topical NSAIDs improve pain and function only over the short term .
• TENS , immunomodulators , glucosamine , and biologic injection therapies should be avoided in OA .
• Cognitive behaviour therapy and balance training appear to improve pain in OA ; acupuncture and thermal interventions slightly improve pain and function .
Other recent clinical practice guidelines for the management of osteoarthritis of the hand , knee and hip were published in 2019 by the American College of Rheumatology / Arthritis Foundation . Their recommendations are shown in Table 1 .
Natural medicine in clinical practice guidelines for osteoarthritis
As is shown in Table 1 , the use of natural medicine modalities like acupuncture , massage and joint manipulation is also included in guidelines where sufficient evidence is available for assessment . Acupuncture is conditionally recommended for knee and hip osteoarthritis , according to the Royal Australian College of General Practitioners ’ Guideline for the management of knee and hip osteoarthritis 8 and for osteoarthritis of the hand . 19 Research into the effectiveness of massage on osteoarthritis of the hand , knee and hip , on the other hand , is limited by the risk of bias from small trials . Kolasinski et al . 19 conditionally recommended against massage therapy for patients with knee and / or hip osteoarthritis for this reason , however the voting panel acknowledged that some studies have shown symptom relief .
Table 2 illustrates the recommendations for a number of natural medicine interventions that appear in the guidelines published by the RACGP , 13 the American College of Rheumatology , 9 the Osteoarthritis Research Society International 10 and the American Academy of Orthopaedic Surgeons . 11 It is important to remember that guidelines can only be developed from existing evidence and it is possible that natural medicine modalities would be more fully represented in clinical guidelines for osteoarthritis if strong supporting evidence were available . There is an urgent need for further research in natural medicine to provide evidence to inform clinical practice .
Evidence-informed practice
Chronic health conditions , like osteoarthritis , are common presentations to natural medicine clinics . A study in 2011 reported that approximately 24 % ( 1.3 million ) Australian adults with a chronic condition regularly use complementary and alternative medicine ( CAM ) to manage their condition . Of those with chronic health conditions , people with arthritis or osteoporosis
Natural medicine intervention |
Recommended ( benefits outweigh harms ) |
Conditionally recommended ( uncertainty about benefits vs harms ) Trial for short term ; stop if ineffective |
Conditionally recommended against |
Recommended against ( harms outweigh benefits ) |
No recommendation ( insufficient evidence ) |
Acupuncture AAOS ( knee ) RACGP , OARSI Avocado / soy bean unsaponifiables Capsaicin for hip OA OARSI ACR ( knee OA ) RACGP Cold therapy Devil ’ s claw ( Harpagophytum p ) Fish oil Ginger
Glucosamine and chondroitin nutraceuticals
OARSI
OARSI
Heat packs or hot water bot-tles RACGP OARSI
Indian frankincense ( Boswellia serrata extract )
Kinesio-taping Manual therapy + exercise ( knee OA ) AAOS , RACGP ACR Massage AAOS ( knee OA ), RACGP ACR
Non-steroidal anti-inflammatory creams applied locally
Pine bark extract Turmeric Vitamin D ACR RACGP Yoga therapy
ACR ( Note : ACR = American College of Rheumatology ; OARSI = Osteoarthritis Research Society International ; RACGP = Royal Australian College of General Practitioners )
RACGP
ACR
RACGP
RACGP
RACGP
OARSI
RACGP
RACGP RACGP
74 | vol28 | no2 | JATMS