OA management should include a holistic assessment considering the global needs of the individual.20 Personal preferences for certain types of therapies should be assessed, as adherence and outcomes may be compromised if the management plan does not match the person’s preferences and beliefs.
Broadly speaking, OA management goals are to minimise pain, optimise function and participation, and to empower the person to self-manage. Given the modest effects of individual treatment approaches, a combination of therapeutic approaches is commonly used. Clinicians should also aim to target modifiable risk factors (eg obesity, strength, depression).
The principles of chronic disease management apply to the care of people with OA, and are based on the following:41
- care should be continuous; tailored to the person according to individual needs, goals, and values; and be person-centred
- decision-making should be based on the best evidence available, and personal preferences and values
- information should be widely accessible to individuals
- anticipation of needs should be prioritised over a reactive health service.
The number of joints involved, degree of pain, movement restriction and functional impairment, and presence of comorbidities should also guide the management plan. Involvement of partners, family and friends is important to provide the individual with support to self-manage their condition, and is one of the pillars of patient-centred care.
Efforts should be made to prioritise interventions that are safer, more accessible and more cost-effective over treatments that have greater adverse events, are less feasible and more expensive. Active, non-pharmacological interventions are the mainstay of OA management, and should be tried first, followed by or in concert with medications to relieve pain when necessary. Non-pharmacological therapies include weight management, promotion of physical activity, strengthening exercises, education and behaviour change support.42
Patient adherence, optimal uptake of recommendations and behaviour modifications are key elements of OA treatment, and can be optimised by education, establishing treatment goals and periodic monitoring.
Education for people with OA is important to improve their understanding of their disease and the importance of self-management.43 Individuals should be informed about the aetiology of OA, the typical fluctuating nature of pain, risk factors (especially those that are modifiable and specific to the person), and expected prognosis, including most people not progressing to requiring joint replacement.44
Clear information about treatment options along with their benefits, harms and costs should be discussed. Providing this information helps to counter common misconceptions and encourages individuals to adopt an active approach in the management of their own disease.45 Language is important, and terms such as ‘wear and tear’ and ‘bone-on-bone’ should be avoided, as this can lead to pessimism about treatment outcomes (ie nothing can be done) and misbeliefs (eg exercise is detrimental and unsafe) that can affect individual engagement. It is also important to instil a sense of optimism and hope, and facilitate positive expectations about treatment outcome.
Goal setting helps the informed person identify current issues, set priorities and focus on specific changes. To develop a realistic plan, goals should be agreed upon with the individual, considering their preferences and biopsychosocial context. In addition, appropriate goals should be specific, timely and measurable, and should be reviewed periodically.
As OA is a chronic condition that is often associated with a number of comorbidities and psychosocial issues, many people receive substantial benefits when care is provided using a multidisciplinary team approach. While it is recognised that not all people will require such an approach to management, a key role of GPs is to determine whether a multidisciplinary team approach is necessary, and if so, to refer to appropriately skilled health professionals (actual or virtual) in the community or hospital settings. Many people with chronic pain are best managed in primary care or the community level with multidisciplinary support, including self-care, while specialist services in hospitals typically focus on treating people who are more complex. GPs are ideally placed to play the role of care coordinator to ensure management continuity, whereby there is a consistent, coherent and collaborative approach to management from all team members who are responsive to the person’s changing needs. The GP can also delegate certain care coordination activities to another suitable health professional, such as practice nurse or team physiotherapist.
Practice nurses can be invaluable in partnership with GPs in care planning and goal setting. Support of allied health professionals will greatly enhance capacity to include all the concepts of chronic care. It will also add value to the person’s experience and outcomes with allied health professionals’ expertise in the care of people with OA and the common comorbidities. Some people may need to be referred to practitioners with requisite knowledge and skills in exercise therapy and behaviour change (eg physiotherapists, sports and exercise physicians, exercise physiologists) to prescribe an individualised exercise/physical activity program and facilitate long-term adherence. Physiotherapists and other practitioners with expertise in manual therapy/massage can provide this as a short-term adjunct to facilitate engagement in lifestyle interventions. Referral to dietitians/nutritionists may benefit people who are overweight or obese and require an individualised dietary assessment and management plan. Occupational therapists can provide specific approaches to self-management (eg occupational and home adaptations). Podiatrists/orthotists may be consulted for prescription of shoe orthoses and braces.
While pain management is a high priority in the clinical care of people, there are broader psychological effects arising from a physical health condition that may necessitate psychological intervention to improve a person’s ability to live with and manage OA. For some individuals, referral to a multidisciplinary pain clinic or a pain specialist may be warranted, particularly if the person is having difficulties managing pain despite current best practice. Based on a systematic assessment of falls risk, referral to a falls clinic may be beneficial. Referral to other medical practitioners (eg rheumatologists, sports and exercise physicians) may be appropriate for complicated cases, or if symptoms persist or worsen. For people with advanced knee and/or hip OA who continue to have substantial pain and functional difficulty despite high-quality conservative management, referral to an orthopaedic surgeon could be considered in discussion with the person (refer to Section 1.9 Timing of and need for referral to an orthopaedic surgeon).
Implementation and referral pathways
As part of the development of this guideline, a specific implementation plan was developed to ensure and optimise appropriate dissemination and use of the guideline. It is important to recognise that there are already a number of good resources in existence that should be used to facilitate evidence-based care. These include:
Consumer information resources and services for patient education and support for self-management are provided by support organisations:
These organisations provide printed and online information, which help reinforce education and self-management advice provided to individuals by clinicians. They may also offer support groups, exercise sessions and other services valuable for social support.
Where possible, GPs should use existing services and referral pathways to optimise targeting appropriate evidencebased care and recommendations within this guideline. These could include allied health referrals (using the Chronic Disease Management MBS items) and access to relevant multidisciplinary state/territory government initiatives.