Complementary and Alternative Medicine and Osteoarthritis

Symptomatic osteoarthritis (OA) is the most frequent cause of dependency in lower limb tasks with substantial physical and psychosocial disability, reduced quality of life and substantial health care costs.1

Currently, there are no effective disease-modifying remedies for OA. Complementary and alternative medicine therapies have been heavily advertised and increasing numbers of chronic pain patients report utilizing alternative therapies.

Clinical trials and observational studies have provided encouraging evidence that acupuncture and mind-body therapy have benefits for patients with arthritis. This section will review the current body of knowledge on the therapeutic benefits of these types of complementary and alternative medicine on pain and symptom relief in patients with OA to better inform clinical decision-making.

Acupuncture for Osteoarthritis  
Acupuncture, originating in China more than 3,000 years ago, is one of the most popular sensory stimulation therapies. It is an ancient technique of inserting and manipulating fine needles to stimulate specific anatomic points, also known as acupuncture points or meridian points.3

Numerous randomized controlled trials and more than 11 systematic reviews and meta-analyses have examined the clinical efficacy of acupuncture in patients with OA. Evidence from these trials indicates that acupuncture does have some efficacy for relief of pain. For example, an early large, high-quality trial concluded that acupuncture significantly improved pain and function when compared with sham acupuncture or patient education.4 A multicenter randomized controlled trial in Germany found acupuncture plus routine care was associated with marked clinical improvement in patients with chronic OA-associated pain of both the knee and hip.5 After the above study, another large German trial showed that both traditional Chinese acupuncture and sham acupuncture (needling at specified non-acupuncture points) improved pain and functionality in patients with knee OA more than conservative therapy. The effect was assessed by success rates based on WOMAC scores. However, no difference was observed between traditional Chinese acupuncture and sham acupuncture.Similarly, a very recent trial found that traditional acupuncture was not superior to sham acupuncture, but the providers’ style affected both pain reduction and satisfaction with treatment. This finding suggests that analgesic benefits of acupuncture may be partially mediated by the acupuncturists’ behavior and may be enhanced by expectations.7

One systematic review concluded that acupuncture is significantly superior to sham acupuncture in improving pain and function in patients with OA.8 Similarly, the latest Cochrane review with 16 randomized trials indicated that when compared with waiting-list control, acupuncture showed statistically and clinically significant short-term improvements in pain and function for OA. In comparison with sham controls, acupuncture provided small, statistically significant improvements that are of questionable clinical importance.9 In contrast, a meta-analysis observed that sham-controlled trials demonstrated clinically irrelevant short-term benefits of acupuncture, while waiting list-controlled trials had clinically relevant short-term benefits in pain and function, suggesting that placebo or expectation effects may be involved.10  Further work is needed to understand the mechanisms by which acupuncture can improve clinical symptoms.

Overall, there is evidence demonstrating that acupuncture does have short-term benefits for both pain and function in patients with symptomatic OA.

Tai Chi Mind-body Therapy for Osteoarthritis 
Tai Chi is a traditional Chinese mind-body exercise that has recently grown in popularity in the United States. In the past two decades, literature has consistently recognized the potential therapeutic benefits of Tai Chi for a variety of chronic conditions.11 As a complementary mind-body approach, Tai Chi may be an especially applicable treatment for older adults with OA. The physical component provides exercise consistent with current recommendations for OA (muscle strength, balance, flexibility, and aerobic cardiovascular exercise) and the mental component could address the chronic pain state through effects on psychological well-being, life satisfaction, and perceptions of health. These effects may reduce pain, improve function, and slow disease progression and disability associated with OA.

Several randomized, controlled studies have examined the effects of Tai Chi for patients with both knee and hip OA. Hartman and colleagues were among the first to conduct a prospective, randomized, controlled clinical trial to test the efficacy of 12 weeks of Tai Chi for patients with OA. 12 A total of 35 community-dwelling participants were randomly assigned to receive either two one-hour Tai Chi sessions per week for 12 weeks or to usual care. The results of Tai Chi training significantly improved arthritis symptoms, self-efficacy, level of tension, and satisfaction with general health status. 12 In another study, Song and colleagues reported that among 72 patients with knee OA, patients receiving 12 weeks of Tai Chi perceived significantly less pain and stiffness than patients receiving routine treatment. In addition, physical functioning, balance and abdominal muscle strength were significantly improved with the Tai Chi group. 13

In a three-armed, randomized, trial of 152 older patients with chronic symptomatic hip and knee OA, Fransen et al found that, when compared with a waiting list control group, both 12-week Tai Chi classes and hydrotherapy classes provided large and sustained improvements in physical function. All significant improvements were sustained at 24 weeks.14 A six-week group Tai Chi program, followed by six weeks of home Tai Chi training, showed significant improvement in knee pain and physical function compared with an attention control in 41 elderly patients with knee OA. However, the benefits for knee pain scores were not sustained throughout the follow-up detraining period (weeks 13-18).15  A single-blind, randomized trial of 40 patients showed that patients randomized to 12 weeks of Tai Chi exhibited significantly greater improvements in pain, physical function, depression, self-efficacy and health status compared with the attention controls. Patients who continued Tai Chi practice after 12 weeks reported durable benefits in pain and function.16  A recent randomized controlled trial of 82 women with OA suggested that six months of Tai Chi exercise significantly improved knee extensor endurance and bone mineral density and decreased patients’ fear of falling, compared with a self-help education program.17  Similar positive findings of short- and long-term Tai Chi have been well-documented on balance control, flexibility, muscular strength and endurance in the elderly, which have important benefits for patients with symptomatic OA.

Overall, there is evidence suggesting that Tai Chi training may provide an ideal form of exercise for older individuals with symptomatic OA, suffering from pain and poor function.

In summary, the pathophysiological basis of OA is complex and multifaceted and symptomatic OA is heterogeneous. Emerging evidence from clinical trials support that both acupuncture and Tai Chi mind-body therapies may offer effective treatments f
or OA. Integrative approaches combine the best of conventional medicine and the wisdom of complementary and alternative medicine. These modalities may lead to the development of better disease modifying strategies that could improve symptoms and decrease progression of OA disease.
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