Dr Ian Bernstein discusses new osteoarthritis guidance from NICE, which promotes management and care around core therapies

The new guideline Osteoarthritis: national clinical guideline for care and management in adults from the National Collaborating Centre for Chronic Conditions (NCCCC) and NICE, estimates that 8.5 million people in the UK have joint pain that may be attributable to osteoarthritis, with knee pain being the leading symptom.1,2 Osteoarthritis is a common problem in the adult population. Risk factors include: genetic predisposition, ageing population, obesity, female sex, injury to joints, occupation, and recreational usage.1

Five million people have radiographic evidence of osteoarthritis and symptoms show greater concordance in patients with more severe disease.1 The burden in general practice mirrors the population prevalence, with resultant high consultation rates. One in five visits to GPs are for a musculoskeletal problem,3 with osteoarthritis accounting for 10% and arthralgia responsible for 25% of these consultations.4 The NICE guideline addresses the biomechanical and psychosocial assessment of patients with osteoarthritis1 and its management recommendations balance efficacy, safety, and cost.

Scope of the guideline

There is good clinical evidence elsewhere for numerous different treatment options for osteoarthritis of the knee,4 however, the NICE recommendations take this further by considering the potential harm of treatments, and by including economic evaluations. The NICE guidance uses an onion skin model (see Figure 1), starting with a core of simple and safe options. The model moves outwards to include effective pain-relieving modalities, and then to the final layer of the onion skin involving more costly, evidence-based interventions.1,2

Figure 1: Model for treatment options*

Model for treatment options*

*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.

Core treatments

The recommendations from NICE include offering all the core treatments, such as improved education and information, and advice to exercise more and lose weight. These should be modified according to the needs of the individual patient, for example if weight-bearing joints are affected.


The full guidance emphasises taking a thorough pain history and providing information on joint protection.1 Psychosocial assessment and provision of information for patients increases patient satisfaction, improves active coping strategies, reduces unnecessary surgery attendances, and reduces requests for investigations.


The trials of increased exercise in patients with osteoarthritis demonstrate modest and variable improvements in pain and functioning. There was no clear difference between general aerobic fitness training and specific strengthening exercises. A combination of class-based and home-based exercise was more effective than home exercises alone, and the guideline economic analysis supports the provision of exercise classes with overall cost savings and improved outcomes.1 Manual therapy provided additional benefits over land-based exercises, with improvements in pain, stiffness, and functional ability.1 However, hydrotherapy was not found to be superior to land-based exercises.1

Weight loss

Weight loss of as little as 6 kg was shown to produce improvements in functioning but there was no consistent improvement in pain, and reduction in weight was not found to affect disease progression. The NICE guideline on Obesity has reviewed the evidence for effective weight loss strategies.6 In practice, weight loss is rarely sustained but there are additional health benefits of losing weight, including making exercise easier and reducing complications from co-morbidities.

Drug interventions

Oral NSAIDs were shown to be superior to paracetamol in reducing pain and stiffness and were preferred by patients for that reason. However, this was accompanied by a significant increase in minor and major adverse events and withdrawals from treatment.1 NICE has found good evidence for paracetamol as first-line pharmacological therapy, particularly for osteoarthritis of the knee, and advised that full and regular dosing is required for good efficacy. Topical NSAIDs had as good an analgesic effect compared to oral NSAIDs, with greater reductions in stiffness and fewer serious adverse events with topical NSAID use compared with oral NSAIDs. NICE has therefore recommended that either paracetamol or topical NSAIDs should be considered ahead of other oral therapies. The economic analysis, which took into account the costs of treating cardiac and gastrointestinal complications, added weight to the use of topical treatment.1

Neither cyclo-oxygenase-2 (COX-2) inhibitors nor standard NSAIDs were clearly shown to be more effective than the other. The drugs had different side-effect profiles and the NICE guideline recommends selecting the drugs on the basis of assessment of patient risk factors.1 These factors include age, gastrointestinal, cardiovascular, renal, and liver disease, as well as interacting drugs, such as warfarin. Health economic modelling showed that it was always more cost effective to coprescribe a proton pump inhibitor with both systemic NSAIDs and COX-2 inhibitors for gastroprotection.3

The guideline recommends that opioid analgesics should be prescribed only after first trying paracetamol and topical NSAIDs because of reports of side-effects and lack of good evidence of benefit.3

The adjunctive use of intra-articular steroid injections for osteoarthritis of the knee, hip, and thumb were reviewed in the full guideline. The evidence was strongest for short-term pain relief, and NICE recommends the use of intra-articular steroid injections in addition to core treatments, for moderate to severe pain.1

Non-pharmacological interventions

Modalities of non-pharmacological therapy that were assessed included specific strength training and exercises, mobilisation, manipulation, stretching, and oscillatory movements. In view of the modest benefits from exercise alone, the NICE guideline recommends manual therapy as an adjunctive treatment to core therapy.1,2

Ultrasound, laser, and interferential therapy were of limited benefit for osteoarthritis of the knee. By contrast, NICE recommends transcutaneous nerve stimulation (TENS) as an adjunct to core treatment for pain relief. TENS machines are available over the counter at pharmacies. The full NICE guidance specifies the settings for starting treatment and the contraindications.1

Acupuncture was shown, in some studies, to be both effective and cost effective for providing short-term (6–12 weeks) pain relief. Electro-acupuncture was more expensive and above the NICE threshold for cost effectiveness.1

Referral for surgical treatments

Surgery is indicated for refractory pain, stiffness, loss of function, or where the osteoarthritis is having a substantial impact on the patient’s quality of life, although patients should be offered core treatments before referral for surgery. Orthopaedic grading scores for referral for arthroplasties are not recommended as they have not been methodically validated. Instead, NICE recommends that referral thresholds should be based on local discussions between patients, their representatives, surgeons, and referring clinicians.

Referral for arthroscopic lavage and debridement is only recommended where there is a history of locking or evidence of loose bodies. Patient factors such as age, gender, obesity and co-morbidities should not be barriers to referral as these are inconsistent predictors of outcomes and complications.

Shortcomings of the guidance

It is disappointing that NICE chose not to make a specific recommendation to use acupuncture as an adjunctive treatment. Although the trials and economic analyses of acupuncture showed mixed results, the guideline development group commented that acupuncture can provide short to medium term relief in some people, albeit with borderline cost effectiveness.

The decision of the guideline development group to not recommend glucosamine supplements (as glucosamine sulphate 1500 mg) or viscosupplementation (hyaluronan injections) appears to be at variance with their own assessment of the Cochrane reviews,7,8 safety data, and economic evaluations.


The guideline from NICE is comprehensive, covering the major pharmacological and non-pharmacological interventions. It promotes the holistic assessment of the patient using a biomechanical and psychosocial approach familiar to GPs. However, there is lack of NHS funding for the core activities, including referrals for aerobic exercise and weight reduction programmes. Patients will require timely access to therapists for specific strengthening and exercise programmes as well as manual treatments and electrotherapies.

In many areas, access to rehabilitation services is still beset by long waits and poor resourcing. It will fall to local commissioners to provide sufficient resources to meet the high burden of pain, disability, and consequent GP consultation rates.

  1. National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults.London: Royal College of Physicians, 2008.
  2. National Institute for Health and Care Excellence. Osteoarthritis: the care and management of osteoarthritis in adults. Clinical Guideline 59. London: NICE, 2008.
  3. Jordan K, Clarke A, Symmons D et al. Measuring disease prevalence: a comparison of musculoskeletal disease using four general practice consultation databases. Br J Gen Pract 2007; 57 (534): 7–14.
  4. Medicines and Healthcare Products Regulatory Agency. The General Practice Research Database. www.gprd.com [Accessed 2001 by Clarke A, Symmons D. The Burden of Rheumatic Disease. Medicine 2006; 34 (9): 333–335.]
  5. Hunter D. Review: evidence exists for 33 different treatment options for osteoarthritis of the knee. Evidence-Based Med 2004; 9: 81.
  6. National Institute for Health and Care Excellence. Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children. Clinical Guideline 43. London: NICE, 2006.
  7. Bellamy N, Campbell J, Robinson V et al. Viscosupplementation for the treatment of osteoarthritis of the knee. Cochrane Database Syst Rev 2006; (2): CD005321.
  8. Towheed T, Maxwell L, Anastassiades T et al. Glucosamine therapy for treating osteoarthritis. Cochrane Database Syst Rev 2005; (2): CD002946.G