About this guideline

NICE clinical guidelines are recommendations about the treatment and care of people with specific diseases and conditions.

NICE guidelines are developed in accordance with a scope that defines what the guideline will and will not cover.

This guideline was developed by the National Clinical Guideline Centre, which is based at the Royal College of Physicians. The Collaborating Centre worked with a Guideline Development Group, comprising healthcare professionals (including consultants, GPs and nurses), patients and carers, and technical staff, which reviewed the evidence and drafted the recommendations. The recommendations were finalised after public consultation.

The methods and processes for developing NICE clinical guidelines are described in The guidelines manual.

NICE produces guidance, standards and information on commissioning and providing high-quality healthcare, social care, and public health services. We have agreements to provide certain NICE services to Wales, Scotland and Northern Ireland. Decisions on how NICE guidance and other products apply in those countries are made by ministers in the Welsh government, Scottish government, and Northern Ireland Executive. NICE guidance or other products may include references to organisations or people responsible for commissioning or providing care that may be relevant only to England.

Update information

This guideline updates and replaces NICE clinical guideline 59 (published February 2008).

Recommendations are marked as [new 2014], [2014], [2008] or [2008, amended 2014]:

  • [new 2014] indicates that the evidence has been reviewed and the recommendation has been added or updated

  • [2014] indicates that the evidence has been reviewed but no change has been made to the recommended action

  • [2008] indicates that the evidence has not been reviewed since 2008

  • [2008, amended 2014] indicates that the evidence has not been reviewed since 2008, but changes have been made to the recommendation wording that change the meaning.

Recommendations from NICE clinical guideline 59 that have been amended

Amended recommendation wording (change to meaning)

Recommendations are labelled [2008, amended 2014] if the evidence has not been reviewed since 2008 but changes have been made to the recommendation wording that change the meaning.

Recommendation in 2008 guideline

Recommendation in current guideline

Reason for change

1.1.5 Healthcare professionals should offer all people with clinically symptomatic osteoarthritis advice on the following core treatments.

  • Access to appropriate information (see section 1.2.1).

  • Activity and exercise (see section 1.3.1).

  • Interventions to achieve weight loss if person is overweight or obese (see section 1.3.2 and 'Obesity' [NICE clinical guideline 43]).

1.2.5 Offer advice on the following core treatments to all people with clinical osteoarthritis.

  • Access to appropriate information (see recommendation 1.3.1).

  • Activity and exercise (see recommendation 1.4.1).

  • Interventions to achieve weight loss if the person is overweight or obese (see recommendation 1.4.3 and Obesity [NICE clinical guideline 43]). [2008, amended 2014]

The GDG felt that the term 'clinical osteoarthritis' is accurate. For most clinicians this would mean 'symptomatic osteoarthritis' (for which analgesia is offered), but advice on core treatments should also be offered to people with asymptomatic osteoarthritis.

1.3.7.1 Referral for arthroscopic lavage4 and debridement should not be offered as part of treatment for osteoarthritis, unless the person has knee osteoarthritis with a clear history of mechanical locking (not gelling, 'giving way' or X-ray evidence of loose bodies).

4 This recommendation is a refinement of the indication in Arthroscopic knee washout, with or without debridement, for the treatment of osteoarthritis (NICE interventional procedure guidance 230). This guideline reviewed the clinical and cost-effectiveness evidence, which led to this more specific recommendation on the indication for which arthroscopic lavage and debridement is judged to be clinically and cost effective.

1.4.10 Do not refer for arthroscopic lavage and debridement4 as part of treatment for osteoarthritis, unless the person has knee osteoarthritis with a clear history of mechanical locking (as opposed to morning joint stiffness, 'giving way' or X-ray evidence of loose bodies). [2008, amended 2014]

4 This recommendation is a refinement of the indication in Arthroscopic knee washout, with or without debridement, for the treatment of osteoarthritis (NICE interventional procedure guidance 230 [2007]). The clinical and cost-effectiveness evidence for this procedure was reviewed for the original guideline (published in 2008), which led to this more specific recommendation on the indication for which arthroscopic lavage and debridement is judged to be clinically and cost effective.

The GDG felt that 'as opposed to morning joint stiffness' is clearer than 'not gelling'.

The footnote wording has also been amended for clarity.

1.5.1.2 Referral for joint replacement surgery should be considered for people with osteoarthritis who experience joint symptoms (pain, stiffness and reduced function) that have a substantial impact on their quality of life and are refractory to non-surgical treatment. Referral should be made before there is prolonged and established functional limitation and severe pain.

1.5.1.3 Patient-specific factors (including age, gender, smoking, obesity and comorbidities) should not be barriers to referral for joint replacement surgery.

1.6.3 Consider referral for joint surgery for people with osteoarthritis who experience joint symptoms (pain, stiffness and reduced function) that have a substantial impact on their quality of life and are refractory to non-surgical treatment. [2008, amended 2014]

1.6.4 Refer for consideration of joint surgery before there is prolonged and established functional limitation and severe pain. [2008, amended 2014]

1.6.5 Patient-specific factors (including age, sex, smoking, obesity and comorbidities) should not be barriers to referral for joint surgery. [2008, amended 2014]

The GDG felt that the message of original recommendation 1.5.1.2 was clearer if it was split into 2 separate recommendations (1.6.3 and 1.6.4).

The GDG removed the word 'replacement' from these recommendations, because it noted that the evidence reviewed to inform the recommendations on surgery made in 2008 had included evidence on both joint replacement and arthroplasty (which includes procedures such as joint remodelling or realignment). The GDG therefore felt that using the wording 'joint replacement' in the recommendations was unduly restrictive.

1.5.1.4 Decisions on referral thresholds should be based on discussions between patient representatives, referring clinicians and surgeons, rather than using current scoring tools for prioritisation.

1.6.2 Base decisions on referral thresholds on discussions between patient representatives, referring clinicians and surgeons, rather than using scoring tools for prioritisation. [2008, amended 2014]

The word 'current' has been removed so that the recommendation remains valid over time.

Strength of recommendations

Some recommendations can be made with more certainty than others. The Guideline Development Group makes a recommendation based on the trade-off between the benefits and harms of an intervention, taking into account the quality of the underpinning evidence. For some interventions, the Guideline Development Group is confident that, given the information it has looked at, most patients would choose the intervention. The wording used in the recommendations in this guideline denotes the certainty with which the recommendation is made (the strength of the recommendation).

For all recommendations, NICE expects that there is discussion with the patient about the risks and benefits of the interventions, and their values and preferences. This discussion aims to help them to reach a fully informed decision (see also Patient-centred care).

Interventions that must (or must not) be used

We usually use 'must' or 'must not' only if there is a legal duty to apply the recommendation. Occasionally we use 'must' (or 'must not') if the consequences of not following the recommendation could be extremely serious or potentially life threatening.

Interventions that should (or should not) be used – a 'strong' recommendation

We use 'offer' (and similar words such as 'refer' or 'advise') when we are confident that, for the vast majority of patients, an intervention will do more good than harm, and be cost effective. We use similar forms of words (for example, 'Do not offer…') when we are confident that an intervention will not be of benefit for most patients.

Interventions that could be used

We use 'consider' when we are confident that an intervention will do more good than harm for most patients, and be cost effective, but other options may be similarly cost effective. The choice of intervention, and whether or not to have the intervention at all, is more likely to depend on the patient's values and preferences than for a strong recommendation, and so the healthcare professional should spend more time considering and discussing the options with the patient.

Recommendation wording in guideline updates

NICE began using this approach to denote the strength of recommendations in guidelines that started development after publication of the 2009 version of 'The guidelines manual' (January 2009). This does not apply to any recommendations ending [2008] (see Update information above for details about how recommendations are labelled). In particular, for recommendations labelled [2008] the word 'consider' may not necessarily be used to denote the strength of the recommendation.

Other versions of this guideline

The full guideline, Osteoarthritis: care and management in adults, contains details of the methods and evidence used to develop the guideline. It is published by the National Clinical Guideline Centre.

The recommendations from this guideline have been incorporated into a NICE Pathway.

We have produced information for the public about this guideline.

Implementation

Implementation tools and resources to help you put the guideline into practice are also available.

Your responsibility

This guidance represents the view of NICE, which was arrived at after careful consideration of the evidence available. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. However, the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, and informed by the summaries of product characteristics of any drugs.

Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Copyright

© National Institute for Health and Care Excellence 2014. All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE.

ISBN: 978-1-4731-0426-6

  • National Institute for Health and Care Excellence (NICE)