Nice | Osteoarthritis

This guideline from NICE is an update of their 2008 osteoarthritis one. There will be more coming soon on pharmacological treatments, so this is covering most of the other stuff. There is only 1 new thing for us, which is in diagnosis. There isn't much else new, but as this is such a common condition, I'll give a brief summary of the guideline.

Diagnosis

There is no need for further investigation if OA is suspected, as long as all 3 of the following criteria are met:

  • Patient is > 45
  • No morning stiffness, or morning stiffness < 30 mins
  • Pain is related to activity

I suspect that most of us are already doing this, but it's nice to have it confirmed. They do warn about 'red-flags' to watch for. Among other things, these include: pain that is unrelated to activity, pain that is worse at night, features of inflammatory arthritis and sudden worsening of pain.

Management

None of this is new, but here's an update.

'Core-Treatment'

We should advise patients that there are 3 main elements in managing OA:

  • Appropriate Information. Patients need to understand what OA is and what it means. Emphasise that it doesn't always get worse. Patient.co.uk has an excellent leaflet that explains what OA is and simple management strategies (including weight loss / aids / medication etc). Something I hadn't really appreciated was that OA is a problem of 'remodeling'. A joint is felt to be continuously remodeling after minor trauma (the wear and tear). If this goes wrong, or can't cope with the degree of damage, then OA results. I think this is a really nice explanation for patients.
  • Exercise - both localised muscle exercises and generalised aerobic exercise. This can be done in classes (these may be more effective and are cost-effective). ARC has good leaflets with exercises.
  • Weight Loss

Other Advice

  • Footwear - ensure it is suitable (eg shock-absorbing)
  • Non-pharmacological pain relief - eg hot and cold packs / TENS / manipulation and stretches / braces and supports
  • Assistive Devices - eg sticks and tap turners.
  • Analgesia - start with regular oral paracetamol (though this may be less effective than previously thought). Then add in topical NSAIDs, then topical capsaicin, then oral NSAIDs or COX-2 inhibitors, then opioids. Intra-articular steroid injections can be used for moderate to severe pain.

Referral on

  • Arthroscopic lavage - for true locking
  • Surgical options - this shouldn't be based upon scoring systems, not should it be left until the person is significantly functionally impaired or in severe pain. They should be having significant symptoms, which are having a significant impact on their quality of life and conservative measures should have been tried first.

What not to advise

  • Heat Rubs
  • Hyaluronan injections
  • Glucosamine / chondroitin (lots of studies show no efficacy, but there are a couple that show positive results, however these were on small numbers of people and were not of high quality)
  • Acupuncture (studies comparing acupuncture to sham acupuncture may show some short term benefits in some measures of pain, though not in others - the evidence is generally not of great quality)

Louise Hudman

I'm a freelance GP locum in Winchester & Southampton locum chambers, and Pallant Medical Chambers Clinical Guidelines Lead Partner.

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