REFERAT COMPLEMENTARY 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-ofpocket. 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 onethird 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 Emperors 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 bodys 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 2hour 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 patients 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 selfrating 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 minds 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.

References: 1. Barnes PM, Powell-Griner E, McFann K, Nahin RL. Complementary and alternative medicine use among adults: United States, 2002. Adv Data 2004; 343: 1-19. 2. Eisenberg DM, Kessler RC, Van Rompay MI, Kaptchuk TJ, Wilkey SA, Appel S, et al. Perceptions about complementary therapies relative to 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 oneyear longitudinal study. Arthritis Rheum 2003; 49:619025. 4. Breuer GS, Orbach H, Elkayam O, Berkun Y, Paran D, Mates M, et al. Perceived afficacy among patients of various methods of complementary alternative medicine for rheumatologic diseases Clin Exp Rheumatol 2005;23:693-96. 5. Eisenberg DM, Kessler RC, Foster C, et al. Unconventinal medicine in the United States: Prevalence, costs, and patterns of use N Engl J Med 1993;328:246. 6. Witt C, Brinkhaus B, Jena S. Linde K, STreng A, Wagenpfeil S, et al. Acupuncture in patients with osteoarthritis of the knee: Randomises trial.

Lancet 2005;366:100-01. 7. Helms JM. Acupuncture Energetic: A Clinical Approach for Physicians. Berkeley, California: Medical Acupuncture Publishers 1995. 8. Reston J. Now about my operation in Peking. The New York Tomes, 26 July 1971: 1,6.