Osteoarthritis–there’s always something that can be done

Reproduced from Issue 135 of Arthritis Today

Jane Tadman looks at new initiatives to help osteoarthritis patients and (opposite) visits an aspiring Clinical and Assessment Treatment Service (CATS) in Bradford.

Osteoarthritis is a by far the most common type of arthritis, affecting at least two million older people in the UK. As the population ages and becomes more obese, that number will rise.

Thirty per cent of visits to the GP are due to arthritis and musculoskeletal conditions. But despite this, many family doctors are unable to deal very effectively with many types of osteoarthritis, back pain and other related degenerative joint problems.

One of the reasons is because they are not adequately taught to deal with arthritis whilst at medical school, and during their GP training. Another reason is the common perception - or misconception - that little or nothing can be done for these patients other than painkilling drugs and joint replacement.

But while it’s true that there are still no drugs available that prevent or slow down the progression of osteoarthritis, there are, as Arthritis Today readers will be aware, many things that can be done to alleviate the pain of osteoarthritis; from physiotherapy and exercise to types of self-management.

In recent years arc has taken on a number of important projects to try and tackle and improve the way patients with arthritis are treated. It produces and updates learning guides, electronic training packages and materials for medical students and for trainee GPs. It has set up fellowships and lectureships and career pathways for GPs and allied health professionals such as nurses, physiotherapists and podiatrists, and hopes to develop a new national training scheme for GPs who want to improve their knowledge and expertise in the treatment of arthritis.

The charity has thrown its weight enthusiastically behind the concept of GPs with a special interest (GPwSIs); GPs who are interested in a particular medical specialty and want to develop more skills and expertise. Already GPwSIs in musculoskeletal conditions are springing up around the country, playing important roles within general practice.

CATS clinics

Another scheme being promoted by the Department of Health that could make a big difference to the way that osteoarthritis patients are treated is a new kind of clinic, a kind of half-way house at the interface between the GP surgery and hospital. These clinics have a variety of names, but the DoH calls them CATS or Clinical Assessment Treatment Services. A typical CATS would be staffed by GPwSIs, extended scope physiotherapists and sometimes podiatrists and rheumatologists, and provides an assessment, diagnostic and advice service for patients with all types of arthritis, managing all referrals and making sure patients are then referred on, if necessary, to a rheumatologist or an orthopaedic surgeon.

There are already a handful of these clinics around the UK, but a new DoH document, the Musculoskeletal Services Framework, launched in October last year, wants to see all primary care trusts in the land take up the idea and set up CATS in their area within the next 12 months.

The original idea behind the new clinics was to cut the orthopaedic waiting lists, by triaging all orthopaedic referrals, and to stop patients being referred to hospitals whose needs could be better met elsewhere. The current aim is to ensure that patients wait no more than 18 weeks from being referred by their GP to the start of treatment by 2008.

How can you find out if you have CATS in your area?

Because CATS are very much local initiatives, there is no national register of clinics but they are scattered around the country in areas such as Kent, Southampton, Leeds, Bradford, Skipton and Stoke on Trent. Not all CATS will be exactly the same, and indeed, may be called Musculoskeletal Rehabilitation Centres, Orthopaedic Triage Clinics or Extended Scope Physiotherapy Clinics. Some may not deal with patients with inflammatory arthritis, who may be referred directly from the GP to a rheumatologist. The best way of finding out if there is one in your area is to ask your GP.

Having the time makes such a big difference

“Thanks doc. No-one has taken the time to explain that to me before.”

According to Dr Adrian Dunbar, a GP with a special interest in musculoskeletal conditions, and also someone with a keen interest in GP education, that’s the single most common piece of feedback from patients attending the CATS clinic at Eccleshill Community Hospital in Bradford. Another regular comment is: “Tell me what I can do to help myself.”

Dr Dunbar outlines the difference between how many GPs treat osteoarthritis, and how they are treated at Eccleshill, a typical CATS.

“We know from studies that the majority of GPs would give their patients painkillers and as their condition declined would up the strength. Then when they could no longer cope they would send them to the surgeon to have the joint removed. This is something we see in many referrals locally.

“The ideal referral from primary care would look like the following: ‘This patient has been diagnosed with osteoarthritis of the knee for five years. She has been to see a physiotherapist and had a rehabilitation programme including patella taping and quadriceps exercise, taken glucosamine at the appropriate dose (1,500mg), had a couple of steroid injections, and we have managed to keep her reasonably active for five years. She has had simple analgesia such as paracetamol and amitriptyline for night pain. The disease is progressing, her range of joint motion is declining, she has been having trouble getting about, and in dressing her lower half. And the time has come for a joint replacement.’

Dr Dunbar has worked at the Eccleshill CATS for the past three years and last summer became a GPwSI in MS conditions, having become disillusioned with general practice – “seeing huge numbers of people and doing relatively little for them.” He now divides his time between CATS in Bradford and Skipton, and also has an academic base at the University of Leeds.

One of the most valuable things that he can now give his patients is more time. Patients’ appointments last half an hour – an hour for complicated cases - rather than the average ten-minute consultation in general practice.

 “It’s very satisfying to spend half an hour with the patient, and do something they are really grateful for and that makes a difference,” he says. “It’s not highly skilled medicine, but you need high level communication skills. I am doing something that any GP could do – given the time and proper education.”

Two typical patients to attend the CATS during one session in early November were Patricia Ibbotson and Colin Smith. Both were in their mid 60s, with knee pain.

“Giving information is an important analgesic”

Although Mrs Ibbotson did have some pain, her main problem was stiffness and lack of mobility which made walking any distance very difficult. A keen walker, she was getting frustrated. The NSAID she was prescribed gave her stomach problems. After a lengthy chat and examination Dr Dunbar diagnosed patello femoral knee OA - in the joint behind the knee cap, which would not respond well to joint replacement surgery. He suggested a course of physiotherapy which would strengthen the quad muscle in the thigh, relieve some of the pain and give her more movement and made her another appointment for a month’s time.

Mr Smith walked into the consultation room with a pronounced limp. He was in considerable pain, which he hoped a knee replacement would reduce and make life bearable again. His quad muscles were found to be extremely weak, and again Dr Dunbar advised a course of physiotherapy to strengthen them, irrespective of whether he had surgery; Mr Smith was a definite contender for a half knee replacement, or unicompartmental knee. Both patients appeared satisfied with their consultation, and had the chance to talk at length about their symptoms and difficulties.

According to Rekha Biloo, the patient services co-ordinator at Eccleshill, most patients are very happy with the service they receive. Their most common gripe is at the length of time they have to wait for an initial appointment, which is currently around 11 weeks. However, if they are considered an emergency they will be seen more promptly. The most frequently seen complaints dealt with at Eccleshill are typical of most CATS – low back pain, osteoarthritis, and sports-type injuries such as meniscal tears.

Eccleshill CATS is based in a new building and is part of a community hospital which houses various medical specialties. With eight clinics a week run by three GPwSIs, two GP registrars, two senior physiotherapists, and orthopaedic surgeons visiting every couple of weeks, it serves the former North Bradford PCT area. It also has use of some private scanning facilities just next door so that patients have easy access to MRI, CT and ultrasound.

It was set up as a cost-saving exercise and because at that time the orthopaedic waiting list in Bradford was four years long. Despite some initial suspicion from local GPs and rheumatologists, it seems to have become accepted and now welcomed.

“GP colleagues now see what happens to their patients and the alternatives to drugs that they were not previously aware of, such as physiotherapy and exercise and that this can make a difference,” says Adrian Dunbar, who doesn’t prescribe drugs. “GPs prescribe drugs as part of the culture, and it will take a generation for that culture to change. It is changing with antibiotic prescribing and it will happen with NSAIDs.

“GPS prescribe drugs as part of the culture, and it will take a generation for that culture to change”

“Patients come to us expecting to be told they need a joint replacement but there are so many other things we can try first. We explain the nature of osteoarthritis, give them the arc leaflets, talk about using adequate levels of simple analgesia and glucosamine, the importance of maintaining strong muscles, patella taping, keeping their weight down, wearing shock absorbing footwear, and steroid and hyaluronic acid injections to relieve pain.

“It’s important to give the patient the natural history of their condition and advice on

How to manage it without writing a prescription. Most patients want to avoid drugs and surgery – something else we know from studies - unless it’s a last resort, and so do we. Giving information is an important analgesic.”

New electronic training package for new GPs

Rugby player Hall Charlton is pictured being filmed for a new arc project aimed at improving GP trainees’ knowledge of arthritis.

The Newcastle Falcons scrum half volunteered to be the model for a filmed examination by a group of Newcastle GPs, rheumatologists and orthopaedic surgeons, who are putting together a national guide to help family doctors treat arthritis more effectively, on behalf of arc.

A team led by Dr Elspeth Wise used Hall as the model for an examination of the shoulder which will be incorporated into a new electronic training package for newly qualified GPs. Filming took place at the audio visual department at Newcastle University medical school.

“As a professional sportsman Hall is very fit, but many rugby and football players can have musculoskeletal injuries during and after their playing career,” explained Dr Wise, who is a GP in Belmont, Durham, and an arc Educational Research fellow based in the musculoskeletal unit at the Freeman Hospital in Newcastle

Dr Wise is funded by arc to improve the knowledge of GP trainees, also called GP registrars, in common musculoskeletal conditions such as osteoarthritis, and other joint conditions.

Junior doctors who go into general practice currently spend three years on a vocational training scheme. Dr Wise’s four-year part-time fellowship aims to produce a learning package for GPs which could be taken up by training schemes across the country.

“GP registrars don’t get to see many people with musculoskeletal conditions in hospital where they train. Then suddenly they go into general practice and are expected to know how to manage the multitude of musculoskeletal problems that can present, for example, back pain, tennis elbow and frozen shoulder,” explained Dr  Wise. “We want to do something about that, in order to improve the way patients with these common conditions are treated.”

Other Articles in this Issue

• New Year, new medical director
• Starting young
• A winning combination?
• Focus on Aberdeen: research in the pipeline
• Spotlight on science