Recent rapid responses

Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on Although a selection of rapid responses will be included as edited readers' letters in the weekly print issue of the BMJ, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window.

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Thank you for a super article.

Sadly no mention of consideration of referral to a Pain Clinic particularly given the lack of a curative treatment and hence the necessity of symptomatic treatment.

Competing interests: None declared

Competing interests: None declared

Dominic J Aldington, Cons Anaes

Frimley Park Hospital Trust, GU16 5UJ

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We find it remarkable that a review of osteoarthritis can be published in 2006 without reference to treatment with acupuncture.1 In their review, Hunter and Felson ignore three high quality studies in the last two years which demonstrate the benefit of acupuncture for pain and function in osteoarthritis of the knee.2-4 These reviewers are demonstrating a case of ‘acupuncture blindness’, but fortunately this is not shared by either our patients or primary care services.5 Acupuncture is worthy at least of discussion in terms of patient preference, safety and the increasing good quality evidence of effectiveness.

Even patients whose osteoarthritis is severe enough for them to have been referred to secondary care still give high priority to safety of their treatment.6 Acupuncture in trained hands is known to be safe,7 and it is increasingly popular with patients and their doctors.5 Our recent work (systematic review, in submission) shows that acupuncture is significantly superior to sham treatment for chronic knee pain, and provides an effect on pain of about 4 units on the WOMAC subscale. This may be modest in clinical terms but reflects a percentage of patients who gain worthwhile benefits. Most importantly, two of the studies suggest that the benefits are sustained for at least 6 months,2;4 which certainly cannot be claimed for non-steroidal anti-inflammatories.8 Only physiotherapy exercises show evidence of a similar long-term effect.9

It could be relevant to speculate on the aetiology of the ‘acupuncture blindness’ of the reviewers, which is commonly observed among doctors. It could arise from lack of awareness that the effects that acupuncture can now be understood in terms of western science: among several mechanisms that underlie acupuncture needling, the ones most relevant to osteoarthritis are stimulation of A delta nerve fibres which produces sustained analgesic effects both in the dorsal horn,10 and in higher pain processing centres.11

Hunter and Felson rightly state that osteoarthritis should be managed on an individual basis which will probably consist of a combination of treatment options. Future research needs to tease out how we can better individualise treatment, including acupuncture and exercise, and which patient subgroups appear to do better with different treatment approaches.

Reference List

(1) Hunter DJ, Felson DT. Osteoarthritis. BMJ 2006; 332(7542):639- 642.

(2) Berman BM, Lao L, Langenberg P, Lee WL, Gilpin AM, Hochberg MC. Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: a randomized, controlled trial. Ann Intern Med 2004; 141(12):901 -910.

(3) Vas J, Mendez C, Perea ME, Vega E, Panadero MD, Leon JM et al. Acupuncture as a complementary therapy to the pharmacological treatment of osteoarthritis of the knee: randomised controlled trial. BMJ 2004;(7476):- 9.

(4) Witt C, Brinkhaus B, Jena S, Linde K, Streng A, Wagenpfeil S et al. Acupuncture in patients with osteoarthritis of the knee: a randomised trial. Lancet 2005; 366(9480):136-143.

(5) Thomas KJ, Coleman P, Nicholl JP. Trends in access to complementary or alternative medicines via primary care in England: 1995- 2001 results from a follow-up national survey. Fam Pract 2003; 20(5):575- 577.

(6) Fraenkel L, Bogardus ST, Jr., Concato J, Wittink DR. Treatment options in knee osteoarthritis: the patient's perspective. Arch Intern Med 2004; 164(12):1299-1304.

(7) Vincent C. The safety of acupuncture. BMJ 2001; 323(7311):467- 468.

(8) Bjordal JM, Ljunggren AE, Klovning A, Slordal L. Non-steroidal anti-inflammatory drugs, including cyclo-oxygenase-2 inhibitors, in osteoarthritic knee pain: meta-analysis of randomised placebo controlled trials. BMJ 2004; 329(7478):1317.

(9) Walker-Bone K, Javaid K, Arden N, Cooper C. Regular review: medical management of osteoarthritis. BMJ 2000; 321(7266):936-940.

(10) Sandkuhler J. Learning and memory in pain pathways. Pain 2000; 88(2):113-118.

(11) Bowsher D. Mechanisms of Acupuncture. In Filshie J, White A, eds. Medical Acupuncture: a Western Scientific Approach, pp 69-82. Edinburgh: Churchill Livinstone, 1998.

Competing interests: AW and MC are employees of the British Medical Acupuncture Society: AW as editor in chief of the journal Acupuncture in Medicine, MC as Medical Director. AW also runs a small private acupuncture practice. NEF is involved in the management of the APEX trial of acupuncture and exercise for knee pain in older adults. PB receives income from teaching acupuncture.

Competing interests: None declared

Adrian R White, Clinical Research Fellow, Peninsula Medical School

Nadine Foster, Mike Cummings, Panos Barlas

N32 ITTC Building, Tamar Science Park, Plymouth PL6 8BX

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In a recent issue of your journal, Hunter and Felson (2006) deliver a consistent and a seemingly thorough clinical review about management of knee osteoarthritis (KOA) for primary care doctors. We would like to make a few comments. We do not entirely agree with the statement “Paracetamol (up to 4g/day) is the oral analgesic of choice for mild to moderate pain in osteoarthritis”. There is fairly strong evidence from randomised controlled trials that paracetamol is no better than placebo for the average KOA patient (Case et al. 2003; Miceli-Richard et al. 2004). Furthermore, their statement that NSAIDs “… are sometimes the first choice because of greater efficacy…” in spite of “…certain disadvantages…” needs to be considered in the context of a meta-analysis which we published in your journal that showed that NSAID efficacy in KOA is smaller than one might believe (Bjordal et al. 2004).

We commend Hunter and Felson for promoting the role of non- pharmacological interventions and for highlighting the problem of inadequate funding in this area because of “lucrative opportunities for drug development”. However, one striking omission was an appraisal of physical agents (PA), despite their widespread use in primary care (Peterson et al. 2005). We fear that this omission reinforces a myth that scientific evidence for PA is non-existent, which is clearly not true. Physical therapy (or the English equivalent “Physiotherapy”) is listed by the authors with several treatment techniques included, but PAs are never mentioned. We should not dismiss PAs under an umbrella term of ‘Physiotherapy’, because physiotherapy is a profession not a treatment and many non-physiotherapists use PAs as part of their treatment strategies.

We undertook a cursory search of the literature and identified at least 26 randomised placebo-controlled trials and 6 systematic reviews of PA interventions for OAK in Medline-indexed journals and the Cochrane Library. Some commonly used PAs have received little attention (e.g. ultrasound therapy and heat/cold therapy) whereas others have been extensively investigated. For example, acupuncture and transcutaneous electrical nerve stimulation (TENS) have been investigated to an extent where statistical power and methodological quality is at least on a similar level to the oral drug of choice (paracetamol). One might claim that trials with PAs end up with negative results more often than drug trials, but this is a result of inadequate procedures and under- or overdosing rather than a sign of lacking efficacy. In one sense, it may be forwarded that PA research is in a phase where negative results are needed to clarify limits of optimal dose intervals. And because of PAs´ superior safety these dose-finding trials take place in a clinical setting rather than pre-clinical setting which is required for drugs. Clinical trials with drugs are, contrary to PA trials, almost exclusively performed with optimal doses. However, in some areas optimal PA administration and dosage has emerged, and a Cochrane review of TENS in OAK calculated the effect size for TENS versus sham TENS as 0.38(Osiri et al. 2000), which surpasses that of paracetamol (0.21, Zhang et al. 2004) and NSAIDs (at best 0.31, Bjordal et al. 2004). Good quality independently-funded trials of electro- acupuncture (EA) demonstrate better pain-relief from EA than NSAIDs (diclofenac).Sangdee et al. (2002) found that EA combined with NSAID was no better than EA alone, and Vas et al. (2004) found significant pain reduction for the combination of EA and NSAID but not for NSAID alone. Interestingly, industry-funded NSAID trials rarely, if ever, compare NSAIDs with PAs head-to-head.

Attempts are being made to establishing optimal doses for other PAs too. For example, recent research in animals has established anti- inflammatory dose intervals for low level laser therapy (LLLT) that are comparable to diclofenac (Albertini et al. 2004) and these findings have been confirmed in situ trials on humans (Bjordal et al. 2006). The importance of establishing effective dose for PAs was demonstrated in our systematic review on LLLT for chronic joint disorders including OA which found beneficial dose dependent effects (Bjordal et al. 2003). We agree that some PAs like ultrasound therapy from our current knowledge are likely to be ineffective in OAK. Still, from our research perspective, it is not a question of whether any PA may be effective or not, but rather to identify the PAs with greatest potential and the mechanisms behind them in order to optimise dose and treatment procedures. Only then can we identify the true effect size of the best PAs for OAK management. We hope that our response will raise awareness of potential benefits of using PAs for KOA.


Albertini, R., F. S. Aimbire, et al. (2004). "Effects of different protocol doses of low power gallium-aluminum-arsenate (Ga-Al-As) laser radiation (650 nm) on carrageenan induced rat paw ooedema." J Photochem Photobiol B 74(2-3): 101-7.

Bjordal, J. M., C. Couppe, et al. (2003). "A systematic review of low level laser therapy with location-specific doses for pain from chronic joint disorders." Aust J Physiother 49(2): 107-16.

Bjordal, J. M., A. E. Ljunggren, et al. (2004). "Non-steroidal anti- inflammatory drugs, including cyclo-oxygenase-2 inhibitors, in osteoarthritic knee pain: meta-analysis of randomised placebo controlled trials." BMJ 329(7478): 1317-23.

Bjordal, J. M., R. A. Lopes-Martins, et al. (2006). "A randomised, placebo controlled trial of low level laser therapy for activated Achilles tendinitis with microdialysis measurement of peritendinous prostaglandin E2 concentrations." Br J Sports Med 40(1): 76-80; discussion 76-80.

Case, J. P., A. J. Baliunas, et al. (2003). "Lack of efficacy of acetaminophen in treating symptomatic knee osteoarthritis: a randomized, double-blind, placebo-controlled comparison trial with diclofenac sodium." Arch Intern Med 163(2): 169-78.

Hunter, D. J. and D. T. Felson (2006). "Osteoarthritis." Bmj 332(7542): 639-42.

Miceli-Richard, C., M. Le Bars, et al. (2004). "Paracetamol in osteoarthritis of the knee." Ann Rheum Dis 63(8): 923-930.

Osiri, M., V. V. Welch, et al. (2000). "Transcutaneous electrical nerve stimulation for knee osteoarthritis (Cochrane Review)." Cochrane Database Syst Rev 4.

Peterson, M., D. Elmfeldt, et al. (2005). "Treatment practice in chronic epicondylitis: a survey among general practitioners and physiotherapists in Uppsala County, Sweden." Scand J Prim Health Care 23(4): 239-41.

Sangdee, C., S. Teekachunhatean, et al. (2002). "Electroacupuncture versus diclofenac in symptomatic treatment of osteoarthritis of the knee: a randomized controlled trial." BMC Complement Altern Med 2(1): 3.

Vas, J., C. Mendez, et al. (2004). "Acupuncture as a complementary therapy to the pharmacological treatment of osteoarthritis of the knee: randomised controlled trial." BMJ: bmj.38238.601447.3A.

Zhang, W., A. Jones, et al. (2004). "Does paracetamol (acetaminophen) reduce the pain of osteoarthritis? A meta-analysis of randomised controlled trials." Ann Rheum Dis.

Competing interests: None declared

Competing interests: None declared

Jan M Bjordal, Postdoctoral Research Fellow

Rodrigo A.B.Lopes-Martins, Bård Bogen, Mark I. Johnson

University of Bergen, Dep. Public Health and Primary Health Care

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I felt that the review by Hunter and Felson would have been comprehensive if they mentioned the promising role of tissue engineering strategies and molecular biology in management of osteoarthritis(1). Our present knowledge indicates that osteoarthritis is a multifactorial disease with both environmental and genetic influences. However, differences in gene expression have been found between normal and diseased chondrocytes (2). Correction of genetic defect and/or delivery of therapeutic gene by gene transfer might prove fruitful in future. Application of local growth factors to enhance cartilage repair and regeneration is also showing promise. Tissue engineering is evolving and autologous chondrocyte transplantation is now successfully used for treatment of localised osteochondral defect (3). Development of cell harvesting and matrix vehicle technology would make treating larger cartilage defect a feasible option.

It is conceivable that advances in basic research would allow us to harvest the intrinsic healing capacity of cartilages to the point where joint replacement surgery may become a thing of the past in our lifetime.


1. Hunter J, Felson DT. Clinical review – Osteoarthritis. BMJ 2006;332:639-642

2. Evans CH, Rosier RN. Molecular biology in orthopaedics: the advent of molecular orthopaedics. J Bone Joint Surg [ Am] 2005; 87-A:2550-64.

3. Smith GD, Knutsen G, Richardson JB. A clinical review of cartilage repair techniques. J Bone Joint Surg [ Br] 2005; 87-B:445-9.

Competing interests: None declared

Competing interests: None declared

Munier Hossain, Staff Grade Surgeon

Ysbyty Gwynedd ( Bangor Hospital) , UK LL57 2PW

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22 March 2006

We appreciate the letters and commend the Dr's interest. Far from forgetting the surgeon we work closely with orthopedic surgeons and enjoy the opportunity for this interaction. Most guidelines for osteoarthritis management recommend initially non-pharmacologic management (such as weight loss, exercise, knee braces) followed by pharmacologic management. Where these conservative measures have failed then we would commend referral to a surgeon. We do not recommend waiting until the patient is markedly functionally impaired or disabled such that their operative recovery would be compromised.

Recent trials have suggested a role for acupuncture in knee osteoarthritis. This is still not uniform practice potentially as a function of access.

Whilst anecdotal experience with intra-articular corticosteroid use is often better than what the evidence suggests the most well conducted systematic review suggests the typical mean duration of symptom relief is 1 week. At four to 24 weeks postinjection, there was a lack of evidence of effect on pain and function. Like most clinical trials in osteoarthritis management these studies demonstrated a consistently large and durable placebo effect.

Competing interests: None declared

Competing interests: None declared

David J Hunter, Assistant Professor

David Felson

Boston, MA, USA 02467

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While acknowledging evidence based medicine, clinicians should be mindful of their personal experience. Majority of the patients with Osteoarthirtis are managed in primary care. Personal experience of injecting intra-articular steroids for OA in weight bearing joints and non -weight bearing joints (especially Carpo-metacarpal joint of the thumb)shows that pain relief and improvement in activities of daily living can improve from a few weeks (about4 weeks) to a few years(upto 5years). Having used it for over 30 years, the pain relief in almost all seems to definitely last more than a week as suggested by the Cochrane review quoted by the authors.It usually takes a few days before the benefit is experienced. Methylprednisolone with lidocaine (Depo-medrone with Lidocaine) - dose depending on the size of the joint has been shown to be effective. In primary care the two commonly injected joints for OA are the knee and carpo-metacarpal joint (CMJ)of the thumb. The significant benefit to the activities of daily living such as walking distance, dressing, lifting a Tea Pot and knitting for elderly ladies makes it extremely worthwhile for the use of Intra-articular steroids for osteoarthritis. For a clinician, Patient Oriented Evidence that Matters is more important than statistical microanalysis which looks at the "part" and not the patient. Even a Bandolier review in 2004 mentions of two RCTs which suggested pain relief for at least a month(1). The ability to inject intra-articular steroids is an important tool in the therapeutic armamentarium and a very useful skill for all primary care physicians.

Reference: 1)

Competing interests: None declared

Competing interests: None declared

Sidha S Sambandan, GP & GPwSI Orthopaedics

Yare Valley Medical Practice,202 Thorpe Rd,Norwich NR1 1TJ,UK

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The review of osteoarthritis by Hunter and Felson(1) discusses the latest therapies for treating this common disease.

Radiographs are an important investigation for diagnosing and staging the condition. I would not expect to see ‘gas within the joint’ as expressed in the article (figure 2) and this would not be consistent with osteoarthritis. The four signs on radiographs indicative of osteoarthritis are joint space narrowing, sclerosis, cyst formation and the presence of osteophytes. Hypertrophy of the synovium and a joint effusion may be seen on the radiograph but these should not be confused with gas.

With regards treating osteoarthritis, late referral to a surgeon is always disappointing. Modern methods employed by Orthopaedic Surgeons can relieve pain and aid function prior to arthroplasty. Steroid injections are a valuable tool to achieve these aims and can provide prolonged relief sometimes far longer than the one week suggested in the article. The reference from Bellamy et al was specific to the knee although steroid and local anaesthetic injections are used in many other joints from the hand to the foot.

The rates of success of surgical intervention can sometimes be impaired by delayed referral. For example early referral of a patient with osteoarthritis of the knee may allow for a high tibial osteotomy which, if successful, will delay the need for arthroplasty. Late referral may mean such interventions are not possible and for this reason I disagree with the ‘tips for general practitioners’ box suggesting referral only at end stage disease when joint replacement is contemplated.

I feel the role of the Orthopaedic Surgeon has not been fully explored by this article and that multidisciplinary care involving the surgical team is invaluable for providing the best care for these patients.

1. Hunter J, Felson DT. Clinical review – Osteoarthritis. BMJ 2005;332:639-42

Competing interests: None declared

Competing interests: None declared

Jonathan Mutimer, SpR Trauma and Orthopaedics

Cheltenham General Hospital

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The review by Hunter and Felson covers the conventional treatments well. There is no mention of alternative therapy or the recent research into acupunture. I searched the BMJ advanced search engine with "acupuncture knee" in the abstract / title (all) section and found the small study by Vas et al comparing diclofenac and acupuncture against diclofenac plus placebo acupuncture. I would suggest my search was not systematic but this research is relevant and should have been mentioned if only to point out its limitations.

Competing interests: Co-authoring a text-book "musculoskeletal medicine" aimed at primary care.

Competing interests: None declared

DR R L DAVIES, General Practitioner

703 Leeds and Bradford Road, Stanningley, Pudsey, Leeds LS28 6PE

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