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Diagnosis and nonsurgical management of osteoarthritis
  1. J W J BIJLSMA
  1. Department of Rheumatology and Clinical Immunology
  2. University Medical Centre
  3. Utrecht, The Netherlands

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    Diagnosis and nonsurgical management of osteoarthritis. 2nd ed. KD Brandt (Pp 304; US $19.95.) Caddo, OK: Professional Communications Inc 2000. ISBN1-884735-57-6.

    Kenneth Brandt is an opinion leader in the field of osteoarthritis. In the pocketsize book, Diagnosis and Nonsurgical Management of Osteoarthritis, he gives an authoritative view on the present state of the field of osteoarthritis, focusing on practical aspects.

    He has a message for the reader: osteoarthritis is sadly often viewed incorrectly as a condition that, once it becomes symptomatic, follows an inexorably downhill course, much like Alzheimer's disease. This is reflected in the use of the inaccurate, depressing term “degenerative joint disease”, causing a sense of inevitability and futility. If physicians continue to convey this view to patients, they are wrong. Most patients with osteoarthritis can be made better and will do well, perhaps even better, without our meddling! On the other hand, it is important for both the patient and physician to understand that though there is as yet no cure for osteoarthritis, much can be done to relieve joint pain, improve mobility, and enhance quality of life. This is the optimistic, but realistic, perspective provided.

    Brandt uses a definition of osteoarthritis emphasising that it is a group of overlapping distinct diseases, which may have different causes, but similar biological, morphological, and clinical outcomes. In this definition emphasis is put not only on the articular cartilage, but on the whole joint, including bone. The focus of research into the pathogenesis of osteoarthritis is nowadays shifting somewhat from cartilage to bone, and this is well documented in the chapter on pathogenesis of osteoarthritis.

    For the diagnosis of osteoarthritis, symptoms and plain radiography still prevail. Descriptions of pitfalls in diagnosis are very educational— for instance, “the source of the pain is not osteoarthritis but . . .”, “the source of the pain is osteoarthritis but not at the joint suspected...”, “the pain is caused by secondary soft tissue rheumatism . . . ”

    Pitfalls regarding misinterpretation of the radiograph are also described, such as “another type of arthritis occurring in a joint with previous arthritic changes”, “neurogenic and metabolic arthropathies”. Sometimes laboratory tests are misinterpreted, such as “common increase in erythrocyte sedimentation rate with age, not excluding osteoarthritis”. Though all these facts are well known, it is a pleasure to read the author's view.

    The chapters on non-surgical treatment are, as expected, somewhat reserved. Brandt needs convincing evidence for all new modalities, before he is willing to present a positive view. He devotes a whole chapter to the new class of NSAIDs that are specific inhibitors of COX-2. In the present COX-2 hype he is rather pessimistic about the claimed superiority of these drugs. His chapters on rubefacients and capsaicin cream are surprisingly positive: “this treatment warrants initial consideration in the management of osteoarthritic pain”. He is also rather positive about injection with steroids, but negative about injection with hyaluronic acid as treatment for knee osteoarthritis. If the rules of evidence based medicine are applied, the data do not support these conclusions: both treatment modalities are only superficially evaluated and the data suggest hyaluronic acid may be slightly better than steroid injections.

    Diagnosis and Nonsurgical Management of Osteoarthritis, incorporating much practical information, is chiefly written for primary care physicians. Many parts of the discussions, however, are more directed towards specialists in these diseases, such as rheumatologists, orthopaedic surgeons, and arthritis health professionals. I am not sure whether this target readership will encourage widespread use in Europe. The specialists in this field are used to more detailed, well written books on osteoarthritis, many with contributions from the same author. The general physician will appreciate the practical information, which, however, can be delivered in smaller sized books. I think Brandt's book would be best used by health professionals working in this field and probably by educated patients themselves.

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