Upload
panji-aryo
View
87
Download
0
Tags:
Embed Size (px)
Citation preview
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.
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 one-
year 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.