The UK guidance by National Institute for Health and Care Excellence (NICE) recommend a holistic approach to osteoarthritis (OA) assessment and management.1 Key to holistic management is a holistic assessment of the patient’s overall situation; NICE encourages assessment of the effect of osteoarthritis on the person's function, quality of life, occupation, mood, relationships and leisure activities – in other words, to consider the domino effects of chronic pain.
International guidance on the management of OA by the Osteoarthritis Research Society International (OARSI) and the American College of Rheumatology (ACR) also focus on a comprehensive approach for the optimal management of OA, striving for both pain relief as well as improved function;2,3 patients should receive an individualised plan that includes both pharmacological and non-pharmacological treatment options.2,3
Key to holistic management is a holistic assessment of the patient’s overall situation1
For holistic management, NICE recommends to consider the whole spectrum of care – ranging from patient education and self-management to non-pharmacological and pharmacological approaches.
Patient education and self-management are recommended to counter any misconceptions that patients may have – such as a perception that their disease will progress ‘inevitably’, or that is it not possible to manage OA. Such education should be ongoing and should encourage positive changes for another key non-pharmacological treatment approach – activity and exercise.1
Exercise and manual therapy are recommended as core treatments, irrespective of a patient’s age, comorbidities, pain severity or disability.1 Exercise is encouraged because it can improve muscle strength and joint mechanics, which can de-sensitise and reduce the feeling of pain.4 Importantly, exercise does not accelerate joint degeneration. Range-of-motion exercises such as stretching can also help maintain and improve joint flexibility and reduce stiffness.5 By reducing the perception of pain,4exercise can break the cycle of fear-avoidance behaviours and allow people to participate in more daily activities.6 Exercise also fits effectively into weight loss programmes, further reducing pressure on weight-bearing joints. Together, this can delay the onset and progression of pain and the worsening of structural damage in the joint, and decrease the risk of secondary health problems, including heart disease, obesity and bone disorders.4
Which pharmacological approaches to OA management are recommended by NICE? The guidelines cover the use of oral analgesics, topical treatments, intra-articular injections, and referrals for joint surgery – refer to the full guidance for more detail.1
How can prehabilitation help patients prior to surgery? Preoperative physical function is a major determinant of post-operative function; therefore, minimising pain and functional deterioration in people awaiting surgery is important to maximise the potential benefit of the procedure. Prehabilitation exercises can improve strength and function before surgery – even in patients with very severe OA or who are older – and can therefore ultimately improve post-operative recovery.7,8,9
What can I do now?
Focus on a holistic approach to care that incorporates both non-pharmacological approaches and pharmacological treatments.
1. NICE. Osteoarthritis: care and management CG177. February 2014. https://www.nice.org.uk/guidance/cg177. Accessed August 4, 2020. 2. Bannuru RR, Osani MC, Vaysbrot EE, Arden NK, Bennell K, Bierma-Zeinstra SMA, Kraus VB, Lohmander LS, Abbott JH, Bhandari M, Blanco FJ, Espinosa A, Haugen IK, Lin J, Mandl LA, Moilanen E, Nakamura N, Snyder-Mackler L, Trojian T, Underwood M, McAlindon TE. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage. 2019;27:1578-1589 3. Kolasinski SL, Neogi T, Hochberg MC, Oatis C, Guyatt G, Block J, Callahan L, Copenhaver C, Dodge C, Felson D, Gellar K, Harvey WF, Hawker G, Herzig E, Kwoh CK, Nelson AE, Samuels J, Scanzello C, White D, Wise B, Altman RD, DiRenzo D, Fontanarosa J, Giradi G, Ishimori M, Misra D, Shah AA, Shmagel AK, Thoma LM, Turgunbaev M, Turner AS, Reston J. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Care Res. 2020;72(2):149-162. 4. Rice D, McNair P, Huysmans E, Letzen J, Finan P. Best evidence rehabilitation for chronic pain part 5: osteoarthritis. J Clin Med. 2019;8(11):1769. 5. Arthritis Foundation. Benefits of exercise for osteoarthritis. January 2020. https://www.arthritis.org/health-wellness/healthy-living/physical-activity/getting-started/benefits-of-exercise-for-osteoarthritis. Accessed August 4, 2020. 6. Hurley M, Dickson K, Hallett R, Grant R, Hauari H, Walsh N, Stansfield C, Oliver S. Exercise interventions and patient beliefs for people with hip, knee or hip and knee osteoarthritis: a mixed methods review. Cochrane Database Syst Rev. 2018;2018(4):CD010842. 7. Swank AM, Kachelman JB, Bibeau W, Quesada PM, Nyland J, Malkani A, Topp RV. Prehabilitation before total knee arthroplasty increases strength and function in older adults with severe osteoarthritis. J Strength Cond Res. 2011;25(2):318-25. 8. Desmeules F, Hall J, Woodhouse LJ. Prehabilitation improves physical function of individuals with severe disability from hip or knee osteoarthritis. Physiother Can. 2013;65(2):116-24. 9. Jahic D, Omerovic D, Tanovic AT, Dzankovic F, Campara MT. The effect of prehabilitation on post-operative outcome in patients following primary total knee arthroplasty. Med Arch. 2018;72(6):439-443.
Key to holistic management is a holistic assessment of the patient’s overall situation.1
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PP-INT-GBR-0215 February 2021