The nonpharmacological treatment of osteoarthritis

Editor, I refer to the article 'The nonpharmacological treatment of osteoarthritis' by Dr J.R. York (Aust Prescr 1995;18:2-4).

This article offers a number of strategies to prevent and manage arthritis which are not supported by the medical literature. Whilst much research has taken place into the nature of osteoarthritis, the aetiology remains in doubt.

I would have liked Dr York to provide references which demonstrate that weight reduction, occupational or sport modification, joint protection, team management, analgesics or education prevents osteoarthritis from developing or progressing.

All of the factors he has mentioned have an important role in the management of established osteoarthritis and they reduce symptoms once they occur.

The question of cruciate ligament repair remains controversial, although there is some evidence that prevention of episodes of giving way minimises the risk of articular damage or meniscal injury, therefore offering the theoretical possibility of preventing osteoarthritis. It is perhaps this singular issue which offers some possibility for prevention.

Finally, as an Australian trained orthopaedic surgeon and current trainer of young orthopaedic surgeons, I can only say that I was taught and teach that surgery is never the best option. Surgery is the option chosen when other methods of management have failed to bring about comfort and quality of life is significantly compromised.

I write to the author because of my concern that many of the physical methods of management involve considerable human resources and expense and, unless there is evidence of their efficacy, they should be used sparingly.

Bruce R.T. Love
Orthopaedic Surgeon
East Melbourne, Vic.

Dr J.R. York, the author of the article, comments:

I thank Mr Love for his comments. I would agree that there are no documented prospective trials to prove that the techniques outlined in my paper prevent osteoarthritis from developing or progressing. The logistics of such studies present formidable problems, particularly the length of follow up time required to produce meaningful results.

However, one can argue a logical case on the premise that if a particular bodily characteristic such as obesity or a person's occupation or sporting activity is associated with an increased prevalence of osteoarthritis in specific joints,^1,2,3 then control of these factors should be attempted. Primary prevention in the absence of a defined aetiology for the disease is elusive and Utopian, but the onusis equally on Mr Love to provide evidence that the measures outlined do not do more than reduce symptoms in affected joints.

Perhaps the question 'Is surgical treatment the best option?' may have been better expressed as 'Is surgical treatment the best available option?'. There is no question in my mind after many years of consultant rheumatology practice that the most significant advance in the management of most forms of arthritis in the last 30 years has been the development of total joint replacement.

I have no argument with Mr Love's indications for surgery or his concluding paragraph with which I concur.