Tier 2 MSK Clinic GP Message of the Month March Osteoarthritis in Adults.

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1 Tier 2 MSK Clinic GP Message of the Month March 2014 Osteoarthritis in Adults. This month s MoM provides a brief review of the revised guidance for the care and management of osteoarthritis (OA) in adults (CG177) published last month, which replaces CG59. We have also included an up-to-date summary of research into OA of the knee currently being undertaken in Manchester: Research in OsteoArthritis Manchester (ROAM). Osteoarthritis: care and management in adults: NICE clinical guideline 177, February 2014 Key: [new 2014] - this indicates that evidence has been reviewed and the 2008 recommendation has been updated or added. [2014] - this indicates that the evidence has been reviewed but no change has been made to the 2008 recommendations. [2008] - this indicates that the evidence has not been reviewed since [2008, amended 2014] - this indicates that the evidence has not been reviewed since 2008, but changes have been made to the recommendation wording that change the meaning. Pharmacology NICE intends to commission a further review of the evidence on the use of paracetamol (it seems that paracetamol is not as effective in the management of OA as we once thought) and NSAIDs but until then, the 2008 guidance remains current advice. Diagnosis [new 2014] 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 Follow up and review [new 2014] Offer regular reviews to all people with symptomatic OA and agree timing with the person. Reviews should include: - monitoring symptoms and ongoing impact of the condition on everyday activities/quality of life - monitoring long-term course of the condition 1

2 - discussing the patient's knowledge of the condition/concerns they have/their preferences and ability to access services - reviewing effectiveness and tolerability of all treatments - support for self-management AND Consider 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 OA Holistic approach to OA assessment and management [new 2014]. Agree a plan with the person (and family members or carers as appropriate for managing their OA. Apply the principles in relation to shared decision-making and with regard to an individualised approach to healthcare services and patient views/preferences Referral for consideration of joint surgery [new 2014]. When discussing the possibility of joint surgery, check that the patient has been offered at least the core treatments for OA and give them information about: - the benefits of surgery and risks, 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 Research recommendations [new 2014] - Treatments for OA in very old people (80 years and over) - Combinations of treatments for OA (most of the OA trials to date evaluate single treatments and such trials are often of short duration) - Treating common presentations of OA for which there is little evidence (almost all trials of treatments for OA focus on a single joint - usually the knee) - Biomechanical interventions (braces, insoles, splints, footwear): which ones are most beneficial and in which subgroups of patients do we see the greatest benefit? - Treatments that modify joint structure in people with OA (for example, disease-modifying drugs). Click below for link to CG

3 Practical advice for GPs DIAGNOSIS In general practice common OA presentations are knee OA, nodular OA of hands, (especially in women) and thumb OA (also stiff necks and backs). None of these clinical presentations ever benefit from imaging or inflammatory blood tests. In addition, soft tissue degenerative tendonopathies also present frequently > 45 age (e.g. rotator cuff syndrome and lateral epicondylitis). Again, these are clinical diagnoses, which seldom - if ever - benefitting from further investigations. PHARMA For now, advise paracetamol +\- codeine +\- NSAIDs such as ibuprofen. BUT, don t forget the role of intra-articular steroid injections, especially with knee or thumb joint. HOLISTIC Decrease weight and increase exercise! Consider physiotherapy for regional functional improvement. Consider PARS referral. SURGERY This is especially the case with hip OA that is functionally deteriorating and would benefit from surgery to abolish pain. Knee OA is not so easy and usually needs longer time frame for surgical consideration. Research in OsteoArthritis Manchester (ROAM) The ROAM programme is funded by ARUK to investigate commonly used treatments for knee OA to find out not only if they work, but also why they work. There were 3 studies. The BRACE clinical trial (using a lightweight knee brace), the SILK study (Shoes and Insoles on Loading at the Knee) and TASK (Targeting Synovitis in Arthritis of the Knee). BRACE The BRACE randomised trial looked at patients with predominantly patellofemoral OA. The Bioskin patella tracking Q brace (a Lycra sleeve type brace from Ossur ( Solutions/kneebraces/kneesupports/bioskin_qbrace) was worn over a 12- week period for a minimum of about 7 hours per day. Function, pain, quadriceps strength, and inhibition were assessed and gadolinium enhanced MR imaging of the knee was used to measure the size of bone marrow lesions (BML) and synovitis. Patients told us that the brace made them feel more confident about moving their knees, more secure, and more stable. Objectively, the brace brought about a clinically important change in pain whilst decreasing the size of the BMLs in the patellofemoral compartment; the speed of stairs ascent and descent and flat walking also improved. There was also an important discovery: 12 weeks of brace wearing did NOT make the quadriceps weak (this is the first ever robust evidence to challenge this received wisdom). In fact, there was a modest improvement in quadriceps muscle strength and inhibition. Thus, this type of sleeve pull-on brace can be recommended for patients with patellofemoral OA without the worry of 3

4 causing quadriceps weakness. This brace does not seem to have an effect on the medial or lateral knee compartments, or on synovitis. Callaghan et al (1) SILK The SILK study looked at predominantly medial compartment knee OA with a typical varus knee deformity and used gait analysis to see which type of shoe or insole would reduce loading on the medial side of the knee. Lateral heel wedge inserts and barefoot walking caused the greatest reduction in medial compartment loading. With regards to knee pain, a special type of lateral wedge insert developed at Salford University (and now commercially available) reduced knee pain in walking. Thus, those who had a substantial reduction load on the medial compartment had little improvement in their knee pain, and vice versa. An interesting finding was that those patients who did not feel any benefit from the lateral wedge had a more everted foot. This poses an interesting question about the role of foot posture in people who have medial knee OA and a varus deformity. It is possible that these people have already started to compensate for their varus knee by adopting a new foot posture. If a lateral wedge is inserted, the foot will be everted even more. This might explain why some patients feel that an insole prescribed to correct knee varus by changing foot position actually makes them worse. Chapman et al(2) TASK The TASK trial looked at patients with a mixed compartment pattern of knee OA with an effusion. It gave the commonplace intervention of steroid injection and used MR scans to see if there was a reduction in the size of an inflamed synovium (synovitis). Within a week of having the steroid injection the synovitis in most patients had reduced. This also decreased patients pain and those with the biggest reduction in synovitis had the greatest pain reduction. Pain eventually returned within 6 months in 46/67 patients, but 21 patients pain never returned to their pre-injection levels meaning that they had some lasting improvement. It seems that the amount of synovitis pre injection does not predict those who had good pain relief. Further work is being done to see if we can predict who will have the greatest and longest pain relief and who will derive least benefit. O Neill et al.(3;4) We will focus on the results of these studies - and the clinical implications of the ongoing research taking place in Manchester - in a future MoM. Watch this space! Reference List (1) Callaghan M, Parkes MJ, Forsythe LM, Williams HE, Stirling F, Felson DT. Beneficial effects of a brace for patellofemoral OA: results of a randomised trial. Osteoarthritis Cart 2013 Apr;21, Supplement(0):S23. (2) Chapman GJ, Parkes MJ, Forsythe LM, Felson DT, Jones RK. Biomechanical factors related to response to lateral wedge insoles. Osteoarthritis Cart 2013;21, Supplement:S95-S96. 4

5 (3) O'Neill TW, Forsythe LM, Parkes MJ, Marjanovic E, Gait A, Hutchinson CE, et al. Change in MRI synovitis correlates with change in pain following intra-articular steroid injection. Osteoarthritis Cart 2013 Apr;21, Supplement(0):S300. (4) O'Neill TW, Forsythe LM, Parkes MJ, Marjanovic E, Gait A, Hutchinson CE, et al. Reduction in synovial tissue volume following intra-articular steroid injection in knee osteoarthritis. Osteoarthritis Cart 2012 Apr;20, Supplement 1(0):S217. Authors Dr Janet Suckley: Consultant Physiotherapist & Registered Osteopath, Tier 2 MSK Clinic, Longsight Health Centre ( /1255). Dr Michael Callaghan: Post Doctorate Research Associate, University of Manchester & Clinical Specialist Physiotherapist, MRI. Dr Bharat Nanavati: General Practitioner, Ailsa Craig GP Practice, and GPwSI in MSK medicine. Please forward any comments/queries to janet.suckley@cmft.nhs.uk Next month s MOM: MSK chest wall pain. 5