Published guidelines on management of osteoarthritis (OA) in general agree on the aims and objectives of management and emphasise the following:
(1) an individualised management plan
(2) consideration of core non-pharmacological interventions (education, weight loss if overweight or obese, regular strengthening and aerobic exercise, and reducing adverse mechanical factors) for every person with OA, and
(3) selective use of other physical treatments and topical, oral or intra-articular pharmacological agents for adjunctive pain relief, as required.
Guidelines also agree that people with OA who derive insufficient benefits from recommended conservative management should be referred early rather than late for consideration of surgical intervention before severe functional impairment has developed. Also, older age and comorbidity are not reasons to not refer a person with OA for surgery.
Unfortunately there are several problems with the research evidence in OA. These include: the low effect size for pain relief (above placebo) from most treatments; difficulty in determining the effect size of many physical treatments in RCTs (including exercise and education) due to inability to blind participants or to construct suitable placebo or sham treatments; a relative paucity of RCTs on OA at sites other than the knee or hip; predominantly short-term rather than long-term trial designs; and an undue focus in RCTs on monotherapy rather than combined treatment approaches. However, a striking feature of RCTs is the substantial effect size of placebo which is often greater than the additional specific effect of an individual treatment. This non-specific contextual response occurs in clinical practice, and being aware of contextual response and ways of optimising this can lead to substantial improvements in patient-centred outcomes.
This evidence-based review will cover the principles and practice of recommended management of OA, address the “treatment paradox” of treatments that are not recommended by guideline groups (e.g acupuncture and nutriceuticals in the UK) yet appear to work well in clinical practice, and highlight factors that enhance contextual response and improve the care of people with OA.
Disclosure of Interest None declared
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