4.1. Algorithms

4.2. Key priorities for implementation

From the full set of recommendations, the GDG selected nine key priorities for implementation. The criteria used for selecting these recommendations are listed in detail in The Guidelines Manual.³²⁷ The reasons that each of these recommendations was chosen are shown in the table linking the evidence to the recommendation in the relevant chapter.

• Diagnose osteoarthritis 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. [new 2014]
• Offer advice on the following core treatments to all people with clinical osteoarthritis.
  • Access to appropriate information (see recommendation 7).
  • Activity and exercise (see recommendation 12).
  • Interventions to achieve weight loss if the person is overweight or obese (see recommendation 14 and Obesity [NICE clinical guideline 43]). [2008, amended 2014]
• Offer accurate verbal and written information to all people with osteoarthritis to enhance understanding of the condition and its management, and to counter misconceptions, such as that it inevitably progresses and cannot be treated. Ensure that information sharing is an ongoing, integral part of the management plan rather than a single event at time of presentation. [2008]
• Agree individualised self-management strategies with the person with osteoarthritis. Ensure that positive behavioural changes, such as exercise, weight loss, use of suitable footwear and pacing, are appropriately targeted. [2008]
• Advise people with osteoarthritis to exercise as a core treatment (see recommendation 6), irrespective of age, comorbidity, pain severity or disability. Exercise should include:
  • local muscle strengthening and
  • general aerobic fitness.

It has not been specified whether exercise should be provided by the NHS or whether the healthcare professional should provide advice and encouragement to the person to obtain and carry out the intervention themselves. 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. [2008]

• Base decisions on referral thresholds on discussions between patient representatives, referring clinicians and surgeons, rather than using scoring tools for prioritisation. [2008, amended 2014]
• Refer for consideration of joint surgery before there is prolonged and established functional limitation and severe pain. [2008, amended 2014]
• Offer regular reviews to all people with symptomatic osteoarthritis. Agree the timing of the reviews with the person (see also recommendation 42). Reviews should include:
  • monitoring the person’s symptoms and the ongoing impact of the condition on their everyday activities and quality of life
  • monitoring the long-term course of the condition
  • discussing the person’s knowledge of the condition, any concerns they have, their personal preferences and their ability to access services
  • reviewing the effectiveness and tolerability of all treatments
  • support for self-management. [new 2014]
• Consider an 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 osteoarthritis. [new 2014]

4.3. Full list of recommendations

1. Diagnose osteoarthritis 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. [new 2014]
2. Be aware that atypical features, such as a history of trauma, prolonged morning joint-related stiffness, rapid worsening of symptoms or the presence of a hot swollen joint, may indicate alternative or additional diagnoses. Important differential diagnoses include gout, other inflammatory arthritides (for example, rheumatoid arthritis), septic arthritis and malignancy (bone pain). [new 2014]
3. Assess the effect of osteoarthritis on the person’s function, quality of life, occupation, mood, relationships and leisure activities. Use Figure 2 as an aid to prompt questions that should be asked as part of the holistic assessment of a person with osteoarthritis. [2008]
4. Take into account comorbidities that compound the effect of osteoarthritis when formulating the management plan. [2008]
5. Discuss the risks and benefits of treatment options with the person, taking into account comorbidities. Ensure that the information provided can be understood. [2008]
6. Offer advice on the following core treatments to all people with clinical osteoarthritis.
   • Access to appropriate information (see recommendation 7).
   • Activity and exercise (see recommendation 12).
   • Interventions to achieve weight loss if the person is overweight or obese (see recommendation 14 and Obesity [NICE clinical guideline 43]). [2008, amended 2014]
7. Offer accurate verbal and written information to all people with osteoarthritis to enhance understanding of the condition and its management, and to counter misconceptions, such as that it inevitably progresses and cannot be treated. Ensure that information sharing is an ongoing, integral part of the management plan rather than a single event at time of presentation. [2008]
8. Agree a plan with the person (and their family members or carers as appropriate) for managing their osteoarthritis. Apply the principles in Patient experience in adult NHS services (NICE clinical guidance 138) in relation to shared decision-making. [new 2014]
9. Agree individualised self-management strategies with the person with osteoarthritis. Ensure that positive behavioural changes, such as exercise, weight loss, use of suitable footwear and pacing, are appropriately targeted. [2008]
10. Ensure that self-management programmes for people with osteoarthritis, either individually or in groups, emphasise the recommended core treatments (see recommendation 6), especially exercise. [2008]
11. The use of local heat or cold should be considered as an adjunct to core treatments. [2008]
12. Advise people with osteoarthritis to exercise as a core treatment (see recommendation 6), irrespective of age, comorbidity, pain severity or disability. Exercise should include:
    • local muscle strengthening and
    • general aerobic fitness.
    It has not been specified whether exercise should be provided by the NHS or whether the healthcare professional should provide advice and encouragement to the person to obtain and carry out the intervention themselves. 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. [2008]
13. Manipulation and stretching should be considered as an adjunct to core treatments, particularly for osteoarthritis of the hip. [2008]
14. Offer interventions to achieve weight loss^b as a core treatment (see recommendation 6) for people who are obese or overweight. [2008]
15. Healthcare professionals should consider the use of transcutaneous electrical nerve stimulation (TENS)^c as an adjunct to core treatments for pain relief. [2008]
16. Do not offer glucosamine or chondroitin products for the management of osteoarthritis. [2014]
17. Do not offer acupuncture for the management of osteoarthritis. [2014]
18. Offer advice on appropriate footwear (including shock-absorbing properties) as part of core treatments (see recommendation 6) for people with lower limb osteoarthritis. [2008]
19. People with osteoarthritis who have biomechanical joint pain or instability should be considered for assessment for bracing/joint supports/insoles as an adjunct to their core treatments. [2008]
20. Assistive devices (for example, walking sticks and tap turners) should be considered as adjuncts to core treatments for people with osteoarthritis who have specific problems with activities of daily living. If needed, seek expert advice in this context (for example, from occupational therapists or Disability Equipment Assessment Centres). [2008]
21. Do not refer for arthroscopic lavage and debridement^d 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). [2008, amended 2014]
22. Healthcare professionals should consider offering paracetamol for pain relief in addition to core treatments (see Figure 3 in section 4.1.2); regular dosing may be required. Paracetamol and/or topical non-steroidal anti-inflammatory drugs (NSAIDs) should be considered ahead of oral NSAIDs, cyclo-oxygenase-2 (COX-2) inhibitors or opioids. [2008]
23. If paracetamol or topical NSAIDs are insufficient for pain relief for people with osteoarthritis, then the addition of opioid analgesics should be considered. Risks and benefits should be considered, particularly in older people. [2008]
24. Consider NSAIDs for pain relief in addition to core treatments (see Figure 3 in section 4.1.2) for people with knee or hand osteoarthritis. Consider topical NSAIDs and/or paracetamol ahead of oral NSAIDs, COX-2 inhibitors or opioids. [2008]
25. Topical capsaicin should be considered as an adjunct to core treatments for knee or hand osteoarthritis. [2008]
26. Do not offer rubefacients for treating osteoarthritis. [2008]
27. Where paracetamol or topical NSAIDs are ineffective for pain relief for people with osteoarthritis, then substitution with an oral NSAID/COX-2 inhibitor should be considered. [2008]
28. Where paracetamol or topical NSAIDs provide insufficient pain relief for people with osteoarthritis, then the addition of an oral NSAID/COX-2 inhibitor to paracetamol should be considered. [2008]
29. Use oral NSAIDs/COX-2 inhibitors at the lowest effective dose for the shortest possible period of time. [2008]
30. When offering treatment with an oral NSAID/COX-2 inhibitor, the first choice should be either a standard NSAID or a COX-2 inhibitor (other than etoricoxib 60mg). In either case, co-prescribe with a proton pump inhibitor (PPI), choosing the one with the lowest acquisition cost. [2008]
31. All oral NSAIDs/COX-2 inhibitors have analgesic effects of a similar magnitude but vary in their potential gastrointestinal, liver and cardio-renal toxicity; therefore, when choosing the agent and dose, take into account individual patient risk factors, including age. When prescribing these drugs, consideration should be given to appropriate assessment and/or ongoing monitoring of these risk factors. [2008]
32. If a person with osteoarthritis needs to take low-dose aspirin, healthcare professionals should consider other analgesics before substituting or adding an NSAID or COX-2 inhibitor (with a PPI) if pain relief is ineffective or insufficient. [2008]
33. Intra-articular corticosteroid injections should be considered as an adjunct to core treatments for the relief of moderate to severe pain in people with osteoarthritis. [2008]
34. Do not offer intra-articular hyaluronan injections for the management of osteoarthritis. [2014]
35. 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 (see recommendation 6 and Figure 3 in section 4.1.2). [2008]
36. Base decisions on referral thresholds on discussions between patient representatives, referring clinicians and surgeons, rather than using scoring tools for prioritisation. [2008, amended 2014]
37. 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. [2008, amended 2014]
38. Refer for consideration of joint surgery before there is prolonged and established functional limitation and severe pain. [2008, amended 2014]
39. Patient-specific factors (including age, sex, smoking, obesity and comorbidities) should not be barriers to referral for joint surgery. [2008, amended 2014]
40. When discussing the possibility of joint surgery, check that the person has been offered at least the core treatments for osteoarthritis (see recommendation 6 and Figure 3 in section 4.1.2), and give them information about:
    • the benefits and risks of surgery 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. [new 2014]
41. Offer regular reviews to all people with symptomatic osteoarthritis. Agree the timing of the reviews with the person (see also recommendation 42). Reviews should include:
    • monitoring the person’s symptoms and the ongoing impact of the condition on their everyday activities and quality of life
    • monitoring the long-term course of the condition
    • discussing the person’s knowledge of the condition, any concerns they have, their personal preferences and their ability to access services
    • reviewing the effectiveness and tolerability of all treatments
    • support for self-management. [new 2014]
42. Consider an 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 osteoarthritis. [new 2014]
43. Apply the principles in Patient experience in adult NHS services (NICE clinical guidance 138) with regard to an individualised approach to healthcare services and patient views and preferences. [new 2014]

Figure 2

Holistic assessment.

Figure 3

Targeting treatment.

4.4. Key research recommendations

1. What are the short-term and long-term benefits of non-pharmacological and pharmacological treatments for osteoarthritis in very old people (for example, aged 80 years and older)?
2. What are the benefits of combinations of treatments for osteoarthritis, and how can these be included in clinically useful, cost-effective algorithms for long-term care?
3. What are effective treatments for people with osteoarthritis who have common but poorly researched problems, such as pain in more than one joint or foot osteoarthritis?
4. Which biomechanical interventions (such as footwear, insoles, braces and splints) are most beneficial in the management of osteoarthritis, and in which subgroups of people with osteoarthritis do they have the greatest benefit?
5. In people with osteoarthritis, are there treatments that can modify joint structure, resulting in delayed structural progression and improved outcomes?