1. By Dan Alston

3.  Osteoarthritis “refers to a clinical syndrome of joint pain accompanied by varying degrees of functional limitation and reduced quality of life.”  “Pain in itself is also a complex biopsychosocial issue”.  “Poor link between x-rays and symptoms”.  “Not caused by ageing and does not necessarily deteriorate”.

4.  “Localised loss of cartilage, remodelling of adjacent bone and associated inflammation”.

5.  Diagnose OA clinically if:  Is 45 or over and  Has activity related joint pain.  Has either no morning joint related stiffness or morning stiffness that lasts no longer than 30mins.

6.  Social 1) Effects on Life ( ADL’s, Family duties, Hobbies) 2) Lifestyle expectations.  Health Beliefs (I.C.E., Current knowledge OA)  Occupational 1) Ability to perform job short and long term. 2) Adjustments to home or workplace.

7.  Mood 1) Screen for depression. 2) Other stressors in life.  Quality of sleep  Support network 1) ICE main carer 2) How carer is coping 3) Isolation

8.  Other MSK pain – Including evidence chronic pain.  Attitudes to exercise.  Influence of co-morbidity 1) Interaction of two or more co-morbidities 2) Falls 3) Assessment of most appropriate medications 4) understanding of surgical options. 5) Fitness for surgery.

9.  Pain assessment 1) Self-help strategies. 2) Analgesics (Drugs, doses, frequency, timing, side effects).

10.  History of trauma, prolonged morning joint related stiffness, rapid worsening of symptoms. Presence of a hot swollen joint. Bone pain  Differentials – Gout, inflammatory arthritis, septic arthritis, malignancy.

11.  To all patients offer advice:  1) Verbal and written info about OA.  2) On activity and exercise.  3) Weight loss if overweight/obese.  4) Correct footwear and aids.  5) Pacing  6) Thermotherapy (Local cold or heat)  7) Pharmalogical  8) Surgical  9) Electrotherapy - TENS

12.  Glucosamine or chondroitin products.  Acupuncture.  Rubefacients

13.  “Information sharing is an ongoing, integral part of the management plan rather than a single event at time of presentation.”

14.  Irrespective of age, comorbidity, pain severity or disability.  Considered a core treatment of OA.  1) Local Muscle strengthening and  2) General aerobic fitness.  Notes – Not specified if done via NHS or privately.  Manipulation and stretching particularly for OA hip.

15.  Shock absorbing footwear for lower limb OA.  Consider assessment for bracing/joint supports/insoles if biomechanical joint pain or instability.  Seek expert advice such as occupational therapists or disability equipment assessment centres for aids such as walking sticks.

16.  Awaiting review by MHRA (Medicines and healthcare Products regulatory Agency).  So guidance will be updated but is largely unchanged from 2008.  Except Paracetamol now felt to be less effective.  1 st line still – Paracetamol and Topical NSAID  2 nd line – Add opiate/Oral NSAID/COX-2 inhibitor.  Consider Topical capsaicin for hand and knee OA.  Consider intra-articuar corticosteroids.

17.  Avoid etoricoxib first line  Co-prescribe with cheapest (Lowest acquistion costs) PPI  If on low dose aspirin consider alternative analgesia first.

18.  Regular reviews – agree timing with patient.  Consider annual reviews if troublesome joint pain, more than one joint with symptoms. More than one co-morbidity, taking regular medications for there OA.  Monitor impact on everyday activities and quality of life.  Monitor long term course of condition.  Discuss patients knowledge, address any concerns.  Review treatment.  Support self management.

19.  Base decision to refer on discussion with patients (patient representatives), referring clinicians and surgeons. Rather than using scoring tools.  Make sure has been offered non surgical options first.  Consider referral for joint surgery if symptoms have a substantial impact on there quality of life.  “Refer for consideration of joint surgery before there is prolonged and established functional limitation and severe pain.”

20.  Do not refer for arthroscopic knee surgery unless clear history of mechanical locking.

21.  NICE acknowledge very little research into OA.  Most research into treatments for single joint without any co-morbidities.  Not much research in elderly.

22.  Diagnosis clinical not x-ray.  Extensive history taking including biopsychosocial.  Exercise very important.  Information sharing important.  1 st line non-pharmalogical.  2 nd line pharmalogical.  3 rd line Surgery.