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Osteoarthritis
Clinical Lecturer in General Practice, Department of Primary Care, University of Southampton School of Medicine, UK
Email: hae1{at}soton.ac.uk
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Abstract |
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 TOP Abstract The GP curriculum and...Aetiology and natural history...DiagnosisInvestigationsAssessmentManagementReferences |
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Osteoarthritis (OA) is the most common type of arthritis and a leading cause of locomotor disability. Over 4.4 million people in the United Kingdom have moderate to severe OA. It is a chronic disease that causes a significant burden to society and healthcare resources and its impact is likely to increase with an ageing population and rising levels of obesity.
The GP curriculum statement 15.9 outlines GP's roles and responsibilities in Rheumatology, Musculoskeletal and Trauma. It states that GPs in training must:
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The main reason for patients seeking medical help is pain. This article aims to provide an up to date overview of Osteoarthritis (OA) diagnosis and management in primary care.
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Aetiology and natural history of OA |
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TOPAbstractThe GP curriculum and...Aetiology and natural history...DiagnosisInvestigationsAssessmentManagementReferences |
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OA used to be considered as ‘wear and tear’ of the bone/cartilage in synovial joints but is now recognized as a metabolically active process involving the whole joint— cartilage, bone, synovium, capsule and muscle. This can include cartilage breakdown, synovial hypertrophy, meniscal damage, bone remodelling and sclerosis and the development of osteophytes (Fig. 1).
Risk factors for the development of OA include:
- increasing age (it is uncommon in those under 45 years)
- female sex
- genetic predisposition (probably polygenic and genes not yet identified)
- excessive or abnormal mechanical loading of joint, for example, obesity, instability
- misalignment
- poor muscle function
- meniscal damage
- it is more common in certain occupations, for example, farming
- nodal OA, with swelling of the distal interphalangeal joints (Heberden's nodes) has a familial tendency
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The level of pain and disability experienced are greatly influenced by the patient's personality, anxiety, depression and activity and often do not correlate well with clinical signs. OA does not inevitably progress. Typically, exacerbations occur that may last weeks to months, interspersed with periods of reduced symptoms. The most commonly affected joints are the hip, knee and hands particularly the base of the thumb.
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Diagnosis |
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TOPAbstractThe GP curriculum and...Aetiology and natural history...DiagnosisInvestigationsAssessmentManagementReferences |
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History and examination
The diagnosis is usually made clinically and then confirmed radiologically. Patients present with joint pain, stiffness, swelling, crepitus, deformity, muscle weakness and wasting and reduced function. X-ray changes can occur quite late in the disease process so patients with typical symptoms but no changes on plain X-rays may have early disease. The most common presentation is pain that is exacerbated by exercise and relieved by rest. Rest pain and night pain can occur with more advanced disease. There may be a reduced range of motion in the joint and joint tenderness, crepitus or bony swelling. Examination includes assessing BMI and a full assessment of the affected joints and assessment of co-morbidities that may be exacerbating the OA.
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Investigations |
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TOPAbstractThe GP curriculum and...Aetiology and natural history...DiagnosisInvestigationsAssessmentManagementReferences |
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X-rays may show reduced joint space, cysts and sclerosis in subchondral bone and osteophytes in advanced disease. However, radiographic features do not correlate well with symptoms and OA is common and may be a coincidental finding.
Blood tests (full blood count and erythrocyte sedimentation (ESR)) should be checked if an inflammatory arthritis is suspected. The ESR may be normal or mildly raised in OA. An ESR of greater that 30 mm/hour suggests the need for further investigation to exclude rheumatoid or psoriatic arthritis.
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Assessment |
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TOPAbstractThe GP curriculum and...Aetiology and natural history...DiagnosisInvestigationsAssessmentManagementReferences |
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NICE advises that there must be a holistic approach to assessment and management (Fig. 2). Patient experiences and perceptions should be actively sought including the effect of OA on function, quality of life, occupation, mood, relationships and leisure activities. They advise using the following to aid assessment:
- The patient's existing thoughts—concerns, expectations and knowledge about OA
- The patient's support network—are they isolated? Do they have a carer? Involve carers in decision making and support the carer.
- The patient's mood—screen for depression, are there other life stresses?
- The effect of OA on:
- Activities of daily living
- Family duties
- Hobbies
- Lifestyle expectations
- Quality of sleep
- Their occupation
- Activities of daily living
- Pain assessment—assess self-help strategies and current drugs, including dosage, frequency, timing and side effects
- Other musculoskeletal pain—is there evidence of chronic pain syndrome or other treatable causes of pain?
- Co-morbidities:
- consider interactions between morbidities
- Is the patient fit for surgery?
- assess most appropriate drug therapy
- Is the patient prone to falls?
- consider interactions between morbidities
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Management |
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TOPAbstractThe GP curriculum and...Aetiology and natural history...DiagnosisInvestigationsAssessmentManagementReferences |
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The aims of management of OA in primary care are to:
- Educate the patient
- Optimize function
- Reduce pain
- Minimize progression of the disease
A management plan should be formulated in partnership with the person with OA and should include individualized self-management strategies. Information about OA should be provided on a regular basis and the risks and benefits of treatment options must be discussed in a way that the patient can understand. The plan should target positive behavioural change, emphasize core treatments (access to appropriate information, encouraging activity and exercise and interventions to help weight loss), take into account co-morbidities that can compound the effect of OA and should be reviewed regularly. See Figure 3 for the NICE treatment recommendations.
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Patient education
Verbal and written information should be provided to improve patient's understanding of OA and its management. The Arthritis Research Campaign (ARC) website (www.arc.org.uk) has a wide range of information leaflets for patients.
Psychological factors have a major impact on the disability from OA. Education about the disease, and emphasis that it is not progressive in most people, is important. Seek and treat depression and anxiety.
Improvement of function
Encourage self-management strategies such as weight loss, exercise, appropriate footwear and application of heat or cold packs to the site of pain or TENS for pain relief.
- Weight reduction should be encouraged in those who are overweight or obese as this reduces loading on the joints and improves mobility.
- Activity and exercise is a core component of therapy irrespective of age, co-morbidity, pain severity and disability and should include local muscle strengthening and general aerobic fitness. Patients are often concerned that they may further damage the joint by using it but continued activity has been shown to reduce pain and disability. The ARC provides a leaflet—‘Keep Moving’ specifically designed to provide information on exercises for those with arthritis.
- Referral to physiotherapy for advice on exercises can be helpful especially in the less mobile when isometric exercises can be helpful. Manipulation and stretching can also be considered particularly for OA hip. Physiotherapy referral is also helpful for those with biomechanical joint pain or instability for assessment for bracing, joint supports and insoles. The use of a walking stick in the opposite hand to the affected OA hip can improve mobility and reduce the risk of falls.
- Aids and devices can have a significant impact on managing activities of daily living. Footwear advice should be offered for lower limb OA. The shock-absorbing properties of good footwear can reduce pain and improve functioning. Occupational therapy can advise on assistive devices (e.g. tap turners) to help with daily activities and maintaining independent living.
Pain management
Non-pharmacological measures, that is, weight loss, increased activity and aids and devices should be advised first line for pain management but many patients also require analgesic drugs.
First-line agents
Paracetamol is the first choice analgesic. Advise regular dosing with adequate dose (that is 1 g four times a day). Paracetamol has a low side effect profile so can be used long term. Patients are often concerned that they are taking regular medication and tend to under dose or omit tablets and thus do not achieve sufficient pain relief. Check the dose and frequency being taken before moving up the analgesic ladder.
Topical NSAIDs can be used in addition to, or instead of, paracetamol as a first-line therapy. They are particularly useful for pain relief in knee and hand OA and have a lower side effect profile than oral NSAIDs. Patients often find them more acceptable than taking tablets. NICE advises that topical capaicin should also be considered for OA knee and hand but does not recommend the use of rubefacients. Local heat and cold, TENS and acupuncture should also be considered.
Second-line agents
Oral NSAIDs (e.g. ibuprofen 400 mg tds, Cox-2s (e.g. celecoxib 200 mg od or bd) and opioids (e.g. codeine 30–60 mg qds) may be considered if paracetamol and/or topical NSAIDs are insufficient, either in addition to, or instead of, paracetamol or topical NSAIDs. These drugs have more side effects, so the lowest effective dose should be used for the shortest possible time. The risks and benefits of opioids should be considered carefully especially in elderly people where they can increase the risk of falls. If considering an oral NSAID or Cox-2 inhibitor, NICE advises starting with a standard NSAID (e.g. ibuprofen 400 mg tds or diclofenac 50 mg tds), not a Cox-2, and co-prescribing a proton pump inhibitor in those under 65 years with no gastrointestinal risk factors. If over 65 years or increased GI risk factors, NICE advises offering either a Cox-2 inhibitor or a standard NSAID co-prescribed with a proton pump inhibitor.
Other agents include low-dose antidepressants (e.g. amitriptyline 10–75 mg nocte—unlicensed). These are often used as an adjunct to other analgesics especially for pain causing sleep disturbance but there is limited research evidence of effectiveness.
Aspiration of joint effusions and joint injections can help in exacerbations. NICE recommends that intra-articular corticosteroid injections should be considered for moderate or severe pain. Hyaluronic acid knee injections improve pain in the short/midterm but are associated with a short-term increase in inflammation and their use has not been supported by NICE.
Glucosamine sulphate (1500 mg daily) has been found to reduce symptoms in knee OA in clinical trials but effective disease progression is uncertain. It is not available on the NHS but many patients chose to buy it privately. NICE does not recommend the use of glucosamine or chondroitin.
Referral to specialist services
Use the whole multidisciplinary team to optimize management.
Consider referral to:
- Physiotherapy for advice on exercises, strapping and splints
- OT for aids
- Chiropody for foot care and insoles
- Social services for advice on disability benefits and housing
- Orthopaedics for assessment for joint replacement should be considered if patient has already been offered all the core treatments (above) and they are experiencing joint symptoms that have a significant impact on their quality of life (for example, pain, stiffness and reduced function). Do not allow patient-specific factors (e.g. age, gender, smoking, obesity and co-morbidities) to be barriers to referral.
- Rheumatology should be considered if there is co-existent psoriasis (psoriatic arthritis can mimic OA), to rule out other causes of arthritis (e.g. pseudogout, haemochromatosis), in young patients with an unusual distribution of joint involvement to exclude other diagnoses or for joint injections if they are not available in the practice.
Complementary and alternative therapies
Complementary or alternative therapies are used by 60% of patients with OA (e.g. copper bracelets, acupuncture, food supplements and dietary manipulation). There is evidence that chiropractic and osteopathy can help back pain and acupuncture may help knee pain, but otherwise evidence of effectiveness is scanty. If patients wish to try alternative therapies, advise them to find a reputable practitioner with accredited training who is a member of a recognized professional body and carries professional indemnity insurance.
Key points
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References |
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TOPAbstractThe GP curriculum and...Aetiology and natural history...DiagnosisInvestigationsAssessmentManagementReferences |
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Arthritis Care. Tel: 0808 800 4050, www.arthritiscare.org.uk.
Arthritis Research Campaign (arc). Tel: 0870 8505000, www.arc.org.uk.
Davies R, Everitt H, Simon C. Musculoskeletal problems: Oxford General Practice Library (2006) Oxford: Oxford University Press. ISBN: 9780198570585.
NICE Guidance on management of Osteoarthritis. (Feb 2008) www.nice.org.uk/guidance/index.jsp?actionby=ID&;o=11926 [date last accessed 10.04.2008].
RCGP GP curriculum. www.rcgp-curriculum.org.uk/ [date last accessed 10.04.2008].
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