The conservative management of osteoarthritis


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Slides from Australia and New Zealand Masterclass series.
The conservative management of osteoarthritis and orthopaedic enhanced recovery update.

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The conservative management of osteoarthritis

  1. 1. @twwainwright OSTEOARTHRITIS & HIP AND KNEE REPLACEMENT Session 1 Rob Middleton Tom Wainwright Auckland, Brisbane, Sydney, Adelaide, Melbourne, Perth - March 2014 Change Champions & Associates 2014 Master Class Series
  2. 2. @twwainwright 2 Welcome and Introductions Robert Middleton Tom Wainwright
  3. 3. @twwainwright 3 Housekeeping • Mobile phones • Fire exits • Toilets • Coffee and lunch breaks • Slides and notes • Plan for the day
  4. 4. @twwainwright 4 Overview of the day • Session 1: 09:00 – 10:30 • 10:30 – 10:50 Morning coffee • Session 2: 10:50 – 12:15 • 12:15 – 13:00 Lunch • Session 3: 13:00 – 14:45 • 14:45 – 15:00 Afternoon tea • Session 4: 15:00 – 16:00
  5. 5. @twwainwright 5 Why are you here?! • In groups of 2-3, explain why you have decided to come today and what are your personal learning objectives (5-10 minutes) • Introduce your partner and report back to the group what they are hoping to learn today • What is the experience in the room?
  6. 6. @twwainwright OSTEOARTHRITIS & HIP AND KNEE REPLACEMENT Session 1 – Update on the NICE guidelines for conservative management of OA
  7. 7. @twwainwright 7 Why is a surgeon looking at the conservative management of OA?
  8. 8. @twwainwright 8 The NICE process
  9. 9. @twwainwright 9 Diagnosis Diagnose OA clinically without investigations if a person: is 45 or over and has activity-related joint pain and has either no morning joint-related stiffness or morning stiffness that lasts no longer than 30 minutes.
  10. 10. @twwainwright 10 Holistic approach to osteoarthritis assessment and management • Assess the effect of osteoarthritis on the person's function, quality of life, occupation, mood, relationships and leisure activities. • Use the following diagram as an aid to prompt questions that should be asked as part of the holistic assessment of a person with osteoarthritis. [2008]
  11. 11. @twwainwright 11
  12. 12. @twwainwright 12
  13. 13. @twwainwright 17 Exercise and manual therapy • Advise people with osteoarthritis to exercise as a core treatment, irrespective of age, comorbidity, pain severity or disability. • Exercise should include: • local muscle strengthening and • general aerobic fitness. It has not been specified whether exercise should be provided by the NHS or whether the healthcare professional should provide advice and encouragement to the person to obtain and carry out the intervention themselves. Exercise has been found to be beneficial but the clinician needs to make a judgement in each case on how to effectively ensure participation. This will depend upon the person's individual needs, circumstances and self-motivation, and the availability of local facilities.
  14. 14. @twwainwright 18 Exercise options
  15. 15. @twwainwright 19 Exercise and manual therapy • Manipulation and stretching should be considered as an adjunct to core treatments, particularly for osteoarthritis of the hip.
  16. 16. @twwainwright 20 Weight loss • Offer interventions to achieve weight loss as a core treatment for people who are obese or overweight.
  17. 17. @twwainwright 21 Diet, nutrition, and lifestyle
  18. 18. @twwainwright 22 Thermotherapy • The use of local heat or cold should be considered as an adjunct to core treatments.
  19. 19. @twwainwright 23 Electrotherapy • Healthcare professionals should consider the use of transcutaneous electrical nerve stimulation (TENS) as an adjunct to core treatments for pain relief.
  20. 20. @twwainwright 24 Nutraceuticals • Do not offer glucosamine or chondroitin products for the management of osteoarthritis. • Cod liver oil
  21. 21. @twwainwright 25 Acupuncture • Do not offer acupuncture for the management of osteoarthritis.
  22. 22. @twwainwright 26 Aids and devices • Offer advice on appropriate footwear (including shock-absorbing properties) as part of core treatments for people with lower limb osteoarthritis.
  23. 23. @twwainwright 27 Aids and devices • People with osteoarthritis who have biomechanical joint pain or instability should be considered for assessment for bracing/joint supports/insoles as an adjunct to their core treatments.
  24. 24. @twwainwright 28 Aids and devices • Assistive devices (for example, walking sticks and tap turners) should be considered as adjuncts to core treatments for people with OA who have specific problems with activities of daily living. • Nordic walking poles
  25. 25. @twwainwright 29 Invasive treatments for knee osteoarthritis • Do not refer for arthroscopic lavage and debridement as part of treatment for osteoarthritis, unless the person has knee osteoarthritis with a clear history of mechanical locking (as opposed to morning joint stiffness, 'giving way' or X-ray evidence of loose bodies).
  26. 26. @twwainwright 30 Topical Treatments • Consider topical NSAIDs for pain relief in addition to core treatments. • Consider topical NSAIDs and/or paracetamol ahead of oral NSAIDs, COX-2 inhibitors or opioids. • Topical capsaicin should be considered as an adjunct to core treatments for knee or hand osteoarthritis. • Do not offer rubefacients for treating osteoarthritis.
  27. 27. @twwainwright 31 Oral analgesics • Consider offering paracetamol for pain relief in addition to core treatments; regular dosing may be required. • Paracetamol and/or topical non-steroidal anti- inflammatory drugs (NSAIDs) should be considered ahead of oral NSAIDs, cyclo-oxygenase 2 (COX-2) inhibitors or opioids. • If paracetamol or topical NSAIDs are insufficient for pain relief for people with osteoarthritis, then the addition of opioid analgesics should be considered. Risks and benefits should be considered, particularly in older people.
  28. 28. @twwainwright 32 NSAIDs and highly selective COX-2 inhibitors • Where paracetamol or topical NSAIDs are ineffective for pain relief, then substitution with an oral NSAID/COX-2 inhibitor should be considered. • Where paracetamol or topical NSAIDs provide insufficient pain relief, then the addition of an oral NSAID/COX-2 inhibitor to paracetamol should be considered. • Use oral NSAIDs/COX-2 inhibitors at the lowest effective dose for the shortest possible period of time. • When offering treatment with an oral NSAID/COX-2 inhibitor, the first choice should be either a standard NSAID or a COX-2 inhibitor (other than etoricoxib 60 mg). In either case, co-prescribe with a proton pump inhibitor (PPI), choosing the one with the lowest acquisition cost.
  29. 29. @twwainwright 33 Intra-articular injections • Intra-articular corticosteroid injections should be considered as an adjunct to core treatments for the relief of moderate to severe pain in people with osteoarthritis. • Do not offer intra-articular hyaluronan injections for the management of osteoarthritis.
  30. 30. @twwainwright 34 Follow-up and review - 1 • Offer regular reviews to all people with symptomatic osteoarthritis. Agree the timing of the reviews with the person. Reviews should include: • monitoring the person's symptoms and the ongoing impact of the condition on their everyday activities and quality of life • monitoring the long-term course of the condition • discussing the person's knowledge of the condition, any concerns they have, • their personal preferences and their ability to access services • reviewing the effectiveness and tolerability of all treatments • support for self-management.
  31. 31. @twwainwright 35 Follow up and review - 2 • Consider an annual review for any person with one or more of the following: • troublesome joint pain • more than one joint with symptoms • more than one comorbidity • taking regular medication for their osteoarthritis.
  32. 32. @twwainwright 36 Referral for consideration of joint surgery - 1 • Clinicians with responsibility for referring a person with osteoarthritis for consideration of joint surgery should ensure that the person has been offered at least the core (non-surgical) treatment options. • Base decisions on referral thresholds on discussions between patient representatives, referring clinicians and surgeons, rather than using scoring tools for prioritisation. • Consider referral for joint surgery for people with osteoarthritis who experience joint symptoms (pain, stiffness and reduced function) that have a substantial impact on their quality of life and are refractory to non- surgical treatment.
  33. 33. @twwainwright 37 Referral for consideration of joint surgery - 2 • Refer for consideration of joint surgery before there is prolonged and established functional limitation and severe pain. • Patient-specific factors (including age, sex, smoking, obesity and comorbidities) should not be barriers to referral for joint surgery.
  34. 34. @twwainwright 38 Referral for consideration of joint surgery - 3 • When discussing the possibility of joint surgery, check that the person has been offered at least the core treatments for, and give them information about: • the benefits and risks of surgery and the potential consequences of not having surgery • recovery and rehabilitation after surgery • how having a prosthesis might affect them • how care pathways are organised in their local area.
  35. 35. @twwainwright 39 Questions?