Complementary and Alternative Modalities to Relieve ...€¦ · Modalities to Relieve Osteoarthritis Symptoms A review of the evidence on several therapies often used for osteoarthritis

State of the Science

S44 AJN ▼ March 2012 ▼ Vol. 112, No. 3 ajnonline.com

Content from the American Journal of Nursing. Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Complementary and Alternative Modalities to Relieve Osteoarthritis Symptoms

A review of the evidence on several therapies often used for osteoarthritis management.

Osteoarthritis (OA), an increasingly prevalent public health problem, affects the physical functioning and quality of life of millions

of adults in the United States. A disease that causes progressive damage to joint cartilage, OA produces pain, joint inflammation, and stiffness with even-tual restriction of movement. The prevalence of clinical OA has continued to increase over the past decade, with estimates approaching 27 million adults in the United States alone.1 OA affects indi-viduals worldwide. Many studies report a higher incidence in women and increasing prevalence with age.1

Given the intense symptom burden of OA and the resulting possibility of disability, costs related to this illness are immense. OA affects physical and social functioning, well-being, productivity, and self-image, all of which significantly impact quality of life. Current conventional pharmacol-ogic treatment, often successful in relieving pain, has serious adverse effects in the gastrointestinal and cardiovascular systems, especially with long-term use. Hence, OA patients continue to search for alternative treatments while a cure remains elu-sive.

This paper provides an overview of complemen-tary and alternative medicine (CAM) therapies used to prevent, control, and manage OA, as well as evi-dence for their efficacy and safety.

CAM OVERVIEWCAM is most often defined as a group of diverse medical and health care treatments, products, and practices not considered part of conventional West-ern medicine. Many of these therapies arise from al-ternative medical systems, such as traditional Chinese medicine and Ayurveda, which have long histories of use across the world. As technology has enhanced our global connections over the past three decades, thera-pies from alternative systems have become increasingly available in the West and now present challenges to conventional care and increase the possibilities for symptom management.

The world of CAM is vast (estimates count thou-sands of therapies and products from many systems of care; see http://nccam.nih.gov/health/whatiscam), and the collection of research evidence supporting the effectiveness and safety of CAM therapies for the management of OA is in its infancy. The National Center for Complementary and Alternative Medicine (NCCAM) has categorized CAM therapies as mind–body therapies, natural products, manipulative and body-based approaches, and other practices, includ-ing energy therapies.

CAM therapies are considered complementarywhen combined with conventional treatment methods and alternative when used in place of conventional treatment. Alternative medical systems are whole sys-tems of care that exist outside of conventional Western

By Judith Fouladbakhsh, PhD, APRN-BC, AHN-BC, CHTP

Overview: Conventional medical treatment of osteoarthritis often successfully relieves pain but can also produce adverse gastrointestinal and cardiovascular effects, especially with long-term use. Hence, many patients use complementary and alternative medicine (CAM) to prevent, control, and manage the pain of osteoarthritis. The author reviews the evidence on the efficacy and safety of several CAM therapies often used for osteoarthritis management, including mind–body therapies, supplements, and body-based treatments.

Keywords: complementary and alternative medicine, osteoarthritis

Preventing and Managing OA

[email protected] AJN ▼ March 2012 ▼ Vol. 112, No. 3 S45

Content from the American Journal of Nursing. Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.Content from the American Journal of Nursing. Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

medicine. Worldwide, integrative medicine—which combines conventional and evidence-based CAM therapies—continues to grow. Patients are very much involved in the changing health care arena as they seek relief from the symptoms of chronic illnesses.

PREVALENCE OF CAM USECurrent estimates of CAM use in the United States, based on the 2002 and 2007 National Health Inter-view Survey (NHIS) data, range from 34% to 76%, depending on the therapies included in the definition of CAM and the population studied.2-5 The number of participants who’d used at least one CAM therapy in the year preceding the NHIS interview increased from 2002 to 2007, with use higher among individu-als affected by cancer in both years. The number of participants who used CAM ranged from 35% to 39% in 2002 and increased to 37% to 44% in 2007 in the noncancer and cancer populations, respectively, demonstrating a continuing increase in CAM use over time.4, 6 Higher rates of CAM use for a variety of con-ditions were reported in 2007 for acupuncture, mas-sage therapy, meditation, and yoga, among others.2

The greatest numbers of CAM users were among middle-aged, well-educated white women, and peo-ple experiencing chronic illness and bothersome symptoms.4, 6, 7

Among people with arthritis, data revealed, the proportion of respondents who’d used CAM was

significantly higher than among those without it (41% and 34.6%, respectively).5 In this population, herbs, supplements, and vitamins (24%) and mind–body therapies (21%) were most often used for treat-ment purposes, followed by chiropractic (9.4%) and massage (almost 5%).5 Limitations of these data include the datedness of the information and the in-clusion of multiple types of rheumatic diseases, pre-venting a determination of CAM use specifically for OA. Other estimates of use range from 59% to 90% but are often limited by sample location and differ-ences in the definition of CAM. 8-10

Among people with OA, differences in patterns of use have also been reported by ethnicity.11, 12 Among the 80% of CAM users noted by Katz and Lee, most used dietary practices (71.5%), mind–body therapies (42%), topical products (38%), herbs and supple-ments (32.9%), and manipulative and body-based methods (21.4%).12 African Americans were most likely to use CAM overall, specifically prayer and topical products, and Asian Americans used alterna-tive medical systems, supplements, and manipulation. Greater use of herbs, magnets, and copper has been reported by Hispanics, and the use of supplements is more prevalent among non-Hispanics.11 Further study is needed to illuminate CAM usage patterns. In addition, information is needed on which CAM therapies are used specifically for arthritis symptom management, as well as the benefits and risks of use.

Participants take part in a t’ai chi class offered through the Hospital for Special Surgery in New York City. These classes, which take place at an off-site gym to reach more of the community, teach simple, rhythmic movements to improve balance and strength, maintain bone mass, and relieve pain. Photo courtesy of the Hospital for Special Surgery.




Current data, however, do provide insight into pat-terns of CAM use among individuals with OA and highlight the need for updated population-specific studies that use clear and consistent CAM defini-tions. It is evident that people with OA are using CAM therapies to manage symptoms such as pain and related problems, minimize adverse effects of pharmacologic treatment, and prevent disabilities arising from OA that affect functioning and quality of life.13 It is also important to recognize that skepti-cism about conventional medical care may prompt people to seek CAM therapy, especially younger peo-ple with OA.8

LITERATURE REVIEWI conducted an extensive literature review in late 2010 and early 2011 to obtain research studies on CAM therapies and OA. The databases and resources I searched include the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, MEDLINE, Ovid SP, Biological Abstracts, the Na-tional Guideline Clearinghouse, Health Reference Center Academic, and the Cochrane Collaboration’s systematic reviews, as well as the Web sites of Clini-calTrials.gov, the Agency for Healthcare Research and Quality, http://online.statref.com [the American College of Physicians’ Information and Education Re-source], the Mayo Clinic, MD Consult, the Centers for Disease Control and Prevention, the NCCAM, and Natural Standard.

Keywords used in the search included but were not limited to osteoarthritis, arthritis (knee, hip, hand), traditional Chinese medicine, Ayurveda, yoga, qigong, t’ai chi, herbal and dietary supplements, mind–body, relaxation, guided imagery, herbal therapy, acupunc-ture, pain management, massage, energy therapies (therapeutic touch, healing touch, Reiki), alternative medicine and therapies, complementary medicine and therapies, CAM, hypnosis, and vitamins. I restricted the search to articles published in a 10-year period and then removed that restriction for studies on en-ergy therapies when that search yielded few studies. I also limited the search to articles published in En-glish and excluded studies that examined only patients with rheumatoid arthritis (RA).

MIND–BODY THERAPIESYoga, an ancient practice originating in Central Asia that is used in Ayurvedic medicine, is a feasible in-tervention for people with OA, although studies are limited and focus primarily on those with knee in-volvement.14 Yoga consists of a series of postures (asa-nas), breathing exercises (pranayama), and meditative practices that vary according to yoga lineage. Hatha yoga includes varying intensities of physical move-ment, while yoga nidra is still and meditative. Yoga incorporates a spiritual component through medi-tation coordinated with movements, breathing, and stillness.

Although yoga has existed for thousands of years, research on its use in medicine is relatively recent and sparse. Haaz and Bartlett found 10 yoga studies pub-lished in the past 30 years, six in individuals with RA and four in those with OA or both OA and RA.15 Us-ing a scoring system for study quality based on U.S. Department of Health and Human Services’ recom-mendations,16 Haaz and Bartlett found that scores for the four OA studies varied from 3 to 5. The range of scores possible was 0 to 8, from low to high quality, for four categories (study design, sample size, inter-vention, and analysis). Recent work by Ulger and Ya-gli noted that yoga had a positive effect on gait and balance among women with OA and low-back pain, although they acknowledged that their small sample size (N = 27) limits generalizability.14 Pilot research (N = 7) in treating symptoms of knee OA indicated that an eight-week program of Iyengar yoga, a style of hatha yoga developed by B.K.S. Iyengar that uses supportive props such as blankets and belts, resulted in significant reductions in pain and stiffness and in-creased physical functioning as measured by the West-ern Ontario and McMaster Universities Osteoarthritis Index.17 The authors further noted that yoga was fea-sible for older patients (older than 50 years of age) with OA, the majority of whom were also obese. Bu-kowski and colleagues also noted functional changes and improvement in quality of life with both yoga and stretching and concluded that more study was needed.18 Raub, summarizing early research studies, stated that yoga may increase strength and flexibility in arthritis patients.19

Evidence for the use of yoga in OA is limited. There’s a lack of studies specifically on OA, but those that have been conducted indicate that its feasibility and safety are good. Future studies should include pa-tients of diverse ethnic groups and ages and use well-described yoga interventions that can be replicated in further studies, thereby increasing the generalizability of the results. Data from studies conducted abroad (which may be less accessible to some researchers because of their language of publication or a lack of

Skepticism about conventional medical care

may prompt people to seek CAM therapy,

especially younger people with OA.




information on the study participants) should be ex-amined. However, studies do indicate that CAM prac-tices that include physical movement and stretching, as yoga does, increase flexibility and muscle strength, thereby promoting joint support.20-22 In addition, yoga may decrease body fat and improve physical fitness, which are known to be preventive factors for OA.

T’ai chi ch’uan, an ancient martial art originating in traditional Chinese medicine, has received increased attention recently to determine its effects on physical functioning and pain. T’ai chi is a movement practice that facilitates the balanced flow of energy and uses meditation and breathing for health promotion and management of symptoms. Among older women with OA (N = 82), t’ai chi increased endurance during knee flexion and extension and bone mineral density while also decreasing fear of falling.23 Significant improve-ments in pain related to knee OA, physical function-ing, and gait following a six-week t’ai chi intervention in another study (N = 40) also suggests that it has beneficial effects for gait kinematics (such as stride length) among older adults.24

Evidence for the use of t’ai chi ch’uan in OA. That similar findings are reported in the literature suggest there is a moderate level of evidence support-ing the use of t’ai chi to manage pain and improve functioning in individuals with knee OA.25-28 Further research is needed to determine the most effective t’ai chi protocols according to age, ethnicity, and sites of OA.

ENERGY THERAPIESTherapeutic Touch, Reiki, and Healing Touch,three energy therapies, focus on balancing energy flow through a series of techniques applied above and directly to the body. Based on the premise that an energetic biofield surrounds and penetrates the physical body, energy therapies aim to remove block-ages that are thought to cause disease and hinder heal-ing. Therapeutic Touch was developed in the 1970s by Dolores Krieger and includes three levels of prac-tice; Healing Touch, developed in the 1980s by Janet Mentgen, includes five levels of preparation and is en-dorsed by the American Holistic Nurses Association; and Reiki, a practice from Japan, was developed by Mikao Usui in 1922 and incorporates the use of symbols in the energy treatment.

My review of the literature on the effects of energy therapies on OA revealed a paucity of research studies. This may reflect a lack of funding support and meth-odologic difficulties such as the absence of instruments able to measure energy, questions concerning placebo effects, and the influence of the practitioner’s pres-ence and intention on the patient’s reported results. However, there is significant, ongoing advancement

in the science of energy healing by the members of, for example, the International Society for the Study of Subtle Energies and Energy Medicine. Early stud-ies on the use of Therapeutic Touch for OA noted improved functional ability, decreased pain and dis-tress, and improved mood.29-31 The study authors noted limitations including sample sizes and study designs and cited the need for further research.

Evidence for the use of Therapeutic Touch, Reiki, and Healing Touch in OA has not been established. Further research using rigorous scientific methods, instruments that measure energy, and larger sample sizes is needed.

Acupuncture, used for millennia in traditional Chinese medicine, has been the subject of intense re-search over the past two decades and is now a popular therapy across the globe. Using the process of system-atic research reviews, Ernst reported that acupuncture overall has an encouraging risk–benefit ratio.32 Acu-puncture protocols vary widely across studies, how-ever, complicating the ability to make conclusions about its effectiveness. Few studies compare acupunc-ture with or evaluate its effectiveness in combination with physical therapy (PT), an often prescribed and effective nonpharmacologic intervention for OA. Thus, further study is recommended to determine and compare the effects of acupuncture used as an adjuvant to PT and medication regimens.33

As a CAM therapy with a long history of effective use in the East, acupuncture works by improving the flow of energy, known as qi, and removing energy blockages related to disease processes.34, 35 Thus, it differs from Western medicine in its theoretical view of OA pathology and in treatment methods. Maa and colleagues state that the mechanism of OA of the knee, for example, “is a slowdown of Qi, the conse-quence of ineffective interaction between the liver, spleen and kidney networks,” creating joint disease and dysfunction.34 Therefore acupuncture treatment, whether performed as needling, pressure, heat, or elec-trical stimulation, is guided by the ancient depictions of the meridians (energy channels) throughout the body and the assessment of blockages by the practi-tioner. Data do support the use of acupuncture in the multimodal treatment of patients with knee OA.34

Data support the use of acupuncture

in the multimodal treatment of

patients with knee OA.




Rigorous randomized control trials (RCTs) of vary-ing sample sizes have documented that acupuncture confers significant improvements in pain, functioning, and quality of life in patients with OA, although some findings have been difficult to interpret. Manheimer and colleagues, in their 2007 review of 11 RCTs on acupuncture in 2,821 patients with knee OA of a mean duration of five years or more, found no clini-cal differences between real and “sham” acupuncture, but did find clinical relevance when acupuncture was compared with usual care.36 These improvements were maintained at six months. The authors suggest there is a possible placebo effect requiring further study and that acupuncture has “a genuine biological effect, sug-gested by the small short-term improvements in pain and function compared with sham.” No serious ad-verse effects were reported, which has been supported by more extensive subsequent reviews.37 Manheimer and colleagues’ 2010 systematic review indicates that as a treatment for knee or hip OA, acupuncture, when compared with sham acupuncture, being on a wait-ing list for treatment, or usual treatment, may result in small improvements in pain and physical func-tioning at eight weeks and for up to 26 weeks after treatment, with minor and infrequent adverse ef-fects such as bruising and bleeding at the needle in-sertion site.37

Witt and colleagues, in a study using a three-group design (N = 3,635) for a 15-week series of acupunc-ture treatments for hip and knee patients, reported significant effects and positive outcomes that lasted throughout the five-month study period.38 Earlier, Ber-man and colleagues described similar findings when “true” acupuncture was compared with sham acu-puncture and patient education.39 In contrast, Tsang and colleagues found no significant differences in pain scores or analgesic use between groups receiving true and sham acupuncture following knee arthroplasty; all participants also had PT, and improved range of motion was reported.40 However, the sample size was small (N = 30). Previous studies have also reported small improvements in pain or a lack of significance when comparing study groups.41 I found one review on the safety of acupuncture, which noted that no ad-verse events were reported in 12 RCTs.42

Evidence for the use of acupuncture in OA is mod-erate for pain relief. Wide variability existed in study designs, sample sizes, treatment protocols, and the control groups used for comparison. Systematic re-views have documented reduction of pain, primarily among patients with knee involvement.32, 33, 43, 44 Fur-ther study is needed to evaluate the effects of acu-puncture on outcomes in patients with OA at other sites, in combination with standard treatment for OA, and on pain management and function over time. More data are also needed to determine adequate dosing (how many treatments are needed and how often), the influence of provider contact, and the ef-fects on physiologic processes.

NATURAL PRODUCTSGlucosamine and chondroitin sulfate are considered “components to the extracellular matrix of articular cartilage” and have been used for the prevention and management of OA for more than 40 years based on the premise that the disease is caused by a deficiency.45

It is hypothesized that glucosamine may repair carti-lage by stimulating synthesis of chondrocytes. These products have been the focus of intense study over the past 15 years, with inconsistency still noted in results from RCTs, meta-analyses, and systematic reviews. Recent results from a comprehensive meta-analysis

(10 RCTs; N = 3,803 patients with OA of the knee, hip, or both) concluded that glucosamine and chon-droitin, used alone or in combination, did not de-crease joint pain or influence joint-space narrowing over time.46 The authors stressed that their use should not be recommended to new patients.

Results from other meta-analyses and reviews in-dicate that the effects of glucosamine and chondroitin range from none to moderate. Lee and colleagues, who measured radiologic outcomes in six RCTs, reported positive effects of glucosamine or chon-droitin on joint-space narrowing over two to three years of use.47 Vlad and colleagues found glucosamine hydrochloride ineffective but were unable to rule out the possibility of effects from glucosamine sulfate.48

In contrast, Vangsness and colleagues concluded that prior studies have provided support for some level of efficacy in managing symptoms of OA and altering

Recent results from a comprehensive meta-analysis concluded that

glucosamine and chondroitin, used alone or in combination, did not

decrease joint pain or influence joint-space narrowing over time.




disease progression, although the results were incon-sistent.45 The multisite Glucosamine–Chondroitin Ar-thritis Intervention Trial showed a significant effect in individuals with severe OA. Follow-up study, how-ever, has failed to confirm effects on joint-space nar-rowing.49 An earlier Cochrane review, one of the most comprehensive meta-analyses (N = 2,570), also re-ported 28% and 21% improvements in OA pain and functioning, respectively; however, the researchers wrote that when including only “the best designed studies,” benefits were no longer seen.50 With regard to use of chondroitin, Reichenbach and colleagues found that effects disappeared when studies with large sample sizes and strong designs were combined for analysis.51

Evidence for the use of glucosamine and chon-droitin in OA is inconsistent. Long-term trials are needed. Systematic reviews and meta-analyses sup-port a positive safety profile. Ongoing research, the Long-Term Evaluation of Glucosamine Sulphate Study, is in progress.

Pycnogenol (pine bark extract), a supplement studied in knee OA, has shown significant effects in decreasing pain and stiffness and improving function-ing. Two studies (N = 35; N = 100) noted a signifi-cant reduction in nonsteroidal antiinflammatory drug use over a two-to-three-month period, thus reducing the severity of the unwanted adverse effects of those drugs.52, 53 Other natural products used for OA include devil’s claw, cat’s claw, avocado and soybean unsa-ponifiables (ASU), bromelain, ginger–turmeric, MSM (methylsulfonylmethane), DMSO (dimethyl sulfoxide), and SKI306X, a cocktail of plant extracts, mineral supplements, and antioxidants.54-56 Brien and col-leagues concluded after reviewing six studies on MSM and DMSO (N = 681) that no definitive conclusions could be made, although some positive outcomes were reported.55 Improvement in pain was noted in two of the four DMSO studies, although questions about the studies’ methodology were raised. In contrast, the MSM studies provided “positive but not definitive evidence that MSM is superior to placebo in the treat-ment of mild to moderate OA of the knee.”

Ameye and Chee conducted a systematic review of the evidence on nutraceuticals and functional foods for the management of OA. They included 53 RCTs exploring the benefits of lipids, vitamins, minerals, plant extracts, and other supplements.54 Using a best-evidence synthesis, 18 of the functional ingredients studied demonstrated efficacy in at least one clinical trial. The authors concluded that nutrition may im-prove OA symptoms and recommended further study of its effects on disease prevention and progression.

Evidence for the use of pycnogenol in OA is good but moderate or lacking for other plant extracts. No

evidence exists for most products, but there is good support for pycnogenol and ASU and moderate evi-dence for MSM and SKI306X.

BODY-BASED MANIPULATIVE THERAPIESMassage has been a well-researched CAM therapy for stress relief and relaxation in both healthy and chronically ill individuals. Studies have focused pre-dominantly on low-back pain and have reported effi-cacy, although massage’s mechanisms of action are as yet unclear.57-59 Fewer studies have focused on patients with arthritis. Perlman and colleagues noted signifi-cant changes in pain, stiffness, and physical function following massage in people with knee OA.60 In an-other study, the use of essential oil with massage re-sulted in reduced pain and improved function in older

adults with moderate-to-severe knee pain.61 No sys-tematic reviews on massage therapy for knee OA were found, as was also reported by Jamtvedt and colleagues.62 A comprehensive meta-analysis published by Moyer and colleagues provided insight into phys-iological and psychosocial mechanisms of massage therapy and made interesting conclusions related to dosage and pain effects.59 Although the study wasn’t specifically focused on OA, the authors’ conclusion that massage works by both physiological and psy-chological mechanisms may hold relevance for this population that has pain as its predominant symp-tom. They noted differences between the effects of single and multiple doses of massage. Single-dose massage resulted in decreased anxiety, blood pressure, and heart rate as compared with the control group. However, results were inconsistent regarding the ef-fects on the parasympathetic nervous system and pain assessment. Multiple-dose massage, while also lower-ing blood pressure, heart rate, and anxiety, also de-creased depression and pain on assessment. Several researchers have investigated the safety of massage and indicated that there is a need to understand the effects of various approaches and protocols and ther-apist training.59, 63

Evidence for the use of massage therapy in OA is moderate for low-back pain and inconclusive for pain

Evidence for the use of massage

therapy in OA is moderate for low-back

pain and inconclusive for pain in the

knee and at other sites.




in the knee and at other sites. Research using strong methodology in the OA population is warranted.

IMPLICATIONS AND CONCLUSIONSMuch variation exists in the evidence supporting the use of CAM therapies for OA. It’s clear that symptom management should be multimodal and include non-pharmacologic therapies along with routine pharma-cological treatment. Focusing on comorbid symptoms is also critical to improving function and overall qual-ity of life. CAM therapies and other nonpharmaco-logic approaches play roles in managing pain and perhaps the insomnia, depression, and anxiety that can result.6, 59, 64-70 Effective therapies for these comor-bid symptoms are essential for the holistic manage-ment of OA. Thus, one may conclude that further study is needed, as are clear and consistent defini-tions of the therapies considered to be complemen-tary or alternative.

Consistency across studies is necessary for com-parison and will ultimately provide clearer answers on whether a therapy’s use is supported. Data are needed on appropriate dosing for the various CAM therapies and the resultant outcomes. In addition, it’s essential that researchers use standardized treat-ments, even though this may contradict the essence of some holistic practices. Comparison of studies on yoga, for example, becomes complicated when dif-ferent yoga practices and traditions are used, which limits the strength of findings. It’s also essential to consider using new methodologies for CAM study such as Whole Systems Research, which addresses the complexities of CAM interventions, many of which come from whole systems of care such as traditional Chinese medicine. Because there might be synergis-tic effects with concomitantly used therapies within these systems, a mixed-methods research approach is needed. This should include qualitative as well as quantitative analyses to capture the effects of CAM therapies.71 Also evident in CAM studies, particularly in the extensive glucosamine trials, is a tendency to-ward not comparing like to like. Differences in prod-uct formulation, CAM practices, and provider services may affect study results. As data increase, it will be-come possible to include proven CAM therapies in the multimodal management of OA. ▼

Judith Fouladbakhsh is assistant professor and director of the Complementary Therapies in Healthcare Graduate Certificate Program at Wayne State University, Detroit. Contact author: [email protected]. The author has disclosed no conflicts of interest, financial or otherwise.

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Complementary and Alternative Modalities to Relieve ...€¦ · Modalities to Relieve Osteoarthritis Symptoms A review of the evidence on several therapies often used for osteoarthritis