Osteoarthritis: Diagnosis and Management for PLAB 1
Osteoarthritis (OA) is a common degenerative joint disease characterized by the breakdown of cartilage, leading to pain, stiffness, and reduced mobility. Understanding its diagnosis and management is crucial for PLAB 1 preparation, focusing on evidence-based guidelines and clinical best practices in the UK.
Understanding Osteoarthritis
OA primarily affects weight-bearing joints like the knees, hips, and spine, but can also impact hands and feet. It's a multifactorial condition influenced by age, genetics, obesity, joint injury, and overuse.
Diagnosis of Osteoarthritis
Diagnosis relies on a combination of patient history, physical examination, and imaging. The NICE (National Institute for Health and Care Excellence) guidelines provide a framework for diagnosis and management.
History, physical examination, and imaging (X-rays).
Clinical History
Key historical features include joint pain that worsens with activity and improves with rest, morning stiffness lasting less than 30 minutes, and a gradual onset of symptoms. Patients may also report crepitus (a grinding sensation) during joint movement.
Physical Examination
Examination involves assessing for joint tenderness, reduced range of motion, crepitus, bony enlargement (e.g., Heberden's and Bouchard's nodes in the hands), and muscle weakness. Gait assessment is important for lower limb OA.
Imaging
X-rays are the primary imaging modality. Typical findings include joint space narrowing, osteophyte formation, subchondral sclerosis (increased bone density beneath the cartilage), and subchondral cysts. In the UK, X-rays are usually only indicated when clinical suspicion is high or to rule out other conditions.
Radiographic features of osteoarthritis include joint space narrowing, osteophyte formation (bone spurs), subchondral sclerosis (thickening of bone beneath cartilage), and subchondral cysts (fluid-filled sacs within the bone). These findings are typically assessed on plain X-rays, often in weight-bearing views for lower limb joints.
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Management of Osteoarthritis
Management is multimodal, aiming to relieve pain, improve function, and slow disease progression. The NICE guidelines emphasize a stepped approach.
| Step | Intervention | Key Considerations |
|---|---|---|
| 1 | Education, lifestyle modifications (weight loss, exercise), self-management strategies | Crucial first step; empower patients. |
| 2 | Pharmacological treatments (paracetamol, topical NSAIDs, oral NSAIDs, intra-articular corticosteroids) | Consider risks and benefits; use lowest effective dose. |
| 3 | Referral for surgery (e.g., joint replacement) or other advanced interventions | For severe, refractory symptoms. |
Non-Pharmacological Management
Weight loss is paramount for overweight or obese individuals with knee or hip OA. Exercise, including muscle strengthening and aerobic activities, is highly recommended. Physiotherapy and occupational therapy can provide tailored advice and support.
Pharmacological Management
Paracetamol is often the first-line analgesic. Topical NSAIDs (e.g., diclofenac gel) are effective for knee and hand OA. Oral NSAIDs should be used cautiously due to gastrointestinal, cardiovascular, and renal risks, particularly in older adults. Intra-articular corticosteroid injections can provide short-term pain relief for flares.
Remember to consider the patient's comorbidities and other medications when prescribing NSAIDs.
Surgical Management
Joint replacement surgery (arthroplasty) is a highly effective treatment for severe OA that significantly impacts quality of life and has not responded to conservative measures. Common procedures include total knee replacement (TKR) and total hip replacement (THR).
Key UK Guidelines and Considerations
NICE guidelines are the cornerstone for OA management in the UK. They emphasize a patient-centered approach, shared decision-making, and the importance of lifestyle modifications. For PLAB 1, be aware of the recommended thresholds for initiating different treatments and the contraindications for NSAIDs.
NICE (National Institute for Health and Care Excellence).
Learning Resources
The official NICE guideline providing comprehensive recommendations on the assessment and management of osteoarthritis in adults.
A patient-focused overview of osteoarthritis from the National Health Service, covering causes, symptoms, diagnosis, and treatment options.
A clinical decision support tool offering evidence-based information on the diagnosis and management of osteoarthritis, updated regularly.
Information from the Royal College of Radiologists on how osteoarthritis is diagnosed using imaging, including X-rays.
Clinical guidance from the Royal College of General Practitioners, tailored for primary care physicians managing osteoarthritis.
A charity providing extensive patient-friendly information on osteoarthritis, including causes, symptoms, and self-management strategies.
A clear and concise video explaining the basics of osteoarthritis, its causes, and how it affects joints.
A review article discussing the current evidence and approaches to managing osteoarthritis, suitable for healthcare professionals.
A detailed overview of osteoarthritis, including diagnostic criteria, differential diagnoses, and treatment strategies from a medical perspective.
Information from the Chartered Society of Physiotherapy on the benefits and types of exercise recommended for individuals with osteoarthritis.