Assessing benefit in osteoarthritis

The primary goals of treatment are reducing pain, stiffness and disability. Associated aims are to improve the quality of life and ensure adverse effects are minimal. All treatments achieve these goals to a greater or lesser extent. A long-term goal is to reduce progressive joint damage, though no treatment yet achieves this.

The medical management of pain in osteoarthritis is by definition nonsurgical. However, it is important to appreciate that surgical intervention in osteo-arthritis can be particularly important in overcoming pain as well as having positive effects in reducing disability and specifically improving mobility. Joint replacement surgery is particularly effective, but it lies outside the themes explored in this review.

Most trials use simple assessments of pain and disability. Pain is recorded using visual analog scales or five-point Likert scales. Pain can be recorded globally or in specific situations such as at rest or during exercise. There are also specific scales that record pain, stiffness and function in osteo-arthritis; the most widely used is the Western Ontario and McMaster Osteo-Arthritis (WOMAC) Scale [6].

As virtually all trials assess global pain, changes in this measure are the focus of the treatment reviews that follow. The benefit of this assessment has been counterbalanced by an assessment of adverse events. In all cases the most recent systematic review has been the basis for judging efficacy. In some situations efficacy and adverse events have been assessed separately, for example with oral nonsteroidal anti-inflammatory drugs (NSAIDs). This is because no single review examines both. The overall benefits of effective treatments are summarized in Table 9.1.

Table 9.1 Strength of evidence for treatments in knee osteo-arthritis: largest systematic reviews compared for effective treatments

Treatment

Placebo-controlled trials

Patients

Effectiveness

Adverse effects

Overall value

Paracetamol

7

1966

SMD -0.13

Minimal

Low efficacy compensated by few adverse effects

Oral NSAID/COXIBs

23

10,845

Pooled effect size 0.32

Multiple serious adverse effects

Efficacy limited by high rates of adverse effects

Local NSAIDs

7

976

Pooled effect size 0.41

Minimal

Efficacy only in short term

Opioids

18

4856

Pooled effect size 0.79

Multiple unpleasant adverse effects

Efficacy limited by high rates of adverse effects

Local steroid

28

1973

Mean weighted

Uncommon

Efficacy only in short term

injections

difference 21.9

Hyaluronic acid

40

2542

Mean weighted

Uncommon

Sustained efficacy but

injections

difference 9.0

limited by need for repeated injections

Arthritis Relief and Prevention

Arthritis Relief and Prevention

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