Anterior, lateral or posterior - OA

Diagnosis and presentation

Osteoarthritis refers to a clinical syndrome of joint pain accompanied by varying degrees of functional limitation and reduced quality of life. It is the most common form of arthritis, and one of the leading causes of pain and disability worldwide (NICE, 2014).

Common signs and symptoms of osteoarthritis include persistent pain, morning stiffness, and decreased function, crepitus, restricted movement, and bony enlargement (Altman RD, 2010).

Prevalence

Approximately 10% to 15% of senior adults (>60 years old) suffer from osteoarthritis worldwide and is predicted to grow to 130 million people by 2050.

Generally, there is a greater prevalence of osteoarthritis among women than men; however, there are additional risk factors associated with osteoarthritis development, including lack of physical activity, obesity, injury, and genetics (Kaplan et al, 2013).

Clinical testing

Diagnose osteoarthritis clinically without investigations if a person:

is 45 or over and
has activity-related joint pain and
has either no morning joint-related stiffness, or morning stiffness that lasts no longer than 30 minutes (NICE, 2014).

The most commonly used clinical criteria for diagnosing hip osteoarthritis are those from the American College of Rheumatology (Altman et al, 1991), which include either of two sets of clinical features (Bennell 2013).

Clinical Set A

Age > 50 Years
Hip Pain
Hip Internal Rotation ≥ 15°
Pain with Hip Internal Rotation
Morning Stiffness of the Hip ≤ 60 minutes

Clinical Set B

Age > 50 Years
Hip Pain
Hip Internal Rotation < 15°
Hip Flexion ≤ 115°

Patient Reported Outcome Measures

The Oxford Hip Score is commonly used in orthopaedics and is a good functional measure.

Imaging

Diagnostic imaging strategy in the painful hip depends on many factors, but in all cases, plain X-ray is the first investigation (Bluma et al, 2015).

Management

Optimise pain management
Exercise and manual therapy
Education of condition and self management
Thermotherapy
Weight management

Patient centred care

Treatment should take into account individual patient needs, preferences, expectations and functional status. Clinical reasoning should inform treatment, based on subjective and objective findings. Good communication between therapist and patient is essential if a successful outcome is to be achieved. Treatment options should be clearly explained so that patients can make informed decisions with regard to their care and management.

Evidence-based strategies

Where appropriate, preventing or delaying the requirement for joint arthroplasty is an important management goal.

The evidence base for the treatment of osteoarthritis is evolving rapidly, and the last 2 years have seen updated clinical practice guidelines or treatment recommendations published by the American College of Rheumatology (ACR), the European League Against Rheumatism (EULAR), Osteoarthritis Research Society International (OARSI), National Institute for Health and Care Quality (NICE) and the American Academy of Orthopaedic Surgeons (AAOS) (Bennell et al, 2014).

The most efficient management of patients with OA hip requires a combination of non pharmacological and pharmacological treatments (Zhang et al, 2008).

Exercise and Manual Therapy

Exercise is recommended as a beneficial treatment for people with hip osteoarthritis by all current guidelines.

People with osteoarthritis are advised to exercise as a core treatment, irrespective of age, co-morbidity, pain severity or disability. Exercise should include: local muscle strengthening, functional and general aerobic fitness. Grade C

Manual therapy can comprise manipulation, manual traction and muscle stretching. (Bennell, 2013, French et al., 2011, Peter et al., 2011) Grade A-B

Manipulation and stretching should be considered as an adjunct to core treatments, particularly for osteoarthritis of the hip (NICE 2014).

Education / Self-Management

Self management, education of condition and patient driven goals was recommended as an adjunct to exercise (Bennell, 2013; Fernandes et al, 2013; NICE, 2008; Pisters et al., 2007; Zhang et al, 2008). Grade A-C

Thermotherapy

The use of local heat or cold should be considered as an adjunct to core treatments (NICE, 2014, Zhang et al, 2007, Zhang et al, 2008). Grade C

Weight Loss

Signpost to lose weight and maintain weight at a lower level in overweight patients with lower limb OA was strongly recommended (Bennell, 2013; Fernandes et al, 2013; NICE, 2014; Peter et al, 2011; Zhang et al., 2007, Zhang et al., 2008). Grade A-C

Non evidence-based strategies

Hydrotherapy

Insufficient evidence

Electrotherapy

Insufficient evidence

Acupuncture

Insufficient evidence
There is inconsistency in recommendations regarding the role of acupuncture for osteoarthritis. However, the newest recommendations published since 2012 show an increasing lack of support for acupuncture in managing people with osteoarthritis (Bennell et al, 2014).

Progression and escalation

Progressing as expected (up to 3 Rxs) before discharge or onward referral.

Refer to ortho, GP, other.

Escalation

Clinicians with responsibility for referring a person with osteoarthritis for consideration of joint surgery should ensure that the person has been offered at least the core (non-surgical) treatment options.

Consider referral for joint surgery for people with osteoarthritis who experience joint symptoms (pain, stiffness and reduced function) that have a substantial impact on their quality of life and are refractory to non-surgical treatment (NICE 2008, amended 2014).

Refer for consideration of joint surgery before there is prolonged and established functional limitation and severe pain (NICE 2008, amended 2014).

Evidence

Altman RD. 2010. New guidelines for topical NSAIDs in the osteoarthritis treatment paradigm. Current Medical Research and Opinion 26(12): 2871–2876

Altman R, Alarcón G, Appelrouth D, Bloch, D., Borenstein, D., Brandt, K., Brown, C., Cooke, T.D., Daniel, W., Feldman, D., Greenwald, R., Hochberg, M., Howell, D., Ike, R., Kapila, P., Kaplan, D., Koopman, W., Marino, C., McDonald, E., McShane, E., Medsger, T., Michel, B., Murphy, W.A., Osial, T., Ramsey-Goldman, R., Rothschild, B. and Wolfe, F. 1991. The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hip.Arthritis Rheum. 1991;34(5):505-514

Bennell K. 2013. Physiotherapy management of hip osteoarthritis.J Physiotherapy 59(3):145-157.

Blume, A., Raymond, A. and Teixeira, P. 2015. Strategy and optimization of diagnostic imaging in painful hip in adults. Orthopaedics & traumatology, surgery & research, 101(1 Suppl): S85-99

Kaplan, W., Wirtz, V.J., Mantel-Teeuwisse, A., Stolk, P., Duthey, B. and Laing, R. 2013. Priority medicines for Europe and the world update report. Switzerland: WHO Press, Report

Bennell K. 2013. Physiotherapy management of hip osteoarthritis.J Physiotherapy 59(3):145-157.

Bennell, K.L., Dobson, K. and Hinman, R.S. 2014. Exercise in osteoarthritis: moving from prescription to adherence. Best Practice & Research in Clinical Rheumatology 28(1): 93-117.

Fernandes, L., Hagen, K.B., Bijlsma, J.W.J., Andreassen, O., Christensen, P., Conaghan, P.G., Doherty, M., Geenen, R., Hammond,H., Kjeken, I., 1 Lohmander, L.S., Lund, H., Mallen, C.D., Nava, T., Oliver, S., Pavelka, K., Pitsillidou, I., da Silva, J.A., de la Torre, J., Zanoli, G. and Vlieland, T.P.M.V. 2013 “EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis”, Annals Rheumatolgical Diseases, 72: 1125-1135

French, H.P., Brennan, A., White, B., Cusack, T., 2011 “Manual therapy for osteoarthritis of the hip or knee – A systematic review”. Manual Therapy, 16 (2):109-117

National Clinical Guideline Centre (NICE). Osteoarthritis. Care and management in adults. Clinical guideline CG177. Methods, evidence and recommendations. London: National Institute for Health and Clinical Excellence; 2014.

Peter, W.F.H., Jansen, M.J., Hurkmans, E.J., Bloo, H., Dekker-Bakker, L.M.M.C.J., Dilling, R.G., Hilbersink, W.K.H.A., Kersten-Smit, C., de Rooij, M., Veenhof, C., Vermeulen, H.M., de Vos, Schoones, J.W and Vliet Vlieland, T.P.M. 2011 “Physiotherapy in hip and knee osteoarthritis: development of a practice guide line concerning initial assessment, treatment and evaluation”, Acta Reumatologica Portuguesa, 36 (3): 268-281

Pisters, M.F., Veenhof, C., Van Meeteren, N.L.U., Ostelo, R.W., De Bakker, D.H., Schelleves, F.G and Dekker, J 2007 “Long-term effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: A systematic review” Arthritis and Rheumatism, 57 (7): 1245-1253

Zhang, W., Moskowitz, R.W., Nuki, G., Abramson, S., Altman, D. W., Arden, N., Bierma-Zeinstra , S., Brandt, K.D., Croft, P., Doherty, M, Dougados, M., Hochberg, M., Hunter, D.J., Kwoh, K., Lohmander, L.S. and Tugwell P. 2007 “OARSI recommendations for the management of hip and knee osteoarthritis, Part I: Critical appraisal of existing treatment guidelines and systematic review of current research evidence”, Osteoarthritis Research Society International, 15: 981-1000

Zhang, W., Moskowitz, R.W., Nuki, G., Abramson, S., Altman, D. W., Arden, N., Bierma-Zeinstra , S., Brandt, K.D., Croft, P., Doherty, M, Dougados, M., Hochberg, M., Hunter, D.J., Kwoh, K., Lohmander, L.S. and Tugwell P. 2008 “OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines”, Osteoarthritis Research Society International,16:137-162