New Guidelines for best practice management of Arthritis


The irony of this post is that these guidelines aren't new at all. In fact the National Institute for Health Care and Excellence in the UK (which publishes evidence based best practice recommendations for many different conditions) published their Guidelines for Osteoarthritis treatment and management back in early 2014. The unfortunate thing is most regular people, and many health professionals still recommend treatments that aren't evidence based best practice.


As I discussed in a recent post HERE, many people with osteoarthritis (particularly focussing on hip and knee arthritis) are told they either just need surgery (which isn't recommended as a first line treatment) OR are told there's nothing they can do and just to take pain killers (which also isn't recommended as best practice treatment).


To quote directly from the guidelines.... The following is best practice management of Osteoarthritis:


Offer advice on the following core treatments to all people with clinical osteoarthritis.

  • Access to appropriate information
  • Activity and exercise
  • Interventions to achieve weight loss if the person is overweight or obese 


And more specifically:


Exercise and manual therapy


Advise people with osteoarthritis to exercise as a core treatment (see recommendation 1.2.5), irrespective of age, comorbidity, pain severity or disability. Exercise should include:

  • local muscle strengthening and
  • general aerobic fitness.


Exercise has been found to be beneficial but the clinician needs to make a judgement in each case on how to effectively ensure participation. This will depend upon the person's individual needs, circumstances and self-motivation, and the availability of local facilities.


Manipulation and stretching should be considered as an adjunct to core treatments, particularly for osteoarthritis of the hip.


Weight loss

  • Offer interventions to achieve weight loss as a core treatment (see recommendation 1.2.5) for people who are obese or overweight.


What about Surgery?


Yes what aobut surgery you ask... Many people have the same story. See a Doctor, get an x-ray, then get told they need surgery or to see a surgeon (as if that is their only option). With regards to surgery, the NICE Guidelines make the following recommendations:


Invasive treatments for knee osteoarthritis

  • Do not refer for arthroscopic lavage and debridement as part of treatment for osteoarthritis, unless the person has knee osteoarthritis with a clear history of mechanical locking (as opposed to morning joint stiffness, 'giving way' or X-ray evidence of loose bodies).


What this means is that unless there are very specific symptoms present, having a keyhole curgery, or a "clean out" of the knee (as was very common) is not recommended and the evidence for this shows that it is no more effective (or less effective) than exercise and appropriate weight management.


Referral for consideration of joint surgery

  • Clinicians with responsibility for referring a person with osteoarthritis for consideration of joint surgery should ensure that the person has been offered at least the core (non-surgical) treatment options
  • Consider referral for joint surgery for people with osteoarthritis who experience joint symptoms (pain, stiffness and reduced function) that have a substantial impact on their quality of life and are refractory to non-surgical treatment.

  • Refer for consideration of joint surgery before there is prolonged and established functional limitation and severe pain.

  • When discussing the possibility of joint surgery, check that the person has been offered at least the core treatments for osteoarthritis


This means that, before even considering surgery, the person should have already completed the core recommended treatments of appropriate exercise, education and weight management. They should only progress to surgery if those treatment have been completed and not successful. In many cases, completing appropriate exercise, education and weight management (if needed) can improve symptoms to a point where the person would no longer consider they need surgery!


Take home Message:


I talk about this a lot, but if you have arthritis, and it is causing you problems:
1. There is definitely a lot you can do to reduce your pain (you don't have to just put up with it)

2. Manual treatments (hands on physiotherapy) can be beneficial for the right person, and

3. There are options you should definitely try before surgery, and to be honest - surgery should never be the first choice unless in extreme or unique cases.



References:


NICE Guidelines for Osteoarthritis treatment and mangement. https://www.nice.org.uk/guidance/cg177



Julian Bowen

Julian is a Director and Senior Physiotherapist at BodyWise Physiotherapy.  He has spent  over 14 years working exclusively in private physiotherapy practice, and estimates he has performed over 40,000 individual treatments in that time. He has worked with everyone from Paralympians,  elite athletes, WAFL Footballers, the Defence Forces and weekend warriors, to thousands of everyday people with all manner of issues.  He is passionate about injury prevention and has a special interest in the treatment of headaches, shoulder issues, hypermobility management and exercise rehabilitation for the prevention and treatment of injuries.