Evidence for the Efficacy of Complementary and Alternative Medicines in the Management of Osteoarthritis

Vijitha De Silva; Ashraf El-Metwally; Edzard Ernst; George Lewith; Gary J. Macfarlane


Rheumatology. 2011;50(5):911-920. 

In This Article

Abstract and Introduction


Objectives. To critically evaluate the evidence regarding complementary and alternative medicine (CAM) taken orally or applied topically (excluding glucosamine and chondroitin) in the treatment of OA.
Methods. Randomized clinical trials of OA using CAMs, in comparison with other treatments or placebo, published in English up to January 2009, were eligible for inclusion. They were identified using systematic searches of bibliographic databases and manual searching of reference lists. Information was extracted on outcomes, and statistical significance, in comparison with alternative treatment of placebo, and side effects were reported. The methodological quality of the primary studies was determined.
Results. The present review found consistent evidence that capsaicin gel and S-adenosyl methionine were effective in the management of OA. There was also some consistency to the evidence that Indian Frankincense, methylsulphonylmethane and rose hip may be effective. For other substances with promising evidence, the evidence base was either insufficiently large or the evidence base was inconsistent. Most of the CAM compounds studied were free of major adverse effects.
Conclusion. The major limitation in reviewing the evidence is the paucity of randomized controlled trials in the area: widening the evidence base, particularly for those compounds for which there is promising evidence, should be a priority for both researchers and funders.


OA is a degenerative and progressive disease mainly affecting the joint cartilage and the subchondral bone. Prevalence increases with age,[1,2] and it is estimated that 18% of females and 9.6% of males >60 years of age have symptomatic OA.[3] Almost 1 in 10 people aged 35–75 years in the UK and over 30 million people in the USA are diagnosed with this disease.[4] Knee and hip joints are the commonest sites affected among the US and Europe populations aged >45 years.[5] Economic costs associated with OA are high. In the USA, it was estimated as $15.5 billion in 1994, with most of the cost due to work loss.[6]

A large number of different therapies have been described in the medical literature in relation to the treatment of OA.[7] According to Osteoarthritis Research International (OARSI), 'treatment of OA is directed towards reducing joint pain and stiffness, maintaining and improving joint mobility, reducing physical disability and handicap, improving health related quality of life, limiting the progression of joint damage and educating patients about the nature of the disorder and its management'.[8] In 2005, an OARSI international committee of experts recommended using combinations of non-pharmacological and pharmacological modalities to achieve optimal management. Non-pharmacological modalities include education about the objectives of treatment and changes in lifestyle, such as exercise and weight reduction.[8]

However, due to the chronic nature of the disease and its effects on quality of life, many patients with OA commonly try alternative methods of treatment.[9] These diverse treatment methods are commonly categorized as complementary and alternative medicines (CAMs). The World Health Organization has defined CAM as 'A broad set of healthcare practices that are not part of the country's own tradition and are not integrated into the dominant healthcare system'.[10] It has been reported that 46% of people in the UK use CAM during their lifetime and ~10% of the population will visit a complementary medical practitioner each year, and it is estimated that >£450 million is spent on CAM in each year in England.[11,12] Further, a study of 1119 persons living in the community in the UK with chronic hip or knee pain (much of which would be related to OA) enquired about health-seeking behaviour in the past 12 months: 9% had seen an alternative therapy provider. Predictors of seeking help from an alternative therapy provider were: female gender, being overweight, reporting comorbidities, high social class, not living in an urban area and lower levels of depression/anxiety and pain severity and a lack of mobility problems.[13] Rheumatological problems are among the commonest disease conditions encountered by CAM practitioners with around four in five of their consultations related to rheumatological conditions.[14]

Given the popularity of CAMs, it is important that patients and practitioners have accessible and clear evaluation of the efficacy and safety of these treatments. The purpose of the review is to produce such evidence regarding CAMs taken orally or applied locally for the treatment of OA. It produces the detailed scientific methods behind the patient- and practitioner-centred leaflet recently published by the Arthritis Research Campaign (www.arthritisresearch.org). We excluded consideration of glucosamine and chondroitin since these have been extensively reviewed in other publications.[15] We have ensured, where possible, that we report the conduct and results of the review according to the recently published guidelines on Transparent Reporting of Systematic Reviews and Meta-Analyses (PRISMA) (http://www.prisma-statement.org).


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