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Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on bmj.com. 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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Contribution from nature
The application of medicinal leeches is quiet common in Osteoarthritis as a CAM. The word "leech is a derivation of the Anglo- Saxon word which means "to-heal." There are many species of leeches found, but most common is Hirudo medicinalis.
Medicinal leeches was widely practiced in ancient times .The first description of leech therapy, classified as blood letting i.e. Raktamokshana, was found in the treaties of Sutra Sthana of Sushrutasamhita (dating 800 B.C.) who was also considered the Father of Plastic Surgery. He mentioned about 6 types of leeches depending upon their nature i.e. variety of poisonous and non-poisonous . Even we are having evidence of bloodletting therapy from ancient Greek times to the Chapin Harris era in the 1840s, but their use declined rapidly in Western countries including US with the advent of modern surgery and pharmacology.
In ancient medical practice, phlebitis and thrombotic states were 2 most common and main indications for leech therapy. In more recent times, the polypeptide Hirudin, one of several biologically active principles in saliva of leech was identified as the most potent known natural inhibitor of coagulation. Bedellins is another compound present in the leech’s saliva that acts as an anti-inflammatory agent by inhibiting trypsin as well as plasmin in blood. And another anti-inflammatory agent is the eglins. Natural medicinal leeches are currently used to treat post-operative local congestions after reconstructive and plastic surgery.
Generally leech therapist uses around 7-10 leeches to suck 150ml of blood. It has been observed that long queue of patients waiting for their turn at the leech therapy unit of the Faculty of Ayurveda, Banaras Hindu University observed by Associate Professor, Department of Kayachikitsa (Dept. of General Medicine), BHU, OP Singh The most common complication from leech treatment is prolonged bleeding, which can easily be treated, although allergic reactions and bacterial infections may also occur. Quality control data on adverse events documented in more than thousand cases who had undergone treatment in Essen-Mitte Hospital showed most of the patients suffering from degenerative diseases like OA merely observed rare complications. Local pain, itching were common complaints.
Microbiological analysis says, in all cases, an infection with Aeromonashydrophila was found. It is also worth mentioning that some blood tests including HIV, HbsAg, Bleeding time and Clotting time ,Total leukocyte count (TLC), Differential Leukocyte Count (DLC), Blood Sugar and other tests for bleeding disorder have been made mandatory under the therapy for ensuring better healing.
Competing interests: None declared
KMC, Manipal University,Manipal 576 104
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+Simon Donnell in his response on osteoarthritis [1]of the knee raises an important point about the understanding of osteoarthritis and highlights the need for education on osteoarthritis not just for patients but for clinicians at all stages of their medical and surgical training. Education is a core treatment in NICE guidance on osteoarthritis[2].
The disease process in osteoarthritis is more than simple wear and tear, there is thinning of articular cartilage with age but it is the body response to this thinning that causes inflammation, pain and decrease in function[3, 4]. Osteoarthritis is not a process which inevitably leads to progression [5]and this is one of the myths which need to be robustly addressed for effective management of this very common condition. There is evidence that about one third of people with hip or knee arthritis will improve with time. The evidence given by Bennell and colleagues [6]demonstrates the beneficial effect of weight loss and exercise in addressing the pain of osteoarthritis.
The NICE guidance core treatments are education, weight loss and exercise. Education is about the understanding of the causes of the condition, the causes of pain and the likely outcome. A lot is known about why osteoarthritis causes pain because of the inflammatory process involving all joint tissues, synovium, capsule, bone and ligaments[4]. Cartilage is poorly innervated and not the cause of pain. The explanation of ‘wear and tear’ is not sufficient to convey an understanding of the condition and may lead the patient to feel that more ‘wear’ will aggravate the condition and lead to ‘bone on bone’ when the evidence is that appropriate exercise is protective.
There is very little long term research in osteoarthritis on the prognosis and effectiveness of conservative management. The language used even in international conferences is one of inevitability of surgery as an end point[7]. This needs to be challenged in order to provide effective education at all levels.
The term osteoarthritis is appropriate to use with patients to explain what is happening and is appropriate in radiology to convey the findings which support a diagnosis of osteoarthritis. The challenge is widening the understanding of this very common condition and the real choices in terms of conservative management.
References
1. Donell, S.T., "Osteoarthritis" on imaging may be normal wear and tear. BMJ. 345: p. e5594.
2. NICE, Osteoarthritis. 2005.
3. Felson, D.T., Developments in the clinical understanding of osteoarthritis. Arthritis Res Ther, 2009. 11(1): p. 203.
4. Yusuf, E., et al., Do knee abnormalities visualised on MRI explain knee pain in knee osteoarthritis? A systematic review. Ann Rheum Dis. 70(1): p. 60-7.
5. Peters, T.J., et al., Factors associated with change in pain and disability over time: a community-based prospective observational study of hip and knee osteoarthritis. Br J Gen Pract, 2005. 55(512): p. 205-11.
6. Bennell, K.L., D.J. Hunter, and R.S. Hinman, Management of osteoarthritis of the knee. BMJ. 345: p. e4934.
7. Slover, J., J. Shue, and K. Koenig, Shared decision-making in orthopaedic surgery. Clin Orthop Relat Res. 470(4): p. 1046-53.
Competing interests: None declared
Gloucestershire Care Services, Edward Jenner Court Gloucester GL3 4AW
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+We appreciate the response from Dr Lyons albeit his results are not consistent with what we would advocate for routine clinical management of this chronic disease. Best evidence would suggest that the mean duration of response from steroid
injections is at best 1-2 weeks (1). This is substantially less than the 3 months reported by Dr Lyons in his clinical practice. Furthermore, most
studies would suggest that with the use of hyaluronic acid, local adverse event
rates are in the order of 30% to 50% (2). We have no problem utilising the placebo
effect where the intervention is safe and inexpensive. However, in the
instance of injections we do not believe this fits into that category based on current evidence. Further the
management should focus on modifiable risk factors (esp. exercise and weight loss) and using injections may sometimes be done at the opportunity cost of other more effective treatments.
We also thank Drs Warburton and Porcheret and Professor Peat for their excellent comments regarding diagnosis and differential diagnosis of knee OA given that the word limit of the review article certainly precluded a thorough discussion of the pertinent issues they have raised.
1.Intraarticular corticosteroid for treatment of osteoarthritis of the knee.
Bellamy N, Campbell J, Robinson V, Gee T, Bourne R, Wells G. Cochrane Database
Syst Rev. 2006 Apr 19;(2):CD005328. Review.
2. Viscosupplementation for Osteoarthritis of the Knee: A Systematic Review and Meta-analysis. Rutjes AW, Jüni P, da Costa BR, Trelle S, Nüesch E,Reichenbach
S. Ann Intern Med. 2012 Aug 7;157(3):180-91.
Competing interests: None declared
Royal North Shore Hospital and University of Sydney, St Leonards, NSW, 2065
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+We would like to congratulate the authors on a comprehensive and well-presented clinical review on the management of osteoarthritis of the knee(1).
The space available to fully explore the issues surrounding the diagnosis of knee osteoarthritis was necessarily limited but deserves further comment. We wholeheartedly agree with the authors’ interpretation of the role of imaging but what of ‘confident clinical diagnosis’ in primary care?
Alongside making a diagnosis of osteoarthritis, we would stress the importance of ruling things out and telling patients what it’s not. Most guidance presupposes the exclusion of specific alternative diagnoses. In reality primary care deals with undifferentiated problems as they are presented. Within the domain relevant to knee
osteoarthritis (knee symptoms among adult patients, typically 45+ years) the range of differential (and sometimes concurrent) diagnoses includes red flags (fracture, sepsis and cancer), referred pain to the knee from the hip, gout, or pseudogout, inflammatory arthritis, bursitis, meniscal disease and fibromyalgia. Conducting research that mimics this diagnostic challenge is difficult so it should perhaps be no surprise that there is a dearth of robust evidence on the accuracy of osteoarthritis diagnosis within the context of such a range of differential diagnoses in representative populations.
Does the claim of confident rule-in diagnosis of knee osteoarthritis using key signs and symptoms stand up to close scrutiny? The usual list of suspects - persistent (use-related) knee pain, limited knee stiffness, reduced function, crepitus, reduced movement, and bony enlargement – has been identified variously in the longstanding American College of Rheumatology clinical classification criteria (2), and more recently in NICE guidelines (3) and EULAR recommendations (4). When present, they do indeed appear to permit confident rule-in ‘diagnosis’ of radiographically confirmed knee osteoarthritis. The problem is that only a relatively small proportion of patients initially presenting to primary care may have such a ‘classical’ presentation (5). What then of the rest? Studies of general practitioner diagnostic coding show the widespread use of non-specific symptom codes like ‘knee pain’ and ‘knee arthralgia’ (6). Patellofemoral osteoarthritis, which appears to be common (7) and that may precede the appearance of tibiofemoral joint osteoarthritis (8), may well not be attended by the classical signs and symptoms of knee osteoarthritis. Bony enlargement and the likes are probably manifestations of later, more advanced tibiofemoral joint osteoarthritis (9,10). Early or less severe osteoarthritis is managed under symptom codes. Far from being evidence of diagnostic failure the current state of the evidence would suggest this is rational.
Of course, pursuit of earlier confident rule-in diagnosis of osteoarthritis (or a selected subtype) is an active area for current and future research which, if accompanied by evidence of safe, effective, and cost-effective early intervention, would be an important advance. But living and practicing with diagnostic uncertainty probably better characterises the current situation in primary care. In that context confident management in the absence of firm diagnosis of osteoarthritis seems a legitimate goal.
George Peat
Professor of Clinical Epidemiology
Arthritis Research UK Primary Care Centre
Primary Care Sciences
Keele University
Louise Warburton
GPwSI in Rheumatology and Musculoskeletal Medicine
Shropshire Community Health NHS Trust
Senior Lecturer, Keele University
Mark Porcheret
Senior Lecturer in General Practice
Arthritis Research UK Primary Care Centre
Primary Care Sciences
Keele University
1. Bennell KL, Hunter DJ, Hinman RS. Management of osteoarthritis of the knee. BMJ. 2012 Jul 30;345:e4934.
2. Altman R, Asch E, Bloch D, Bole G, Borenstein D, Brandt K, Christy W, Cooke TD, Greenwald R, Hochberg M, et al. Development of criteria for the classification and reporting of osteoarthritis. Classification of osteoarthritis of the knee. Diagnostic and Therapeutic Criteria Committee of the American Rheumatism Association. Arthritis Rheum. 1986 Aug;29(8):1039-49.
3. National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults. London: Royal College of Physicians, 2008.
4. Zhang W, Doherty M, Peat G, Bierma-Zeinstra MA, Arden NK, Bresnihan B, Herrero-Beaumont G, Kirschner S, Leeb BF, Lohmander LS, Mazières B, Pavelka K, Punzi L, So AK, Tuncer T, Watt I, Bijlsma JW. EULAR evidence-based recommendations for the diagnosis of knee osteoarthritis. Ann Rheum Dis. 2010 Mar;69(3):483-9
5. Peat G, Thomas E, Duncan R, Wood L, Wilkie R, Hill J, Hay EM, Croft P. Estimating the probability of radiographic osteoarthritis in the older patient with knee pain. Arthritis Rheum. 2007 Jun 15;57(5):794-802
6. Jordan KP, Kadam UT, Hayward R, Porcheret M, Young C, Croft P. Annual consultation prevalence of regional musculoskeletal problems in primary care: an observational study. BMC Musculoskelet Disord. 2010 Jul 2;11:144.
7. Duncan RC, Hay EM, Saklatvala J, Croft PR. Prevalence of radiographic osteoarthritis--it all depends on your point of view. Rheumatology (Oxford). 2006 Jun;45(6):757-60
8. Duncan R, Peat G, Thomas E, Hay EM, Croft P. Incidence, progression and sequence of development of radiographic knee osteoarthritis in a symptomatic population. Ann Rheum Dis. 2011 Nov;70(11):1944-8.
Competing interests: None declared
Keele University, Arthritis Research UK Primary Care Centre
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+The recent excellent clinical review on 'Management of osteoarthritis of the knee' gave intra-articular injections only a brief mention. This condition is cited by the Cochrance Collaboration as the single most common cause of disability in the western world. Not a trivial condition. As a GP in West London's largest practice I have a huge following of little old ladies who attend 3-4 x annually for a high-volume intra-articular injection (10mls lidocaine 0.5% & 20mg triamcinolone) which takes about 1 minute, costs about £2 and lasts about 3 months. No adverse events after several thousand treatments. Add 3mls hyaluronic acid and you're up to 5-6 months. As the authors rightly point out, there is little scientific evidence of any efficacy as most of the trials are of poor quality. However, as so often in medicine, just because we don't have any high quality RCTs, it doesn't necessarily mean a certain treatment doesn't work. No choice but to (most unscientifically) carry on injecting!
Competing interests: None declared
North End Medical Centre, 160-164 North End Road, West Kensington, London W14 9PR
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+We greatly appreciate the thoughtful responses that have emanated from our review article.
We agree with Dr Donell that for many persons with knee pain the etiology can lay outside the knee. This differential diagnosis includes pes anserine bursitis, iliotibial band friction syndrome (Runner’s knee), patella tendonosis, patellofemoral pain syndrome, prepatellar bursitis, and semimembranosous bursitis. Like many musculoskeletal ailments, an appropriate history and physical examination is typically sufficient to diagnose these problems. As was stated, they also commonly occur in persons with radiographic features of osteoarthritis, reinforcing the importance of good clinical skills above what an x-ray might tell you.
We appreciate the comments from Benjamin Dean, that there are different perspectives on the benefit of clinical trials, and that evidence is not always the answer for some clinical dilemmas. However, where there is consistent evidence (knee arthroscopy has demonstrated no benefit over conservative treatments in the management of knee OA) it behoves those that question it, to come up with robust evidence to refute that which is existing.
Competing interests: None declared
Royal North Shore Hospital and University of Sydney , St Leonards, NSW, 2065
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+I read with interest the excellent review by Bennell et al on the management of knee osteoarthritis which reflects a sensible and measured approach based on the evidence. Recently GPs and triage staff have had access to MRI scans resulting in a flood of patients sent to hospital for an arthroscopy for tears of the posterior horn of the medial meniscus. History and examination of these patients do not reflect this diagnosis. This finding on MRI scan is a “normal” finding (1) in the over 50 year-olds, and reflects the ageing process.
However there is a problem with using “osteoarthritis” as a diagnosis in these patients. Pain experienced around the knee is frequently not from within the knee. Patients with radiological findings that fit the criteria for a diagnosis of osteoarthritis may not have pain. This therefore means that a patient with knee pain and radiological changes may have these occurring coincidentally. It may be that the high rate of knee pain reported after knee replacement (2) reflects the wrong diagnosis, not a poorly performed operation.
I prefer to tell patients that their knee has undergone normal wear-and-tear similar to a car engine that has done 70 000 miles. It needs care and attention, not replacement. The time for replacement is when the subchondral bone is exposed and conservative and medical management has failed.
This review notes that lifestyle changes are more important than operation in the initial management. The term “osteoarthritis” implies ending up in a wheelchair as far as the patient is concerned, and referral to a surgeon when used in a radiology report.
References
1. Kemp MA, Lang K, Dahill M, Williams JL. Investigating meniscal symptoms in patients with knee osteoarthritis—Is MRI an unnecessary investigation? The Knee 2011; 18: 252-253.
2. Wylde V, Dieppe P, Hewlett S, Learmonth ID. Total knee replacement: Is it really an effective procedure for all? The Knee 2007; 14: 417-423.
Competing interests: President Elect, British Association Surgery of the Knee Co-Editor The Knee journal Consultant for Tornier (implant manufacturer)
Norfolk & Norwich University Hospital, Colney Lane, Colney, Norwich NR4 7UY
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+I read the recent review on the management of knee osteoarthritis with great interest (1). The 'role of surgery' in pre-end stage knee osteoarthritis is far from fully defined and although some randomised trials have shown no benefit to arthroscopic treatment, these results must be seen in context with the certain key methodological failings in these studies (2, 3) which include limitations in terms of staging disease, a lack of pre-operative MRI and the wide range of patient characteristics included. Although guidelines recommend arthroscopy "only in patients with mechanical symptoms", it is hard to justify this stance based on the evidence available. There are distinct sub groups of patients with knee pain who may well benefit from arthroscopic debridement including those without bone on bone cartilage loss but with significant meniscal pathology on MRI. There are also new arthroscopic treatments such as radiofrequency chondroplasty which show promise when compared to older more traditional methods in treating partial thickness cartilage defects (4,5). There are many big questions for future research but the role of surgery in early osteoarthritis is something that should near the top of all of our lists. We badly need better designed randomised controlled surgical trials that investigate the treatment of early knee osteoarthritis in specific sub groups of patients.
1. Bennell K et al. Management of osteoarthritis of the knee. BMJ 2012; 345 doi: 10.1136/bmj.e4934
2. Kirkley A, Birmingham TB, Litchfield RB, Giffin JR, Willits KR, Wong CJ, et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med2008;359:1097-107.
3. Moseley JB, O'Malley K, Petersen NJ, Menke TJ, Brody BA, Kuykendall DH, Hollingsworth JC, Ashton CM, Wray NP. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002 Jul 11;347(2):81-8.
4. Voloshin I, Morse KR, Allred CD, Bissell SA, Maloney MD, DeHaven KE. Arthroscopic evaluation of radiofrequency chondroplasty of the knee. Am J Sports Med. 2007 Oct;35(10):1702-7. Epub 2007 Jul 20. Arthroscopy. 2010 Sep;26(9 Suppl):S73-80.
5. Spahn G, Klinger HM, Mückley T, Hofmann GO. Four-year results from a randomized controlled study of knee chondroplasty with concomitant medial meniscectomy: mechanical debridement versus radiofrequency chondroplasty. Arthroscopy. 2010 Sep;26(9 Suppl):S73-80.
Competing interests: None declared
Oxford University, NDORMS, Botnar Research Centre, Oxford
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+
Total cost of overdiagnosis is probably 50 times higher than modelled here
Published 21 May 2013
Re: Antibiotics for back pain: hope or hype?
Published 21 May 2013
Re: Are antidepressants overprescribed? No
Published 21 May 2013
UGC India and MCI should lower the beam for a while for teachers in FAMILY MEDICINE, to let it come up as a different entity taught by specialists from FAMILY MEDICINE only
Published 21 May 2013