Centros de excelência no manejo da osteoartrite na América Latina: uma proposta baseada em uma revisão da literatura

Osteoarthritis (OA) is a common chronicmusculoskeletal condition and one of the leading causes of rheumatology consultations. OA contributes significantly to pain, disability, and functional limitations, all of which adversely affect patients' quality of life (1). Estimating the incidence and prevalence of OA can be challenging, as the disease is often asymptomatic in its early stages, making early diagnosis difficult in the absence of clinical manifestations. Consequently, many individuals with early OA may not be captured in registries. The prevalence of OA varies by region. In the USA, studies suggest that OA affects 12% of individuals over the age of 25, with 3% experiencing related disabilities (1).

In Latin America, a study by Reginato AM et al.found a prevalence of approximately 10%, although the full characteristics of OA in theregion are not yet fully understood. Several studies from the Community Oriented Program for the Control of Rheumatic Diseases (COPCORD) have reported OA prevalence ranging from 2.3% to 20.4% across different Latin American countries. However, these studies have not evaluated OA prevalence in all countries, and geographical differences may exist. The study also found a higher prevalence than previous reports. The average age of patients was 62.5 years, with a female-to-male ratio of 4.8:1. Approximately 88% had primary OA. A breakdown of affected joints includes: knee (31.2%), hand (9.5%), hand and knee (22.9%), proximal and distal interphalangeal joints (6.5%), axial joints (6.6%), and hip (1.3%) (2).

OA is primarily influenced by factors such as mechanical stress and aging. While it is more common in older individuals, symptoms may emerge earlier, sometimes without noticeable pain or limitations. Due to its clinical features and epidemiological patterns, managing OA requires a comprehensive, multidisciplinary approach that addresses all aspects of patient care. The Pan American Health Organization (PAHO) has highlighted significant challenges in managing chronic diseases, noting that fragmented healthcare services hinder effective access, diagnosis, treatment, and overall management (3–5). In response, innovative strategies are being implemented to
enhance healthcare delivery, one of which is the creation of specialized, comprehensive healthcare centers, leading to the establishment of Centers of Excellence (CoEs).

A CoE is defined as "a program within a healthcare institution that consolidates a high level of expertise and resources in a specific area of medicine, providing comprehensive, multidisciplinary care to achieve optimal patient outcomes" (6). These centers aim to deliver high-quality care while using resources efficiently.

Three fundamental pillars are essential for establishing CoEs: (a) the volume and demand for the specific condition, (b) a culture of continuous improvement, and (c) the expertise of the healthcare workforce (7). Based on a narrative review of the literature and expert insights, this paper proposes the establishment of CoE for Osteoarthritis (CoEs-OA) in Latin America (LATAM).

Materials and methods

This study employed a two-step process: a narrative review of the literature on OA care, followed by a consensus-building process among a panel of rheumatology experts in OA management across Latin America (LATAM). The panel comprised fifteen rheumatologists from ten countries. The primary objective was to review the literature on comprehensive healthcare in OA and quality of care, while also facilitating consensus among the experts. The secondary objective was to develop a framework for the creation of CoEs-OA management in Latin America. The methodology is outlined as follows:

Literature Search Strategy

A thorough narrative review of the literature was conducted using electronic databases, including PubMed, Google Scholar, Lilacs, and SciELO. Search terms included "osteoarthritis," "quality," "efficiency," "center of excellence," and "comprehensive healthcare," combined using Boolean operators (AND, OR, NOT). The search focused on studies published in English, Spanish, and Portuguese up until May 2024. Both MeSH terms and free-text keywords were used to ensure comprehensive results.

Expert Panel and Consensus Process

After completing the literature review, an expert panel of rheumatology specialists was convened. The panel reviewed the literature findings and divided into working groups to evaluate specific topics, such as early diagnosis, multidisciplinary approaches, and pharmacological and non-pharmacological treatments. Each expert was responsible for assessing particular areas in detail.

The consensus process required that each major recommendation be approved by at least 75% of the panel members. Voting was conducted anonymously to maintain impartiality. Following the consensus process, the final set of recommendations for the diagnosis and treatment of OA was compiled, aiming to harmonize decisions while considering the diverse perspectives of the rheumatology experts and addressing the specific healthcare needs and realities of Latin America.

The expert panel reviewed the literature and was organized into working groups to evaluate the following topics:

• Early diagnosis and referral pathways
• OA phenotypes and specific interventions
• Multidisciplinary healthcare team model
• OA management protocol
• Pharmacological strategies
• Non-pharmacological strategies
• Education
• Long-term follow-up
• Integration of telemedicine and digital health tools

Results

The literature review and expert panel discussions identified essential elements for establishing a Center of Excellence for osteoarthritis (CoE-OA) management in Latin America (LATAM). A structured approach was adopted, with a designated coordinator synthesizing the literature findings and formulating specific statements on critical aspects of CoE development. These statements were presented to the expert panel for discussion and consensus voting (Fig. 1). This process ensured that the proposed CoE framework was grounded in scientific evidence and regional expert opinions, addressing the unique challenges and healthcare needs of OA patients in LATAM.

Screening Clinic and Early Diagnosis of OA

The primary goal of a screening clinic is to reduce false-positive diagnoses and proactively identify new OA cases, particularly in asymptomatic individuals. OA is often diagnosed when significant joint damage has already occurred (1). Early identification of high-risk individuals, such as those in certain occupations or sports, is crucial for timely intervention. Risk factors such as limb malalignment, muscle weakness, age, obesity, and family history are vital for early detection. Imaging techniques, including ultrasound and MRI, can detect OA before clinical symptoms appear. Additionally, future biomarkers show promise for improving diagnostic accuracy (8–11).

OA Phenotypes and Specific Interventions

Phenotyping OA based on its underlying mechanisms involves classifying the disease into subtypes according to distinct pathophysiological pathways. This approach aims to address the heterogeneity of OA and improve personalized treatment strategies. Given the variability in OA progression and treatment response, well-defined phenotypes are essential to guide targeted interventions (12). This approach is particularly useful for optimizing treatment outcomes and improving patient care by tailoring treatments to each patient’s unique characteristics (13).

• Chronic Pain-Associated OA (Central Sensitization Phenotype): This phenotype is characterized by increased pain sensitivity and central sensitization, with amplified pain signals extending beyond the injury site. Patients often report widespread pain, psychological distress, sleep disturbances, and fatigue (14). Management includes a multidisciplinary approach with pain management, psychological support, and pharmacological interventions aimed at reducing central sensitization.
• Inflammatory Phenotype: This phenotype is marked by the overexpression of inflammatory cytokines such as IL-1β, IL-8, COX-2, and MIP-1α/β. It is associated with higher pain levels and faster disease progression, as seen in radiographs (13). Treatment strategies for this phenotype, in addition to the multidisciplinary approach, include disease-modifying osteoarthritis drugs (DMOAs) targeting inflammatory pathways. Biomarkers of inflammation, such as C-reactive protein (CRP) and some interleukins, can help guide the selection of appropriate therapies for these patients. (15)
• Metabolic Syndrome-Associated OA: This phenotype is driven by systemic inflammation and metabolic dysfunction, often seen in patients with obesity, diabetes, or hypertension (14). Interventions for this phenotype should address both metabolic and inflammatory components. A multidisciplinary approach involving weight management, dietary changes, and pharmacological treatment for metabolic syndrome (e.g., antihypertensive or antidiabetic medications) is key. Additionally, exercise programs targeting metabolic health can alleviate symptoms. Comorbidities, as components of these heterogeneous features, often coexist with knee osteoarthritis, and are particularly prevalent in end-stage knee osteoarthritis (16,17)
• Mechanical OA: Also known as degenerative joint disease, mechanical OA results from joint overload and misalignment, leading to cartilage breakdown, particularly in older individuals (18). Management includes a multidisciplinary approach, with surgical interventions like joint replacement considered for patients with significant structural damage. Conservative treatments such as physical therapy, weight reduction, and mechanical support can help manage symptoms and slow progression.  While there is some variability in phenotyping, identifying these distinct subtypes allows clinicians to apply targeted interventions based on the mechanisms driving each patient's OA (12-18).

Healthcare Model – Multidisciplinary Team

One of the key challenges in managing OA is the variability in pharmacological and non-pharmacological treatment approaches, as highlighted by a review of major clinical practice guidelines (e.g., from ESCEO, OARSI, ACR, EULAR, and PANLAR) (11,19). While international guidelines show significant variation, we base our approach primarily on PANLAR, EULAR, and ACR guidelines, with a focus on PANLAR to create a more aligned framework for patient management.

A multidisciplinary and multimodal approach is essential, as OA patients often benefit from a combination of pharmacological and non-pharmacological treatments. Viscosupplementation may also be considered due to the complexity of the condition. Follow-up visits with specialists, including rheumatologists, physiatrists, and physical therapists, are scheduled regularly (Fig. 2). Comprehensive clinical records and tools, such as the Visual Analog Scale (VAS), WOMAC index, and KOOS index, are integral to assessment, along with physical examination, which includes evaluating pain, inflammation, crepitation, and hyperlaxity (11,17).

Routine laboratory tests and imaging modalities, such as X-rays, ultrasound, and MRI, are used to monitor disease progression and guide treatment. Additionally, ultrasound can be employed for periodic follow-ups (8,20,21,22).

OA Management Protocol

OA management requires a personalized, multidisciplinary approach that integrates pharmacological and non-pharmacological strategies. Centers of Excellence (CoEs) prioritize patient education, structured exercise programs, and weight management, tailoring these interventions to the patient’s specific phenotype and socioeconomic status (23, 24,25).

Pharmacological Strategies

Topical NSAIDs and capsaicin are recommended for knee OA, with conditional use for hand OA. Oral NSAIDs are effective for most joints, but COX-2 inhibitors are preferred for patients with cardiovascular or gastrointestinal risks, and for short-term use (26). Paracetamol is a first-line agent for pain control, with a maximum dose of 3 grams per day; it should be maintained at low doses if the patient responds well, to avoid escalation to opioids (26,27).

DMOAs/Symptomatic Slow-Acting Drugs for Osteoarthritis (SYSADOAs e.g., glucosamine, chondroitin, and diacerein) can be used both for short-term pain relief and for slowing the progression of knee OA when used long-term (28). Duloxetine and tramadol are considered for cases of persistent pain, while opioids are reserved for severe cases. Intra-articular glucocorticoids are recommended for short-term relief, particularly during acute inflammation, but their long-term use is discouraged (11,26,27).

Viscosupplementation, especially with hyaluronic acid, is commonly used for pain relief and may slow radiographic progression in knee OA (11,26). The use of platelet-rich plasma and orthobiologics has expanded in recent years, showing positive clinical outcomes in selected patients. Biologics and antimalarials are not recommended (11,25,26). Surgical interventions, including joint replacement, are considered only after conservative measures fail in patients with severe pain and/or dysfunction (19,26).

Non-Pharmacological Strategies in OA Management

Non-pharmacological approaches are essential in managing osteoarthritis (OA), particularly in the disease's early stages. These strategies, including exercise, weight loss, joint protection education, can significantly improve patient function and quality of life (11). Complementary therapies such as tai chi, yoga, kinesiotaping, acupuncture, and orthotic devices also contribute to OA management (11).

Exercise and Physical Activity

Exercise is a cornerstone of OA management, supported by strong evidence showing improvements in pain, function, and quality of life. Tailored, structured, and supervised exercise programs are highly recommended, with intensity and type individualized according to the patient's phenotype and specific needs. Emphasis should be placed on aerobic, strengthening, and range-of-motion exercises to address the underlying pathophysiology of the OA phenotype. Recent research highlights the importance of gradually progressing exercise modalities for maximizing long-term benefits (30, 31).

Weight Management and Diet

Weight loss has proven especially beneficial for patients with knee OA, with studies showing improved symptoms and functional outcomes. Combining weight reduction with exercise further enhances these benefits. For patients with metabolic syndrome-associated OA, a multidisciplinary approach, including nutrition counseling, weight management, and exercise, is vital for reducing systemic inflammation and improving joint health (30, 32).

Biomechanical Interventions

Biomechanical interventions, such as orthotic devices, bracing, and shoe inserts, aim to reduce joint load and improve alignment. While these interventions are most effective when combined with exercise and weight management, their standalone efficacy is less robust. However, for OA phenotypes with significant mechanical joint overload, these interventions can help alleviate pain and improve function (30, 31).

Psychosocial and Mind-Body Approaches

Psychosocial factors such as depression, anxiety, and sleep disturbances can exacerbate OA symptoms and contribute to disability. Psychosocial interventions, including cognitive-behavioral therapy (CBT), stress reduction techniques, and mindfulness practices, have demonstrated benefits in reducing pain perception and improving quality of life especially for patients with central sensitization or chronic pain-associated OA phenotypes (31).

Manual Therapy and Other Physical Therapies

Manual therapy and electrotherapeutic modalities like transcutaneous electrical nerve stimulation (TENS) can complement exercise programs. While evidence for the efficacy of these therapies is mixed, they may provide short-term pain relief and improve joint mobility, particularly in patients with mechanical or inflammatory OA phenotypes (30, 32).

Education

Patient education is central to the CoE model, empowering patients to actively participate in their care. Educational activities, such as seminars and patient-focused meetings, are essential, with mobile health apps further facilitating self-management and patient engagement. Strategies such as symptom monitoring, exercise adherence, and joint protection techniques are encouraged. These approaches are particularly beneficial for inflammatory or chronic pain-associated OA phenotypes (33–39).

Long-Term Follow-Up

Given OA's progressive nature, ongoing follow-up is crucial. Routine imaging (e.g., X-rays, ultrasound, MRI) and lab tests should be used for long-term monitoring. In addition, CoEs should assess patients’ quality of life, using patient-reported outcome measures (PROMs) like the WOMAC scale and KOOS to guide treatment adjustments (40). Regular follow-up visits are vital to assess adherence, modify treatment plans, and ensure sustained patient engagement as the disease progresses.

Telemedicine in OA Management

Telemedicine enhances access to care, particularly for patients in remote areas, allowing continuous monitoring and adherence to rehabilitation programs. Remote consultations via telehealth platforms support physical therapy and self-management, extending the reach of CoEs (41, 42). Telerehabilitation has also shown benefits in implementing home rehabilitation exercises, reducing healthcare costs (42).

For successful telemedicine integration, it is essential to establish clear criteria for patient selection, ensuring the system’s effectiveness. Ideal candidates for telemedicine include technologically proficient patients with access to necessary equipment (e.g., smartphones, computers), and those motivated to engage in remote care. Telemedicine is especially beneficial for patients in rural or underserved areas who have limited access to in-person healthcare services.

Patients with mild to moderate OA, particularly in the early stages of the disease, are likely to benefit the most from telemedicine, as it can help prevent disease progression and improve functional outcomes. While telemedicine may still play a supplementary role for patients with advanced OA, particularly in follow-up consultations, education, and monitoring, it is less likely to replace in-person interventions for complex clinical needs.