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WITH the Royal Australian College of General Practitioners’ (RACGP) revised Guideline for the Management of Knee and Hip Osteoarthritis now on GPs’ desks, experts say clinicians can confidently step away from the referral pad when appropriate, and ramp up recommendations for physical activity and weight management.
Dr Dan Ewald, a GP in northern NSW and member of the RACGP’s guideline development working group, said osteoarthritis (OA) management was a “hugely important” area in general practice.
“It’s such a common condition and a big part of the general burden on wellness in the community,” he said. “This [guideline] helps us to sort the wheat from the chaff in terms of what’s useful and what’s not useful because there is a huge amount of wasted time and money – for patients and the health system – in pursuing therapies that are either known to be not useful or are reasonably likely to be not useful.”
A draft of the guideline was circulated in late 2017, with the final guideline launched on 29 August this year.
The guideline – which was developed using the newly adopted international Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to rate the quality of evidence – gives a big tick of approval to land-based exercise and weight management in managing knee and hip OA.
It states that such an approach can be inexpensive, less invasive and take many forms, from exercising in group settings to one-on-one approaches.
The guideline strongly recommends against the use of opioids and suggests a reduction in the use of diagnostic imaging. It recommends that knee replacement surgery only be considered when a patient’s symptoms fail to respond to non-surgical treatments.
The guideline also strongly recommends against treatments such as viscosupplementation injection, stem cell therapy and arthroscopic lavage and debridement, meniscectomy and cartilage repair of the knee.
In a media statement, RACGP President-elect, Dr Harry Nespolon said there was a need for improved guidelines to cater for Australia’s ageing population and increasing rates of obesity, with 12% of the population expected to have osteoarthritis by 2030.
Dr Ewald, who also has a background in epidemiology and public health, said the guideline should give GPs greater confidence in managing and supporting patients with OA.
“I hope GPs use these guidelines to give them confidence to be proactive about what works – which is exercise and weight loss if they are overweight,” Dr Ewald said. “GPs can also be confident in stopping doing the stuff that doesn’t work.”
And, he added, it was unacceptable to do nothing about OA and to treat it like an “unmanageable fact of life”.
“[The guideline] helps address therapeutic nihilism,” Dr Ewald told MJA InSight. “In general practice, it’s all too easy to be seeing loads of people who are really overweight and think ‘well there’s nothing much I can do that really makes a difference’. There can be an attitude that [OA is] just inevitable, it comes with ageing and you spin them along until they get a knee or hip replacement. So now, we know we can do a lot better than that.”
Dr Justin Coleman, Queensland GP and chair of the RACGP’s working group on the Choosing Wisely initiative, welcomed the updated guideline.
“It’s a wonderful, all-in-one-place guideline,” he said. “The really neat [plain language] summary of what works well and what doesn’t work well is particularly what GPs need.”
Dr Coleman said the guideline could also help GPs to make the case for exercise and weight management in patients who may be looking for other options in managing their condition.
“Some patients do, understandably, get upset if they feel you are ‘only’ offering those modalities, but this helps you have more confidence in what you’re doing.”
Dr Coleman also welcomed the guideline’s recommendations on complementary therapies, which were often overlooked in traditional medical guidelines.
The guideline states that glucosamine and chondroitin nutraceuticals, vitamin D and acupuncture should not be offered. For herbal remedies, such as turmeric and pine bark extract, the guidelines state there is a lack of high quality evidence to make a recommendation.
Dr Coleman said the recommendation against the use of knee arthroscopy was also an important message for general practice.
“This gives GPs the confidence not to refer someone if [arthroscopy] is the expected outcome of the referral,” Dr Coleman said. “We tend to defer to the opinion of the knee specialist so we can be a bit reluctant to, off our own bat, say ‘no, you shouldn’t have an arthroscopy’. But guidelines can support GPs in making an appropriate, evidence-based decision.”
Dr Ewald said the guideline would also support GPs in dispelling myths around the wear-and-tear of joints.
“I can disabuse people of myths that more activity is just wearing their joint out. I sometimes have to redress some of the language used by surgeons when they look at an x-ray and tell a patient that they have a problem with bone-on-bone grinding in their joints and the only option is joint replacement,” he said. “That kind of language can be a barrier to good conservative management of hip and knee OA.”
Dr Ewald added that an orthopaedic surgeon was on the guideline development working group, so the document was not antisurgery.
He said joint replacement could provide great benefits and be cost selective, but only in well selected patients who were well prepared, and who underwent good post-operative rehabilitation.
“So, the elements of weight loss and exercise are very important for those who do end up with joint replacement as well,” he said.
Professor Jane Hall, Professor of Health Economics at University of Technology Sydney, said although the guideline did not contain a health economics analysis, it was likely to be a step in the right direction from a funding point of view, so long as the messages to increase physical activity and lose weight were effective.
“It always seems like a sensible approach to try a low intervention first. We know with surgery there can be unintended consequences; it’s a small risk, but there is always a risk,” she said. “So, you don’t always need a formal health economics analysis to decide that something looks like better value care than the alternative.”
The development of the guideline was funded in part by Medibank Better Health Foundation.
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OA is due to wear-and-tear of joints (over-use of the joints). The more movement, the more pain in the joints (rubbing can cause inflammation). Why guideline encourage patient to do more exercise/more movement? My advice to patient is: avoid over use the joints, if pain get worse, have rest, take paracetamol (if not regularly taking) and/or short term NSAID (if joint is swollen and hot, or paracetamol is not effective). After pain settled, resume routine activity (not to “exercise” the joints). The guideline should use the term “reduce the use of the affected joints” to replace “exercise”.
Errm, we haven’t had a ‘referral pad’ for perhaps twenty years. Younger GPs won’t know what you are talking about.
I find it amusing, when the “modus operandi” is for plenty of exercise , “to reduce weight”, when many of these people are so morbidly obese, they have difficulty walking !
What exercise would the Academics prescribe for these people ?
NB. I am not suggesting surgery will fix these.
I had a healthy , obese ,(osteoarthritic knees), 51 year old friend, who had Bariatric surgery about 1 month ago, who died from a PE two weeks ago. She was going to have the weight reduction to alleviate the OA.
Perhaps the theorists could have managed this more appropriately ? (in hindsight ,of course—a very exact science)
The RACGP guidelines for knee and hip osteoarthritis are welcome, and to the extent that this article discourages referral to knee surgeons for knee arthroscopy, this is a welcome overview of the topic. However, “referral” for knee OA shouldn’t just be associated with surgical referral. A great umbrella term to start using is “exercise-based practitioners”, which includes physiotherapists, exercise physiologists and sport & exercise medicine physicians. In avoiding referral for knee arthroscopy, GPs should make more referrals to exercise-based practitioners. The caveat is that MBS funding for exercise-based practitioners is currently poor and out-of-pocket costs are usually significant, but hopefully guidelines based on evidence can help with MBS reform towards funding the evidence-based treatment for OA.
It is intriguing that there were double the number of industry representatives from a health fund, than there were orthopaedic surgeons, on this panel. Reading the conflict of interest declaration, there is no stated conflict of interest by people who are employed by a body which saves money if fewer surgical procedures are performed. It is not stated whether a reader should be simply expected to infer such a conflict of interest. And of course, the ultimate statement in this article, “The development of the guideline was funded in part by Medibank Better Health Foundation”. It is not stated whether any of the individual participants received travel funding, research support funding etc as part of this.
The AMA Private Health Insurance Report Card 2018 notes: “In 2016, the ACCC instituted proceedings against Medibank, alleging that Medibank made false, misleading, or deceptive representations and engaged in unconscionable conduct.
The ACCC alleged that Medibank failed to notify its members, and members of ahm (a subsidiary brand), of the decision to limit benefits for in-hospital pathology and radiology services, despite describing in some marketing materials that it would.
While the Medibank case was dismissed by the Federal Court, the ACCC has responded by lodging an appeal.” The same AMA document notes that Medibank has a 26.9% market share, but 46.3% of all complaints to the Ombudsman.
As the RACGP document clearly disclaims: “Persons implementing any recommendations contained in this publication must exercise their own independent skill or judgement or seek appropriate professional advice relevant to their own particular circumstances when so doing.” The question is whether that professional advice is appropriate from a health fund employee whose business saves tens of thousands of dollars for each averted joint replacement, or an orthopaedic surgeon who earns hundreds or thousands of dollars for each operation performed.
This report’s concluding statement (about knee arthroscopy) is damning: “Side effects from arthroscopic surgeries can include local pain and swelling, infection, prolonged drainage from the surgical site, bleeding into the joint, and thrombophlebitis. It [sic] is also associated with a number of potential harms, including deep venous thrombosis, premature joint replacement, and rarely, pulmonary embolism and death.” Strong words indeed, for the only surgery mentioned, given that “the document was not antisurgery.”
However, this report may be a boon for the bariatric surgeons, who have the only reliable means of producing long-term weight loss. Although this report advocates weight loss and claims it is “covering all interventions other than joint replacement for the hip and knee”, there is no specific mention of weight-reduction surgery options. The current (2014) Cochrane review ‘Surgery for Obesity’ is specific: “Surgery results in greater improvement in weight loss outcomes and weight associated comorbidities compared with non-surgical interventions, regardless of the type of procedures used.”
Perhaps the RACGP should be lobbying to have weight reduction surgery included in all private health policies, not only gold extras, and in all public hospitals.
(Disclaimer – although originally trained in Orthopaedics, I am a full-time hand surgeon with no pecuniary interest in hip or knee surgery, nor bariatric surgery.)