Although clinical guidelines are undoubtedly useful, a major issue is how to use them to improve the quality of patient care without putting a disproportionate burden on particular groups of services or healthcare professionals. This is particularly true in the present economic climate where new funding for resources to tackle the problem is extremely unlikely.
The production and use of guidelines are crucial. For many disease areas and disorders there are easily measurable biological values, clear diagnostic investigations, and treatments with clear measurable responses; the production and acceptance of guidelines in such conditions is relatively straightforward. Cardiovascular conditions would be one example, not least, hypertension. Lifestyle plays its part, but it runs parallel to the medication or procedures, which require little effort in terms of patient compliance.
What about osteoarthritis (OA)? This condition composes a significant proportion of workload for GPs and other healthcare professionals. There are huge variations between the joints in one individual in addition to variations in function between individuals with apparently severe changes as shown in X-rays or gross clinical findings; this is complicated even further as some individuals with major symptoms will have only modest clinical findings or X-ray changes.1 There is no clear definitive diagnostic test for OA or simple objective measure of treatment success.
Although it is more difficult to produce guidelines in conditions such as OA it is probably more critical. The NICE guideline on OA demonstrates that there is much to be learnt about the management of this condition particularly on how to implement best practice, questions about fringe treatments, and subsets of patients within the diagnosis.1,2This guideline could help to shape care positively for people with this very common condition. Osteoarthritis is a metabolically active repair process; in some people, the repair process cannot match the wear and tear, resulting in symptomatic presentation. Osteoarthitis is a clinical syndrome of joint pain accompanied by varying degrees of functional limitation and reduced quality of life. This is a loose definition and makes epidemiology difficult.1,2 Variations in imaging techniques and definition can also affect which individuals are defined as having OA and make it difficult to compare studies.3
The prevalence of OA increases with age,4 but not as an inevitable consequence, with many people of working age developing this condition. The incidence of OA rises as the prevalence of risk factors such as obesity and poor levels of physical fitness also continues to rise. Approximately 8.5 million people in the UK are affected by joint pain that may be attributed to OA.5 Population estimates of the prevalence of joint symptoms depends heavily on the specific definition used.
Global disability in terms of general function is high among people reporting isolated knee pain. In adults aged 50 years and over, 23% report severe pain and disability.6 The impact of OA on individuals is profound and many experience persistent pain7 that can impact greatly on aspects of daily life; restriction in mobility is broadly proportional to the severity of pain.1
The burden of OA on society as a whole is massive. It is estimated that by 2020, OA will be the fourth leading cause of disability.8 Approximately 2 million people visit their GP each year and in 2000, hip and knee replacements cost the NHS £405 million.7 In economic terms OA costs the UK 1% of the gross national product per year.1 Osteoarthritis is by far the most common form of arthritis and one of the leading causes of pain and disability worldwide. The exact incidence and prevalence of this condition is difficult to determine because the clinical syndrome of OA (joint pain and stiffness) does not always correspond with the structural changes shown on imaging.1,2
Good patient care and appropriate management of OA flow from correct recognition. The published NICE guideline unfortunately does not cover diagnostic criteria.2 However, the full guideline Osteoarthritis: national clinical guideline for care and management in adults suggests the following diagnostic criteria for a working diagnosis of OA:1
- Persistent joint pain that is worse with use
- Aged 45 years old and over
- Morning stiffness lasting no more than half an hour.
Patients meeting the working diagnosis of OA do not normally require radiological or laboratory investigations. Other symptoms and findings, which will if required add to diagnostic certainty, include:2
- inactivity pain and stiffness, known as ‘gelling’. This is extremely common, for example, after prolonged sitting
- examination findings of crepitus or bony swelling
- radiological evidence of OA
- absence of evidence indicating inflammation or inflammatory markers (raised erythrocyte sedimentation rate/C-reactive protein/plasma viscosity).
It is vital that clinicians are able to differentiate between OA and inflammatory arthritis. Early referral to a specialist rheumatologist is mandatory in cases of inflammatory arthritis. However, patients with inflammatory arthritis may also have secondary OA, and the NICE guideline would therefore be applicable to these patients.
The NICE guideline emphasises the need for a holistic approach in patients with OA, particularly when assessing the impact on various aspects of an individual’s life—function, quality of life, occupation, mood, relationships, and leisure activities.1,2 Considering the global needs of patients as individuals has a beneficial effect on their quality of life.9 The principles of this holistic approach are illustrated in Figure 1.
|Figure 1: Holistic assessment of person with osteoarthritis1,2|
Inner core therapies
Figure 2 illustrates the three levels of intervention. The inner core is often loosely termed the core therapies as these are considered appropriate for all patients with OA. The important principle is that the therapies are logically applied starting from the centre.1,2
Strengthening exercises to the musculature around an affected joint and aerobic fitness training
Exercise is widely used by healthcare professionals and patients to reduce pain.10 It is a common myth among patients that activity wears out the joint. However, while some individuals may experience an exacerbation of symptoms, the vast majority of people, including those severely affected, will not have any adverse reaction to controlled exercise.11 For example, patients with significant OA can ride a bicycle, go swimming, or exercise at a gym, often with no or minimal discomfort.
Exercise, both local muscle strengthening, and general aerobic fitness should be a core treatment for patients with OA, irrespective of age, co-morbidity, pain severity, or disability.1,2
The NICE guideline pushes weight loss as a core treatment with the implication that weight loss has proven benefit to OA. There are few doctors I meet who are not convinced that abnormal or excessive mechanical loading of a joint facilitates progressive deterioration in OA joints. It is logical and fits in with what we see as GPs. The association of obesity with the development and progression of OA, especially at the knee, provides the justification for weight reduction.1 However, the evidence is patchy. The data does suggest that weight loss of sufficient magnitude can lead to an improvement in function.1 However, the only study to show an unequivocal effect on WOMAC (Western Ontario and McMaster Osteoarthritis Index) pain as a primary outcome measure included exercise as one part of a complex intervention.12
Despite the limitations of the available evidence, the benefits of weight loss in people with OA who are overweight are generally perceived to be greater than the risks. The Guideline Development Group (GDG) therefores advocate weight loss in all adults who are overweight or obese with OA of the knee and hip who have associated functional limitations.1
Education, advice, and information access
Patient education has been advocated as a method of limiting the impact of long-term conditions.13 The NICE guideline states that healthcare professionals should offer verbal and written information to all people with OA to enhance understanding and dispel misconceptions and this is coupled with the recommendation that individualised self-management strategies should be agreed between healthcare professionals and the person with OA.1,2 It is indisputable that patients do not retain all the verbal information from a consultation and written information helps, and information sharing should be an ongoing process.14 The logic is faultless but I hear alarm bells asking where the manpower to deliver this is going to come from. Most, if not all of us, are comfortable with improving communication and sharing information and see it as a valuable part of our work. However at a time when we are hammered repeatedly to practise evidence-based medicine, the link between this aspect of core treatment and positive outcomes in patients with OA is tenuous even if the human resources to deliver it were available.
|Figure 2: Model for treatment options*1,2|
*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.
Middle core therapies
Paracetamol is the treatment of choice. It is safe and effective especially if taken regularly in knee arthritis. The evidence is less strong for other forms of arthritis.1 The safety benefits are well recognised but in practice the main issue for most of us is to persuade patients to take it on a regular ongoing basis, particularly when many of them know that non-steroidal anti-inflammatory (NSAIDs) drugs give good pain relief.
Topical NSAIDs are recommended as the next pharmacological treatment. The available evidence shows short-term benefits over placebo, although there are no long-term studies. However, this therapy is popular with patients and as it produces a plasma concentration that is 15% of that resulting with oral NSAID treatment, it is a safe option.1 Topical NSAIDs have the same mode of pharmacological effects on intra- and extra-articular structures.15
Outer core therapies
Acupuncture and nutraceuticals should not be used as there is a paucity of consistent evidence of clinical or cost effectiveness.1 However, appropriate use of aids and devices are thought to be beneficial. Advice on footwear for lower limb OA is considered part of the core information and education process. Biomechanical problems contributing to joint pain should be corrected with orthotics or bracing/joint support. Assistive devices, walking sticks, and tap turners should be considered where there are specific problems with activities of daily living.1,2
Manual therapy (manipulation and stretching) is particularly beneficial in hip OA and should be considered.16 The use of local heat or cold should be considered as an adjunct to core therapy. The only form of electrotherapy that should be considered is TENS, which produces an analgesic effect.17,18
Opioid analgesics should be considered when paracetamol or topical NSAIDs have failed to provide effective pain relief. The NICE guideline goes on to say oral NSAIDs and cyclo-oxygenase 2 (COX-2) inhibitors should be considered when paracetamol or topical NSAIDs have failed to provide effective pain relief. The choice should be a standard NSAID or COX-2 inhibitor (other than etoricoxib 60 mg), prescribed with a proton pump inhibitor, with the lowest acquisition cost. There is no specific guidance on whether opioids or NSAIDs/COX-2 inhibitors should be the first next choice. The guideline is clear that the side-effect risk to the individual and their circumstances should be considered and it would seem logical for this consideration to guide the choice.
Capsaicin and other rubefacients often produce relief. It is debatable as to whether the rubbing process and expectation of benefit are the major source of relief.1 However, there is clear evidence that capsaicin does alter neurotransmitters in the tissues. The NICE guideline recommends considering capsaicin but does not recommend the use of rubefacients.1,2
Intra-articular injections of corticosteroids should be considered as an adjunct to core treatment for the relief of moderate to severe pain,19 but hyaluronan injections are not recommended based on lack of cost effectiveness although the GDG recommended further research.1,2
Arthroscopy and lavage should not be offered as part of treatment for OA, unless the person has knee OA with a clear history of mechanical locking (not gelling, ‘giving way’, or X-ray evidence of loose bodies).1,2,20
The guideline suggests referral for arthoplasty for patients with OA who have joint symptoms having a substantial impact on their quality of life and who are refractory to non-surgical treatment. Age, gender, smoking, obesity, and co-morbidities should not be barriers to referral. The use of scoring tools for prioritisation is not recommended.1,2
Successful outcomes following surgery are dependent on:1
- careful selection of patients most likely to benefit
- thorough preparation in terms of general health and information
- well-performed anaesthesia and surgery
- appropriate rehabilitation and domestic support for the first few weeks.
In my experience implementation of the NICE guideline on OA in primary care is patchy. The main issue is time constraints. Use of paracetamol is gaining momentum through the guideline and the general increased caution regarding NSAIDs/COX-2 inhibitors. However, the uptake of the inner core therapies is less good. In many areas, access to exercising facilities is not easy or available, but the main difficulty is the time and effort required to motivate individual patients to change their lifestyle.
Extrapolating from the UK OA prevalence figure of 8.5 million, in my practice of 5200 patients, approximately 700 of these individuals will have this condition. I confirmed this in a simple search as a ball-park figure. If one accepts that to devise and provide information and an agreed individual plan takes 30 minutes; this adds up to 700 hours per year if this done at a minimum of twice a year. This is equivalent to 4200 normal 10-minute appointments or 91 appointments a week allowing for holidays. Even if the review can be done in 20 minutes, this still requires 60 appointments a week. I cannot see these core therapies taking hold due to lack of time to implement them effectively.
The NICE guideline on OA is clear and precise as one would expect as it is evidence based, but given the scale of burden associated with this condition, there is relatively little research in many areas and the lack of a clear objective diagnostic test is an obstacle to implementation. However, the major barrier to implementing the guideline is that the core treatments demand a level of input from various clinicians that is simply not available and requires patients to continue the core therapies on a long-term basis, which they tend not to do. The concept that subsets of OA, with different causes or underlying problems, exist within the global diagnosis of this condition, is interesting. It is a possible explanation for why many clinicians maintain that a proportion of individuals respond particularly well to acupuncture, nutraceuticals (glucosamine and chondroitin), steroid injections, and hyaluronan. The guideline highlights the need for future research in general.1,2
- Osteoarthritis is a major cost to the NHS particularly through medication costs and joint arthoplasty
- Commissioners should consider ensuring the availability of self-help facilitators to support people with arthritis
- Expert patient groups could be another option for education and support at minimal cost to the NHS
- Local formularies for low-cost analgesics can help save prescribing costs
- Orthopaedic procedures (most commonly for osteoarthritis) represent a major cost for commissioners
- The decision to operate should not be based on scoring systems. However, referral criteria, triage by physiotherapists, and symptom scoring systems are sensible ways to ensure that patients needs are matched with a referral to the most appropriate service thus helping to rationalise referral quantities and costs
- Tariff costs:a
- Orthopaedic outpatients=£148 (new), £83 (follow up)
- Knee replacement=£2934 (HB22c)
- Hip replacement=£4863 (HB12c)
- National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults. London: Royal College of Physicians, 2008. Available at: www.nice.org.uk/guidance/CG59
- 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
- Duncan R, Hay E, Saklatvala J, Croft P. Prevalence of radiographic osteoarthritis—it all depends on your point of view. Rheumatology 2006; 45 (6): 757–760.
- Arthritis and Musculoskeletal Alliance. Standards of care for people with osteoarthritis. London: ARMA, 2004.
- Arthritis Care. OA Nation. London: Arthritis Care, 2004. Available at: www.arthritiscare.org.uk/PublicationsandResources/Forhealthprofessionals/OANation
- Jinks C, Jordan K, Ong B, Croft P. A brief screening tool for knee pain in primary care (KNEST). 2. Results from a survey in the general population aged 50 and over. Rheumatology 2004; 43 (1): 55–61.
- Arthritis Research Campaign. Arthritis: the big picture. London: ARC, 2002.
- Woolf A, Pfleger B. Burden of major musculoskeletal conditions. Bulletin of the World Health Organization 2003; 81 (9): 646–656.
- Sobel D. Rethinking medicine: improving health outcomes with cost-effective psychosocial interventions. Psychosom Med 1995; 57 (3): 234–244.
- Fransen M, McConnell S, Bell M. Therapeutic exercise for people with osteoarthritis of the hip or knee. A systematic review. J Rheumatology 2002; 29 (8): 1737–1745.
- Hurley M, Walsh N, Mitchell H et al. Clinical effectiveness of a rehabilitation program integrating exercise, self-management, and active coping strategies for chronic knee pain: a cluster randomized trial. Arthritis Rheum 2007; 57 (7): 1211–1219.
- Messier S, Loeser R, Miller G et al. Exercise and dietary weight loss in overweight and obese older adults with knee osteoarthritis: the Arthritis, Diet, and Activity Promotion Trial. Arthritis Rheum 2004; 50 (5): 1501–1510.
- Department of Health. Self care—a real choice: self care support—a practical option. London: DH, 2005.
- Donovan J, Blake D, Fleming W. The patient is not a blank sheet: lay beliefs and their relevance to patient education. Br J Rheumatol 1989; 28 (1): 58–61.
- Lin J, Zhang W, Jones A et al. Efficacy of topical non-steroidal anti-inflammatory drugs in the treatment of osteoarthritis: meta-analysis of randomised controlled trials. BMJ 2004; 329 (7461): 324.
- Hoeksma H, Dekker J, Ronday H et al. Comparison of manual therapy and exercise therapy in osteoarthritis of the hip: a randomized clinical trial. Arthritis Rheum 2004; 51 (5): 722–729.
- Cheing G, Hui-Chan C. Analgesic effects of transcutaneous electrical nerve stimulation and interferential currents on heat pain in healthy subjects. J Rehabil Med 2003; 35 (1): 15–19.
- Cheing G, Tsui A, Lo S et al. Optimal stimulation duration of TENS in the management of osteoarthritic knee pain. J Rehabil Med 2003; 35 (2): 62–68.
- Ostergaard M, Stoltenberg M, Gideon P et al. Changes in synovial membrane and joint effusion volumes after intraarticular methylprednisolone. J Rheumatol 1996; 23 (27): 1151–1161.
- National Institute for Health and Care Excellence. Arthroscopic knee washout, with or without debridement, for the treatment of osteoarthritis, with or without debridement for the treatment of osteoarthritis. London: NICE, 2007. Available at: www.nice.org.uk/guidance/IPG230 G