Created : #jan2025

Radiotherapy in Painful Osteoarthritis

Study : Low-dose radiotherapy for painful osteoarthritis of the elderly: A multicenter analysis of 970 patients with 1185 treated sites

Summary

1. Title of the article:
Low-dose radiotherapy for painful osteoarthritis of the elderly: A multicenter analysis of 970 patients with 1185 treated sites

2. First two Authors followed by et al:
Alexander Rühle, Elisabeth Tkotsch, et al.

3. One line summary of the article:
Low-dose radiotherapy significantly reduces pain in elderly patients with osteoarthritis, showing no decline in effectiveness with increasing age.

4. Six key points from the article:

1. Study Population: A total of 970 patients with 1185 treated osteoarthritis sites were analyzed with a median age of 76 years.
2. Pain Reduction: Pain scores decreased significantly after radiotherapy (NRS score from 66 to 44, p<0.001).
3. Effectiveness Across Age Groups: Pain response was consistent across all elderly age groups, including those above 85 years.
4. No Difference in Treatment Sites: Pain relief was comparable across different joint sites (knees, hands, feet, etc.).
5. Re-irradiation Success: Second radiotherapy was performed on 32.4% of sites, with a pain relief rate of 61%.
6. Safety and Tolerability: Radiotherapy was well tolerated with minimal reported side effects, making it suitable for the elderly.

5. Practical take-home message:
Low-dose radiotherapy provides effective pain relief for osteoarthritis in elderly patients regardless of age, with minimal side effects, making it a viable non-invasive option for pain management.

6. Citation (Vancouver format):
Rühle A, Tkotsch E, Mravlag R, Haehl E, Spohn SKB, Zamboglou C, et al. Low-dose radiotherapy for painful osteoarthritis of the elderly: A multicenter analysis of 970 patients with 1185 treated sites. Strahlenther Onkol. 2021;197:895–902.

Additional points from the Study

The criteria for patient selection in the study were:

1. Age: Patients aged ≥65 years at the time of radiotherapy.

2. Diagnosis: Patients with painful osteoarthritis.

3. Treatment Period: Patients received low-dose radiotherapy between 2008 and 2020.

4. Treated Joints: Inclusion of both large joints (knees, hips, shoulders) and small joints (wrists, fingers, thumbs, ankles, feet).

5. Treatment Protocol: Radiotherapy administered as per the guidelines of the German Society of Radiation Oncology, typically in 6 fractions with doses of either 0.5 Gy or 1 Gy.

6. Pain Assessment: Baseline pain intensity and response were measured using the Numerical Rating Scale (NRS) and the Pannewitz score.

7. Ethical Approval: Approval from the Independent Ethics Committees of University of Freiburg and University of Heidelberg.

These patients were selected to assess the efficacy of low-dose radiotherapy for pain reduction in elderly osteoarthritis patients .

Treatment Algorithm for Low-Dose Radiotherapy in Elderly Patients with Painful Osteoarthritis (Based on the Study)

Step 1: Patient Eligibility Criteria

• Age ≥ 65 years

• Diagnosis of painful osteoarthritis (large or small joints)

• Persistent pain despite prior conservative treatments (e.g., NSAIDs, corticosteroid injections)

Step 2: Pre-Treatment Assessment

• Obtain informed consent.

• Assess baseline pain using:

• Numerical Rating Scale (NRS)

• Pannewitz score

• Review previous therapeutic measures (NSAIDs, corticosteroid injections).

Step 3: Radiotherapy Planning

• Imaging: Perform either:

• CT-based 3D treatment planning or

• 2D X-ray simulation for treatment guidance.

• Radiotherapy Equipment: Use a linear accelerator for photon therapy.

Step 4: Radiotherapy Protocol

• Standard Fractionation Regimen:

• Dose: 6 fractions of 1 Gy each (total 6 Gy)

OR

• Alternative Dose: 6 fractions of 0.5 Gy each (total 3 Gy)

• Frequency: 2-3 sessions per week

• Total Duration: Approximately 2-3 weeks

Step 5: Post-Treatment Evaluation (t1: End of Radiotherapy)

• Reassess pain using NRS and Pannewitz score.

• Expected pain response distribution:

• Complete Pain Relief (Score 0): ~1.5%

• Partial Pain Relief (Score 1-2): ~58.5%

• Unchanged Pain (Score 3): ~36.1%

• Worsened Pain (Score 4): ~3.9%

Step 6: Follow-Up Assessment (t2: 8 Weeks Post-Treatment)

• Reevaluate pain using NRS and Pannewitz score.

• Assess for residual pain and response rate:

• Complete Pain Relief: ~6.9%

• Partial Pain Relief: ~58.6%

• Unchanged Pain: ~28.1%

• Worsened Pain: ~6.3%

Step 7: Re-Irradiation Criteria (If Pain Persists)

• Indicated if pain remains significant after initial radiotherapy.

• Protocol:

• Same as the initial course (6 fractions of 1 Gy or 0.5 Gy).

• Response Rate: ~61% show pain reduction after the second course.

Step 8: Long-Term Follow-Up

• Monitor pain and functional improvement.

• Reassess for additional treatment if pain recurs.

Numeric Rating Scale (NRS)

The NRS is a unidimensional measure of pain intensity used for adults, including those with chronic pain due to rheumatic diseases like osteoarthritis[1][3].

Key features of the NRS:

• It is an 11-point scale ranging from 0 to 10
• 0 represents "no pain"
• 10 represents "worst pain imaginable" or "pain as bad as you can imagine"
• Patients select a whole number that best reflects their pain intensity
• It can be administered verbally or in writing
• Takes less than 1 minute to complete

The NRS has shown good psychometric properties, including high test-retest reliability and construct validity when correlated with other pain measures[3][5].

Pannewitz Score

The Pannewitz score is used to assess pain response after treatments like low-dose radiotherapy for osteoarthritis. It typically uses the following scale[2][4]:

• 0: Complete pain relief
• 1-2: Partial pain relief (less pain)
• 3: No change in pain (equal pain)
• 4: Worsening of pain

Studies have used the Pannewitz score to evaluate pain outcomes, with scores of 0-2 generally considered a positive pain response to treatment[2][4].

Both the NRS and Pannewitz score provide quantitative measures to assess pain intensity and treatment responses in osteoarthritis patients. The NRS offers more granularity in pain intensity, while the Pannewitz score focuses on categorizing pain relief after interventions.

Important Note

• This treatment is available in Ahmedabad
• If you are a patient with type 2 diabetes, osteoporosis or hypothyroidism, and painful osteoarthritis and would like to consider this as treatment please meet Dr. Om J Lakhani in OPD at Zydus Hospital with an appointment

Additional citations

Citations:

[1] https://physiotherapy.ca/divisions/pain-science/numeric-rating-scale-nrs-11/

[2] https://pmc.ncbi.nlm.nih.gov/articles/PMC8458208/

[3] https://pubmed.ncbi.nlm.nih.gov/21149497/

[4] https://pubmed.ncbi.nlm.nih.gov/34342662/

[5] https://www.physio-pedia.com/Numeric_Pain_Rating_Scale

[6] https://www.mdpi.com/2076-3271/9/4/66

[7] https://journals.lww.com/pain/fulltext/2023/07000/three_dimensions_of_pain_in_osteoarthritis_.15.aspx

[8] https://www.redjournal.org/article/S0360-3016(22)00357-1/fulltext

[9] https://academic.oup.com/rheumap/article/6/1/rkac016/6540871?login=false

[10] https://www.researchgate.net/publication/353679013_Low-dose_radiotherapy_for_painful_osteoarthritis_of_the_elderly_A_multicenter_analysis_of_970_patients_with_1185_treated_sites

[11] https://ijdmsrjournal.com/issue_dcp/Assessment of Pain in the Osteoarthritis Knee following Vitamin D3 supplementation using NRS Scor.pdf

[12] https://www.redjournal.org/article/S0360-3016(22)00357-1/abstract

[13] https://pubmed.ncbi.nlm.nih.gov/22325619/

[14] https://x.com/KoneruMd/status/1843277171717988439