Clinical assessment

Traditionally, osteoarthritis has been understood as a condition of ‘structural damage’ and that non-surgical approaches are not effective. However, current evidence supports that osteoarthritis is a condition that involves different facets of the individual’s life. Therefore a patient-centred approach that considers the different biopsychosocial factors surrounding the individual is necessary to manage their condition effectively. This means that during the subjective assessment, approaching potentially sensitive topics such as weight, mood, mental health and history of disease (including cancer) may be necessary.

Ivan Lin et al (2020) has provided some recommendations on how clinicians can improve the effectiveness of their communication to ensure that their care is patient centred. Click on the link below to read the article.

I. Lin, L. Wiles, R. Waller, J.P. Caneiro, Y. Nagree, L. Straker, C.G. Maher, P.P.B. O’Sullivan.
British Journal of Sports Medicine (2020)
Patient-centred care: the cornerstone for high value musculoskeletal pain management.

Reference: 

Lin, I., Wiles, L., Waller, R., Caneiro, J. P., Nagree, Y., Straker, L., … & O’Sullivan, P. P. (2020). Patient-centred care: the cornerstone for high-value musculoskeletal pain management. British Journal of Sports Medicine, 54(21), 1240-1242.

Changing the traditional perspective of osteoarthritis is also important in the management of individuals with osteoarthritis. Below you will find an editorial by JP Caneiro et al, on three steps that you can take to change this narrative. It also includes examples of how to reframe questions and answers surrounding knee osteoarthritis

J.P. Caneiro, P.B. O’Sullivan, E.M. Roos, A. J. Smith, P. Choong, M. Dowsey, D.J. Hunter, J. Kemp, J. Rodriguez, S. Lohmander, S. Bunzli, C.J. Barton
British Journal of Sports Medicine (2020)
Three steps to changing the narrative about knee osteoarthritis care: a call to action. 

Reference: 

Caneiro, J. P., O’Sullivan, P. B., Roos, E. M., Smith, A. J., Choong, P., Dowsey, M., … & Barton, C. J. (2020). Three steps to changing the narrative about knee osteoarthritis care: a call to action. British journal of sports medicine, 54(5), 256-258.

Assessments of an individual’s pain and symptoms should include the following considerations. Click on each info button to expand and learn more about each consideration.

Pain from OA is usually of gradual onset, painful with weightbearing/activity, and can become painful at night at the later stage of the disease.

Atypical features from this natural progression may indicate alternative or additional diagnosis. These atypical features include:

1. History of trauma
2. Prolonged morning joint-related stiffness
3. Rapid worsening of symptoms, or
4. Presence of a hot swollen joint.

Important differential diagnosis include:

1. Gout
2. Other inflammatory arthropathis (e.g., rheumatoid arthritis)
3. Septic arthritis
4. Malignancy (bone pain).

There are more details of differential diagnosis in the Diagnosis page.

When completing an objective assessment of an individual with osteoarthritis, these elements should be included.

There are other additional tests that you may choose (as required). These are (but not limited to):

Neurological tests: Reflexes, sensation, upper motor neuron testing (Babinski), clonus

Vascular tests: Palpation of pulses, capillary refill

When describing osteoarthritis, the language that is used is important. Traditional terms such as “wear and tear” or “bone on bone” should be avoided, as it contradicts the current literature about OA and sends the wrong message about the condition.

S.D. French et al (2015) have listed a list of essential statements when communicating with patients about osteoarthritis. Click on the link below to read the article

S. D. French, K. I Bennell, P. J. A. Nicholson, P. W. Hodges, F. I. Dobson, R. S. Hinman.
Arthritis Care and Research (2015)
What do people with knee or hip osteoarthritis need to know? An international consensus list of essential statements for osteoarthritis 

Reference: 

French, S. D., Bennell, K. L., Nicolson, P. J., Hodges, P. W., Dobson, F. L., & Hinman, R. S. (2015). What do people with knee or hip osteoarthritis need to know? An international consensus list of essential statements for osteoarthritis. Arthritis care & research, 67(6), 809-816.

As a summary of the paper above, the key messages that patients should know are:

1. OA is not just a disease of the cartilage, but it affects the whole joint including muscles and ligaments.
2. Joint damage or changes shown on x-rays do not indicate how much OA will affect you.
3. OA is not an inevitable part of getting older
4. Not all people’s symptoms from OA get worse over time
5. Exercise can reduce pain and improve function regardless of the severity of OA (for hips and knees)
6. If an individual is overweight, losing weight can improve pain and function, and reduce the risk of worsening symptoms. This is shown more in knee OA in comparison to hip and hands OA
7. Living a sedentary lifestyle can worsen OA
8. Most people with OA do not need surgery.

Click here if you would like to brochure containing all these messages that you can give to your patients

There are many resources out there for both clinicians and patients about knee osteoarthritis.

To begin, here is a short 60 second video by BMJ Learning with Dr. Tom Margham (GP & lead for primary care, Arthritis Research UK). It demonstrates the impact of using a different narrative to explain osteoarthritis to patients and how it can facilitate effective engagement in exercise.

Below you will find another great video from one of the leading experts in the field of pain science (Associate Professor David Butler) on rethinking the language around OA.

We also have a video from OPUS with Dr. Samantha Bunzli and Dr. JP Caneiro on communicating with people seeking care for musculoskeletal pain.

OPUS is a Centre for Research Excellence with a focus on revolutionising osteoarthritis care to improve patient outcome. They are multidisciplinary group of surgeons, physiotherapists and researchers, spread globally to tackle the issues in OA care. Click on their logo to the right to take you to their website

Lastly, watch the podcast below with Dr. JP Caneiro and Jennifer Persaud (Arthritis and Osteoporosis Western Australia) discussing the paper “Three steps to changing the narrative about knee osteoarthritis care: A call to action” (Click here to take you to the article). They discuss self-management strategies for joint pain and how structure is important, but only one of a handful of considerations for those with joint pain. They also discuss imaging findings and how to discuss this with patients.