Osteoarthritis
This Clinical Information Sheet (CIS) has been developed to assist RACF staff, medical practitioners and relevant professionals (pharmacists, allied health clinicians) involved in the management of residential aged care patients with osteoarthritis. It addresses issues that may occur in RACF, particularly:
Diagnosis of residents presenting with signs and symptoms of osteoarthritis; Ongoing management of residents with a pre-existing diagnosis of osteoarthritis; and Management of residents experiencing an acute exacerbation of osteoarthritis.
This CIS covers:
About Osteoarthritis; Assessment Management; Non-pharmacological Strategies; Medications; and Sources of Information Reference Card:
Clinical Pathway Model of Care for Osteoarthritis
This clinical information sheet is a guide only. It should be used with consideration to the:
Resident’s preferences, existing medical care plans, and advance care plan; Health professional’s role, knowledge, preferences and professional experience; Policies and resources available within the RACF; Requirements of local professional registration and regulatory bodies; and Relevant local legislation.
About Osteoarthritis
Osteoarthritis is the most commonly experienced musculoskeletal disease and one of the primary causes of pain and disability within the Australian community [1, 2].
The precise disease process of OA remains poorly understood, however, the outcome is thinning and eventual breakdown of articular cartilage, microfractures and thickening of bone, inflammation of the synovial lining and fluid within the joint. This process leads to a decline in the resilience of the bones and joint to shock, and eventual exposure of the underlying bone within the joint requiring corrective surgery [2].
The most common joints affected are the knee and hip, followed by the hands and spine [2]. Prevalence increases with advancing age [1-3] with as many as 30% of adults, aged over 65 years diagnosed with OA [3]. Osteoarthritis is more common in females than males, except for hip OA, which occurs as commonly in males. Hip OA is often unilateral. Knee arthritis in males is often unilateral with a history of trauma, and in females is more likely to be bilateral with a greater genetic component and associated generalised OA. Most research focuses on knee OA which is associated with greater disability than other joints [2].
OA has no known cure and is a significant burden among older adults. It is a chronic condition with waxing and waning of symptoms and a slow progressive course. OA is common among residents of RACFs and is frequently in advanced stages with associated pain, stiffness, reduced mobility and physical function [4].
Assessment
Diagnosis of OA is usually made a long time prior to admission to residential care. X-rays, particularly weight bearing X-rays with lower limb OA, are helpful in confirming diagnosis. Radiographic findings indicative of OA include narrowing of the cartilage space, marginal osteophytes, subchondral sclerosis, and breaking of the tibial spines [1, 5] .
The aims of assessment are to confirm diagnosis, assess disease status and inform the development of an appropriate management plan [1, 2, 6]. See Reference Card: Clinical Pathway Model of Care for Osteoarthritis (Phase 1 – Diagnosis).
Assessment includes:
Joint signs and symptoms
Signs and symptoms of both new onset of OA and an exacerbation of pre-existing OA include [1, 2, 5]:
Joint pain that usually increases with activity (particularly weight bearing activity with lower limb OA); Joint stiffness; Loss of joint mobility and function; Local joint inflammation, particular in knee OA; and Crepitus (a crinkly, crackling or grating feeling in the joint).
Risk factors
Consider the following risk factors when making a diagnosis of OA [1-3]:
Increasing age and female gender Genetic disposition, i.e. family history of OA; Overweight or obesity; History of joint injury, particularly for males; and Over-use, e.g. history of occupational use.
Co-morbidities
A number of co-morbidities and medications impact significantly on the management of OA, therefore the resident’s overall medical history should be considered. Physical examination includes BP, height, weight and body mass index (BMI) [1, 2, 4, 7]. Blood tests may include urea and electrolytes, renal function tests, liver function tests, and serum creatinine [1, 4].
Specific co-morbidities to consider, especially when developing the resident’s analgesia regime, include [2, 8]:
Cognitive impairment; Cardio-vascular disease; Peptic ulcer disease; Renal disease; Diabetes; Depression; Liver disease; Allergies, e.g. glucosamine is contraindicated if the resident has seafood allergy, NSAID is contraindicated if there is a history of aspirin induced asthma; and Medications, e.g. warfarin, diuretics, ACE inhibitors, angiotensin-2 receptor agonists.
Pain
Pain is one of the primary features of OA. Pain relates to a variety of pathological changes that occur in the disease process and may also be influenced by the resident’s psychological condition, e.g. presence of depression, and level of education, e.g. adults with less knowledge of the disease have been shown to experience greater levels of pain [2]. Pain assessment should be conducted on a regular basis and the pain management plan adjusted accordingly.
Pain assessment and pain assessment tools are discussed further in the Pain Management Clinical Information Sheet.
Functional status
Assessment of the impact of OA on the resident’s ability to function and maintain independence provides an indication of the most appropriate intervention strategies, especially aids [1, 2, 4]. Functional assessment includes the resident’s mobility, and ability to perform activities of daily living (ADLs) [4]. Numerous tools are available to assess the resident’s mobility and global functioning in daily life. It is recommended that residents with osteoarthritis be assessed using the tools available within the facility.
Falls Risk Assessment
Pain and loss of function from OA impacts upon the resident’s mobility and has been shown to contribute to risk of falls. A falls risk assessment should be conducted on a regular basis and a prevention plan initiated as appropriate. Refer to the Falls Management and Prevention Clinical Information Sheet.
Management
Goals
As there is no cure for osteoarthritis, management goals are to reduce pain, improve function and prevent associated disability.
Goals of care for a resident diagnosed with OA are to [1-3, 8]:
Decrease pain, stiffness and other symptoms; Increase joint function and decrease disability; Prevent morbidity associated with OA, e.g. falls, medication adverse effects; Manage an acute exacerbation; Increase quality of life; and Provide the resident and his or her representatives with education.
Development of Management Plan
Management plans for OA generally include [1, 2, 4, 6]:
Identification and management of modifiable risk factors; Appropriate non-pharmacological strategies for maintenance and an acute flare; An analgesia regime commencing with simple analgesics and that is regularly re-assessed for maintenance and an acute flare; Monitoring for medication adverse effects; and Long term strategies to prevent loss of function and reduce disease progression , with consideration to the resident’s overall health and well being.
See the Reference Card: Clinical Pathway Model of Care for Osteoarthritis (Phase 2 – Disease Management). Pain management is discussed in detail in the Pain Management Clinical Information Sheet.
Education
Having a strong understanding of OA improves self management throughout the slow progression of this disease [1, 2, 4, 6, 9]. Increasing the knowledge that residents, relatives and RACF staff have regarding OA is effective in reducing pain associated with OA. Providing information on risk modification, joint protection and ensuring that the resident and carers are able to implement both short and long term strategies contributes to positive outcomes.
Referral
Management of OA requires a multidisciplinary approach, therefore referrals may be required to: [1-6]:
Physiotherapist for exercise programs; Dietician for weight management; Pharmacist for medication review; Orthotist if the resident requires physical aids; Occupational therapist for aids to assist in ADLs; Rheumatologist; and Orthopaedic surgeon.
Non-pharmacological Strategies
Weight control
Being overweight or obese is a significant risk factor for OA and losing weight is shown to contribute to a decrease in pain levels and can increase in function and quality of life. Support should be provided for residents who could benefit from weight loss to undertake an appropriate exercise and diet regime, e.g. referral to a dietician and/physiotherapist [1, 2, 4, 5, 10].
Exercise
Exercise programs are effective in relieving symptoms of OA. Programs should be tailored to the resident’s needs and abilities, with consideration to co-morbidities [2, 4, 7, 10]. In general, aerobic exercise is most appropriate for hip OA, whilst quadriceps strengthening and resistance exercises are more effective for knee OA [2, 10].
Hand splints and knee braces may provide some short term relief from symptoms; e.g. patella taping may provide some short term relief for anterior knee pain, when combined with exercise [1-3, 5, 10].
Tai Chi may be appropriate for some residents who are independently mobile and without cognitive impairment. A program of hour long sessions, twice weekly for 12 weeks has been shown to improve balance, flexibility and cardiovascular fitness [1].
Hydrotherapy (exercising in water) provides short and long term symptom relief and may be appropriate for some residents, particularly those who have low tolerance to weight bearing exercises[1, 3, 4].
Physical aids
Referral may be made to a physiotherapist, occupational therapist or orthotist for walking aids, braces and orthotics. Heel wedges may decrease mal-alignment and prevent ongoing joint damage when OA occurs on only one side of the body [2, 3, 10].
TENS
Transcutaneous Electrical Nerve Stimulator (TENS) has been shown to have positive effects for some residents. TENS and other non-pharmacological pain management strategy are discussed in more detail in the Pain Management Clinical Information Sheet.
Management of Acute Exacerbations
In addition to increased analgesia, management of an acute exacerbation of OA is guided by the principles of RICE outlined in the following box [2].
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RICE for managing acute exacerbations of OA [2, 7]
Rest: When experiencing a flare-up of symptoms the resident is advised to rest the joint for up to 48 hours to avoid provoking pain.
Ice: Apply ice to the joint in a protective covering, i.e. not directly to skin, for 10 minutes every 1-2 hours for up to 48 hours. Heat application is contra-indicated in the first 48 hours following symptom flare-up.
Compression: Apply compression bandaging to the affected joint for up to 48 hours.
Elevation: Elevate the affected joint to reduce swelling and associated pain for as long as necessary if effective.
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Surgery
Consider surgery only if medical and lifestyle management fail and the resident is an appropriate candidate for surgery. Overall outcomes from total knee replacement are reported as highly successful, however no research reports outcomes specific to adults in RACF [3, 6]. Total hip replacement (THR), is recommended for adults aged over 60 years [1, 3, 6, 10], and may be appropriate for some residents depending on co-morbidities, age and ability to undergo effective post-operative rehabilitation [1]. Arthroscopy is usually only appropriate in younger adults with mild to moderate knee OA in whom there is evidence of mechanical derangement [1].
Medications
The aim of medication is to relieve symptoms of pain and stiffness. Reduced symptoms will enable the resident to improve mobility and independence, including exercise to increase strength and mobility. Medications for OA include oral analgesia, topical preparations, and intra-articular injections [1-3, 5, 7, 9, 11, 12].
Oral Analgesia
The choice of analgesia is based on assessment of the pattern and severity of baseline pain and exacerbations; as well as the resident’s comorbidities and risk of adverse effects of medications. Principles of use of analgesics are discussed in the Pain Management Clinical Information Sheet.
Current recommendations for a step wise approach to analgesic choices in chronic musculoskeletal pain, including osteoarthritis, are to [11, 12]:
Use regular paracetamol as ongoing therapy in adequate doses for control of mild to moderate pain; Add NSAIDs where cardiovascular, renal and gastrointestinal risk is acceptable, at the lowest effective dose for the shortest possible duration; and Consider an opioid when non-opioids offer inadequate pain control or NSAIDs are unsuitable.
Paracetamol
Due to its effectiveness and low level of side effects, paracetamol is recommended as the first line medication in the management of OA, unless contraindicated, e.g. concurrent liver disease [1-5, 9].
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Paracetamol [1-5, 9, 12]
Immediate release tables
0.5-1g orally, 4-6 hourly as required
Maximum daily dose of 4g
Sustained release tablets
1330mg orally, 6-8 hourly
Maximum daily dose of 3990mg
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NSAIDs
If non pharmacological therapy and paracetamol provide insufficient pain relief, consider prescribing a non steroidal anti-inflammatory drug (NSAID). NSAIDs are recommended for short-term use to control acute exacerbations, as the risk of gastrointestinal and cardiovascular adverse effects is associated with dose and duration of use. It is preferable to commence a NSAID with regular paracetamol, commencing on a low NSAIDs dosage and increasing to the minimum effective dose to ensure the lowest NSAID dose is used [1, 2, 4, 5, 8, 11, 12]
In osteoarthritis, maximal analgesic and anti-inflammatory effect are unusually seen within 2 weeks; about 60% of patients will gain benefit from any NSAID; those who do not respond to one may respond to another [13].
Residents at high risk of adverse effects should avoid NSAIDs if possible. Before starting or switching NSAIDs, assess the individual resident’s risk of all adverse effects [14].
Assess for the following adverse effects of NSAIDs [14]:
There is a high risk in using NSAIDs in older adults and/or those with a history of peptic ulcer, renal, liver or cardiovascular disease [1, 3, 9]. Avoid NSAIDs in people with a history of aspirin-induced asthma, i.e. symptoms of asthma, facial flushing and rhinitis within 3 hours of exposure to aspirin or a NSAID. It is estimated that this occurs in 5-20% of adults with asthma [12].
Serious gastrointestinal effects (bleeding, obstruction, perforation) occur in about 7 in 1000 people with osteoarthritis who take NSAID for one year [14]. Risk factors for gastrointestinal adverse effects are age greater than 65 years, history of ulcer, concomitant us of anticoagulants or corticosteroids, presence of serious comorbidity. Prefer NSAIDs, i.e. Ibuprofen, diclofenac and the COX-2 selective NSAIDS celecoxib and lumiracoxib, with a low risk of gastrointestinal adverse effects, e.g. ulcers, perforation [2, 9, 11]. Note that the gastrointestinal advantage is lost when these NSAIDs are combined with low dose aspirin complications [2]. Consider use of prophylactic proton-pump inhibitors to reduce the risk of GIT complications [2, 6, 11].
Serious vascular events occur in about 12 in 1000 people taking COX-2 selective NSAID for one year (compared with 3 per 1000 more than with placebo in randomised controlled trials), and evidence of increased vascular risk is emerging for conventional NSAIDs, in observational studies, [14]. Residents with cardiovascular disease, diabetes plus renal impairment, familial hypercholesterolemia or left ventricular hypertrophy have the highest increase in absolute risk of myocardial infarction or stroke when taking a NSAID [11]. Do not stop low dose aspirin when using a NSAID as NSAID antiplatelet effect is unreliable [13].
NSAIDs increase the risk of developing or exacerbating symptoms of cardiac failure, leading to increased hospital admissions [11, 12].
Avoid or use NSAID with caution in people with or at risk of impaired renal function [11]:
Glomerular filtration rate 60 ml/l or less; Volume depletion; Age greater than 60 years; Salt-restricted diet; Cirrhosis; Cardiac failure; and Concomitant use of NSAID (including more than 150mg aspirin) plus diuretic plus ACE inhibitor (or angiotensin 11 receptor blocker) – this ‘triple whammy’ has led to reports of acute renal failure to the Australian Drug Reactions Advisory Committee.
Monitor residents taking a NSAID before commencement, after 2-4 weeks, and at regular intervals (at least annually) during treatment [1, 11, 13]:
Plasma sodium, potassium and creatinine levels; FBE; LFT; BP; and Weight, presence of oedema, symptoms and signs of heart failure.
Opioids [1, 2, 4, 11]
Consider a weak opioid when paracetamol and NSAIDs provide ineffective pain relief or are not suitable.
Codeine may be useful for short duration mild to moderate pain as it has a short half-life. Add codeine as a separate prescription for flexible dosing to achieve effective dose with minimal adverse effects, particularly constipation. Codeine is ineffective in about 10% Caucasian people and 1-2% Asian people who cannot metabolise it to morphine [11].
Avoid dextropropoxyphene because regular use leads to accumulation of the parent drug, causing dizziness and confusion, and its cardiotoxic metabolite [11]. Tramadol’s role in mild to moderate pain is limited by drug interactions and CNS adverse effects, particularly in the elderly [11].
Strong opioids have a role in persistent pain that is not adequately controlled by weak opioids or NSAIDs. Use of opioids, including appropriate dosages and side effects, is discussed in the Pain Management Clinical Information Sheet.
Glucosamine Sulphate
Glucosamine sulphate and chondroitin sulphate are substances used by the body to synthesise articular cartilage, therefore their effectiveness in slowing the progression of OA is being investigated. Preliminary research showed a positive effect of glucosamine sulphate on signs and symptoms of OA [1-4, 9]. However, recently published evidence varies, so that overall the long term effectiveness of glucosamine in osteoarthritis is yet to be established [2, 4]. The dose of glucosamine sulphate is 1200-200 mg daily in divided doses with food [2, 4]. Care should be taken when using this medication in residents with diabetes as it may increase glucose resistance, although it has not been shown to affect type-II diabetes [1]. Not to be used in residents with seafood allergy [2].
Intra-articular injections
Intra-articular injections should be administered by a physician with specific training in the technique and the use of appropriate imaging techniques [1]. They may be used as an adjunct therapy to provide short term pain relief during acute exacerbations [1-4].
Corticosteroid injections are prescribed as a single dose to reduce local inflammation in the joint (repeated injections are less successful) and provide pain relief for up to 4 weeks. Residents should rest the joint for 24 hours following the injection [2]. Hyaluronan acid is prescribed as a course of weekly injections for 3-5 weeks. Although it has a slow onset of beneficial effects, pain relief may last up to 12 weeks [2].
Topical Preparations
Topical NSAIDs, e.g. diclofenac, felbinac, ibuprofen, ketoprofen, piroxicam, naproxen, flurbiprofen, have been shown to provide safe and effective short term pain relief [4, 7, 15]. NSAIDs gels and creams contain similar ingredients to their oral forms, in much lower doses and without the adverse side effects. These preparations are currently recommended for short term use (up to 2 weeks) during acute exacerbations and have minimal side effects, e.g. topical reaction, mild GIT complaints [15].
Topical capsaicin is a chilli-based analgesic rub that causes blood vessels to dilate and provide a soothing warm feeling. Capsaicin cream has been found to be effective for short term management (up to 2 weeks) of acute exacerbation of OA [7, 15].
Sources of Information
Where to go for more information
Arthritis Victoria
Arthritis Victoria incorporating Osteoporosis Victoria provides support for residents, family and professional carers of those diagnosed with all forms of arthritis and or osteoporosis. The organisation provides information about local exercise programs and support groups and provides community education on the diseases.
Website: http://www.arthritisvic.org.au
Address: 263 Kooyong Rd, Elsternwick Victoria 3185
Ph: (03) 8531 8000 or 1800 011 041
Arthritis Australia
Based in NSW, Arthritis Australia provides information, support and counselling for people around the country diagnosed with arthritis, their families and their carers.
Contact: 1800 111 101 (free call within Australia)
Further reading
In addition to the references, more information can be found on osteoarthritis from:
Health Insite The Australian Government website Health Insite, which provides up to date educational material on a range of health issues. Information relating to OA can be found at: http://www.healthinsite.gov.au/topics/Osteoarthritis National Prescribing Service Contact the National Prescribing Service for up to date information on use of medications in osteoarthritis, as the evidence-base is rapidly changing in this topic.
Website: http://www.nps.org.au Osteoarthritis Pathway The Clinical Epidemiology & Health Service Evaluation Unit provides resources, information and useful links on osteoarthritis for health care providers and consumers, including a ‘guide for people living with OA of Hip and Knee’ at: http://www.oapathway.org.au
References
Brand, C.,Fox, S., Evidence-based clinical pathway for best practice management of OA of the hip and knee. 2006, Clinical Epidemiology & Health Service Evaluation Unit, (CEHSEU): Melbourne. p. 90. eTG, Therapeutic Guidelines: Rheumatology, in http://www.tg.com.au (accessed August 2006), eTG. 2006 Jordan, K., Arden, N., Doherty, M., Bannwarth, B., Bijlsma, J., Diepee, P., Gunther, K., Hauselmann, H., Herrero-Beaumont, G., Kaklamanis, P., Lohmander, S., Leeb, B., Lequesne, M., Mazieres, B., Martin-Mola, E., Pavleka, K., Pendleton, A., Punzi, L., Serni, U., Swoboda, B., Verbruggen, G., Zimmerman-Gorska, I., Dougados, M., EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: International Clinical Studies Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeuatic Trials (ESCISIT). Ann Rheum Dis, 2003. 62: p. 1145-1155. Ruth, D.,Condon, B., Osteoarthritis Pathway Implementation Project Report. 2006, Otway division of general practice site, (Otway DGP): Victoria, Australia. p. 13. American Academy of Orthopaedic Surgeons, (AAOS), AAOS clinical practice guideline on osteoarthritis of the knee. 2003, American Academy of Orthopaedic Surgeons: Rosemont (IL). p. 17. Ganz, D., Chang, J., Roth, C., Guan, M. , Kamberg, C., Niu, F. , Reuben, D., Shekelle, P., Wenger, N., MacLean, C., Quality of Osteoarthritis for Community-Dwelling Older Adults. Arthritis Care & Research, 2006. 55(2). Brand, C., B., Amattya., Tosti, T, Osteoarthritis management: Summary of literature review. 2006, Clinical Epidemiology & Health Service Evaluation Unit, (CEHSEU): Melbourne. p. 38. Drew, A., COX-2 inhibitors: selective but still NSAIDs. National Prescribing Service News, 2001. 18: p. 2-3. Drew, A., Osteoarthritis—have COX-2s changed its management? National Prescribing Service News, 2001. 18: p. 1. Brigham and Women's Hospital, (BWH), Lower extremity musculoskeletal disorders. A guide to diagnosis and treatment. 2003, Brigham and Women's Hospital: Boston (MA). p. 11. Cohen, M., Analgesic choice in persistent pain. Prescribing Practice Review, 2006. 35. Cohen, M., Analgesic options for pain relief. NPS News, 2006. 47. Pharmaceutical Society of Australia, (PSA)., Royal Australian College of General Practitioners, (RACGP)., Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists, (ASCEPT). Australian Medicines Handbook. 2006 National Prescribing Service Limited, (NPS). Fact sheet: Diclofenac and cardiovascular risk. 2006, National Prescribing Service Limited, (NPS). Sydney. p. 4. Bandolier Extra, (BE), Topical analgesics: a review of reviews and a bit of perspective, in http://www.ebandolier.com, Bandolier Extra evidence-based health care. 2005 National Health And Medical Research Council, (NHMRC), Guidelines for the development and implementation of clinical practice guidelines. 1995, Canberra: AGPS.
Levels of Evidence
Background information on the management of Osteoarthritis provided in this Clinical Information Sheet is based on summary information produced in Australia by the Clinical Epidemiology & Health Service Evaluation Unit (http://www.oapathway.org.au). Support for recommendations is provided by other level 1 evidence including EULAR guidelines (specific to knee OA) and guidelines produced by the American Academy of Orthopaedic Surgeons.
The following table outlines the level of evidence of each reference:
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Reference |
Year |
Level of Evidence |
1. |
Brand, C.,Fox, S., Evidence-based clinical pathway for best practice management of OA of the hip and knee. 2006, Clinical Epidemiology & Health Service Evaluation Unit, (CEHSEU): Melbourne. p. 90. |
2006 |
Level I evidence |
2. |
eTG, Therapeutic Guidelines: Rheumatology, in http://www.tg.com.au (accessed August 2006), eTG. 2006 |
2006 |
Level IV C evidence |
3. |
Jordan, K., Arden, N., Doherty, M., Bannwarth, B., Bijlsma, J., Diepee, P., Gunther, K., Hauselmann, H., Herrero-Beaumont, G., Kaklamanis, P., Lohmander, S., Leeb, B., Lequesne, M., Mazieres, B., Martin-Mola, E., Pavleka, K., Pendleton, A., Punzi, L., Serni, U., Swoboda, B., Verbruggen, G., Zimmerman-Gorska, I., Dougados, M., EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: International Clinical Studies Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeuatic Trials (ESCISIT). Ann Rheum Dis, 2003. 62: p. 1145-1155. |
2003 |
Level I evidence |
4. |
Ruth, D.,Condon, B., Osteoarthritis Pathway Implementation Project Report. 2006, Otway division of general practice site, (Otway DGP): Victoria, Australia. p. 13. |
2006 |
Level IV A evidence |
5. |
American Academy of Orthopaedic Surgeons, (AAOS), AAOS clinical practice guideline on osteoarthritis of the knee. 2003, American Academy of Orthopaedic Surgeons: Rosemont (IL). p. 17. |
2003 |
Level I evidence |
6. |
Ganz, D., Chang, J., Roth, C., Guan, M. , Kamberg, C., Niu, F. , Reuben, D., Shekelle, P., Wenger, N., MacLean, C., Quality of Osteoarthritis for Community-Dwelling Older Adults. Arthritis Care & Research, 2006. 55(2). |
2006 |
Level IV A evidence |
7. |
Brand, C., B., Amattya., Tosti, T, Osteoarthritis management: Summary of literature review. 2006, Clinical Epidemiology & Health Service Evaluation Unit, (CEHSEU): Melbourne. p. 38. |
2006 |
Level I evidence |
8. |
Drew, A., COX-2 inhibitors: selective but still NSAIDs. National Prescribing Service News, 2001. 18: p. 2-3. |
2001 |
Level IV C evidence |
9. |
Drew, A., Osteoarthritis—have COX-2s changed its management? National Prescribing Service News, 2001. 18: p. 1. |
2001 |
Level IV C evidence |
10. |
Brigham and Women's Hospital, (BWH), Lower extremity musculoskeletal disorders. A guide to diagnosis and treatment. 2003, Brigham and Women's Hospital: Boston (MA). p. 11. |
2003 |
Level I evidence |
11. |
Cohen, M., Analgesic choice in persistent pain. Prescribing Practice Review, 2006. 35. |
2006 |
Level IV C evidence |
12. |
Cohen, M., Analgesic options for pain relief. NPS News, 2006. 47. |
2006 |
Level IV C evidence |
13. |
Pharmaceutical Society of Australia, (PSA)., Royal Australian College of General Practitioners, (RACGP)., Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists, (ASCEPT). Australian Medicines Handbook. 2006 |
2006 |
Level IV C evidence |
14. |
National Prescribing Service Limited, (NPS). Fact sheet: Diclofenac and cardiovascular risk. 2006, National Prescribing Service Limited, (NPS). Sydney. p. 4. |
2006 |
Level IV C evidence |
15. |
Bandolier Extra, (BE), Topical analgesics: a review of reviews and a bit of perspective, in http://www.ebandolier.com, Bandolier Extra evidence-based health care. 2005 |
2005 |
Level IV C evidence |
Literature was identified through a standardised search for systematic reviews and clinical guidelines published by relevant health organisations; and ‘clinical guidelines’ and ‘practice guidelines’ in CINAHL, MEDLINE & Cochrane databases and HONcode search engine. Literature was evaluated according to relevance to residential aged care patients, and strength of evidence using the NHMRC (1995) [16] scale for randomised control data and lower levels of evidence when RCT is not available. The scale was adapted by adding a level of evidence (level V) for non-referenced material e.g. developed in local RACFs. Prescribing information is consistent with the Australian Therapeutic Guidelines, at the time of writing.
Applicability of information
This Clinical Information Sheet has been developed with consideration to legislation and any requirements of or recommendations from professional registration groups or regulating bodies (e.g. NBV, RCNA, ANF) overseeing the residential aged care industry in Victoria, Australia. Readers outside Victoria, Australia are advised to review the material in the context of their local legislation and health system regulations.
The Clinical Information Sheet was funded through the Otway Division of General Practice: Osteoarthritis Pathway Implementation in Residential Aged Care Project, with the Clinical Epidemiology & Health Services Evaluation Unit, Melbourne Health as part of Commonwealth Government Grant (NAMSCIG 2004). The CIS was developed using material from the project and the process outlined in Section 5, and is provided under the terms of the disclaimer in Section 1 of the GP and Residential Aged Care Kit.
GP and Residential Aged Care Kit: http://nwmdgp.org.au/pages/after_hours/
For more detailed or up to date information than is provided in this CIS, please refer to cited sources and current literature.
Reference Cards for Osteoarthritis
The following reference cards are designed to be used in conjunction with the Osteoarthritis Clinical Information Sheet. Because the evidence base and availability of national guidelines for clinical care and multidisciplinary service delivery is rapidly changing, we strongly recommend that the these Reference Cards be regularly reviewed and revised as with Clinical Information Sheets.
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Reference Cards:
Clinical Pathway Model of Care for Osteoarthritis
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