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EDITORIALS: Carmel M Hughes and Chris M Bleakley Treatment of knee pain in primary care: Pharmacists and physiotherapists need to be a part of the team BMJ 2006; 333: 981-982 [Full text]

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Need for Integrated Patient Care Pathway

Suresh Kumar Chhetri   (13 November 2006)

treatment of knee pain

edwin n wardle   (15 November 2006)

Physio and acupuncture

Rod N Mitchell   (16 November 2006)

Knee Pain in Primary Care Treatment

Mark R Palmer   (28 November 2006)

Need for Integrated Patient Care Pathway 13 November 2006
Suresh Kumar Chhetri, Clinical Observer Rheumatology, Pontefract General Infirmary, WF8 1PL Send response to journal: Re: Need for Integrated Patient Care Pathway	The study conducted by Hay et al1 to evaluate the effectiveness of enhanced pharmacy review and community physiotherapy on the management of knee pain in people aged over 55 presenting to primary care surfaces an interesting finding that effects of such interventions are short lived. The pharmacy group showed significant improvements in pain and needed less anti inflammatory drug; however these effects were not sustained for long. Poor adherence to treatment has been offered as a possible explanation. This arises either because of apparent lack of effect or the real or perceived side effects of the drugs. The placebo effect of being a part of the study might in itself explain the encouraging results noticed at the outset. The authors of the study have concluded that community physiotherapy affected a shift in care from a traditional general practitioner led model. However, it is interesting to note that the study did not have a design to reflect this finding. A study comparing the effectiveness of a conventional General Practitioner led multidisciplinary team approach with that of a pharmacy review and physiotherapy program would have been best placed to arrive at this conclusion. The result of the study definitely shows the short lived effectiveness of community treatment .This may underline the need for a well structured integrated patient care pathway to ensure effective follow up and referral to appropriate specialist services so that patients do not drop out of the nest of service and continue to experience sustained benefits. 1. Hay EM, Foster NE, Thomas E, Peat G, Phelan M, Yates HE, Effectiveness of community physiotherapy and enhanced pharmacy review for knee pain in people aged over 55 presenting to primary care: pragmatic randomised trial. BMJ 2006 doi: 10.1136/bmj.38977.590752.0B Competing interests: None declared
treatment of knee pain 15 November 2006
edwin n wardle, retired physician Baldock SG7 6SY Send response to journal: Re: treatment of knee pain	As a long time sufferer from bilateral medial compartment degeneration caused by running long distance on roads ,and also running up and down mountains,I would like to share a benefit that I have developed in the form of a lotion that is rubbed into the skin over the medial joint line of the knees twice or thrice daily.This lotion is citric acid 20 grams,glycerol 60 mls and chloroform spirit 40 mls.Clearly it must not be applied to any large nerves as on the outer side of the knees.The analgesic effect is quite effective. Furthermore citric acid seeping into the skin helps the local synthesis of glycosaminoglycans.Unfortunately there has been no trial,but used sensibly,its effect is impressive E Nigel Wardle MRCP. Competing interests: None declared
Physio and acupuncture 16 November 2006
Rod N Mitchell, Private Practise Physiotherapist Langford Physio and Medical Acupuncture, 105-877 Goldstream Ave., V ictoria, Canada, V9B 2X8 Send response to journal: Re: Physio and acupuncture	It’s nice to see physiotherapy getting a mention in the BMJ. Physio can cover quite different approaches and the protocols used need to be assessed. A simple approach might be something specific, in this case inner range quads exercises; some functional exercise which might be the mechanics of getting out of a chair; and a home assessment that would include among other things making sure that the height of the chairs was such as to allow safe movement from sitting to standing and clearing the floor of obstacles that might cause a fall. Treating pain and swelling with acupuncture at the knee ‘eye’ points is simple and very effective. I have found it to be diagnostic in the sense that if the problem is a simple one then the swelling will resolve very quickly, only one to three treatments needed, but if the swelling does not resolve then further investigation is probably a good idea. Competing interests: None declared
Knee Pain in Primary Care Treatment 28 November 2006
Mark R Palmer, GP Warwick CV34 5QJ Send response to journal: Re: Knee Pain in Primary Care Treatment	It would have been interesting to have studied if improved specific training for the GPs based on audits of their own cases of knee pain would have produced a better oucome.. Also GPs are currently being actively discouraged from referring patients by local PCT targets and are then described as over referrers so are then seen as being out of step clinicians-it would be interesting to know if this was a factor in the study group.. Little impact on workload is not surprising as patients often have several reasons for presenting so eliminating one does not stop them coming in for their other problems -also if one group of patients that has one problem does not present then other bodies do who might not otherwise have been able and they may have multiple problems thereby increasing workload! Unfortunately there is inherent bias within the editorial as no GP was involved in the authorship of the study whereas both pharmacy and physiotherapist were.. Competing interests: general practitioner