title sub title Pain, Pain, Go Away: Management Guidelines for Knee and Hip Osteoarthritis

EXPERT MONOGRAPH ISSUE 48

Introduction

Osteoarthritis (OA) is a common disabling condition that has significant implications for affected individuals, the healthcare system and society. It comprises up to 0.5% of the gross domestic product (GDP) of most developed

countries.1 The 2017-2018 National Health Survey showed that 2.2 million Australians of all ages (9.3% of the population) were currently burdened with OA2 and figures project an exponential increase to this in the coming years.3 General practitioners (GPs) are often the first point of contact for patients with this condition4 and 2.9 of every 100 GP encounters in 2015-2016 were related to OA.2

Despite a multitude of well-developed guidelines discussing the condition, studies show that management of OA often doesn’t correlate with these, resulting in patients receiving variable care for their condition.5 New guidelines have also been developed to match emerging research, marking a shift towards a primary care focus in the treatment of OA. These guidelines update the frequently-used

Take Home Messages ` Optimal management of osteoarthritis can lead to significant improvement in pain, function, and quality of life.

` Pain in osteoarthritis is best understood in the context of a biopsychosocial model.

` The therapeutic plan for OA should be individualised and patient-centred, based on a comprehensive assessment of the patient.

` Non-pharmacological and pharmacological inter-ventions should be combined and the patient’s co-morbidities and baseline physical function should be considered.

` Surgical intervention should only be considered when conservative management has been exhausted.

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This article discusses the modern guidelines concerning the management of osteoarthritis of the hip and knee.

MAY 22, 2020

PROF DAVID HUNTER MBBS, MSc, M SpMed, PhD, FRACP

Professor Hunter is a rheumatology clinician researcher with a focus on osteoarthritis (OA). He is the

Florance and Cope Chair of Rheumatology and Professor of Medicine at University of Sydney, and Joint

Research and Staff Specialist at Royal North Shore Hospital. Prof Hunter holds a medical degree and Master

of Sports Medicine from the University of NSW, and completed a fellowship in Rheumatology at the Royal

Australian College of Physicians. He earned a Masters of Medical Science (Clinical Epidemiology) from the

University of Newcastle, and received his PhD from the University of Sydney in 2001.

This article was supported by an independent educational sponsorship by Reckitt Benckiser. It has been prepared by Professor David Hunter and has not been independently verified by Reckitt Benckiser.

title sub title

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Hormonal Contraception Trouble-shooting Part One: The Overweight Woman

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Pain, Pain, Go Away: Management Guidelines for Knee and Hip Osteoarthritis

palliative treatments that have been shown to have no clinical benefit over placebo and are potentially harmful to the patient and uneconomical to society.6 There is robust evidence showing that this pertains to the use of paracetamol, opioids, viscosupplements, as well as to common complementary therapies such as glucosamine and chondroitin.6 This article will outline the recently updated Royal Australia College of General Practitioners (RACGP) Guidelines for appropriate treatment options in the day-to-day management of osteoarthritis.

OA Management Guidelines

There are a plethora of OA guidelines available,7 and we are often asked why new guidelines were needed. It is important to recognise that the prior RACGP Guidelines were out of date and there were substantial changes in evidence that would warrant modifying them. These guidelines involve a systematic review and meta-analysis of all of the interventions in osteoarthritis followed by expert consensus using the grade approach.

Despite the fact that guidelines are infrequently used by practitioners, they are a helpful platform for implementation activities (including educational activities and practice audits) and health service reform and are sorely needed for the management of OA. There are a number of fundamental changes that have occurred in the evidence base. We will try to focus on these as they relate to the updated RACGP Guidelines.7

A detailed clinical assessment should be used in

the diagnosis of OA.

It is important to recognise that the first step in any health professional encounter involves appropriate assessment and diagnosis. Notably, the Guidelines emphasise a number of key elements here that can help practitioners. In recent times, the management of OA has shifted to focus more on individual patient needs through the use of a biopsychosocial framework. Care for patients with OA should be tailored to individual needs and goals and a collaborative patient-professional partnership with shared decision making should be utilised to improve patient outcome.8 A detailed clinical assessment should be used in the diagnosis of OA. This should include the impacts of the condition on a patient’s quality of life, mood, function, occupation, attitudes towards physical activity, relationships and leisure activities.9 It is also of importance to focus on the impact of comorbidities (e.g. obesity, hypertension, diabetes) on overall patient function and the management course.

Non-drug, Non-surgical Treatments

The cornerstone of OA management lies in the recognition and treatment of modifiable risk factors.7 These risk factors include obesity, muscle weakness, sedentary behaviour and psychosocial difficulties as they can be greatly detrimental to patient outcomes.7 More importantly, however, they provide a focus for the proactive management of patients, giving them areas that they can target that have evidence of demonstrable benefit. OA, due to the comorbidities and psychosocial issues that are often associated with the condition, is well-treated using a multidisciplinary team approach.7 It is imperative in the appropriate treatment of OA to focus on behaviours and treatments that make a difference to pain, as well as to the function, of the patient.

Patient education is essential in the management of OA.7 All GPs should educate their patients about the nature of the condition as well as the evidence-based treatment options available to them. It is important to ask the patient about their knowledge of the disease and treatment alternatives, dispelling any misconceptions such as ‘exercise will worsen my OA’, that can limit the success of an appropriately tailored management plan. It is important to provide reassurance to the patient that whilst there is no cure for OA, the course of the disease can be appropriately managed and that joint replacement surgery is not an inevitable outcome.9 Similarly, it is important to foster a sense of optimism and hope through careful choice of language. Phrases such as ‘bone-on-bone’ or ‘wear and tear’ create a false sense that nothing can be done and thus, these phrases should be avoided.10 Management plans should also adapt and evolve as the patient progresses with treatment. Regular follow-up appointments are important to monitor adherence to treatment plans and to encourage positive patient behaviour.

It is important to foster a sense of optimism and hope through

careful choice of language.

Exercise and improving muscle strength are also helpful with the pain and loss of function associated with this condition. This approach has been shown to be as effective as drugs in reducing pain in people with knee and hip OA.11 Guidelines strongly recommend land-based exercise for both knee and hip OA.7 Walking, muscle-strengthening exercise and Tai Chi are all shown to be beneficial in improving the course of OA symptoms.7 It is helpful to tailor your patient’s exercise to their preferences and routine. Reassure patients that pain may be apparent, or even increase, initially during exercise but that this does not worsen their OA. If needed, activity may be modified until a flare-up settles.

Weight management for people who are overweight or obese is highly recommended as part of the treatment of OA. There is a

weight-response relationship evident between weight-loss and improvement of symptoms.12 A minimum weight-loss in people who are overweight or obese of 7.5% is recommended, and a loss of 10% will yield even more benefit.13 A dietitian can also be utilised to increase muscle mass and to facilitate weight loss if needed, as well as help in the management of comorbidities.

Cognitive behavioural therapy (CBT) may also be considered for

some patients.

Cognitive behavioural therapy (CBT) may also be considered for some patients, as it may be helpful in overcoming fear-avoiding behaviours, poor sleep or mild depression in order to improve the patient’s ability to live with the disease.7,14 This may also be helpful in treating the often comorbid problems of depression that accompanies chronic pain.

There is also evidence for the use of thermotherapy (self-applied hot or cold packs), and walking aids (crutches, walking stick, etc.)7 Transcutaneous electrical nerve stimulation (TENS) used independently at home may also be appropriate for both knee and hip OA.7

Pharmacological Treatments

If further pain relief is required, medication should be considered.

Analgesia should be used judiciously and GPs should monitor for

any adverse health outcomes that patients may experience.

The RACGP Guidelines7 recommend that non-steroidal anti-

inflammatory drugs (NSAIDs) be taken orally at low doses and for

short periods of time. Relevant co-morbidities and contraindications

should be taken into account before prescription. GPs should advise

patients about potential adverse health outcomes with these

medications, particularly relating to gastrointestinal, respiratory

and cardiovascular events. Topical NSAIDs should be considered in

those at very high risk of complications.15 Consideration should be

given to the concomitant use of gastroprotective agents or COX-2

specific inhibitors in those at increased risk of gastrointestinal

side-effects. Irrespective of the route of administration, it is

important to re-emphasise that NSAIDs should be administered at

the lowest dose possible and for the shortest duration to provide

therapeutic benefit during symptomatic flare-ups. OA pain is

characterised by flares or fluctuations in symptoms, and ongoing,

regular administration of NSAIDs does nothing to alter the course

of this disease.7

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Pain, Pain, Go Away: Management Guidelines for Knee and Hip Osteoarthritis

FIRST-LINE FOR A REASON1

When it comes to treating OA flare‑up pain with oral therapy, provide patients with balanced pain relief.1‑7

Nurofen 400 Double Strength offers the same low risk of GI side effects as paracetamol^5‑7 with the powerful pain relief of an NSAID for up to 8 hours, in just 1 tablet.2‑4

MAKE THE MOVE TO NUROFEN

^When taken as directed in an over‑the‑counter setting in people without contraindications/precautions. GI: gastrointestinal. OA: osteoarthritis. NSAID: non‑steroidal anti‑inflammatory drug. Nurofen 400 Double Strength contains 400mg ibuprofen. For the temporary relief of pain.References: 1. The Royal Australian College of General Practitioners. Guideline for the management of knee and hip osteoarthritis. 2nd edn. East Melbourne, Vic: RACGP, 2018. 2. Mehlisch DR et al. Clin Ther 2010;32(6):1033‑1049. 3. Malmstrom K et al. Clin Ther 1999;21(10):1653‑1663. 4. Malmstrom K et al. Clin Ther 2004;26(5):667‑679. 5. Moore N et al. Clin Drug Invest 1999;18:89–98. 6. Rampal P et al. J Int Med Res 2002;30:301–308. 7. Varrassi G et al. Adv Ther 2019; doi: 10.1007/s12325‑019‑01144‑9.®NUROFEN is a registered trademark of the Reckitt Benckiser Group of Companies. Level 47, 680 George St, Sydney 2000, NSW Australia. Prepared February 2020.

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An important shift from the prior guidelines is that paracetamol is no longer recommended as the

first-line analgesic. Paracetamol is shown to be no more effective than placebo16 and has a dose-related increased risk of adverse effects (such as cardiovascular, renal and gastrointestinal side effects).17 The Guidelines do not recommend for or against its use. The RACGP instead advises that it be trialled for a short amount of time, the patient monitored for side-effects and paracetamol discontinued if it is found not to be effective.7

Corticosteroid injections may be used for short-term pain relief as an adjunct therapy in some patients, however repeated use has been shown to lead to structural disease progression of joint disease.18,19

The serotonin–norepinephrine reuptake inhibitor (SNRI) duloxetine may also be considered in some patients if other forms of pain relief are inadequate.7 The mechanism is through altered pain pathways as opposed to the relief of depression.

The RACGP Guidelines7 recommend against the following drugs: oral or transdermal opioids, doxycycline, strontium ranelate, interleukin-1 (IL-1) inhibitors, stem cell therapy and viscosupplementation injection for hip OA.

Opioids, if considered at all, should be prescribed on a short-term basis with clear goals and regular review of treatment response, as well as adverse effects. Recent estimates from Australia indicate that around one in five patients with hip OA and one in ten patients with knee OA receive at least one opioid prescription as part of their OA management.20,21

Current evidence indicates that opioids offer only limited benefit for chronic OA pain and carry substantial risks regarding side-effects, addiction and accidental overdose.22

Surgical Treatments

The RACGP Guidelines strongly recommend against surgery such as arthroscopic lavage and debridement, meniscectomy and cartilage repair for people with knee OA, unless they have the rare circumstance of a ‘locked knee’.7 However, in appropriately selected patients, total joint replacement surgery is a cost-effective treatment for end-stage OA.23 It is important to note that surgery is not inevitable, in fact, the vast majority of patients with OA never need surgery.24 The hallmarks of end-stage OA include significant joint pain and/or deformity that disrupts normal sleeping patterns, causes a severe reduction in walking distance and markedly restricts activities of daily living.24 GPs should only consider surgery when conservative options, delivered for a reasonable time, have failed and the OA is significantly and consistently affecting daily activities and quality of life.7 Patients planning on having surgery should still maintain the range of motion in their joint, and should engage in as much strengthening and physical activity as possible. It is important to note that not all surgery is effective and 25% of patients who

Summary of Treatments Interventions to aim for (green boxes) and practices that should be used judiciously (yellow boxes) or discouraged (red boxes) are highlighted.

Green Yellow Red

Education & self management of OA

Exercise (walking, muscle strengthening exercise & Tai Chi)

Weight loss in overweight or obese persons

Cognitive behavioural therapy

Hot & cold packs

Walking aids

NSAIDs (including topical)

Duloxetine

Joint Replacement Surgery

Paracetamol

Repeat corticosteriod Injections

Glucosamine and chondroitin supplements

Opioids

Viscosupplementation

Arthroscopy

* 4 out of 10 of patients achieved at least 50% pain relief with either ibuprofen 400mg or diclofenac 25mg.Contains 400mg ibuprofen. For the temporary relief of pain. Reference: 1. Moore, 2015.

SIMILAR SUCCESS RATEIN PAIN RELIEF VS DICLOFENAC 25mg*1

0 50% patients

ibuprofen 400mg

diclofenac 25mg

SIMILAR SUCCESS RATE in pain relief vs diclofenac 25mg1*

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had an uncomplicated operation for OA still complain of pain and disability twelve months after their surgery.25

Typical cases

I will now cover two examples of cases that GPs might commonly see. Other case examples and management algorithms are available in a recently published article.26

Case 1

An obese 65-year-old male with symptomatic knee OA presents to primary care for treatment. He has depression and hypertension, both controlled on medication, and sleep apnoea that responds favourably to continuous positive airway pressure (when he uses this). He experiences pain in and around one knee (including the patellofemoral joint) and has been taking paracetamol long-term to help with the pain.

In the first instance, it is important to educate the patient about his paracetamol use, explaining the efficacy and potential adverse effects of the drug. It is also important to determine whether the drug is effective for him by trialling a period of cessation of the drug. Exercise and weight loss would be recommended for this patient, including the use of exercise and dietary professionals. Certain patients may be able to access this through a chronic diseases management plan under Medicare. Other lifestyle (Tai Chi, Yoga, Hydrotherapy etc.), medical and surgical treatments would also be discussed to determine the patient’s preferred management.

Case 2

A 48-year-old woman with a highly sedentary lifestyle and concomitant anxiety presents to primary care for the treatment of symptomatic hip OA. She is a normal weight and experiences pain over the lateral aspect of her hip on movement; hip internal rotation is limited to 5o due to pain. She has experienced no benefit from over-the-counter NSAID use.

In this scenario, it is important to educate the patient about the condition, recommend increasing physical activity and the range of joint motion as part of a self-management plan. Referral to a physiotherapist may assist in this regard. Also, consider non-addictive antianxiety medication or psychological interventions (e.g. CBT). Because of her anxiety she may warrant a mental health plan for assistance with her psychological symptoms. Discuss possible medical and surgical interventions (considering comorbidities) and the problems of long-term NSAID use.

Conclusion

GPs are usually the first point of contact for patients with osteoarthritis. It is therefore important to understand the RACGP Guidelines and to use them to assist therapeutic choices. The management of a patient should also take into consideration their lifestyle and preferences. The core treatments of education, exercise and weight management should be used to improve the pain, function and quality of life of patients with osteoarthritis.

Declaration

Professor David Hunter was commissioned by Healthed for this article. The ideas, opinions and information presented are solely those of the author. The advertiser does not necessarily endorse or support the views expressed in this article. The author declares no significant competing financial, professional or personal interests that might influence this article.

Acknowledgements

Professor Hunter is supported by an NHMRC Practitioner Fellowship. Sincere appreciation to Samuel Hunter for editorial assistance.

Further Reading

Hunter, D.J., Guideline for the management of knee and hip osteoarthritis 2nd edition. 2018, RACGP.

Hunter, D.J. and J.L. Bowden, Therapy: Are you managing osteoarthritis appropriately? Nat Rev Rheumatol, 2017. 13 (12): p. 703-704.

References

1. Hunter DJ, Schofield D and Callander E. The individual and socioeconomic impact of osteoarthritis. Nat Rev Rheumatol. 2014 Jul; 10(7): 437-41. DOI: 10.1038/nrrheum.2014.44

2. Australian Institute of Health and Welfare. Osteoarthritis [Internet]. Canberra (ACT): Australian Institute of Health and Welfare; 2019 (updated 2019 Aug 30). Available from: https://www.aihw.gov.au/reports/chronic-musculoskeletal-conditions/osteoarthritis

*When taken as directed in an over-the-counter setting in people without contraindications/precautions.

GI: gastrointestinal. Contains 400mg ibuprofen. For the temporary relief of pain. References: 1. Moore, 1999. 2. Rampal, 2002. 3. Varrassi, 2019

SAME LOW RISKOF GI SIDE EFFECTS AS PARACETAMOL*1-3

GI events (dyspepsia)

4% IBUPROFEN VS

5.3% PARACETAMOL1

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3. Ackerman IN, Pratt C, Gorelik A, Liew D. Projected Burden of Osteoarthritis and Rheumatoid Arthritis in Australia: A Population-Level Analysis. Arthritis Care Res (Hoboken). 2018 Jun; 70(6): 877-83.

4. Britt H, Miller GC, Bayram C, Henderson J, Valenti L, Harrison C, et al. A decade of Australian general practice activity 2006-07 to 2015-16. General practice series no. 41. Sydney: Sydney University Press, 2016. Available from: https://ses.library.usyd.edu.au/bitstream/handle/2123/15482/9781743325162_ONLINE.pdf;jsessionid=870A632A8846FAD31D82E9D9FB6951BD?sequence=5

5. Runciman WB, Hunt TD, Hannaford NA, Hibbert PD, Westbrook JI, Coiera EW, et al. CareTrack: assessing the appropriateness of health care delivery in Australia. Med J Aust. 2012 Jul 16: 197(2): 100-5. DOI: 10.5694/mja12.10510

6. Hunter DJ, Osteoarthritis Management: Time to Change the Deck. J Orthop Sports Phys Ther, 2017 Jun; 47(6): 370-2. DOI: 10.2519/jospt.2017.0605

7. The Royal Australian College of General Practitioners. Guideline for the management of knee and hip osteoarthritis. 2nd ed. East Melbourne: RACGP, 2018.

8. Lim AY, Doherty M. What of guidelines for osteoarthritis? Int J Rheum Dis. 2011 May; 14(2): 136-44. DOI: 10.1111/j.1756-185X.2011.01609.x

9. de Rooij M, van der Leeden M, Heymans MW, Holla JFM, Häkkinen Arja, Lems WF, et al. Prognosis of Pain and Physical Functioning in Patients With Knee Osteoarthritis: A Systematic Review and Meta-Analysis. Arthritis Care Res (Hoboken), 2016 Apr; 68(4): 481-92. DOI: 10.1002/acr.22693

10. Bunzli S, O’Brien P, Ayton D, Dowsey M, Gunn J, Choong P, et al. Misconceptions and the Acceptance of Evidence-based Nonsurgical Interventions for Knee Osteoarthritis. A Qualitative Study. Clin Orthop Relat Res. 2019 Sep; 477(9): 1975-83. DOI: 10.1097/CORR.0000000000000784

11. Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL. Exercise for osteoarthritis of the knee. Br J Sports Med. 2015 Dec; 49(24): 1554-7. DOI: 10.1136/bjsports-2015-095424

12. Atukorala I, Makovey J, Lawler L, Messier SP, Bennell K, Hunter DJ. Is There a Dose-Response Relationship Between Weight Loss and Symptom Improvement in Persons With Knee Osteoarthritis? Arthritis Care Res (Hoboken), 2016 Aug. 68(8): 1106-14. DOI: 10.1002/acr.22805

13. Messier SP, Mihalko SL, Legault C, Miller GD, Nicklas BJ, DeVita B, et al. Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: the IDEA randomized clinical trial. JAMA. 2013 Sep; 310(12): 1263-73. DOI: 10.1001/jama.2013.277669

14. O’moore K, Newby JM, Andrews G, Hunter DJ, Bennell K, Smith J, et al. Internet Cognitive-Behavioral Therapy for Depression in Older Adults With Knee Osteoarthritis: A Randomized Controlled Trial. Arthritis Care Res. 2018 Jan; 70(1): 61-70. DOI: 10.1002/acr.23257

15. Zeng C, Wei J, Persson M, Sarmanova A, Doherty M, Xie D, et al. Relative efficacy and safety of topical non-steroidal anti-inflammatory drugs for osteoarthritis: a systematic review and network meta-analysis of randomised controlled trials and observational studies. Br J Sports Med; 52(10): 642-50. DOI: 10.1136/bjsports-2017-098043

Video Resources

Pharmacology and Pain by Dr Guy Bashford

The Opioid Crisis in Australia by Prof Stephan Schug

Watch the full lectures on the Healthed website. Visit www.healthed.com.au/video

Pain, Pain, Go Away: Management Guidelines for Knee and Hip Osteoarthritis

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16. Machado GC, Maher CG, Ferreira PH, Pinheiro MB, Lin CC, Day RO, et al., Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials. BMJ. 2015 Mar; 350: h1225. DOI: 10.1136/bmj.h1225

17. Roberts E, Nunes VD, Buckner S, Latchem S, Constanti M, Miller P, et al. Paracetamol: not as safe as we thought? A systematic literature review of observational studies. Ann Rheum Dis. 2016 Mar; 75(3): 552-9. DOI: 10.1136/annrheumdis-2014-206914

18. National Clinical Guideline Centre. Osteoarthritis: care and management [Internet]. London, UK. National Institute for Health and Clinical Excellence; 2014. Available from: https://www.nice.org.uk/guidance/cg177

19. McAlindon TE, LaValley MP, Harvey WF, Price LL, Driban JB, Zhang M, et al. Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial. JAMA. 2017 May; 317(19): 1967-75. DOI: 10.1001/jama.2017.5283

20. Brand CA, Harrison C, Tropea J, Hinman RS, Britt H, Bennell K. Management of osteoarthritis in general practice in Australia. Arthritis Care Res (Hoboken), 2014 Apr. 66(4): 551-8. DOI: 10.1002/acr.22197

21. Ackerman IN, Zomer E, Gilmartin-Thomas JF-M, Liew D. Forecasting the future burden of opioids for osteoarthritis. Osteoarthritis Cartilage. 2018 Mar; 26(3): 350-5. DOI: 10.1016/j.joca.2017.11.001

22. da Costa BR, Nüesch E, Kasteler Rahel, Husni Elaine, Welch V, Rutjes AWS, et al. Oral or transdermal opioids for osteoarthritis of the knee or hip. Cochrane Database Syst Rev. 2014 Sep 17; (9): CD003115. DOI: 10.1002/14651858.CD003115.pub4

23. Higashi H, Barendregt JJ. Cost-effectiveness of total hip and knee replacements for the Australian population with osteoarthritis: discrete-event simulation model. PLoS One. 2011; 6(9): e25403. DOI: 10.1371/journal.pone.0025403

24. Culliford DJ, Maskell J, Kiran A, Judge A, Javaid MK, Cooper C, et al. The lifetime risk of total hip and knee arthroplasty: results from the UK general practice research database. Osteoarthritis Cartilage. 2012 Jun. 20(6): 519-24. DOI: 10.1016/j.joca.2012.02.636

25. Dowsey MM, Gunn J, Choong PF. Selecting those to refer for joint replacement: who will likely benefit and who will not? Best Pract Res Clin Rheumatol. 2014 Feb; 28(1): 157-71. DOI: 10.1016/j.berh.2014.01.005

26. Meneses SRF, Goode AP, Nelson AE, Lin J, Jordan JM, Allen KD, et al. Clinical algorithms to aid osteoarthritis guideline dissemination. Osteoarthritis Cartilage. 2016; 24(9): 1487-99. DOI: 10.1016/j.joca.2016.04.004

Editorial TeamMedical Editors: Dr Linda Calabresi, Dr Vivienne Miller Managing Editor: Neil Harris Production Editor: Amanda Bryan Editorial Assistant: Sai Machiraju Executive Editor: Dr Ramesh Manocha

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