ann rheum dis 2001

8/9/2019 Ann Rheum Dis 2001

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Ann Rheum Dis 2001;60:91-97 doi:10.1136/ard.60.2.91

• Review

Knee pain and osteoarthritis in olderadults: a review of community burden and

current use of primary health care

1. G Peat,

2. R McCarney,

3. P Croft

+ Author Affiliations

1. Primary Care Sienes Researh Cen!re" #ee$e %ni&ersi!y" %#

1. Dr G Peat, Primary Care ciences Research Centre, chool of Post!ra"uate Me"icine,

#eele $niversity, %he Me"ical &nstitute, 'artshill Roa", to(e)on)%rent %* -,

$# !.m.eat/hfac.(eele.ac.u(

• Accete" 20 uly 2

Abstract

BACKGROUN steoarthritis is the sin!le most common cause of "isa4ility in ol"er

a"ults, an" most atients with the con"ition will 4e mana!e" in the community an" rimary

care.

A!" %o "iscuss case "efinition of (nee osteoarthritis for rimary care an" to summarise the

4ur"en of the con"ition in the community an" relate" use of rimary health care in the $nite"

#in!"om.

#$!GN arrative review.

"#%&O A literature search i"entifie" stu"ies of inci"ence an" revalence of (nee ain,

"isa4ility, an" ra"io!rahic osteoarthritis in the !eneral oulation, an" "ata relate" to

rimary care consultations. 5in"in!s from $# stu"ies were summarise" with reference to

6uroean an" international stu"ies.

R#$U'%$ Durin! a one year erio" 207 of eole over 00 years have a ersistent eiso"e

of (nee ain, of whom a4out one in si8 in the $# an" the etherlan"s consult their !eneral

ractitioner a4out it in the same time erio". %he revalence of ainful "isa4lin! (nee

osteoarthritis in eole over 00 years is 17, of whom one 9uarter are severely "isa4le".

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CONC'U$!ON #nee osteoarthritis sufficiently severe to consi"er :oint relacement

reresents a minority of all (nee ain an" "isa4ility suffere" 4y ol"er eole. 'ealthcare

rovision in rimary care nee"s to focus on this 4roa"er !rou to imact on community levels

of ain an" "isa4ility.

Poulation healthcare nee" has 4een "efine" as ;the oulation the occurrence rate of a health

ro4lem an", in the conte8t of current service rovision, the effectiveness an" cost

effectiveness of availa4le interventions. 5or many common ro4lems, nee"s assessments

which focus only on the nee" for secon"ary care will i!nore the ma:ority of eole with the

con"ition in 9uestion. uch assessments nee" to em4race ro4lems as they resent in rimary

care an" the health care availa4le in that settin!.

steoarthritis reresents a articularly stron! ar!ument for a rimary care ersective on

nee"s assessment. &t is the secon" most common "ia!nosis ma"e in ol"er eole consultin!

their !eneral ractitioner,2 an" the commonest cause of "isa4ility at ol"er a!es.3

5urthermore, ?ane an" %homson, in an evi"ence 4ase" review, have i"entifie" a ran!e of rimary care interventions @4oth harmacolo!ical an" non)harmacolo!ical which have

some evi"ence of effectiveness for atients with osteoarthritis.

%his aer is concerne" with (nee osteoarthritis an" its o4:ective is to consi"er three other

areas re9uire" to comlete a $nite" #in!"om rimary care health nee"s assessment> "efinin!

the con"ition for rimary care, its revalence in the !eneral oulation @community 4ur"en,

an" the roortion with the con"ition who mi!ht currently resent to rimary care @use of

health care. %he 4ur"en reresents the total ool of otential nee" for health care, whereas

the attern of healthcare use reflects current "eman" for that health care.

%hrou!hout the aer we have en"eavoure" to summarise results from stu"ies con"ucte" in

the $nite" #in!"om an" to contrast these with estimates from similar 6uroean an"

international stu"ies.

Be consi"er first how to "efine the ro4lem at a community an" rimary care level.

efinin( osteoarthritis: pain) disability) or radio(raphy*

steoarthritis of the (nee is an active "isease rocess involvin! cartila!e "estruction,

su4chon"ral 4one thic(enin!, an" new 4one formation. Ra"io!rahic aearance has

tra"itionally 4een the cornerstone of "ia!nosis 4ecause the effects of the atholo!ical rocesses can 4e i"entifie" as features on the 'ray> :oint sace narrowin!, su4chon"ral

sclerosis, an" osteohyte formation. %he ra"io!rahic chan!es can 4e classifie" accor"in! to

their location within the :oint @the two ti4iofemoral :oint comartments an" the

atellofemoral :oint an" their severity.

$ to a thir" of ol"er a"ults in the !eneral oulation show ra"iolo!ical evi"ence of (nee

osteoarthritis an" this is stron!ly a!e relate".0) %wo fin"in!s from oulation surveys,

however, illustrate why a "istinction must 4e ma"e 4etween the ra"io!rahic an" the clinical

syn"romes. 5irstly, 07 of su4:ects in the !eneral oulation with ra"io!rahic (nee

osteoarthritis "o not have ain. econ"ly, 07 of su4:ects who comlain of (nee ain, an"

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who are at or a4ove the a!e when osteoarthritis starts to 4ecome common @a4out 00 years,

have no "efinite ra"io!rahic evi"ence of osteoarthritis.1

%he choice 4etween ra"io!rahic an" clinical case "efinitions will "een" on how they are to

4e alie". &nvesti!ations of the causes of osteoarthritis can focus on ra"io!rahic criteria,

re!ar"less of symtoms. %he un"erlyin! assumtion is that if the atholo!ical rocess which!ives rise to the ' ray chan!es coul" 4e averte" or slowe" "own this woul" 4e one means of

reventin! ain an" "isa4ility. y contrast, any attemt to assess nee"s an" otions for health

care in atients with esta4lishe" ra"io!rahic (nee osteoarthritis must focus on the associate"

symtoms an" "isa4ility. Gui"elines u4lishe" 4y the American Colle!e of Rheumatolo!y

rovi"e for the classification of osteoarthritis as a clinical syn"rome in ol"er a"ults who

resent with (nee ain, mornin! stiffness, an" :oint creitus.11 12 Althou!h its shortcomin!s

are reco!nise",13 this classification of (nee osteoarthritis ro4a4ly reflects accete" clinical

ractice,1 4ut at resent there is no evi"ence on how the la4el of osteoarthritis is actually

assi!ne" in ractice. &n a Cana"ian stu"y 207 of atients 4ein! mana!e" as (nee

osteoarthritis ha" normal ra"io!rahs.10 Prosective cohort "ata su!!est that ra"io!rahic

chan!e may not 4e stron!ly relate" to clinical outcome,1E an" current rimary care!ui"elines re!ar" ' rays as non)essential for "ia!nosis an" mana!ement.1* Pain an" "isa4ility

are the main resentin! features an" the tar!ets of rimary care mana!ement.

An estimate of the oulation 4ur"en of (nee osteoarthritis in ol"er a"ults mi!ht then

reasona4ly ta(e as its startin! oint the resentin! symtom of ;(nee ain=. Dia!nosis is

hele" 4y a!e !rouin!. elow the a!e of 00, there are more common causes of (nee ain

than osteoarthritisFnota4ly, in:uries to cartila!e, li!aments, an" soft tissue structures aroun"

the :oint. uch in:uries may re"isose to later osteoarthritis an" 4e relevant to the rimary

revention of (nee osteoarthritis. A4ove the a!e of 00, ra"io!rahic (nee osteoarthritis is an

increasin!ly common cause of (nee ain.1 1

5rom this startin! oint, this aer consi"ers two 9uestions re!ar"in! a oulation 4ase"

assessment of the 4ur"en of (nee osteoarthritis an" relate" use of rimary health care. 5irstly,

how common is (nee ain an" associate" "isa4ility in ol"er a"ults livin! in the community,

an" what roortion can 4e e8ecte" to have ra"io!rahic evi"ence of osteoarthritisH

econ"ly, what is the associate" revalence an" inci"ence of rimary care consultationsH

+revalence and incidence of ,nee pain) disability) and

radio(raphic osteoarthritis in re(istered practice

populations

$#ARC& $%RA%#G-

A Me"line search was con"ucte" to i"entify ori!inal stu"ies reortin! estimates of oulation

revalence an"Ior inci"ence of (nee ain an" (nee osteoarthritis in ol"er atients @erio">

1EEJK lan!ua!e> 6n!lish. %he !ives the search strate!y an" (eywor"s.

everal hi!h 9uality surveys of the occurrence of (nee ain an" osteoarthritis con"ucte" in

$nite" #in!"om oulations were i"entifie". Be have chosen to summarise these fin"in!s

an" to use estimates from other 6uroean an" international stu"ies for comarison. &n

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reviewin! evi"ence on consultations for (nee ain an" osteoarthritis, !reater consi"eration

was !iven to 6uroean an" orth American stu"ies 4ecause of relatively sarse $# "ata.

+R#.A'#NC# O/ KN## +A!N

Althou!h most !eneral ain surveys in the oulation have not searately consi"ere" (nee ain or clearly "efine" it, a num4er of stu"ies in the $nite" #in!"om have estimate" the

revalence of (nee ain in ol"er a"ults. %a4le 1 shows the fin"in!s from these surveys.

Liew this ta4le>

• &n this win"ow

• &n a new win"ow

%a4le 1

Prevalence of (nee ain in ol"er a"ults

%wo surveys secifically concernin! (nee ain in ol"er a"ults, con"ucte" in ristol1 an"

ottin!ham,2 4oth estimate" an annual revalence of 207 for (nee ain in ol"er a"ults.

%his is consistent with a more recent survey of musculos(eletal "isor"ers in %amesi"e,

Greater Manchester, which foun" a revalence of (nee ain that laste" for at least a wee( in

the revious month of 4etween 217 an" 307 in men an" women a!e" 0 or over.21%wo

other $# stu"iesFfrom Chin!for" an" Cal"er"ale22 Fto!ether with surveys con"ucte" in

the $nite" tates0 23 2 an" the etherlan"s,* have ten"e" to yiel" lower estimates of the

revalence of (nee ain in ol"er a"ults. Lariation in case "efinitions, the comosition of stu"y!rous, whether the metho" was ostal or interview, an" the inclusion of 9uestions a4out

other ain sites may e8lain these "ifferences.20

Bhen allowance is ma"e for variations in "efinition, (nee ain in ol"er a"ults is common the

worl" over. &n one oulation 4ase" survey of Chinese su4:ects a!e" * an" over, the (nee

was the most commonly reorte" site of ain comlaints,2E suortin! similar o4servations

in 6uroean countries.21 22 2* %he revalence of (nee ain increases universally with a!e,

thou!h a!e tren"s are clearer in women than men.

+R#.A'#NC# O/ KN## +A!N 0!%& RA!OGRA+&!C

O$%#OAR%&R!%!$

%he ristol an" ottin!ham stu"ies1 2 e8amine" the revalence of ra"io!rahic

osteoarthritis in ol"er a"ults with (nee ain @ta4le 2.

Liew this ta4le>

• &n this win"ow

• &n a new win"ow

%a4le 2

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Prevalence of symtomatic ra"io!rahic (nee osteoarthritis in ol"er a"ults

6stimates of 07 to 107 have 4een reorte" in surveys un"erta(en in other countries.* 2

2 2 %he hi!hest estimate has 4een an American survey of a rural oulation, which foun" a

revalence of 37 for "efinite ra"io!rahic (nee osteoarthritis.3un an" collea!ues, in a

wi"e ran!in! review of oulation revalence stu"ies in the literature, hi!hli!hte" the imactof variations in stu"y "esi!n, stu"y !rou, an" case "efinition on these estimates.31

Most of the variation is attri4uta4le to "ifferences in estimatin! the total revalence of ain

rather than in the roortion of this !rou who "emonstrate ra"io!rahic chan!es. Bhen the

a!e relate" influence on revalence is ta(en into account, the fi!ures for symtomatic

ra"io!rahic osteoarthritis are remar(a4ly consistent across "ifferent stu"ies.

Bith the e8cetion of the Cal"er"ale stu"y, revalence estimates of (nee ain from $#

surveys are unli(ely to inclu"e cases of transient eiso"es of ain that woul" imly minimal

or no nee" for rimary health care. evertheless, (nee ain of lon!er "uration, even when

accomanie" 4y ra"io!rahic features of osteoarthritis, is not always associate" withsi!nificant imact uon eole


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?e9uesne in"e8 of severity "eveloe" for (nee osteoarthritis. %he revalence of ain an"

"isa4ility scorin! 1 oints or more on the ?e9uesne in"e8 @e8tremely severe (nee ain an"

"isa4ility33 was 1.37 at a!e 00JE years, 1.E7 at E0J* years, an" 3.07 at *0 an" over.

ver E0 years, the revalence of such severe ro4lems was twice as common in women as in

men.

+R#.A'#NC# O/ KN## +A!N AN !$AB!'!%- 0!%&

RA!OGRA+&!C O$%#OAR%&R!%!$

Clinicians foun" the north of 6n!lan" stu"y controversial 4ecause it e8traolate" from self

reorte" (nee ain an" "isa4ility to estimates of the nee" for (nee relacement sur!ery.32

%he controversy lay in the fact that no clinical or ra"iolo!ical assessment was carrie" out.

%he ristol stu"y1 1 use" a "ifferent "isa4ility measure @the 'ealth Assessment

uestionnaire @'A. $nli(e the ?e9uesne instrument emloye" in the north of 6n!lan"

stu"y, the 'A is not (nee)secific, 4ut the ristol stu"y was a4le to rovi"e an estimate of

;(nee ain associate" with "isa4ility in "aily livin! an" with ra"io!rahic chan!e=> 12.07 of

a"ults a!e" over 00 ha" (nee ain an" any "e!ree of "isa4ility, *.07 ha" 'ray chan!es of

osteoarthritis in the (nee as well @ta4le.

Liew this ta4le>

• &n this win"ow

• &n a new win"ow

%a4le

Prevalence of (nee ain an" "isa4ility with ra"io!rahic osteoarthritis in ol"er a"ults, $nite"

#in!"om

&f an 'A cut off score of two or more is use" to "efine severe "isa4ility, the ristol

estimates are remar(a4ly similar to fi!ures "erive" from the north of 6n!lan" stu"y. %his is

li(ely to reflect the stron! association of ra"io!rahic chan!e with a!e an" with "isa4ility, so

that the su4!rou of ol"er eole with (nee ain who reort severe "isa4ility are hi!hly li(ely

to have ra"io!rahic osteoarthritis as well. %he imortance of this is that cru"e estimates of

the revalence of severe (nee osteoarthritis can 4e 4ase" on self reorte" ain an" "isa4ility

alone.

% +R#.A'#NC# $%A!RCA$#

%he estimates from the rece"in! sections can 4e use" to construct a staircase summarisin!

the e8ecte" revalence of (nee ain an" "isa4ility in a oulation of ol"er a"ults an" the

roortion within each level with ra"io!rahic features of osteoarthritis @fi!1.

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Liew lar!er version>

• &n a new win"ow

• Downloa" as PowerPoint li"e

5i!ure 1

%he revalence staircase. ha"in! reresents the roortion in each cate!ory withra"io!rahic evi"ence of (nee osteoarthritis. N%he roortion with ra"io!rahic evi"ence in

this cate!ory is not (nown, thou!h seems li(ely to 4e hi!h.

%he cate!ories in the staircase are inclusive. An a""itional searate su4cate!ory is the

estimate" 12 eole with ra"io!rahic osteoarthritis 4ut no ain.

!NC!#NC# O/ KN## O$%#OAR%&R!%!$

&n the Chin!for" tu"y, aro8imately 137 of women a!e" 4etween 0 an" E0 "eveloe"

inci"ent ra"io!rahic evi"ence of (nee osteoarthritis over a four year follow u.3 %he

5ramin!ham tu"y of an ol"er samle of men an" women, followe" u over ei!ht years,foun" 10.E7 "eveloe" inci"ent ra"io!rahic osteoarthritis.1 either of these stu"ies

reorte" levels of ain or "isa4ility, thou!h another analysis of the 5ramin!ham "ata

su!!este" that fewer than one in four cases of inci"ent ra"io!rahic osteoarthritis was

associate" with symtoms.30

Cumulative annual inci"ence coul" rovi"e a useful estimate of the li(ely a""itional 4ur"en

in the future. %his assumes that the healthcare nee"s of eole with current revalent (nee

ain an" osteoarthritis are met an" that rimary healthcare nee"s associate" with inci"ent

cases are similar to revalent cases. 'owever, "eman" for health care may more reasona4ly

4e 4ase" on the rate at which cases manifest as resentations to the health services. %his will

4e consi"ere" in the followin! section.

$U""AR- O/ CO""UN!%- BUR#N

• A4out one 9uarter of eole over the a!e of 00 will reort a si!nificant eiso"e of

(nee ain in the ast year. Aro8imately half of these reort some associate"

"isa4ility.

• Painful, severely "isa4lin! ra"io!rahic (nee osteoarthritis affects a4out 1.07 of

a"ults over the a!e of 00. %his roortion is hi!her in the ol"er a!e cate!ories. Painful

(nee osteoarthritis associate" with mil" to mo"erate "isa4ility affects u to 17 ofa"ults a!e" over 00.

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+rimary care consultations for symptomatic ,nee

osteoarthritis

$#ARC& $%RA%#G-

%he strate!y "escri4e" earlier was e8ten"e" to inclu"e rimary care consultations an" referral

rates. fficial statistics from the $nite" #in!"om were also use".2

+R#.A'#NC# O/ +R!"AR- CAR# CON$U'%A%!ON$

;Prevalence= in relation to consultations with rimary care rofessionals is ta(en here to

mean ;the roortion of the re!istere" ractice oulation who consult at least once for a

con"ition such as (nee osteoarthritis "urin! a secifie" erio" of o4servation=. %his contrasts

with inci"ence, which is "ealt with in a later section, an" which is ta(en here to refer to ;the

fre9uency of first ever consultation for that con"ition=.

5rom $# fi!ures, 17 of re!istere" E0J* year ol"s consult their "octor a4out osteoarthritis

in the course of one year, half of them with chronic ro4lems.2 %his fi!ure rises to 17 of

over 0 year ol"s, 4ut is lower 4elow E0 years. %he (nee is not i"entifie" searately in these

fi!ures, an" such "ata refer to ;osteoarthritis as "ia!nose" 4y the !eneral ractitioner=, which

is li(ely to 4e a mi8ture of ;ain thou!ht to 4e osteoarthritis= an" ra"io!rahically confirme"

osteoarthritis.

A rosective case review 4y the Primary Care Rheumatolo!y ociety, a networ( of $#

!eneral ractitioners with a secific interest in musculos(eletal ro4lems, foun" that 7 of

su4:ects consultin! their !eneral ractitioners a4out osteoarthritis ha" ro4lems with the (nee@Dic(son , ersonal communication. Bhen this fi!ure is alie" to the "ata a4ove, the

estimate is that 7 of the ol"er oulation consult their !eneral ractitioners at least once in

the course of a year 4ecause of (nee osteoarthritis, of whom half @27 of the ol"er oulation

are consultin! for the first time or with an acute flare u of the ro4lem.

Parallel fi!ures from a oulation samle come from the Rotter"am tu"y of "isa4ility in

eole ol"er than 00 years, which use" ra"io!rahs, symtoms, an" self reorte"

consultations in a ran"om oulation samle.3E %he roortion of this ol"er community

samle who reorte" current ain in the hi or (nee for which they ha" consulte" their

!eneral ractitioner an" which ha" 4een !iven a la4el of ;arthritis, rheumatism, wear an" tear,

or a!in!= was 107, with :ust un"er half @E.27 of the whole samle havin! ' ray evi"ence of(nee osteoarthritis as well.

&n the north of 6n!lan" oulation stu"y,32 most of those i"entifie" as havin! severe ain

an" "isa4ility @7 of a"ults over 00 years reorte" that they ha" seen their !eneral

ractitioner within the revious year an" 4een tol" at some time that they ha" arthritis. %hese

fi!ures are comati4le with the estimate of .7 of the Dutch oulation who consult their

!eneral ractitioner a4out (nee ain each yearFa fi!ure 4ase" on !eneral ractice recor"s

rather than atient recall.3* ecific fi!ures on rimary care are not availa4le from America,

4ut of the E million atient visits to "octors in that country each year that are attri4ute" to

osteoarthritis, (nee osteoarthritis is the most common resentation.3

!NC!#NC# O/ +R!"AR- CAR# CON$U'%A%!ON$

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5i!ures from a rosective case review of !eneral ractitioner consultations estimate" that

aro8imately half of atients consultin! for (nee osteoarthritis were consultin! for the first

time or with an acute flare u of the ro4lemF27 of the ol"er oulation @Dic(son ,

ersonal communication. A stu"y of a health maintenance or!anisation oulation in

America su!!este" an overall annual inci"ence of 2. er 1 re!istere" oulation for first

consultation with "efinite ra"io!rahic (nee osteoarthritis an" accomanyin! ain, risin! to1 er 1 in women a!e" *J.3 &n a one year rosective stu"y of hysician visits in

rural 5inlan" the inci"ence of confirme" symtomatic (nee osteoarthritis was E er 1.

&n a oulation 4ase" cohort from Rochester, $A, the inci"ence of new consultations with

hosital 4ase" hysicians in EJ* year ol"s for symtomatic ra"io!rahic (nee osteoarthritis

was 1 er 1 er year .1 %his latter fi!ure reresents a mi8 of what in the $# an" the

etherlan"s woul" 4e rimary care @initial contact an" secon"ary care @secialist contact.

'owever, if it is assume" that all these fi!ures reresent confirme" ra"io!rahic osteoarthritis

an" first ever resentations, then they are consistent with estimates from ritain.

% +R!"AR- CAR# CON$U'%A%!ON $%A!RCA$#

Across 6uroe, consultation fi!ures will vary with the referral system, 4ecause in some

countries secialists will, as in the $A, 4e accesse" "irectly rather than throu!h the family

ractitioner. 'owever, if it is assume" that the total fi!ures for those see(in! health care for

symtomatic (nee osteoarthritis "o not vary !reatly across "ifferent countries, a very cru"e

estimate woul" 4e that 1.07 of the el"erly oulation over 00 years @roortionately more in

those over *0 years consult with severely ainful an" "isa4lin! osteoarthritis of the (nee in

the course of any one year, 1.07 consult with less "isa4lin! chronic (nee ain, an" 1.7

consult their rimary care ractitioner with (nee symtoms for the first time @fi!2.

Liew lar!er version>

• &n a new win"ow

• Downloa" as PowerPoint li"e

5i!ure 2

%he consultation revalence staircase.

$U""AR- O/ +R!"AR- CAR# CON$U'%A%!ON$

• Amon! a"ults over 00 years, one in si8 eole with (nee ain consult their "octor in

the course of one year. Aroun" one thir" of these have severe ain an" "isa4ility.

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• %he annual inci"ence of consultations for symtomatic (nee osteoarthritis is estimate"

to 4e .07 overall of those over 00 years, risin! to 17 in those over * years.

Conclusion

%he review has 4rou!ht to!ether u4lishe" oulation revalence estimates of ain,

"isa4ility, an" ra"io!rahic chan!es in ol"er a"ults with (nee ain, to rovi"e a 4asic

"escrition of the otential 4ur"en of (nee osteoarthritis in the community. ecause most

stu"ies "o not e8amine all three asects to!ether, the estimates that we have !enerate" from a

review of availa4le hi!h 9uality stu"ies remain relatively cru"e. &n a""ition, we consi"ere"

the current use of health care in relation to this 4ur"en, conclu"in! that severely "isa4lin!

(nee ain reresents a minority of all (nee ain resentin! to rimary health care in any one

year. Given the ran!e of otentially effective rimary care treatments availa4le for sufferers,

it is imortant that the focus of rimary care for osteoarthritis shoul" not 4e limite" to those

with ra"io!rahic "isease or to those with severely "isa4lin! symtoms who are can"i"ates

for :oint relacement.2

Much "isa4lin! (nee ain in ol"er atients in rimary care may not reresent

ra"io!rahically "efine" osteoarthritis. 'owever, non)sur!ical treatments are li(ely to e8ert

their effects on ain an" "isa4ility re!ar"less of the resence of ra"io!rahic chan!es an" so

it can 4e ar!ue" that a ra"io!rahic "ia!nosis of osteoarthritis is not re9uire" in or"er to start

treatment in new consulters. 'owever, there is an a4sence of emirical evi"ence a4out this.

%he concor"ance 4etween clinical an" ra"io!rahic fin"in!s may eventually imrove 4ecause

of "eveloments in ima!in!, such as the systematic inclusion of the atellofemoral :oint in

!ra"in! systems.3 &n the meantime it seems reasona4le to consi"er the 4asic case

"efinition in relation to the nee" an" "eman" for rimary health care as 4ein! one of (nee

:oint ain an" "isa4ility in ol"er eole.

%here are some issues for future research. 5irstly, it is imortant to esta4lish whether those

eole with (nee ain who "o not consult in any one year @the ma:ority have si!nificant

nee"s which health care coul" meet effectively. econ"ly, the effectiveness of rimary care

treatments nee"s to 4e esta4lishe" as :u"!e" 4y their lon! term imact in re"ucin! the

community 4ur"en of ain an" "isa4ility an" the nee" for sur!ery. %his is articularly

imortant !iven li(ely future rise in "eman" for :oint relacement.0 %hir"ly, clear criteria

for referral to secon"ary care nee" to 4e teste" for effectiveness in rimary care.

Be have resente" ;staircase= fi!ures to illustrate the 4ur"en of clinical an" ra"io!rahic

osteoarthritis in the community an" current use of rimary care. uch estimates, to!ether with

effectiveness stu"ies, can form the 4asis for assessin! the nee" an" "eman" for rimary

health care for this con"ition. 'owever, such estimates nee" to 4e a"ate" for "ifferent

healthcare systems an" to chan!in! or more "etaile" evi"ence of the short an" lon! term

effectiveness of rimary care treatments.

Ac,nowled(ments

%his review was suorte" in art 4y an e"ucational !rant from ohnson an" ohnson, as art

of the Renovare initiative. Be than( Professor Paul Diee an" Professor tefan ?ohman"er

for their helful comments.

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11/25

"edline search strate(y

1

(nee.ti or (nee.a4

2

osteoarthritis.ti or osteoarthritis.a4

3

A.ti or A.a4

osteoarthrosis.ti or osteoarthrosis.a4

0

!onarthrosis.ti or !onarthrosis.a4

E

"isa4ility.ti or "isa4ility.a4

*

ain.ti or ain.a4

2 or 3 or or 0 or E or *

an" 1

1

outcome.ti or outcome.a4

11

ei"emiolo!y.ti or ei"emiolo!y.a4

12

rimary care.ti or rimary care.a4

13family ractice.ti or family ractice.a4

1

!eneral ractice.ti or !eneral ractice.a4

10

oulation.ti or oulation.a4

1E

inci"ence.ti or inci"ence.a4

1*

consultation.ti or consultation.a4

1

revalence.ti or revalence.a41

1 or 11 or 12 or 13 or 1 or 10 or 1E or 1* or 1

2

1 an"

References

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1. tevens A,

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12/25

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16/25

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ann rheum dis 2001

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