Owing to increased demand on the Irish healthcare service and economic constraints, an effort has been made to seek alternative solutions for patients living with chronic illness, including those with rheumatic and musculoskeletal diseases (RMDs) (Carney, 2016; Department of Health (DH), 2016). The role of the rheumatology advanced nurse practitioner (ANP) in an Irish healthcare context is to improve patient flow, to shorten outpatient waiting lists, facilitate earlier discharge, and provide early, appropriate access to services (DH, 2019). The DH has sought to increase the percentage of nurse practitioners in Ireland. Several demonstrator sites were used to evaluate the development of roles and the implementation of posts (DH, 2019). The programme introduced an additional 27 rheumatology candidate advanced nurse practitioner (cANP) posts in October 2017 across the seven hospital groups in Ireland. The rheumatology ANP is an expert practitioner who can provide patient education, retrieve and record a medical/surgical/psychosocial patient history, assess presenting symptoms, diagnose, treat, and discharge patients autonomously, thus reducing the burden on rheumatology medical clinics (DH, 2019). With the increasing rates of obesity, the rheumatology ANP is a useful addition to the multidisciplinary team to tackle obesity-related knee osteoarthritis. The clinical role of the ANP on the rheumatology team has fostered and enhanced the management of knee osteoarthritis in the Irish healthcare setting.
Knee osteoarthritis and obesity
A direct relationship was found between the degree of obesity and the level of clinical knee osteoarthritis (Raud et al, 2020). Globally, 16% of adults have been found to be obese, equating to approximately 890 million people worldwide and this number has tripled since 1975 (World Health Organization (WHO), 2024).
Ireland's obesity levels are growing considerably, with 60% of Irish adults overweight, according to the latest available figures (DH, 2016) compared to 39% in 2016 and 43% of adults worldwide today (WHO, 2024). In England in 2021, 25.9% of adults self-reported to be obese, with an additional 37.9% overweight (Baker, 2023). Similar data are seen in Ireland, with 56% of individuals over the age of 15 years self-reporting that they were either overweight or obese in 2019 (Central Statistics Office, 2020). In a qualitative study undertaken by Morden et al (2014), where participants were overweight and over the age of 50 years, an association was found between an excess of weight and the development of knee pain. Participants self-reported that their body mass index (BMI) increased after their knee pain started as they were less able to exercise (Morden et al, 2014).
Macfarlane et al (2011) reviewed data collected in the 1958 Birth Cohort Study, which involved more than 8000 participants and explored BMI across the lifespan and its relationship to the development of knee pain in later life. It was found that when a person's BMI exceeded 30 kg/m2, it was associated with the development of knee pain. The results also showed that being overweight as a teenager or young adult could be a predictive factor for knee pain by age 40 years.
Osteoarthritis
Osteoarthritis pathology involves the whole joint, including cartilage degradation, bone remodelling, osteophyte (bony spur) formation, and synovial inflammation (swelling of the lining of a joint), leading to pain, stiffness, and swelling (Kolasinski et al, 2020). Knee osteoarthritis can be classified using the Kellgren and Lawrence Scale (Kohn et al, 2016), which grades severity from 0 to 4, with zero being the absence of radiographic changes and four being severe joint space narrowing, large osteophyte formation, severe sclerosis and bony deformation.
Swain et al (2020) identified a variation in the occurrence of knee osteoarthritis across the UK. This distribution throughout regions could be due to differences in health-seeking behaviours, socioeconomic background or lifestyle behaviours. The osteoarthritis distribution correlates with the obesity distribution across the northern UK (Swain et al, 2020). The incidence of osteoarthritis is rising nationally largely due to the ageing population, the obesity pandemic and reduced levels of physical activity (Arthritis Ireland, 2021; WHO, 2024). In Ireland, 500 000 individuals are affected with osteoarthritis and regional musculoskeletal pain (National Clinical Programme for Rheumatology, 2018) with one in five women and one in 10 men in Ireland over the age of 60 years diagnosed with osteoarthritis (Arthritis Ireland, 2021). Osteoarthritis is typically managed with a combination of pharmacological and non-pharmacological treatments (Kolasinski et al, 2020). The average BMI of those receiving a total knee replacement in the UK was found to be 30.7 kg/m2 in 2022, falling into the obese category (National Joint Registry, 2023). The Irish Longitudinal Study on Ageing (TILDA) found that 12.9% of adults over 50 years of age had a diagnosis of osteoarthritis (23.4% males and 73.6% females) (French et al, 2016). There was a prevalence of 10.7% in persons 20 years and over (Swain et al, 2020).
There are six identified modifiable risk factors for knee osteoarthritis: weight, comorbidities, occupational factors, physical activity, biomechanical factors and dietary exposures (Georgiev and Angelov, 2019), all of which can be addressed by the rheumatology ANP. National Institute for Health and Care Excellence (NICE) guidance suggests assessing a person's function, quality of life, mood, relationships, and exercise activities, taking into consideration comorbidities, as part of the treatment recommendations for knee osteoarthritis (NICE, 2022).
Review of international guidelines
A review of the current international guidance for the treatment of knee osteoarthritis was conducted, examining guidelines from the Osteoarthritis Research Society International (OARSI) (Bannuru et al, 2019), American College of Rheumatology (ACR) (Kolasinski et al, 2020), NICE (2022), and several of the European Alliance of Associations for Rheumatology (EULAR) guidelines (Fernandes et al, 2013; Geenan et al, 2018; Uson et al, 2021; Moseng et al, 2024). As detailed in Table 1, there are discrepancies between recommendations published. The commonalities that became apparent was that all four groups recommended exercise, weight management, a self-management programme, behavioural change/cognitive behavioural therapy and oral and topical NSAIDs with an intra-articular (IA) steroid for short-term symptomatic relief/in the presence of an effusion. The ANP is in a position to implement all these recommendations autonomously.
Table 1. Intervention recommendations in the guidelines
| Type of intervention | ACR | EULAR | NICE | OARSI |
|---|---|---|---|---|
| Exercise | ||||
| Aerobic exercise | ||||
| Strength and resistance | ||||
| Balance training | ||||
| Neuromuscular exercise | ||||
| Tai Chi | ||||
| Yoga | ||||
| Aquatic exercise | ||||
| Patient education | ||||
| Weight management | ||||
| Self-management programme | ||||
| Personalised management plan | ||||
| Advice about pacing | ||||
| Dietary weight management | ||||
| Tibiofemoral (TF) brace (specifically for TF knee osteoarthritis) | ** | |||
| Patellofemoral knee brace (PF) (specifically for PF knee osteoarthritis) | ** | |||
| Sleeve | ||||
| Elastic bandage | ||||
| Orthosis | ||||
| Insoles | ** | |||
| Orthopaedic shoes | ||||
| Appropriate footwear | ||||
| Cane/single stick | ||||
| Gait aide | ||||
| Assisted technology | ||||
| Home/work adaption | ||||
| Heat/cool therapeutic treatment | ||||
| Cognitive behavioural therapy | **** | |||
| Psychosocial and coping interventions | ||||
| Acupuncture | ||||
| Kinesiotaping | ** | |||
| Manual therapy/mobilisation | * | |||
| Massage therapy | ||||
| Radiofrequency ablation | ||||
| TENs/other electrotherapy | *** | |||
| Pulsed vibration therapy | ||||
| Oral NSAIDs | ||||
| Topical NSAIDs | ||||
| COX-2 inhibitor | ||||
| Colchicine | ||||
| Intra-articular steroid | ||||
| Intra-articular hyaluronic acid | ||||
| Intra-articular botulinum toxin | ||||
| Prolotherapy | ||||
| Paracetamol | ||||
| Tramadol | ||||
| Non-tramadol opioids | ||||
| Duloxetine | ||||
| Topical capsaicin | ||||
| Chondroitin/glucosamine | ||||
| Fish oil | ||||
| Vitamin D | ||||
| Sleep hygiene intervention | ||||
| Multidisciplinary treatment |
☐ Strongly recommended
☐ Conditionally recommended
☐ Recommended
☐ Strongly not recommended
☐ Conditionally not recommended
☐ Not included in recommendation
Items in bold are recommended by all guidance
Key: ACR=American College of Rheumatology (Kolasinski et al, 2021); EULAR=European Alliance of Associations for Rheumatology; NICE=National Institute for Health and Care Excellence (NICE, 2022); OARSI=Osteoarthritis Research Society International (Bannuru et al, 2019)
****=in conjunction with exercise
***=not to be routinely offered − they are only used infrequently for short-term pain relief and all other pharmacological treatments are contraindicated, not tolerated or ineffective;
**=not to be offered unless there is joint instability or abnormal biomechanical loading, and therapeutic exercise is ineffective or unsuitable without the addition of an aid or device. The addition of an aid or device is likely to improve movement and function;
*=to be done in conjunction with exercise
Intra-articular injections
Depo-Medrone (methylprednisolone acetate) 10-80 mg can be administered intra-articularly, depending on joint size and condition (MIMS Ireland, 2024). Other preparations that are used in practice include triamcinolone acetate, betamethasone acetate, betamethasone sodium phosphate, triamcinolone hexacetonide, and dexamethasone (Ayhan et al, 2014). Hyaluronic acid (visco-supplementation) preparations administered intra-articularly are used to restore viscosity and elasticity of synovial fluid. There are a number of hyaluronic acid products available on the market comprising different preparations of high or low molecular weight hyaluronic acid, namely: sodium hyaluronate, Hylan G-F 20, and high-molecular-weight hyaluronan (Ayhan et al, 2014). There is no consensus on the use of hyaluronic acid in practice for the treatment of knee osteoarthritis. It is also more expensive than intra-articular steroids.
Plasma rich protein (PRP) is being increasingly used for the treatment of osteoarthritis but it is not a treatment included in the current international guidance. At present there is insufficient data to support the use of PRP (Ayhan et al, 2014; Shahid et al, 2023).
Nursing role
The role of the rheumatology clinical nurse specialist (CNSp) and the rheumatology ANP in an Irish healthcare setting has historically included lifestyle assessments, addressing risk factors and behavioural modifications and undertaking extended roles when competent to do so (Table 2). The administration of intra-articular joint injections is a role identified in the Model of Care for Rheumatology in Ireland which the rheumatology nurse can fulfil (National Clinical Programme for Rheumatology, 2018) along with other members of the wider multidisciplinary team. Use of an IA corticosteroid is a known and well-documented short-term treatment for symptomatic knee osteoarthritis (Meadows and Sheehan, 2005; He et al, 2017; Hirsch et al, 2017; Uson et al, 2021). IA sodium hyaluronate is not an authorised product in Ireland at present; when administered for the treatment of knee osteoarthritis, it is being used as an exempt medicinal product. Although there are multiple treatment recommendations for the management of knee osteoarthritis, many of these require patient participation and commitment. IA injections are a quick and effective way to provide symptomatic relief where patients are unable or unwilling to engage in lifestyle modification, dietary changes, exercise or physiotherapy sufficiently to improve symptoms of knee osteoarthritis.
Table 2. The role of graduate, specialist and advanced practice nurses in rheumatology
| Staff nurse | Clinical nurse specialist in rheumatology | Advanced nurse practitioner in rheumatology | |
|---|---|---|---|
| Knowledge of rheumatology | Develops knowledge of the pathology and diagnosis of rheumatology-related illnesses. Ability to communicate information to clients and their family regarding the current stage of illness | Links the pathology of rheumatology illness to appropriate treatment options. Understands the pathological differences of various conditions and recognises appropriate drugs in different illnesses | Teaches nursing and medical staff about new theories. Develops awareness of new evidence-based treatments within nursing and interdisciplinary team. Discusses with the client relevant investigations and treatment options that are acknowledged by their peers as exemplary. Provides clinical leadership by demonstrating advanced theoretical knowledge and clinical skills in managing defined rheumatology conditions |
| General critical management | Effectively manages the nursing care of clients/groups/communities within the hospital | Articulates and demonstrates the concept of nursing specialist practice by being responsible for own caseload and the provision of specialist knowledge to the identified client group. Possesses specially focused knowledge and skills in a defined area of nursing at a higher level than that of a staff nurse − performs a nursing assessment, plans and initiates care and treatment within agreed disciplinary protocols to achieve patient/client-centred outcomes and evaluates their effectiveness | Accountable and responsible for advanced levels of decision making that occur through the management of specific client/patient caseload. Demonstrates expert skill in the assessment and treatment of defined aspects of rheumatology care within a collaboratively agreed scope of practice model. Initiates and maintains open communication with the multidisciplinary team (MDT). Facilitates a team approach to planned patient care |
| Caring for well rheumatology patients | Is able to identify the type of rheumatology illness. Offers advice on management strategies and when to refer on. At all times for every interaction with a client, ensures clinical assessments are documented and communicated to other relevant health professionals | Identifies the clinical need and provides evidence-based management. Provides a central point for continuity of care. Facilitates access to other services as appropriate. Manages nurse-led clinic. Documents all assessments and communicates to the MDT | Uses advanced clinical assessment skills to perform a holistic assessment. Introduces and evaluates management programmes that are sensitive to the client's needs in partnership with them. At all times for every interaction with a client, ensures clinical assessments are documented and communicated to other relevant health professionals |
| Caring for the debilitated clients | Uses clinical assessment guidelines to identify symptoms and clinical need. Recognises potential complications from polypharmacy, drug side effects, frequent clinic appointments and gains advice from the MDT on management strategies | Advises on self-management, on-going assessment, and advises when complications arise. Devises a self-care plan with the client. Assess, plan, implement and evaluate nursing intervention altering treatments as required with agreed protocols | Ensures that the service is responsible to changing need and ensures good communication and quick access to service when required. Recognises complications and manages change |
| Caring for the complex cases | Identifies a need for increased patient and family support and intervention | Assesses, monitors and evaluates disease activity. Uses expertise, communication and co-ordination skills to ensure continuity of care between the hospital and the community care setting | Receives referrals. Works proactively with agencies to promote good quality management tailored to the client's choice and need. Mediates between services and facilitates complex ethical decision making |
| Research and audit | Understands what is meant by evidence-based care, accesses evidence relevant to rheumatology. Critically appraises audit results and participates in the implementation of the recommendations as appropriate | Identifies, critically analyses, disseminates and integrates nursing and other evidence in the area of specialist practice. Carries out an audit of key aspects of service. Interprets the outcomes of audit findings and responds with initiatives to improve service provision | Identifies research priorities for the area of practice. Initiates and co-ordinates nursing research, which ensures the advancement of nursing practice, policy and education, informing the wider health agenda. Initiates, participates in and evaluates audit findings to improve/enhance service provision |
Discussion
As there is an association with a raised BMI and the occurrence of knee pain and the development of knee osteoarthritis (Jordan et al, 2003; Raud et al, 2020), it is not sufficient to simply treat symptomatic knee pain but to address lifestyle factors such as diet (sufficient nutrition), exercise (aerobic, strength and stretching), comorbidities and modifiable risk factors. Education regarding lifestyle factors that may be contributing to symptomatic disease is an ongoing role performed by the rheumatology ANP in an outpatient setting, along with clinical interventions. Geenen et al (2018) recommends that the health professional should explain to the patient that obesity can contribute to pain and disability and should discuss accessible weight-management options and/or refer them for specialised weight-management support. EULAR guidelines recommend the implementation of general healthy lifestyle advice for the maintenance of a normal BMI. This includes limiting salt and fat intake, eating at least five portions of fruit and vegetables a day, and taking 30 minutes of exercise per day (Fernandes et al, 2013). It is also suggested that self-monitoring of progress and the identification of weight-loss goals, along with motivational interviewing, can be helpful. Follow-up over a 4-year period contributes to the success of long-term weight management goals (Fernandes et al, 2013).
IA injections can be useful in providing a window of opportunity to engage in physiotherapy and lifestyle modifications while pain is under good control. This may help to build muscle, supporting the knee joint, preparing it to take the impact rather than the weighted load burdening the damaged joint. Although both IA methylprednisolone acetate and hyaluronic acid are suggested treatments mentioned in the international guidance that can be administered by the rheumatology ANP, they usually only provide temporary relief.
Although the ACR guideline (Kolasinski et al, 2020) strongly recommend (when clinically indicated) the use of IA injections as one method of treating knee osteoarthritis along with other pharmacological and non-pharmacological interventions, the guideline does not address the effectiveness of IA treatments for the management of symptomatic knee osteoarthritis in patients who are overweight or obese.
At present, there is no national guidance with regard to the use of IA steroid or visco-supplementation for the management of chronic knee pain due to osteoarthritis in the obese cohort. Neither the Irish Society of Rheumatology nor the Irish Rheumatology Health Professionals Society produce treatment guidelines for the management of knee osteoarthritis or indeed obesity. There is no available national treatment guideline in Ireland for the management of knee osteoarthritis (DH, 2023). The Irish Rheumatology Nursing Forum work to gather and share information to develop policies, protocols, procedures, and guidelines. A national guideline for the treatment of knee osteoarthritis or national adaptation of international guidelines has yet to be developed.
The rheumatology ANP assesses, diagnoses, and treats knee osteoarthritis autonomously as part of their extended and expanded practice in the Irish health service. Arthritis is a common, disabling condition and knee osteoarthritis can occur as a direct result of obesity (Raud et al, 2020). The international clinical guidelines available recommend both pharmacological and non-pharmacological treatments for the management of knee osteoarthritis. IA injections are often administered by rheumatology ANPs for the management of knee osteoarthritis and while the rheumatology ANP does not perform/partake in all the recommendations set out by the international guidance, it is within their scope to prescribe medications, refer for X-rays and MRI scans, refer to allied health professionals, pain management specialists, rehabilitation units, and/or orthopaedic surgeons, in order to meet the international treatment recommendations.
Sellam and Berenbaum (2013) suggested that there is evidence to support a metabolic process associated with osteoarthritis where adipose tissue is also considered endocrine tissue with the ability to release adipokines, which are involved in mediating the inflammatory response. This means that the maintenance of a healthy weight not only reduces the load burden on the larger joints but would prevent or greatly reduce the occurrence of an inflammatory process causing joint damage. With the increasing obesity levels globally a causative factor for the development of knee osteoarthritis, it is difficult to determine if treatments are as effective in obese patients or whether chronic knee pain is a direct result of an increased weight burden on the knee joint itself. Increasing rates of obesity in turn will place a greater demand on chronic healthcare services and thus warrant the development of more ANP posts to consider the management of the growing chronic health concerns of this population group. The rheumatology ANP in an Irish healthcare setting does not rotate as the non-consultant hospital doctors do, thus providing stability to a service and continuity of care for the chronically ill patient, including those with obesity-related arthritis.
Conclusion
A robust, holistic approach needs to be undertaken to manage pain and symptoms, improving modifiable lifestyle risk factors contributing to the development of obesity-related knee osteoarthritis. The rheumatology ANP may be in a unique position to provide the tailored support this patient cohort requires. It is observed that although most available guidelines for the treatment of knee osteoarthritis give similar recommendations, the availability of resources may influence the treatment choice, as will the patient's preference and the presence of comorbidities. The cause and contributing factors for obesity-related knee osteoarthritis should be addressed, along with providing symptomatic relief.
Consideration should be given to the development of national guidelines for the assessment and treatment of obesity-associated knee osteoarthritis for use in the Irish healthcare setting. More research is required in this area to assess the effectiveness of IA steroid injections and IA visco-supplementation for the treatment of symptomatic knee osteoarthritis in persons with obesity.
KEY POINTS
- Current increasing levels of obesity in the general population give rise to an increase in knee osteoarthritis
- A multifaceted approach should be taken in the treatment of knee osteoarthritis
- Rheumatology advanced nurse practitioners are in a position to manage the care of the person with obesity-related osteoarthritis holistically with their ability to assess, diagnose, treat, refer and discharge
- The availability of or access to resources may influence treatment choice of the person with obesity-related osteoarthritis
- The development of specific osteoarthritis guidelines should be considered because a significant number of people with knee osteoarthritis are living with obesity
CPD reflective questions
- Could an obesity specialist service in your organisation or area adequately tackle all the obesity-related health issues?
- How do you adapt generic treatment guidance to apply to your patients?
- Can the development of a nursing rapport influence a patient's desire to engage in behavioural/lifestyle change? Have you found this in your practice? Think about how this could be applied to more patients