Bora BOSTAN, Ufuk ŞEN, TANER GÜNEŞ, Seyyid Ahmet ŞAHİN, Cengiz ŞEN, MEHMET ERDEM, ÜNAL ERKORKMAZ

Comparison of intra-articular hyaluronic acid injections and mud-pack therapy in the treatment of knee osteoarthritis

Amaç: Diz osteoartritinde cerrahi tedaviden önce zaman kazandırıcı konservatif yöntemler denenmelidir. Çalışmamızda, diz osteoartritinde tıbbi çamur tedavisinin kısa dönemde ağrı ve fonksiyonlar üzerine etkisi değerlendirildi ve eklemiçi hiyalüronik asit uygulamasıyla karşılaştırıldı. Çalışma planı: Çalışmaya, Amerikan Romatoloji Derneği ölçütlerine göre diz osteoartriti tanısı konan ve yakınmaları üç aydan uzun süren 23 hasta alındı. Kellgren-Lawrence sistemine göre radyografik olarak bütün hastalarda evre 2 veya 3 diz osteoartriti vardı. On iki hastanın (3 erkek, 9 kadın; ort. yaş 54±6.; dağılım 46-67) her iki dizine, günde bir kez, 12 gün süreyle, 45 ˚C sıcaklıkta ve 30 dakika süreyle, diz üzerine paket tarzında çamur tedavisi uygulandı. On bir hastanın (2 erkek, 9 kadın; ort. yaş 53±9; dağılım 40-66) her iki dizine de, birer hafta arayla üç kez hiyalüronik asit enjeksiyonu uygulandı. Hastalar tedavi öncesi ve tedavi sonrası son kontrollerinde WOMAC osteoartrit ölçeğinin (Western Ontario and McMaster Universities) ağrı altbölümü, HSS skoru (Hospital for Special Surgery) ve Diz Derneği (Knee Society) fonksiyon skoru ve diz skoru ile ağrı ve fonksiyon açısından değerlendirildi. Çamur tedavisi grubunda ortalama takip süresi 5.9±6.3 ay (dağılım 4-8 ay), hiyalüronik asit grubunda 5.8±0.8 ay (dağılım 5-7 ay) idi. Sonuçlar: Hem tedavi öncesi hem de tedavi sonrası WOMAC, HSS, diz ve fonksiyon skorları iki grup arasında anlamlı farklılık göstermedi (p>0.05). Her iki grup içinde de, işlem öncesine göre işlem sonrasında tüm skorlarda anlamlı iyileşme görüldü (p0.05). Çıkarımlar: Diz osteoartritinde eklemiçi hiyalüronik asit ve tıbbi çamur uygulamaları hastaların fonksiyonlarında iyileşme ve ağrının azaltılmasında kısa dönemde benzer sonuçlar göstermektedir. Girişim gerektirmemesi, komplikasyonsuz ve düşük maliyetli bir seçenek olması nedeniyle, tıbbi çamur diz osteoartritinde kullanılabilecek önemli bir konservatif tedavi seçeneğidir.

Anahtar Kelimeler:

Tedavi sonucu, Hiyalüronik asit, Enjeksiyon, eklem içi, Çamur tedavisi, Osteoartrit, diz

Diz osteoartritinde eklemiçi hiyalüronik asit uygulaması ile tıbbi çamur tedavisinin kısa dönem sonuçlarının karşılaştırılması

Objectives: Conservative treatment should be tried prior to surgical treatment in knee osteoarthritis. This study was designed to evaluate the short-term effects of mud-pack therapy on pain relief and functional improvement in knee osteoarthritis in comparison with intra-articular hyaluronic acid injections. Methods: The study included 23 patients who were diagnosed as having knee osteoarthritis according to the ACR (American College of Rheumatology) criteria, and had complaints lasting for more than three months. All the patients had stage 2 or 3 osteoarthritis radiographically according to the Kellgren-Lawrence criteria. Twelve patients (3 males, 9 females; mean age 54±6 years; range 46 to 67 years) received mud therapy bilaterally. Mud packs were heated to 45 °C and applied on both knees for 30 minutes daily for a total of 12 weekdays. Eleven patients (2 males, 9 females; mean age 53±9 years; range 40 to 66 years) received a total of three bilateral intra-articular hyaluronic acid injections, each interspersed by weekly intervals. The patients were evaluated before and after treatment in terms of pain and functionality using the pain subscale of the WOMAC (Western Ontario and McMaster Universities) osteoarthritis index, Hospital for Special Surgery (HSS) score, and Knee Society clinical rating system (knee and function scores). The patients were followed-up for a mean of 5.9±6.3 months (range 4 to 8 months) after mud-pack therapy, and 5.8±0.8 months (range 5 to 7 months) after intra-articular hyaluronic acid injections. Results: No significant differences were found between the two groups with respect to pre-and posttreatment WOMAC, HSS, and knee and function scores (p>0.05). The scores of all instruments showed significant improvements following treatment in both groups (p<0.001). Posttreatment changes in relation to baseline scores did not differ significantly between the two groups (p>0.05). Conclusion: Treatment of knee osteoarthritis with intra-articular hyaluronic acid injections or mud-pack therapy yielded similar results in the short-term in terms of functional improvement and pain relief. Mud-pack therapy is a noninvasive, complication-free, and cost-effective alternative modality for the conservative treatment of knee osteoarthritis.

Keywords:

Treatment Outcome, Hyaluronic Acid, Injections, Intra-Articular, Mud Therapy, Osteoarthritis, Knee,

___

1. Buckwalter JA, Stanish WD, Rosier RN, Schenck RC Jr, Dennis DA, Coutts RD. The increasing need for nonoperative treatment of patients with osteoarthritis. Clin Orthop Relat Res 2001;(385):36-45.
2. Leslie M. Knee osteoarthritis management therapies. Pain Manag Nurs 2000;1:51-7.
3. Petrella RJ, DiSilvestro MD, Hildebrand C. Effects of hyaluronate sodium on pain and physical functioning in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled clinical trial. Arch Intern Med 2002; 162:292-8.
4. Bunyaratavej N, Chan KM, Subramanian N. Treatment of painful osteoarthritis of the knee with hyaluronic acid. Results of a multicenter Asian study. J Med Assoc Thai 2001;84 Suppl 2:S576-81.
5. Waddell D, Rein A, Panarites C, Coleman PM, Weiss C. Cost implications of introducing an alternative treatment for patients with osteoarthritis of the knee in a managed care setting. Am J Manag Care 2001;7:981-91.
6. Ayral X. Injections in the treatment of osteoarthritis. Best Pract Res Clin Rheumatol 2001;15:609-26.
7. Brandt KD, Block JA, Michalski JP, Moreland LW, Caldwell JR, Lavin PT. Efficacy and safety of intraarticular sodium hyaluronate in knee osteoarthritis. ORTHOVISC Study Group. Clin Orthop Relat Res 2001;(385):130-43.
8. Karagülle MZ. Kaplıca tedavisinin etkinliği. Klinik Gelişim 2000;13:258-61.
9. Wigler I, Elkayam O, Paran D, Yaron M. Spa therapy for gonarthrosis: a prospective study. Rheumatol Int 1995; 15:65-8.
10. Nguyen M, Revel M, Dougados M. Prolonged effects of 3 week therapy in a spa resort on lumbar spine, knee and hip osteoarthritis: follow-up after 6 months. A randomized controlled trial. Br J Rheumatol 1997;36:77-81.
11. Sukenik S, Flusser D, Codish S, Abu-Shakra M. Balneotherapy at the Dead Sea area for knee osteoarthritis. Isr Med Assoc J 1999;1:83-5.
12. Guillemin F, Virion JM, Escudier P, De Talancé N, Weryha G. Effect on osteoarthritis of spa therapy at Bourbonne-les- Bains. Joint Bone Spine 2001;68:499-503.
13. Altman R, Asch E, Bloch D, Bole G, Borenstein D, Brandt K, et al. Development of criteria for the classification and reporting of osteoarthritis. Classification of osteoarthritis of the knee. Diagnostic and Therapeutic Criteria Committee of the American Rheumatism Association. Arthritis Rheum 1986;29:1039-49.
14. Kellgren JH, Lawrence JS. Radiological assessment of osteo-arthrosis. Ann Rheum Dis 1957;16:494-502.
15. Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol 1988;15:1833-40.
16. Insall JN, Ranawat CS, Aglietti P, Shine J. A comparison of four models of total knee-replacement prostheses. J Bone Joint Surg [Am] 1976;58:754-65.
17. Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res 1989;(248):13-4.
18. Şen U, Karagülle MZ, Karagülle M. Diz osteoartritinde peloidoterapinin etkinliği. Romatizma 2007;22:55-9.
19. Evcik D, Kavuncu V, Yeter A, Yiğit I. The efficacy of balneotherapy and mud-pack therapy in patients with knee osteoarthritis. Joint Bone Spine 2007;74:60-5.
20. Odabaşı E, Turan M, Erdem H, Tekbas F. Does mud pack treatment have any chemical effect? A randomized controlled clinical study. J Altern Complement Med 2008; 14:559-65.
21. Watterson JR, Esdaile JM. Viscosupplementation: therapeutic mechanisms and clinical potential in osteoarthritis of the knee. J Am Acad Orthop Surg 2000;8:277-84.
22. Smalley WE, Griffin MR, Fought RL, Ray WA. Excess costs from gastrointestinal disease associated with nonsteroidal anti-inflammatory drugs. J Gen Intern Med 1996;11:461-9.
23. Guidolin DD, Ronchetti IP, Lini E, Guerra D, Frizziero L. Morphological analysis of articular cartilage biopsies from a randomized, clinical study comparing the effects of 500-730 kDa sodium hyaluronate (Hyalgan) and methylprednisolone acetate on primary osteoarthritis of the knee. Osteoarthritis Cartilage 2001;9:371-81.
24. Takahashi K, Hashimoto S, Kubo T, Hirasawa Y, Lotz M, Amiel D. Hyaluronan suppressed nitric oxide production in the meniscus and synovium of rabbit osteoarthritis model. J Orthop Res 2001;19:500-3.
25. Díaz-Gallego L, Prieto JG, Coronel P, Gamazo LE, Gimeno M, Alvarez AI. Apoptosis and nitric oxide in an experimental model of osteoarthritis in rabbit after hyaluronic acid treatment. J Orthop Res 2005;23:1370-6.
26. Takahashi K, Goomer RS, Harwood F, Kubo T, Hirasawa Y, Amiel D. The effects of hyaluronan on matrix metalloproteinase- 3 (MMP-3), interleukin-1beta(IL-1beta), and tissue inhibitor of metalloproteinase-1 (TIMP-1) gene expression during the development of osteoarthritis. Osteoarthritis Cartilage 1999;7:182-90.
27. Martens PB. Bilateral symmetric inflammatory reaction to hylan G-F 20 injection. Arthritis Rheum 2001;44:978-9.
28. Allen E, Krohn K. Adverse reaction to Hylan GF-20. J Rheumatol 2000;27:1572.
29. Bellometti S, Cecchettin M, Galzigna L. Mud pack therapy in osteoarthrosis. Changes in serum levels of chondrocyte markers. Clin Chim Acta 1997;268:101-6.
30. Galzigna L, Ceschi-Berrini C, Moschin E, Tolomio C. Thermal mud-pack as an anti-inflammatory treatment. Biomed Pharmacother 1998;52:408-9.
31. Kristof O, Gatzen M, Hellenbrecht D, Saller R. Analgesic efficacy of the serial application of a sulfurated mud bath at home. Forsch Komplementarmed Klass Naturheilkd 2000; 7:233-6.
32. Bellometti S, Galzigna L, Richelmi P, Gregotti C, Bertè F. Both serum receptors of tumor necrosis factor are influenced by mud pack treatment in osteoarthrotic patients. Int J Tissue React 2002;24:57-64.
33. Bellometti S, Poletto M, Gregotti C, Richelmi P, Bertè F. Mud bath therapy influences nitric oxide, myeloperoxidase and glutathione peroxidase serum levels in arthritic patients. Int J Clin Pharmacol Res 2000;20:69-80.
34. Bellometti S, Galzigna L. Serum levels of a prostaglandin and a leukotriene after thermal mud pack therapy. J Investig Med 1998;46:140-5.
35. Bender T, Karagülle Z, Bálint GP, Gutenbrunner C, Bálint PV, Sukenik S. Hydrotherapy, balneotherapy, and spa treatment in pain management. Rheumatol Int 2005; 25:220-4.
36. Codish S, Abu-Shakra M, Flusser D, Friger M, Sukenik S. Mud compress therapy for the hands of patients with rheumatoid arthritis. Rheumatol Int 2005;25:49-54.
37. Poensin D, Carpentier PH, Féchoz C, Gasparini S. Effects of mud pack treatment on skin microcirculation. Joint Bone Spine 2003;70:367-70.
38. Tishler M, Rosenberg O, Levy O, Elias I, Amit-Vazina M. The effect of balneotherapy on osteoarthritis. Is an intermittent regimen effective? Eur J Intern Med 2004;15:93-6.
39. Mazzulla S, Chimenti R, Sesti S, De Stefano S, Morrone M, Martino G. Effect of sulphurous Bioglea on psoriasis. Clin Ter 2004;155:499-504. [Abstract]
40. Koyuncu H. Yüzeyel ısıtıcılar. In: Sarı H, Tüzün Ş, Akgün K, editörler. Hareket sistemi hastalıklarında fiziksel tıp yöntemleri. 2. baskı, İstanbul: Nobel Tıp Kitabevi; 2002. s. 43-50.
41. Weber DC. Brown AW. Physical agent modalities. In: Braddom RL, editor. Physical medicine and rehabilitation. 2nd ed. Philadelphia, W. B. Saunders; 2000. p. 440-58.
42. Cutović M, Jović S, Konstantinović L, Lazović M, Jovanović T, Vesović V. The effects of balneotherapy on knee osteoarthritis. Med Pregl 2006;59 Suppl 1:47-50. [Abstract]
43. Flusser D, Abu-Shakra M, Friger M, Codish S, Sukenik S. Therapy with mud compresses for knee osteoarthritis: comparison of natural mud preparations with mineral-depleted mud. J Clin Rheumatol 2002;8:197-203.
44. Klimiuk PA, Muklewicz E, Sierakowski S. Therapeutic efficacy of peloid plasters in the treatment of osteoarthritis of the peripheral joints and spondylosis. Pol Merkur Lekarski 2004;16:344-7. [Abstract]