6.2.3.1. Body function and structure (Symptoms)

Ten studies^{86,143,163,174,175,251,398,440,461,475}.

Observational and qualitative studies found that pain, function and negative feelings were important factors affecting the lives of patients with OA. Patients found their pain was distressing and that their OA caused limitations and had a major impact on their daily life. The areas that caused major problems for patients were: pain, stiffness, fatigue, disability, depression, anxiety and sleep disturbance.

6.2.3.2. Activities and participation

Nine studies^{45,86,163,254,378,380,398,440,475}.

Observational and qualitative studies found that poor performance of tasks was associated with female gender, BMI, pain and pessimism. Patients often felt embarrassed at not being able to do things that their peers could do and one of the things they felt most distressing was not being able to do activities that they used to be able to do. The most frequent activities affected by osteoarthritis were: leisure activities, social activities, close relationships, community mobility, employment and heavy housework. Personal care activities were rarely mentioned. OA also impacted employment status. Both middle-aged and older-age adults described the loss of valuable roles and leisure activities such as travel, and were less likely to mention employment. Loss of these activities was described as extremely upsetting.

Pre-task self-efficacy beliefs and knee pain was found to influence the speed of movement, post-task difficulty ratings and perceptions of physical ability. Work ability did not differ with gender, however patients with hip OA had the worst work ability scores and in non-retired patients white-collar workers had significantly higher work ability than blue-collar workers, regardless of age.

6.2.3.3. Psychosocial and personal factors: feeling old

Two studies^163,398

Observational and qualitative studies found that many patients viewed their OA symptoms as an inevitable part of getting old, that their older age had rendered their disabilities ‘invisible’ and they were not viewed as being legitimately disabled because they were old (i.e. disability should be expected and accepted in old age). Many also felt that there were negative stereotypes of older age and that they were a burden on society and wanted to distance themselves from such stereotypes. Patients often minimised or normalised their condition (which was more commonly done among older patients who attributed it to age).

6.2.3.4. Psychosocial and personal factors: depression, anxiety, life satisfaction

Eleven studies^{21,45,86,143,163,174,175,251,254,438,440}

Observational and qualitative studies found that pessimism was correlated with all physical outcome measures. More joint involvement was associated with negative feelings about treatment and with negative mood. Being female was associated with less impact of osteoarthritis on AIMS2 Affective Status and stressed women reported greater use of emotion-focused coping strategies, felt their health was under external control, perceived less social support and were less satisfied with their lives. Greater perceived social support was related to higher internal health locus of control. Patients expressed that their aspirations for future life satisfaction had declined appreciably and that depression and anxiety were major problems that they experienced. Older patients with advanced OA felt that the disease threatened their self-identities and they were overwhelmed by health and activity changes and felt powerless to change their situation. Many ignored their disease and tried to carry on as normal despite experiencing exacerbated symptoms.

Patients were unable to guarantee relief from symptoms based on lifestyle changes alone and this was linked to upset feelings, helplessness and depression. Many expressed frustration, anxiety and fear about the future. Pain was correlated with greater depression and lower life satisfaction whereas support and optimism were correlated with fewer depressive symptoms and greater life satisfaction.

In non-retired patients, white-collar workers had worse mental status than blue-collar workers. Those with hip OA also had the worst mental status. Those with worse mental status had lower work ability. Mental health was worse for persons with OA compared with those not suffering from OA.

6.2.3.5. Psychosocial and personal factors: relationships

Three studies^21,163,174

Observational and qualitative studies found that in OA patients, symptoms affected mood and made them frustrated and annoyed with others. Informal social networks (family, friends and neighbours) were critical to patients management and coping, particularly marital relationships and the decision not to have joint replacement surgery, since networks helped with tasks, gave emotional support and helped keep patients socially involved and connected to others despite their physical limitations, reinforcing the idea that surgery is avoidable. Decisions were made on ability of marital couple’s ability to cope rather than individual’s capacity and thus health professionals may need to consider the couple as the patient when considering disease management options.

6.2.3.6. Psychosocial and personal factors: knowledge of arthritis and its management

Six studies^{21,174,188,251,398,475}

Observational and qualitative studies found that most patients expected to have OA permanently and did not believe that a cure for OA was likely or that there was no effective way of treating OA and this they were reluctant to seek treatment for their OA. Beliefs about the cause and control of OA and the helpfulness of treatment showed no relationship to general health perceptions. Patients were predominantly externally controlled in terms of their health beliefs (believe their health is the result of fate or another’s actions). Most patients thought their OA was a ‘normal’ and ‘integral’ part of their life history, was an inevitable result of hardship or hard work (common view amongst men and women and across different occupational groups). Some felt that younger people might be more ‘deserving’ of treatment than themselves. Younger respondents did not perceive their symptoms as being normal, this affected their approach to management and their determination to get formal treatment.

Many patients were unsure as to the causes and physiology of OA, were uncertain how to manage an acute episode and unclear as to the likely ‘end point’ of the disease (ending up in a wheelchair). The most frequently cited causes were: accidents/injuries, occupational factors, cold or damp weather, too much acid in the joints, old age, weight and climatic factors. Many patients knew about NSAIDs and steroid injections but did not always know about their side-effects and some thought that taking their drug therapy regularly would reducing the progression of their OA. Many also knew about the benefits of exercise and weight loss but did not know suitable forms of exercise. Many did not know about the benefits of lifestyle changes or using aids and devices. Arthritis was perceived as debilitating but was not the primary health concern in participants’ lives.

6.2.3.7. Psychosocial and personal factors: expectations desired from treatment

Three studies^174,398,475

Observational and qualitative studies found that most patients felt it was ‘very’ or ‘extremely’ important to try to prevent their OA from getting worse. Areas where patients most wanted improvements were in pain management, mobility/functional ability and maintaining an independent life in the community. Pain was a major concern for most patients, however their main goals were to maximise and increase their daily activity as a strategy to manage their pain, rather than identifying ‘pain control’ itself as a major or single issue.

6.2.3.8. Psychosocial and personal factors: use of self-management methods

Five studies^{174,175,398,438,440}

Observational and qualitative studies found that patients with more education were more likely to use active pain coping methods. The more serious and symptomatic that participants perceived their condition to be, the less positive they felt about the management methods they used to control it). Patients reporting use of alcohol (compared to never using alcohol) reported less control over good and bad days. Use of self-management methods was associated with symptoms and seriousness but not with age or gender. A number of patients felt embarrassed about their disabilities and felt stigma in using walking aids or wheelchairs – some disguised their needs for using walking aids. Frequent use of problem-focused coping strategies was associated with greater perceived social support. Alternative therapies (e.g. ginger, cod-liver oil, acupuncture, magnets and others) were frequently used by many of the patients. Some felt they were helpful and others thought benefits were due to placebo effects. Despite lack of evidence for complementary therapies and dismissal from the medical profession, patients were prepared to try anything that others had found helpful. Patients wanted more information about the condition, self-help and available treatment options. Coping strategies used by patients included carrying on regardless, taking medication as required, exercise, use of aids to daily living, restricting movement and resting.

6.2.3.9. Psychosocial and personal factors: treatment / healthcare

Seven studies^{21,163,174,398,440,475}

Observational and qualitative studies found that most patients found at least one aspect of their treatment made them feel better, no aspect of their treatment made them feel worse, perceived helpfulness of treatment was inversely related to negative feelings about treatment. Older patients and women were more likely to rate their treatment as more helpful. Patients with higher occupational status were more likely to feel more negatively about their treatment. Employed younger respondents had all paid for private referrals to specialists and had all undergone or were being considered for total joint replacement surgery. Drugs were seen as helpful, surgery was perceived as the only way to ‘cure’ the disease (but some avoided it due to fear of risks or felt they were too old to benefit). Canes were perceived as useful but some felt embarrassed and did not use them. Physiotherapy and regular exercise were seen as beneficial treatments. Most patients were satisfied with their treatment and felt there was little more their GP could do for them.

Treatments most used by patients were: very often (tablets, aids and adaptations, physical therapy) and treatments most patients had not tried were injections, removal of fluid/debris, aids and adaptations, physical therapy, complementary therapy, education and advice, no treatment and knee replacement. Treatments found moderately helpful by patients were tablets and top treatments found extremely helpful were tablets, physical therapy, aids and adaptations and removal of fluid/debris. The top treatment found not helpful was physical therapy. Treatments that patients felt should be made priority for researchers were knee replacement, pain relief, cure, reduced swelling, education and advice and physical therapy.

Many were unwilling to use medication and obtained information on activities and foods that were perceived as harmful. Treating pain with medication for these people was seen as masking rather than curing symptoms and was seen as potentially harmful due to increased risk of unwanted side-effects. Long delays between experiencing symptoms and an osteoarthritis diagnosis made OA symptoms more difficult to deal with. Younger respondents attributed this delay to health professionals not considering OA as a possibility because participants were ‘too young’ to have arthritis. Barriers receiving support noted mainly by younger OA patients were the ‘invisibility’ of symptoms and their unpredictable nature. Others often exhorted them to engage in activities when they were in pain, were disappointed when plans were unexpectedly cancelled or were suspicious about the inability of participants to engage in some activities.

Patients felt that they there was a real lack of information and support given to them (from their GP and other primary care team member) about their condition, especially in the areas of managing pain and coping with daily activities. Many felt difficulties in communicating with doctors and some were extremely dissatisfied with the service they had received. Many patients reported that their doctor/health professional ignored their symptoms and had re-enforced the view that their OA was normal for their age and patients were aware that they could be considered a burden on the NHS. Obtaining information and more visits to the doctor was associated with reporting more symptoms and with believing treatment to be more helpful.

Common problems reported by patients were: Inadequate supply of medications to last until their next GP appointment, GI problems, barriers to attending clinic (e.g. finances, transportation) and problems requiring rapid intervention. Women were significantly more likely to have inadequate supply of medication and GI complaints were more prevalent among persons who were Caucasian, younger and non-compliant. Persons with worse AIMS ratings or with poorer psychological health were more likely to have reported barriers to care.

Some participants mentioned that previous non-arthritis related surgical experiences (their own or others) created fear and mistrust of surgery that contributed to the avoidance of TJA. Some noted that previous experience with physicians, particularly around prescribing medications, had undermined their trust in their physicians and often left them believing that their interests came second. Several noted that their family physician had never discussed surgery with them and because they were regarded as experts in treatment, participants assumed that surgery was not possible and was also not a viable option and were given the impression that surgery was something to be avoided. Where surgery had been mentioned by health professionals, it was often described as a last resort, leaving many participants wanting to try all other alternatives before TJA.

Assessment of the individual

Every patient brings their thoughts, health beliefs, experiences, concerns and expectations to the consultation. It is important to acknowledge distress and assess current ability to cope. Exploring the background to distress is fruitful as psychosocial factors are often more closely associated with health status, quality of life and functional status than measures of disease severity (such as X-rays).^395,422 Identifying psychosocial barriers to recovery and rehabilitation is important in a subgroup of patients.

There is evidence to show that patients’ perception of how patient centred a consultation is strongly predicts positive health outcomes and health resource efficiency (i.e. fewer referrals and investigations).⁴³¹

The GDG considered that there were three key areas to include in patient-centred assessment:

Clinical assessment

The evidence base given in other parts of this guideline tends to assess interventions in terms of patient reported outcomes. The working diagnosis of osteoarthritis is a clinical one based on symptoms and therefore when considering which treatment options to discuss with the patient, it is also important accurately to assess and examine the locomotor system. There are several points to consider:

• It is important to assess function. For example, assessment of the lower limb should always include an assessment of gait. (See footwear section, aids and devices for evidence base).
• The joints above and below the effected joint should be examined. Sometimes pain can be referred to a more distal joint, for example hip pathology can cause knee pain.
• An assessment should be made as to whether the joint pain is related to that region only, whether other joints are involved, or whether there is evidence of a widespread pain disorder.
• It is worth looking for other treatable periarticular sources of pain such as bursitis, trigger finger, ganglions, very localised ligament pain, etc, which could respond quickly to appropriate treatment. (see analgesic sections for evidence base).
• An assessment should be made of the severity of joint pain and/or dysfunction to decide whether early referral to an orthopaedic surgeon is required. There is evidence that delaying joint replacement until after disability is well established reduces the likelihood of benefit from surgery. (see referral to surgery section for evidence base).

Pain assessment

Pain is the most common presentation of osteoarthritis. It can be episodic, activity related, or constant. It can disturb sleep. Analgesics are readily available over the counter, or prescribed, or sometimes borrowed from others. It is important to know how the analgesics are being taken – regularly or “as required”, or both as well as timing, dose frequency and different drugs being used. Attitude to taking painkillers, side effects (experienced or anticipated) are all relevant in understanding the impact of painful joints for the patient as well as providing valuable information for a management plan. Disturbed sleep can lead to the loss of restorative sleep which in turn can cause daytime fatigue, deconditioning of muscles and muscle pain similar to that found in chronic widespread pain syndromes. Some patients can progress to developing chronic pain which is now known to be maintained by several pathophysiological mechanisms which currently can be dealt with only partially.

Patient-centred decision making

In order to achieve a holistic approach to care patients must be encouraged to consider a range of factors that can enhance their self management approaches to coping with their condition.^113,241

Self-management requires a “toolbox” approach of core treatments and adjuncts which can be tried if required. The patient is then able to deal with exacerbations confidently and quickly.

It is worth considering what part of the osteoarthritis journey the patient is on. In the early stages there is joint pain and uncertain diagnosis, later on symptomatic flares, with possible periods of quiescence of varying length. In one longitudinal study in primary care over 7 years,³⁵⁵ 25% of patients with symptomatic osteoarthritis improved. Some people have rapidly progressive osteoarthritis; others have progressive osteoarthritis which may benefit from surgery. Some patients will opt for and benefit from long term palliation of their symptoms. As a rough guide, osteoarthritis of the hip joint can progress to requiring joint replacement fairly quickly over the first few years, osteoarthritis of the knee joint often has a slower progression over five to ten years, and nodal hand osteoarthritis can have a good prognosis, at least in terms of pain. Within these generalizations there can be substantial variation.

To effectively deliver these evidence based guidelines a holistic approach to the needs of the patient needs to be made by the practitioner. One focus of this should be the promotion of their health and general wellbeing. An important task of the practitioner is to reduce risk factors for osteoarthritis by promoting self care and empowering the patient to make behavioural changes to their lifestyle. To increase the likelihood of success, any changes need to be relevant to that person, and to be specific with achievable, measurable goals in both the short and the long term. Devising and sharing the management plan with the patient in partnership, including offering management options, allows for the patient’s personality, family, daily life, economic circumstances, physical surroundings and social context to be taken into account. This patient centred approach not only increases patient satisfaction but also adherence with the treatment plan. Rehabilitation and palliation of symptoms often requires coordination of care with other health care professionals and other agencies such as social services. The GMC publication “Good Medical Practice”¹⁶¹ encourages practitioners to share with patients, in a way they can understand, the information they want or need to know about their condition, its likely progression, and the treatment options available to them, including associated risks and uncertainties. This is particularly relevant when discussing surgical options or using drugs such as NSAIDs. Risk is best presented to patients in several ways at once: for example as absolute risk, as relative risk and as “number needed to harm”.

These guidelines give many different options for the management of a patient who has osteoarthritis. The core recommendations can be offered to all patients and a choice can be made from the other evidence based and cost effective recommendations. The knowledge that osteoarthritis is a dynamic process which does include the potential for repair if adverse factors are minimized, in addition to the many different interventions should allow practitioners to give advice and support which is positive and constructive. The power of the therapeutic effect of the practitioner- patient relationship must not be forgotten. Good communication skills imparting accurate information honestly and sensitively and in a positive way greatly enhance the ability of the patient to cope. Conversely, negative practitioner attitudes to osteoarthritis can increase the distress experienced.

Joint protection

These guidelines indirectly address the concept of joint protection by looking specifically at evidence bases for single interventions. The principles are:

• Resting inflamed joints by reducing loading, time in use and repetitions.
• Using the largest muscles and joints that can do the job. For example, standing up from a chair using hips and knees rather than pushing up with hands.
• Using proper movement techniques for lifting, sitting, standing, bending and reaching.
• Using appliances, gadgets and modifications for home equipment to minimise stress on joints. Examples include raising the height of a chair to make standing and sitting easier, using a smaller kettle with less water, boiling potatoes in a chip sieve to facilitate removal when cooked.
• Planning the week ahead to anticipate difficulties.
• Using biomechanics to best effect. This will include good posture, aligning joints correctly, and avoiding staying in one position for a long time.
• Balancing activity with rest and organising the day to pace activities.
• Simplifying tasks.
• Recruiting others to help.
• Making exercise a part of every day including exercises which improve joint range of movement, stamina and strength. Exercise should also be for cardiovascular fitness and to maintain or improve balance.

Pain

Pain is a complex phenomenon. Effective pain relief may require using a number of analgesics or pain relieving strategies together. The complexity of multiple pain pathways and processes often mean that two or more treatments may combine synergistically or in a complementary way to act on the different components of the pain response. This technique is known as balanced, or multi-modal analgesia.

By tackling pain early and effectively it is hoped that the development of chronic pain can be stopped but more work needs to be done in this area. Timing of analgesia is important. Regular analgesia will be appropriate if the pain is constant. Pain with exertion can be helped by taking the analgesia before the exercise. Some patients will need multi-disciplinary care for their joint pain. For these people long term opioids can be of benefit (see section 9).