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膝关节骨关节炎的糖皮质激素注射和物理疗法——优先选用后者
Physical Therapy before the Needle for Osteoarthritis of the Knee


Kim L. Bennell ... 其他 • 2020.04.09
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膝关节骨关节炎的治疗指南强调教育、运动和(适合的情况下)减重,而非药物或手术治疗1,2。然而,在欧洲四个国家进行的一项调查表明,医师仅向不到一半的患者推荐了上述治疗;而向52%的患者推荐了更强效的止痛药,并将36%的患者转诊接受手术治疗3。关节内注射糖皮质激素常被用于治疗膝关节骨关节炎,部分原因是给药方便,比其他疗法所需的就诊次数少,而且不存在患者依从性方面的问题。但注射糖皮质激素产生的益处可能是短暂的,而且已有对关节产生不良作用的报道,包括临床意义不明的软骨量丢失小幅增多4。而包括运动在内的物理疗法则较少被采用,此外虽然物理疗法需要患者参与和时间投入,但物理疗法无创,副作用微乎其微,而且产生的益处可能比注射糖皮质激素持久。

目前只有极少试验直接比较膝关节骨关节炎的不同疗法。Deyle及其同事5在本期NEJM发表了主要在美国一家军队医院开展的一项实用性、随机、对照试验的结果。共计156例膝关节骨关节炎门诊患者被分配接受物理疗法或者关节内注射糖皮质激素。研究者在12个月时评估了结局。由于无法向患者或医务人员隐瞒治疗分组,因此试验设计中不包括安慰剂注射。





作者信息

Kim L. Bennell, Ph.D., and David J. Hunter, Ph.D.
From the Centre for Health, Exercise, and Sports Medicine, Department of Physiotherapy, University of Melbourne, Melbourne, VIC (K.L.B.), and the Institute of Bone and Joint Research, Kolling Institute, University of Sydney, and the Rheumatology Department, Royal North Shore Hospital, Sydney (D.J.H.) — all in Australia.

 

参考文献

1. Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Rheumatol 2020;72:220-233.

2. Bannuru RR, Osani MC, Vaysbrot EE, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage 2019;27:1578-1589.

3. Østerås N, Jordan KP, Clausen B, et al. Self-reported quality care for knee osteoarthritis: comparisons across Denmark, Norway, Portugal and the UK. RMD Open 2015;1(1):e000136-e000136.

4. McAlindon TE, LaValley MP, Harvey WF, et al. Effect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis: a randomized clinical trial. JAMA 2017;317:1967-1975.

5. Deyle GD, Allen CS, Allison SC, et al. Physical therapy versus glucocorticoid injection for osteoarthritis of the knee. N Engl J Med 2020;382:1420-1429.

6. Gregori D, Giacovelli G, Minto C, et al. Association of pharmacological treatments with long-term pain control in patients with knee osteoarthritis: a systematic review and meta-analysis. JAMA 2018;320:2564-2579.

7. Jüni P, Hari R, Rutjes AWS, et al. Intra-articular corticosteroid for knee osteoarthritis. Cochrane Database Syst Rev 2015;10:CD005328-CD005328.

8. Henriksen M, Christensen R, Klokker L, et al. Evaluation of the benefit of corticosteroid injection before exercise therapy in patients with osteoarthritis of the knee: a randomized clinical trial. JAMA Intern Med 2015;175:923-930.

9. van Middelkoop M, Arden NK, Atchia I, et al. The OA Trial Bank: meta-analysis of individual patient data from knee and hip osteoarthritis trials show that patients with severe pain exhibit greater benefit from intra-articular glucocorticoids. Osteoarthritis Cartilage 2016;24:1143-1152.

10. Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev 2015;1:CD004376-CD004376.

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