Musculoskeletal problems are very common in primary care: they are the third most common reason for a patient seeking a consultation in general practice and account for about 15% of all consultations. Of these, a considerable proportion, especially in the older age groups, will be for osteoarthritis (OA), and of all the OA consultations those relating to the knee are probably the most common.
Despite its common occurrence and the amount of morbidity it generates, many people, both lay and health professionals, have a very negative attitude to OA. It is regarded as an inevitable consequence of growing older, and is often treated inappropriately with non-steroidal anti-inflammatory drugs (NSAIDs).
This negative message is picked up by patients, who may feel that nothing can be done to delay the changes that occur with ageing. They become less mobile, lose motivation and may become more dependent on others.
OA is a chronic problem, with symptoms present over a long period of time. Many patients with OA seek help and support from the primary healthcare team on a regular basis. It is therefore essential that medical and nursing staff have the knowledge and confidence to provide this support within primary care.
The Primary Care Rheumatology Society (PCRS) was aware of the need for education in OA in general practice, but equally aware of the demands on members of the primary healthcare team to take on more and more work in all clinical areas.
General practice is exactly what it says it is obviously impossible for all GPs to be expert in all clinical topics, and the PCRS felt it would be useful to have some easy-to-use guidance that would improve patient care.
We felt that the guidance should indicate:
|Typical features of osteoarthritis|
|Management options suitable for all patients|
|Management options in particular situations|
|A suggested order for drug therapy|
|'Red flags' suggesting potentially serious conditions|
Reasons for referral outside primary care.
We wanted the document to act as a ready reference with straightforward help and advice; it was not intended to be fully comprehensive. We felt therefore that the resultant document should comprise a single A4 sheet for simplicity, should look sufficiently attractive to avoid being relegated to the dustbin without being read, and be sufficiently sturdy to survive on a GP's or a practice nurse's desk.
The result was an A4-sized strong card, pleasantly coloured in shades of deep and pale purple, containing all the above information together with a list of useful addresses and a few important references. (See Figure 1, below, for a summary of the guidance.)
To go with this professional guidance for healthcare staff, we also produced a booklet for patients, giving information about OA, the various therapies available, lifestyle advice, and advice on self-help.
|Figure 1: Primary Care Rheumatology Society guidelines on the management of knee osteoarthritis, |
as summarised in Guidelines, Vol 10, February 2000
We believe that there is a dearth of simple, common sense advice about OA. Many healthcare professionals are unaware of the many simple and effective lifestyle changes that patients can undertake in order to reduce the effects of OA. It does, however, take time to educate patients about OA and the options available, and practice staff need support materials to help them achieve a good outcome.
We felt that the Knee Osteoarthritis Management Options document together with the patient booklet would prove useful as an educational package to improve the knowledge and confidence of practice staff in treating OA of the knee. The patient booklet would, at the same time, provide an appropriate means of reinforcing the advice and information given by the healthcare staff.
The guidelines have only recently been distributed, but already we have had some very positive feedback from GPs who have found the guidance helpful and easy to use in consultations. Several have also commented on the fact that they now have something positive to offer their patients instead of the negative and depressing message that OA is inevitable and virtually untreatable except by joint replacement surgery.
Most patients benefit from having information about their condition. Much of the perceived knowledge of OA is pessimistic, and reassurance and education are thus of great importance.
The good prognosis for most patients with OA should be emphasised, together with the fact that they can do a great deal to help themselves. Long-term encouragement and support will probably be required to achieve this.
Patients should be told about the many different treatment options available, and be reassured that lack of success with one therapy does not mean that 'nothing can be done'.
A recent meta-analysis shows that educational interventions do add a considerable benefit when compared with other treatments.1 The effect, however, is not large and may be time-consuming and expensive to deliver. If all GPs could impart a little education at every contact with OA patients, sufferers would become much better informed and thus better equipped to deal with their condition.
A number of studies have been set up to look at the effect of patient education in rheumatoid arthritis, but to date there are only a few in OA.
There is good evidence from a number of long-term studies, particularly the Framingham studies in the US, that obese subjects with knee OA are at higher risk of developing progressive disease than non-obese subjects.
One study has shown that a weight loss of 11lb in women of average height was associated with around a 50% decrease in the risk of developing symptomatic knee OA.2 Another study, in which patients with knee OA were treated with medication causing weight loss, showed a definite link between the amount of weight lost and symptomatic improvement.3
Further data from the Framingham study have shown that weight gain over 8 years is associated with the devel-opment of radiographic knee OA.4
A number of epidemiological studies have shown that being overweight increases the risk of developing radiographic OA4-6 but does not necessarily mean an increase in pain or disability. This confirms a fact that we are all aware of clinically, namely that the correlation between X-ray changes and symptoms is often poor.
It is most important to emphasise to patients that joints are designed to move and be used, and that inactivity causes many more problems than appropriate activity.
There are two main thrusts to recommending exercise for knee OA.
|Improving general or aerobic fitness.|
There is good evidence that improvement of quadriceps function reduces disability in patients with OA of the knee.7 Physiotherapists are excellent at educating patients to improve quadriceps fuction, but physiotherapy is not a feasible option for many in the community. Patients can be shown simple ways to improve quadriceps function by the primary healthcare team and this advice can be reinforced by our patient advice leaflet, which contains simple diagrams demonstrating how to do the exercises.
There is also evidence that improving quadriceps function may protect patients from developing knee OA, and may reduce the rate of progression for those who already have OA.8,9
Improving general or aerobic fitness helps to improve general muscle strength, aids weight loss, and often leads to a marked improvement in morale and mood.
Weight loss, if appropriate, and increasing exercise both require a consideral degree of motivation on the part of patients. Many patients start out with good intentions but quickly revert to bad habits, and for these patients, in particular, regular support and encouragement is necessary to achieve any improvement in outcome.
Randomised controlled trials involving footwear and impact-absorbing insoles are difficult to set up, and there is very little evidence as yet that the use of such footwear improves outcome.
Expert opinion and again common sense suggest that reducing the impact on a painful joint would help to reduce pain. The use of a flat, comfortable, thick-soled shoe is a simple measure that most patients can try, and many patients benefit considerably from using such footwear.
This is another common sense measure that has the backing of expert opinion.
Patellar taping is an effective treatment for some patients with patellar-femoral knee OA.10 The patella is taped medially, and the alteration of the alignment of the track of the patella may give pain relief.
The North of England Evidence Based Guideline Development Group looked closely at drug therapies for OA, and on the basis of randomised controlled trials made several recommendations:11
|Paracetamol should be used first|
|If this is ineffective then ibuprofen may be tried initially in a low dose|
|If this is still ineffective the dose of ibuprofen may be increased or paracetamol can be added|
If these means are still not effective then a different NSAID may be used.
This group also looked at topical NSAIDs but felt there was insufficient evidence to recommend them at present. A meta-analysis12, however, came to a different conclusion. This group looked at a large number of studies involving topical NSAIDs and concluded that they were effective in relieving pain in both acute and chronic conditions.
Such drugs may be effective for some patients. They also involve the patient in applying his or her own treatment often a good thing psychologically in improving patient control over the condition and reducing dependency on medical intervention. Topical NSAIDS have a very good safety profile but may be relatively expensive.
Topical capsaicin is included as a treatment in Guidelines on The Medical Management of Osteoarthritis of the Knee produced by the American College of Rheumatology.12
It is recommended for patients who do not respond to, or do not wish to take, oral therapies, and there is some evidence to support its use.13,14
Intra-articular injections of hyaluronans are being used increasingly around the world, and the evidence for the use of this therapy is slowly building up. However, the drugs are quite expensive, time-consuming to administer, and many patients do not like the idea of repeated joint injections.
The content of the document Knee Osteoarthritis Management Options was put together by a group of PCR Society Steering Committee members, together with input from a consultant rheumatologist, who is a recognised world expert on OA, and an expert and experienced physiotherapist. The resultant document represents the current and independent views of the PCR Society.
- Copies of the full guideline Knee Osteoarthritis Management Options are available from the Primary Care Rheumatology Society, PO Box 42, Northallerton, North Yorkshire DL7 8YG (Tel 01609 774794).
- We are grateful to Shire Pharmaceuticals who provided an educational grant to the PCR Society for the purpose of producing this document.
- Superio-Cabusulay E, Ward MM, Lorig K. Patient education interventions in OA and RA: a meta-analytic comparison with non-steroidal anti-inflammatory treatment. Arthritis Care Res 1996; 9: 292-301.
- Felson DT, Zhang Y, Anthony JM, Naimark A, Anderson JJ. Weight loss reduces the risk for symptomatic knee osteoarthritis in women. Ann Intern Med 1992; 1(16): 535-9.
- Willims RA, Foulsham BM. Weight reduction in osteoarthritis using phentermine. Practitioner 1981; 225: 231-2.
- (4) Felson DT, Zhang Y, Hannan MT et al. Risk factors for incident radiographic knee osteoarthritis in the elderly. Arthritis Rheum 1997; 40: 728-33.
- Manninen P, Riihimaki H, Helliovaara M, Makela P. Overweight, gender and knee osteoarthritis. Int J Obesity 1996; 20: 595-7.
- Spector TD, Hart DJ, Doyle DV. Incidence and progression of osteoarthritis in women with unilateral knee disease in the general population: the effect of obesity Ann Rheum Dis 1994; 53: 565-8.
- Hurley MV, Scott DL. Improvements in quadriceps sensorimotor function and disability of patients with knee osteoarthritis following a clinically practicable exercise regime. Br J Rheumatol 1998; 37: 1181-7.
- Slemenda C, Mazzuca S, Brandt K, Katz B. Lower extremity lean tissue mass and strength predict increases in pain and in functional impairment in knee osteoarthritis. Arthritis Rheum 1996; 39 Suppl 9: S212.
- Ettinger WH Jr, Burns R, Messier SP et al. A randomised trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis: the Fitness Arthritis and Seniors Trial (FAST). JAMA 1997; 277: 25-31.
- Eccles M, Freemantle N, Mason J et al. North of England Evidence Based Guideline Development Project: Summary guideline for non-steroidal anti-inflammatory drugs (NSAIDs) versus basic analgesia in treating the pain of degenerative arthritis. Br Med J 1998; 317: 526-30.
- Cushnaghan J, McCarthy C, Dieppe P. Taping the patella medially, a new treatment for osteoarthritis of the knee joint? Br Med J 1994; 308: 753-5.
- Hochberg MC, Altman RD, Brandt KD et al. Guidelines for the medical management of osteoarthritis. Part 2: Osteoarthritis of the knee. Arthritis Rheum 1995; 38(11):1541-6.
- Moore RA, Tramer MR, Carroll D, Wiffen PJ, McQuay HI. Quantitive systematic review of topically applied non-steroidal anti-inflammatory drugs. Br Med J; 316 :333-8.
- Deal CL, Schnitzer TJ, Lipstein E et al. Treatment of arthritis with topical capsaicin: a double-blind trial. Clin Ther 1991; 13: 383-95.