The National Institute of Clinical Excellence (NICE) draft guidance on osteoarthritis makes the point that "A holistic assessment of the individual’s medical, social and psychological needs can enable a tailored approach to treatment options encouraging positive health seeking behaviours that are relevant to the individual’s goals."
Patient education.
Current thinking supports the principle of patient education so that the patient is in a better position to make informed choices as to his or her treatment options. The NICE guidance sets out three possible approaches that patients may adopt with regard to treatment:
The guidance goes on to set out what it sees as the main components of patient education:
Patient self-management.
Patient self-management is viewed as an integral part of the care of all people with long term conditions. Self-management should empower patients to use their own knowledge and skills to access appropriate resources and build on their own experiences of managing their condition. The NICE guidance states that "individuals who are able to recognise and believe in their ability to control symptoms and become more active participants in managing their condition and thus improve control over their symptoms."
Thermotherapy
The NICE guidance states- "It seems appropriate to use hot and cold packs in osteoarthritis". Local heat and cold are currently widely used as part of self-management. Some people use hot baths to get the same effect as packs." The guidance makes the observation that some patients use hot baths to get tje same beneficial effects.
The guidance recommends that "the use of local heat or cold should be considered as an adjunct to core treatment".
Exercise and manipulation.
There is strong evidence of the benefits of exercise in the treatment of osteoarthritis although most of this evidence concerns osteoarthritis of the knee.
One randomised controlled trial for people with knee OA found that exercise reduced pain, disability and medication intake whilst improving physical functioning, stair climbing, walking distance, muscle strength, balance, mental health and physical functioning. It is however felt that the mechanisms of exercise on the hip and hand may be different to those for knee osteoarthritis."
NICE found limited evidence for the benefits of one form of exercise over another but did discover that exercise in a class setting supplemented by home exercise may be superior to home based exercise alone.
It is felt that manual therapies (manipulation) may work best alongside an exercise regime. NICE could only find limited evidence to suggest that exercise in water may be beneficial.
The guidance recommends that "exercise should be a core component of therapy, irrespective of age, comorbidity, pain severity and disability......Manipulation and stretching should considered as an adjunct to core treatment particularly for hip osteoarthritis."
Weight loss
There is good evidence that weight loss improves the function of load-bearing joints (the knee and the hip) but the evidence is more equivocal for weight loss helping with pain. Nevertheless there are other significant health gains associated with losng weight and the NICE guidance recommends weight loss as a core treatment for those patients who are obese or overweight.
Electrotherapy.
There are a number of techniques which claim to reduce pain in osteoarthritis. Of these only TENS has been shown to be effective but this depends on people with osteoarthritis being given training on the placing of the pads and also the selection of the appropriate stimulation intensity. This instruction should be complemented by the provision of an instruction booklet. The guidance points out that people should be encouraged to experiment with intensities and durations until they find the combination that suits them best.
The guidance recommends that doctors should consider the use of TENS as an adjunct to core treatments for pain relief.
Acupuncture.
The evidence from studies would seem to indicate that acupuncture is effective in the short-medium term for some people. There was no significant difference when compared with placebo at 26 weeks. We don't yet know whether there is a specific group of people that will benefit from this technique. The guidance suggests that acupuncture is used where there are few remaining treatment options or where the individual with osteoarthrtis has experienced a benefit.
Food supplements.
Glucosamine sulfate and chondroitin are the most popular supplements in the UK for people with osteoarthrits. Unfortunately the evidence only demonstrates a slight
improvement in knee OA when taking 1500mg of glucosamine sulfate per day. There is no evidence to suggest that chondroitin has any beneficial effect at all. The guidance recommends that doctors should "consider a trial of glucosamine (1500mg per day) for symptom relief but not structure modification in knee
osteoarthritis as an adjunct to core treatment. The use of other glucosamine and chondroitin products is not recommended."
