Download osteoarthritis for GPs

Osteoarthritis for GPs
7% of GP population affected. (mostly >55). Increases with age.
In people with OA, roughly 10% will be in unbearable pain and 20% give up holidays, hobbies and retire early.
Diagnosis
OA is chronic interfering joint pain, affecting the knee, hands, hips (in that order). Diagnose clinically on 4
things (i.e. without x-ray):
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Patient over 45y
Pain >3m worse with use (often intermittent with flare ups, patient presents during flare ups)
No prolonged morning stiffness as in RhA (i.e. morning stiffness is less than 30 mins)
An alternative diagnosis is unlikely.
Other diagnostic symptoms
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Affects ADL
Worse with physical activity – esp up and downstairs.
Joints stiffen after rest
X-rays
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X-ray not needed for diagnosis.
Most people > 60 have OA changes on x-ray which do not correlate with their functional ability or
pain (many are symptom free!).
Only do if there is diagnostic uncertainty – and not to confirm your diagnosis!
Examination
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Examine affected joint AND the joint above and below.
Look, feel, move – move the jt through its full range.
Often not much to see. May see some of the things below…
o Knee
 crepitus – hand over patella, ask patient to rise from sitting
 medial compartment OA – bow legged (genu varum)
 advanced OA – fixed flexion deformity
o Hip
 Early sign – reduced internal rotation
 Later – reduced external rotation
 Active/passive movements of hip  pain
o Hands
 DIP Heberden’s nodes, PIP Bouchards nodes
 Tenderness at and squaring of base of thumb (common site for OA)
 pain on axial loading through the thumb.
Differentials
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Red flags for both: fracture, sepsis, cancer
Knee: Inflammatory arthritis, gout, meniscal disease, bursitis, fibromyalgia
Hip: PMR, avasc necrosis, bursitis, fibromyalgia, meralgia paraesthetica (entrapment of lateral
cutaneous nerve of the thigh)
Remember referred pain (back problem hip pain; hip problem knee pain)
Osteoarthritis for GPs
Explanations
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Rather than use wear and tear, use Tear, flare and repair or Wear and repair. Incorporates the
concept that OA does not inevitably get worse. Different joints have different prognoses &
something we can do about it.
Joints are living tissue and can repair themselves and we need to help them by minimising the
stress on them through (i) rest (ii) lose weight (iii) exercises to correct malalignment through
muscle strengthening (iv) avoid injury – sports/occupation (v) medication to reduce
pain/inflammation (topical NSAIDs or paracetamol).
A good explanation OA is not just about wearing out of the joint. ‘In OA the whole joint starts to
wear out a bit and the surrounding structures weaken. The good news is that the joint recognises
this and will try and repair itself by building new bone – but this will take time. However, we can
help it further by things like rest, taking care with what we put our joints through and with exercises
to build up the surrounding muscles and things. How does that sound?’
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Prognosis.
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OA does not inevitably get worse – the course is generally intermittent with flare ups. It can even
improve. (4 outcomes –stay the same, get worse, improve, intermittent flare-ups & remissions)
Painful OA hands – settles after a few years.
OA knee can improve and only 30% get progressive disease.
OA hip – 25% need a hip replacement after 4y of seeing GP for the first time. The other 75% won’t.
Self-Management
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Co-creating health: www.health.org.uk/areas-of-work/programmes/co-creating-health
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moving away from ‘passive patients’ and ‘active health professionals’ to ‘active patients’ and
‘active health professionals’ working together.
Muscle strengthening and flexibility exercises really work!
o ‘If we take 100 people like you with knee OA then in 2 years, 30 are going to have significantly
less pain but 70 won’t. However, with exercise, an extra 10 people will have significantly less
pain after 2 years (that’s 40 people instead of 30). You might be one of those 40!’
o NNT = 9; comparable with simple pain killers
o There is an excellent Arthritis Research UK booklet for patients called ‘Keep Moving’
o What’s the best type of exercise? Simple  the one the patient will definitely do!
o So  explore what patient might be able to do, small realistic steps. Small successes breed
success for doing more.
Losing weight
o Only 6kg loss needed!
o Use change talk rather than ‘telling’ them to lose weight. – where they are literally talking
themselves into losing weight (motivational interviewing). Telling them to lose weight merely
results in patients explaining why they can't lose weight – talking themselves out of it.
o DARN: DESIRE - I would like to lose weight; ABILITY - I might be able to cut down a bit; REASONS
- I know I would feel better; NEED - I really do need to get my weight down
Medication
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1st line: Topical NSAIDs (as good as oral NSAIDs but safer).
2nd line: Capsaicin topical – knee and hand OA; use small amount.
3rd line: Oral NSAIDs – advise of GI, liver, cardiac, renal risks. Lowest effective dose shortest amount
of time. Co prescribe PPI? Beware if already on aspirin – use something else other than NSAIDs
4th line: IA steroids – good evidence for knee OA – reduces pain. NNT around 3-5; v good.
Osteoarthritis for GPs
Glucosamine
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Glucosamine and chondroitin (separately or combined) only reduce pain by a very small amount.
This may have a greater benefit for some people and a lesser effect for others
If taken, it should be as glucosamine sulphate at a dose of 1500 mg a day
Exploring the psycho-social & ICE
The symptoms of OA are predominantly managed by patients themselves, and to support self-management
you need to consider the problem in terms of distress caused, dysfunction and expectations.
Psycho-social
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How the problem impacts on day-to-day life: the amount of pain experienced, what activities are
affected/limited by the problem, how it affects participation in usual activities.
What the patient has already done to help themselves: most people have tried many things to help
their problem. You need to acknowledge and affirm what they are doing
ICE: ideas, concerns & expectations.
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What are their ideas/beliefs about what is going on? (their health belief model).
What is causing them most concern.
Do they have any expectations? What they would like help with?
Exploring these things will help you to correct misunderstanding, align yours and their understanding and
finally help you to set an agenda and set a goal. You can then review steps towards that goal in follow up.
Other things that can help
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Footwear – snug fitting shoes so feet don’t slide around. Well cushioned insoles as shock absorbers.
Contralateral cane use – improves walking. Refer to physio or OT for measurement and advice on use.
Joint Replacement
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Joint replacement – great for hips. New Zealand score.
NHS patient decision aid for OA knee: http://sdm.rightcare.nhs.uk/pda/osteoarthritis-of-the-knee
OA hip: http://sdm.rightcare.nhs.uk/pda/osteoarthritis-of-the-hip
Cates diagram for exercise in OA of the knee
More at: www.nntonline.net/visualrx/cates_plot