Effect of therapeutic exercise on knee osteoarthritis after intra-articular injection of botulinum toxin type A, hyaluronate or saline: A randomized controlled trial
Xiao Bao, Jie-Wen Tan, Michael Flyzik, Xian-Cong Ma, Howe Liu, Hui-Yu Liu
Department of Rehabilitation Medicine, Yue Bei People’s Hospital, 512000 ShaoGuan, China
Objective: To study the effect of therapeutic exercise on knee osteoarthritis after injection of botulinum toxin type A, hyaluronate or saline.
Methods: Sixty participants with knee osteoarthritis were randomly assigned to 3 groups: injection of saline (control) (group A), botulinum toxin type A (group B), or hyaluronate (group C). All participants received therapeutic exercise. Western Ontario and McMaster Universities Osteoarthritis Index questionnaire score, visual analogue scale pain scale, and Medical Outcomes Study 36-item Health Survey were conducted at baseline, and at the end of the 4th and 8th weeks.
Results: At end of the 4th and 8th weeks, the scores on the Western Ontario and McMaster Universities Osteoarthritis Index questionnaire and visual analogue scale were higher in the control group. There were significant differences in Physical Component Summary-36 and Mental Component Summary-36 scores between the 3 groups (p < 0. 05) at the end of the 4th and 8th weeks, but not between groups A (control) and C (hyaluronate) at the end of the 4th week. No changes were seen on magnetic resonance imaging and X-ray images of the affected knees after the intervention.
Conclusion: Therapeutic exercise plus botulinum toxin type A or hyaluronate injection can significantly reduce pain and improve knee functioning. Botulinum toxin type A plus therapeutic exercise appears to be more effective.
Patients with knee osteoarthritis often have pain and joint dysfunction, which are not easy to treat using conventional therapy. The effect of a new therapy for relieving pain in patients with knee osteoarthritis was studied. This therapy involves ultrasound-guided injection of botulinum toxin type A, followed by therapeutic exercise. We compared this treatment with conventional therapy using injection with hyaluronate (a component of the synovial fluid), and a control treatment using saline injection, followed by the same exercises. The results showed that injection of botulinum toxin type A followed by therapeutic exercises resulted in greater improvements in knee pain and function in patients with knee osteoarthritis. Combined treatment with botulinum toxin type A, followed by therapeutic exercise is therefore recommended for people who have knee pain that does not respond well to conventional therapy.
Dr. Yeowleng Tan
Consultant, Singapore General Hospital
Dear Editor, i congratulate Xiao et al. for success in publication of this study. I read with great interest and will like to offer two comments.
Firstly, the study highlights limitation of providing multiple doses of hyaluronic acid versus single dose of botolinium toxin and saline. At present, both single and multiple dosing regimen of hyaluronic acid are available in the market. One study by Dıraçoğlu et al (2016) revealed multiple dosing being superior to single dose at six months. However there is still lack of world wide consensus on single versus multi-dosing. Future study can consider single dose of hyaluronic acid versus single dose of saline and botolinium toxin.
Secondly it was unclear the number of patients in the three groups had significant joint effusion that required aspiration. In this study, musculoskeletal ultrasound was used to guide aspiration in subjects with significant effusion followed by administration of treatment. Could joint aspiration in those with significant effusion have contributed to improvement in the various outcome measures? Daisuke et al (2016) had quantitatively measured the degree of suprapatellar effusion and found significant correlation with pain sub-scale as one of the outcomes. I hope authors of this study can provide more information with regards to above. Thank you.
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