Les paramètres de validité d'un essai thérapeutique et leur influence sur l'élaboration d'une médecine fondée sur les preuves : revue de la littérature

Crenobalneotherapy for limb osteoarthritis: systematic literature review and methodological analysis

OBJECTIVES

To conduct a systematic literature review on crenobalneotherapy for limb osteoarthritis and to discuss the study methods used to evaluate this treatment modality.

METHODS

We searched Medline using the following keywords: "spa therapy", "mud", "radon", "balneotherapy", and "hydrotherapy" in combination with "osteoarthritis", "arthrosis", and "gonarthrosis". We also reviewed the reference lists of articles retrieved by the Medline search. Studies that compared crenobalneotherapy to any other intervention or to no intervention were selected, and a checklist was used to assess their internal validity. External validity and the quality of the statistical analysis were evaluated also.

RESULTS

Crenobalneotherapy was associated with improvements in the evaluation criteria (pain, function, and quality of life) compared to baseline. However, inadequate internal validity precluded the establishment of a causal link between these improvements and crenobalneotherapy. External validity was often poorly defined. Some studies found no significant differences with the control group but failed to include a sample-size calculation, suggesting inadequate statistical power as a possible explanation for the result. In several studies, the use of multiple evaluation criteria and measurements led to a high risk of Type I error.

CONCLUSION

Although the consistency of the results suggests a therapeutic effect of crenobalneotherapy in limb osteoarthritis, available studies are methodologically inadequate and sample sizes too small to allow definitive conclusions. We suggest a number of solutions to these shortcomings. Carefully designed studies in larger patient populations are needed to determine the role crenobalneotherapy in knee osteoarthritis.

[Feet insoles and knee osteoarthritis: evaluation of biomechanical and clinical effects from a literature review]

OBJECTIVE

To determine the biomechanical and clinical effectiveness of foot insoles in patients with knee osteoarthritis.

MATERIALS AND METHODS

A systematic review of the literature (Medline, Pascal and Embase) using the MESH words knee, and insole and plantar orthosis for the biomechanical part and osteoarthritis, and insole and plantar orthosis for the clinical part. Clinical studies were classified by 2 independent readers using the Jadad scale.

RESULTS

Two biomechanical theories were found: the adduction moment theory, which explains the effect of heel wedging, and articular chain theory, which explains the effect of lateral wedged insoles. The clinical effect was explained more by an anti-algesic effect than an anatomic or functional effect: the treated group consumed fewer nonsteroidal anti-inflammatory drugs than the placebo group for up to 2-years of treatment. Evidence is lacking because of methodological weakness and few clinical trials. The information on side effects is limited.

DISCUSSION

Laterally wedged foot insoles are proposed for the treatment of knee medial compartment osteoarthritis. The clinical effect is probably limited, but the treatment may reduce the digestive and renal side effects of prolonged use of nonsteroidal anti-inflammatory drugs. Foot insoles could be recommended in clinical practice despite the lack of evidence in comparing the effectiveness of other therapeutics in knee osteoarthritis.

CONCLUSION

Use of foot insoles is a nonpharmacologic treatment of osteoarthritis of the knee medial compartment.