Hip Osteoarthritis Care Pathway

Oral or Topical Medications:

• Rationale: Alleviates pain.

• Advantages: Quick relief.

• Disadvantages: Mixed evidence on efficacy. Potential side effects and risk of dependency. Must consider patient’s comorbidities when making recommendations, particularly non-steroidal anti-inflammatory drugs (NSAIDs).

• Key Points: Techniques like mindfulness, meditation, CBT, counselling.

  • Referral Threshold: Includes over the counter (OTC) pain relievers, paracetamol, NSAIDs. Use judiciously and combine with other treatments. Should be considered as adjunct to core treatment strategies. If OTC/prescribed medication is out of practice scope for practitioners (e.g., chiropractors, physiotherapists) refer to the appropriate provider (e.g., medical physician, nurse practitioner, pharmacist).

 

Cognitive Behavioural Therapy (CBT):

• Rationale: Addresses emotional and cognitive aspects of pain.

• Advantages: Reduces psychological barriers to recovery.

• Disadvantages: Requires patient willingness to engage.

• Key Points: Referrals should be considered for patients showing significant disorders of thought, mood, or behavior, particularly when: symptoms are severe or persistent; there is no improvement in symptoms despite conservative management; functional impairment significantly impacts the patient’s daily activities and quality of life; there are signs of moderate to severe pathology based on Patient-Reported Outcome Measures (PROMs) thresholds (e.g., PHQ-9, GAD-7); management falls outside the scope of practice, such as the need for specialized psychotherapy or psychiatric intervention.

 

Heat Therapy:

• Rationale: Reduce pain.

• Advantages: Easy to use, cost-effective, and provides short-term pain relief.

• Disadvantages: Mixed evidence.

• Key Points: Prescribe based on individual needs and preferences.

 

Mobility Assistive Devices:

• Rationale: Maintains independence and reduces fall risk.

• Advantages: Increases safety and confidence.

• Disadvantages: Can be costly, may lead to dependency if not used appropriately.

• Key Points: Examples include canes, walkers, orthotic devices. Prescribe based on individual needs and preferences.

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Corticosteroid Injections:

• Rationale: May reduce inflammation and alleviate pain..

• Advantages: Provides targeted relief, can reduce the need for oral medications, and may help improve mobility and function.

• Disadvantages: Potential side effects such as headache, infection, bleeding, and, in rare cases, nerve damage. Relief may be temporary, and repeated injections may be required. Mixed evidence for benefits.

• Key Points: Used primarily for patients with moderate to severe pain not responding to conservative treatments. Should be considered as adjunct with core treatment strategies.

 

Treatments not supported by guidelines:

Needling Therapies:

• Rationale: May provide pain relief.

• Advantages: Patients may have unique preferences and experiences that drive a strong desire for this modality.

• Disadvantages: May cause discomfort. Most guidelines recommend against.

• Key Points: Educate patients on risk versus benefit. If patient desires modality, it should only be considered as supportive to guideline-supported interventions and not recommended on its own.

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Electrotherapies (e.g., TENS, IFC, laser):

• Rationale: May provide temporary relief.

• Advantages: Non-invasive. Patients may have unique preferences and experiences that drive a strong desire for this modality.

• Disadvantages: Skin irritation or burns. Most guidelines recommend against.

• Key Points: Educate patients on risk versus benefit. If patient desires modality, it should only be considered as supportive to guideline-supported interventions and not recommended on its own.

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Nutraceuticals:

• Rationale: May help reduce pain and improve joint health.

• Advantages: May reduce joint pain in the short-term. Patients may have unique preferences and experiences that drive a strong desire for a supplement.

• Disadvantages: Educate patients on risk versus benefit. If patient desires nutraceuticals, it should only be considered as supportive to guideline-supported interventions and not recommended on its own. Nutraceuticals include glucosamine, chondroitin, fish oil/omega 3, and vitamin D. Refer to the appropriate provider (e.g., medical physician, nurse practitioner, pharmacist) if additional management required.

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Opioids:

• Rationale: Alleviates pain.

• Advantages: Quick relief. Weak opioids (e.g., Tramadol) could be recommended in select patients.

• Disadvantages: No guidelines recommend opioids as a first-line option for pain relief. Strong opioids were recommended against by all guidelines. Potential side effects and risk of dependency.

• Key Points: Weak opioids could be considered as adjunct to guideline-supported care in select patients. If OTC/prescribed medication is out of practice scope for practitioners (e.g., chiropractors, physiotherapists) refer to the appropriate provider (e.g., medical physician, nurse practitioner, pharmacist).

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Other intra-articular injections (stem cell injection, platelet-rich plasma injection, hyaluronic acid):

• Rationale: Alleviates pain.

• Advantages: Provides targeted relief, can reduce the need for oral medications, and may help improve mobility and function. Patients may have unique preferences and experiences that drive a strong desire for these types of injections.

• Disadvantages: Guidelines recommend against the listed intra-articular injections. Potential side effects.

• Key Points: Educate patients on risk versus benefit. If patient desires one of these types of injections, it should only be considered as supportive to guideline-supported interventions and not recommended on its own. If OTC/prescribed medication is out of practice scope for practitioners (e.g., chiropractors, physiotherapists) refer to the appropriate provider (e.g., medical physician, nurse practitioner, pharmacist).

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Operative management (arthroscopy):

• Rationale: Alleviates pain and improves function.

• Advantages: Select patients may benefit from surgery if conservative care was not effective to improve their pain and function.

• Disadvantages: High-quality guidelines do not provide specific recommendations regarding operative management. Mixed evidence on effectiveness. Associated with risks.

• Key Points: Conservative guideline-supported care should be provided prior to surgical referral. If OTC/prescribed medication is out of practice scope for practitioners (e.g., chiropractors, physiotherapists) refer to the appropriate provider (e.g., medical physician, nurse practitioner, pharmacist).

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Examples

Example: Hip Osteoarthritis

 

Patient Presentation: A 69-year-old patient presents with right hip pain that began 4 months ago. The pain radiates into the anterior thigh, is aching and occasionally sharp, aggravated by walking and going up stairs, and immediately relieved with rest. The patient reports morning stiffness that lasts < 1 hour and does not report any red flags.

 

Core Interventions:

1. Education and Reassurance:

   • Frequency: Initial visit and reinforced in follow-up visits.

   • Action: Provide a clear explanation of the condition, expected course with treatment (may be 6-12 weeks), prognosis (e.g. management vs “cure”), and encourage the patient to stay active. Use visual aids or pamphlets for better understanding.

2. Address Yellow Flags (Psychosocial Factors):

   • Frequency: Regularly, integrated into each visit.

   • Action: Identify and address psychosocial factors such as fear of movement, depression, or anxiety. Use cognitive-behavioral strategies to modify negative beliefs about pain.

3. Exercise Therapy:

   • Frequency: 2-3 times per week for 6-8 weeks.

   • Dose: Include a combination of aerobic exercises and strengthening exercises. Sessions are supervised initially and then transitioned to a home-based program.

4. Weight loss/management:

   • Frequency: Daily.

   • Action: Educate on importance of weight management, tailor lifestyle strategies according to patient’s goals, set SMART goals. Recommend diet advice and appropriate physical activity. 

 

Optional Interventions:

1. Manual Therapy:

   • Frequency: 2-3 times per week for 6-8 weeks.

   • Protocol: Spinal manipulation/mobilization and soft tissue techniques to relieve pain and improve mobility. Adjust techniques based on the patient's response.

2. Oral or Topical Medications:

   • Frequency: As needed.

   • Dose: Over-the-counter NSAIDs or acetaminophen for pain relief, used judiciously and in combination with other treatments. Consider muscle relaxants if indicated.

3. Psychological Support:

   • Frequency: Weekly or as needed.

   • Protocol: Cognitive-behavioral therapy (CBT) to manage chronic pain and improve mental health.

Follow-Up:

• Regular follow-up at each visit, and every 2-4 weeks to reassess pain levels, functional status, goal achievement and adjust the treatment plan as necessary.