Adjunct Treatments

STANDARD 7

If the individual with hip or knee osteoarthritis (OA) is unable to participate in Core Treatments, reports minimal progression towards goals, or requires additional support to manage symptoms the care team can consider Adjunct Treatments. Adjunct Treatments include non-pharmacological and pharmacological interventions to improve the individual’s pain, function, and ability to participate in Core Treatments. Use of shared decision-making techniques will ensure the individual’s priorities, values and preferences are considered when choosing Adjunct Treatments.
Home 9 Clinician Standards: 7. Adjunct Treatments

OVERVIEW

Key Messages for Adjunct Treatments

  • Adjunct Treatments are used to improve the individual’s ability to fully participate in the Core Treatments
  • The costs of Adjunct Treatments should be discussed before adding a treatment to a care plan
Non-pharmacological Treatments
  • Supports can improve stability and mobilization, conserve energy, minimize the risk of falling and provide options for safe movement to reduce the lower limb loading that can increase pain
  • The individual’s pain experience can be influenced by changes in physical, emotional, behavioural, and cognitive states so cognitive behaviour therapy can be offered that may or may not include Acceptance Commitment Therapy (ACT) and mindfulness
  • Inter-disciplinary self-management programs offer more specific resources and strategies to help struggling individuals develop coping skills in response to their evolving symptoms
Pharmacological Treatments
  • The algorithm guides progressive use of pharmacological treatments
  • The individual’s full history should be considered before prescribing
  • Complications, side effects and possible interactions of medications should be considered
  • Intra-articular injections includes: steroids, hyaluronic acid and platelet rich plasma
  • Advanced pain management includes opioids (use with extreme caution), peripheral nerve blocks or referral for joint surgery

INTRODUCTION

Core Treatments (Standard 4, Standard 5, and Standard 6) are essential foundations of every care plan and have the strongest evidence for conservative management of osteoarthritis (OA)1-4. However, Adjunct Treatments can be considered if individuals with OA:

1Bowden 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.

2Gay C, Chabaud A, Guilley E, Coudeyre E. Educating patients about the benefits of physical activity and exercise for their hip and knee osteoarthritis. Systematic literature review. Annals of Physical and Rehabilitation Medicine. 2016;59(3):174-83.

3Rice D, McNair P, Huysmans E, Letzen J, Finan P. Best evidence rehabilitation for chronic pain part 5: Osteoarthritis. Journal of Clinical Medicine. 2019;8(11):1769.

4Wellsandt E, Golightly Y. Exercise in the management of knee and hip osteoarthritis. Current Opinion in Rheumatology. 2018;30(2):151-9.

  • 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:

Type Facts and Benefits Examples
Assistive Devices
  • Reduces load on compromised hip or knee joints for joint stability
  • Increases size of base of support for overall balance improvement
  • Redirect a portion of body weight to the upper extremities
  • Canes
  • Crutches
  • Hiking poles/walking sticks
  • Walkers
Braces
  • Worn under clothing
  • Support joint and improve alignment
  • Redistribute forces on weight-bearing joints
  • Decrease pain
  • Improve overall function
Footwear and Orthotics
  • Decrease pain
  • Improve overall function
  • Improve alignment

Note: consider cost vs. benefit. See learn mores for more information.

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

Type Facts and Benefits Examples
Assistive Technologies
  • Conserve energy
  • Reduce painful joint positions
  • Promotes independence for activities of daily living
  • Long shoehorn
  • Long Handled Reacher
  • Sock aids
Home Adaptations
  • Reduces painful joint position
  • Increasing seat to floor height can impact joint loading forces, magnitude of movement and stability
  • Promotes Safety/Fall Prevention
  • Raised toilet seat
  • Toilet armrests/commodes
  • Higher seat/hip cushions

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:

Priority and goal setting

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

Self-evaluation strategies

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

Problem-solving strategies

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

Mental health strategies

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

Symptom management strategies
  • 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 OA6,76Ali 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 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.

INTRODUCTION

Core Treatments (Standard 4, Standard 5, and Standard 6) are essential foundations of every care plan and have the strongest evidence for conservative management of osteoarthritis (OA)1-4. However, Adjunct Treatments can be considered if individuals with OA:

1Bowden 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.

2Gay C, Chabaud A, Guilley E, Coudeyre E. Educating patients about the benefits of physical activity and exercise for their hip and knee osteoarthritis. Systematic literature review. Annals of Physical and Rehabilitation Medicine. 2016;59(3):174-83.

3Rice D, McNair P, Huysmans E, Letzen J, Finan P. Best evidence rehabilitation for chronic pain part 5: Osteoarthritis. Journal of Clinical Medicine. 2019;8(11):1769.

4Wellsandt E, Golightly Y. Exercise in the management of knee and hip osteoarthritis. Current Opinion in Rheumatology. 2018;30(2):151-9.

  • 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:

Type Facts and Benefits Examples
Assistive Devices
  • Reduces load on compromised hip or knee joints for joint stability
  • Increases size of base of support for overall balance improvement
  • Redirect a portion of body weight to the upper extremities
  • Canes
  • Crutches
  • Hiking poles/walking sticks
  • Walkers
Braces
  • Worn under clothing
  • Support joint and improve alignment
  • Redistribute forces on weight-bearing joints
  • Decrease pain
  • Improve overall function
Footwear and Orthotics
  • Decrease pain
  • Improve overall function
  • Improve alignment

Note: consider cost vs. benefit. See learn mores for more information.

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

Type Facts and Benefits Examples
Assistive Technologies
  • Conserve energy
  • Reduce painful joint positions
  • Promotes independence for activities of daily living
  • Long shoehorn
  • Long Handled Reacher
  • Sock aids
Home Adaptations
  • Reduces painful joint position
  • Increasing seat to floor height can impact joint loading forces, magnitude of movement and stability
  • Promotes Safety/Fall Prevention
  • Raised toilet seat
  • Toilet armrests/commodes
  • Higher seat/hip cushions

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 THERAPY

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:

Priority and goal setting

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

Self-evaluation strategies

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

Problem-solving strategies

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

Mental health strategies

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

Symptom management strategies
  • 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 OA6,76Ali 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 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.

Q

Custom Braces

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Custom Orthotics

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Custom Footwear

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Advanced Pain Management

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Bone and Joint Health SCN

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Cannabinoids

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Intra-articular Injections

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Stem Cell Therapy

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Peripheral Nerve Blocks

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Shared Decision Making

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Alberta Referral Directory

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Referral Between Clinicians