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OA Guidelines and Management

Osteoarthritis (OA) is the most common form of arthritis, affecting more than 27 million U.S. residents, 11% of the population.¹ The risk of mobility disability (defined as needing help walking or climbing stairs) attributable to knee OA alone is greater than that due to any other medical condition in people 65 and older,^2,3 and causes aggregate annual medical care expenditures of $185.5 billion (1.3% of the gross domestic product).⁴

OA reduces both quality and quantity of life. In the estimates for the Global Burden of Disease 2000 study,⁵ OA is the 4th leading cause of total years lost due to disease at the global level. On average, a person with knee OA, 50 to 84 years old, who is not obese, will lose 1.9 quality-adjusted life years due to the condition.⁶ Obesity increases the loss to 3.5 quality-adjusted life years, and the estimated remaining quality-adjusted life expectancy is decreased by 21% to 25%. This effect of symptomatic knee OA on quality of life is similar to that of metastatic breast cancer. A recent study also found that people with OA are at higher risk of death compared with the general population.⁷

OA Diagnosis

• OA can occur in any synovial joint but is most common in the hands, knees and hips.⁸ Diagnosis is primarily made by assessing the constellation of presenting clinical features through history and physical examination. The cardinal features that suggest a diagnosis of OA include the following:
• Stiffness of short duration. Also termed “gelling,” stiffness is brought on by inactivity.
• Increasing pain with activity (mechanical). Pain is often described as deep, aching and poorly localized. The onset is usually gradual and insidious.
• Reduced movement, minimal swelling and joint crepitus.
• Increased age. The condition is unusual before age 40.
• Absence of systemic or constitutional symptoms (e.g., fever).

Radiographs are notoriously insensitive to the earliest pathological features of OA, and the absence of positive radiographic findings should not be interpreted as confirming the complete absence of symptomatic disease. Conversely, positive radiographic findings do not guarantee that an osteoarthritic joint is the active source of the patient’s current knee symptoms.⁹ According to the American College of Rheumatology (ACR) criteria for classification of hand OA, x-rays are less sensitive and specific than physical examination in the diagnosis of symptomatic disease in this region.¹⁰ While clinical criteria can also be used to render a provisional diagnosis of OA in other regions, x-rays are the method by which hip or knee OA can be confirmed in cases of clinical uncertainty.

Advanced OA is visible on plain radiographs. Findings consistent with a diagnosis of OA include asymmetric narrowing of joint space, marginal osteophytosis, subchondral sclerosis and, on occasion, radiolucent “cysts” in the cancellous subchondral bone (Figure).

Figure. Radiographic Findings

A weight-bearing, plain radiograph of the knee depicting the characteristic features seen in OA: joint space narrowing, osteophytosis, and subchondral sclerosis
Source: David Hunter, MD, PhD

Click here for a larger view of this image.

OA Management

Sir William Osler, considered the father of modern medicine, once said, “Osteoarthritis is an easy disease to take care of. When the patient walks in the front door, I walk out the back door.”¹¹ No one denies that managing OA is a challenge; however, modern clinicians are armed with a plethora of effective treatment options. We are also charged with discerning what agents are less effective yet still receive generous publicity rigorously eulogizing their benefits.

Patient management has several aims: education about the disease, pain control, improved function and decreased disability, and alteration of the disease process and its consequences.

Current therapeutic options are primarily aimed at reducing pain and improving joint function by modalities targeted toward symptom relief that do not facilitate any improvement in joint structure. Management should be individualized to conform to the specific findings of the clinical examination, especially in cases involving obesity, malalignment and muscle weakness. Comprehensive management always includes a combination of treatment options that are directed toward improving the patient’s pain and tolerance for functional activity. Treatment plans should never be defined rigidly according to the x-ray appearance of the joint, but should remain flexible according to function and symptoms.

Recommendations

Evidence-based guidelines or recommendations have the potential to improve the quality of health care by promoting interventions of proven benefit and discouraging unnecessary, ineffective or harmful interventions.¹² Numerous recommendations for OA management have been developed in recent years by a number of scientific societies and health care organizations.^13-17 Typically these recommendations have emanated from a combined evidence consensus approach and have been widely endorsed by clinicians, professional groups and some payers. The guidelines represent an overarching grouping of nonpharmacologic conservative interventions, pharmacologic and surgical interventions that are consistent with recommendations that conservative, safer interventions be adopted prior to interventions with more adverse safety and cost profiles.

Confusion could potentially arise from this multitude of sometimes inconsistent guidelines, although some amount of replication is necessary to facilitate appropriate contextualization of recommendations for specific users, such as clinicians, countries or health care organizations. Fortunately, general consistency exists, despite some differences in quality, in the available OA recommendations.^12,18-22

Clinical Practice

Despite remarkable consistency between recommendations and in spite of some dissemination attempts, clinical practice does not reflect these evidence-based recommendations.^19-22 The recommended hierarchy of management should consist first of nonpharmacologic modalities, fol-​lowed by drugs and then surgery. Frequently, clinicians do not ad-​equately recommend conservative nonpharmacologic management,²⁰ lead​ing to unnecessary imaging and inappropriate referral to orthopedic surgeons.²² This divergence from​ evidence-based care is also com-​monly seen with other diseases, where half of the treatment rendered by clinicians may be inappropriate.²³

Despite its prevalence and impact on disability, OA is a condition often poorly managed in clinical practice.²⁴ For many of our current therapies (including acetaminophen, hyaluronic acid, glucosamine, acupuncture and arthroscopic debridement and lavage), placebo effects can be substantial.^25,26 Furthermore, many of these agents have side-effect profiles that raise legitimate concerns about their long-term safety,²⁷ especially gastrointestinal and cardiovascular safety.

With few conservative options offered by their physicians, increasing numbers of patients are turning to untested alternative therapies and aggressively marketed dietary supplements with little substantive evidence to support their efficacy.²⁸

Current Interventions

Clinicians managing OA should seek to influence modifiable risk factors, where possible. The clinical encounter should target identification of individual risk factors (including altered alignment, obesity and muscle weakness), and the therapeutic intervention should be tailored to the individual. The majority of patients with OA are overweight or obese. Good evidence supports the efficacy of weight management for OA,²⁹ and this strategy is advocated by most guidelines. For each kilogram of weight lost, the knee will experience a fourfold reduction in load during daily activities.³⁰ Another pivotal and frequently ignored^20,31,32 conservative treatment is exercise, which increases aerobic capacity, muscle strength and endurance, and also facilitates weight loss.^29,33

Numerous studies have highlighted the importance of mechanical factors on the etiopathogenesis of this disease, with recent studies suggesting that mechanical forces play an important role in predisposing to both symptoms and structural change.^34,35 Despite the recognition that joint mechanics is critically important in both disease pathogenesis and symptoms, little is done to effectively intervene on these important risk factors. Although currently underemphasized in clinical trials and practice, therapies targeting the pathomechanics of OA are efficacious.^35-37 A number of therapeutic options can modify joint forces, including patella taping, braces, orthotics, shoes and osteotomies for the knee and surgical correction of hip deformity associated with femoroacetabular impingement syndrome.^36,38,39

Implementation

The discrepancy between recom-​mendations and clinical practice suggests problems with dissemination or implementation or both.⁴⁰ Given the number of guidelines available for OA and the consistency of recommendations within them, and considering the time and resources required for guideline development, future efforts to guide management of hip or knee OA are better directed toward implementing practices known to be effective and facilitating research to answer important questions where little evidence exists.¹² A number of methods can be used to facilitate guideline implementation, reduce unexplained variation in practice patterns and optimize care, including development of quality indicators.

Health System Delivery

OA treatment is multifaceted and involves contributions diverse health professionals across different sectors. Providing care in the context of a chronic disease management model is more appropriate than in the current model of episodic delivery. A comprehensive and integrated model of OA care will facilitate implementation of best evidence, patient education and self-management, and collaboration among providers,^42,43 including general practitioners, rheumatologists, orthoped-​ic surgeons and allied professionals, such as physiotherapists, dieticians and psychologists. Such models are effective for other conditions, including chronic heart failure and diabetes.

Conclusion

Clinicians have access to numerous evidence-based guidelines that have the potential to improve the quality of health care by promoting interventions of proven benefit and discouraging unnecessary, ineffective or harmful interventions. Nevertheless, clinical practice does not reflect these recommendations. Efforts to guide management are better directed toward implementing practices known to be effective in a context-dependent manner to optimize health care quality. The increase in medical need, progress in information technology and unsustainable health care costs have converged to create favorable conditions for the funding, development, use and publication of this new vision for a patient-centered and provider-integrated model for OA management. In efforts to improve quality and reduce cost, quality measures will be integral. Quality measurement, accountability and reporting are challenging clinical practice, yet will be expected of us going forward.

Acknowledgment

Dr. Hunter is funded by an Australian Research Council Future Fellowship. He had full access to all the data in the study and had final responsibility for the decision to submit for publication. This is a narrative review and the comments and editorial expressed herein represent those of the author and do not reflect those of any official scientific role or institution that the author may hold or be affiliated with.

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