BMJ  2005;330:E336 (12 February), doi:10.1136/bmj.330.7487.E336

BMJ USA: Editor's choice

Kneed to know

One of my medical school teachers told us that God made a mistake when He (God had a gender then) designed our knees. Another said it was our own fault for walking up-right, as knees just weren't designed to take that kind of stress. The human knee is a joint that is both frequently injured and seemingly not up to the job of lasting our current extended lifetimes carrying our current excess of weight. The results: osteoarthritis, and a good part of this issue.

Non-steroidal anti-inflammatory drugs (NSAIDs) are the mainstay of treating osteoarthritis. Jan Bjordal and colleagues systematically reviewed clinical trials of NSAID treatment of osteoarthritic knee pain (p 18). They found that the drugs helped in the short term but there was little evidence for their long-term use. In an accompanying editorial (p 8), general practitioner Domhnall MacAuley offers some practical advice: start with acetaminophen and strength training, and use NSAIDs and joint injections sparingly and intermittently.

What about acupuncture? Jorge Vas et al (p 24) randomized 97 patients with knee osteoarthritis to receive diclofenac plus either acupuncture or sham acupuncture. Admittedly, it was not a perfect study: it lasted only 12 weeks, the acupuncturist carried out the evaluations, and some patients may have seen through the placebo needle technique. The results were positive, however, with improved physical function and quality of life and decreased pain seen in the acupuncture plus NSAID group.

When arthritis pain can no longer be controlled and/or function is significantly reduced, surgery can offer relief. Gidwani and Fairbank (p 32) review what surgeons can do for these patients. While arthroscopic palliative measures for osteoarthritic knees have been discredited, total knee replacement usually brings impressive pain relief and functional improvement. Questions remain about specific techniques and the timing of knee replacement, and complications are fairly common, but most patients are happy with their results. The future offers hope that more precise, minimally invasive surgery will replace today's techniques.

We also explore the placebo effect in this issue, with report of a survey of Israeli doctors and nurses by Nitzan and Lichtenberg (p 28). The vast majority of respondents said they use placebo medications on occasion and find them effective. Most deceived their patients by telling them they were receiving actual medication. Others used placebos as a diagnostic tool, reasoning (incorrectly) that if the patient responded to a placebo their pain was not "real." David Spiegel (p 9) points out that placebos can be best understood as an extension and effect of the doctor-patient relationship, what psychiatrist Michael Balint called the most powerful pill of all: the doctor.

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