Rheumatology International

, Volume 36, Issue 1, pp 133–142 | Cite as

The efficacy and safety of low-dose radiotherapy on pain and functioning in patients with osteoarthritis: a systematic review

  • M. J. M. Minten
  • E. Mahler
  • A. A. den Broeder
  • J. W. H. Leer
  • C. H. van den Ende
Original Article - Observational Research


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.


Osteoarthritis Radiotherapy Systematic review Pain Functioning Safety 



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.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical standards

The authors declare that they have no competing interests and that they have full control of all primary data. The manuscript does not contain clinical studies or patient data.

Supplementary material

296_2015_3337_MOESM1_ESM.pdf (206 kb)
Supplementary material 1 (PDF 205 kb)
296_2015_3337_MOESM2_ESM.pdf (260 kb)
Supplementary material 2 (PDF 260 kb)


  1. 1.
    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 PubMedCrossRefGoogle Scholar
  2. 2.
    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 PubMedCrossRefGoogle Scholar
  3. 3.
    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 PubMedCrossRefGoogle Scholar
  4. 4.
    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 PubMedCrossRefGoogle Scholar
  5. 5.
    Davis MA, Ettinger WH, Neuhaus JM, Mallon KP (1991) Knee osteoarthritis and physical functioning: evidence from the NHANES I epidemiologic followup study. J Rheumatol 18:591–598PubMedGoogle Scholar
  6. 6.
    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 17:255–263PubMedCrossRefGoogle Scholar
  7. 7.
    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 CrossRefGoogle Scholar
  8. 8.
    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 PubMedPubMedCentralCrossRefGoogle Scholar
  9. 9.
    Spector TD, MacGregor AJ (2004) Risk factors for osteoarthritis: genetics. Osteoarthr Cartil 12:S39–S44. doi: 10.1016/j.joca.2003.09.005 PubMedCrossRefGoogle Scholar
  10. 10.
    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 PubMedCrossRefGoogle Scholar
  11. 11.
    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 PubMedCrossRefGoogle Scholar
  12. 12.
    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 PubMedCrossRefGoogle Scholar
  13. 13.
    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 PubMedCrossRefGoogle Scholar
  14. 14.
    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) 39:22–28Google Scholar
  15. 15.
    Rissanen P, Aro S, Slätis P et al (1995) Health and quality of life before and after hip or knee arthroplasty. J Arthroplasty 10:169–175PubMedCrossRefGoogle Scholar
  16. 16.
    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 27:1745–1752PubMedGoogle Scholar
  17. 17.
    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 PubMedCrossRefGoogle Scholar
  18. 18.
    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 PubMedCrossRefGoogle Scholar
  19. 19.
    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 PubMedCrossRefGoogle Scholar
  20. 20.
    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 PubMedPubMedCentralCrossRefGoogle Scholar
  21. 21.
    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 CrossRefGoogle Scholar
  22. 22.
    Sokoloff N (1898) X-rays against joint rheumatism. Fortschr Röntgenstr 1:209–213Google Scholar
  23. 23.
    Schmid-Monnard C (1898) About cure of joint rheumatism by X-rays in children. Fortschr Röntgenstr 1:209Google Scholar
  24. 24.
    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 Google Scholar
  25. 25.
    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 PubMedCrossRefGoogle Scholar
  26. 26.
    Freeman CR, Podgorsak EB (2007) Radiation oncology: times of practice change. Curr Oncol 14:165–166. doi: 10.3747/co.2007.143 PubMedPubMedCentralCrossRefGoogle Scholar
  27. 27.
    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 PubMedCrossRefGoogle Scholar
  28. 28.
    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 CrossRefGoogle Scholar
  29. 29.
    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 PubMedGoogle Scholar
  30. 30.
    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 PubMedCrossRefGoogle Scholar
  31. 31.
    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 PubMedCrossRefGoogle Scholar
  32. 32.
    Lindner H, Freislederer R (1982) Long term results of radiotherapy of degenerative joint diseases (author’s transl). Strahlentherapie 158:217–223PubMedGoogle Scholar
  33. 33.
    Keinert K, Schalldach U, Schumann E (1982) Results of irradiation therapy of arthrosis deformans of the knee-joint. Dt Gesundh-Wesen 10:445–447Google Scholar
  34. 34.
    Yaneva M, Vlaikova M, Dimitrova M, Grigorov L (1986) X-ray therapy in degenerative-distrophic diseases of the bones and joints. Folia Med (Plovdiv) 28:26–28Google Scholar
  35. 35.
    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) 29:689–698Google Scholar
  36. 36.
    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 CrossRefGoogle Scholar
  37. 37.
    Keilholz L, Seegenschmiedt H, Sauer R (1998) Radiotherapy for painful degenerative joint disorders. Indications, technique and clinical results. Strahlenther Onkol 174:243–250PubMedCrossRefGoogle Scholar
  38. 38.
    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 PubMedCrossRefGoogle Scholar
  39. 39.
    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 PubMedPubMedCentralCrossRefGoogle Scholar
  40. 40.
    Buchholz J, Ludewig E (2009) How sensible is radiation therapy in the treatment of degenerative joint diseases? Prakt Tierarzt 90(5):416–422Google Scholar
  41. 41.
    Calin A (1985) X-radiation in the management of rheumatoid disease. Br J Hosp Med 33:261–265PubMedGoogle Scholar
  42. 42.
    Hassenstein E (1986) Radiation treatment of benign diseases–indications, results and technic. Rontgenblatter 39:21–23PubMedGoogle Scholar
  43. 43.
    Hensel E (1980) Degenerative and inflammatory diseases and their radiotherapy. Wien Med Wochenschr 130:152–153PubMedGoogle Scholar
  44. 44.
    Merte H, Pfab R (1995) Radiotherapy of degenerative inflammatory joint diseases in the elderly. A worthwhile therapeutic measure. Fortschr Med 113:323–324PubMedGoogle Scholar
  45. 45.
    Puett DW, Griffin MR (1994) Published trials of nonmedicinal and noninvasive therapies for hip and knee osteoarthritis. Ann Intern Med 121:133–140PubMedCrossRefGoogle Scholar
  46. 46.
    Seegenschmiedt MH, Micke O (2012) Strahlentherapie nichtmaligner Erkrankungen. Strahlentherapie und Onkol 188:272–290. doi: 10.1007/s00066-012-0195-z CrossRefGoogle Scholar
  47. 47.
    Weitmann HD, Niewald M (2013) Niedrig dosierte Strahlentherapie. Nicht nur bei Arthrosen erfolgversprechend. Fortschr Med 155:43–46CrossRefGoogle Scholar
  48. 48.
    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 PubMedCrossRefGoogle Scholar
  49. 49.
    Öner-Dinçbas F, Akyazici E, Koca S et al (2004) Radiotherapy for benign diseases: a retrospective analysis. J BU ON 9:57–61Google Scholar
  50. 50.
    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 CrossRefGoogle Scholar
  51. 51.
    Schäfer U, Micke O, Willich N (1996) Radiotherapy of pain in degenerative bone diseases. Rontgenpraxis 49:251–254PubMedGoogle Scholar
  52. 52.
    Wannenmacher M (1983) The importance of radiotherapy in backache. Radiologe 23:174–178PubMedGoogle Scholar
  53. 53.
    Feldmann HJ (2013) Painful degenerative and inflammatory diseases of joints and soft tissue: X-ray instead of pharmaceutics? MMW Fortschr Med 155:42PubMedCrossRefGoogle Scholar
  54. 54.
    Grosu AL (2001) Radiotherapy outside of oncology. When is it indicated? (interview by Waltraud Paukstadt). MMW Fortschr Med 143:16PubMedGoogle Scholar
  55. 55.
    Merte H, Proske H, Pfab R (1993) Strahlentherapie degenerativ-entzündlich bedingter Gelenkserkrankungen: Indikationssicherung durch Telethermographie? Med Welt 44:273–275Google Scholar
  56. 56.
    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 CrossRefGoogle Scholar
  57. 57.
    Schultze J, Eilf K (2006) Perspektiven der strahlentherapie gutartiger erkrankungen. Strahlentherapie und Onkol 182:259–262. doi: 10.1007/s00066-006-1579-8 CrossRefGoogle Scholar
  58. 58.
    Seegenschmiedt MH, Katalinic A, Makoski HB et al (1999) Radiotherapy of benign diseases: a pattern of care study in Germany. Strahlenther Onkol 175:541–547PubMedCrossRefGoogle Scholar
  59. 59.
    Bogdashevskaia VG, Nadtochiĭ AG, Shestakov IN (1983) X-ray study in secondary osteoarthrosis deformans of the temporomandibular joints in children. Stomatologiia (Mosk) 62:27–29Google Scholar
  60. 60.
    Pereslegin IA, Zolotkov AG, Aleĭnikov GE (1984) Radiotherapy in degenerative-dystrophic and inflammatory diseases of the osteoarticular system. Med Radiol (Mosk) 29:38–41Google Scholar
  61. 61.
    Pereslegin IA, Podliashchuk EL, Ustinova VF (1990) Problems and perspectives of radiotherapy of non-tumor diseases. Vestn Rentgenol Radiol 1:54–58PubMedGoogle Scholar
  62. 62.
    Rödel F, Kamprad F, Sauer R, Hildebrandt G (2002) Functional and molecular aspects of anti-inflammatory effects of low-dose radiotherapy. Strahlenther Onkol 178:1–9PubMedCrossRefGoogle Scholar
  63. 63.
    Pretorius FJ, Alberts AS, Klopper ER (1995) Radiation of benign disease–a South African perspective. S Afr J Surg 33:115–116PubMedGoogle Scholar
  64. 64.
    Kellgren JH, Lawrence JS (1957) Radiological assessment of osteo-arthrosis. Ann Rheum Dis 16:494–502. doi: 10.1136/ard.16.4.494 PubMedPubMedCentralCrossRefGoogle Scholar
  65. 65.
    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 61–126Google Scholar
  66. 66.
    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 PubMedPubMedCentralCrossRefGoogle Scholar
  67. 67.
    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 PubMedCrossRefGoogle Scholar
  68. 68.
    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 PubMedCrossRefGoogle Scholar
  69. 69.
    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 PubMedCrossRefGoogle Scholar
  70. 70.
    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 PubMedCrossRefGoogle Scholar
  71. 71.
    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 PubMedCrossRefGoogle Scholar
  72. 72.
    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 PubMedCrossRefGoogle Scholar
  73. 73.
    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 34:505–514PubMedCrossRefGoogle Scholar
  74. 74.
    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 CrossRefGoogle Scholar
  75. 75.
    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 4:247–249PubMedCrossRefGoogle Scholar
  76. 76.
    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 CrossRefGoogle Scholar

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Authors and Affiliations

  1. 1.Department of RheumatologySint MaartenskliniekNijmegenThe Netherlands
  2. 2.Department of RadiotherapyRadboud University Medical CentreNijmegenThe Netherlands

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