KEELE, UK—More aggressive pharmacist review of osteoarthritis (OA) pain control and drug treatment plans combined with community physiotherapy can reduce pain, increase patient satisfaction, and reduce NSAID use in patients with knee OA, Elaine M. Hay, MD, reports.¹ Dr. Hay, professor/consultant in community rheumatology at Keele University in the UK, concludes that physiotherapists and pharmacists can safely and effectively deliver evidence- based care to knee pain patients.

The investigators also found that physiotherapy, which included counseling on exercise, pacing, pain relief, coping strategies, and an individualized exercise program also reduced general practitioner consults. The pragmatic randomized trial appears online in the British Medical Journal.

"The challenge posed by these results is to investigate how the early clinical benefits seen might be enhanced in the longer term, and whether potential reductions in use of heath care make these interventions cost effective as first line primary care management strategies," Dr. Hay says.

While both pharmacological and nonpharmacological approaches are effective for the primary management of knee pain, the authors write that the general practitioner is increasingly unable to provide such care in the UK. The research team set out to determine whether other health care providers could deliver the needed care to adults older than age 55 presenting with knee pain.

In the study, 325 adults aged 55 years or over, with a mean age of 68 years, who presented with knee pain were randomized to receive enhanced pharmacy review. Interventions included pharmacological management in accordance with an algorithm, community physiotherapy comprising advice about activity and pacing together with an individualized exercise program, or an advice pamphlet reinforced by a telephone call (control group). The primary endpoint was change in Western Ontario and McMaster Universities osteoarthritis index (WOMAC) at 3, 6, and 12 months. Of the initial cohort, 297 (91%) reached 6-month follow-up.

WOMAC changes at 3 months

WOMAC pain score was 9.1 at baseline and mean baseline function score was 29.9. At 3 months, the mean reductions in pain scores were 0.41 for control, 118 for pharmacy (P = .006) and 1.19 for physiotherapy (P = .008), the study showed. Control patients showed nonsignificant differences in function at 3 months. The improvements in pain scores were not sustained at 6 or 12 months in the treatment groups.

Enhanced pharmacy review did not produce significant improvements in WOMAC functional scores, but physiotherapy significantly improved function scores at 3 months (P = .008). Again, these improvements were not sustained at 6 months.

Significantly fewer participants in the physiotherapy group reported consulting their general practitioner for knee pain in the follow-up period, and use of NSAIDs was lower in both the physiotherapy and pharmacy groups than in the control group.

Is it really worth it?

"The overall concepts are good," Roland Moskowitz, MD, told CIAOMed. Dr. Moskowitz is director of the division of rheumatic disease at University Hospitals of Cleveland and professor of medicine at Case Western Reserve University, both in Cleveland, Ohio. "Outsourcing a patient has merit because a doctor doesn't really have the time in a lot of cases to instruct a patient on exercises, and if we have 10 to 15 minutes to see a patient, we don't do it," he said.

But outsourcing pharmacy care is another story, Dr. Moskowitz said. "The pharmacist may not be evaluating a patients' response and looking at the balance of benefit to toxicity. It's nice to have pharmacists look over medication orders to catch errors, but pharmacists are not physicians, and they are going by an algorithm that not everyone agrees with. When you start going by a chart, you don't give patients the best care."

Marc C. Hochberg, MD, MPH, professor of medicine and head of the division of rheumatology and clinical immunology at the University of Maryland School of Medicine, told CIAOMed that he reviews the drug therapy of all his patients at every visit, but does not use the algorithm used in the new study. "I refer patients for a consult visit with a physical therapist so that they may have an evaluation and be instructed in a home exercise program," he said. "[Community physiotherapy] might be more cost-effective than individual physiotherapy referrals; however, the improvement was only seen at 3 months, and I don't think it reaches the level of minimally clinically important improvement."


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Reference

1. Hay EM, Foster NE, Thomas E, et al. Effectiveness of community physiotherapy and enhanced pharmacy review for knee pain in people over 55 presenting to primary care: pragmatic randomized trial. BMJ. 2006 October 20; [Epub ahead of print].