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New guidance on osteoarthritis focuses on patient education

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NICE guidance on the management of this debilitating condition stresses the importance of taking a holistic approach. Nerys Hairon reports

  • This article has been double-blind peer reviewed
  • Figures and tables can be seen in the attached print-friendly PDF file of the complete article found under “related files”

NICE has published new guidance on treating osteoarthritis in adults, which outlines a number of nurse-led interventions to improve management of the condition (NICE, 2008). The guidance, developed by the National Collaborating Centre for Chronic Conditions, recommends a set of core treatments. It also details the key priorities for implementation, which include exercise and the consideration of pharmacological management for pain relief.

Background

Osteoarthritis refers to a clinical syndrome of joint pain accompanied by varying degrees of functional limitation and reduced quality of life. It is the most common form of arthritis and one of the leading causes of pain and disability worldwide. The areas most often affected are the knees, hips and small hand joints.

Although pain and reduced function can be significant consequences of the condition, structural changes often occur without accompanying symptoms. The guidance points out that, contrary to popular belief, osteoarthritis is not caused by ageing and does not necessarily deteriorate.

Holistic approach

AssessmentNICE emphasises that healthcare professionals should use a holistic approach in assessment and management. They should assess the impact of the condition on a patient’s function, quality of life, work, mood, relationships and leisure activities.

The guidance includes a diagram to help practitioners ask questions covering all aspects of patients’ lives. The recommended areas for holistic assessment include: social aspects; existing thoughts such as concerns and expectations; work issues; mood; quality of sleep; support network; other musculoskeletal pain; attitudes to exercise; co-morbidity; and pain assessment. The diagram is intended as an aide-memoire. Not every topic will be relevant to every patient and other specific issues may need to be considered for particular people.

Management
As part of a holistic approach to management, patients with symptomatic osteoarthritis should have periodic reviews tailored to their needs. Practitioners should formulate a management plan with patients. Co-morbidities that exacerbate the effect of the condition should be taken into account in this plan.

The guidance stresses that healthcare professionals should offer all people with clinically symptomatic osteoarthritis advice on the following three core treatments:

  • Access to appropriate information;

  • Activity and exercise;

  • Interventions to help overweight or obese patients lose weight – refer to NICE guidance on obesity (NICE, 2006).

Healthcare professionals should explain the risks and benefits of treatment options, taking into account co-morbidities and ensuring that the information is understood.

The guidance also contains a useful diagram that illustrates various treatment options. These are arranged in concentric circles in the order in which they should be considered. It is expected that patients’ individual needs, risk factors and preferences will modify this approach. The three core treatments that should be considered for all patients are in the central circle, although some of these may not be relevant, depending on the patient. Where further treatment is necessary, practitioners should consider therapies in the second circle, which contains relatively safe pharmacological options. Treatments should be considered in light of patients’ individual needs and preferences.

The outer circle outlines adjunctive treatments divided into four categories: pharmacological options; self-management techniques; surgery; and other non-pharmacological treatments.

All these treatments meet at least one of the following: less well-proven efficacy; less symptom relief; or increased risk to patients.

For a summary of the three stages of treatment, see box below right. For the diagram see the full guidance.

Education and self-management

Healthcare professionals should offer both verbal and written information to all patients with osteoarthritis to improve their understanding and dispel misconceptions surrounding the condition. NICE stresses that information provision should be an ongoing, integral part of patients’ management plans, rather than just a single event when patients first present.

Practitioners should agree individualised self-management strategies with patients. These should include behavioural changes such as exercise, weight loss, using suitable footwear and pacing, where periods of exercise are interspersed with rest.

Self-management programmes should emphasise the core treatments, especially exercise. Local heat or cold should be considered as an adjunct to core treatment.

Non-drug management

Exercise should be a core treatment, regardless of age, co-morbidity, pain severity or disability. It should include:

  • Local muscle strengthening;

  • General aerobic fitness.

However, the guidance does not specify whether the NHS should provide exercise or whether practitioners should give patients advice and encouragement. Clinicians need to make judgements in each case on how to ensure patients do exercise and this will depend on individual factors.

Manipulation and stretching should be considered as an adjunct to core treatment, particularly for osteoarthritis of the hip. Interventions to help overweight or obese patients lose weight should be a core treatment.

Transcutaneous electrical nerve stimulation (TENS) can be considered as an adjunct to core treatment for pain relief. These machines are generally loaned to patients by the NHS for a short time and, if the therapy is effective, patients are advised where they can buy their own. Electro-acupuncture should not be used to treat the condition.

Patients with lower limb osteoarthritis should be given advice on appropriate footwear (including shock-absorbing properties) as part of core treatment. Those with biomechanical joint pain or instability should be considered for assessment for bracing, joint supports and insoles as an adjunct to core treatment. For patients who have specific problems with daily activities, assistive devices such as walking sticks and tap turners should be considered as adjuncts to core treatment. Practitioners may need to seek expert advice on this.

Glucosamine or chondroitin products are not recommended for treating osteoarthritis.

On invasive treatments for knee osteoarthritis, NICE recommends that referral for arthroscopic lavage and debridement should not be offered as part of treatment, unless the patient has knee osteoarthritis with a clear history of mechanical locking (not gelling, ‘giving way’ or X-ray evidence of loose bodies).

This advice is a refinement of the indication in NICE interventional procedure guidance on arthroscopic knee washout (NICE, 2007; updated 2008).

Drug treatment

Healthcare professionals should consider offering patients paracetamol for pain relief in addition to core treatment – regular dosing may be necessary. Paracetamol and/or topical NSAIDs should be considered before other oral NSAIDs, COX-2 inhibitors or opioids.

For specific indications for topical treatments, details on prescribing oral NSAIDs, COX-2 inhibitors and opioid analgesics, guidance on intra-articular injections and referral for specialist services, see the full guidance.

Conclusion

Nurses are vital in ensuring holistic assessment and management of patients with osteoarthritis. They can improve management by ensuring all patients are offered the three core treatments of information, activity and exercise, and interventions to lose weight if necessary.

TARGETING TREATMENT

Stage 1: Core treatments:

  • Education, advice, access to information;

  • Strengthening exercise and aerobic fitness training;

  • Weight loss for overweight/obese patients.

Stage 2: Where further treatment is needed:

  • Paracetamol;

  • Topical NSAIDs.

Stage 3: Adjunctive treatments to consider:

  • Capsaicin;

  • Oral NSAIDs including COX-2 inhibitors;

  • Opioids;

  • Intra-articular corticosteroid injections;

  • Local heat and cold;

  • Assistive devices;

  • Joint arthroplasty;

  • Manual therapy (manipulation and stretching);

  • TENS;

  • Shock-absorbing shoes or insoles;

  • Supports and braces.

Source: NICE (2008)

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