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provide earlier non-surgical management interventions for individuals with metabolic, inflammatory or body composition changes that are impacting their symptoms and contributing to disease progression37 . 9 Bone and Joint Health Strategic Clinical Network Knowledge Synthesis Methods A scoping review was conducted to capture and synthesize current published review articles regarding treatment recommendations for adults with obesity and osteoarthritis of the hip and knee joints. Scoping review methodologies are appropriate to summarize the breadth of evidence on a topic and identify knowledge gaps38 . A systematic search of the published literature was utilized, and review articles were included if they were published between January 2010 and January 2017, in English, with human subjects, relevant to treatment of knee and hip osteoarthritis in adults with obesity. In addition, reference lists of included studies were reviewed to identify any articles that may have been missed. The complete search strategy is detailed in Appendices 2, 3 and 4. Included articles were categorized by the methodology the authors used for their review (Table 2). Category 1 review articles systematically searched the literature, reported the search results, and assessed the bias/quality of included studies. Category 2 review articles systematically searched the literature and reported the search results, but did not include an assessment of bias/quality. Category 3 review articles did not report a systematic search strategy or results, and didn’t assess bias/quality of included studies. Table 2. Consideration of methodologies of included review articles Category of Methodology used in the Review Article Utilized a systematic search of literature Reported results of literature search Assessed included studies for bias/quality Examples of types of review articles 1 Yes Yes Yes Clinical practice guidelines and systematic reviews 2 Yes Yes No Scoping and evidence mapping reviews 3 No/Unclear No No Narrative reviews Results The knowledge synthesis incorporated 50 review articles, with approximately half (n=24) being category 3 reviews. Second were category 1 reviews (n=15), then category 2 reviews (n=8), and a few articles (n=3) fit between categories. The full list of included review articles, their category of evidence, and key findings are reported in Appendix 6. Category 1 reviews included four clinical practice guidelines: a) Ottawa panel guidelines for management of osteoarthritis in adults who are obese or overweight (published in 2011)39 , b) Osteoarthritis Research Society International (OARSI) guidelines for the non-surgical management of knee osteoarthritis (published in 2014)40 , c) American Academy of Orthopaedic Surgeons (AAOS) guidelines for surgical management of knee osteoarthritis (published in 2015)41 , and d) American Association of Clinical Endocrinologists (AACE) and American College 10 Bone and Joint Health Strategic Clinical Network of Endocrinology (ACE) guidelines for medical care of patients with obesity (published in 2016)42 . The remainder (n=11) were systematic reviews on: patellofemoral pain43 (n=1), total knee arthroplasty (TKA) outcomes44–46 (n=3), total hip arthroplasty (THA) outcomes47,48 (n=2), bariatric surgery for osteoarthritis symptoms49,50 (n=2), bariatric surgery before total joint arthroplasty (TJA) 51 (n=1), weight loss before TJA52 (n=1), and weight loss after TJA53 (n=1). Topic distribution of articles relative to joint favoured the knee (n=23), with relatively fewer articles specific to hip (n=2) and the remainder on both hip and knee or non-specific (n=25). Few articles were on conservative (non-surgical) treatment (n=8), with the majority focused on surgical treatment or weight loss. Treatment recommendations specific for osteoarthritis patients with obesity were extracted from the articles and sorted into non-surgical (conservative) treatment and surgical treatment recommendations under topic themes. Non-surgical osteoarthritis treatment (conservative management) for adults with obesity Development of integrated treatment interventions that address both osteoarthritis and obesity concurrently are recommended10,54 . Pharmacotherapies that address the inflammatory pathways relative to both osteoarthritis and obesity could be beneficial, particularly if combined with weight management interventions11 . There is no indication that BMI can predict response to non-surgical treatment55 . Physical activity Considerations for adapting physical activity recommendations should be based on the patients’ comorbid conditions (i.e. diabetes, cardiac disease)56 , and physical limitations related to their obesity40 . Fear of movement or activity avoidance should be assessed, as it is common in patients with mobility limitations57 . Obesity, mobility disability and environmental factors can reduce patients’ confidence, motivation and ability to access community activity programs, so recommendations should be patient-focused58 . Additionally, as increased physical activity could increase pain and fatigue, health care practitioners should educate patients on pacing and rest breaks to reduce symptom exacerbation, which could lead to discontinuation and avoidance of the activity56,59,60 . The evidence is unclear if there are specific types of physical
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