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Inclusion of nonpharmaceutical components in the treatment of osteoarthritiscomment on the article by Williams et al.

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Number 6, June 1994, pp %3-W
0 1994, American College of Rheumatology
Inclusion of nonpharmaceutical components in the
treatment of osteoarthritis: comment on the article by
Williams et a1
To the Editor:
I was somewhat dismayed to read the article by
Williams et a1 (Williams HJ, Ward JR, Egger MJ, Neuner R,
Brooks RH, Clegg DO, Field EH, Skosey JL, Alarc6n GS,
Willkens RF, Paulus HE, Russell IJ, Sharp JT: Comparison
of naproxen and acetominophen in a two-year study of
treatment of osteoarthritis of the knee. Arthritis Rheum
36: 11961206, 1993), concerning the treatment of osteoarthritis (OA). The main thrust of their study was to compare
the relative efficacy of acetaminophen versus naproxen used
as the sole treatment modality in OA.
While family practitioners and internists are accustomed to treating OA with chemical agents alone, rheumatologists should strive to achieve a more complete program.
Specifically, the real treatment of OA should be education of
the patient, in order to try to halt the progression of
deterioration of joint cartilage. This would include discussions of body dynamics, weight loss, and exercise for tone of
supporting structures and for range of motion. Every patient
with OA ought to have at least one visit with a physical
therapist and ought to spend significant amounts of time in
counseling with a knowledgeable physician. Only in this way
can the osteoarthritic process truly be arrested or slowed,
which, when all things are considered, should really be our
aim in therapy, rather than simple pain relief.
I realize that this approach to the treatment of OA
involves concepts that are difficult to teach and are best
learned by experience, but I fear that simple comparisons
between chemical agents can foster the naive view that pain
relief alone is the only valid treatment of this prevalent and
debilitating condition.
Brian Peck, MD
Arthritis Center of Connecticut
Waterbury, CT
To the Editor:
We appreciate Dr. Peck’s interest in our study on the
medical ‘treatment of OA of the knee. As mentioned in the
article, the purpose of the investigation was to evaluate the
differences in efficacy and safety of an analgesic compared
with an analgesic/antiinflammatorydrug. We were studying
only the drug treatment of OA, but we would agree with Dr.
Peck that the physical measures he mentions are important.
Certainly, physical therapy can help patients maintain muscle mass and mobility, but the suggestion that
physical therapy will halt the progression of cartilage deterioration has not been rigorously studied. A comparison of
the relative benefits of the physical treatments versus the
pharmacologic treatments has also not been investigated.
Both may provide only symptomatic and functional benefit
without affecting the actual progression of the disease.
Until further evidence is forthcoming, OA is best
managed with symptom-directed medical therapy and appropriate physical therapy. Whether the pharmacologic approach should favor analgesic or antiinflammatory drugs was
the question we addressed in our study, and we found no
strong advantage to either.
H. James Williams, MD
John R. Ward, MD, MPH
For the Cooperative Systematic Studies of
the Rheumatic Diseases Group
Salt Lake City, UT
Chronic Fatigue Syndromes: The Limbic Hypothesis. J . A .
Goldstein. Binghamton, N Y , Haworth Medical Press, 1993.
259 p p . Illustrated. Indexed. $89.95 hardcover, $49.95
The limbic hypothesis is just that, a thesis to explain
the fatigue and other multiple somatic symptoms experienced by patients with the chronic fatigue syndrome (CFS).
At the outset of the book Dr. Goldstein states: “I have come
to the conclusion that most of the symptoms of CFS can be
explained by postulating a limbic encephalopathy ; the next
201 pages expand on this notion.”
Unfortunately, the complexity of functional neuroanatomy and the multiple feedback loops of psycho-neur+
endocrine-immunologic circuits provide an often contradictory viewpoint which this reviewer could not integrate into a
logical hypothesis. There are many references to fibromyalgia (FM), and practicing rheumatologists may be interested
in the following observations: 1) “Many CFS patients with
fibromyalgia appear to have different neuro-chemistry or
functional neuroanatomy than do CFS patients without FM”
(page 83); 2) “I feel more confident about making the CFS
diagnosis if the fibromyalgia tender points are present” (page
98); 3) “Many CFS patients have temporal limbic epilepsy”
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treatment, articles, william, osteoarthritiscomment, inclusion, components, nonpharmaceutical
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