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It’s the Keele difference. OA Controversies
- 1. It’s the Keele difference. Evidence based management of OA in Primary Care: Conversations and controversies RCGP msk day Dr Jonathan Quicke NIHR Academic Clinical Lecturer in Physiotherapy
- 2. Arthritis Research UK 2013: Arthritis in General Practice 8.75 million!
- 3. Talk Aims: • The burden of OA in Primary Care • The natural history of OA • Diagnosing OA in Primary Care • Update on clinical guidelines • Discussion of management controversies • Explaining OA and providing quality information • Keele OA implementation projects
- 4. Defining OA- multiple choices “OA refers to a clinical syndrome of joint pain accompanied by varying degrees of functional limitation and reduced quality of life” NICE 2014 • In epidemiology studies various definitions of OA are used in different settings
- 5. The problem of OA in Primary Care • Osteoarthritis (OA) is the most common musculoskeletal condition in older adults • Around 1/3 of people over the age of 45 have consulted to primary care with OA • Major source of pain and disability • In the future the negative impact of OA is likely to rise ARUK 2013 OA in general practice Neogi et al 2013 Osteoarthritis and Cartilage
- 6. Rising up the charts: Global burden of disease Vos et al 2016 Lancet
- 7. Common sites affected by OA ARUK website
- 8. How common is it?-(chronic, interfering joint pain) Thomas E. et al, 2004; Dziedzic K. et al, 2007; Thomas M. et al 2011 16% FOOT (pain lasting 1m) aged 65 yrs
- 9. Focus on a person you know (Pairs discussion, 5 min) • Think of someone you know with OA – patient, friend, relative • Describe that person to your neighbour and hear his/her account of a person too: • Their life and aspirations • What you think OA means to them? • What impact does it have on their life? • What do you feel about it?
- 10. OA impact on the person
- 12. How does OA present in the consultation? What are the clinical signs and symptoms?
- 13. Diagnosing OA in primary Care • Diagnose OA clinically without investigations if: – 45 years old or older – Activity related joint pain – No morning stiffness or stiffness lasting less than half an hour
- 14. Can you name 3 differential diagnoses to consider How do these present?
- 15. Differential diagnosis • Be aware that atypical features, such as a history of trauma, prolonged morning joint- related stiffness, rapid worsening of symptoms or the presence of a hot swollen joint, may indicate alternative or additional diagnoses. Important differential diagnoses include gout, other inflammatory arthritides (for example, rheumatoid arthritis), septic arthritis and malignancy (bone pain).
- 16. Natural History of OA – what do you think? (Group discussion 5 min) • What is the cause of OA? • Why does it affect people differently? • What can you say about the outlook for someone with OA? • Does anything make a difference to the outcome?
- 17. The risk factors contributing to OA onset are complex
- 18. OA prognosis • Not progressive for everyone (but flares common) • Level of pain and disability can be significant for some • Joint replacement is not the eventual outcome for most patients
- 19. The natural history of knee OA (n=600) Nicholls Osteoarthritis Cartilage 2014
- 20. © Floris Lafeber The Underlying Problem – Many factors are modifiable • Remove / reduce stressors • Rx inflammation / muscle weakness / joint laxity / malalignment • Address psycho- social issues Joint capable of repair
- 22. Offer advice on the following core treatments to all people with clinical OA: • Advice and education • Weight loss if overweight • Physical activity and exercise
- 23. NICE Core Treatments for OA education, advice, information access strengthening and aerobic exercise weight loss if overweight topical NSAIDs paracetamol supports and braces intra-articular corticosteroid injections opioids joint arthroplasty oral NSAIDs including COX-2 inhibitors TENS local heat and cold capsaicin manual therapy (manipulation and stretching) assistive devices shock-absorbing shoes or insoles
- 24. It’s the Keele difference. OA Controversies • To x-ray or not? • Glucosamine sulphate • Pharmacological management • Exercise help or harm? • The scope of arthroscopy
- 25. It’s the Keele difference. Should we use x-rays for OA diagnosis? Bedson and Croft 2008 BMC Musculoskeletal Disorders Finan et al 2013 Arthritis and Rheumatology What do you think? • Diagnose OA clinically without investigations if: – 45 years old or older – Activity related joint pain – No morning stiffness or stiffness lasting less than half an hour • Some discordance between pain and radiographic severity
- 26. It’s the Keele difference. Glucosamine Sulphate Runhaar et al Osteoarthritis Cartilage 2017 What do you think? • Do not offer Glucosamine or Chondroitin based products for the management of OA • “No evidence to support the use of GS in hip or knee OA”
- 27. It’s the Keele difference. • In addition to core management Paracetamol and topical NSAIDS should be considered for pain relief before oral NSAIDS, COX 2 inhibitors and opiates • Weigh up the risks and benefits • The efficacy and safety of paracetamol is being challenged and reviewed Pharmacological management Machedo et al 2015 British Medical Journal Bannaru et al 2015 Annals of Internal Medicine
- 28. It’s the Keele difference. Continued… • Consider Capsaicin cream for hand and knee OA • Where paracetamol and topical NSAIDS provide insufficient pain relief consider oral NSAIDS/COX 2 inhibitors at the lowest effective dose for the shortest possible time and co- prescribe with a proton pump inhibitor
- 29. It’s the Keele difference. Exercise help or harm? • What do you think? • Wide range in attitudes towards exercise and exercise advice from GPs Cottrell et al 2010 BMC Family Practice
- 30. The benefits of physical activity
- 31. “There are few contraindications to the prescription of strengthening or aerobic exercise in patients with hip or knee OA” Roddy et al. Rheumatology 2005, Bennell et al. Journal of Science and Medicine in Sport 2010 “No evidence of serious adverse events, increases in pain, decreases in physical function, progression of structural OA on imaging or increased TKR at group level with long-term therapeutic exercise” Quicke et al. Osteoarthritis and Cartilage 2015
- 33. It’s the Keele difference. The scope of OA arthroscopy Thorlund et al 2015 British Medical Journal What do you think? • Do not offer arthroscopic lavage unless there is a clear history of mechanical locking • Weighing the benefits and harms the evidence does not support the use of arthroscopy for people with knee OA
- 34. It’s the Keele difference. When to consider referral for consideration of joint replacement? • What do you think? • Consider in those with pain, functional limitations and substantially reduced quality of life which is refractory to core non-surgical treatments • Referral prioritisation should not be based on scoring tools • If considering referral discuss the risks and benefits, recovery and local service pathways
- 35. Striking the right balance… Optimum conservative management Timely and appropriate total joint replacement
- 36. Explaining OA What do we need to explain? Which words may not be so helpful?
- 37. • “Wear, flare and repair” • Realistic messages about natural history and positive messages about the benefits of exercise and weight loss • “There are things you can do to help your condition” • “Degenerative” • “Worn out, bone on bone” • “Joints of an 80 year old” Useful to explain Unhelpful language French et al 2015, Quicke et al 2016 Arthritis Care and Research
- 39. If I exercise my joints will wear out even quicker It’s not safe for someone like me to exercise Rest is best Nothing much can be done to help Attitudes and beliefs we can challenge
- 40. It’s the Keele difference. Providing quality information
- 41. What are your take home messages?
- 42. Keele OA “JIGSAW” key innovations GP and Nurse Training Model OA Consultation Keele OA Guidebook
- 43. Quality Standards [QS87] June 2015 • Statement 1. Adults aged 45 or over are diagnosed with OA clinically without investigations if they have activity-related joint pain and any morning joint stiffness lasts no longer than 30 minutes. • Statement 2. Adults newly diagnosed with OA have an assessment that includes pain, impact on daily activities and quality of life. • Statement 3. Adults with OA participate in developing a self-management plan that directs them to any support they may need. • Statement 4. Adults with OA are advised to participate in muscle strengthening and aerobic exercise. • Statement 5. Adults with OA who are overweight or obese are offered support to lose weight. • Statement 6. Adults with OA discuss and agree the timing of their next review with their primary healthcare team. • Statement 7. Adults with OA are supported with non-surgical core treatments for at least 3 months before any referral for consideration of joint surgery. • Statement 8. Healthcare professionals do not use scoring tools to identify which adults with OA are eligible for referral for consideration of joint surgery
- 44. OA Template Effects on prescribing Quality Indicator achievement via an OA e- template in primary care Edwards JJ, et al. Quality of care for OA: the effect of a point-of-care consultation recording template. Rheumatology 2014
- 45. It’s the Keele difference. Acknowledgments Thanks to Dr Mark Porcheret, Dr John Edwards and Dr Lizzie Cottrell for their initial thoughts on the slide topics. Thanks to Dr Vince Cooper for his contribution to the group activities. Jonathan Quicke is funded by a National Institute for Health Research (NIHR) Academic Clinical Lectureship in Physiotherapy awarded as part of Professor Christian Mallen’s NIHR Research Professorship (NIHR-RP-2014-026). The views expressed are those of the author and not necessarily those of the NHS, the NIHR or the Department of Health.
- 46. Thank you Research Institute for Primary Care and Health Sciences David Wetherall Building Keele University Newcaslte-under-Lyme ST5 5BG Tel: 01782 733905 Fax: 01782 734719 www.keele.ac.uk/pchs
- 47. The general physical activity safety balance Long term decrease in falls Increased life Decreased long term risk of heart attacks Prevention of secondary conditions Brief increased risk of heart attack Minority experience mild adverse events Occasional moderate adverse events eg, falls
- 48. The top 3 1. “Regular physical activity and individualized exercise programs (including muscle strengthening, cardiovascular activity, and flexibility exercises) can reduce your pain, prevent worsening of your osteoarthritis, and improve your daily function” 2. “If you are overweight and have osteoarthritis, it will be beneficial to lose weight and maintain a healthy weight through an individualized plan involving dietary changes and increased physical activity” 3. “Your osteoarthritis symptoms can often be eased significantly without requiring an operation” French et al 2015 Arthritis Care and Research
Editor's Notes
- OA has been defined in different ways…and one size does not fit all So NICE define OA as a clinical syndrome of joint pain accompanied by varying degrees of functional limitation and reduced quality of life… In epidemiology studies different working definitions of OA are used…these are often based on self-reported chronic pain, self reported doctor diagnosed OA or imaging findings on x-ray and MRI. I acknowledge that the evidence for this presentation uses a range of different OA case definitions and no single definition gives us the full picture but I will try to combine some of the key evidence in a digestible format.
- So looking at impact of OA on the person …well…it is a major source of disability with lower limb OA associated with slower walking speeds and difficulty with stairs… Furthermore older adults with lower limb OA are more likely to fall which can be responsible for major health consequences such as hip fractures and premature death (Scott et al 2012, Marlene Fransen 2014) Perhaps linked to reduced mobility older adults with knee pain are more likely to have 4 or more comorbidities (Fransen et al 2014)…and reduced social participation (Ross Wilkie 2007). Considering mental health, OA is associated with lower quality of life and higher levels of depression. …And that is before considering the economic cost of healthcare, days lost to work, and surgery. The problem of knee pain in older adults is far reaching….
- So the population burden of knee OA can be thought of as an iceberg….with much of the impact hidden from view… Many older adults with knee OA do not consult….and the often unseen impact on work, social life and quality of life can be significant.
- Many factors combine to contribute to the onset of osteoarthritis and knee pain in older adults. These are well summarised by Melicia’s systematic review but in summary… Common risk factors associated with knee arthritis onset include previous knee injury, increased BMI, knee mal alignment (both bow legs and knock knees), older age, female gender and some genetic factors. However, risk factors for onset are not the same as factors for progression which have been less conclusive in the literature. Arthritis in multiple joints and knee malalignment are the only factors that have been consistently linked with condition progression.
- Many aspects of OA are modifiable…
- This is further emphasised by the recommendations that NICE give regarding an holistic assessment of the person with OA. This holistic assessment very much links in with the broad impact of OA in the person that we discussed earlier. As we would expect we need to understand the pain an individual presents with and any other comorbidity history that may also interact such as obesity or diabetes. … other important psychosocial factors to consider are the effect that the pain and stiffness is having on work, sleep and other social activities as well as the knock on effect these may be having on quality of life. …there is now compelling evidence that pain and mood are interlinked although it can be challenging to entangle to what extent both influence the other. …one sometimes overlooked aspect of assessment is the persons understanding of their condition. What do they understand by OA and what do they think is going on? What are their expectations of the condition and do they think that anything can be done? It is of vital importance that attitudes and beliefs about the condition and potential management strategies are elicited as these attitudes and beliefs influence perceptions of the condition, what can be done about it and also their likely adherence to any recommended treatment. For example, my PhD investigated the relationships between attitudes, beliefs and physical activity behaviour in older adults with knee OA and found an association between a range of attitudes and beliefs about exercise and physical activity level. …outcome expectations for exercise, self-efficacy for exercise, and fear of movement and harm were all linked to the amount of physical activity adults with knee OA carried out at the time and in the future.
- Focus on core management
- The benefits of physical activity and exercise for older adults with knee pain are just as wide reaching as the negative associations of knee pain. Therapeutic exercise interventions have been shown unequivocally in high quality systematic reviews such as that by Uthman and colleagues in 2013 from this centre to have small to moderate treatment effects in terms of reductions in pain and improvements in physical function- similar to non steroidal anti inflammatories. The latest Cochrane systematic review by Fransen et al 2015 found people who completed exercise interventions rated their pain 12 points better and function 10 points better out of 100 than those in non exercise controls. Regular physical activity has also been shown to reduce all cause mortality and multimorbidity, long term regular physical activity can also reduce the risk of falling and is associated with improved mental health and quality of life.
- Experts consensus is that there are few contraindications to strengthening and aerobic exercise for people with lower limb OA… unstable angina… We also conducted a large systematic review of RCTs that investigated long term- exercise for older adults with knee pain attributed to OA. Most of the evidence related to low impact moderate cardiovascular intensity exercise interventions, but we found no evidence of serious adverse events described as disabling or life threatening. The most common moderate adverse event was falls in 6 of about 7,000 participants…there was no evidence of increased OA progression with exercise interventions or higher numbers of people undergoing TKR…most studies showed improvements in pain and function at a group level in the exercise group. So for all those people who say they can not exercise because of their OA there are appropriate exercises that they can carry out.
- The evidence from the included studies suggests that we can recommend a wide range of physical activities so choices can often be made on enjoyment and personal choice. Walking, tai chi, swimming or aqua classes, cycling (although most of the evidence relates to exercise bikes and cycling on the road has its unique safety profile because of the risk of RTAs) , functional lower limb strengthening exercise, flexibility work, stretching and resisted general strengthening exercises and balance exercises were all found to be safe within the review. However, everyone is different and we all have different baseline levels of fitness and health so if you are beginning an exercise programme for the first time it is worth discussing it with your GP or physiotherapist.
- In my opinion there is a balance to be achieved between optimum conservative management delaying and reducing the need for surgery and its potential associated adverse events…and the timely and appropriate use of TKR to improve pain function and quality of life. Evidence examples…Svege…2015 For example, Soren Skou et al 2015 vs risk
- So we as therapists can influence the attitudes, beliefs of our patients…and hence have an important role in shaping positive condition management behaviours such as strengthening and aerobic exercise….but…
- Read…do these patient concerns sound familiar to you? These are attitudes and beliefs we can challenge. Do we as physios ever unintentionally reinforce these beliefs?
- So the service quality standards for OA, accompany the intervention “fried egg”. This set of 8 statements recommend the routine clinical diagnosis of OA without the need for x-rays or MRI They recommend the holistic assessment of OA as described previously…click… …and encourage a supported self-management strategy for people with OA….that comprises the core management of exercise, education and weight loss if over weight… Importantly, …click… they also recommend non surgical conservative management core treatments for at least 3 months prior to any referral for consideration of surgery.
- There are some other aspects of physical activity safety to consider from other research in populations without knee pain. When weighing up the safety of any medication, surgery or potential treatment we must weigh the benefits and potential harms. Physical activity carries with it a brief increased risk of heart attacks (Schmeid and Borjesson 2014) although regular physical activity in the long term reduces this risk (Thompson et al 2007) . Similarly there is a temporary increased risk of falling whilst carrying out physical activity, however regular physical activity is known to reduce falls and fear of falling in the long run (Gillespie et al 2012) . A minority of older adults report mild or temporary reductions in knee pain although most will get pain improvements. And finally, and importantly, regular physical activity is associated with living longer (Nocon et al 2008) and living with less additional health conditions such as obesity and type two diabetes.