Healthcare Service Improvement Team

Primary and secondary prevention of osteoarthritis

Author: Norma Prosser, Dr Mary Webb, Public Health Specialists

Date: 11 June 2010 Version: 1

Publication/ Distribution: (Delete as applicable) Public (Internet)

Review Date: A review of this document is not planned by Public Health Wales NHS Trust.Purpose and Summary of Document:The document has been produced to assist local health boards to implement the Commissioning Directive on Arthritis and Chronic Musculoskeletal Conditions, and should be read in conjunction with that publication.

This is an evidence-based summary of effective interventions for primary and secondary prevention of osteoarthritis.

Reduction of body weight is a primary and secondary prevention measure. Physical activity and pain control both have a role in secondary prevention.Work Plan reference: HS02

Public Health Wales Primary and secondary prevention ofosteoarthritis

CONTENTS

1 BACKGROUND......................................................................................3

2 OSTEOARTHRITIS.................................................................32.1 Introduction....................................................................................32.2 Search methodology.......................................................................32.3 Prevalence......................................................................................42.4 Hospital admissions........................................................................5

3 PRIMARY PREVENTION.........................................................6

4 SECONDARY PREVENTION.....................................................74.1 Information.....................................................................................74.2 Activity and exercise......................................................................74.3 Pain relief........................................................................................8

5 FURTHER INFORMATION.......................................................8

6 References...........................................................................................9

© 2010 Public Health Wales NHS Trust.Material contained in this document may be reproduced without prior permission

provided it is done so accurately and is not used in a misleading context.Acknowledgement to Public Health Wales NHS Trust to be stated. 

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Public Health Wales Primary and secondary prevention ofosteoarthritis

1 BackgroundThis document has been produced to assist local health boards to implement the Welsh Assembly Government’s, Designed for people with chronic conditions. Service development and commissioning directives. Arthritis and chronic musculoskeletal conditions1, and should be read in conjunction with that publication.

A key action identified in chapter 2, Prevention – reducing the risks (p.9) of the publication, is evidence-based primary and secondary prevention1. From the key categories identified in the commissioning directive (p.2), the aim in this document is the identification of currently available information and evidence-based literature with a focus on osteoarthritis.

To supplement the evidence–base, and provide an overview of the topic, information with regard to prevalence (where available); hospital admissions (where information is available from Patient Episode Database Wales - PEDW); and links to additional information resources have been included. The links to further information resources is included to indicate where additional details, or management and treatment guidance can be sought.

The information contained in this document is not exhaustive.

2 Osteoarthritis

2.1 IntroductionOsteoarthritis (OA) is the most common form of arthritis and refers to a clinical syndrome of joint pain accompanied by varying degrees of functional limitation and reduced quality of life. Knee, hip and hands are the joints most frequently affected2.

The causes of osteoarthritis are complex and include physical, environmental and genome factors. This interaction contributes to articular cartilage damage which impacts differently in various joints3.

2.2 Search methodologySearch terms used: primary prevention, secondary prevention, osteoarthritis.

Search terms were kept broad to maximise retrieval of literature and search limits set to retrieve papers published between January 2003 to January 2010.

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Public Health Wales Primary and secondary prevention ofosteoarthritis

Electronic databases: Medline; Embase; Cochrane Database of Systematic Reviews; Database of Abstracts of Reviews of Effects; Cochrane Central Register of Controlled Trials and British Nursing Index.

Meta search engines: Turning Research Into Practice (TRIP); Google Scholar; SUMsearch.

Websites: NHS Evidence; International Network of Agencies for Health Technology Assessment (INAHTA); National Institute for Health and Clinical Excellence (NICE); National Horizon Scanning Centre and Map of Medicine; UpToDate.

2.3 PrevalenceThere is little authoritative data on the prevalence of OA in England and Wales because of problems associated with defining the disease, and determining its onset2.

OA at individual joint sites demonstrates consistent age-related increase, and estimates suggest that up to 8.5 million people in the United Kingdom are affected by joint pain that may be attributed to OA2.

Hand pain is reported more common in women than men, a one-month period of hand pain ranges from 12% in adults 45 and over, and 30% in adults 50 and over2.

In adults 45 years and over, the most common site for peripheral joint pain lasting more than one week during the previous month, is the knee (19%), and women aged 75 and over report the highest incidence of knee pain (35%). Table 1 indicates the number of cases of OA and incidence of knee OA based on symptomatic diagnosis used in the National Institute for Clinical Excellence (NICE) national costing report for OA2.

Table 1: Prevalence of osteoarthritis and the incidence of knee osteoarthritis in England and Wales

Details Aged 45 and over

Prevalence of osteoarthritis

Incidence of knee osteoarthritis

Number % Number % NumberFemales 10,695,072 18 1,925,113 0.75 80,213Males 9,393,022 9.6 901,730 0.75 70,448Total 20,088,093 2,826,843 150,661Source: NICE2, Osteoarthritis Costing Report

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Public Health Wales Primary and secondary prevention ofosteoarthritis

2.4 Hospital admissionsFigure 1: Persons admitted to hospital in Wales 2000-2006 with a principal diagnosis of osteoarthritis (ICD-10, M15 & M19) by Unitary Authority

Persons admitted to hospital with a principal diagnosis of osteoarthritis2000-2006

0500100015002000250030003500400045005000

Unitary Authority

Adm

issi

ons

Source: PEDW

Figure 2: Persons admitted to hospital in Wales 2000-2006 with a principal diagnosis of osteoarthritis (ICD-10, M15 & M19) by Local Health Board

Persons admitted to hospital with a principal diagnosis of osteoarthritis2000-2006

0

2000

4000

6000

8000

10000

12000

14000

Betsi CadwaladrUniversity

Powys Hywel Dda Abertawe BroMorgannwg

Cardiff and ValeUniversity

Cwm Taf Aneurin Bevan

Local Health Board

Adm

issi

ons

Source: PEDW

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Table 2: Persons admitted to hospital in Wales 2000-2006 with a principal diagnosis of osteoarthritis (ICD-10, M15 & M19)

Local Health Board Unitary Authority AdmissionsBetsi Cadwaladr University Isle of Anglesey 1333

Gwynedd 2098Conwy 2641Denbighshire 2215Flintshire 2597Wrexham 2283

Powys Powys 3113Hywel Dda Ceredigion 1578

Pembrokeshire 3451Carmarthenshire 3800

Abertawe Bro Morgannwg Swansea 4358Neath Port Talbot 3224Bridgend 3520

Cardiff and Vale University Vale of Glamorgan 2523Cardiff 4575

Cwm Taf Rhondda Cynon Taff 4201Merthyr Tydfil 1227

Aneurin Bevan Caerphilly 3074Blaenau Gwent 1996Torfaen 1750Monmouthshire 2108Newport 2069

Total 59734Source: PEDW

3 Primary preventionPrimary prevention strategies for OA should include health promotion strategies for the general population that include:4, 5, 6, 7

weight control; physical activity; injury prevention; infectious disease control.

Health promotion strategies should also be aimed at identifying high risk individuals:4, 5, 6, 7

>50 years old; female sex; a first degree family relative with OA; previous history of hip or knee injury or surgery; obesity; job requiring bending or lifting.

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Managing obesity in later life has recognized benefits for osteoarthritic joints but needs to be taken within the context of other health issues in elderly people, and joints that are worn benefit from a reduction in load8.

4 Secondary preventionGuidance recommends that healthcare professionals should offer all people with clinically symptomatic osteoarthritis advice on2, 4, 9:

access to appropriate information; activity and exercise; interventions to achieve weight loss if overweight or obese.

There is a complex interplay between pain, physical activity and bodyweight. Pain can result in sedentary life which can lead to weight gain. Being overweight is one of the factors which can lead to osteoarthritis. Keeping mobile can assist with reduction of weight and may assist in reducing pain. Thus physical activity and pain control both have a role in secondary prevention.

4.1 Information

All patients should be given information and education about the objectives of treatment and the importance of changes to lifestyle: weight reduction; exercise; pacing of activities and measures to unload the damaged joint(s)2, 4, 9.

Pharmacological interventions must be prescribed in conjunction with non-pharmacological interventions2, 9. The initial focus should be on self-help and patient-driven treatments rather than on passive therapies delivered by health professionals9.

4.2 Activity and exercise

Patients should be encouraged to undertake and continue to undertake, regular aerobic and muscle strengthening activities and a range of motion exercises2, 9. Exercise in water has some benefit9, 10.

Patients may benefit from referral to a physiotherapist for evaluation and instruction in appropriate exercise to reduce pain and improve functional capacity9. The evidence on the effectiveness of physiotherapy is controversial, particularly after knee arthroplasty11.

There is good quality evidence that land-based therapeutic exercise has at least short term benefit in terms of reduced knee pain, and improved physical function for people with knee OA. The magnitude of the treatment effect would be considered small, but comparable to estimates reported for non-steroidal anti-inflammatory drugs12.

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There is some evidence from a small randomised controlled trial (RCT) that patients with OA report a reduction in pain following progressive resistance strength training. Caution is needed with transferring these exercises for use with clinical populations because adverse events are not adequately reported13.

There is only silver level evidence that land-based exercise will reduce hip pain and improve physical function among people with symptomatic hip OA (to achieve a platinum or gold standard for the level of scientific evidence requires at least one well-conducted RCT with > 50 participants per treatment allocation. The authors were not able to retrieve any RCTs with > 50 participants per treatment allocation from the literature search they undertook)14.

4.3 Pain reliefWhere a non-steroidal anti-inflammatory or COX-2 inhibitor is prescribed protein pump inhibitors should be given automatically.  A health technology assessment suggested that the COX-2 drugs are less liable to cause gastrointestinal problems, and it is a possibility that they could be given without a proton pump inhibitor in low risk cases, but this needs to be formally evaluated15.

Transcutaneous electrical nerve stimulation (TENS) can help with short-term pain control and particularly for knee OA9.

Some thermal modalities may be effective for relieving symptoms in hip and knee OA. Heat and cryotherapy administered by a variety of techniques may be effective9.

The evidence from a systematic review on the effectiveness of Tai Chi for painful joints was poor, although it could be a preventative method of maintaining good control and proprioception16.

5 Further informationArthritis and Musculoskeletal Alliance.

Standards of care for people with osteoarthritis. http://www.arma.uk.net/pdfs/oa06.pdf

Clinical Knowledge summaries Osteoarthritishttp://www.cks.nhs.uk

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Map of Medicine Osteoarthritis suspected; Management of osteoarthritic joints; Management of osteoarthritis (OA) of the knee;http://nhsevidence.mapofmedicine.com/evidence/map/index.html

NHS Evidence Musculoskeletal. 2009 annual evidence update on osteoarthritishttp://www.library.nhs.uk//musculoskeletal/ViewResource.aspx?resID=320429

NICE: The care and management of osteoarthritis in adults.CG59. 2008.

http://guidance.nice.org.uk/CG59

Osteoarthritis Research Society International OARSI recommendations for the management of hip and knee

osteoarthritis, Part II: OARSI evidence - based, expert consensus guidelines. Osteoarthritis and Cartilage 2008; 16: 137e162. Available at: http://www.oarsi.org/pdfs/oarsi_recommendations_for_management of_hip_and_knee_oa.pdf [Accessed 13th Nov 2009]

6 References1. Welsh Assembly Government. Designed for people with chronic

conditions. Service development and commissioning directives. Arthritis and chronic musculoskeletal conditions. Cardiff: WAG; 2007. Available at: http://www.wales.nhs.uk/documents/Final-Arthritis_English.pdf [Accessed 13th Nov 2009]

2. National Institute for Health and Clinical Excellence. Osteoarthritis: the care and management of osteoarthritis in adults. CG59. London: NICE; 2008. Available at: http://www.nice.org.uk/nicemedia/pdf/CG59NICEguideline.pdf [Accessed 13th Nov 2009]

3. NHS Evidence. [Website]. Musculoskeletal. 2009 annual evidence update on osteoarthritis. Available at: http://www.library.nhs.uk/musculoskeletal/viewResource.aspx?resid=324800&code=5d394294e3ae534645fd1f5f22e2a1d0 [Accessed 13th Nov 2009]

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4. Arthritis Community Research & Evaluation Unit. Care for people with arthritis: evidence and best practices. Toronto: ACREU; 2005. Available at: http://www.acreu.ca/pdf/pub5/05-05.pdf [Accessed 13th

Nov 2009]

5. National Institute for Health and Clinical Excellence. Obesity. CG43. London: NICE; 2006. Available at: http://www.nice.org.uk/guidance/index.jsp?action=download&o=30365 [Accessed 13th Nov 2009]

6. National Institute for Health and Clinical Excellence. Workplace health promotion: how to encourage employees to be physically active. PH13. London: NICE; 2008. Available at: http://www.nice.org.uk/Guidance/PH13/Guidance/pdf/English [Accessed 13th Nov 2009]

7. National Institute for Health and Clinical Excellence. Four commonly used methods to promote physical activity: brief interventions in primary care, exercise referral schemes, pedometers and community-based exercise programmes for walking and cycling. PH2. London: NICE; 2006. Available at: http://www.nice.org.uk/Guidance/PH2/Guidance/pdf/English [Accessed 13th Nov 2009]

8. Bales CW; Buhr.G. Is obesity bad for older persons? A systematic review of the pros and cons of weight reduction in later life. J Am Med Dir Assoc 2008;9:302

9. Zhang W et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part 11: OARSI evidence-based expert consensus guidelines. Osteoarthritis Cartilage 2008; 16: 137-62

10. Bartels EM et al. Aquatic exercise for the treatment of knee and hip osteoarthritis. Cochrane Database Syst Rev 2007, Issue 4. Art. No.: CD005523. DOI: 10.1002/14651858.CD005523.pub2. Available at: http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005523/frame.html [Accessed 13th Nov 2009]

11. Minns Lowe CJ; Barker KL; Dewey M et al. Effectiveness of physiotherapy exercise after knee arthroplasty for osteoarthritis: systematic review and meta-analysis of randomised controlled trials. BMJ 2007; 335: 812. Available at: http://www.bmj.com/cgi/content/full/335/7624/812 [Accessed 13th Nov 2009]

12. Fransen M, McConnell S. Exercise for osteoarthritis of the knee. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.:

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CD004376. DOI: 10.1002/14651858.CD004376.pub2. Available at: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004376/frame.html [Accessed 13th Nov 2009]

13. Liu CJ, Latham NK. Progressive resistance strength training for improving physical function in older adults. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD002759. DOI: 10.1002/14651858.CD002759.pub2. Available at: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD002759/frame.html [Accessed 13th Nov 2009]

14. Fransen, M., McConnell, S., Hernandez-Molina, G., and Reichenbach, S. Exercise for osteoarthritis of the hip. Cochrane Database Syst. Rev. 8-7-2009; CD007912. Available at: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD007912/frame.html [Accessed 13th Nov 2009]

15. Chen YF; Jobanputra J; Barton P et al. Cyclooxygenase-2 selective non-steroidal anti-inflammatory drugs (etodolac, meloxicam, celecoxib, rofecoxib, etoricoxib, valdecoxib and lumiracoxib) for osteoarthritis and RA: a systematic review and economic evaluation. Health Technology Assessment 2008; 12:11.

16. Lee MS; Pittler MH; Ernst E. Tai chi for osteoarthritis: a systematic review. Clinical Rheumatology 2008; 27: 211

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