Medical management of osteoarthritis
BMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7266.936 (Published 14 October 2000) Cite this as: BMJ 2000;321:936
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Editor
Walker-Bone and colleagues have reviewed an extremely common
condition, which causes considerable disability (1). Patient education is
increasingly important in the area of arthritis, but has also been around
for longer than the nine years included in this review. Unfortunately the
authors have failed to provide an accurate account of patient education.
Patient education is a set of very diverse approaches, which should
not be assumed to be comparable. The meta-analysis quoted (2) included
very heterogeneous studies (e.g. stress reduction, home-study behavioural
instruction, telephone information and support). The conclusions of the
authors of this meta-analysis that there is a significant beneficial
effect of education on joint pain have been included in this review,
despite the confidence intervals for the effect sizes including zero. The
original authors interpretation of the results, has also been criticised
as being inaccurate by the Cochrane review body (3).
Amalgamating the results of studies is difficult but reviewers must
analyse and interpret data themselves or risk perpetuating results that
may be flawed. The authors focus was to provide a pragmatic approach to
care, but a rigourous approach to evaluating the evidence is a necessary
first step.
1 Walker-Bone, K., Javaid, K., Arden, N and Cooper, C. Medical
management of osteo-arthritis. British Medical Journal 2000;321: 936-940.
2 Superio-Cabuslay, Ward, M and Lorig, K. Patient education interventions
in osteoarthritis and rheumatoid arthritis: A meta-analytic comparison
with nonsteriodal antiinflammatory drug treatment. Arthritis Care and
Research 1996; 9 292-301.
3 The Cochrane Library: Database of Abstracts of Reviews of Effectiveness.
1997.
Competing interests: No competing interests
I read with great interest the paper by Karen Walker-Bone et
al.However,I was surprised by the proposed algorithm for the management of
osteoarthritis.Although the authors underlined the crucial role of
education and physiotherapy,it is important to keep in mind that optimal
management of osteoarthritis should combine pharmacological and
nonpharmacological interventions[1].Furthermore,the place of topical
NSAIDs is disputable.Since "there is reasonably strong evidence to
conclude that topical NSAIDs are effective and safe" for these
patients,they should be used in those patients who do not respond to
paracetamol alone.In other words,systemic NSAIDs,including COX-2
inhibitors should be considered if a patient failed to respond to
topically applied NSAIDs.Based on the meta-analysis by Moore et
al[2],local skin reactions were rare(3.6%) and systemic side effects were
less than 0.5% in patients receiving topical NSAIDs.These figures compare
favourably with those of any NSAID given orally.
1.Wollheim FA.Current pharmacological treatment of
osteoarthritis.Drugs 1996;52(Suppl 3:27-38.
2.Moore RA,Tramèr MR,Carroll D,Wiffen PJ,McQuay HJ.Quantitative systematic
review of topically applied non-steroidal anti-inflammatory drugs.BMJ
1998;316:333-8.
Competing interests: No competing interests
The authors wrote;
"The use of acupuncture is supported by case series and uncontrolled
studies, but trials that have compared random needling with acupuncture
have failed to show measurable benefit for true acupuncture".
Unfortunately, the authors forgot to add that the studies with no
measurable outcome of benefit were methodologically flawed, as originally
noted by Ernst (1). Hence the results are less than useful in the authors
non-support of acupuncture. In fact, their support for physiotherapy
without providing any data represents a bias in their evaluation of non-
pharmcological agents in the treatment of osteoarthritis. Perhaps in
future, a non-partison approach in evaluating studies for both acupuncture
and physiotherapy will provide a better balanced evaluation of non-
pharmcological therapies for the treatment of osteoarthritis.
Sean Walsh
B.Hlth.Science. (Acupuncture)
1. Ernst E. Acupuncture as a symptomatic treatment of osteoarthritis.
Scand J Rheumatol 1997; 26: 444-447
Competing interests: No competing interests
Karen Walker-Bone and her colleagues gave an excellent review of
recent management strategies of OA. But they miss to evaluate a
traditional and complementary alternative; balneotherapy or spa therapy
existing for centuries and enjoying a rejuvenate recently(1). Last decade,
some randomised, controlled trials published in English and reported
modest short and long term effects in reducing pain and improving
functional indexes(2-5). A Cochrane Review on balneotherapy for rheumatoid
arthritis and osteoarthritis has concluded that "One cannot ignore the
positive findings reported in most trials. However the scientific evidence
is weak because of the poor methodological quality"(6)
1. Sukenik S, Flusser D, Abu-Shakra M. The role of spa therapy in
various rheumatic diseases. Rheum Dis Clin North Am. 1999;25:883-97.
2. Elkayam O, Wigler I, Tishler M, Rosenblum I, Caspi D, Segal R, Fishel
B, Yaron M. Effect of spa therapy in Tiberias on patients with rheumatoid
arthritis and osteoarthritis. J Rheumatol. 1991;18:1799-803.
3. Wigler I, Elkayam O, Paran D, Yaron M. Spa therapy for gonarthrosis: a
prospective study. Rheumatol Int. 1995;15:65-8.
4. Nguyen M, Revel M, Dougados M. Prolonged effects of 3 week therapy in a
spa resort on lumbar spine, knee and hip osteoarthritis: follow-up after 6
months. A randomised controlled trial. Br J Rheumatol. 1997;36:77-81.
5. Sukenik S, Flusser D, Codish S, Abu-Shakra M. Balneotherapy at the Dead
Sea area for knee osteoarthritis. Isr Med Assoc J. 1999;1:83-5.
6. Verhagen AP, de Vet HC, de Bie RA, Kessels AG, Boers M, Knipschild PG
Balneotherapy for rheumatoid arthritis and osteoarthritis. Cochrane
Database Syst Rev 2000;(2):CD000518
Competing interests: No competing interests
The medical management of osteoarthritis
EDITOR: Several recent lay publications enthusiastically promote the
benefits of glucosamine and chondroitin preparations in osteoarthritis
(1). This has led to a surge of interest among patients and spectacular
success in the marketplace; sales in the US approach $1 billion. The
medical community has been reluctant to endorse these products,
principally because of concerns about the quality of the evidence
available from clinical trials. Since the completion of our review, there
have been several research developments.
The issue of trial quality was recently reviewed by McAlindon et al
(2). From 37 identified placebo-controlled clinical trials of symptom
relief in osteoarthritis with glucosamine and chondroitin preparations, 15
fulfilled pre-defined quality inclusion criteria for their meta-analysis.
It was the authors' overall conclusion that the clinical trials
demonstrated substantial effects on symptom relief in osteoarthritis, but
that attendant methodological biases were likely to exaggerate the size of
these benefits.
The chondroprotective properties of glucosamine sulphate have been
evaluated in two recent randomised controlled trials (3,4). The data from
each of these are currently only available in abstract form but both
studies show a statistically significant reduction in joint space
narrowing among patients receiving 1500mg of glucosamine sulphate daily,
compared with placebo, over three years of follow-up.
These agents are safe and are readily available to patients in health food
shops and by mail order. As a consequence, they have great potential
utility in the management of osteoarthritis, even if only modestly
effective. Further data on efficacy and cost utility are eagerly awaited.
Dr Karen Walker-Bone
Dr Kassim Javaid
Dr Nigel Arden
Professor Cyrus Cooper
(1) Theodosakis J, Adderly B, Fox B. The Arthritis Cure. New York, NY: St
Martin's Press; 1997.
(2) McAlindon TE, LaValley MP, Gulin JP, Felson DT. Glucosamine and
chondroitin for treatment of osteoarthritis. JAMA 2000;283:1469-75.
(3) Reginster J-Y, Deroisy R, Paul I, Lee RL, Henroitoin Y, Giacovelli G,
et al. Glucosamine sulfate significantly reduces progression of knee
osteoarthritis over 3 years: A large, randomised, placebo-controlled,
prospective trial. Arthritis Rheum 1999;42: S400.
(4) Pavelka K, Olejarova M, Machacek S, Giacovelli G, Rovati LC.
Glucosamine sulfate decreases progression of knee osteoarthritis in a long
-term randomised placebo-controlled trial. Arthritis Rheum 2000;43: S384
Competing interests: No competing interests