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The National Collaborating Centre for Chronic ConditionsFunded to produce guidelines for the NHS by NICE

OSTEOARTHRITISNational clinical guideline for care and management in adults

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Mission statementThe Royal College of Physicians plays a leading role in the delivery of high quality patient care by setting standards of medical practice and promoting clinical excellence. We provide physicians in the United Kingdom and overseas with education, training and support throughout their careers. As an independent body representing over 20,000 Fellows and Members worldwide, we advise and work with government, the public, patients and other professions to improve health and healthcare.

The National Collaborating Centre for Chronic ConditionsThe National Collaborating Centre for Chronic Conditions (NCC-CC) is a collaborative, multiprofessional centre undertaking commissions to develop clinical guidance for the NHS in England and Wales. The NCC-CC was established in 2001. It is an independent body, housed within the Clinical Standards Department at the Royal College of Physicians of London. The NCC-CC is funded by the National Institute for Health and Clinical Excellence (NICE) to undertake commissions for national clinical guidelines on an annual rolling programme.

Citation for this documentNational Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults. London: Royal College of Physicians, 2008.

ISBN 978-1-86016-329-6 ROYAL COLLEGE OF PHYSICIANS 11 St Andrews Place, London NW1 4LE Registered charity No 210508 Copyright 2008 Royal College of Physicians of London All rights reserved. No part of this publication may be reproduced in any form (including photocopying or storing it in any medium by electronic means and whether or not transiently or incidentally to some other use of this publication) without the written permission of the copyright owner. Applications for the copyright owners written permission to reproduce any part of this publication should be addressed to the publisher. Typeset by Dan-Set Graphics, Telford, Shropshire Printed in Great Britain by The Lavenham Press Ltd, Sudbury, Suffolk

ContentsMembers of the Guideline Development Group Acknowledgements Preface List of abbreviations Glossary v vii viii ix xi

DEVELOPMENT OF THE GUIDELINE1 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 2.10 3 3.1 3.2 Introduction What is osteoarthritis? Risk factors for osteoarthritis The epidemiology of osteoarthritis pain and structural pathology Prognosis and outcome The impact on the individual The impact on society Features of the evidence base for osteoarthritis The working diagnosis of osteoarthritis This guideline and the previous technology appraisal on COX-2 inhibitors Methodology Aim Scope Audience Involvement of people with osteoarthritis Guideline limitations Other work relevant to the guideline Background The process of guideline development Disclaimer Funding Key messages of the guideline Key priorities for implementation Algorithms 19 20 11 11 11 11 12 12 12 13 17 17 3 3 4 6 6 7 8 8 10

THE GUIDELINE4 4.1 4.2 Holistic approach to osteoarthritis assessment and management Principles of good osteoarthritis care Patient experience and perceptions 25 25



5 5.1 5.2 5.3 5.4 6 6.1 6.2 6.3 6.4 6.5 6.6 6.7 7 7.1 7.2 7.3 7.4 8 8.1 9

Education and self-management Patient information Patient self-management interventions Rest, relaxation and pacing Thermotherapy Non-pharmacological management of osteoarthritis Exercise and manual therapy Weight loss Electrotherapy Acupuncture Aids and devices Nutraceuticals Invasive treatments for knee osteoarthritis Pharmacological management of osteoarthritis Oral analgesics Topical treatments NSAIDs and highly selective COX-2 inhibitors Intra-articular injections Referral for specialist services Referral criteria for surgery Areas for future research 269 297 299 171 198 218 239 53 96 100 117 126 145 160 35 46 47 48



Members of the Guideline Development GroupProfessor Philip Conaghan (Chair) Professor of Musculoskeletal Medicine, University of Leeds; Consultant Rheumatologist, Leeds Teaching Hospitals Trust Dr Fraser Birrell Consultant Rheumatologist, Northumbria Healthcare NHS Trust; Honorary Clinical Senior Lecturer, University of Newcastle upon Tyne Dr Michael Burke General Practitioner, Merseyside Ms Jo Cumming Patient and Carer Representative, London Dr John Dickson Clinical Adviser to the GDG; Clinical Lead for Musculoskeletal Services, Redcar and Cleveland Primary Care Trust Professor Paul Dieppe Professor of Health Services Research, University of Bristol Dr Mike Doherty Head of Academic Rheumatology, University of Nottingham, and Honorary Consultant Rheumatologist, Nottingham University Hospitals NHS Trust Dr Krysia Dziedzic Senior Lecturer in Physiotherapy, Primary Care Musculoskeletal Research Centre, Keele University Professor Roger Francis Professor of Geriatric Medicine, University of Newcastle upon Tyne Mr Rob Grant Senior Project Manager, NCC-CC and Medical Statistician, Royal College of Physicians of London Mrs Christine Kell Patient and Carer Representative, County Durham Mr Nick Latimer Health Economist, NCC-CC; Research Fellow, Queen Mary University of London Dr Alex MacGregor Professor of Chronic Diseases Epidemiology, University of East Anglia; Consultant Rheumatologist, Norfolk and Norwich University Hospital NHS Trust Ms Carolyn Naisby Consultant Physiotherapist, City Hospitals Sunderland NHS Foundation Trust



Dr Rachel OMahony Health Services Research Fellow in Guideline Development, NCC-CC Mrs Susan Oliver Nurse Consultant in Rheumatology, Litchdon Medical Centre, Barnstaple, Devon Mrs Alison Richards Information Scientist, NCC-CC Dr Martin Underwood Vice-dean, Warwick Medical School

The following experts were invited to attend specific meetings and to advise the Guideline Development Group: Dr Marta Buszewicz Senior Lecturer in Community-based Teaching and Research, University College London Dr Alison Carr Lecturer in Musculoskeletal Epidemiology, University of Nottingham Mr Mark Emerton Consultant Orthopaedic Surgeon, Leeds Teaching Hospitals NHS Trust Professor Edzard Ernst Laing Professor of Complementary Medicine, Peninsula Medical School Dr Alison Hammond Arthritis Research Campaign Senior Lecturer, Brighton University Dr Mike Hurley Reader in Physiotherapy; ARC Research Fellow, Kings College London Professor Andrew McCaskie Professor of Orthopaedics, University of Newcastle upon Tyne Dr Mark Porcheret General Practitioner Research Fellow, Keele University Dr Tony Redmond Arthritis Research Campaign Lecturer in Podiatric Rheumatology, University of Leeds Dr Adrian White Clinical Research Fellow, Peninsula Medical School Ms Rahana Mohammed of Arthritis Care attended one meeting as a deputy for Ms Jo Cumming


Members of the Guideline Development Group

AcknowledgementsThe Guideline Development Group (GDG) are grateful to Bernard Higgins, Jane Ingham, Ian Lockhart, Jill Parnham, Nicole Stack, Susan Tann and Claire Turner of the NCC-CC for their support throughout the development of the guideline. The GDG would especially like to record their gratitude for the great amount of work voluntarily given to the refinement of the economic model of non-steroidal antiinflammatory drugs by Dr Joanne Lord of the National Institute for Health and Clinical Excellence (NICE). The GDG would also like to thank the following people for giving their time to advise us on the design and interpretation of the economic model:q q q q

q q q


Dr Phil Alderson, NICE Mr Garry Barton, School of Economics, University of Nottingham Professor Chris Hawkey, Institute of Clinical Research, University of Nottingham Professor Tom MacDonald, Hypertension Research Centre and Medicines Monitoring Unit, University of Dundee Dr Jayne Spink, NICE Dr Rafe Suvarna, Medicines and Healthcare Regulatory Agency Professor Richard Thomson, Professor of Epidemiology and Public Health, University of Newcastle upon Tyne Dr Weiya Zhang, Associate Professor, Centre for Population Sciences, University of Nottingham.


PrefaceOsteoarthritis is the most common disease of the joints, and one of the most widespread of all chronic diseases. Frequently described as wear and tear, its prevalence increases steadily with age and by retirement age the associated radiological changes can be observed in over half the population. Symptoms can vary from minimal to severe pain and stiffness, but overall the disease is responsible for considerable morbidity and is a common reason for GP consultation. Unfortunately, it is also difficult to treat and inevitably a wide range of potential therapies have been advocated, both by conventional and complementary practitioners, and not necessarily with strong supporting evidence. The high prevalence of osteoarthritis, the numerous forms of potential treatment and the uncertainty around these all make the disorder an excellent topic for a clinical guideline. The lack of evidence in some areas is a less favourable feature, and although this has presented something of a challenge, the GDG has risen to this admirably. As with all NICE guidelines, an exhaustive literature search has been performed and the papers identified in this process have been rigorously assessed. Where it is possible to make recommendations based on good evidence, the GDG have done so; where evidence is not available or is weak, they have either made recommendations on the basis of strong clinical consensus, or have advocated appropriate research. The guideline contains a number of recommendations which