Osteoarthritis

Key NICE recommendations on management

Non-pharmacological management

Offer all people with osteoarthritis therapeutic exercise tailored to their needs (e.g., local muscle strengthening, general aerobic fitness).

• Consider supervised therapeutic exercise sessions.

Consider combining therapeutic exercise with an education programme (e.g., those based on behavioural theory) or behaviour change approaches (e.g., pain coping skills training, motivational coaching, goal setting) in a structured treatment package.

Support people with osteoarthritis who have overweight or obesity to choose a weight loss goal. Explain that any amount of weight loss is likely to be beneficial, but losing 10% of their body weight is likely to be better than 5%.

Only consider manual therapy (e.g., manipulation, mobilisation or soft tissue techniques) for people with hip or knee osteoarthritis and alongside therapeutic exercise.

• Explain that there is not enough evidence to support use of manual therapy alone for managing osteoarthritis.

Consider walking aids (e.g., sticks, crutches, frames) for people with lower limb osteoarthritis.

Do not offer:

• Insoles, braces, tape, splints or supports routinely, unless:

  • There is joint instability or abnormal biomechanical loading and

  • Therapeutic exercise is ineffective or unsuitable without the addition of an aid or device and

  • The addition of an aid or device is likely to improve movement and function

• Acupuncture or dry needling to manage osteoarthritis

• Any of the following electrotherapy treatments to people with osteoarthritis because there is insufficient evidence of benefit:

  • Transcutaneous electrical nerve stimulation or neuromuscular electrical stimulation

  • Ultrasound therapy, interferential therapy, laser therapy or pulsed short-wave therapy

• Arthroscopic lavage or debridement to people with osteoarthritis.

Pharmacological management

If pharmacological treatments are needed to manage osteoarthritis, use them:

• Alongside non-pharmacological treatments and to support therapeutic exercise

• At the lowest effective dose for the shortest possible time.

Offer a topical non-steroidal anti-inflammatory drug (NSAID) for knee osteoarthritis.

• Consider a topical NSAID for people with osteoarthritis that affects other joints.

If topical medicines are ineffective or unsuitable, consider an oral NSAID (if suitable).

• Offer a gastroprotective treatment (e.g., proton-pump inhibitor) for people with osteoarthritis while they are taking an NSAID.

Do not routinely offer paracetamol (no strong evidence of benefit) or weak opioids unless:

• They are only used infrequently for short-term pain relief and

• All other pharmacological treatments are contraindicated, not tolerated or ineffective.

Do not offer glucosamine (no strong evidence of benefit), strong opioids (the risks outweigh the benefits), or intra-articular hyaluronan injections to manage osteoarthritis.

Intra-articular corticosteroid injections should be considered when other pharmacological treatments are ineffective or unsuitable, or to support therapeutic exercise.

• Explain that these injections only provide short-term relief (2 to 10 weeks).

Review with the person whether to continue pharmacological treatment. Base review frequency on clinical need.

Patient advice

Advise people with osteoarthritis:

• That osteoarthritis is diagnosed clinically and usually does not need imaging to confirm the diagnosis

• That management should be guided by symptoms and physical function

  • Symptoms may fluctuate and ‘flares’ are common

  • Flares are temporary episodes of ‘worse than normal’ symptoms (e.g., pain, swelling, stiffness) that may affect sleep, activity, function and psychological wellbeing. They may lead to a change in therapy for at least 24 hours

• That the core treatments for osteoarthritis are therapeutic exercise and weight management (if appropriate), along with information and support. Advise:

  • That joint pain or discomfort may initially increase when they start therapeutic exercise but regular and consistent exercise will benefit their joints

  • That long-term adherence to an exercise plan increases its benefits by reducing pain and increasing functioning and quality of life

  • People with overweight or obesity, that weight loss will improve quality of life and physical function, and reduce pain

• That there is no strong evidence of benefit for paracetamol

• To seek follow-up if planned management is not working within an agreed follow-up time or if they are having difficulties with the agreed approaches.

Follow-up and referral

Consider:

• Patient-initiated follow-up for most people with osteoarthritis

• Planned follow-up when the person’s needs and preferences suggest that this is necessary. Take into account treatments/interventions that need monitoring, the person’s ability to seek help, their occupation/activities, multimorbidity, and the severity of their symptoms or functional limitations.

Do not routinely use imaging for follow-up or to guide non-surgical management.

Consider referring people with hip, knee or shoulder osteoarthritis for joint replacement if symptoms (e.g., pain, stiffness, reduced function or progressive joint deformity) are substantially impacting quality of life and non-surgical management is ineffective or unsuitable. When deciding to refer for joint replacement:

• Use clinical assessment, instead of systems that numerically score disease severity

• Do not exclude people because of age, sex or gender, smoking, comorbidities or overweight or obesity. Explain that these factors can impact the risks of surgery.

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