REFERATCOMPLEMENTARY AND ALTERNATIVE

MEDICINE IN OSTEOARTHRITIS

NAME : PANJI ARYO

NIM : 0761050097

FAKULTAS KEDOKTERAN UNIVERSITAS KRISTEN INDONESIA

RSUD BEKASI

PERIODE

Complementary and Alternative Medicine in Osteoarthritis

A. Introduction

Complementary and alternative medicine (CAM) represents a diverse

and large group of products, therapies, and health care systems that are not

considered a part of conventional medicine. During the past few decades, the

interest in and popularity of CAM have been rapidly growing among adults in

the United States. It has been estimated that about 60% of adults used at least

one form of alternative therapy in 2002, spending billions of dollars out-of-

pocket. The increase in use of CAM may be explained by market forces, the

desire of patients to be proactive in their health care, access to information on

the internet and frustration or dissatisfaction with conventional medicine.1

The majority of people use CAM therapies as a complement to

conventional medicine. In the 2002 national Health Interview Survey

conducted by the Centers for Disease Control and Prevention, respondents

were more likely use CAM if they believed such therapies combined with

conventional medicine would improve their health and/or if they were simply

interested in trying the alternative practices. Eisenberg et al. reported that out

of 831 people who saw a medical doctor and used a CAM during the past year,

79% believed the combination was superior to either practice alone.2

Users of complementary and alternative practices are more likely to be

female than male, to be college educated, and to have chronic conditions. The

most common reason for CAM use is to treat musculoskeletal conditions or

other conditions associated with chronic pain. Studies have estimated that one-

third to two-thirds of patients followed in private and university-based

rheumatology practices have used some of form of alternative therapy in the

past year.3 In a cross-sectional survey of patients in an outpatient

rheumatology clinic, about 42% of patients reported using CAM. Acupuncture

and homeopathy were the most common alternative practices. Patients with

fibromyalgia used significantly more CAM therapies per person than patients

with other rheumatologic conditions. Self-perceived efficacy of alternative

therapies was greatest in patients with osteoarthritis (OA) and

spondyloarthropathies, whereas satisfaction was lowest in rheumatoid arthritis

(RA), vasculitis, and connective tissue disorders.4

Because complementary and alternative therapy use is prevalent among

patients with OA, it is important for health care practitioners to have some

knowledge about these therapies and objective evidence of efficacy and safety.

This chapter focuses on the most common and well-studied alternative

practices used to treat OA, including acupuncture, herbal therapies, mind-body

therapies, tai chi, and yoga.

B. Acupuncture

It has been estimated that more than 15 million Americans have used

acupuncture, primarily for pain relief.5 Pain, of course, is one of the most

common symptoms of our patients with OA. Throughout Asia, acupuncture is

often used not only to treat diseases but to maintain health. Acupuncture is

based on the theory that essential life energy (qi), the blood, and essence of

body fluid are fundamental substances in the human body that help sustain

normal vital activities. The qi flows through the body along channels called

meridians, which connect with various tissues and organs. There are more than

300 major acupuncture points that lie along these meridians. Disorders

(including physical and emotional disturbance) can unbalance the energy flow

(qi) in the meridians and connected tissues and organs.

Out-of-balance qi can cause a variety of symptoms and pain.

Stimulation and manipulation of specific points along the meridians are

proposed to restore the flow of qi to optimize health or to relieve pain.6

Acupuncture has evolved over several thousands of years in China. The

earliest major source of acupuncture theory is the Huang Di Nei Jing (Yellow

Emperor’s Inner Classic), dated to the Han dynasty in the second century BC.

It views the human body as a microcosmic reflection of the universe and

considers acupuncture a tool for regulating and maintaining the body’s

harmonious balance.7 Most Americans heard of acupuncture in 1972, when

President Nixon visited China.

In a front-page article in the New York Times, journalist James Reston

described how acupuncture needles alleviated his postoperative pain from an

emergency appendectomy.8 In 1997, a National Institutes of Health (NIH)

panel published its Consensus Development Statement on Acupuncture. They

concluded that acupuncture showed efficacy in alleviating adult post-operative

and chemotherapy nausea and vomiting and in alleviating postoperative dental

pain. Other situations (such as addictions, stroke rehabilitation, headache,

menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, low back pain,

carpal tunnel syndrome, asthma, and OA ) were only considered possible

situations in which acupuncture might be useful as an adjunct treatment,

acceptable alternative, or part of a comprehensive management program. In

the last few years, three large randomized controlled trials (RCTs) studying

the role of acupuncture in knee OA have been published.6

Berman et al. examined whether acupuncture provides greater pain

relief and improved function compared with sham acupuncture or education in

patients with OA of the knee (mean age [SD], 65.5; 8.4 years). Twenty-three

true acupuncture sessions were given over 26 weeks. Controls received six 2-

hour sessions over 12 weeks or 23 sham acupuncture sessions over 26 weeks.

Primary outcomes were patient global assessment, 6-minute walk distance,

and physical health scores of the 360 Item Short-Form Health Survey (SF-36).

Participants in the true acupuncture group experienced greater

improvement in WOMAC function scores than the sham acupuncture group at

8 weeks (mean difference, -0.5 [Cl, -1.2 to 0.2]; p=0.18) or the patient global

assessment (mean difference 0.16 [Cl, -0.02 to 0.34]; p > 0.2). At 26 weeks,

the true acupuncture group experienced significantly greater improvement

than the sham group in the WOMAC function score (mean difference -2.5 [Cl,

-4.7 to -0.4]; p=0.01), WOMAC pain score (mean difference, -0.87 [Cl, -1.58

to -0.16]; p=0.003), and patient global assessment (mean difference 0.26 [Cl,

0.07 to 0.45]; p=0.02). In this study, it seems acupuncture provided

improvement in function and pain relief as an adjunctive therapy for OA of the

knee when compared with sham acupuncture control and education control

groups.

Vas et. Al. analyzed the efficacy of acupuncture as a complementary

therapy to the pharmacologic treatment of OA of the knee with respect to pain

relief, reduction of stiffness, and increased physical function during treatment;

and to changes in the patient’s quality of life. They have done a randomized,

controlled, single blind trial, with blinded evaluation and statistical analysis of

results. Ninety-seven outpatients with OA of the knee were recruited. Patients

were randomly separated into two groups: one receiving acupuncture plus

diclofenac (n=48) and the other placebo acupuncture plus diclofenac (n=49).

The clinical variables examined included intensity of pain as measured

by a visual analogue scale; pain, stiffness, and physical function subscales of

the WOMAC OA index; dosage of diclofenac taken during treatment; and the

profile of quality of life in the chronically ill (PQLC) instrument, evaluated

before and after the treatment. Eighty0eight patients completed the trial. In the

intention-to-treat analysis, the WOMAC index had a greater reduction in the

intervention group than in the control group (mean difference 23.9, 95%

confidence interval 15.0 to 32.8).

The reduction was the greatest in the subscale of functional activity.

The same result was observed in the pain visual analogue scale, with a

reduction of 26.6 (18.5 to 34.8). The PQLC results indicate that acupuncture

treatment produces significant changes in physical capability (p=0.021) and

psychologic functioning (p=0.046). three patients reported bruising after the

acupuncture sessions. This RCT trial demonstrated that acupuncture plus

diclofenac is more effective than placebo acupuncture plus diclofenac for the

symptomatic treatment of OA of the knee. Thus, acupuncture can be a part of a

comprehensive management program for patients with knee OA.

There is another recently published acupuncture study that showed

after 8 weeks of acupuncture treatment pain and joint function were improved

more with acupuncture than with minimal acupuncture or no acupuncture in

patients with OA of the knee. However, this benefit decrease over time.

Patients with chronic OA of the knee (Kellgren grade < or = 2) were randomly

assigned to ], acupuncture (n = 150), minimal acupuncture (superficial

needling at non-acupuncture points; n= 76), or a waiting-list control (n=74).

Specialized physicians in 28 outpatient centers administered acupuncture and

minimal acupuncture in 12 sessions over 8 weeks.

Patients completed standard questionnaires at baseline and after 8

weeks, 26 weeks, and 52 weeks.

The primary outcome was the WOMAC index at the end of week 8

(adjusted for baseline score). All main analyses were by intention to treat. A

total of 294 patients were enrolled, with eight patients lost to follow-up after

randomization but included in the final analysis. The mean baseline-adjusted

WOMAC index at week 8 was 26.9 (SE 1.4) in the acupuncture group, and

49.6 in the waiting-list group (treatment difference of acupuncture versus

minimal acupuncture -8.8 [95% CL -13.5 to -4.2], p=0.0002; acupuncture

versus waiting list -22.7 [27.5 to -17.9], p<0.0001). however, after 52 weeks

the difference between the acupuncture and minimal acupuncture groups was

no longer significant (p=0.08).6

In these three RCT trials, acupuncture consistently demonstrated

effectiveness in function improvement and pain relief for patients with knee

OA. Acupuncture can also be used with non-steroidal anti-inflammatory drugs

(NSAIDs) as an adjunctive thereapy for pain relief with minimal side effects.

Further studies are needed to study the effective duration of acupuncture.

Optimal acupuncture protocols may still need to be established in the

management of the knee OA. Chen, Farrar, and the authors at the University

of Pennsylvania have been conducting an NIH-sponsored sham-needle

controlled acupuncture study to evaluate combining acupuncture with physical

therapy in knee OA. In the study, we have tested a newly developed method of

sham needling in which the needle is placed in the true acupuncture point but

does not penetrate the skin. The appearences of true and sham needles are

indistinguishable by patients.

Hip and knee are the two common joints involved in OA. Two studies

have examined the role of acupuncture in managing hip OA. Stener-Victorin

have done a study to evaluate the therapic effect of slectro-acupuncture (EA)

and hydrotherapy, both in combination with patient education or woth patient

education alone, in the treatment of OA in the hip. Forty-five patients aged 42

to 86 years with radiographic changes consistent with OA in the hip, pain

related to motion, pain on load, and aching during day or night were chosen.

They were randomly allocated to EA, hydrotherapy, both in combination with

patient education or patient education alone.

Outcome measures were the disability rating index (DRI), global self-

rating index (GSI), and visual analogue scale (VAS). Assesments were done

before the intervention and immediately after the last treatment, as well as 1,3

and 6 months after the last treatment. It was found that pain related to motion

and pain on load was for the hydrotherapy group reduced for as long as 3

months after the last treatment and for the EA group as long as 6 months.

Aching during the day was significantly improved in both EA and

hydrotherapy groups. Aching during the night was reduced in the

hydrotherapy group for as long as 3 months after the last treatment and in the

EA group for as long as 6 months.

C. Herbal Therapies

According to the 2002 National Health Interview Survey, about 19%

of adults in US used some form of natural product-including herbal medicines,

food products such as garlic, and animal based products such as glucosamine

—during the 12 months surveyed. The natural products included are

Echinacea, ginseng, ginkgo biloba, garlic supplements, glucosamine, fish oil,

and ginger supplements.1

The most commonly cited reasons for using herbal medicines include

overall health improvement and chronic conditions such as headache, memory

loss, arthtritis, and fatigue. People typically use these therapies as an adjunct to

allopathic medical therapies.

Allopathic health care practitioners are frequently unaware of the

occurent use of prescription and herbal medicines by their patients, it has been

estimated from a national survey that about 60 to 70 % of patients do not

disclose the use of a complementary and alternative therapy to their allopathic

physician. The main reasons reported for not disclosing this information are

that patient thought it was not important or that the doctor did not ask.2 People

often perceive herbal therapies as safe because they are “natural” and because

the person does not consider them to be drugs.

Many people who suffer from OA turn to herbal products for relief of

symptoms. They are usually motivated by curiosity, frustration with the

inability of conventional medicine to provide a cure for the condition or to

fully relieve symptoms or lack of tolerance to the side effects of conventional

pharmaceutical medicines used to treat OA.3 The herbal products are often

used without knowledge of their efficacy, potential for interactions with other

medicines, and side effects. Due to rapid rise in use by patients with OA

during the past two decades, the medical community has been increasingly

concerned with the lack of objective evidence of efficacy and safety. As a

result, many RDTs have been conducted investigating the use of herbs and

nutritional supplements in the treatment of OA.7

D. Mind-Body Therapist

Meditation, relaxation, biofeedback, cognitive-behavioural theraphy,

hypnosis, and guided imagery are practices referred to as mind-body

theraphies. According to the NIH, mind-body therapies are “interventions that

focus on the interactions among brain, mind, body and behaviour, and the

powerful ways in which emotional, mental, social, spiritual, and behavioural

factors can directly affect health. The therapies are based on the principal

belief in the mind’s ability to affect how the body functions. The techniques of

mind-body therapies are used to relieve stress, to develop coping skills, to

relax the mind and body and to facilitate cognitive restructuring.

A few studies have investigated the use of multimodal patient

education therapies in the treatment of RA, OA, and fibromyalgia. Findings

from a prospective study of participants in the Arthritis Self Management

program conducted in the early 1980s suggested that a community-based

program of education, cognitive restructuring, relaxation, and exercise may

help reduce pain and disability in patients with arthritis. An analysis of 500

patients, which included 340 patients with OA, showed that pain reductions

after maintained after 4 years of follow-up. In addition, health care visits for

arthritis decreased by 40%.8

In a meta analysis of 19 controlled trials of patient educational

interventions, which included realaxation techniques, the average effect size of

pain reduction in patients with OA and RA was 0.17 with the effect being

greater in RA compared to OA. Most of these patients were using NSAIDs

throughout the trials. The authors also compared results of this meta-analysis

to a meta-analysis of placebo controlled trials of NSAID treatments. They

report that the parient education and relaxation teachniques may provide about

20 to 30 % additional benefit in pain relief to that achieved from NSAIDs.

Currently, mind-body therapies have not been directly compared to NSAIDs

or other pharmaceutical drugs in an RCT.4

E. Tai Chi

Tai chi is an ancient Chinese martial art and exercise that involves

slow repetitive movements, changes in the center of balance and meditation.

The basic movements of each style include weight shifting between the right

and left legs, knee flexion and extension, flexion and rotation of head and

trunk, and asymmetrical arm and leg movements.

Exercise and physical therapy are important parts of a multidisciplinary

approach to the management of OA. Evidence from RCTs has suggested that

aerobic exercise, strength training, and flexibility can have beneficial effects

for patients with OA.7 By strengthening the muscles, providing joint stability,

improving joint circulation, and assisting in weight loss, regular exercise can

help reduce arthritic pain and improve functional status. Current guidelines

from the American College of Rheumatology recommend that aerobic

exercise, range of motion, and quadriceps resistance patients with OA of the

hip should be “to preserve at least 30 degrees of flexion and full extension of

the hip and to strengthen the hip abductors and extensors.4-6

However, the exact mechanism by which tai chi may reduce symptoms

and improve function in patients with OA is not clear. Current theories

speculate that tai chi allows patients to exercise, increase flexibility and

strengthen their joints while simultaneously increasing awareness of posture

and eight bearing during the exercise. By improving balance and gait, leading

to a decrease in the risk of falls, tai chi may prevent further injury to joints. In

addition, evidence from a meta-analysis suggests that this form of exercise

improves aerobic capacity both in healthy subjects and patients with chronic

diseases. Further work needs to be done to evaluate potential mechanism of

Tai Chi.

F. Yoga

Although there are many types of yogic disciplines, Hatha yoga is well

known and has bee subjected to the most clinical research. It was initially

developed as the a means of meditating or of calming the mind, given the

focus on activity ad exercise, it is currently mainly practiced for health and

vitality in Western countries. Multiple styles reflecting a different approach to

the asanas1 have arisen within Hatha yoga. Iyengar yoga is a particular Hatha

style that has become widely popular in the US. It is unique in that it is

designed to be accessible to everyone. The use of props (such as chairs,

blanket, pillow and blocks) allows the practitioners to assume precise and

appropriate positioning without straining the joints or muscles.

Multiple research studies have shown that Hatha yoga can improve

muscle strength and flexibility.3-4 In addition, there has been some evidence to

suggest that yoga may help control blood pressure, respiration, heart rate, and

metabolic rate. In that the static postures of yoga emphasize stretching and

improve strength and flexibility, it has been considered an alternative form of

exercise to be used in the treatment of OA. Similar to that of OA has received

little objective evaluation. Only two prospective studies have been completed,

which respectively investigated the use of Hatha yoga as a treatment for OA of

the hand and knee.5

Although the mechanism responsible for the possible benefits of yoga

for symptoms of OA are currently unknown, some hypotheses have been

proposed. For instance, yogic postures that emphasize knee extension and

flexion may help reduce symptoms of OA of the knee by strengthening the

quadriceps. The use of certain props, such as ropes and bands to stretch the

knee joint may also play a role. Other mechanisms may include improvements

in cardiovascular fitness, flexibility, and awareness of body positioning at rest

and during exercise.

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conventional therapies among adults who use both: Results from a natinal

survey. Ann Intern Med 2001: 135:344-51

3. Rao JK, Kroenke K, Mihaliak KA, Grambow SC, Weinberger M.

Rheumatology patients’ use of complementary therapies: Results from a one-

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Perceived afficacy among patients of various methods of complementary

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Berkeley, California: Medical Acupuncture Publishers 1995.

8. Reston J. Now about my operation in Peking. The New York Tomes, 26 July

1971: 1,6.