Abstract
Low-dose radiotherapy (LD-RT) has been widely used for treatment of non-malignant disorders since its introduction and animal studies show anti-inflammatory effects in osteoarthritis (OA). However, the evidence for its effect in clinical practice remains unclear. Therefore, the aim of this study is to systematically summarise the literature on effectiveness of LD-RT on pain and functioning in patients with OA and its safety. Broad search terms were used to search PubMed, EMBASE and Web of Science. Primary inclusion criteria were osteoarthritis as indication, radiotherapy as intervention, written in English, German or Dutch and published since 1980. Study quality was assessed using the EPHPP Quality Assessment Tool for Quantitative Studies (scale: strong, moderate, weak). Seven studies were suitable for inclusion, all with retrospective uncontrolled observational design. Methodological quality of all studies was judged as weak. Most studies used 2–3 RT sessions per week for 2 weeks, some with booster session after 6 weeks. Generally, non-validated single-item measurement instruments were used to evaluate the effect of LD-RT on pain and function. Across the studies, in 25–90 and 29–71 % of the patients pain and functioning improved, respectively. Side effects were described in one study, none were reported. Our results show that there is insufficient evidence for efficacy or to confirm the safety of LD-RT in treatment of OA, due to absence of high-quality studies. Therefore, a well-designed, sham-controlled and blinded randomised trial, using validated outcome measures is warranted to demonstrate the value of LD-RT for OA in clinical practice.
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References
Helmick CG, Felson DT, Lawrence RC et al (2008) Estimates of the prevalence of arthritis and other rheumatic conditions in the United States: Part I. Arthritis Rheum 58:15–25. doi:10.1002/art.23177
Grynpas MD, Alpert B, Katz I et al (1991) Subchondral bone in osteoarthritis. Calcif Tissue Int 49:20–26. doi:10.1016/S8756-3282(00)80079-4
Tan AL, Grainger AJ, Tanner SF et al (2005) High-resolution magnetic resonance imaging for the assessment of hand osteoarthritis. Arthritis Rheum 52:2355–2365. doi:10.1002/art.21210
Sellam J, Berenbaum F (2010) The role of synovitis in pathophysiology and clinical symptoms of osteoarthritis. Nat Rev Rheumatol 6:625–635. doi:10.1038/nrrheum.2010.159
Davis MA, Ettinger WH, Neuhaus JM, Mallon KP (1991) Knee osteoarthritis and physical functioning: evidence from the NHANES I epidemiologic followup study. J Rheumatol 18:591–598
Salaffi F, Carotti M, Stancati A, Grassi W (2005) Health-related quality of life in older adults with symptomatic hip and knee osteoarthritis: a comparison with matched healthy controls. Aging Clin Exp Res 17:255–263
Van Dijk GM, Dekker J, Veenhof C, Van Den Ende CHM (2006) Course of functional status and pain in osteoarthritis of the hip or knee: a systematic review of the literature. Arthritis Care Res 55:779–785. doi:10.1002/art.22244
Dahaghin S, Bierma-Zeinstra SM, Ginai AZ et al (2005) Prevalence and pattern of radiographic hand osteoarthritis and association with pain and disability (the Rotterdam study). Ann Rheum Dis 64:682–687. doi:10.1136/ard.2004.023564
Spector TD, MacGregor AJ (2004) Risk factors for osteoarthritis: genetics. Osteoarthr Cartil 12:S39–S44. doi:10.1016/j.joca.2003.09.005
Oliveria SA, Felson DT, Cirillo PA et al (1999) Body weight, body mass index, and incident symptomatic osteoarthritis of the hand, hip, and knee. Epidemiology 10:161–166. doi:10.1097/00001648-199903000-00013
Bijlsma JWJ, Berenbaum F, Lafeber FPJG (2011) Osteoarthritis: an update with relevance for clinical practice. Lancet 377:2115–2126. doi:10.1016/S0140-6736(11)60243-2
Zhang W, Nuki G, Moskowitz RW et al (2010) OARSI recommendations for the management of hip and knee osteoarthritis. Part III: changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthr Cartil 18:476–499. doi:10.1016/j.joca.2010.01.013
Hawker GA, Badley EM, Borkhoff CM et al (2013) Which patients are most likely to benefit from total joint arthroplasty? Arthritis Rheum 65:1243–1252. doi:10.1002/art.37901
Cushner F, Agnelli G, FitzGerald G, Warwick D (2010) Complications and functional outcomes after total hip arthroplasty and total knee arthroplasty: results from the Global Orthopaedic Registry (GLORY). Am J Orthop (Belle Mead NJ) 39:22–28
Rissanen P, Aro S, Slätis P et al (1995) Health and quality of life before and after hip or knee arthroplasty. J Arthroplasty 10:169–175
Jones CA, Voaklander DC, Johnston DW, Suarez-Almazor ME (2000) Health related quality of life outcomes after total hip and knee arthroplasties in a community based population. J Rheumatol 27:1745–1752
Frankel L, Sanmartin C, Conner-Spady B et al (2012) Osteoarthritis patients’ perceptions of “appropriateness” for total joint replacement surgery. Osteoarthr Cartil 20:967–973. doi:10.1016/j.joca.2012.05.008
Kortekaas MC, Kwok WY, Reijnierse M et al (2014) Follow-up study of inflammatory ultrasound features in hand osteoarthritis over a period of 3 months: variable as well as constant. Osteoarthr Cartil 22:40–43. doi:10.1016/j.joca.2013.10.015
Bevers K, Bijlsma JWJ, Vriezekolk JE et al (2014) The course of ultrasonographic abnormalities in knee osteoarthritis: 1 year follow up. Osteoarthr Cartil 22:1651–1656. doi:10.1016/j.joca.2014.06.012
Chan KKW, Sit RWS, Wu RWK, Ngai AHY (2014) Clinical, radiological and ultrasonographic findings related to knee pain in osteoarthritis. PLoS ONE 9:e92901. doi:10.1371/journal.pone.0092901
Arenas M, Sabater S, Hernández V et al (2012) Entzündungshemmende Effekte von niedrigdosierter Strahlentherapie. Strahlentherapie und Onkol 188:975–981. doi:10.1007/s00066-012-0170-8
Sokoloff N (1898) X-rays against joint rheumatism. Fortschr Röntgenstr 1:209–213
Schmid-Monnard C (1898) About cure of joint rheumatism by X-rays in children. Fortschr Röntgenstr 1:209
Anders JM, Daland J, Pfahler GF (1906) The treatment of arthritis deformans with the roentgen rays. A preliminary report. JAMA, J Am Med Assoc. doi:10.1001/jama.1906.62510470026001g
Leer JWH, Van Houtte P, Davelaar J (1998) Indications and treatment schedules for irradiation of benign diseases: a survey. Radiother Oncol 48:249–257. doi:10.1016/S0167-8140(98)00051-6
Freeman CR, Podgorsak EB (2007) Radiation oncology: times of practice change. Curr Oncol 14:165–166. doi:10.3747/co.2007.143
Leer JW, van Houtte P, Seegenschmiedt H (2007) Radiotherapy of non-malignant disorders: where do we stand? Radiother Oncol 83:175–177. doi:10.1016/j.radonc.2007.04.008
Seegenschmiedt MH, Micke O, Willich N (2004) Radiation therapy for nonmalignant diseases in Germany: current concepts and future perspectives. Strahlentherapie und Onkol 180:718–730. doi:10.1007/s00066-004-9197-9
Moher D, Liberati A, Tetzlaff J, Altman DG (2009) Reprint—preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Phys Ther 89:873–880. doi:10.1136/bmj.b2535
Thomas BH, Ciliska D, Dobbins M, Micucci S (2004) A process for systematically reviewing the literature: providing the research evidence for public health nursing interventions. Worldviews Evid Based Nurs 1:176–184. doi:10.1111/j.1524-475X.2004.04006.x
Steultjens EMJ, Dekker J, Bouter LM et al (2003) Occupational therapy for stroke patients: a systematic review. Stroke 34:676–686. doi:10.1161/01.STR.0000057576.77308.30
Lindner H, Freislederer R (1982) Long term results of radiotherapy of degenerative joint diseases (author’s transl). Strahlentherapie 158:217–223
Keinert K, Schalldach U, Schumann E (1982) Results of irradiation therapy of arthrosis deformans of the knee-joint. Dt Gesundh-Wesen 10:445–447
Yaneva M, Vlaikova M, Dimitrova M, Grigorov L (1986) X-ray therapy in degenerative-distrophic diseases of the bones and joints. Folia Med (Plovdiv) 28:26–28
Gärtner C, Schüttauf M, Below M et al (1988) The radiotherapeutic treatment of chronically relapsing, degenerative skeletal changes at the Oncology Clinic (Charité). Radiobiol Radiother (Berl) 29:689–698
Sautter-Bihl M-L, Liebermeister E, Scheurig H, Heinze H-G (1993) Analgetische Bestrahlung degenerativentzündlicher Skeletterkrankungen: Nutzen und Risiko. DMW Dtsch Medizinische Wochenschrift 118:493–498. doi:10.1055/s-2008-1059354
Keilholz L, Seegenschmiedt H, Sauer R (1998) Radiotherapy for painful degenerative joint disorders. Indications, technique and clinical results. Strahlenther Onkol 174:243–250
Ruppert R, Seegenschmiedt MH, Sauer R (2004) Radiotherapy of osteoarthritis. Indication, technique and clinical results. Orthopade 33:56–62. doi:10.1007/s00132-003-0568-1
Keller S, Müller K, Kortmann R-D et al (2013) Efficacy of low-dose radiotherapy in painful gonarthritis: experiences from a retrospective East German bicenter study. Radiat Oncol 8:29. doi:10.1186/1748-717X-8-29
Buchholz J, Ludewig E (2009) How sensible is radiation therapy in the treatment of degenerative joint diseases? Prakt Tierarzt 90(5):416–422
Calin A (1985) X-radiation in the management of rheumatoid disease. Br J Hosp Med 33:261–265
Hassenstein E (1986) Radiation treatment of benign diseases–indications, results and technic. Rontgenblatter 39:21–23
Hensel E (1980) Degenerative and inflammatory diseases and their radiotherapy. Wien Med Wochenschr 130:152–153
Merte H, Pfab R (1995) Radiotherapy of degenerative inflammatory joint diseases in the elderly. A worthwhile therapeutic measure. Fortschr Med 113:323–324
Puett DW, Griffin MR (1994) Published trials of nonmedicinal and noninvasive therapies for hip and knee osteoarthritis. Ann Intern Med 121:133–140
Seegenschmiedt MH, Micke O (2012) Strahlentherapie nichtmaligner Erkrankungen. Strahlentherapie und Onkol 188:272–290. doi:10.1007/s00066-012-0195-z
Weitmann HD, Niewald M (2013) Niedrig dosierte Strahlentherapie. Nicht nur bei Arthrosen erfolgversprechend. Fortschr Med 155:43–46
Hackenberg L, Schäfer U, Micke O, Liljenqvist U (2001) Die schmerzbestrahlung des chronischen, degenerativen lumbalsyndroms-Ergebnisse einer prospektiven randomisierten studie. Z Orthop Ihre Grenzgeb 139:294–297. doi:10.1055/s-2001-16913
Öner-Dinçbas F, Akyazici E, Koca S et al (2004) Radiotherapy for benign diseases: a retrospective analysis. J BU ON 9:57–61
Ott OJ, Hertel S, Gaipl US et al (2012) Benign painful shoulder syndrome: initial results of a single-center prospective randomized radiotherapy dose-optimization trial. Strahlentherapie und Onkol 188:1108–1113. doi:10.1007/s00066-012-0237-6
Schäfer U, Micke O, Willich N (1996) Radiotherapy of pain in degenerative bone diseases. Rontgenpraxis 49:251–254
Wannenmacher M (1983) The importance of radiotherapy in backache. Radiologe 23:174–178
Feldmann HJ (2013) Painful degenerative and inflammatory diseases of joints and soft tissue: X-ray instead of pharmaceutics? MMW Fortschr Med 155:42
Grosu AL (2001) Radiotherapy outside of oncology. When is it indicated? (interview by Waltraud Paukstadt). MMW Fortschr Med 143:16
Merte H, Proske H, Pfab R (1993) Strahlentherapie degenerativ-entzündlich bedingter Gelenkserkrankungen: Indikationssicherung durch Telethermographie? Med Welt 44:273–275
Mücke R, Seegenschmiedt MH, Heyd R et al (2010) Strahlentherapie bei schmerzhafter Kniegelenkarthrose (Gonarthrose): Ergebnisse einer deutschen Patterns-of-Care-Studie. Strahlentherapie und Onkol 186:7–17. doi:10.1007/s00066-009-1995-7
Schultze J, Eilf K (2006) Perspektiven der strahlentherapie gutartiger erkrankungen. Strahlentherapie und Onkol 182:259–262. doi:10.1007/s00066-006-1579-8
Seegenschmiedt MH, Katalinic A, Makoski HB et al (1999) Radiotherapy of benign diseases: a pattern of care study in Germany. Strahlenther Onkol 175:541–547
Bogdashevskaia VG, Nadtochiĭ AG, Shestakov IN (1983) X-ray study in secondary osteoarthrosis deformans of the temporomandibular joints in children. Stomatologiia (Mosk) 62:27–29
Pereslegin IA, Zolotkov AG, Aleĭnikov GE (1984) Radiotherapy in degenerative-dystrophic and inflammatory diseases of the osteoarticular system. Med Radiol (Mosk) 29:38–41
Pereslegin IA, Podliashchuk EL, Ustinova VF (1990) Problems and perspectives of radiotherapy of non-tumor diseases. Vestn Rentgenol Radiol 1:54–58
Rödel F, Kamprad F, Sauer R, Hildebrandt G (2002) Functional and molecular aspects of anti-inflammatory effects of low-dose radiotherapy. Strahlenther Onkol 178:1–9
Pretorius FJ, Alberts AS, Klopper ER (1995) Radiation of benign disease–a South African perspective. S Afr J Surg 33:115–116
Kellgren JH, Lawrence JS (1957) Radiological assessment of osteo-arthrosis. Ann Rheum Dis 16:494–502. doi:10.1136/ard.16.4.494
Von Pannewitz G (1933) The X-ray therapy of arthritis deformans-clinical and experimental studies. In: Holfelder H (ed) Ergebnisse der Medizinischen Strahlenforsch. Thieme, Leipzig, pp 61–126
Smith-Bindman R (2009) Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Arch Intern Med 169:2078. doi:10.1001/archinternmed.2009.427
Jansen JTM, Broerse JJ, Zoetelief J et al (2005) Estimation of the carcinogenic risk of radiotherapy of benign diseases from shoulder to heel. Radiother Oncol 76:270–277. doi:10.1016/j.radonc.2005.06.034
Dewey WC, Ling CC, Meyn RE (1995) Radiation-induced apoptosis: relevance to radiotherapy. Int J Radiat Oncol Biol Phys 33:781–796. doi:10.1016/0360-3016(95)00214-8
Zhang W, Robertson J, Jones AC et al (2008) The placebo effect and its determinants in osteoarthritis: meta-analysis of randomised controlled trials. Ann Rheum Dis 67:1716–1723. doi:10.1136/ard.2008.092015
Abhishek A, Doherty M (2013) Mechanisms of the placebo response in pain in osteoarthritis. Osteoarthr Cartil 21:1229–1235. doi:10.1016/j.joca.2013.04.018
Altman R, Asch E, Bloch D et al (1986) 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 29:1039–1049. doi:10.1002/art.1780290816
Altman R, Alarcón G, Appelrouth D et al (1990) The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hand. Arthritis Rheum 33:1601–1610. doi:10.1002/art.1780331101
Altman R, Alarcón G, Appelrouth D et al (1991) The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hip. Arthritis Rheum 34:505–514
Goldie I, Rosengren B, Moberg E, Hedelin E (1970) Evaluation of radiation treatment of painful conditions of the locomotor system: a double blind study. Acta Oncol (Madr) 9:311–322. doi:10.3109/02841867009129108
Valtonen EJ, Lilius HG, Malmio K (1975) The value of roentgen irradiation in the treatment of painful degenerative and inflammatory musculoskeletal conditions. A double-blind study. Scand J Rheumatol 4:247–249
Ott OJ, Niewald M, Weitmann H-D et al (2014) DEGRO guidelines for the radiotherapy of non-malignant disorders. Strahlentherapie und Onkol 191:1–6. doi:10.1007/s00066-014-0757-3
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We would like to thank Joke Vriezekolk for her help and advice regarding the search strategy of this review. This work was not supported by external funding.
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Minten, M.J.M., Mahler, E., den Broeder, A.A. et al. The efficacy and safety of low-dose radiotherapy on pain and functioning in patients with osteoarthritis: a systematic review. Rheumatol Int 36, 133–142 (2016). https://doi.org/10.1007/s00296-015-3337-7
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DOI: https://doi.org/10.1007/s00296-015-3337-7