Complementary and alternative medicines for the treatment of rheumatoid arthritis, osteoarthritis and fibromyalgia

A report by the Arthritis Research Campaign (UK)

This report is written and produced by the Arthritis Research Campaign is an evidence-based report on the use of complementary and alternative medicines for arthritis and musculoskeletal conditions. It uses evidence from randomised controlled trials and aims to help people with arthritis or fibromyalgia select which complementary medicines may be beneficial for them.  The report scores medicines according to their effectiveness with 1 indicating that the available evidence suggests that the compound is not effective and 5 indicating that there is consistent evidence that the compound is effective. Effectiveness is measured by improvements in pain, movement, or general well-being.  The report also grades the medicines according to safety, providing traffic light classifications for each.
The authors of the report focused on compounds taken by mouth or applied to the skin. They did not look at therapies such as acupuncture and chiropractic massage, which have been commonly used for arthritis and musculoskeletal conditions. The role of these will be considered in a subsequent report.
Despite the number of complementary medicines available and used, this report found only 40 with evidence available from randomised controlled trials
- the type of studies that give the best evidence on whether a treatment is effective or not. Even for those, which had been studied, many had been tested in only a single or just a few studies. This makes it difficult to be sure whether they work or not.
Rheumatoid arthritis
For people with rheumatoid arthritis (RA) the medicines researched score poorly, with 13 out of 21 complementary medicines (62 per cent) scoring just 1 point i.e. the available evidence suggests that the compound is not effective.  At the other end of the scale, fish body oil scores a maximum 5 for effectiveness among people with RA, offering real benefits. It also receives a green light for safety.
Osteoarthritis
Alternative medicines appear to be more promising for people with osteoarthritis (OA) with only 6 out of 27 approaches (22 per cent) scoring 1 point.
Found to be safe to use and scoring well are the herbal preparation phytodolor and nutritional supplement SAMe, both receiving a 4 for effectiveness. Capsaicin gel, made from chilli peppers, proved the most effective for OA, scoring the full 5 points.
Glucosamine is one of the most widely taken products and there have been many trials conducted. The evidence however is mixed, many trials show benefit while some do not. The evidence is stronger for glucosamine sulphate (which scored 3) compared to glucosamine hydrochloride (which scored 1).
Fibromyalgia
Only four products were assessed for fibromyalgia but none of them were highly effective with three medicines scoring just 2 out of 5, and the fourth an ineffective 1.

In terms of safety, there is much less information available for complementary medicines in comparison to conventional medicines. However for approximately one quarter of the compounds considered we gave them an “amber” safety classification indicating there were important side effects which had been reported. A “red” safety classification was issued against thunder god vine.

The research studies used in the report are referenced so that you can find out more information on individual medicines should you wish to.

The compleate report is availble here in PDF

Filed under: Alternative therapies, Arthritis, Osteoarthritis, Rheumatoid arthritis

Physical Therapy Treatment Effectiveness for Osteoarthritis of the Knee: A Randomized Comparison of Supervised Clinical Exercise and Manual Therapy Procedures Versus a Home Exercise Program

Deyle, Allison, Matekel, Ryder et al

Background and Purpose. Manual therapy and exercise have not previously been compared with a home exercise program for patients with osteo-arthritis (OA) of the knee. The purpose of this study was to compare outcomes between a home-based physical therapy program and a clinically based physical therapy program.

Subjects. One hundred thirty-four subjects with OA of the knee were randomly assigned to a clinic treatment group (n=66; 61% female, 39% male; mean age [±SD]=64±10 years) or a home exercise group (n=68, 71% female, 29% male; mean age [±SD]=62±9 years).

Methods. Subjects in the clinic treatment group received supervised exercise, individualized manual therapy, and a home exercise program over a 4-week period. Subjects in the home exercise group received the same home exercise program initially, reinforced at a clinic visit 2 weeks later. Measured outcomes were the distance walked in 6 minutes and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).

Results. Both groups showed clinically and statistically significant improvements in 6-minute walk distances and WOMAC scores at 4 weeks; improvements were still evident in both groups at 8 weeks. By 4 weeks, WOMAC scores had improved by 52% in the clinic treatment group and by 26% in the home exercise group. Average 6-minute walk distances had improved about 10% in both groups. At 1 year, both groups were substantially and about equally improved over baseline measurements. Subjects in the clinic treatment group were less likely to be taking medications for their arthritis and were more satisfied with the overall outcome of their rehabilitative treatment compared with subjects in the home exercise group.

Discussion and Conclusion. Although both groups improved by 1 month, subjects in the clinic treatment group achieved about twice as much improvement in WOMAC scores than subjects who performed similar unsupervised exercises at home. Equivalent maintenance of improvements at 1 year was presumably due to both groups continuing the identical home exercise program. The results indicate that a home exercise program for patients with OA of the knee provides important benefit. Adding a small number of additional clinical visits for the application of manual therapy and supervised exercise adds greater symptomatic relief.

Physical Therapy, Vol. 85, No. 12, December 2005, pp. 1301-1317

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Filed under: Exercise therapy, Knee, Manual therapy, Osteoarthritis

Massage Therapy for Osteoarthritis of the Knee

Perlman, Sabina, Williams, Njike, Katz

Background Massage therapy is an attractive treatment option for osteoarthritis (OA), but its efficacy is uncertain. We conducted a randomized, controlled trial of massage therapy for OA of the knee.

Methods Sixty-eight adults with radiographically confirmed OA of the knee were assigned either to treatment (twice-weekly sessions of standard Swedish massage in weeks 1-4 and once-weekly sessions in weeks 5-8) or to control (delayed intervention). Primary outcomes were changes in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and functional scores and the visual analog scale of pain assessment. The sample provided 80% statistical power to detect a 20-point difference between groups in the change from baseline on the WOMAC and visual analog scale, with a 2-tailed of .05.

Results The group receiving massage therapy demonstrated significant improvements in the mean (SD) WOMAC global scores (–17.44 [23.61] mm; P<.001), pain (–18.36 [23.28]; P<.001), stiffness (–16.63 [28.82] mm; P<.001), and physical function domains (–17.27 [24.36] mm; P <.001) and in the visual analog scale of pain assessment (–19.38 [28.16] mm; P<.001), range of motion in degrees (3.57 [13.61]; P = .03), and time to walk 50 ft (15 m) in seconds (–1.77 [2.73]; P<.01). Findings were unchanged in multivariable models controlling for demographic factors.

Conclusions Massage therapy seems to be efficacious in the treatment of OA of the knee. Further study of cost effectiveness and duration of treatment effect is clearly warranted.

Archives of Internal Medicine. 2006;166:2533-2538

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Filed under: Knee, Massage, Osteoarthritis

Effectiveness of Manual Physical Therapy and Exercise in Osteoarthritis of the Knee

Deyle, Henderson, Matekel, Ryder et al

Background: Few investigations include both subjective and objective measurements of the effectiveness of treatments for osteoarthritis of the knee. Beneficial interventions may decrease the disability associated with osteoarthritis and the need for more invasive treatments.

Objective: To evaluate the effectiveness of physical therapy for osteoarthritis of the knee, applied by experienced physical therapists with formal training in manual therapy.

Design: Randomized, controlled clinical trial.

Setting: Outpatient physical therapy department of a large military medical center.

Patients: 83 patients with osteoarthritis of the knee who were randomly assigned to receive treatment (n = 42; 15 men and 27 women [mean age, 60 ± 11 years]) or placebo (n = 41; 19 men and 22 women [mean age, 62 ± 10 years]).

Intervention: The treatment group received manual therapy, applied to the knee as well as to the lumbar spine, hip, and ankle as required, and performed a standardized knee exercise program in the clinic and at home. The placebo group had subtherapeutic ultrasound to the knee at an intensity of 0.1 W/cm² with a 10% pulsed mode. Both groups were treated at the clinic twice weekly for 4 weeks.

Measurements: Distance walked in 6 minutes and sum of the function, pain, and stiffness subscores of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). A tester who was blinded to group assignment made group comparisons at the initial visit (before initiation of treatment), 4 weeks, 8 weeks, and 1 year.

Results: Clinically and statistically significant improvements in 6-minute walk distance and WOMAC score at 4 weeks and 8 weeks were seen in the treatment group but not the placebo group. By 8 weeks, average 6-minute walk distances had improved by 13.1% and WOMAC scores had improved by 55.8% over baseline values in the treatment group (P < 0.05). After controlling for potential confounding variables, the average distance walked in 6 minutes at 8 weeks among patients in the treatment group was 170 m (95% CI, 71 to 270 m) more than that in the placebo group and the average WOMAC scores were 599 mm higher (95% CI, 197 to 1002 mm). At 1 year, patients in the treatment group had clinically and statistically significant gains over baseline WOMAC scores and walking distance; 20% of patients in the placebo group and 5% of patients in the treatment group had undergone knee arthroplasty.

Conclusions: A combination of manual physical therapy and supervised exercise yields functional benefits for patients with osteoarthritis of the knee and may delay or prevent the need for surgical intervention.

Annals of Internal Medicine, 1 Feb 2000, Vol 132 Issue 3, 173-181

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Filed under: Exercise therapy, Knee, Manual therapy, Osteoarthritis

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Therapeutic Exercises and Manual Therapy in the Management of Osteoarthritis

Ottawa Methods Group: Brosseau, Wells, Tugwell, Egan et al

BACKGROUND AND PURPOSE: Osteoarthritis (OA) affects a large and growing proportion of the population. The purpose of this project was to create guidelines for the use of therapeutic exercises and manual therapy in the management of adult patients (>18 years of age) with a diagnosis of OA. All stages of the disease were included in the analysis, and studies of patients who had recent surgery or other rheumatologic, musculoskeletal, or spinal problems or of subjects without known pathology or impairments were excluded.

METHODS: The Ottawa Methods Group used Cochrane Collaboration methods to find and synthesize evidence from comparative controlled trials and then asked stakeholder groups to nominate representatives to serve on a panel of experts. The Ottawa Panel agreed on criteria for grading the strength of the recommendations and their supporting evidence. Of the 609 potential articles on therapeutic exercises for OA that were identified, 113 were considered potentially relevant, and 26 randomized controlled trials and controlled clinical trials were ultimately used.

RESULTS: Sixteen positive recommendations of clinical benefit were developed for therapeutic exercises, especially strengthening exercises and general physical activity, particularly for the management of pain and improvement of functional status. Manual therapy combined with exercises also is recommended in the management of patients with OA.

DISCUSSION AND CONCLUSION: The Ottawa Panel recommends the use of therapeutic exercises alone, or combined with manual therapy, for managing patients with OA. There were a total of 16 positive recommendations: 13 grade A and 3 grade C+. The Ottawa Panel recommends the use of therapeutic exercises because of the strong evidence (grades A, B, and C+) in the literature.

Physical Therapy, Vol. 85, No. 9, September 2005, pp. 907-971

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Filed under: Exercise therapy, Manual therapy, Osteoarthritis, Treatment guidelines

Investigation of Clinical Effects of High- and Low-Resistance Training for Patients With Knee Osteoarthritis: A Randomized Controlled Trial

Mei-Hwa Jan et al

Background and Purpose: Muscle strength training is important for people with knee osteoarthritis (OA). High-resistance exercise has been demonstrated to be more beneficial than low-resistance exercise for young subjects. The purpose of this study was to compare the effects of high- and low-resistance strength training in elderly subjects with knee OA.

Subjects and Methods: One hundred two subjects were randomly assigned to groups that received 8 weeks of high-resistance exercise (HR group), 8 weeks of low-resistance exercise (LR group), or no exercise (control group). Pain, function, walking time, and muscle torque were examined before and after intervention.

Results: Significant improvement for all measures was observed in both exercise groups. There was no significant difference in any measures between HR and LR groups. However, based on effect size between exercise and control groups, the HR group improved more than the LR group.

Discussion and Conclusion: Both high- and low-resistance strength training significantly improved clinical effects in this study. The effects of high-resistance strength training appear to be larger than those of low-resistance strength training for people with mild to moderate knee OA, although the differences between the HR and LR groups were not statistically significant.

Physical Thrapy, Vol. 88, No. 4, April 2008, pp. 427-436
DOI: 10.2522/ptj.20060300

Full text available in through MTABC member only website

Filed under: Exercise therapy, Knee, Osteoarthritis

OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines

Zhang, Moskowitz, Nuki, Abramson et al

PURPOSE: To develop concise, patient-focussed, up to date, evidence-based, expert consensus recommendations for the management of hip and knee osteoarthritis (OA), which are adaptable and designed to assist physicians and allied health care professionals in general and specialist practise throughout the world.

METHODS: Sixteen experts from four medical disciplines (primary care, rheumatology, orthopaedics and evidence-based medicine), two continents and six countries (USA, UK, France, Netherlands, Sweden and Canada) formed the guidelines development team. A systematic review of existing guidelines for the management of hip and knee OA published between 1945 and January 2006 was undertaken using the validated appraisal of guidelines research and evaluation (AGREE) instrument. A core set of management modalities was generated based on the agreement between guidelines. Evidence before 2002 was based on a systematic review conducted by European League Against Rheumatism and evidence after 2002 was updated using MEDLINE, EMBASE, CINAHL, AMED, the Cochrane Library and HTA reports. The quality of evidence was evaluated, and where possible, effect size (ES), number needed to treat, relative risk or odds ratio and cost per quality-adjusted life years gained were estimated. Consensus recommendations were produced following a Delphi exercise and the strength of recommendation (SOR) for propositions relating to each modality was determined using a visual analogue scale.

RESULTS: Twenty-three treatment guidelines for the management of hip and knee OA were identified from the literature search, including six opinion-based, five evidence-based and 12 based on both expert opinion and research evidence. Twenty out of 51 treatment modalities addressed by these guidelines were universally recommended. ES for pain relief varied from treatment to treatment. Overall there was no statistically significant difference between non-pharmacological therapies [0.25, 95% confidence interval (CI) 0.16, 0.34] and pharmacological therapies (ES=0.39, 95% CI 0.31, 0.47). Following feedback from Osteoarthritis Research International members on the draft guidelines and six Delphi rounds consensus was reached on 25 carefully worded recommendations. Optimal management of patients with OA hip or knee requires a combination of non-pharmacological and pharmacological modalities of therapy. Recommendations cover the use of 12 non-pharmacological modalities: education and self-management, regular telephone contact, referral to a physical therapist, aerobic, muscle strengthening and water-based exercises, weight reduction, walking aids, knee braces, footwear and insoles, thermal modalities, transcutaneous electrical nerve stimulation and acupuncture. Eight recommendations cover pharmacological modalities of treatment including acetaminophen, cyclooxygenase-2 (COX-2) non-selective and selective oral non-steroidal anti-inflammatory drugs (NSAIDs), topical NSAIDs and capsaicin, intra-articular injections of corticosteroids and hyaluronates, glucosamine and/or chondroitin sulphate for symptom relief; glucosamine sulphate, chondroitin sulphate and diacerein for possible structure-modifying effects and the use of opioid analgesics for the treatment of refractory pain. There are recommendations covering five surgical modalities: total joint replacements, unicompartmental knee replacement, osteotomy and joint preserving surgical procedures; joint lavage and arthroscopic debridement in knee OA, and joint fusion as a salvage procedure when joint replacement had failed. Strengths of recommendation and 95% CIs are provided.

CONCLUSION: Twenty-five carefully worded recommendations have been generated based on a critical appraisal of existing guidelines, a systematic review of research evidence and the consensus opinions of an international, multidisciplinary group of experts. The recommendations may be adapted for use in different countries or regions according to the availability of treatment modalities and SOR for each modality of therapy. These recommendations will be revised regularly following systematic review of new research evidence as this becomes available.

Osteoarthritis and Cartilage, Volume 16, Issue 2, February 2008, Pages 137-162

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Filed under: Exercise therapy, Hip, Knee, Osteoarthritis, Patient education, Treatment guidelines

A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee

A Kirkley, TB Birmingham, RB Litchfield, JR Giffin et al.

ABSTRACT

Background – The efficacy of arthroscopic surgery for the treatment of osteoarthritis of the knee is unknown.

Methods – We conducted a single-center, randomized, controlled trial of arthroscopic surgery in patients with moderate-to-severe osteoarthritis of the knee. Patients were randomly assigned to surgical lavage and arthroscopic débridement together with optimized physical and medical therapy or to treatment with physical and medical therapy alone (for details please see “details of physical therapy provided” below) . The primary outcome was the total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score (range, 0 to 2400; higher scores indicate more severe symptoms) at 2 years of follow-up. Secondary outcomes included the Short Form-36 (SF-36) Physical Component Summary score (range, 0 to 100; higher scores indicate better quality of life).

Results – Of the 92 patients assigned to surgery, 6 did not undergo surgery. Of the 86 patients assigned to control treatment, all received only physical and medical therapy. After 2 years, the mean (±SD) WOMAC score for the surgery group was 874±624, as compared with 897±583 for the control group (absolute difference [surgery-group score minus control-group score], –23±605; 95% confidence interval [CI], –208 to 161; P=0.22 after adjustment for baseline score and grade of severity). The SF-36 Physical Component Summary scores were 37.0±11.4 and 37.2±10.6, respectively (absolute difference, –0.2±11.1; 95% CI, –3.6 to 3.2; P=0.93). Analyses of WOMAC scores at interim visits and other secondary outcomes also failed to show superiority of surgery.

Conclusions – Arthroscopic surgery for osteoarthritis of the knee provides no additional benefit to optimized physical and medical therapy

the New England Journal of Medicine. 2008 Sep 11;359(11):1169-70.

Details of physical therapy provided: Optimized physical and medical therapy was initiated within 7 days after surgery and followed an identical program in both groups. Physical therapy was provided for 1 hour once a week for 12 consecutive weeks. The intervention was standardized and based on a review of the literature and a formal survey of university physical therapists.³¹ Information regarding a home exercise exercises program that emphasized range-of-motion and strengthening was provided to all patients. Individualized exercises were recommended on the basis of the severity of osteoarthritis, the patient’s age, and the patient’s specific needs. Instruction was also provided regarding activities of daily living, walking, use of stairs, and methods of treatment involving cold and heat. The patients were asked to perform the exercises twice daily and once on the day of a scheduled physical-therapy session. After the patients had completed 12 weeks of supervised activity, they continued an unsupervised exercise program at home for the duration of the study. The patients received additional education from attendance at local Arthritis Society workshops, from a copy of The Arthritis Helpbook³² that was provided to them, and from an educational videotape.

Filed under: Exercise therapy, Knee, Osteoarthritis, Patient education, Surgery

A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee

JB Moseley, K O’Malley, NJ Petersen, TJ Menke et al

Abstract

Background – Many patients report symptomatic relief after undergoing arthroscopy of the knee for osteoarthritis, but it is unclear how the procedure achieves this result. We conducted a randomized, placebo-controlled trial to evaluate the efficacy of arthroscopy for osteoarthritis of the knee.

Methods – A total of 180 patients with osteoarthritis of the knee were randomly assigned to receive arthroscopic débridement, arthroscopic lavage, or placebo surgery. Patients in the placebo group received skin incisions and underwent a simulated débridement without insertion of the arthroscope. Patients and assessors of outcome were blinded to the treatment-group assignment. Outcomes were assessed at multiple points over a 24-month period with the use of five self-reported scores — three on scales for pain and two on scales for function — and one objective test of walking and stair climbing. A total of 165 patients completed the trial.

Results – At no point did either of the intervention groups report less pain or better function than the placebo group. For example, mean (±SD) scores on the Knee-Specific Pain Scale (range, 0 to 100, with higher scores indicating more severe pain) were similar in the placebo, lavage, and débridement groups: 48.9±21.9, 54.8±19.8, and 51.7±22.4, respectively, at one year (P=0.14 for the comparison between placebo and lavage;P=0.51 for the comparison between placebo and débridement) and 51.6±23.7, 53.7±23.7, and 51.4± 23.2, respectively, at two years (P=0.64 and P=0.96, respectively). Furthermore, the 95 percent confidence intervals for the differences between the placebo group and the intervention groups exclude any clinicallymeaningful difference.

Conclusions – In this controlled trial involving patients with osteoarthritis of the knee, the outcomes after arthroscopic lavage or arthroscopic débridement were no better than those after a placebo procedure.

the New England Journal of Medicine Vol 347:81-88, July 11 2002, No 2

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Filed under: Knee, Osteoarthritis

EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT)

Objectives: To update the EULAR recommendations for management of knee osteoarthritis (OA) by an evidence based medicine and expert opinion approach.

Methods: The literature search and guidelines were restricted to treatments for knee OA pertaining to clinical and/or radiological OA of any compartment of the knee. Papers for combined treatment of knee and other types of OA were excluded. Medline and Embase were searched using a combination of subject headings and key words. Searches for those treatments previously investigated were conducted for January 1999 to February 2002 and for those treatments not previously investigated for 1966 to February 2002. The level of evidence found for each treatment was documented. Quality scores were determined for each paper, an effect size comparing the treatment with placebo was calculated, where possible, and a toxicity profile was determined for each treatment modality.

Results: 497 new publications were identified by the search. Of these, 103 were intervention trials and included in the overall analysis, and 33 treatment modalities were identified. Previously identified publications which were not exclusively knee OA in the initial analysis were rejected. In total, 545 publications were included. Based on the results of the literature search and expert opinion, 10 recommendations for the treatment of knee OA were devised using a five stage Delphi technique. Based on expert opinion, a further set of 10 items was identified by a five stage Delphi technique as important for future research.

Conclusion: The updated recommendations support some of the previous propositions published in 2000 but also include modified statements and new propositions. Although a large number of treatment options for knee OA exist, the evidence based format of the EULAR Recommendations continues to identify key clinical questions that currently are unanswere

Final set of 10 recommendations based on both evidence and expert opinion    (table 6)
1.     The optimal management of knee OA requires a combination of non-pharmacological and pharmacological treatment modalities
2.     The treatment of knee OA should be tailored according to:
(a) Knee risk factors (obesity, adverse mechanical factors, physical activity)
(b) General risk factors (age, comorbidity, polypharmacy) (c) Level of pain intensity and disability
(d) Sign of inflammation—for example, effusion
(e) Location and degree of structural damage
3.     Non-pharmacological treatment of knee OA should include regular education, exercise, appliances (sticks, insoles, knee bracing), and weight reduction
4.     Paracetamol (acetaminophen) is the oral analgesic to try first and, if successful, the preferred long term oral analgesic
5.     Topical applications (NSAID, capsaicin) have clinical efficacy and are safe
6.     NSAIDs should be considered in patients unresponsive to paracetamol (acetaminophen). In patients with an increased gastrointestinal risk, non-selective
NSAIDs and effective gastroprotective agents, or selective COX 2 inhibitors should be used
7.     Opioid analgesics, with or without paracetamol (acetaminophen), are useful alternatives in patients in whom NSAIDs, including COX 2 selective inhibitors, are contraindicated, ineffective, and/or poorly tolerated
8.     SYSADOA (glucosamine sulphate, chondroitin sulphate, ASU, diacerein, hyaluronic acid) have symptomatic effects and may modify structure
9.     Intra-articular injection of long acting corticosteroid is indicated for flare of knee pain, especially if accompanied by effusion
10.     Joint replacement has to be considered in patients with radiographic evidence of knee OA who have refractory pain and disability

Annals of the Rheumatic Disease. 2003 December; 62(12): 1145–1155.

doi: 10.1136/ard.2003.011742.

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Filed under: Arthritis, Exercise therapy, Knee, Osteoarthritis, Patient education, Surgery