sBMJ | Physical treatments have a valuable role in osteoarthritis

Physical treatments have a valuable role in osteoarthritis

Editor-Hunter and Felson deliver a consistent and seemingly thorough clinical review about managing knee osteoarthritis for primary care doctors.¹ We commend them for promoting the role of non-pharmacological interventions and for highlighting the problem of inadequate funding because of “lucrative opportunities for drug development.” However, one striking omission in their review was an appraisal of physical treatments, which are widely used in primary care. A cursory search of the literature identified at least 26 randomised placebo controlled trials and six systematic reviews of physical interventions for knee osteoarthritis in Medline indexed journals and the Cochrane Library.

NEIL BORDEN/SPL

One of the few examples where the efficacy of physical treatments was tested against drugs is a good quality independently funded trial, in which electroacupuncture showed better pain relief than non-steroidal anti-inflammatory drugs (diclofenac).² A Cochrane review of transcutaneous electrical nerve stimulation (TENS) calculated the effect size for TENS v sham TENS as 0.38, even when inclusion criteria were not restricted to optimal doses.³

Attempts are being made to establish optimal doses for TENS, acupuncture, and low level laser treatment. Recent research in animals has established anti-inflammatory dose intervals for low level laser treatment, and this has been confirmed in situ with humans.⁴ A meta-analysis of such laser treatment in knee osteoarthritis when inclusion was limited to trials with optimal doses showed an effect size of 0.71.⁵ Optimal acupuncture, TENS, and low level laser treatment also seem to give persisting pain relief in knee osteoarthritis for some weeks after the end of treatment.

Jan M Bjordal, postdoctoral research fellow, Department of Public Health and Primary Health Care, University of Bergen, 5018 Bergen, Norway
Email: Jan.Bjordal@hib.no
Rodrigo Alvaro Brandao Lopes-Martins, assistant professor, Institute of Biomedicine, Pharmacology Department, University of Sao Paulo, Sao Paulo, Brazil
Bård Bogen, physiotherapist, Bergen Deaconal Hospital, Ulriksdal 10, 5009 Bergen
Mark Johnson, professor of pain and analgesia, Faculty of Health, Leeds Metropolitan University, Leeds LS1 3HE

Competing interests: None declared.

This letter was first published in the BMJ (2006;332:853).

studentBMJ 2006;14:265-308 July ISSN 0966-6494

Hunter DJ, Felson DT. Osteoarthritis. BMJ 2006;332: 639-42. (18 March).
Sangdee C, Teekachunhatean S, Sananpanich K, Sugandhavesa N, Chiewchantanakit S, Pojchamarnwiputh S, et al. Electroacupuncture versus diclofenac in symptomatic treatment of osteoarthritis of the knee: a randomized controlled trial. BMC Complement Altern Med 2002;2: 3.
Osiri M, Welch VV, Brosseau, L, Shea B, McGowan J, Tugwell P, et al. Transcutaneous electrical nerve stimulation for knee osteoarthritis. Cochrane Database Syst Rev 4, 2000.
Bjordal JM, Lopes-Martins RA, Iversen VV. 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 2006;40:76-80.
Bjordal JM, Bogen B, Lopes-Martins RA, Klovning A. Can Cochrane Reviews in controversial areas be biased? A sensitivity analysis based on the protocol of a Systematic Cochrane Review on low-level laser therapy in osteoarthritis. Photomed Laser Surg 2005;23:453-8.