Communication Skills: Explaining Osteoarthritis

Osteoarthritis is a common chronic disease that is seen by General Practitioners. It is a good exam station as it tests candidates ability to explain diseases and management, alongside their ability to have insight into each patient's particular needs. For example, a sports player or patient with a physical job will have different concerns to a older patient with multiple co morbidities. Remember "Ideas, Concerns and Expectations"!

Possible OSCE scenario: "A 68 year old patient has been visiting her GP with regards to painful knees, particularly at the end of the day. Examination has previously been normal. She has come to see you regarding her investigation results. Blood test results including rheumatoid factor are normal. X-rays of the knee joints show signs consistent with early osteoarthritis.

Please discuss the diagnosis with her and answer any questions she may have."

• Wash your hands
• Introduce yourself
• Ask patient's name
• Ask permission to discuss her results with her
• Ask patient what they know about the condition first, then you can offer them further knowledge to fill the gaps. An example of what to say is shown below.

• Osteoarthritis is a disease of the joints caused by 'wear and tear' of the joints. This leads to pain and stiffness
• It usually occurs in the bigger, weight bearing joints such as the hips and knees. However, it can occur in any joint
• Generally symptoms worsen with use of the joint, I.e.: at the end of the day or after exercise
• It is a very common condition.

• It is thought to be caused by 'wear and tear' of the joint
• There may be a family history of osteoarthritis
• You may be predisposed if you have one of the following risk factors
  • Older
  • Obese
  • Female sex
  • Certain occupations e.g.: footballers
  • It may also occur in a previously damaged joint.

• There are multiple ways we can diagnose this condition.
  • From history and examination
  • From routine blood tests
    • Rheumatoid factor and anti CCP (would be normal)
    • ESR/CRP (would be normal)
  • From X-rays. (For the exam, the classic radiographic findings of osteoarthritis are: narrowing of the joint space, osteophyte formation, subchondral cysts and subchondral sclerosis)

• There are many different ways of treating osteoarthritis
• First and foremost, it is important that you understand the condition and how it might affect you, so that you can tell us how you need support
  • There are charities and organisations available for you to speak to about, such as "Arthritis Care". I will give you a few leaflets at the end of our meeting
  • We should also see you regularly to see how you are getting on, and we can explore different options to try to minimise your symptoms
• There are many lifestyle changes you can make to improve your symptoms. Examples include:
  • Exercise
  • Weight loss – you may want to consider joining a weight loss programme
  • Healthy eating
  • Stopping smoking
• Physiotherapy
  • I can refer you for this
• Aids
  • Splints
  • Walking sticks
  • For more severe limitations to your function at home, we can refer you to an Occupational Therapist who can help adapt your way of living.
• Medication
  • Simple pain relief such as Paracetamol and anti inflammatory local preparations (though any anti-inflammatories carry risks to the digestive tract and renal function)
  • Stronger pain relief if required (opioid agents carry side effects, but are needed in some cases, including long term forms of administration such as analgesia patches)
  • Intra-articular steroid injections (require special training to carry out, and usually have a limit of 3 or less per year per joint)
• Surgical options
  • Explain that this is an option that can be explored if simple measures don't work. It might be worth explaining that joint replacement has risks and only lasts for a certain period of time, so trying out medical options first is the normal practice
  • For specific symptoms (e.g. 'locking' or 'giving-way'), it might be worth undergoing arthroscopy and a joint wash out, and a referral to an orthopaedic surgeon can be made.

• This is a very difficult question to answer
• The severity of the disease depends on the person – some suffer to a higher degree than others with osteoarthritis
• Without treatment, movement can become quite limited in the affected joint. However, with treatment and support, we can help to minimise the impact that it has on your enjoyment of life.

• Ask the patient to briefly explain to you what they have understood, and clarify any uncertainties that they have
• Ask the patient if they have any specific concerns about this diagnosis. What impact will this have on their day-to-day activity (ICE!)
• Discuss with the patient which course of action they would like to take in the first instance
• Thank the patient
• Offer leaflets and provide follow up

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