Introduction by Croakey: The Australian Commission on Safety and Quality in Health Care (ACSQHC) recently released a revised clinical standard for knee osteoarthritis, with the aims of reducing unnecessary imaging and surgery, promoting non-surgical treatments, and improving patient understanding of the condition.
The standard highlights the importance of how clinicians talk about the condition and the options available to patients.
Rather than promoting unhelpful beliefs through “an impairment discourse”, it’s recommended that clinicians use a “participatory discourse” that empowers people to feel that they are in charge and can take action to change the course of their disease, says ACSQHC Medical Advisor Dr Phoebe Holdenson Kimura and her colleague, Fiona Doukas, from the Commission’s Clinical Care Standards team.
Phoebe Holdenson Kimura and Fiona Doukas write:
How often have you heard the terms ‘bone on bone’, ‘wear and tear’ or ‘degenerative’ being used when talking about knee osteoarthritis?
Knee osteoarthritis is characterised by knee pain and functional limitation, leading to the widely held view that the symptoms are entirely related to structural damage.
This has been the dominant narrative and, while we have seen a paradigm shift in our understanding of low back pain, we still have some way to go with knee osteoarthritis.
The revised Osteoarthritis of the Knee Clinical Care Standard, released by the Australian Commission on Safety and Quality in Health Care on 15 August, challenges the way we think and talk about knee osteoarthritis, moving away from a joint-centric understanding of the disease to a person-centred approach.
Terms such as ‘bone on bone’ belong to an ‘impairment discourse’, where the body is seen as a machine that has broken down, that knees are past their ‘use-by date’, and that disability due to osteoarthritis is an inevitable part of ageing.
Research shows that misconceptions grounded in this impairment discourse may underlie reluctance to engage in active strategies such as exercise or weight management. This can increase expectations of surgery to repair cartilage and meniscal defects or to replace knee joints.
Unhelpful beliefs amongst people with knee osteoarthritis include that being physically active will cause damage to the knee joint. This can be unintentionally fostered by clinicians in the language they use to explain the disease or discuss imaging results.
Motivating patients to self-manage
Rather than an impairment discourse, the use of a ‘participatory discourse’ to talk about knee osteoarthritis empowers people to feel that they are in charge and can take action to change the course of their disease. At the same time, this approach acknowledges the experience of people with osteoarthritis, and the challenges of managing knee pain and attempting to increase physical activity.
Importantly, if a person with knee osteoarthritis sees themselves as an active participant, they are more likely to engage in self-managing their condition. The focus is on what they can do, rather than what they can’t do.
Positive conversations that help to empower patients include statements such as:
- ‘Knee joints are strong – they stay healthy through movement and are designed to be loaded. It’s safe to be active, even if it’s a bit sore at the start. The key is to find the right amount of activity based on what you can do now and what you want to do in the future.’
- ‘There is good evidence that most people who are physically active and maintain a healthy weight can be healthy and strong and participate in the activities they enjoy without ever needing surgery.’
- ‘Joint changes seen on X-rays and MRI scans are also seen in people who are free of pain. These changes don’t predict future pain or response to treatment.’
Using these phrases may not come naturally to clinicians unfamiliar with this approach.
Alongside the Standard, the Commission has developed a fact sheet for clinicians, highlighting useful phrases and framing to avoid unhelpful beliefs and support self-management.
Factors that influence knee health
Evidence also supports the understanding that knee health is influenced by a range of biopsychosocial factors that modulate inflammatory processes, tissue sensitivity and behavioural responses that lead to pain and disability.
This further reinforces the critical role of education and self-management, physical activity, exercise, weight management, and appropriate pain management.
While knee replacement surgery has a role for people with severe pain despite optimal non-surgical management, many people do not receive first-line non-surgical care.
In NSW, 70 percent of patients waiting for total knee replacement surgery through the public system had not accessed non-surgical interventions such as exercise and weight management before referral. Yet these approaches can allow patients to avoid or delay surgery.
The revised Standard emphasises the limited role of imaging for people with suspected knee osteoarthritis, calling on clinicians to ‘treat the person not the scan’.
Guidelines are clear that knee osteoarthritis can be confidently diagnosed based on clinical assessment alone, without the need for any imaging unless the patient has atypical features suggesting an alternate diagnosis.
Imaging can escalate unhelpful beliefs about the disease and further discourage physical activity. It is not uncommon for imaging to lead to a cascade of unwarranted investigations including MRI and CT scans, which can lead to surgical referrals that are neither appropriate nor necessary.
The Standard suggests that clinicians discuss the risks and benefits of imaging with people, and advise that imaging is unlikely to change management, which is primarily non-surgical.
While medicines are the mainstay of pain management for many people, their primary role is to support physical activity rather than change the physiology of the disease.
Strengthened advice in the Standard highlights non-evidence-based treatments – with opioid analgesics, stem cells and protein rich plasma (PRP) not recommended. In the case of opioids, the benefits do not outweigh the substantial risks, while treatments such as stem cells and PRP remain unproven and costly.
The Standard has been endorsed by 21 professional and consumer organisations, and supported amongst the clinical community as an important tool to support best practice care.
With the high prevalence of knee osteoarthritis and the projected increases in knee replacement surgery, it is clearly a time for change.
For the Commission, a vital step on the pathway is for all clinicians to ‘speak the same language’ and empower people with knee osteoarthritis to feel confident about appropriate non-surgical care.
Access a copy of the Standard and practical resources at safetyandquality.gov.au/oak-ccs