Managing osteoarthritis in general practice: a long-term approach

Deborah C Saltman, Natalie A O'Dea and Philip N Sambrook

MJA 2001; 175: S92-S96

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What do GPs want to know? - Introducing Susan - The "later on" consultation - Late consultation - Issues to consider - Postscript - Acknowledgements - References - Authors' Details Register to be notified of new articles by e-mail - Current contents list - More articles on Rheumatology

• A greater understanding of how to increase the role of the patient in managing their osteoarthritis.

• Strategies that slow the progression of osteoarthritis.

• Enhanced skills in lifestyle counselling.

• More logical ways to progress through a number of consultations to achieve a successful outcome.

• Ways to measure the efficacy of their osteoarthritis management.

• An improved approach as a case manager in a multidisciplinary team.

Through a case study, we address these issues and review the key activities of a GP in managing a patient who presents with osteoarthritis of the knee. We introduce "Susan" at the consultation when her osteoarthritis is first recognised, then follow her through a number of consultations spanning over 20 years.

Susan represents the one in five females in the 45-64 year age group who say they suffer from osteoarthritis. In this middle-years age group, one in 10 men say they suffer from osteoarthritis.² In the older age group (65 years and over), arthritis and rheumatism are the most common complaints of both males and females.

She has come to see you today to discuss a mild ache in her left knee; the pain increases particularly after 18 holes of golf. Her mother had a knee replacement due to osteoarthritis and Susan does not want to follow in her mother's footsteps.

This is a new problem in a well-known patient. The combination lends itself well to the use of a clinical pathway. Such a clinical pathway can remind the GP to seek specific information that may have been assumed with a well-known patient. Pathways can also help to incorporate other comorbidities into the management plan.

In the course of our workshops, an osteoarthritis clinical pathway was developed by GPs to outline options for the ongoing management of osteoarthritic patients such as Susan (see Box 1).³ This pathway starts with the assessment of a patient's risk factors.

Some risk factors for osteoarthritis are unchangeable, such as:

• Age. By age 70, osteoarthritis is almost universal. It is unclear whether this represents the clinical development of osteoarthritis over years as people age or aging-related changes in cartilage predisposing to osteoarthritis.

• Sex. Women are more commonly affected, although the female:male ratio varies from 1.5:1 to 4:1 in different studies.

• Genetics. Geographical differences have been reported in the prevalence of osteoarthritis, but these probably have more to do with genetic variability than race. A number of studies have now confirmed the importance of genetic factors.⁴

• Family history.

The impact of other factors can be minimised or prevented, such as:

• Overweight/obesity. A relationship between obesity (usually defined as a BMI 30) and knee osteoarthritis has been confirmed in many studies.

• Injury and joint trauma (occupational or non-occupational).

• Mechanical problems in joints or muscles, including hypermobility syndromes and abnormal joint shape, such as acetabular dysplasia.

• Systemic diseases. Associations have also been observed with diabetes, hypertension and hyperuricaemia independent of obesity.

Susan has the unalterable risk factors of age (approaching 60 years), female sex, genetics (Caucasian race) and family history (her mother has osteoarthritis). Some of her risk factors that can be altered are obesity (she has a BMI of 30) and joint trauma (she stands while teaching). Careful questioning of Susan and/or review of case notes could identify further risk factors. Preventing the progression of Susan's osteoarthritis requires the early detection of these risk factors.

• activity-related pain

• bony/soft tissue swelling

• joint crepitus

• joint effusion.

As this is the first consultation in which osteoarthritis appears as a health problem, targeted history taking should include an assessment of the severity of Susan's osteoarthritis, including:

• the intensity, frequency and duration of pain, and if the pain wakes her up from her sleep or occurs at rest.

• the level of disability and her capacity to complete activities of daily living.

In addition to history and physical examination, diagnostic tests may be considered. In the early stages of the disease, tests such as x-rays may be normal and therefore are often unnecessary. However, x-rays that show early osteoarthritic changes may help to motivate a patient like Susan, particularly when long-term prognosis is discussed, and may allow positive feedback to Susan that it is not too late to commence an active care program.

• patient factors, such as motivation, level of pain, degree of disability and capacity for self-management

• GP factors, including an assessment of the severity of the disease, identification of other related health problems and appropriate management strategies

• consultation factors, which include the assignment of health priorities and follow-up arrangements.

• There is good evidence that many interventions work, but little good evidence to establish what works best.

• Evidence-based non-pharmacological interventions that work (E2 or E3) include weight reduction, patient education, monthly telephone calls to follow up, aerobic and strengthening exercises, patellar taping and orthotic heel wedges.⁵ See March and Stenmark.⁶

• A broad range of physical activities have been shown to reduce pain, stiffness, and disability and improve general mobility, muscle strength and quality of life in patients (E2 or E3).^6-8

• Other non-pharmacological therapies, such as acupuncture, electrotherapy, spa therapy, ultrasound, heat, walking stick, relaxation therapies, orthotics and relaxation techniques, have been shown to elicit a response, which may in some cases be due to the placebo effect.⁶

• Pharmacological interventions, such as paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), capsaicin, topical anti-inflammatory agents, COX-2-selective inhibitors, viscosupplementation, glucosamine and chondroitin sulfate, have all been shown to modify symptoms (E1 or E2).^6,9,10

• Reliable evidence for the benefit of some current management strategies over others is lacking. For example, there is no good evidence to suggest that NSAIDs are any better than simple analgesics, topical NSAIDs or over-the-counter preparations.¹¹

• Switching between medications, in particular from one NSAID to another, or increasing dosage when it is already in the therapeutic range, does not provide any additional benefit.¹²

• Intra-articular injection of corticosteroid provides definite, but relatively short-term, pain relief (E1).¹³

In this first consultation for osteoarthritis, Susan's main concerns are pain relief and preventing progression of disease. A combination of pharmacological and non-pharmacological strategies could be initiated.

Another way of increasing compliance is to set manageable goals with patients. Short-, medium- and long-term goals can be set independently; however, motivation is more likely to be maintained if long-term goals are a composite of several short- or medium-term goals. Examples of an achievable set of short-, medium- and long-term goals for Susan include:

• Short-term goals: daily charting of pain and limitations to activities of daily living.

• Medium-term goals: maintenance of daily medication and an exercise program for the next six months to reduce inflammation, pain and weight.

• Long-term goals: preventing progression of osteoarthritis and maintaining current activities of daily living, assisted by regular medication and exercises.

She is depressed about the pain in her knees and her libido is reduced. She finds playing with the grandchildren exhausting; she just can't keep up with them.

By using the osteoarthritis consultation checklist, Susan's GP will be able to assess whether the timing and content of her consultations are appropriate and what has changed (or hasn't changed) from the last consultation and why. The checklist will prompt Susan to ask questions that concern her about her ongoing management.

A referral should contain:

• A statement regarding the purpose of the referral and the knowledge to date. Sending a brief history may prevent a consultant sending a longer one back!

• A definition of the problem from a community perspective. Allowing the consultant to understand the environment in which Susan operates will help him/her suggest or initiate appropriate management strategies.

• An explanation of the type of help sought, including a statement of what has been done to date (and doesn't need repeating), such as x-rays or household modifications.

• The GP's opinion on qualifying factors in the continuing management of the patient (eg, Susan's depression).

The return correspondence from the consultant should address the following areas:

• A definition of the problem as the consultant sees it.

• What was done and why? Was it beyond what was asked and if so why?

• Feedback on what the GP has done.

• Does the consultant want to see Susan again and why? If Susan needs to go back, what might happen in between visits? For example, when should a change in symptoms be apparent?

• How serious is Susan's problem? How urgent is her problem?

Studies of the referral process between GPs and consultants have highlighted areas where communication could be improved from the consultant to the GP, including less repetition of history and more identification of prognosis and prognostic indicators.¹⁵

• exercise¹⁶

• weight reduction¹⁷

• antioxidants¹⁸

• glucosamine¹⁹

• chondroitin.²⁰

However, these all need further testing to establish such effects. In the future, calcium pentosan polysulfate, metalloproteinase inhibitors, tetracyclines, interleukin-2 inhibitors, growth factors, diacerrhein and gene therapy may also be of use.

In severe cases, perhaps even later in Susan's life, there is the possibility of a range of surgical interventions, such as:

• arthroscopic debridement

• full or partial joint replacement

• tidal irrigation of the knee.

No well controlled trials of arthroscopic debridement have been conducted but selected patients may experience pain relief afterwards (E3). Tidal irrigation of the knee similarly needs further study.²¹ While there are no published evidence-based indications for total knee replacement, Dieppe and colleagues have summarised the results of various consensus meetings (E3).²²

Susan often wakes during the night from the pain in her left knee. The pain is unremitting and does not respond to any of the management options you have worked out with her. When she gets up, both her knees are stiff and painful. She feels she has become irritable with her family and is not coping with simple everyday tasks such as shopping. She would like to enjoy her retirement years.

The nature and style of the primary care consultation allows for effective information gathering and communication between general practitioners, their patients and the consultants to whom patients are referred. On average, patients see their general practitioners three times a year. It is this contact that places a general practitioner in the ideal position to provide continuing care for patients with osteoarthritis.

The osteoarthritis clinical pathway and consultation checklist were developed by 60 GPs within the Northern Area Health Service in Sydney. The series of workshops was funded by MBF (Medical Benefits Fund of Australia) as a part of its "Caring About Health" program. This program was aimed at early detection of and intervention in patients with osteoarthritis, heart failure or depression. It was conducted by the University of Sydney.

These tools were subsequently reviewed by GPs at a workshop funded by Pharmacia/Pfizer.

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Reprints will not be available from the authors.
Correspondence: Professor Deborah C Saltman, Department of General Practice, University of Sydney, Sydney, NSW 2006.
dsaltmanATsanofi.com.au

This educational supplement is supported by an
educational grant from Pharmacia Australia and Pfizer

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