Smedslund, G., Kjeken, I., Musial, F., Sexton, J., & Østerås, N. (2022). Interventions for osteoarthritis pain: A systematic review with network meta-analysis of existing Cochrane reviews. Osteoarthritis And Cartilage Open, 4(2), 100242. https://doi.org/10.1016/j.ocarto.2022.100242
Currently, professional bodies have different guidelines with regards to the most optimal treatment for OA, and some of the recommendations are inconsistent with research findings. Furthermore, many intervention studies only investigated one treatment modality at a time, making it difficult to ascertain which intervention is superior.
Hence, this study (SR) aims to conduct a network meta-analysis on systematic reviews from Cochrane Library and Epistemonikos, in order to compare the efficacy of various interventions on OA pain.
What They Did
A total of 35 SRs from Cochrane Library (22) and Epistemonikos (13) were included, and they amount to 445 RCTs and 153 different types of interventions altogether. All of the selected SRs included OA pain as one of the outcomes of interest. Publication dates of the SRs ranged from 2013 to 2022. Studies on knee OA were the most prevalent (339), followed by hip (24) and hand (6).
What They Found
Moderate confidence of a positive effect:
- Mind-body exercise
- Regenerative medicine (platelet-rich plasma injection)
- Intra-articular injections
Low confidence of a positive effect:
- Passive treatment
- Diet modification / weight loss
Comparing with EULAR*, ACR** and OARSI*** guidelines:
- Similar to EULAR, ACR and OARSI, this SR also found exercise to have a positive effect and should be the core treatment for OA pain.
- ACR recommends against platelet-rich plasma (PRP) injection, but this SR showed that it has a strong effect on OA pain. However, this SR only has 2 studies that used PRP injections.
- OARSI recommends against herbs, but this SR showed that it has a strong effect on OA pain.
- Diet modification / Weight loss is recommended by EULAR, ACR and OARSI, but this category did not show clinical relevance in this SR.
EULAR* = European Alliance of Associations for Rheumatology
ACR** = American College of Rheumatology
OARSI*** = Osteoarthritis Research Society International (OARSI)
There is a moderate likelihood that exercise, regenerative medicine, herbs and intra-articular injections are effective in managing OA pain. There is also a low likelihood that NSAIDs, opioids, analgesics, passive treatment and weight loss are effective in managing OA pain.
Although this study found support for interventions that are contrary to guideline recommendations, it is important to note that this study only looked at the reduction in OA pain. Professional bodies often have to consider multiple outcomes in totality, such as cost-effectiveness, duration of effect and risk of adverse events, before making recommendations on a particular intervention.
Although diet modification/weight loss has not been found to have a strong positive effect in this study, there are other cardiovascular and metabolic benefits to lowering BMI as well, such as reduction in inflammatory adipokines. Hence, prudence should be exercised when interpreting results from a single study, even if the research design is as robust as a network meta-analysis.