Dr Elspeth Wise (left) and Prof Philip G. Conaghan explain how shared decision-making, patient information, and uniform access to surgery will improve osteoarthritis care


Osteoarthritis (OA) remains a very common problem in the UK with around 8.5 million people affected.1 Seventy-one percent of these individuals are in constant pain from their OA and many give up activities that were once significant parts of their lives, for example work, hobbies, holidays, and leisure activities.2,3 It is predicted that the prevalence of OA will rise dramatically as the population ages and the obesity epidemic continues.4

A UK survey has revealed that many individuals with OA think that the NHS views their condition as a low priority.2 Many wait until their pain is unbearable before they seek help from medical services.2

The need for an update

NICE first produced a guideline for the management of OA in 2008 (Clinical Guideline [CG] 59, see www.nice.org.uk/guidance/CG59).5 Each published NICE guideline has a date for review, so that new evidence can be appraised and included in an updated guideline if necessary.

A review of new evidence in the field of OA highlighted a need to reconsider and update certain specific recommendations in NICE CG59, and so NICE CG177 on Osteoarthritis: Care and management in adults, which updated and replaced CG59, was published in February 2014 (see www.nice.org.uk/guidance/CG177).3

Improving diagnosis and management

There are 13 new and/or updated recommendations in CG177 that are relevant to primary care. A couple of these recommendations link to other recent NICE guidelines, for example on patient experience (NICE CG138, see www.nice.org.uk/guidance/CG138)6 and obesity (NICE CG43, see www.nice.org.uk/guidance/CG43).7 Attention to the key priorities highlighted in the updated guideline will underpin best practice (see also Table 1).

Diagnosis

The updated OA guideline highlights that OA is predominantly a clinical diagnosis in people aged over 45 years.3 This should reassure clinicians that investigations are often not necessary in this group as long as individuals have a ‘non-inflammatory’ history, i.e. they have joint pain that has minimal morning stiffness (<30 min), is often worse on weight-bearing or after prolonged immobility, and there is no evidence of widespread synovitis of small joints.3 Good history-taking and examination skills are essential.

Holistic assessment and management

The original OA guideline discussed the importance of holistic care, and the new guideline continues a patient-centred focus (see Figure 1). A recommendation about the use of shared decision-making is included, which links to NICE CG138 on Patient experience in adult NHS services (see www.nice.org.uk/guidance/CG138),6 and the white paper declaration of ‘no decision about me, without me’.10 NICE CG177 states that a plan of management should be agreed with the person and/or family members/carers.3 A number of effective interventions that ease the symptoms of OA depend on the individual ‘taking them on board’. Shared decision-making has been shown to empower patients and to improve compliance with management options; it is hoped that if healthcare practitioners increasingly adopt this approach, patient management will improve.11

Education and self-management

Decision aids for people with OA are available (see Box 1).12-15 These aids may help when discussing treatments. NICE currently has a scholar in County Durham working on a project to implement shared decision-making in care pathways for hip and knee osteoarthritis.16

Table 1: Suggested key priorities for clinicians
  • Ensure that everyone with OA has access to a surgical opinion:
    • funding may be an issue, especially in areas where prioritising tools have been used
  • Reinforce the core treatments, which are simple and cost-effective. Clinicians often forget these when focusing on medication or referring patients to surgery and may need to be educated about the core treatments
  • Encourage patients to exercise:
    • referring all patients with OA to a physiotherapist would be costly. Interventions such as ‘ESCAPE knee’—a rehabilitation programme that integrates exercise and self-management strategies for knee pain—may be worth considering8
  • Address the patient’s weight issues:
    • the Chief Medical Officer has raised concerns that being overweight is now considered the norm.9 Seeing an overweight patient with OA should stimulate a discussion about their weight and strategies to reduce it.
  • OA=osteoarthritis

Box 1: Useful sources of information for patients*

  • * Accessed 3 June 2014
Figure 1: Holistic assessment of a person with osteoarthritis
Figure 1: Holistic assessment of a person with osteoarthritis
  • OA=osteoarthritis
  • NICE. Osteoarthritis: care and management in adults. Clinical Guideline 177. NICE, 2014. Adapted from Figure 1 and reproduced with kind permission.

Non-surgical interventions

Exercise and weight loss

NICE CG177 highlights that the core treatment for OA remains exercise—this not only helps relieve pain for some people but also improves function. The symptoms often caused by OA, such as pain and limited joint movement, can be managed with muscle-strengthening, exercise, and weight loss if people are overweight.3 Obesity is a recognised risk factor for OA and reducing weight can significantly help to reduce pain (although most studies have focused on the knee).1 NICE CG59 did recommend weight loss as part of the core treatment for people with OA but the updated guideline encourages healthcare professionals to be more proactive by offering advice on weight management, and it specifically references NICE guidance on obesity.7

Other non-surgical interventions

The updated guideline offers definitive recommendations on three options that people with OA may ask about during consultations.3 The first is glucosamine and chondroitin. NICE CG59 advised that these should not be prescribed but that patients could try over-the-counter agents for a time if they wished. This was because the evidence available at the time suggested that glucosamine might work in certain people, but it was impossible to tell in whom. Updated reviews of the evidence have shown that the analgesic effect of these agents appears to be equivalent to that only of a placebo; therefore the new recommendation no longer suggests over-the-counter trials; rather, it states, ‘do not offer glucosamine or chondroitin products for the management of osteoarthritis’.3

The review of the evidence also shows that intra-articular hyaluronan injections for the management of OA have no clinically meaningful benefit over placebo, and so should not be offered.3 The latest evidence for acupuncture in the management of OA likewise shows no clinical benefit over a sham procedure, again suggesting the benefits relate to the non-specific components of the intervention.1

Pharmacological management

The guideline update initially planned to review the existing recommendations on pharmacological management of OA. As the Medicines and Healthcare products Regulatory Agency (MHRA) intends to undertake a wide review on use of drug treatments, including paracetamol, that would be helpful in informing the NICE guideline, NICE will wait until the MHRA’s work is complete before reviewing all pharmacological management for OA. This will enable all relevant painkillers to be considered together. Until the full pharmacological update is undertaken, the guideline recommendations on drug management for OA remain unchanged.3

Surgical interventions

Five specific recommendations have been made regarding referral to surgery. Over recent years, there have been regional variations as to who can be considered for surgery; the aims of updated NICE recommendations are to guide uniform practice and to get people to see a surgeon before their symptoms progress to severe pain and significant functional limitation. These patients may not get as good a result from a joint replacement as they would have done if the procedure had been performed earlier. A specific recommendation is made against the use of scoring tools when deciding who and when to refer. Instead, anyone who has symptoms that are impacting upon their quality of life and are not responding to non-surgical treatments should be considered for referral.3

Before referring, it is advised to recap on whether or not the core treatments have been offered and to discuss what a joint replacement involves. Patients considering a replacement should have realistic expectations as to what the operation involves, what the recovery time is, and most importantly that their prosthetic joint will not behave exactly as their own joint did (e.g. a knee replacement may only allow flexion to 90 degrees). Factors such as age, smoking, or obesity should not be a barrier to referral.3

Patient review

For the first time, the new NICE OA guidance formalises reviewing people with symptomatic OA. The perception of people with OA is that the NHS does not prioritise their condition. They often have multiple chronic conditions and their OA may be overlooked because it is not life-threatening and is not part of the quality and outcomes framework.17

It is recommended that people with any of the following:3

  • troublesome joint pain
  • more than one joint with symptoms
  • more than one comorbidity
  • regular medication for their osteoarthritis

should be considered for review on at least an annual basis to ensure that any necessary checks are performed (for example, UEs/FBC/BP for people on regular non-steroidal anti-inflammatory drugs). Everyone with symptomatic OA should also get the chance on a regular basis to discuss their symptoms, treatment, and any concerns with a healthcare professional. At these reviews, self-management should be encouraged and the core guidance discussed to ensure that the effects of treatments are being maximised.3

Promoting best practice in primary care

The new clinical guideline will encourage doctors to use their clinical skills as the basis for diagnosing OA, rather than relying on investigations such as X-rays. It is well recognised that an individual’s symptoms do not correlate with the findings on X-rays and over-reliance on investigations can be detrimental to the patient,1 because people may have severe pain and only ‘mild OA’ on X-ray and may not be believed or treated appropriately.

A major effect of the new guideline will be to ensure equity of access to a surgical opinion (see text under heading ‘Surgical interventions’). Joint replacement is a very effective way of easing pain when used appropriately but there appear to be differences across the country as to who can be referred. In some regions, prioritising tools have been used, and an individual’s weight has also been used as a reason as to why they may not be considered for a joint replacement. The data from the National Joint Registry show that the improvements reported by people following a total knee replacement are irrespective of their weight18 and so a high body mass index should not be a deterrent.

Conclusion

We do not have a wide range of effective interventions for OA but NICE CG177 promotes exercise, and the use of consultation skills in the form of shared decision-making, to try to maximise the effect of the interventions that we do have. It also highlights therapies that will not be of benefit and ensures equality of access for a surgical opinion.

  1. National Clinical Guideline Centre. Osteoarthritis. Care and management in adults. Clinical Guideline 177. NCGC, 2014. Available at: www.nice.org.uk/nicemedia/live/14383/66524/66524.pdf
  2. Arthritis Care. OA Nation 2012. London: Arthritis Care, 2012. Available at: www.arthritiscare.org.uk/LivingwithArthritis/oanation-2012
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  4. Arthritis Research UK. Osteoarthritis in general practice. Chesterfield: Arthritis Research UK, 2013. Available at: www.arthritisresearchuk.org
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  6. NICE. Patient experience in adult NHS services: improving the experience of care for people using NHS services. Clinical Guideline 138. London: NICE, 2012. Available at: www.nice.org.uk/guidance/CG138
  7. NICE. 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
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  9. Howard S. Chief medical officer urges action to tackle overweight and obesity BMJ 2014; 348: g2375.
  10. Department of Health. Equity and Excellence: Liberating the NHS. London: DH, 2010. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_117353
  11. O’Connor A, Bennett C, Stacey D et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2009; 3: CD001431.
  12. Patient.co.uk website. Osteoarthritis (OA) of the knee. www.patient.co.uk/decision-aids/osteoarthritis-oa-of-the-knee (accessed 3 June 2014).
  13. NHS website. Shared decision making. Osteoarthritis of the knee. Available at: sdm.rightcare.nhs.uk/pda/(accessed 3 June 2014).
  14. Arthritis Care website. www.arthritiscare.org.uk (accessed 10 June 2014).
  15. Arthritis Research UK website. www.arthritisresearchuk.org (accessed 10 June 2014).
  16. NICE website. NICE Fellows and Scholars. Scholars. Jim Brown. www.nice.org.uk/getinvolved/nice_fellows_and_scholars/scholars/JamesBrown.jsp (accessed 30 May 2014).
  17. NHS Employers website. Quality and outcomes framework. www.nhsemployers.org/your-workforce/primary-care-contacts/general-medical-services/quality-and-outcomes-framework (accessed 30 May 2014).
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