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Osteoarthritis overview

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Osteoarthritis

About

What is covered

This pathway covers the care and management of osteoarthritis in adults.
Osteoarthritis refers to a clinical syndrome of joint pain accompanied by varying degrees of functional limitation and reduced quality of life. It is the most common form of arthritis, and one of the leading causes of pain and disability worldwide. The most commonly affected peripheral joints are the knees, hips and small hand joints. Pain, reduced function and effects on a person's ability to carry out their day-to-day activities can be important consequences of osteoarthritis. Pain in itself is also a complex biopsychosocial issue, related in part to a person's expectations and self-efficacy (that is, their belief in their ability to complete tasks and reach goals), and is associated with changes in mood, sleep and coping abilities. There is often a poor link between changes visible on an X-ray and symptoms of osteoarthritis: minimal changes can be associated with a lot of pain, or modest structural changes to joints can occur with minimal accompanying symptoms. Contrary to popular belief, osteoarthritis is not caused by ageing and does not necessarily deteriorate. There are a number of management and treatment options (both pharmacological and non-pharmacological), which are covered in this pathway and which represent effective interventions for controlling symptoms and improving function.
Osteoarthritis is characterised pathologically by localised loss of cartilage, remodelling of adjacent bone and associated inflammation. A variety of traumas may trigger the need for a joint to repair itself. Osteoarthritis includes a slow but efficient repair process that often compensates for the initial trauma, resulting in a structurally altered but symptom-free joint. In some people, because of either overwhelming trauma or compromised repair, the process cannot compensate, resulting in eventual presentation with symptomatic osteoarthritis; this might be thought of as 'joint failure'. This in part explains the extreme variability in clinical presentation and outcome that can be observed between people, and also at different joints in the same person.

Pharmacological management of osteoarthritis

NICE intends to undertake a full review of evidence on the pharmacological management of osteoarthritis. This will start after a review by the MHRA of the safety of over-the-counter analgesics is completed. For more information, see the NICE guideline on osteoarthritis.
In the meantime, the recommendations in this pathway on the pharmacological management of osteoarthritis remain current advice. However, the GDG would like to draw attention to the findings of the evidence review on the effectiveness of paracetamol that was presented in the consultation version of the osteoarthritis guideline. That review identified reduced effectiveness of paracetamol in the management of osteoarthritis compared with what was previously thought. The GDG believes that this information should be taken into account in routine prescribing practice until the planned full review of evidence on the pharmacological management of osteoarthritis is published (see the NICE website for further details).

Updates

Updates to this pathway

20 September 2016 Link to NICE pathway on multimorbidity added.
15 December 2015 Joint distraction for ankle osteoarthritis (NICE interventional procedure guidance 538) added to surgical options.
21 July 2015 Joint distraction for knee osteoarthritis without alignment correction (NICE interventional procedure guidance 529) added to surgical options.
10 June 2015 Osteoarthritis (NICE quality standard 87) added.
27 January 2015 Implantation of a shock or load absorber for mild to moderate symptomatic medial knee osteoarthritis (NICE interventional procedure guidance 512) added to management of osteoarthritis.
2 September 2014 Total prosthetic replacement of the temporomandibular joint (NICE interventional procedure guidance 500) added to management of osteoarthritis.
27 May 2014 Platelet-rich plasma injections for osteoarthritis of the knee (NICE interventional procedure guidance 491) added to management of osteoarthritis.
25 February 2014 Total hip replacement and resurfacing arthroplasty for end-stage arthritis of the hip (review of technology appraisal guidance 2 and 44) (NICE technology appraisal guidance 304) added to management of osteoarthritis.

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Patient-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Osteoarthritis: the care and management of osteoarthritis in adults

What is covered

This pathway covers the care and management of osteoarthritis in adults.
Osteoarthritis refers to a clinical syndrome of joint pain accompanied by varying degrees of functional limitation and reduced quality of life. It is the most common form of arthritis, and one of the leading causes of pain and disability worldwide. The most commonly affected peripheral joints are the knees, hips and small hand joints. Pain, reduced function and effects on a person's ability to carry out their day-to-day activities can be important consequences of osteoarthritis. Pain in itself is also a complex biopsychosocial issue, related in part to a person's expectations and self-efficacy (that is, their belief in their ability to complete tasks and reach goals), and is associated with changes in mood, sleep and coping abilities. There is often a poor link between changes visible on an X-ray and symptoms of osteoarthritis: minimal changes can be associated with a lot of pain, or modest structural changes to joints can occur with minimal accompanying symptoms. Contrary to popular belief, osteoarthritis is not caused by ageing and does not necessarily deteriorate. There are a number of management and treatment options (both pharmacological and non-pharmacological), which are covered in this pathway and which represent effective interventions for controlling symptoms and improving function.
Osteoarthritis is characterised pathologically by localised loss of cartilage, remodelling of adjacent bone and associated inflammation. A variety of traumas may trigger the need for a joint to repair itself. Osteoarthritis includes a slow but efficient repair process that often compensates for the initial trauma, resulting in a structurally altered but symptom-free joint. In some people, because of either overwhelming trauma or compromised repair, the process cannot compensate, resulting in eventual presentation with symptomatic osteoarthritis; this might be thought of as 'joint failure'. This in part explains the extreme variability in clinical presentation and outcome that can be observed between people, and also at different joints in the same person.

Pharmacological management of osteoarthritis

NICE intends to undertake a full review of evidence on the pharmacological management of osteoarthritis. This will start after a review by the MHRA of the safety of over-the-counter analgesics is completed. For more information, see the NICE guideline on osteoarthritis.
In the meantime, the recommendations in this pathway on the pharmacological management of osteoarthritis remain current advice. However, the GDG would like to draw attention to the findings of the evidence review on the effectiveness of paracetamol that was presented in the consultation version of the osteoarthritis guideline. That review identified reduced effectiveness of paracetamol in the management of osteoarthritis compared with what was previously thought. The GDG believes that this information should be taken into account in routine prescribing practice until the planned full review of evidence on the pharmacological management of osteoarthritis is published (see the NICE website for further details).

Updates

Updates to this pathway

20 September 2016 Link to NICE pathway on multimorbidity added.
15 December 2015 Joint distraction for ankle osteoarthritis (NICE interventional procedure guidance 538) added to surgical options.
21 July 2015 Joint distraction for knee osteoarthritis without alignment correction (NICE interventional procedure guidance 529) added to surgical options.
10 June 2015 Osteoarthritis (NICE quality standard 87) added.
27 January 2015 Implantation of a shock or load absorber for mild to moderate symptomatic medial knee osteoarthritis (NICE interventional procedure guidance 512) added to management of osteoarthritis.
2 September 2014 Total prosthetic replacement of the temporomandibular joint (NICE interventional procedure guidance 500) added to management of osteoarthritis.
27 May 2014 Platelet-rich plasma injections for osteoarthritis of the knee (NICE interventional procedure guidance 491) added to management of osteoarthritis.
25 February 2014 Total hip replacement and resurfacing arthroplasty for end-stage arthritis of the hip (review of technology appraisal guidance 2 and 44) (NICE technology appraisal guidance 304) added to management of osteoarthritis.

Sources

NICE guidance and other sources used to create this pathway.
Osteoarthritis (2014) NICE guideline CG177
Joint distraction for ankle osteoarthritis (2015) NICE interventional procedure guidance 538
Joint distraction for knee osteoarthritis without alignment correction (2015) NICE interventional procedure guidance 529
Total prosthetic replacement of the temporomandibular joint (2014) NICE interventional procedure guidance 500
Platelet-rich plasma injections for osteoarthritis of the knee (2014) NICE interventional procedure guidance 491
Minimally invasive total hip replacement (2010) NICE interventional procedure guidance 363
Shoulder resurfacing arthroplasty (2010) NICE interventional procedure guidance 354
Mini-incision surgery for total knee replacement (2010) NICE interventional procedure guidance 345
Total wrist replacement (2008) NICE interventional procedure guidance 271
Metatarsophalangeal joint replacement of the hallux (2005) NICE interventional procedure guidance 140
Artificial trapeziometacarpal joint replacement for end-stage osteoarthritis (2005) NICE interventional procedure guidance 111
Osteoarthritis (2015) NICE quality standard 43

Quality standards

Osteoarthritis

These quality statements are taken from the osteoarthritis quality standard. The quality standard defines clinical best practice for osteoarthritis care and should be read in full.

Quality statements

Diagnosis

This quality statement is taken from the osteoarthritis quality standard. The quality standard defines clinical best practice in osteoarthritis care and should be read in full.

Quality statement

Adults aged 45 or over are diagnosed with osteoarthritis clinically without investigations if they have activity-related joint pain and any morning joint stiffness lasts no longer than 30 minutes.

Rationale

There is often a poor link between changes visible on an X-ray, MRI or ultrasound scan and the symptoms of osteoarthritis: minimal changes can be associated with substantial pain, or modest structural changes to joints can occur with minimal accompanying symptoms. It is recommended that a clinical diagnosis of osteoarthritis is made for adults aged 45 years or over with typical symptoms without the need for further investigations. This will reduce both potential harm from exposure to radiation from X-rays and costs of unnecessary imaging procedures. However, if an alternative diagnosis is possible it may be necessary to carry out further investigations, including imaging, to aid diagnosis.

Quality measures

Structure
Evidence of local arrangements to ensure that adults aged 45 or over are diagnosed with osteoarthritis clinically without investigations if they have activity-related joint pain and any morning joint stiffness lasts no longer than 30 minutes.
Data source: Local data collection.
Process
Proportion of adults aged 45 years or over who have activity-related joint pain and in whom any morning joint stiffness lasts no longer than 30 minutes who are diagnosed with osteoarthritis clinically without investigations.
Numerator – the number in the denominator who are diagnosed with osteoarthritis clinically without investigations.
Denominator – the number of adults aged 45 years or over who have activity-related joint pain and in whom any morning joint stiffness lasts no longer than 30 minutes who are diagnosed with osteoarthritis.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GPs and community healthcare providers) ensure that they have clear policies and processes for diagnosing osteoarthritis clinically. Service providers should also monitor the use of imaging for diagnosing osteoarthritis in adults to ensure that it is not being used inappropriately.
Healthcare professionals diagnose osteoarthritis in adults aged 45 years or over clinically without investigations if the person has typical symptoms.
Commissioners (such as clinical commissioning groups and NHS England) ensure that they commission services with clear policies and processes for diagnosing osteoarthritis clinically. Commissioners should also require providers to show that imaging is not being used inappropriately for diagnosing osteoarthritis in adults.

What the quality statement means for patients, service users and carers

Adults aged 45 years or over who go to their GP with joint pain that is typical of osteoarthritis are usually diagnosed with osteoarthritis without the need for an X-ray or a scan. This is because the results of X-rays and scans do not explain symptoms or help when deciding about treatment, and will mean that people do not have unnecessary X-rays or scans.

Source guidance

  • Osteoarthritis (2014) NICE guideline CG177, recommendation 1.1.1 (key priority for implementation)

Definitions of terms used in this quality statement

Alternative diagnosis
If an alternative diagnosis is possible, it may be necessary to carry out imaging or other investigations to confirm the diagnosis. Alternative diagnoses include gout, other inflammatory arthritides such as rheumatoid arthritis, septic arthritis and malignancy. A history of trauma, prolonged morning joint-related stiffness, rapid worsening of symptoms or the presence of a hot swollen joint may indicate the need for further investigations to identify possible additional or alternative diagnoses.
[Adapted from Osteoarthritis (NICE guideline CG177) recommendation 1.1.2, and expert opinion]

Assessment at diagnosis

This quality statement is taken from the osteoarthritis quality standard. The quality standard defines clinical best practice in osteoarthritis care and should be read in full.

Quality statement

Adults newly diagnosed with osteoarthritis have an assessment that includes pain, impact on daily activities and quality of life.

Rationale

Adults with osteoarthritis may experience a number of challenges because of their symptoms, which may affect their ability to carry out their daily activities, work and enjoy a reasonable quality of life. It is important that an assessment is carried out at diagnosis that goes beyond the clinical presentation of osteoarthritis, to include pain, impact on daily activities and quality of life, while taking comorbidities into account. This will support self-management that empowers the person by focusing on their individual goals and preferences and allows healthcare professionals to give patient-centred advice and support that is positive and constructive. This has been shown to increase patient satisfaction and the effectiveness of the treatment plan, thereby reducing demand on the health service.

Quality measures

Structure
Evidence of local arrangements to ensure that adults newly diagnosed with osteoarthritis have an assessment that includes pain, impact on daily activities and quality of life.
Data source: Local data collection.
Process
Proportion of adults newly diagnosed with osteoarthritis who have an assessment that includes pain, impact on daily activities and quality of life.
Numerator – the number in the denominator who have an assessment that includes pain, impact on daily activities and quality of life.
Denominator – the number of adults newly diagnosed with osteoarthritis.
Data source: Local data collection. Data on assessment of pain and function are included in the Keele Primary Care Consortium Osteoarthritis (OA) e-template for primary care consultations (endorsed by NICE).
Outcome
Patient satisfaction with assessment of their osteoarthritis.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GPs, community healthcare providers and hospitals) ensure that systems and resources are in place for adults newly diagnosed with osteoarthritis to have an assessment that includes pain, impact on daily activities and quality of life.
Healthcare professionals carry out an assessment that includes pain, impact on daily activities and quality of life for people newly diagnosed with osteoarthritis.
Commissioners (such as clinical commissioning groups and NHS England) ensure that they commission services in which adults newly diagnosed with osteoarthritis have an assessment that includes pain, impact on daily activities and quality of life.

What the quality statement means for patients, service users and carers

Adults who have been diagnosed with osteoarthritis have an assessment in which they are asked about their pain, how they are managing on a day-to-day basis and how the condition is affecting their life overall, including their mood. This will help when deciding the best way to try to improve their symptoms and quality of life.

Source guidance

Definitions of terms used in this quality statement

Assessment
An assessment for people newly diagnosed with osteoarthritis includes:
  • a pain assessment
  • the impact on the person’s day-to-day activities, including activities of daily living, employment and leisure activities
  • the person’s overall quality of life, including their mood.
The assessment should be adapted to meet the person’s individual needs and take comorbidities into account.
[Adapted from Osteoarthritis (NICE guideline CG177) recommendations 1.2.1 and 1.2.3]

Equality and diversity considerations

Healthcare professionals should take into account cultural and communication needs (including any learning disabilities) when assessing an adult newly diagnosed with osteoarthritis.

Self-management

This quality statement is taken from the osteoarthritis quality standard. The quality standard defines clinical best practice in osteoarthritis care and should be read in full.

Quality statement

Adults with osteoarthritis participate in developing a self-management plan that directs them to any support they may need.

Rationale

Providing a framework that encourages and supports self-management is an important tool to support shared decision making and ensure that people are at the centre of their care. Self-management principles empower the person by enhancing their understanding and knowledge of osteoarthritis and its management, and by enabling them to identify their own priorities and goals for their treatment. This may include developing skills such as problem solving, goal setting, coping strategies and managing relationships. They can then use this knowledge and their skills to access resources and build on their own experiences of managing their osteoarthritis. Self-management can improve patient experience and health outcomes, as well as increasing adherence with the treatment plan and reducing reliance on healthcare interventions.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with osteoarthritis participate in developing a self-management plan that directs them to any support they may need.
Data source: Local data collection.
Process
a) Proportion of adults with osteoarthritis with a record of having received written information about osteoarthritis and its management.
Numerator – the number in the denominator with a record of having received written information about osteoarthritis and its management.
Denominator – the number of adults newly diagnosed with osteoarthritis.
Data source: Local data collection. Data on the provision of information about osteoarthritis are included in the Keele Primary Care Consortium Osteoarthritis (OA) e-template for primary care consultations (endorsed by NICE).
b) Proportion of adults diagnosed with osteoarthritis who participate in developing a self-management plan.
Numerator – the number in the denominator who participate in developing a self-management plan.
Denominator – the number of adults newly diagnosed with osteoarthritis.
Data source: Local data collection. Data on self-management plans are included in the ‘care.data’ extract for the Health and Social Care Information Centre (not specific to people with osteoarthritis).
c) Proportion of adults with osteoarthritis who participate in reviewing a self-management plan.
Numerator – the number in the denominator who participate in reviewing a self-management plan.
Denominator – the number of adults with osteoarthritis attending for a scheduled review of their care.
Data source: Local data collection.
Outcome
Adults with osteoarthritis are satisfied that they have the knowledge and confidence they need to self-manage their condition.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (GPs and community healthcare providers) ensure that processes are in place so that adults with osteoarthritis participate in developing a self-management plan that directs them to any support they may need. Service providers should also agree local referral pathways that may include support provided by voluntary sector organisations.
Healthcare professionals work with adults with osteoarthritis to develop an individual self-management plan that gives the person information and advice and directs them to any support they may need to help them manage their condition.
Commissioners (such as clinical commissioning groups and NHS England) ensure that they commission services in which adults with osteoarthritis participate in developing a self-management plan that directs them to any support they made need, and which have local arrangements in place to ensure that support is available, including services provided by the voluntary sector. Commissioners should request monitoring data and consider an audit of community healthcare providers to check that self-management plans are in place for all adults with osteoarthritis. Commissioners should also ensure that community care providers have sufficient capacity to offer specialised support if needed, including from physiotherapists, occupational therapists, dietitians and podiatrists.

What the quality statement means for patients, service users and carers

Adults with osteoarthritis agree a self-management plan with their GP or nurse that covers what they can do to help manage their condition, including improving their symptoms and quality of life. The plan should identify where they can get the support they may need to help them do this.

Source guidance

  • Osteoarthritis (2014) NICE guideline CG177, recommendations 1.2.5, 1.3.1, 1.3.2 (key priorities for implementation), 1.2.2 and 1.3.3

Definitions of terms used in this quality statement

Self-management plan
A self-management plan is jointly developed with the person with osteoarthritis and should be provided in verbal and written formats. It can include:
  • a record of the agreed approach to self-managing the condition, including individual goals
  • information and advice about the condition and its treatment, including how to find support groups and online information sources
  • advice and support to increase physical activity and exercise, including pacing strategies, that gives information about local services such as physiotherapy, or exercise classes, groups and facilities
  • advice and support for people who are overweight or obese to lose weight, which may include referral to local resources such as weight-loss and exercise programmes
  • details of self-management programmes available locally on an individual or group basis
  • referral to local services such as occupational therapy, orthotics and podiatry that can provide advice on suitable footwear, orthotic devices (such as insoles and braces) and assistive devices (such as walking sticks and tap turners)
  • pain management advice
  • medicines management advice, including who can provide support (for example, community pharmacies)
  • when to have a review of their osteoarthritis.
[Adapted from Osteoarthritis (NICE guideline CG177) recommendations 1.3.1, 1.3.2, 1.4.1 (key priorities for implementation), 1.2.2, 1.3.3, 1.4.3, 1.4.7, 1.4.8, 1.4.9 and 1.7.1]

Equality and diversity considerations

Healthcare professionals should take into account cultural and communication needs (including any learning disabilities) when providing information and support for adults with osteoarthritis. This should include providing printed information for people who cannot access information online and providing information in accessible large print and easy read formats where required.
Not all people will want to self-manage osteoarthritis or be able to do so, and healthcare professionals should identify any vulnerable people who may need additional support.

Exercise

This quality statement is taken from the osteoarthritis quality standard. The quality standard defines clinical best practice in osteoarthritis care and should be read in full.

Quality statement

Adults with osteoarthritis are advised to participate in muscle strengthening and aerobic exercise.

Rationale

Exercise is a core treatment for osteoarthritis that will improve joint pain and function. It is important that people are advised to undertake specific exercise that is relevant for their condition, including muscle strengthening that targets affected joints and general aerobic exercise. Healthcare professionals will need to make a judgement about the best way to encourage participation in exercise, because this will vary for each person depending on their needs, circumstances and self-motivation, and may change over time. It is important that support and encouragement to exercise is ongoing and reinforced at every opportunity.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with osteoarthritis are advised to participate in muscle strengthening and aerobic exercise.
Data source: Local data collection.
Process
a) Proportion of adults diagnosed with osteoarthritis who receive advice on participating in muscle strengthening exercise.
Numerator – the number in the denominator who receive advice on participating in muscle strengthening exercise.
Denominator – the number of adults newly diagnosed with osteoarthritis.
Data source: Local data collection. Data on exercise advice are included in the ‘care.data’ extract from the Health and Social Care Information Centre (not specific to people with osteoarthritis). Data on exercise advice and referrals to physiotherapy are included in the Keele Primary Care Consortium Osteoarthritis (OA) e-template for primary care consultations (endorsed by NICE).
b) Proportion of adults diagnosed with osteoarthritis who receive advice on participating in aerobic exercise.
Numerator – the number in the denominator who receive advice on participating in aerobic exercise.
Denominator – the number of adults newly diagnosed with osteoarthritis.
Data source: Local data collection. Data on exercise advice are included in the ‘care.data’ extract from the Health and Social Care Information Centre (not specific to people with osteoarthritis) and also in the Keele Primary Care Consortium Osteoarthritis (OA) e-template for primary care consultations (endorsed by NICE).
c) Proportion of adults with osteoarthritis who receive advice on participating in muscle strengthening and aerobic exercise at their review.
Numerator – the number in the denominator who receive advice on participating in muscle strengthening and aerobic exercise.
Denominator – the number of adults with osteoarthritis attending for a scheduled review of care.
Data source: Local data collection. Data on exercise advice are included in the ‘care.data’ extract from the Health and Social Care Information Centre (not specific to people with osteoarthritis). Data on exercise advice and referrals to physiotherapy are included in the Keele Primary Care Consortium Osteoarthritis (OA) e-template for primary care consultations (endorsed by NICE).
Outcome
a) Physical activity in adults with osteoarthritis.
Data source: Local data collection.
b) Patient satisfaction with advice on exercise.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (GPs and community healthcare providers) ensure that processes and referral pathways are in place so that adults with osteoarthritis are advised and encouraged at both diagnosis and review to participate in muscle strengthening and aerobic exercise. It may be useful to compile information about local exercise classes, groups and facilities, so that people can be given information about any that are suitable.
Healthcare professionals ensure that they advise and encourage adults with osteoarthritis at both diagnosis and review to participate in muscle strengthening and aerobic exercise, and provide information about suitable local exercise classes, groups and facilities.
Commissioners (such as clinical commissioning groups and NHS England) ensure that they commission services in which adults with osteoarthritis are advised and encouraged at both diagnosis and review to participate in muscle strengthening and aerobic exercise. Commissioners also ensure that there is sufficient capacity in physiotherapy and exercise support resources to meet demand for adults with osteoarthritis.

What the quality statement means for patients, service users and carers

Adults with osteoarthritis are advised and encouraged by healthcare professionals to exercise, both for general fitness and to strengthen the muscles that support their affected joints, because this may help to improve their symptoms.

Source guidance

  • Osteoarthritis (2014) NICE guideline CG177, recommendations 1.2.5 and 1.4.1 (key priorities for implementation)

Definitions of terms used in this quality statement

Muscle strengthening exercise
Exercise to strengthen the muscles around the affected joint.
[Adapted from Osteoarthritis (NICE guideline CG177) full guideline section 8.1]
Aerobic exercise
Aerobic exercise aims to improve general mobility, function, cardiovascular fitness, wellbeing and self-efficacy, and could include cycling, swimming or exercise at a gym.
[Adapted from Osteoarthritis (NICE guideline CG177) full guideline section 8.1, and expert opinion]

Equality and diversity considerations

Healthcare professionals should take into account cultural and communication needs (including any learning disabilities) when providing information and support for adults with osteoarthritis. This should include providing printed information for people who cannot access information online and providing information in accessible large print and easy read formats where needed.
All adults with osteoarthritis should be encouraged to exercise. If age, comorbidities, pain severity or disability are seen as a barrier, the person may need specific advice and support to encourage participation, and should be advised that exercise may improve their symptoms.

Weight loss

This quality statement is taken from the osteoarthritis quality standard. The quality standard defines clinical best practice in osteoarthritis care and should be read in full.

Quality statement

Adults with osteoarthritis who are overweight or obese are offered support to lose weight.

Rationale

Weight loss is a core treatment for osteoarthritis that will improve joint pain and function. Adults with osteoarthritis who are overweight or obese should be offered support to help them to lose weight, which may include weight-loss programmes tailored to their individual needs. It is important that support and encouragement to lose weight are ongoing and reinforced at every opportunity. Ongoing weight management support may be needed to ensure that a lower weight is maintained.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with osteoarthritis who are overweight or obese are offered support to lose weight.
Data source: Local data collection.
Process
Proportion of adults with osteoarthritis who are overweight or obese who are offered support to lose weight.
Numerator – the number in the denominator who are offered support to lose weight.
Denominator – the number of adults with osteoarthritis who are overweight or obese.
Data source: Local data collection. Data on BMI values and dietary advice are included in the ‘care.data’ extract for the Health and Social Care Information Centre (not specific to people with osteoarthritis). Data on BMI values and weight advice are included in the Keele Primary Care Consortium Osteoarthritis (OA) e-template for primary care consultations (endorsed by NICE).
Outcome
a) Weight loss in adults with osteoarthritis who are overweight or obese.
Data source: Local data collection. Data on BMI values are included in the ‘care.data’ extract for the Health and Social Care Information Centre (not specific to people with osteoarthritis). Data on BMI values and weight advice are included in the Keele Primary Care Consortium Osteoarthritis (OA) e-template for primary care consultations (endorsed by NICE).
b) Patient satisfaction with support to lose weight.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (GPs, community healthcare providers and hospitals) ensure that processes and referral pathways are in place so that adults with osteoarthritis who are overweight or obese are offered support to lose weight.
Healthcare professionals ensure that they offer support to adults with osteoarthritis who are overweight or obese to lose weight, such as referral to a weight-loss service.
Commissioners (such as clinical commissioning groups and NHS England) ensure that they commission services in which adults with osteoarthritis who are overweight or obese are offered support to lose weight. Commissioners also ensure that there is sufficient capacity in weight-loss services to meet demand for adults with osteoarthritis.

What the quality statement means for patients, service users and carers

Adults with osteoarthritis who are overweight or obese are offered help to lose weight, because being overweight can make joint pain worse and losing weight should improve symptoms.

Source guidance

  • Osteoarthritis (2014) NICE guideline CG177, recommendations 1.2.5 (key priority for implementation) and 1.4.3

Definitions of terms used in this quality statement

Overweight or obese
An adult with a BMI of 25–29.9 kg/m2 is classified as overweight and an adult with a BMI of 30 kg/m2 or more is classified as obese. Waist circumference may be used in addition to BMI to identify health risk in people with a BMI below 35 kg/m2. BMI may be a less accurate measure of body fat in adults who are very muscular, so BMI should be interpreted with caution in this group. Some other population groups, such as people of Asian family origin and older people, have comorbidity risk factors that are of concern at different BMIs (lower for adults of an Asian family origin and higher for older people.
Support to lose weight
Support to help someone with osteoarthritis to lose weight should focus on diet and physical activity, and may also include pharmacological and surgical interventions. The level of support should be determined by the person’s needs, and be responsive to changes over time. Weight management programmes should be delivered by a trained professional. They should include behaviour change strategies to increase physical activity and encourage healthy eating. Pharmacological and surgical treatment options should be considered only after dietary, exercise and behavioural approaches have been tried and evaluated.
[Adapted from Obesity: identification, assessment and management of overweight and obesity in children, young people and adults (NICE guideline CG189) recommendations 1.2.11, 1.4.1, 1.4.4 and 1.10.1]

Equality and diversity considerations

Healthcare professionals should take into account cultural and communication needs (including any learning disabilities) when providing information and support for adults with osteoarthritis. This should include providing printed information for people who cannot access information online and providing information in accessible large print and easy read formats where needed.
When referring adults with osteoarthritis to a weight loss service, any potential difficulties in accessing services, which may include distance, disability and financial obstacles, should be taken into account.

Timing of review

This quality statement is taken from the osteoarthritis quality standard. The quality standard defines clinical best practice in osteoarthritis care and should be read in full.

Quality statement

Adults with osteoarthritis discuss and agree the timing of their next review with their primary healthcare team.

Rationale

Adults with osteoarthritis should be offered regular reviews to assess the progress of the condition and its impact on their quality of life, provide support for self-management and review treatments to reduce further deterioration and the need for additional medication and/or referral for surgery. It is important to address appropriate medication use, including prescribed and over-the-counter analgesics, monitor side effects and review polypharmacy. The timing of reviews will depend on individual needs, including severity of symptoms and response to treatment. It is important that adults with osteoarthritis are made aware of the need for reviews, and for the timing to be discussed and agreed with their primary healthcare team.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with osteoarthritis discuss and agree the timing of their next review with their primary healthcare team.
Data source: Local data collection.
Process
Proportion of adults with osteoarthritis with an agreed date for a review.
Numerator – the number in the denominator who have an agreed date for a review.
Denominator – the number of adults with osteoarthritis.
Data source: Local data collection.
Outcome
Adults with osteoarthritis are confident that their needs will be reviewed regularly.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (general practices, primary and community healthcare providers) ensure that processes are in place for adults with osteoarthritis to discuss and agree the timing of their next review based on the person’s individual needs.
Healthcare professionals discuss and agree the timing of the next review with adults with osteoarthritis, based on the person’s individual needs.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which processes are in place for adults with osteoarthritis to discuss and agree the timing of their next review based on the person’s individual needs.

What the quality statement means for patients, service users and carers

Adults with osteoarthritis discuss and agree (usually with their GP or practice nurse) when they should have their next review to check how well they are managing and if they need any more support. The timing of their next review will depend on how much their osteoarthritis is affecting them and how well any treatment is working.

Source guidance

  • Osteoarthritis (2014) NICE guideline CG177, recommendations 1.7.1 and 1.7.2 (key priorities for implementation)

Equality and diversity considerations

Healthcare professionals should take into account cultural and communication needs (including any learning disabilities) when arranging reviews for adults with osteoarthritis.

Core treatments before referral for consideration of joint surgery

This quality statement is taken from the osteoarthritis quality standard. The quality standard defines clinical best practice in osteoarthritis care and should be read in full.

Quality statement

Adults with osteoarthritis are supported with non-surgical core treatments for at least 3 months before any referral for consideration of joint surgery.

Rationale

Core treatments for adults with osteoarthritis are: verbal and written information to support a better understanding of the condition, activity and exercise, and weight loss if the person is overweight or obese. Core treatments support the person to self-manage their condition and help to relieve symptoms. It is therefore important that these treatments are tried before a surgical solution is explored. Currently a relatively low proportion of people referred for possible joint surgery progress to hip or knee replacements, and ensuring that core treatments are tried first will help to reduce referrals that may not be needed. People who do go on to have surgery are likely to have improved outcomes if core treatments are undertaken pre-operatively.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with osteoarthritis are supported with non-surgical core treatments for at least 3 months before any referral for consideration of joint surgery.
Data source: Local data collection.
Process
Proportion of adults with osteoarthritis referred for consideration of joint surgery who were supported with non-surgical core treatments for at least 3 months.
Numerator – the number in the denominator who were supported with non-surgical core treatments for at least 3 months.
Denominator – the number of adults with osteoarthritis referred for consideration of joint surgery.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (GPs, community healthcare providers and hospitals) ensure that policies and processes are in place so that adults with osteoarthritis are not referred for consideration of joint surgery until they have been supported with non-surgical core treatments for at least 3 months. Hospitals should provide information to commissioners about inappropriate referrals and referrals for people who have not been offered 3 months of core treatments.
Healthcare professionals ensure that they do not refer adults with osteoarthritis for consideration of joint surgery until the person has been supported with non-surgical core treatments for at least 3 months.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which adults with osteoarthritis are not referred for consideration of joint surgery until they have been supported with non-surgical core treatments for at least 3 months. Commissioners should consider audits of people referred for consideration of joint surgery to ensure that the patient record shows that they were supported with core treatments for at least 3 months before referral.

What the quality statement means for patients, service users and carers

Adults with osteoarthritis are given information, and are advised and supported to exercise and (if appropriate) lose weight to help with joint pain and stiffness, for at least 3 months before any referral for possible joint surgery.

Source guidance

  • Osteoarthritis (2014) NICE guideline CG177, recommendations 1.2.5 (key priority for implementation) and 1.6.1, and expert opinion

Definitions of terms used in this quality statement

Core treatments
Core treatments for osteoarthritis include:
  • ongoing verbal and written information about the condition and its management
  • advice on physical activity and exercise for muscle strengthening and general fitness
  • support to lose weight if the person is overweight or obese.
[Adapted from Osteoarthritis (NICE guideline CG177) recommendations 1.2.5, 1.3.1, 1.4.1 (key priorities for implementation) and 1.4.3]
Support with non-surgical core treatments
Healthcare professionals will need to make a judgement about the best way to encourage people to participate in exercise, because this will vary for each person depending on their needs, circumstances and self-motivation, and may change over time. Support to increase physical activity and exercise will include advice and information, which may include information about local services such as physiotherapy or exercise classes, groups and facilities.
Support to help someone with osteoarthritis to lose weight should focus on diet and physical activity, and may also include pharmacological and surgical interventions. The level of support should be determined by the person’s needs, and be responsive to changes over time. Weight management programmes should be delivered by a trained professional. They should include behaviour change strategies to increase physical activity and encourage healthy eating. Pharmacological and surgical treatment options should be considered only after dietary, exercise and behavioural approaches have been tried and evaluated.
[Adapted from Osteoarthritis (NICE guideline CG177) recommendations 1.2.5, 1.4.1 (key priorities for implementation) and 1.4.3, and Obesity: identification, assessment and management of overweight and obesity in children, young people and adults (NICE guideline CG189) recommendations 1.2.11, 1.4.1, 1.4.4 and 1.10.1, and expert opinion]

Equality and diversity considerations

Healthcare professionals should take into account cultural and communication needs (including any learning disabilities) when providing information and support for adults with osteoarthritis. This should include providing printed information for people who cannot access information online and providing information in accessible large print and easy read formats where needed.
All adults with osteoarthritis should be encouraged to exercise. If age, comorbidities, pain severity or disability are seen as a barrier, the person may need specific advice and support to encourage participation, and should be advised that exercise may improve their symptoms.
When referring adults with osteoarthritis to a weight loss service, any potential difficulties in accessing services, which may include distance, disability and financial obstacles, should be taken into account.

Referral for consideration of joint surgery

This quality statement is taken from the osteoarthritis quality standard. The quality standard defines clinical best practice in osteoarthritis care and should be read in full.

Quality statement

Healthcare professionals do not use scoring tools to identify which adults with osteoarthritis are eligible for referral for consideration of joint surgery.

Rationale

There is currently considerable variation in the criteria used to decide whether an adult with osteoarthritis is eligible for referral for consideration of joint surgery in England, with no evidence to support the range of scoring tools used and the decisions made. The person with osteoarthritis should be given support and advice by their healthcare professional to reach a shared decision on whether surgery is likely to be beneficial, based on the severity of their symptoms, their general health, their expectations of lifestyle and activity, and the effectiveness of any non-surgical treatments. Ensuring that inappropriate scoring tools are not used will improve equality of access to surgery.

Quality measures

Structure
Evidence of local arrangements to ensure that healthcare professionals do not use scoring tools to identify which adults with osteoarthritis are eligible for referral for consideration of joint surgery.
Data source: Local data collection.
Process
Proportion of adults with osteoarthritis referred for consideration of joint surgery whose referral is based on a scoring tool.
Numerator – the number in the denominator for whom the referral decision is based on a scoring tool.
Denominator – the number of adults with osteoarthritis referred for consideration of joint surgery.
Data source: Local data collection.
Outcome
Patient-reported health outcomes for adults with osteoarthritis.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (GPs, community healthcare providers and hospitals) ensure that scoring tools are not used to identify which adults with osteoarthritis are eligible for referral for consideration of joint surgery. Decisions on referral thresholds should instead be based on discussions between patient representatives, referring clinicians and surgeons.
Healthcare professionals ensure that they do not use scoring tools to identify which adults with osteoarthritis are eligible for referral for consideration of joint surgery.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services that do not use scoring tools to identify which adults with osteoarthritis are eligible for referral for consideration of joint surgery. Commissioners should not restrict referral pathways on the basis of arbitrary referral thresholds, but should ensure that thresholds are agreed with patient representatives, referring clinicians and surgeons.

What the quality statement means for patients, service users and carers

Adults with osteoarthritis who are considering joint surgery discuss this with their healthcare professional to decide if it is right for them, and are not denied a referral because they have not met particular requirements.

Source guidance

  • Osteoarthritis (2014) NICE guideline CG177, recommendations 1.6.2 (key priority for implementation) and 1.6.5

Definitions of terms used in this quality statement

Scoring tools
The use of orthopaedic scores and questionnaire-based assessments to identify people who are eligible for referral for consideration of joint surgery has become widespread. These usually assess pain, functional impairment and sometimes radiographic damage. The commonest are the New Zealand score and the Oxford Hip or Knee score. Many (such as the Oxford tools) were designed to measure population-based changes after surgery, and none have been validated for assessing appropriateness of referral.
[Adapted from Osteoarthritis (2014) NICE guideline CG177, full guideline section 11.1.7]

Equality and diversity considerations

Age, sex, obesity, smoking, disability (including learning disabilities) and comorbidities should not be barriers to referral for consideration of joint surgery.

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Effective interventions library

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Implementation

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.
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Pathway information

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Patient-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Glossary

Cyclo-oxygenase 2
Guideline Development Group
Medicines and Healthcare Products Regulatory Agency
Non-steroidal anti-inflammatory drugs
Proton pump inhibitor
Transcutaneous electrical nerve stimulation

Paths in this pathway

Pathway created: February 2014 Last updated: September 2016

© NICE 2016

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