Home 5 Hip & Knee OA Clinician Standards 5 Clinician Assessment

 

 

 

 

Standards

1-3: Setting Up for Success
4-6: Core Treatments
7-9: Rounding out the OA Journey

CLINICIAN STANDARDS

Standard 1. Comprehensive Clinical Assessment for Osteoarthritis Diagnosis

For adults who present with the typical signs and symptoms of osteoarthritis, a diagnosis can be made through a comprehensive biopsychosocial clinical assessment. No imaging is required to make the diagnosis.

Overview

Key Messages for Clinician Assessment

Adults (typically aged 40+) who present with joint pain, swelling or stiffness in hips, knees or lowers backs should be thoroughly examined for a diagnosis of OA.

  1. Screening questions, ruling out red flags and assessing for yellow flags
  2. Health history
  3. Physical exam

Imaging and laboratory investigations are not required to assist with clinical OA diagnosis of typical presentation. Findings on imaging may not always match the individual’s symptoms, and do not predict the response to treatment.

If required, weight bearing x-rays are the most appropriate imaging for viewing OA degradation.

Stay familiar with the criteria for immediate referral to an orthopaedic surgeon as every individual seeks care at a different stage of their journey.

The use of the terms ‘early’, ‘moderate/mild’ or ‘late/advanced’ are not recommended to describe clinical presentation of OA because they don’t accurately describe an individual’s lived experience.

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Introduction

This standard sets out the components that should be present to make an accurate clinical diagnosis of osteoarthritis (OA). OA is a chronic disease caused by joint changes from a progression of cartilage loss which may result in pain, declining quality of life, loss of function and increasing disability.

Both regulated and non-regulated clinicians may be involved in the assessment and care of an individual with OA.

Adults (typically aged 40 years and older) who present with joint pain, swelling or stiffness in their hips, knees or lower backs should be assessed thoroughly to determine if they have OA in their knees or hips. 1, 2

1 Arthritis Association of Canada, The College of Family Physicians of Canada, Centre for Effective Practice. Osteoarthritis tool. 2017.

2 The Arthritis Society. Getting a grip on arthritis: Best practice guidelines. 2017.

Osteoarthritis of the hip or knee will likely present with at least one of these symptoms:

  • Persistent atraumatic movement-related joint pain
  • Aching
  • Swelling
  • Joint instability due to bone misalignment
  • Catching
  • Morning stiffness lasting less than 30 minutes

    These symptoms may affect more than one joint at a time. Prior injuries, existing comorbidities and congenital deformities may be present along with typical OA symptoms.

    If the individual does not have hip and/or knee OA or meets criteria for consideration for inflammatory arthritis then these standards are not appropriate and other guidelines and tools should be used to inform diagnoses and care.

      Screening

      If OA is suspected, a diagnosis can be made with a comprehensive biopsychosocial clinical assessment. The Hip & Knee Osteoarthritis Assessment Template can be used to help guide the assessment and to record the details.

      1. Asking Five Screening Questions 1

      1 Arthritis Association of Canada, The College of Family Physicians of Canada, Centre for Effective Practice. Osteoarthritis tool. 2017.

      Consider the following screening questions to help rule out other pathologies:

      Serious pathologies to screen for:

      If inflammatory arthritis or other serious pathologies are identified, then these standards are not the appropriate tool for the individual.

      Red Flags

      Below is a list of serious pathologies which may require urgent care and/or a different approach to care planning: 1

      1 Arthritis Association of Canada, The College of Family Physicians of Canada, Centre for Effective Practice. Osteoarthritis tool. 2017.

      ⚠ Infection

      Indication: Fever, meningism, history of immunosuppression or IV drug use

      Investigations to consider: x-rays, MRI, CBC

      ⚠ Inflammatory Arthritis

      Indication: Rheumatoid arthritis, polymyalgia rheumatica, giant cell arthritis

      Investigations to consider: Rheumatology consult and blood tests for ESR, CRP, and rheumatological markers

      ⚠ Fracture

      Indication: Osteoporotic fracture, traumatic fall with risk of fractures

      Investigations to consider: x-rays, CT

      ⚠ Tumour

      Indication: History of cancer, unexplained weight loss, significant night pain, severe fatigue

      Investigations to consider: x-rays, MRI

      Psychosocial risk factors which may affect diagnosis and care planning

      Presence of psychosocial risk factors means the individual will benefit from reassurance and education to reduce chronicity. Reassess psychosocial risk factors for any individual with unimproved or poorly managed pain, after six weeks of treatment.

      ⚠ Risk Factor #1

      Belief that joint pain is harmful or potentially severely disabling.

      Key Screening Question: Do you think your pain will improve or become worse?

      ⚠ Risk Factor #2

      Fear and avoidance of activity or movement.

      Key Screening Question: Do you think you would benefit from activity, movement or exercise?

      ⚠ Risk Factor #3

      Tendency to low mood and withdrawal from social interaction.

      Key Screening Question: How are you emotionally coping with your joint pain?

      ⚠ Risk Factor #4

      Expectation of passive treatment(s) rather than a belief that active participation will help.

      Key Screening Question: What treatments or activities do you think will help you recover?

      History

      2. Documenting a Thorough Health History

      Documenting a thorough health history must include:

      History of joint trauma

      • Past medical history of the symptomatic joint
      • Joint instability from ligament pathology
      • Understanding co-morbidities and their current management
      Descriptions of pain experience
      • Identifying the joints with pain or stiffness symptoms
      • Mechanical symptoms, possibly from cartilage pathology
      • Understanding the individual’s pain experience (intensity, type, when, and sleep quality)

      Identifying limitations to activities and mobility

      • Understanding the engagement in activities. Consider asking: How many minutes of exercise and/or physical activity (Standard 5) do you do per week?
      • Screening for falls in the past six months
      • Understanding the person’s support network, lifestyle and occupation. Consider asking: “Do you (ever) have difficulties making ends meet?”
      • Understanding the avoidance of activities because of pain, stiffness or weakness

      Physical Exam

      3. Performing a Physical Exam

      The physical examination helps to deepen the understanding of the individual’s disease activity and allows for a baseline collection of information to inform treatment planning over time. It is important to explain the process and ask for consent as the clinician moves through each step of the physical examination.

      The examination must include recording the height, weight, body mass index (BMI) and blood pressure. Blood pressure is only necessary for medication modification.

      A good examination will include:

      Tests to confirm diagnosis

      • Observation of spinal and general posture
      • Observation of knee joint alignment when weight bearing and non-weight bearing
      • Scanning of lower extremity to evaluate referred pain and neurological signs
      • Observation of joint appearance and presence of swelling in knees only
      • Assessment of affected and associated joints’ range of motion, strength and stability tests:

        • Internal rotation (hips)
        • Flexion (both)
      • Use additional investigations to rule out other conditions
      Collecting a baseline of function
      • Observation of spinal and general posture
      • Observation of knee joint alignment when weight bearing and non-weight bearing
      • Assessment of balance
      • Observation of gait pattern to test for mobility function

        • Timed Up and Go Test 2

          2 The Arthritis Society. Getting a grip on arthritis: Best practice guidelines. 2017.

      • Assessment of risk for falls and/or functional strength of lower extremities using:

      Imaging Referrals

      Imaging

      Imaging and laboratory investigations are not required to assist with clinical OA diagnosis of typical presentation.3

      3 Wang X, Oo WM, Linklater JM. What is the role of imaging in the clinical diagnosis of osteoarthritis and disease management? Rheumatology. 2018;57(suppl_4):iv51–iv60.

      Clinical diagnosis is sufficient to begin care planning and treatment of OA and clinical presentation, in combination with shared decision-making, should guide the ongoing conservative management of OA. Findings on imaging may not always match the individual’s symptoms, and do not predict the response to treatment.

      If the screening questions have indicated further investigation is required or if the diagnosis is uncertain, then the assessing clinician can begin with preliminary imaging (x-rays) and proceed to advanced imaging only if indicated. Preferred x-rays views can be found here.

      ⚠ Repeated use of imaging to track OA progression is not typically warranted. Repeated imaging does not provide added value to treatment planning unless the progression of symptoms is unexpected and an x-ray has not been done in 1-2 years.

      Immediate Orthopaedic Surgeon Referral

      The goal with these standards is to encourage an adequate trial of non-surgical treatment prior to referral to a surgeon (Standard 8). However, certain criteria warrant urgent referral to an orthopaedic surgeon.

      These criteria include:

      1. Other pathologies are identified:
        1. Suspected fracture; or
        2. Ligament injury
      2. During the documenting of history or the performing of the physical exam the individual with OA describes all of the following:

        • Dull/aching pain punctuated by short episodes of unpredictable pain; and
        • Pain interrupting sleep; and
        • Loss of independence and ability to do self care; and
        • Increase of frequency and dosing of pharmacological treatments; and
        • Avoidance of all daily activities
      3. Increased reliance on use of opioids
      4. Preliminary imaging was appropriately pursued and radiographical evidence reveals a severe joint spacing reduction.

      Standard 8 provides more details on a routine referral to surgeon after non-surgical treatment has been exhausted. In Alberta, x-rays are required to refer to an orthopaedic surgeon.

        Staging Osteoarthritis

        Assigning an Osteoarthritis “Stage” to the Individual

        Typical terms for OA clinical stages are: ‘early/mild’, ‘moderate’ or ‘advanced/late’. The nine standards will not use ‘clinical stage terms’ to describe an individual’s OA and/or their applicable treatment options.

        Clinical presentation should guide the use of these standards and the tailoring of non-surgical treatments is appropriate no matter what the stage of OA (clinical or radiographical) and classification should not discourage or limit individuals from non-surgical treatment options (more in Standard 2 and Standard 3).

        Individuals will seek care at different points in their disease journey; a clinician’s diagnosis may be building on care the individual has already received. For instance, an individual may still be ‘early’ but has been managing their condition for some time: their disease activity may be ‘early’ but their journey and their perception of treatment options may be ‘advanced’.