BMJ  2005;330:673 (19 March), doi:10.1136/bmj.330.7492.673

Letter

Managing osteoarthritis of the knee

Holistic approach is important

EDITOR—The editorial by MacAuley on managing osteoarthritis of the knee provides a welcome emphasis on the EULAR recommended, holistic, multidisciplinary approach to the condition.¹

Excessive prescribing of non-steroidal anti-inflammatory drugs in primary care reflects the dependence of health professionals on "medicines based evidence" rather than evidence based medicine and the chronic underinvestment in other approaches to osteoarthritis of the knee.² No reference was made to evidence of benefit of weight loss programmes linked to exercise; this is important, since increasing levels of obesity and incident knee osteoarthritis are strongly associated.³ Even relatively small amounts of weight loss can reduce pain and improve activity levels. At the point at which knee replacement is appropriate, severely disabled patients with a high body mass index may be denied surgery.

MacAuley comments that physiotherapy may delay decline. Community physiotherapists could have a central role in the treatment of knee osteoarthritis, using motivating clinical skills for individual or group exercise programmes, gait retraining, taping, falls prevention, walking aids, footwear advice, and pain relief techniques including acupuncture and steroid injections.⁴ The new cohort of NHS physiotherapy practitioners with extended scope can independently assess, treat, and improve appropriateness of referral to orthopaedic consultants.⁵ A physiotherapist may be a highly appropriate lead musculoskeletal specialist in primary care, providing a functional approach to treatment to minimise disability for people with osteoarthritis of the knee and overall offering far more in a consultation than the average general practitioner.

The large community disability burden and high knee pain referral rates to orthopaedic specialists, warrant intervention at a population level and an integrated care pathway for osteoarthritis of the knee.³ Primary care trusts are in an ideal position to develop expert initiatives for patients, encourage the use of community sports facilities, and promote the work of voluntary bodies such as the Arthritis Research Campaign, which provide excellent patient information and professional education resources.

Woodhouse Medical Centre, Sheffield S13 7LY C.Mitchell{at}sheffield.ac.uk

Barnsley District General Hospital, Barnsley S75 2ED

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Competing interests: None declared.

References

1. MacAuley D. Managing osteoarthritis of the knee. BMJ 2004;329: 1300-1. (4 December.)[Free Full Text]
2. Dieppe P. Evidence-based medicine or medicines-based evidence? Ann Rheum Dis 1998;57: 385-6.[Free Full Text]
3. Underwood MR. Community management of knee pain in older people: is knee pain the new back pain? Rheumatology 2004;43: 2-3.[Free Full Text]
4. Jordan KM, Arden NK, Doherty M, Bannwarth B, Bijlsma JWJ, Dieppe P, et al. EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT). Ann Rheum Dis 2003;62: 1145-55.[Abstract/Free Full Text]
5. Hattam P, Smeatham A. Evaluation of an orthopaedic screening service in primary care. Br J Clin Governance 1999;4: 45-9. 1999.

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Relevant Article

Managing osteoarthritis of the knee

Domhnall MacAuley
BMJ 2004 329: 1300-1301. [Extract] [Full Text] [PDF]