Much of so-called alternative medicine (SCAM) is used in the management of osteoarthritis pain. Yet few of us ever seem to ask whether SCAMs are more or less effective and safe than conventional treatments.
This review determined how many patients with chronic osteoarthritis pain respond to various non-surgical treatments. Published systematic reviews of randomized controlled trials (RCTs) that included meta-analysis of responder outcomes for at least 1 of the following interventions were included: acetaminophen, oral nonsteroidal anti-inflammatory drugs (NSAIDs), topical NSAIDs, serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants, cannabinoids, counselling, exercise, platelet-rich plasma, viscosupplementation (intra-articular injections usually with hyaluronic acid ), glucosamine, chondroitin, intra-articular corticosteroids, rubefacients, or opioids.
In total, 235 systematic reviews were included. Owing to limited reporting of responder meta-analyses, a post hoc decision was made to evaluate individual RCTs with responder analysis within the included systematic reviews. New meta-analyses were performed where possible. A total of 155 RCTs were included. Interventions that led to more patients attaining meaningful pain relief compared with control included:
- exercise (risk ratio [RR] of 2.36; 95% CI 1.79 to 3.12),
- intra-articular corticosteroids (RR = 1.74; 95% CI 1.15 to 2.62),
- SNRIs (RR = 1.53; 95% CI 1.25 to 1.87),
- oral NSAIDs (RR = 1.44; 95% CI 1.36 to 1.52),
- glucosamine (RR = 1.33; 95% CI 1.02 to 1.74),
- topical NSAIDs (RR = 1.27; 95% CI 1.16 to 1.38),
- chondroitin (RR = 1.26; 95% CI 1.13 to 1.41),
- viscosupplementation (RR = 1.22; 95% CI 1.12 to 1.33),
- opioids (RR = 1.16; 95% CI 1.02 to 1.32).
Pre-planned subgroup analysis demonstrated no effect with glucosamine, chondroitin, or viscosupplementation in studies that were only publicly funded. When trials longer than 4 weeks were analysed, the benefits of opioids were not statistically significant.
The authors concluded that interventions that provide meaningful relief for chronic osteoarthritis pain might include exercise, intra-articular corticosteroids, SNRIs, oral and topical NSAIDs, glucosamine, chondroitin, viscosupplementation, and opioids. However, funding of studies and length of treatment are important considerations in interpreting these data.
Exercise clearly is an effective intervention for chronic osteoarthritis pain. It has consistently been recommended by international guideline groups as the first-line treatment in osteoarthritis management. The type of exercise is likely not important.
Pharmacotherapies such as NSAIDs and duloxetine demonstrate smaller but statistically significant benefit that continues beyond 12 weeks. Opioids appear to have short-term benefits that attenuate after 4 weeks, and intra-articular steroids after 12 weeks. Limited data (based on 2 RCTs) suggest that acetaminophen is not helpful. These findings are consistent with recent Osteoarthritis Research Society International guideline recommendations that no longer recommend acetaminophen for osteoarthritis pain management and strongly recommend against the use of opioids.
Limited benefit was observed with other interventions including glucosamine, chondroitin, and viscosupplementation. When only publicly funded trials were examined for these interventions, the results were no longer statistically significant.
Adverse events were inconsistently reported. However, withdrawal due to adverse events was consistently reported and found to be greater in patients using opioids, SNRIs, topical NSAIDs, and viscosupplementation.
Few of the interventions assessed fall under the umbrella of so-called alternative medicine (SCAM):
- some forms of exercise,
It is unclear why the authors did not include SCAMs such as chiropractic, osteopathy, massage therapy, acupuncture, herbal medicines, neural therapy, etc. in their review. All of these SCAMs are frequently used for osteoarthritis pain. If they had included these treatments, how do you think they would have fared?
Seems to me the goal should be to do what one can to get these people exercising. If “chiropractic” can help achieve that goal…
Vernon H (2013) Manipulation/Manual Therapy in the Treatment of Osteoarthritis. J Arthritis 2: e107. doi:10.4172/2167-7921.1000e107
no doubt Vernon concluded that Manipulation/Manual Therapy is ineffective and unsafe in the Treatment of Osteoarthritis
[article not Medline listed]
NICE guidelines in the UK (section 1.4.2) recommend considering stretching and manipulation as an adjunct therapy. Particularly for hip OA this is in line with the way many chiropractors approach OA
Dr. Ernst, I respect the theme of what you are trying to do, sifting through tons of literature and trying to make sense of much of what is offered as various forms of treatment. But you do yourself no favors by whimsically presuming the outcome of a study and casting it aside without having read it. It implies, “Don’t confuse me with new information, I’ve already made up my mind.” Is that okay to do, and is it scientific? Because if it is, it’s going to save me a helluva lot of reading.
my point was that the reference cannot be read because it is not available electronically; I was trying to take DC’s Mikey.
Actually it is if one knows how to search for it.
so good to have an expert searcher here.
it turns out that this is a mere bibliography, not a systematic review. no methods section, no assessment of the quality of the primary studies, no conclusion.
but thanks anyway.
no, but it would be helpful to post even a hint of what the paper says.
Clin J Pain;
. Jul-Aug 2004;20(4):244-55.
Complementary and alternative approaches to the treatment of persistent musculoskeletal pain
Debra K Weiner 1 , Edzard Ernst
“Some evidence exists to support the superiority of homeopathic remedies over placebo for treating osteoarthritis and rheumatoid arthritis.”
yes, 16 years ago this was true.
@Edzard: Do you want your readers to think the same remedies used by you and Dr. Weiner are no longer manufactured or successfully used to treat the pain of osteo and rheumatoic arthritis pain in patients? Surely, you don’t want to mislead your blog followers.
Not mentioned in this bio about Dr.Weiner https://profiles.dom.pitt.edu/geri/faculty_info.aspx/Weiner5092 ; Other info about Dr. Weiner includes her successful use of acupuncture for pain control.
what we published was a review, not a study. so we did not use remedies ‘to treat the pain of osteo and rheumatic arthritis pain in patients’.
Update to the Lancet LBP Series:
The Lancet Series call to action to reduce low value care for low back pain: an update
Buchbinder, Rachelle; Underwood, Martin; Hartvigsen, Jan, Jane; Maher, Chris G.
They have also noted new low value care creeping in with the medical regenerative therapies.
Interestingly Buchbinder, Hartvigsen and Maher just resigned fron the IASP back pain taskforce due to concerns about transparency, ties to industry and independence. All over Twitter right now.