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Physiatric approaches to pain management in osteoarthritis: a review of the evidence of effectiveness
Practice Points
Aydan Oral† & Elena Ilieva1
Education and self-management interventions can play important roles in improving pain in the short and long term in patients with knee or hip osteoarthritis (OA).
Rapidly growing evidence on the association of obesity and both knee and hip OA enhances the importance of weight reduction for the management of pain in patients with both types of OA.
There is a considerable body of consistent evidence supporting the efficacy of exercise in reducing pain in knee OA. Furthermore, the diversity of exercise programs used in trials offers new options that may better meet the individual patient’s needs and preferences. The effectiveness of exercise in hip OA is based on a lower level of evidence; however, emerging studies add to evidence with more encouraging results on this significant management option in hip OA.
Regarding physical modalities in the treatment of hip or knee OA, inconclusive evidence exists on the effectiveness of transcutaneous electrical nerve stimulation. Recent evidence points to favorable effects of therapeutic ultrasound for decreasing pain in both knee and hip OA. There is contradictory evidence that low-level laser therapy has pain relieving effects in knee OA. Electromagnetic fields do not appear to provide any additive benefits on pain reduction in knee OA.
As for complementary therapies, despite good evidence for the effectiveness of acupuncture for pain reduction in knee OA, there is a lack of evidence for its benefits in hip OA.
Encouraging new evidence exists on the effectiveness of manual therapy in hip OA, but not in knee OA.
Studies reveal beneficial effects of knee braces, foot orthoses and taping in reducing pain in knee OA. Footwear deserves more attention in the treatment of hip, knee and foot OA.
Emerging studies suggest the effectiveness of balneotherapy in reducing pain in knee OA.
There is consistent evidence regarding the efficacy of splints in reducing pain in hand OA.
New evidence points to the efficacy of splinting and low level laser therapy in temporomandibular joint OA in addition to conventional approaches.
Unloading strategies may be helpful for pain management in ankle OA.
Department of Physical Medicine & Rehabilitation, Plovdiv Medical University, University Hospital “Sv. Georgi”, Peshtersko shosse 66, Plovdiv, 4002, Bulgaria † Author for correspondence: Department of Physical Medicine & Rehabilitation, Istanbul University, Istanbul Faculty of Medicine, Capa, 34093, Istanbul, Turkey; Tel.: +90 212 635 1185; Fax: +90 212 631 1167; [email protected] 1
10.2217/PMT.11.46 © 2011 Future Medicine Ltd
Pain Manage. (2011) 1(5), 451–471
ISSN 1758-1869
451
Review Oral & Ilieva SUMMARY
Osteoarthritis (OA), which is highly prevalent in the general population, is one of the leading causes of pain and physical disability. A large number of nonpharmacological interventions are available for the management of pain in patients with OA. These include education and self-management, weight reduction, various forms of exercises, physical agents/modalities, complementary therapies, manual therapy, unloading strategies such as braces and orthoses, and balneotherapy. The aim of this article is to assess the evidence of effectiveness of nonpharmacological interventions pertaining to physiatry to identify best practices for pain management in OA. The importance of treatment of osteoarthritis It is well known that osteoarthritis (OA) is the most common type of joint disorder causing chronic musculoskeletal pain and disability in elderly populations worldwide [1] . Increasing in prevalence and progressing with aging, for a decade OA has moved from the tenth to the sixth leading cause of nonfatal burden accounting for 3% of total years lost to disability in the world [2] . OA not only affects the elderly, but also the younger populations in the workforce. The 2009 National Health and Wellness Survey revealed significantly greater work impairment among workers with OA pain than among those without OA pain (34.4 vs 17.8%) in addition to significantly higher healthcare resource utilization with total costs almost twice as much of those without OA pain [3] . Therefore, OA management strategies are of substantial importance for alleviating the burden resulting from this condition. The aim of this narrative review is to assess the evidence of effectiveness of nonpharmacological interventions pertaining to physiatry to identify best practices for pain management in OA. The broad question attempted to be addressed in this nonsystematic review is “what are the latest evidences on physiatric/ nonpharmacological approaches for relieving pain in different types of osteoarthritic conditions (i.e., OA of the knee, hip, hand and of other regions)?” The latest systematic reviews, meta-analyses and narrative reviews, and those individual trials of various designs published after the last search date in the selected reviews are examined in this article to answer this question. The intention of the authors of this article is to provide the readers with a bigger picture of research evidence on the subject that is not restricted only to the rigorously structured and well-conducted high-quality reviews tending to exclude weak evidence or those randomized controlled trials (RCTs) with very low risk
452
Pain Manage. (2011) 1(5)
of bias. This will thus allow the reader to be updated with what has been done in this area in a wide range of studies while leaving a space for judgment of best practices based on quality assessment of RCTs. Literature review We conducted a comprehensive literature review of reviews, systematic reviews, overview of systematic reviews and those subsequent trials not included in the reviews on OA published between the dates 1 January 2005 and 15 May 2011 using PubMed® MEDLINE, Cochrane Database of Systematic Reviews and ISI Web of Knowledge. The conducted literature search was as follows: we started searching for reviews with the search term ‘osteoarthritis’ limited to ‘humans’, ‘meta-analysis’, ‘review’, ‘English’, ‘MEDLINE’, ‘systematic reviews’, publication date from the 1st January 2005 to the 15th May 2011. This search revealed 1982 articles from PubMed/MEDLINE. The reviews were checked by titles or abstracts when there was uncertainty about the content to identify relevant ones for inclusion in the review. When the title or abstract included any pharmacological/medicinal or surgical intervention, the review was not taken into consideration. Searching the Cochrane Database of Systematic Reviews revealed no additional reviews when searched under the headings > subheadings: acute pain > physical therapy; rheumatology > osteoarthritis > non-pharmacological treatment > rehabilitation; rheumatology > soft tissue disorders > lower limb pain. However, ISI Web of Knowledge revealed one additional review. Review selection strategy was as follows: evaluating reviews with regard to the time period covered and the studies included; excluding the reviews with the same time period coverage and those evaluating almost the same articles (those reviews published at the same time period but coming up with variable conclusions or preferably those on a very specific subject matter were included). After selection of the reviews, we
future science group
Physiatric approaches to pain management in osteoarthritis searched for recent relevant trials not included in the reviews. Before searching for recent individual trials, the dates of search for a specific nonpharmacological approach were assessed in the selected reviews and then searches were made accordingly (i.e., limiting search dates to a time period after those search dates in reviews). The last search date of the robust systematic review of Zhang and colleagues [4] was considered as the starting point for some of the interventions for hip and knee OA. However, considering the situation that evidence for some interventions (e.g., laser) was based on earlier studies in the OA Research Society International (OARSI) review [4] , some searching was based on the last search date of other reviews. The most recent reviews on specific subjects also necessitated other search dates. The search terms and publication time limitations used for searching individual trials are shown in Figure 1. Selection of individual trials was based on the relevancy of the content of the present review with the exclusion of those trial protocols, adherence studies, cost–effectiveness studies/economic evaluations, those not evaluating pain as an outcome as well as duplicates retrieved under search headings. Although the individual trials evaluated in any selected review was excluded by checking citation status using ISI Web of Knowledge, the only exception was the latest review of Hawker and colleagues, where only four selected articles were commented on [5] . Therefore, we intended to comment on those relevant trials included in the references section of this specific review [5] other than the four highlighted. The individual RCTs were assessed for quality using the three-item Jadad scale [6] . For those trials such as exercise or manual therapy not allowing for blinding of the recipients and providers due to their inherent nature, one point was given if the study was indicated as single blinded (assessors’ blindness to treatment allocation), and an additional one point if the method of appropriate ‘single’ blinding was expressed, as has previously been done similarly in systematic reviews of exercise trials [7] . We did not intend to decrease points or to say the study is of moderate quality if the study could not be designed otherwise due to the nature of the treatment. However, this requires caution when interpreting the results as discussed in a systematic review of scales used in physical therapy trials [8] . Furthermore, the main findings of small trials (
Physiatric approaches to pain management in osteoarthritis: a review of the evidence of effectiveness
Practice Points
Aydan Oral† & Elena Ilieva1
Education and self-management interventions can play important roles in improving pain in the short and long term in patients with knee or hip osteoarthritis (OA).
Rapidly growing evidence on the association of obesity and both knee and hip OA enhances the importance of weight reduction for the management of pain in patients with both types of OA.
There is a considerable body of consistent evidence supporting the efficacy of exercise in reducing pain in knee OA. Furthermore, the diversity of exercise programs used in trials offers new options that may better meet the individual patient’s needs and preferences. The effectiveness of exercise in hip OA is based on a lower level of evidence; however, emerging studies add to evidence with more encouraging results on this significant management option in hip OA.
Regarding physical modalities in the treatment of hip or knee OA, inconclusive evidence exists on the effectiveness of transcutaneous electrical nerve stimulation. Recent evidence points to favorable effects of therapeutic ultrasound for decreasing pain in both knee and hip OA. There is contradictory evidence that low-level laser therapy has pain relieving effects in knee OA. Electromagnetic fields do not appear to provide any additive benefits on pain reduction in knee OA.
As for complementary therapies, despite good evidence for the effectiveness of acupuncture for pain reduction in knee OA, there is a lack of evidence for its benefits in hip OA.
Encouraging new evidence exists on the effectiveness of manual therapy in hip OA, but not in knee OA.
Studies reveal beneficial effects of knee braces, foot orthoses and taping in reducing pain in knee OA. Footwear deserves more attention in the treatment of hip, knee and foot OA.
Emerging studies suggest the effectiveness of balneotherapy in reducing pain in knee OA.
There is consistent evidence regarding the efficacy of splints in reducing pain in hand OA.
New evidence points to the efficacy of splinting and low level laser therapy in temporomandibular joint OA in addition to conventional approaches.
Unloading strategies may be helpful for pain management in ankle OA.
Department of Physical Medicine & Rehabilitation, Plovdiv Medical University, University Hospital “Sv. Georgi”, Peshtersko shosse 66, Plovdiv, 4002, Bulgaria † Author for correspondence: Department of Physical Medicine & Rehabilitation, Istanbul University, Istanbul Faculty of Medicine, Capa, 34093, Istanbul, Turkey; Tel.: +90 212 635 1185; Fax: +90 212 631 1167; [email protected] 1
10.2217/PMT.11.46 © 2011 Future Medicine Ltd
Pain Manage. (2011) 1(5), 451–471
ISSN 1758-1869
451
Review Oral & Ilieva SUMMARY
Osteoarthritis (OA), which is highly prevalent in the general population, is one of the leading causes of pain and physical disability. A large number of nonpharmacological interventions are available for the management of pain in patients with OA. These include education and self-management, weight reduction, various forms of exercises, physical agents/modalities, complementary therapies, manual therapy, unloading strategies such as braces and orthoses, and balneotherapy. The aim of this article is to assess the evidence of effectiveness of nonpharmacological interventions pertaining to physiatry to identify best practices for pain management in OA. The importance of treatment of osteoarthritis It is well known that osteoarthritis (OA) is the most common type of joint disorder causing chronic musculoskeletal pain and disability in elderly populations worldwide [1] . Increasing in prevalence and progressing with aging, for a decade OA has moved from the tenth to the sixth leading cause of nonfatal burden accounting for 3% of total years lost to disability in the world [2] . OA not only affects the elderly, but also the younger populations in the workforce. The 2009 National Health and Wellness Survey revealed significantly greater work impairment among workers with OA pain than among those without OA pain (34.4 vs 17.8%) in addition to significantly higher healthcare resource utilization with total costs almost twice as much of those without OA pain [3] . Therefore, OA management strategies are of substantial importance for alleviating the burden resulting from this condition. The aim of this narrative review is to assess the evidence of effectiveness of nonpharmacological interventions pertaining to physiatry to identify best practices for pain management in OA. The broad question attempted to be addressed in this nonsystematic review is “what are the latest evidences on physiatric/ nonpharmacological approaches for relieving pain in different types of osteoarthritic conditions (i.e., OA of the knee, hip, hand and of other regions)?” The latest systematic reviews, meta-analyses and narrative reviews, and those individual trials of various designs published after the last search date in the selected reviews are examined in this article to answer this question. The intention of the authors of this article is to provide the readers with a bigger picture of research evidence on the subject that is not restricted only to the rigorously structured and well-conducted high-quality reviews tending to exclude weak evidence or those randomized controlled trials (RCTs) with very low risk
452
Pain Manage. (2011) 1(5)
of bias. This will thus allow the reader to be updated with what has been done in this area in a wide range of studies while leaving a space for judgment of best practices based on quality assessment of RCTs. Literature review We conducted a comprehensive literature review of reviews, systematic reviews, overview of systematic reviews and those subsequent trials not included in the reviews on OA published between the dates 1 January 2005 and 15 May 2011 using PubMed® MEDLINE, Cochrane Database of Systematic Reviews and ISI Web of Knowledge. The conducted literature search was as follows: we started searching for reviews with the search term ‘osteoarthritis’ limited to ‘humans’, ‘meta-analysis’, ‘review’, ‘English’, ‘MEDLINE’, ‘systematic reviews’, publication date from the 1st January 2005 to the 15th May 2011. This search revealed 1982 articles from PubMed/MEDLINE. The reviews were checked by titles or abstracts when there was uncertainty about the content to identify relevant ones for inclusion in the review. When the title or abstract included any pharmacological/medicinal or surgical intervention, the review was not taken into consideration. Searching the Cochrane Database of Systematic Reviews revealed no additional reviews when searched under the headings > subheadings: acute pain > physical therapy; rheumatology > osteoarthritis > non-pharmacological treatment > rehabilitation; rheumatology > soft tissue disorders > lower limb pain. However, ISI Web of Knowledge revealed one additional review. Review selection strategy was as follows: evaluating reviews with regard to the time period covered and the studies included; excluding the reviews with the same time period coverage and those evaluating almost the same articles (those reviews published at the same time period but coming up with variable conclusions or preferably those on a very specific subject matter were included). After selection of the reviews, we
future science group
Physiatric approaches to pain management in osteoarthritis searched for recent relevant trials not included in the reviews. Before searching for recent individual trials, the dates of search for a specific nonpharmacological approach were assessed in the selected reviews and then searches were made accordingly (i.e., limiting search dates to a time period after those search dates in reviews). The last search date of the robust systematic review of Zhang and colleagues [4] was considered as the starting point for some of the interventions for hip and knee OA. However, considering the situation that evidence for some interventions (e.g., laser) was based on earlier studies in the OA Research Society International (OARSI) review [4] , some searching was based on the last search date of other reviews. The most recent reviews on specific subjects also necessitated other search dates. The search terms and publication time limitations used for searching individual trials are shown in Figure 1. Selection of individual trials was based on the relevancy of the content of the present review with the exclusion of those trial protocols, adherence studies, cost–effectiveness studies/economic evaluations, those not evaluating pain as an outcome as well as duplicates retrieved under search headings. Although the individual trials evaluated in any selected review was excluded by checking citation status using ISI Web of Knowledge, the only exception was the latest review of Hawker and colleagues, where only four selected articles were commented on [5] . Therefore, we intended to comment on those relevant trials included in the references section of this specific review [5] other than the four highlighted. The individual RCTs were assessed for quality using the three-item Jadad scale [6] . For those trials such as exercise or manual therapy not allowing for blinding of the recipients and providers due to their inherent nature, one point was given if the study was indicated as single blinded (assessors’ blindness to treatment allocation), and an additional one point if the method of appropriate ‘single’ blinding was expressed, as has previously been done similarly in systematic reviews of exercise trials [7] . We did not intend to decrease points or to say the study is of moderate quality if the study could not be designed otherwise due to the nature of the treatment. However, this requires caution when interpreting the results as discussed in a systematic review of scales used in physical therapy trials [8] . Furthermore, the main findings of small trials (
