Physio Charlie

Click here for a useful diagram of these guidelines

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 (other than etoricoxib 60 mg)

The National Collaborating Centre for Chronic Conditions. Osteoarthritis. National clinical guideline for care and management in adults. London: Royal College of Physicians, 2008.

Summary:

"The guideline contains a number of recommendations which are not currently routine practice for many clinicians. While the place of paracetamol in early pain management is confirmed, the guideline also suggests early consideration of topical non-steroidal anti-inflammatory drugs (NSAIDs) for knee and hand arthritis, and suggests that wherever systemic NSAIDs or cyclooxygenase-2 (COX-2) inhibitors are used, they should be coprescribed with cover from a proton pump inhibitor (PPI). This latter recommendation will surprise many, but with PPIs now coming off patent, it is clearly backed up by our health economic analysis. The positive role of exercise is emphasised in contrast to the natural inclination some might have to rest when a joint is affected by osteoarthritis. The GDG has also not shied away from negative recommendations. They suggest that arthroscopic lavage and debridement is not suitable therapy for osteoarthritis except in clear instances where this is associated with mechanical locking; and they do not recommend the use of intra-articular hyaluronans. Elsewhere, there is only restricted support for the use of acupuncture."

Interesting facts from this study:

"...there is no clear evidence so far that weight loss, either alone or in combination with exercise, can slow disease progression."

"There is evidence that TENS is clinically beneficial for pain relief and reduction of stiffness inknee osteoarthritis, especially in the short term. However, this was not shown in a community setting. There is no evidence that efficacy tails off over time, or that periodic use for exacerbations is helpful. Proper training for people with osteoarthritis in the placing of pads and selection of stimulation intensity could make a difference to the benefit they obtain. Good practice guidance recommends an assessment visit with the health professional with proper training in the selection of stimulation intensity (for example, low intensity, once a day, 40 minutes duration, 80Hz 140 microseconds pulse) with reinforcement with an instruction booklet. People with osteoarthritis should be encouraged to experiment with intensities and duration of application if the desired relief of symptoms is not initially achieved. This enables patients control of their symptoms as part of a self-management approach. A further follow-up visit is essential in allowing the health professional to check patients’ usage of TENS and problem solve."

"The results from acupuncture studies are mixed. Certainly the studies which have shown superiority of acupuncture over placebo have shown this only in the short term (6–12 weeks).  At 26 weeks there are few studies, and overall they do not support a benefit over placebo. It
therefore seems likely that acupuncture can provide short- to medium-term relief for some people."

"Healthcare professionals should offer advice on appropriate footwear (including shock absorbing properties) as part of core treatment for people with lower limb osteoarthritis."

"The use of glucosamine or chondroitin products is not recommended for the treatment of osteoarthritis."

"Referral for arthroscopic lavage and debridement should not be offered as part of treatment for osteoarthritis, unless the person has knee osteoarthritis with a clear history of mechanical locking (not gelling, ‘giving way’ or x-ray evidence of loose bodies)."

"Healthcare professionals should consider offering paracetamol for pain relief in addition to core treatment (see Fig 3.2); regular dosing may be required. Paracetamol and/or topical NSAIDs should be considered ahead of oral NSAIDs, COX-2 inhibitors or opioids."

"Topical capsaicin should be considered as an adjunct to core treatment for knee or hand osteoarthritis; rubefacients are not recommended for the treatment of osteoarthritis."