference lists of identified studies were also searched. Studies of all designs were included including meta- analyses and systematic reviews, randomized controlled trials (RCTs), controlled trials and uncontrolled studies. Only English- language publications and full-length articles were included. Assessment of methodological quality Methodological quality was assessed by a single reviewer according to a validated scoring system [7]. This system scores the reporting of studies on 27 items leading to a maximum quality score (QS) of 28 (0���1 for 26 items, 0���2 for one item). Quantitative assessment of treatment effect Outcomes of interest were identified by the Delphi process and relevant data were abstracted (e.g. pain, self-reported disability, health status, muscle strength). The mean and distribution for baseline, endpoint and difference (endpoint minus baseline) were recorded for each outcome measure in addition to the number of subjects in each treatment arm. Where sufficient data were provided, the effect size (ES) [8] for the difference between exercise and control groups was calculated. Categories of evidence/strength of recommendation (Table 1) The evidence from each study was then categorized according to study design. The strength of recommendation for each of the final 10 propositions was allocated by the committee based on the level of evidence available [9]. Results The Delphi process Eighteen of the experts participated in the Delphi process and the first round returned 123 propositions which were sent back to participants. Seventy-two propositions were returned follow- ing the second round and similar propositions were combined. Forty-seven propositions were sent out for the third round and two of these were accepted as final recommendations, having been selected by over two-thirds of the participants. After the third round, propositions selected by fewer than 25% were rejected, leaving 13 propositions, six of which had been accepted as final recommendations. Following the fourth round, eight propositions selected by over two-thirds of the panel and two further pro- positions selected by over half of the panel made up the 10 final recommendations. Literature search One hundred and fifty-nine articles relating to exercise therapy for hip or knee OA were identified by the literature search. There were three systematic reviews of exercise for OA of the hip or knee, 57 intervention trials relating to knee OA and nine relating to hip OA. Eight hundred and two articles were identified by the search for articles relating to adherence and exercise, including 73 articles relating to interventions to increase adherence. The propositions These are considered in no particular order. 1. Both strengthening and aerobic exercise can reduce pain and improve function and health status in patients with knee and hip OA. Both aerobic and strengthening exercises are effective for knee OA. Three RCTs of aerobic walking have shown TABLE 1. Categories of evidence and strength of recommendation [9] Categories of evidence 1A: Meta-analysis of RCT 1B: At least one RCT 2A: At least one CT without randomization 2B: At least one type of quasi-experimental study 3: Descriptive studies (comparative, correlation, case���control) 4: Expert committee reports/opinions and/or clinical opinion of respected authorities Strength of recommendation A: Directly based on category 1 evidence B: Directly based on category 2 evidence or extrapolated recommendation from category 1 evidence C: Directly based on category 3 evidence or extrapolated recommendation from category 1 or 2 evidence D: Directly based on category 4 evidence or extrapolated recommendation from category 1, 2 or 3 evidence RCT �� randomized controlled trial, CT �� controlled trial. 68 E. Roddy et al.