Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Intra operative death
- Peter S L Barling (4 December 2004)
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Management of OA
- Roger Chalmers (6 December 2004)
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Bicycle ergometer in osteoarthritis of the knee?
- Madhur D Bhattarai (6 December 2004)
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Physiotherapy led exercise is effective
- Christopher, J. McCarthy (7 December 2004)
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Osteoarthritis of the knee – vitamin D is important
- Peter J Lewis (10 December 2004)
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A holistic approach to knee osteoarthritis
- Caroline A Mitchell, Ade Adebajo, Consultant Rheumatologist, Barnsley (7 January 2005)
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Opioids to manage pain in osteoarthritis
- Martin Johnson (1 March 2005)
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Re: Opioids to manage pain in osteoarthritis
- Dr. Herbert H. Nehrlich (2 March 2005)
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Glucosamine & Chondroitin Sulphate in Osteoarthritis of the Weight Bearing Joints
- Kevin Hardinge (8 March 2005)
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Re: Glucosamine & Chondroitin Sulphate in Osteoarthritis of the Weight Bearing Joints
- milind m deshpande (21 March 2005)
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Peter S L Barling, GP OSWESTRY
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Dear Sir, Your quoted intra operative death rate of 0.5% is certainly worrying.Our local Orthopaedic Hospital have had no such deaths in the last 500 patients having this form of surgery,and not the expected two and a half.Does this mean that other centres are in excess of this percentage and if so ,should we not avoid them? Peter Barling Competing interests: None declared |
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Roger Chalmers, Full time NHS locum GP East Anglia
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Thank you for this excellent review. Can anyone explain why glucosamine / chondoitin is usually recommended (as by the author) as an off prescription preparation, despite evidence of efficacy that is as good or better than most NSAIDs (and despite the latter drugs huge burden of morbidity and mortality)? Yet me-too NSAIDs, and cleverly marketed variations of the theme continue to be licensed and adopted for NHS prescription for OA, and I am sure will continue to do so despite the Cox- 2 debacle (remember also benoxaprofen - Opren - 25 years ago?). Most patients with OA will qualify for free prescriptions and are in the age group with least income flexibility. Most do not need surgery, but are still suffering. I understand that glucosamine is actually prescribable but rheumatologists and GPs seem to advise patients to buy their own - why? I fear that the background to this is the huge threat to NSAID sales that is posed by any form of help that patients with OA may receive from other sources. And no doubt due to worries about costs from the NHS financial side - but why do we spend on many expensive NSAIDs, with no convincing overall benefit to patients over cheaper alternatives (and sometimes major harms as shown by recent events re Cox 2s) and not on glucosamine /chondroitin? Competing interests: Concerned about the damaging effect if drug company influence on NHS and doctors decisions in the interest of patients |
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Madhur D Bhattarai, Consultant Physician Bir Hospital, Post Box: 3245, Kathmandu, Nepal
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Editor -- I feel MacAuley (1) has rightly highlighted that for the management of osteoarthritis of the knee the facilities for getting people started and providing support through a programme of exercise training are not commonly available, so referral is rarely an option. NSAIDs do not seem to offer a long term solution (2). Total knee replacement is a good, but virtually a last, option when other strategies fail. For most patients the most difficult period is between onset of the symptoms and the point when surgery becomes necessary (1). In this regard, I would like to add that I had noticed a possible beneficial effect of bicycle ergometer in the management of osteoarthritis of the knee (3). The advantage of bicycle ergometer is that it does not require multiple visits and referrals to exercise training programme; the exercise can be easily continued at home. Thus, the beneficial effect of exercise with a bicycle ergometer in the management of osteoarthritis of knee, a common condition with limited therapeutic options, deserves further study. Reference 1. MacAuley D. Managing osteoarthritis of the knee. BMJ 2004; 329: 1300-1. 2. Bjordal JM, Ljunggren AE, Klovning A, Slørdal L. Non-steroidal anti-inflammatory drugs, including coxibs, in osteoarthritic knee pain: a meta-analysis of randomised placebo-controlled trials. BMJ 2004; 329: 1317 -20. 3. Bhattarai MD. Osteoarthritis of the knee. Lancet 1997; 350: 1328. Competing interests: None declared |
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Christopher, J. McCarthy, Research Physiotherapist The Centre for Rehabilitation Science, University of Manchester
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Dear Sir, In a month where physiotherapy practice has been criticised following the Oxford Low Back Pain study(1) and also praised for it’s effectiveness in the same condition(2) it is encouraging to see the editor of the BMJ recommending physiotherapy for another common musculoskeletal condition. Exercise provision, for patients with knee osteoarthritis, has been strongly recommended in a recent multidisciplinary Delphi consensus(3) and more recently a Health Technology Assessment Agency report(4) has shown that supplementing home exercise with physiotherapy led class exercise provides patients with clinically important long-term reductions in pain. Physiotherapists are in the position of having strong evidence for only some of the treatments currently provided, however we would all agree with the editor in asserting that physiotherapy led exercise is something we should be strongly recommending to patients with knee osteoarthritis. Reference List (1) Frost H, Lamb SE, Doll HA, Carver PT, Stewart-Brown S. Randomised controlled trial of physiotherapy compared with advice for low back pain. BMJ 2004; 329(7468):708. (2) Wand BM, Bird C, McAuley JH, Dore CJ, MacDowell M, De Souza LH. Early intervention for the management of acute low back pain: a single- blind randomised controlled trial of biopsychosocial education, manual therapy, and exercise. Spine 2004; 29(21):2350-2356. (3) Roddy E, Zhang W, Doherty M, Arden NK, Barlow J, Birrell F et al. Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or knee--the MOVE consensus. Rheumatology (Oxford) 2004. e publication ahead of print doi:10.1093/rheumatology/keh399 (4) McCarthy CJ, Mills PM, Pullen R, Richardson G, Hawkins N, Roberts CR et al. Supplementation of a home-based exercise programme with a class-based programme for people with osteoarthritis of the knees: a randomised controlled trial and health economic analysis. Health Technol Assess 2004; 8(46):1-76. Competing interests: None declared |
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Peter J Lewis, integrative physician 15 South Steyne, Manly, NSW 2095, Australia
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Editor – I was surprised to see no mention at all of the importance of vitamin D in MacAuley’s editorial on managing osteoarthritis of the knee (BMJ 220;329:1300-1301). Normal cartilage metabolism depends on the presence of vitamin D, and research indicates that maintaining adequate levels of vitamin D may slow the progression and possibly help prevent the development of osteoarthritis (OA). Vitamin D has a direct effect on articular cartilage by stimulating synthesis of proteoglycan by articular chondrocytes (2) Low serum levels of vitamin D levels have been associated with an increased risk for progression of knee OA. High levels of vitamin D increase muscle strength and improve physical function in patients with knee OA, according to a recent study presented at the American College of Rheumatology annual meeting (3). In this study of 221 patients with knee OA, who had an average age of 67, were followed up over a 30-month period. It was found that persons with low baseline vitamin D levels (</= 20 ng/ml [50 nmol/L]) had more knee pain and disability compared with those who were not vitamin D deficient (> 20 ng/ml [50 nmol/L]). The study also found that changes in vitamin D status over time predicted changes in disability. Those with sufficient serum vitamin D that became deficient over time experienced worsening disability scores, while those with deficient serum vitamin D that became sufficient over time improved their disability scores. As data indicates that many people may be vitamin D deficient (especially the elderly and darker skinned individuals), serum 25- hydroxyvitamin D levels should be measured in all patients with knee OA, and vitamin D supplementation, preferably as vitamin D3 (cholecalciferol; typical dose 4,000 IU daily), prescribed if needed. Evidence suggests that optimal levels of 25-hydroxyvitamin D are in the range 100-150 nmol/L. References 1. MacAuley D. Managing osteoarthritis of the knee. BMJ 2004;329:1300 -1301. 2. Gerstenfeld LC, Kelly CM, Von Deck M, Lian JB. Effect of 1,25- dihydroxyvitamin D3 on induction of chondrocyte maturation in culture: extracellular matrix gene expression and morphology. Endocrinology 1990;126:1599-1609. 3. Baker K, Zhang YQ, Goggins J, Clancy M, LaValley M, Niu J, Felson D. Hypovitaminosis D and its association with muscle strength, pain and physical function in knee osteoarthritis: A 30-month longitudinal, observational study. Presentation Number: 1755. Presented at the American College of Rheumatology annual meeting, San Antonio, October 20, 2004. Competing interests: None declared |
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Caroline A Mitchell, General Practitioner/Senior Clinical Lecturer Woodhouse Medical Centre, Sheffield S13 7LY, Ade Adebajo, Consultant Rheumatologist, Barnsley
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This editorial provides a welcome emphasis on the EULAR recommended holistic, multidisciplinary approach to knee osteoarthritis. Excessive primary care prescribing of NSAIDs reflects the dependence of health professionals on ‘medicines based evidence’ rather than evidence based medicine and the chronic underinvestment in other approaches to knee osteoarthritis 1. Surprisingly no reference was made to evidence of benefit of weight loss programmes linked to exercise; important since there is a strong association between increasing levels of obesity and incident knee osteoarthritis 2. Even relatively small amounts of weight loss can reduce pain and improve activity levels3. At the point at which knee replacement is appropriate, severely disabled patients with a high BMI 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 injections4. The new cohort of NHS physiotherapy extended scope practitioners can independently assess, treat and improve appropriateness of referral to orthopaedic consultants 5. A physiotherapist may be a highly appropriate lead primary care musculoskeletal specialist, providing a functional treatment approach to minimise disability for people with knee osteoarthritis and overall offering far more in a consultation than the average GP. The large community disability burden and high knee pain referral rates to orthopaedic specialists, warrant population level intervention and an integrated care pathway for knee osteoarthritis2. Primary Care Trusts are in an ideal position to develop expert patient initiatives, encourage the use of community sports facilities and to promote the work of voluntary bodies such as the Arthritis Research Campaign, which provide excellent patient information and professional education resources. Reference List 1. Dieppe P. Evidence-based medicine or medicines-based evidence? Ann Rheum Dis 1998;57:385-6. 2. Underwood MR. Community management of knee pain in older people: is knee pain the new back pain? Rheumatology 2004;43:2-3. 3. Madhok R, Kerr H, Capell HA. Rheumatology. BMJ 2000;321:882-5. 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. 5. Hattam, P. and Smeatham, A. Evaluation of an orthopaedic screening service in primary care. British Journal of Clinical Governance 4(2), 45-49. 1999. Competing interests: None declared |
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Martin Johnson, General Practitioner Barnsley
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MacAuley raises a very important point regarding the poor long-term management of pain in osteoarthritis (OA). A recent survey carried out by Arthritis Care (1) in order to assess the impact of OA on patients showed that a staggering 81% of the sample said they experience constant pain and that when their OA is bad, 69% have difficulty carrying out even the simplest of daily household tasks. Undoubtedly exercise is of benefit to patients with mild to moderate OA, so our priority as healthcare professionals should be the symptomatic relief of chronic pain. Along with paracetamol and NSAIDs there is further ammunition at our disposal to target pain relief. Opioid therapy can and should be considered in these patients. As stated by the Pain Society (2), the primary effect of the appropriate use of opioids in chronic pain is analgesia which leads to improved function, sleep and reduced distress. There may also be a reduction in use of other analgesics. With improved education of healthcare professionals and the patient, opioid treatment can be initiated and managed in the primary care setting through developing an individualised treatment plan in discussion with the patient. Thus doctors in general practice should recognise that appropriate prescribing of opioids can offer a significant increase in a patient’s quality of life. References (1)’OA nation: the most comprehensive UK report of people with osteoarthritis’ Arthritis Care. TNS. April 2004 (2) ‘Recommendations for the appropriate use of opioids for persistent non -cancer pain’ The Pain Society, March 2004 Competing interests: Dr Martin Johnson has carried out consultancy work with Napp Pharmaceuticals, Pfizer, Janssen-Cilag |
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Dr. Herbert H. Nehrlich, Private Practice Bribie Island, Australia 4507
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I suggest to Dr. Johnson that, instead of listening to the Pain Society or to patients demanding heavy duty medication for their pain, he avail himself of the work of Dr. Kaufman on Niacinamide for the treatment (not management) of OA of the knee. Kaufman presented his work in the late 1940's and it never ceases to amaze me how some of these breakthroughs are either completely ignored or take 40 years (on average) to become (grudgingly) accepted. The use of opioids for OA of the knee is akin to operating on carpal tunnel syndrome without first trying the rather harmless Pyridoxine therapy. As Dr. Kaufmann pointed out, over two thirds of OA patients benefitted significantly from Niacinamide treatment, as over 80 % of carpal tunnel patients are cured by Vitamin B 6. It's a bit like having the steroid syringe handy for anything that hurts. drhhnehrlich@westnet.com.au Competing interests: None declared |
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Kevin Hardinge, Consultant Orthopaedic Surgeon 10 St John Street, Manchester, M3 4DY.
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Re: Glucosamine and Chondroitin Sulphate in Osteoarthritis of the Weight Bearing Joints. I am not able to understand the logic of taking these medicaments for degenerative arthritis of the weight bearing joints. Presumably the cartilage deteriorates because of biological or biomechanical reasons and merely taking the components of the articular cartilage in excessive amounts would not normally be expected to be of benefit. I wonder if there is any basic evidence for taking these medicaments which are very expensive. Competing interests: None declared |
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milind m deshpande, consulting orthosurgeon hubli,India 580031
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Sir I have used the combination in over 1500 patients and have been able to bring down the need for NSAIDS substantially. However I do not prescribe it to diabetics since I have observed a definite loss of glycemic control. I use glucosamine hydrochloride in patients allergic to sulpha. Competing interests: None declared |
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