Chiropractic. One small randomized controlled trial (RCT) matched participants with knee OA pain measured by visual analog scale (VAS) and assigned them to receive either treatment according to the Macquarie Injury Management Group Knee Protocol or nonforceful contact.32 The treatment group reported significantly decreased knee symptoms such as crepitus and improvement in mobility and ability to perform general activities. A systematic review found fair evidence for efficacy of manipulative therapy of the knee combined with multimodal or exercise therapy for knee OA.33
Transcutaneous electrical nerve stimulation (TENS). Evidence for the effectiveness of TENS for OA is mixed. A 2009 Cochrane systematic review of TENS for knee OA concluded that available studies were too small and poorly designed to judge its effectiveness.34 However, its use in tibiofemoral OA has yielded good results.35
Tai Chi. This ancient form of meditative exercise has long been acknowledged as a means for enhancing balance and dexterity, but studies of chronic pain reduction and improved mobility with Tai Chi have been few and usually underpowered to yield reliable results. One systematic review of 9 RCTs, 23 non-RCTs, and 15 observational studies included studies that showed benefits for osteoarthritic symptoms with improved functional mobility and quality of life.36 Another systematic review of 5 RCTs and 7 nonrandomized clinical trials found that Tai Chi was effective for pain control of OA of the knee, but that evidence was inconclusive for pain reduction or mobility improvement.37 In a long-term study comparing Tai Chi with regular exercise in patients with symptomatic OA of the knee, researchers found that those in the Tai Chi group showed greater improvement in pain, physical function, self-efficacy, depression, and health-related quality of life, with some improvements lasting as long as 48 weeks.38
Massage. A longitudinal analysis of the use of a variety of alternative therapy offerings by older adults with OA found that the most commonly utilized treatment during a 20-week intervention period was massage (57%) followed by chiropractic (20.7%).39 In the first prospective randomized trial to evaluate the efficacy of massage for adults with OA of the knee, participants who received 8 weeks of Swedish massage therapy showed significant improvements in pain, stiffness, and physical function. These improvements persisted at the 16-week evaluation.40
Dietary supplements. Omega-3 fatty acids have shown promise in reducing chronic neuropathic pain when taken at levels that exceed 2 g/d of eicosapetaenoic acid and docosahexaenoic acid.41 This effect is probably enhanced when combined with a dietary reduction of omega-6 fatty acids and saturated fats. This dietary measure may also have some effect on joint pain.42
Glucosamine/chondroitin has been shown in a meta-analysis to reduce OA pain,43 although another meta-analysis showed no effect on either joint pain or narrowing of joint space.44 More recently, data from the long-term Glucosamine/Chondroitin Arthritis Intervention (GAIT) trial found that patients who took glucosamine or glucosamine/chondroitin in combination had similar results to those who took celecoxib or placebo. Over the 2-year study period, all groups showed improvement in painand function.45
It is worth noting that not all supplements are made the same, and there may be varying potencies. For example, some glucosamine products work better than others.46 When discussing supplements, to get the most potential benefit it is advisable to suggest those with a strong body of evidence or refer patients to providers who are familiar with CAM therapies.
Other promising dietary aids for reducing OA pain include soy protein,47 avocado-soybean unsaponifiables,48 Cat’s claw,49 white willow,49 green tea,49,50 turmeric,51 ginger,52 and propolis.53
Widening your integrative approach to OA treatment
There is emerging evidence that integrating multiple conventional and CAM therapies such as glucosamine and walking may provide the best results for OA patients.54 The realization that many patients with pain and diminished mobility are already exploring CAM therapies presents an opportunity for you to discuss their decisions and direct their attention to options that are supported by strong evidence. By evaluating the increasing body of evidence in support of specific CAM therapies, you can feel confident in offering your patients a wider range of choices than standard pharmacologic and nonpharmacologic OA options, and integrate these options to improve care.
Acknowledgement—The author wishes to thank Charles F. Williams for his assistance in researching and writing this article.
REFERENCES
1. Lawrence RC, Felson DT, Helmick CG, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II. Arthritis Rheum. 2008;58:26-35.
2. Centers for Disease Control and Prevention. Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation—United States, 2007–2009. MMWR Morb Mortal Wkly Rep. 2010;59:1261-1265.
3. Barnes PM, Bloom B, Nahin R. CDC National Health Statistics Report #12. Complementary and alternative medicine use among adults and children: United States, 2007. December 2008. Available at: http://nccam.nih.gov/news/camstats/2007/camsurvey_fs1.htm#use.