Dr Claire Wenham (left) and Professor Philip Conaghan discuss why all individuals with osteoarthritis should be offered a combination of therapies


Osteoarthritis (OA) is the most common form of arthritis in the world and a major cause of joint pain and disability. In 2003 the OA Nation survey showed that 81% of people with OA are in constant pain or are limited in their ability to perform everyday tasks.1 Osteoarthritis is also the most common reason for total knee and hip replacement surgery, and places a large burden on primary care, with 3-million GP consultations for the condition taking place in the UK in 2000.2

Many people presenting to their GP with symptomatic OA have had symptoms for months and some may never seek help, which perhaps reflects a negative perception of the treatments for OA.3 However, effective treatments are available and many of these can and should be initiated in the primary care setting. For people affected by OA, it is the effect of the joint pain and stiffness on their functional ability and quality of life that is the biggest problem.

The role of primary care is to:

  • confidently diagnose OA
  • provide education and advice for patients with OA
  • initiate treatments, including the NICE ‘core’ treatment options
  • make appropriate referrals to secondary care.

Pathogenesis
Medically, OA is a syndrome of joint pain with associated structural changes affecting many joint tissues.4 There is hyaline cartilage loss, meniscal damage, and changes within the subchondral bone, including osteophyte formation and bone attrition.4 Weakness of the supporting ligaments and muscles is a frequent finding and we now understand from sensitive modern imaging studies using magnetic resonance imaging that synovial inflammation is also common in painful osteoarthritic joints.4

Diagnosis
The knee, hand, hip, and first metatarsophalangeal joint are the most common peripheral joints affected by OA.4 Prolonged morning stiffness lasting longer than 1 hour warrants investigation for an inflammatory arthritis.5 The most common symptom described by patients is pain. This tends to be worse after weight-bearing activities, such as going up stairs, and towards the end of the day. Patients may complain of gelling (stiffness of a joint with disuse, e.g. sitting for a period of time), which may be mistaken for locking—an inability to move the flexed knee without physical manipulation.6

Assessment

A holistic assessment of any person with OA is essential, and in the primary care setting more than one consultation may be required. The initial assessment should take into account a person’s existing concerns and expectations about their joint symptoms and also evaluate their mood, as high levels of anxiety and depression are frequent in people with OA.6 Effects on personal life, hobbies, and sleep should be noted, as well as any impact on a person’s job, both in the short- and long-term, as adjustments in the workplace may be helpful (e.g. keyboard wrist rests or varying the length of time spent typing). Current pain symptoms, pain medications, and any self-help treatments should also be recorded in order that a specific management plan can be implemented.6

Guidelines and treatments for osteoarthritis

Currently there are no widely accepted structure-modifying drugs available for OA, so treatments for this condition are aimed at symptom modification. Current treatments include both pharmacological and non-pharmacological therapies and in practice most people with OA will need multiple treatment modalities.

There are two recent guidelines available for the management of OA: the 2008 NICE guideline Osteoarthritis: the care and management of osteoarthritis in adults,6–8 which includes an economic analysis relevant to the UK, and the 2008 Osteoarthritis Research Society International (OARSI) recommendations for the management of hip and knee osteoarthritis, Part 11: OARSI evidence-based, expert consensus guidelines.9 Both guidelines are evidence-based and involve expert consensus; the NICE guideline also received input from people with OA.

The NICE guideline introduces a model for treatment of OA that arranges the therapies in the order in which they should be considered (see Figure 1). The core therapies recommended by NICE, which are also strongly recommended by OARSI, include:6,7,9

  • education, advice, and information access
  • exercise
  • weight loss (if needed).

It is a common misconception that OA is a side-effect of ageing, deteriorates over time, and that there are no helpful treatments. General practitioners have an important role in dispelling the negative attitudes the public has towards OA. Healthcare professionals should offer verbal and written information to all patients. Patient information leaflets are widely available, for example, from the Arthritis Research Campaign10 (www.arthritisresearchuk.org) and should be used to improve peoples’ understanding from an early stage. Patient information should also include advice on appropriate footwear (broad fit, good arch support, and shock-absorbing soles).

Exercise
Exercise is recommended as a core therapy based on numerous randomised controlled trials and systematic reviews that have demonstrated the benefits of keeping active.6,7 It has been shown to improve physical functioning and mental health, and reduce pain, disability, and medication intake. Exercise should be both aerobic and muscle-strengthening specific to the joints involved, for example, forearm-strengthening exercises for
hand OA and quadricep exercises
for knee OA.6,7

Pain, disability, age, or other co-morbidities should not be barriers to exercise, and pain relief is likely to be required to permit regular exercise. In its guideline, NICE did not clarify whether exercise should be provided by the NHS or whether the patient should carry out this intervention after receiving advice from their GP.6,7 Each person should be assessed on an individual basis, but referral to a physiotherapist should be considered for any person with symptomatic knee or hip OA, particularly if they are finding the advised exercises difficult or are not noticing an improvement in their symptoms.9

The Exercise on prescription scheme is a partnership between primary care trusts (PCTs) and local authority leisure services, which is now widely available. For the cost of a prescription, suitable patients can be referred for a 10-week, individually tailored fitness program at a nearby leisure centre.11

Weight loss in those who are overweight or obese has been shown to improve function in hip and knee OA.6,7 The aim is for people to maintain their body mass index between 18.5 and 24.9 as recommended in the NICE guideline on the management of obesity.12 Primary care trusts may also fund local schemes for weight loss, for example the Weight Watchers or Slimming World programmes, where PCTs can purchase a course at a much reduced price, thereby allowing patients to attend at no cost to themselves.

These core treatments should be implemented in conjunction with further pharmacological therapies. Non-pharmacological interventions are also suggested.6,7

Figure 1: Model for treatment options*
figure 1
*Treatment options begin in the central core with simple, safe options and then progress outwards to preferred pharmacological options. The outer ring shows alternatives with higher cost or lower efficacy or increased risk to the patient, which could be used as adjunctive treatments to the inner options.

NSAIDs=non-steroidal anti-inflammatory drugs; COX-2=cyclo-oxgenase-2; TENS=transcutaneous electrical nerve stimulation

Adapted from National Institute for Health and Care Excellence (NICE) (2008) CG 59 Osteoarthritis: the care and management of osteoarthritis in adults. London: NICE. Reproduced with permission. Available from www.nice.org.uk.

Pharmacological treatments

Paracetamol and topical NSAIDs
Paracetamol and topical non-steroidal anti-inflammatory drugs (NSAIDs) for knee and hand OA are recommended before use of oral NSAIDs or cyclo-oxygenase-2 (COX-2) inhibitors. There is good evidence for the effectiveness of paracetamol, particularly for knee OA, although infrequent dosing may lead to reduced efficacy.7 Topical NSAIDs may require multiple daily applications to be effective, which can reduce compliance, but they are effective in the short-term. As with paracetamol, topical NSAIDs are not associated with serious toxicity.13

Oral NSAIDs, COX-2 inhibitors, and opioids
If insufficient pain relief is gained from paracetamol and topical NSAIDs, then the physician should consider adding an oral NSAID, COX-2 inhibitor, or an opioid. Both NSAIDs and COX-2 inhibitors should be used at the lowest effective dose and their long-term use should be avoided if possible.6,7 The potential cardio-renal, gastrointestinal and liver toxicity of individual agents must be taken into account when prescribing; it is worth reviewing patient risk factors on at least a yearly basis. Based on a health economics analysis, NICE recommends that all NSAIDs and COX-2 inhibitors should be co-prescribed with a proton pump inhibitor. For people taking low-dose aspirin, other analgesics, for example, paracetamol or weak opioids, should be trialled before considering an NSAID or COX-2 inhibitor.6,7

Although there is less trial data on opioids than on NSAIDs, there is evidence for analgesic efficacy of opioids.14 These drugs have a high incidence of side-effects (confusion, drowsiness, and constipation),7 which may be particularly troublesome in the elderly.

Glucosamine and/or chondroitin
There is some evidence for symptomatic relief of knee OA with the use of glucosamine sulphate at a dose of 1.5 g daily.9,15 However, this regimen is not currently licensed in the UK. A 3-month trial could be considered for patients willing to buy this medication over the counter. A preparation of glucosamine hydrochloride is now licensed in the UK,16 but trials have not demonstrated a substantial benefit.15 The evidence from systematic reviews of the analgesic efficacy of chondroitin is less convincing and hence due to the inconsistency of trial results, neither drug is currently recommended by NICE.6,7

Topical capsaicin
Topical capsaicin is cost effective when compared with placebo and can be an effective analgesic for knee or hand OA when applied up to four times a day.6 Local redness or irritation can occur in up to 40% of users,9 although this is mild in the majority of patients.

Intra-articular corticosteroids
Intra-articular corticosteroid injections can be used for the relief of moderate to severe pain in people with knee and base of thumb OA. The NICE Guideline Development Group concluded that intra-articular corticosteroid offers short-term pain relief for between 1 and 4 weeks, with the best effects demonstrated for knee OA. There are no current NICE recommendations on which dose or preparation of corticosteroid is most effective. This form of treatment is recommended for people who have moderate to severe pain that is not responding to oral analgesics or anti-inflammatories, or in those people with symptomatic knee OA with effusion or signs of local inflammation.9,17 The OARSI guideline recommends that usually no more than three or four injections per year are given. Such injections should be coupled with review of muscle-strengthening exercises during the reduced pain ‘window’ that follows each injection.17

Intra-articular hyaluronan
There is ongoing controversy with regard to the efficacy, cost effectiveness, and risk:benefit ratio with hyaluronans.Although there are many trials of hyaluronans, there are mixed data on their effectiveness.6,7,9 The NICE guideline does not recommend these drugs (based on a health economics analysis),6,7 however, the OARSI guideline notes that some preparations may be useful for knee and hip OA.9 As with many OA treatments, there is no good evidence to select subgroups of people that may have a better and, therefore, more cost-effective response to treatment.

Non-pharmacological treatments

Application of heat or cold
This is a simple self-management treatment that may give pain relief. Although there is little evidence for its effectiveness, the application of heat or cold is recommended by NICE as it is very low cost and extremely safe.6,7

Transcutaneous electrical nerve stimulation
There is limited evidence for short-term pain relief in knee OA after using transcutaneous electrical nerve stimulation (TENS)6,7,9 and a trial may be considered. The NICE guideline suggests that proper training in the placing of pads and selection of stimulation intensity could make a difference to the benefit obtained.7 Some physiotherapy departments may offer training in the use of TENS machines. Patients who find this therapy effective can be encouraged to buy their own machine, which may be available at a local pharmacy.

Acupuncture
The use of acupuncture remains controversial due to varying trial results and different regimens and types of acupuncture interventions.6 There is some evidence for short-term (2–6 weeks) symptomatic relief for knee OA.9 Again, there is no good evidence to select subgroups of patients who may have a better response to treatment. Further evidence of cost effectiveness is required before acupuncture can be recommended by NICE.6,7 The OARSI guideline concluded that real acupuncture (techniques intended to stimulate known acupuncture points) is more effective than sham acupuncture (techniques not intended to stimulate known acupuncture points) for improving pain, but the effect is generally small and short term (2–6 weeks), and no substantial effect on function has been noted.9

Bracing/joint supports/insoles
Assessment for bracing, joint supports, and insoles should be considered for people with biomechanical joint pain or instability, and patients will require a referral to a podiatry or orthotics department.6,7 A knee brace can improve pain, stiffness, and physical function in mild or moderate valgus or varus instability; however, this is not a substitute for quadricep exercises for most people with OA who complain of a knee ‘giving way’.9

Walking aids
Walking aids can reduce the pain of knee or hip OA.6,7 People may have started using a walking stick before presenting to their GP for further advice and they should be advised on how to use it correctly, i.e. in the contralateral hand.

Surgical referral

Replacement arthroplasties are efficient and cost-effective interventions for patients who have significant pain, and/or functional limitations that are associated with a reduced health-related quality of life, despite conservative therapy.9 Unicompartmental knee replacement can be effective for knee OA that is limited to one compartment of the knee. The NICE guideline recommends that referral should be made before prolonged or established functional limitation occurs or severe pain is felt. Useful questions to ask patients, include:6,7

  • Can you still do leisure activities?
  • Is your job affected by your OA?
  • Is your sleep disturbed?

Surgical referral should be considered regardless of age, obesity, or other co-morbidities. Referral for arthroscopic lavage and debridement is only appropriate in the presence of a clear history of mechanical locking. Loose bodies on plain X-ray do not warrant referral unless there is associated locking.6,7

Implementation

The NICE guideline is easy to implement in primary care and ideally should be started by all GPs who have patients presenting with OA. One of the problems with the current management of OA in primary care is the general public belief (and sometimes that of GPs themselves) that OA is simply a natural part of ageing and cannot be treated. General practitioners who are aware of the available treatment options, are prepared to use a variety of treatments, and refer early to appropriate specialists, can ensure that OA is managed effectively.

Summary

Good primary care management of OA must take into account a person’s day-to-day symptoms, their mood, sleep, and daily function. This assessment is time-consuming and, where possible, a longer consultation time should be allocated. The basic therapies of education, exercise, and weight loss should be offered to all patients with OA. These are ideal to initiate in the primary care setting.
A combination of pharmacological and non-pharmacological treatments should also be offered to all patients. Early referral to physiotherapy, podiatry, and/or occupational therapy will help maintain patients’ mobility and functional status. Surgical referral should be considered for anyone with significant pain and/or functional limitation, regardless of age or other co-morbidities.

Useful websites

References

  1. Arthritis Care. OA Nation. London: Arthritis Care, 2004. Available at: www.arthritiscare.org.uk/PublicationsandResources/Forhealthprofessionals/OANation
  2. Arthritis Research Campaign. Arthritis: the big picture. Chesterfield: ARC, 2002. Available at: www.arthritisresearchuk.org
  3. Peat G, McCarney R, Croft P. Knee pain and osteoarthritis in older adults: a review of community burden and current use of primary health care. Ann Rheum Dis 2000; 60 (2): 91–97.
  4. Felson D, Lawrence R, Dieppe P et al. Osteoarthritis: new insights. Part 1: the disease and its risk factors. Ann Intern Med 2000; 133 (8): 635–646.
  5. Emery P, Breedveld F, Dougados M et al. Early referral recommendation for newly diagnosed rheumatoid arthritis: evidence based development of a clinical guide. Ann Rheum Dis 2002; 61 (4): 290–297.
  6. National Institute for Health and Care Excellence. Osteoarthritis: the care and management of osteoarthritis in adults. Clinical Guideline 59. London: NICE, 2008. Available at: www.nice.org.uk/guidance/CG59/NiceGuidance/pdf/English
  7. The National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults. London: RCP, 2008. Available at: www.nice.org.uk/guidance/CG59/Guidance/pdf/English
  8. Conaghan P, Dickson J, Grant R. Care and management of osteoarthritis in adults: summary of NICE guidance. BMJ 2008; 336 (7642): 502–503.
  9. Zhang W, Moskowitz R, Nuki G et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage 2008; 16 (2): 137–162.
  10. Arthritis Research Campaign website. www.arthritisresearchuk.org (accessed 9 October 2009).
  11. Department of Health. Exercise referral systems: a national quality assurance framework. London: DH, 2001.
  12. National Institute for Health and Care Excellence. Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. Clinical Guideline 43. London: NICE, 2006. Available at: www.nice.org.uk/guidance/CG43
  13. Lin J, Zhang W, Jones A, Doherty M. Efficacy of topical NSAIDs in the treatment of osteoarthritis: a meta-analysis of randomized controlled trials. Chin J Evid Based Med 2005; 5 (9): 667–674.
  14. Avouac J, Gossec L, Dougados M. Efficacy and safety of opioids for osteoarthritis: a meta-analysis of randomized controlled trials. Osteoarthritis Cartilage 2007; 15 (8): 957–965.
  15. Towheed T, Maxwell L, Anastassiades T et al. Glucosamine therapy for treating osteoarthritis. Cochrane Database Syst Rev 2005; (2): CD002946.
  16. Glucosamine for knee osteoarthritis—what’s new? Drugs Ther Bull 2008; 46 (11): 81–84.
  17. Bellamy N, Campbell J, Robinson V et al. Intra-articular corticosteroid for treatment of osteoarthritis of the knee. The Cochrane Database Syst Rev 2006; (2): CD005328.G
written by Dr David Jenner, NHS Alliance GMS contract/PBC Lead
  • The NICE guideline contains a useful diagram that can form the basis of a local care pathway
  • Exercise therapy and weight loss are effective at reducing symptoms of osteoarthritis
  • Physiotherapy, podiatry, and orthotic services can all help to reduce symptoms and prevent the need for surgical intervention
  • Commissioners should ensure these services are commissioned and available as part of the care pathway
  • This will help reduce inappropriate and expensive referrals to orthopaedic hospital services
  • Triage of orthopaedic referrals by physiotherapists could ensure the agreed local care pathway is followed and ensure patients receive optimal care before any planned surgery
  • Tariff costs:a
    • orthopaedic outpatient = £135 (new), £74 (follow up)
    • elective hip replacement = £5590 (HB11C)
    • elective knee replacement = £4102 (HB21C)