INTRODUCTION

• Find it difficult to participate in Core Treatments
• Report minimal progression toward their goals or
• Require additional support to manage symptoms

Adjunct Treatments are used to improve the individual’s ability to fully participate in Core Treatments. The clinician can provide evidence informed non-pharmacological and pharmacological treatments options to support the individual’s goals. In particular, muscle weakness, joint pain and fear of exacerbating symptoms can be barriers to adhering with prescribed exercise and physical activity (Standard 5). Addressing these physical and emotional barriers with Adjunct Treatments can support:

• Affected joints to ease mobility⁵⁵Yu SP, Hunter DJ. Managing osteoarthritis. Australian Prescriber. 2015;38(4):115-9.
• Behavioural change¹¹Bowden JL, Hunter DJ, Deveza LA, Duong V, Dziedzic KS, Allen KD, et al. Core and adjunctive interventions for osteoarthritis: Efficacy and models for implementation. Nature Reviews Rheumatology. 2020;16(8):434-47.
• Long-term commitment to exercise and physical activity¹¹Bowden JL, Hunter DJ, Deveza LA, Duong V, Dziedzic KS, Allen KD, et al. Core and adjunctive interventions for osteoarthritis: Efficacy and models for implementation. Nature Reviews Rheumatology. 2020;16(8):434-47.

The clinician may refer to other disciplines with additional skills in OA management and expertise in specific Adjunct Treatments to build and strengthen the individual’s support network. This multidisciplinary care team approach combined with collaboration with the individual will ensure the individual’s priorities, values and preferences are considered when pursuing Adjunct Treatments. Any additional costs of Adjunct Treatments should be considered and discussed with the individual before adding to an OA care plan.

WALKING & ENVIRONMENTAL SUPPORTS

Non-pharmacological Adjunct Treatments include any non-medicinal intervention proven to support symptom management. They are:

• Supports (walking and environmental)^1,51Bowden JL, Hunter DJ, Deveza LA, Duong V, Dziedzic KS, Allen KD, et al. Core and adjunctive interventions for osteoarthritis: Efficacy and models for implementation. Nature Reviews Rheumatology. 2020;16(8):434-47.
  ⁵Yu SP, Hunter DJ. Managing osteoarthritis. Australian Prescriber. 2015;38(4):115-9.
• Cognitive behavioural therapy¹¹Bowden JL, Hunter DJ, Deveza LA, Duong V, Dziedzic KS, Allen KD, et al. Core and adjunctive interventions for osteoarthritis: Efficacy and models for implementation. Nature Reviews Rheumatology. 2020;16(8):434-47./span>
• Inter-disciplinary self-management programs¹¹Bowden JL, Hunter DJ, Deveza LA, Duong V, Dziedzic KS, Allen KD, et al. Core and adjunctive interventions for osteoarthritis: Efficacy and models for implementation. Nature Reviews Rheumatology. 2020;16(8):434-47.

The use of walking supports can improve stability, mobilization, minimize the risk of falling and the severity of injury if a fall does occur, and reduce the lower limb loading that can increase pain. Walking supports include:

The use of environmental supports can conserve energy and provide options for safe movement. Environmental supports include:

Supports are relatively affordable options that can address symptoms and allow individuals to better participate in exercise and physical activities. If these treatment options are applicable, the Primary Clinician can refer the individual to appropriate supporting clinicians or medical supply stores that are familiar with the walking supports commonly used by people with hip or knee OA. The individual can also self-refer to many clinicians who have supports expertise.

COGNITIVE BEHAVIOURAL THERAPY¹¹Bowden JL, Hunter DJ, Deveza LA, Duong V, Dziedzic KS, Allen KD, et al. Core and adjunctive interventions for osteoarthritis: Efficacy and models for implementation. Nature Reviews Rheumatology. 2020;16(8):434-47.

The individual’s OA pain experience can be influenced by changes in physical, emotional, behavioural, and cognitive states .

Cognitive behaviour therapy can be offered to individuals to:

• Support mental health
• Develop pain coping strategies
• Develop stress and anxiety management strategies
• Promote behavioural modifications

The clinician may offer advice for these or refer the individual to skilled supporting clinicians or other trained cognitive specialists.

SELF MANAGEMENT

Inter-disciplinary self-management programs offer resources and strategies to help individuals develop, adhere to, and modify their goals and course of action in response to their evolving symptoms¹¹Bowden JL, Hunter DJ, Deveza LA, Duong V, Dziedzic KS, Allen KD, et al. Core and adjunctive interventions for osteoarthritis: Efficacy and models for implementation. Nature Reviews Rheumatology. 2020;16(8):434-47.. These programs are more specific and focused than the self-management principles embodied in Core Treatments; the programs are appropriate for an individual who has struggles with employing coping strategies and wants more practice and examples. These programs aim to increase an individual’s confidence to self-manage their symptoms and health outcomes. These programs emphasize the following topic areas:

Empowering individuals to play an active role in identifying what needs to change and set realistic goals including appropriate pace setting.

Helping individuals monitor their progression and changes in symptoms, in order to recognize when they need to ask for additional support.

Evaluation of progress in meeting goals and how to overcome barriers and challenges.

Guidance for managing emotional impacts of OA for individuals and their family support systems.

• Thermotherapy: Heat modalities and cryotherapy to manage joint inflammation; and
• Activity self-selection: Building their understanding of their local structured exercise programs and physical activity options so they can choose new ones as they wish.

When these programs are offered in a group setting, they can also provide an opportunity for individuals to build a support network, and feel less alone (universality). Peer support can improve self-management of OA^6,76Ali SA, Walsh KE, Kloseck M. Patient perspectives on improving osteoarthritis management in urban and rural communities. Journal of pain research. 2018;11:417-25.
⁷Bryk C, Lewis TR, Miller J, Penman C, Teare S. The Experience of Waiting for Help with Osteoarthritis. Calgary, AB: PACER; 2013. Contract No.: Report. .

All education resources and sessions (Standard 4) will be combined with guidance on self-management strategies. The clinician should work with the individual to review and modify self-management strategies on an ongoing basis and as symptoms evolve.

PHARMACOLOGICAL INTERVENTIONS

Pharmacological treatments include three types of medications:

• Non-prescription treatments: topical and oral
• Prescription treatments: topical and oral
• Intra-articular injectables

Pharmacological pain management strategies can be recommended by a primary care physician and/or in collaboration with a pharmacist or nurse practitioner. Prior to making pharmacological treatment recommendations, it is important that the clinician team assess the individual’s:

• Symptoms
• Pain experience
• Comorbidities
• History of pharmacological treatment use

Complications, side effects and possible interactions of the OA with other medicines should also be considered. Further consultation with other medical specialties may be required to ensure safety of the individual with OA prior to making recommendations. Intra-articular injections should be performed by a skilled clinician.

Symptom self-management strategies should be discussed in conjunction with pharmacological treatment planning. Pharmacological treatments should be used to reduce pain symptoms to promote and enable full participation in Core Treatments. Since medications cannot reduce pain to zero and come with the potential for side effects or tolerance development, encourage the individual to combine pharmacological treatments with other non-pharmacological treatments such as thermotherapy or activity self-selection to help optimize pain management.

As symptoms evolve, the pain management strategy must be modified to suit the individual’s current needs. Below is a stepped algorithm for pharmacological treatments that may be used by the clinician when considering options for best relief of the individual’s current pain symptoms. The individual’s needs, preferences, values, blood pressure, risks of side-effects and socio-economic status must be discussed when making pharmacological treatment choices. Selection of pharmacological treatments will influence the follow-up plan the clinician and the individual agree to (Standard 2). The individual with OA must be reassessed, as needed, to understand the efficacy and side effects of the pharmacological treatment(s), and to highlight any need for modifications in a timely manner.

The algorithm should be read top to bottom. These tables provide example medications for each category from the algorithm.

The algorithm begins with topical nonsteroidal anti-inflammatory drugs (NSAIDs) for individuals who have mild pain from their OA. Topical NSAIDs are better suited for knee OA versus the hip as the knee joint is closer to the surface of the skin allowing for better penetration of the medication. Next, consider an oral NSAIDs or Cox-2 inhibitor for patients without contraindications. NSAIDs and Cox-2 Inhibitors can cause serious side effects and increase risk of CV events. Try to use at the lowest dose for the shortest time-period possible. Consider providing a prescription for a PPI for gastroprotection in patients with increased GI risk. A short-term trial of acetaminophen could also be tried. Note that in clinical trials, acetaminophen appears to offer little clinically meaningful benefit. However, a short-term trial is often recommended as it is considered relatively safe compared to alternatives. This might also be a good choice for patients unable to take oral NSAIDs.

If oral NSAIDs do not provide adequate relief or a patient has a contraindication to oral NSAIDs, consider a trial of duloxetine for those with moderate to severe pain. Duloxetine has an official indication only for knee OA but may also be beneficial in patients with hip OA with comorbid depression and anxiety.

Intra-articular injections include: steroids, hyaluronic acid preparations and platelet rich plasma (PRP). These can be considered if complementary supplements are still not providing adequate pain relief. Stem cell therapy is also a form of intra-articular injection, but Health Canada has a moratorium on this therapy. Note: the evidence on all intra-articular injections is evolving and costs vs. benefits should be carefully considered.

The final option in the algorithm is advanced pain management. Advanced pain management includes:

• Opioids: oral or transdermal (not recommended)
• Peripheral nerve block
• Referral to an orthopaedic surgeon for joint surgery assessment (Standard 8)

Opioids are not recommended for routine use to treat OA pain⁸⁸Ivers N, Dhalla IA, Allan GM. Opioids for osteoarthritis pain: Benefits and risks. Canadian Family Physician. 2012;58(12).. Opioids can have harmful side effects.
Cannabinoids are not routinely recommended for individuals with OA⁹⁹Toward Optimized Practice (TOP). PEER simplified guideline: Medical Cannabinoids clinical practice guideline. 2018. .

PRESCRIBING ADJUNCT TREATMENTS

Pain medications must be prescribed very carefully, and a full history of the individual’s active prescriptions, history of addictions, comorbidities and pain experience must be evaluated. Based on the pharmaceutical treatment algorithm, develop a tailored medication plan taking into consideration the individual’s symptoms, ability to participate in Core Treatments, other health conditions, and values and preferences.

Use the Resource Inventory to track which Adjunct Treatments are available locally. Use the Tables of Examples of Conservative OA Treatments to consider the breadth of options for adjunct treatments.

Standard 3 describes how it is every clinician’s responsibility to communicate to the Primary Clinician, and vice versa. Any changes in the care plan or health status of the individual should be communicated. This is particularly important for the management of pharmacological treatments. Communications between clinicians can emphasize that the goal is to provide Adjunct Treatments to encourage return to Core Treatments.

At all follow-up visits, work with your individual with OA to reassess, track, and modify their Adjunct Treatments to better reflect their current needs and progress. This collaborative process will improve commitment to Core Treatments.