Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Review: Some nondrug therapies decrease pain and improve function in osteoarthritis

ACP J Club. 1995 Jan-Feb;122:7. doi:10.7326/ACPJC-1995-122-1-007


Source Citation

Puett DW, Griffin MR. Published trials of nonmedicinal and noninvasive therapies for hip and knee osteoarthritis. Ann Intern Med. 1994 Jul 15;121:133-40.


Abstract

Objective

To review the efficacy of nonmedicinal, noninvasive treatments in reducing pain and increasing function in patients with osteoarthritis (OA) of the knee and hip.

Data sources

Studies were identified by MEDLINE (1966 to 1993) using the subheadings drug therapy, radiotherapy, surgery, and rehabilitation of osteoarthritis, cross-indexed with clinical trials, comparative study, or trials; and by bibliographies of relevant papers. More than 600 citations were identified.

Study selection

Studies were selected if they included patients with OA of the knee or hip; assigned patients to nonmedicinal, noninvasive therapy or to a concurrent group that received an alternate intervention, placebo, or no intervention; and included pain or a measure of lower extremity function as an outcome.

Data extraction

Study quality, adequacy of sample size, pain and function, type of therapy, number of patients, and duration of follow-up.

Main results

14 articles (15 trials comprising 760 patients) were included. Data were not combined. In 2 trials where diathermy (e.g., ultrasound) was added to exercise treatments, the groups receiving diathermy had a reduction in pain similar to that of those getting only exercise. 2 trials assessed quadriceps strengthening in patients with knee OA; both showed decreased pain and improved function. 2 trials assessed aerobic activity; both showed improved function and 1 showed less pain. Topical capsaicin reduced pain in 1 study of knee OA. 2 studies assessed low-level laser therapy; both showed decreased pain and 1 showed increased self-reported function. Of 2 studies assessing acupuncture, the 1 using sham acupuncture showed no differences, whereas the other showed decreased pain and increased function. 2 small studies and 1 with poor follow-up evaluated transcutaneous electrical nerve stimulation (TENS) in patients with knee OA; all showed decreased pain. 1 study of pulsed electromagnetic fields in patients with knee OA showed that pain decreased. No trials evaluating superficial heat or cold, orthoses, assistive devices, weight loss, or vibration therapy have been reported.

Conclusions

Strengthening exercises reduce pain and increase function in patients with osteoarthritis of the knee. Diathermy does not. Data on acupuncture are inconsistent. Based on single studies, topical capsaicin and laser treatments show promise. Data on other nonmedicinal, noninvasive therapies are inconclusive or unavailable.

Sources of funding: Food and Drug Administration and Agency for Health Policy and Research.

For article reprint: Dr. M.R. Griffin, Department of Preventive Medicine, Vanderbilt University, A-1124 Medical Center North, Nashville, TN 37232-2537, USA. FAX 615-343-8722


Commentary

Nonmedicinal and nonsurgical treatments of knee or hip OA can be conceptualized in 2 ways. First, joint biomechanics can be altered, thereby lessening the load across painful areas within the joint. Second, nerve transmission from articular pain fibers can be modified. Treatments such as exercise and orthotics can be used to alter joint biomechanics, whereas TENS, capsaicin, and, possibly, laser and pulsed electromagnetic fields can affect nerve transmission.

Because patients with knee and hip OA are deconditioned and because muscles that bridge joints deflect the load away from painful joints, strengthening these shock-absorbing muscles should decrease the load across the joint, diminish pain, and improve function. Exercise is effective in knee OA, but each trial in this review tested different interventions and was designed differently. Thus, it is unclear what an optimal exercise regimen might be. A reasonable overall approach should incorporate muscle strengthening (e.g., isometric quadriceps strengthening for knee OA). Similar strengthening of hip abductors and extensors in hip OA might be effective. When muscles have been strengthened, graded weight-bearing exercise, such as walking, could be of value.

Since this review was completed, a trial (1) has shown that patients with symptomatic patellofemoral knee OA who taped the patella medially for several days (a procedure that unloads the often-affected lateral patellar facet) had less knee pain.

Capsaicin, a topical application, has been found to be more effective than topical placebo in relieving hand pain caused by OA (2).

David Felson, MD
Boston University School of MedicineBoston, Massachusetts, USA


References

1. Cushnaghan J, McCarthy C, Dieppe P. Taping the patella medially: a new treatment for osteoarthritis of the knee joint? BMJ. 1994;308:753-5.

2. McCarthy GM, McCarty DJ. Effect of topical capsaicin in the therapy of painful osteoarthritis of the hands. J Rheumatol. 1992;19:604-7.