Use of non-pharmacological therapies among patients with osteoarthritis

(Aging 15: 419-425, 2003),©2003, Editrice Kurtis

Aging Clin Exp Res, Vol. 15, No. 5 419

ABSTRACT. Background and aims: Non-pharma-cological therapies are an important component oftreatment for osteoarthritis (OA), but they may be un-der-used. This study examined the prevalence ofself-reported use of common non-pharmacologicaltherapies, as well as patient and physician-related pre-dictors of use. Methods: Subjects included 205 vet-erans who completed a survey regarding OA symp-toms and treatments. Analyses examined the preva-lence of use of three specific non-pharmacologicaltherapies: exercise, physical therapy (PT), and di-etary/herbal supplements. We also examined whetherpatient variables (demographics, clinical characteris-tics, and perceived helpfulness of non-pharmacolog-ical therapies) and physician characteristics (age,gender, race, and recommendation of non-pharma-cological therapies) were associated with use of eachtherapy. Results: Forty-six percent of subjects re-ported current use of exercise, 11% reported usingPT, and 12%, dietary/herbal supplements. Patient de-mographic and clinical characteristics were generallypoor predictors of use of non-pharmacological ther-apy. However, females were more likely to report ex-ercising than males (p<0.05), and patients withgreater disease severity were more likely to report cur-rent use of PT (p<0.001). Patients’ perceived help-fulness of each therapy significantly predicted use(p<0.05). Physician demographic characteristics werenot strong predictors of patients’ use of therapy,but physician recommendation for exercise and PTpredicted patients’ use (p≤0.05). Conclusions:Among this sample of veterans with OA, there wasrelatively low use of exercise, PT, and dietary/herbalsupplements. Patients’ perceptions of treatment help-fulness and physician recommendations strongly pre-dicted use. These results signal the importance of in-

terventions aimed at educating both patients andphysicians about these therapies. (Aging Clin Exp Res 2003; 15: 419-425)©2003, Editrice Kurtis

INTRODUCTIONOsteoarthritis (OA) is the most common chronic disease

and the leading cause of disability among older adults (1,2). Because of the forecast growth in the older adult pop-ulation over the next few decades, the demand for OA-re-lated health care is expected to rise substantially (2-6). Themost common treatment for OA is pharmacotherapy.Although analgesic and anti-inflammatory drugs play an im-portant role in OA treatment, they are associated with ad-verse side-effects such as gastrointestinal (GI) bleeding(7). Furthermore, in a time of increasing medical careexpenditure and budget cuts, medication costs can put agreat strain on both patients and health care systems.

Non-pharmacological approaches to OA treatmenthave received increasing attention and research, and someof them may be an essential part of managing the growingepidemic of OA. Some of these non-pharmacologicaltherapies include exercise, physical therapy (PT), occupa-tional therapy, weight loss, prayer, herbs, dietary supple-ments, heat, massage, and walking aids (8-12). In thisstudy, we focus on three of the most common non-phar-macological therapies used for OA: exercise, PT, and di-etary/herbal supplements. There are several importantadvantages to these therapies. First, non-pharmacologicalapproaches can be cheaper than medications. Second,these methods can give patients a sense of control and own-ership over their health, which may be critical in chronicconditions such as OA. Third, studies have shown that somenon-pharmacological therapies can be as effective in de-creasing pain as NSAIDs (13). Several clinical trials havesupported the efficacy of both aerobic and strength training

Aging Clinical and Experimental Research

Use of non-pharmacological therapies among patientswith osteoarthritisJason B. Hsieh1 and Kelli L. Dominick1,2,3

1Health Services Research and Development Service, Durham Veterans Affairs Medical Center,2Department of Medicine, Division of General Internal Medicine, Duke University Medical Center,3Center for Aging and Human Development, Duke University, Durham, NC, USA

Key words: Dietary supplements, exercise, osteoarthritis, physical therapy.Correspondence: K.L. Dominick, PhD, Health Services Research and Development (152), VA Medical Center, 508 Fulton Street, Durham,NC 27705, USA.E-mail: [email protected] Received March 1, 2003; accepted in revised form July 2, 2003.

exercises for the treatment of OA (14-16), and exercise isnow endorsed by the American College of Rheumatologyas a first-line treatment for OA (17). PT is one of themost long-standing non-pharmacological therapies forOA, and may involve multiple modalities and treatments(e.g., heat, joint mobilization, aquatic therapy). PT is also re-garded as an integral component of OA treatment (17). Di-etary supplements and herbs are a somewhat newer non-pharmacological strategy for treating OA. Three specific di-etary supplements that have demonstrated some efficacy inclinical trials include glucosamine, chondroitin, and s-adenosylmethionine (18-20).

Despite evidence supporting the efficacy of somenon-pharmacological therapies, literature suggests thatthese strategies are under-utilized (8, 11). It is therefore im-portant to understand factors that may be related to pa-tients’ use of these treatments. Previous studies haveshown that patients with greater disease severity aremore likely to improve their self-care and to use com-plementary and alternative therapies (9, 10, 12). How-ever, studies examining relationships of demographiccharacteristics in using these therapies have not been con-sistent. For example, some data indicate that white indi-viduals with arthritis may be more likely to exercise thanAfrican Americans (10), but other research has found nodifference between these two groups (21). Other recent re-search indicates that African Americans report seekingcare from a physical therapist more often than whites (22).

It is also important to understand whether physician-re-lated factors are associated with patients’ use of non-pharmacological therapies. Other studies have shownthat practice patterns differ according to physicians’ de-mographic characteristics, as well as physician specialty(23, 24). Very little research has examined relationships be-tween physician characteristics and non-pharmacologi-cal therapy use among patients with OA. However, onestudy found that younger physicians were more likely toprescribe exercise than their older counterparts (25), andanother observed that rheumatologists are more likelythan general practitioners to instruct patients regardingstrengthening exercises, joint protection strategies, and useof heat (23).

Although prior research has provided some insight re-garding patterns of use of non-pharmacological therapy,there are several limitations to previous studies. First, fewstudies have examined predictors of exercise and physicaltherapy, which are two key non-pharmacological treat-ments for OA. Second, most studies have not simultane-ously examined whether the demographic and clinicalcharacteristics of patients with OA are associated with useof specific types of non-pharmacological therapy. Third,most studies have not examined whether physician char-acteristics are related to use of these treatments. Thepurpose of the present study was to examine the preva-lence of self-reported use of exercise, physical therapy, di-

etary/herbal supplements, and “other” non-pharmaco-logical therapies in a group of veterans with OA. In addi-tion, we examined the relationships of both patient andphysician characteristics to use of each specific therapy.

METHODSStudy sampleParticipants were patients of the Durham VA Medical

Center. Potential participants were initially identified onthe basis of an ICD-9 code indicating OA (715), using VAelectronic medical records. We also identified individualswith an upcoming clinic appointment, so that the in-person survey could be conducted in conjunction with aregularly scheduled clinic visit. This was done becausemany VA patients travel long distances for their clinic ap-pointments. Patients were recruited by telephone. Among359 veterans who were contacted, 32 indicated theydid not have OA and 29 stated their upcoming VA ap-pointment had been cancelled or rescheduled. Of theremaining 298 eligible patients, 25 refused participa-tion. Another 68 individuals initially agreed to participatebut then did not show up for the interview. This is prob-ably due to appointment rescheduling. The final studysample included 205 veterans.

Measures Participants were asked to complete a survey including

questions about arthritis symptoms, current use of arthritistreatments, perceptions about the helpfulness of thesetreatments, and physician characteristics. These analyses fo-cused on responses to four questions related to non-phar-macological treatments. Specifically, participants wereasked to indicate whether they currently used the following:home exercises, seeing a physical therapist, dietary sup-plements (such as Nutrajoint or Glucosamine) or herbal ther-apies, and “other” non-pharmacological therapies. If par-ticipants indicated “other”, they were asked to describe thetype of therapy used. Because of the small number of“other” responses, and the varied types of responses, wechose to focus our analyses on the first three discrete cat-egories. However, we report the proportion of individualswho indicated using some “other” therapy, and we listgeneral categories of “other” therapies reported.

We examined the relationships of the following patient-related variables to self-reported use of each type of ther-apy: age, gender, race (African American vs Caucasian),education level, Western Ontario McMaster Universities Os-teoarthritis Index (WOMAC), number of joints affected byOA, number of years with OA symptoms, and whether thepatient believed the specific type of therapy was helpful.Education was categorized as those who had some collegeeducation vs those with less than college education. TheWOMAC is a validated and reliable scale (Chronbach’s al-pha ≥0.80), designed to assess pain and function in OA(26, 27). Scores range from 0 (no pain or disability) to 96

J.B. Hsieh and K.L. Dominick

420 Aging Clin Exp Res, Vol. 15, No. 5


(extreme pain or disability). With respect to the helpfulnessof therapies, participants were asked to indicate whetherthey thought each was “not at all helpful”, “somewhathelpful”, or “very helpful”. For these analyses, we com-bined “somewhat” or “very helpful” and compared thisgroup with those who indicated “not at all helpful”. Thiscategorization was chosen for ease of analysis and inter-pretation of results. We also assessed whether physicianage, gender, and race (reported by the patient) were relatedto patients’ use of each therapy. Physician age was broad-ly categorized as younger than 50 vs 50 or older. Physicianrace was categorized as Caucasian vs Other. In addition,we assessed whether physician recommendation for ex-ercise and PT predicted use of these specific therapies. Da-ta to examine physician recommendation for dietary/herbalsupplements were not available.

Statistical analysisChi-square tests were used to examine relationships of

all categorical variables to patients’ reports of using ex-ercise, physical therapy, or dietary/herbal supplements.T-tests were used to examine relationships of each con-tinuous variable to use of each therapy. All statisticalanalyses were performed using SAS PC, Version 8 (SASInc., Cary, NC).

RESULTS The study sample included 205 veterans with OA.

Demographic and clinical characteristics of the sample arepresented in Table 1. There was a fairly high level of dis-ease severity in this sample. The average number ofjoints affected was 6.1 and the average duration of arthri-tis was 19 years. The average disease severity score, asmeasured by WOMAC, was 50. Individuals with a WOM-AC score ≥39 are often considered candidates for joint re-placement surgery.

Approximately 46% of patients reported current useof exercise, 11% were using PT, 12% dietary/herbalsupplements, and 6% other non-pharmacological ther-apies. The latter included chiropractics (N=1), heat/cold(N=3), stress management (N=1), and home TENSunits (N=3).

Exercise The only demographic variable significantly associated

with current use of exercise was gender (Table 2). Ofthose who reported current use of exercise, 14% were fe-male, while only 5% of those not reporting exercisewere female (p=0.018). African Americans and those whodid not attend college tended to report use of exercise lessfrequently, although these differences were not statisticallysignificant. None of the OA-related variables had signifi-cant associations with current use of exercise. Among sub-

Non-pharmacological therapies and osteoarthritis



Table 1 - Characteristics of sample.

Demographic characteristicsFemale, % 8.7African American, % 30.2Age, mean (SD) 63.9 (11.2)Some college education, % 54.9Low incomea, % 37.8Workingb, % 17.8Married or living with partner, % 65.7OA-related characteristicsNumber of joints affected, mean (SD) 6.1 (3.7)WOMAC 50.3 (17.7)Years with arthritis 19.0 (13.0)Physician characteristicsFemale physician, % 37.8Physician age <50, % 83.7Non-white physician, % 29.1

aDefined as “You have money to pay the bills, but only because you have tocut back on things,” or “You are having difficulty paying the bills, no matterwhat you do.” bCompared with being retired, disabled, or unemployed.

Table 2 - Relationships of patient and physician characteristics to self-reported exercise.

Yes No p-value(Total N=94) (Total N=112)

Demographic characteristicsFemale, N (%) 13 (13.8) 5 (4.5) 0.018African American, N (%) 24 (26.1) 36 (33.6) 0.247Age, mean (SD) 64.6 (11.2) 63.2 (11.2) 0.385Some college, N (%) 56 (59.6) 57 (50.9) 0.212OA-related characteristicsNumber of joints, mean (SD) 6.4 (4.1) 5.8 (3.4) 0.244WOMAC, mean (SD) 48.9 (17.6) 51.5 (17.7) 0.298Years with arthritis, mean (SD) 20.5 (13.6) 17.8 (12.5) 0.143Exercise helpful, N (%) 66 (86.8) 43 (71.7) 0.028Physician characteristicsFemale physician, N (%) 25 (32.1) 43 (42.2) 0.166Physician age <50, N (%) 59 (80.8) 74 (86.1) 0.375Non-white physician, N (%) 26 (27.7) 34 (30.4) 0.671Physician recommendation for exercise, N (%) 52 (61.9) 46 (47.4) 0.051

jects who reported exercising, 87% said it was eithersomewhat helpful or very helpful, while 72% who werenot currently using exercise said it was helpful (p=0.028).Patients who had doctors who were female and youngertended to report less current use of exercise, although dif-ferences did not reach statistical significance. Amongthose who reported exercise, 62% reported a physi-cian’s recommendation for it, compared with 42% whodid not currently exercise (p=0.051).

Physical therapyNo demographic variables were significantly related to cur-

rent use of PT (Table 3). However, the relationship with ageapproached statistical significance. Of those who reportedcurrent use of PT, the mean age was 59, while of those whoreported no current use of PT, the mean age was 64(p=0.053). African Americans and those who had attendedsome college tended to be more likely to use PT, but thesedifferences were not statistically significant.

Individuals who reported current use of PT had higherWOMAC scores (p<0.001), indicating greater diseaseseverity. Among subjects who reported using PT, 96% be-lieved that PT was either somewhat helpful or very helpful,while 71% who were not currently using PT said it washelpful (p=0.016). Patients with older physicians also tend-ed to report current PT use (p=0.058). Among patients cur-rently using PT, 77% reported a physician referral, com-pared with 34% of those not using PT (p<0.001).

Dietary/herbal supplementsNone of the demographic or clinical variables had sig-

nificant associations with current use of dietary/herbalsupplements (Table 4). However, females and thosewho had attended at least some college tended to bemore likely to report use of dietary/herbal supplements.Among subjects who reported currently using them,82% believed they were either somewhat helpful orvery helpful, while only 38% who were not currently us-




Table 3 - Relationships of patient and physician characteristics to self-reported physical therapy.


Demographic characteristicsFemale, N (%) 3 (13.0) 15 (8.2) 0.443African American, N (%) 8 (36.4) 52 (29.6) 0.512Age, mean (SD) 59.4 (10.5) 64.3 (11.1) 0.053Some college, N (%) 14 (60.9) 98 (53.9) 0.524OA-related characteristicsNumber of joints, mean (SD) 6.7 (4.1) 6.0 (3.7) 0.394WOMAC, mean (SD) 61.8 (15.8) 48.8 (17.5) <0.001Years with arthritis, mean (SD) 22.1 (12.1) 18.5 (13.1) 0.215PT helpful, N (%) 21 (95.5) 66 (71.0) 0.016Physician characteristicsFemale physician, N (%) 8 (40.0) 60 (37.7) 0.844Younger physician, N (%) 13 (68.4) 119 (85.6) 0.058Non-white physician, N (%) 6 (26.1) 53 (29.1) 0.762Physician referral for PT, N (%) 17 (77.3) 58 (34.3) <0.001

Table 4 - Relationships of patient and physician characteristics to self-reported use of dietary/herbal supplements.


Demographic characteristicsFemale, N (%) 3 (12.5) 15 (8.2) 0.488African American, N (%) 6 (27.3) 54 (30.5) 0.755Age, mean (SD) 63.3 (11.8) 63.9 (11.1) 0.802Some college, N (%) 15 (62.5) 98 (53.9) 0.423OA-related characteristicsNumber of joints, mean (SD) 6.3 (3.8) 6.0 (3.7) 0.786WOMAC, mean (SD) 51.9 (19.9) 50.1 (17.4) 0.641Years with arthritis, mean (SD) 20.2 (9.2) 18.9 (13.4) 0.539Herbs helpful 18 (81.8) 18 (37.5) <0.001Physician characteristicsFemale physician, N (%) 7 (36.8) 61 (37.9) 0.929Younger physician, N (%) 15 (75.0) 118 (84.9) 0.263Non-white physician, N (%) 5 (20.8) 55 (30.2) 0.341

ing them believed they were helpful (p<0.001). Pa-tients with older or white physicians tended to be morelikely to use herbs, although these relationships were notstatistically significant.

DISCUSSION This study examined use of non-pharmacological

therapies among a group of veterans under care forOA. In particular, we focused on three of the most com-mon non-pharmacological therapies: exercise, PT, anddietary/herbal supplements. Only 46% of the samplereported currently using exercise as a treatment for theirarthritis. This is an important finding, considering thelarge number of studies confirming the efficacy of ex-ercise for OA (15, 16, 28, 29). Because exercise issafe, efficacious, and inexpensive, this therapeuticstrategy may play a critical role in reducing OA-relatedcosts, improving patients’ quality of life, and providingpatients with a sense of control over their condition. Re-sults of this study indicate that interventions aimed at in-creasing the use of exercise among patients with OAmay be needed.

Gender was the only demographic characteristic as-sociated with self-reported exercise, with females beingmore likely to exercise than males. Studies in the gener-al population show that males tend to participate inhigher impact exercise than women, and with more fre-quency (30). However, other studies have shown that, intreating a specific condition (such as osteoporosis orcardiovascular disease), women are more adherent toexercise regimens than men (31). In agreement withthese studies, the women in our sample used exercisemore often than men to treat their OA. However, thisstudy is limited with respect to examining gender differ-ences in exercise for OA, given the small number of fe-male participants. Further research is needed to examinethis pattern in a more gender-balanced patient sample. Inaddition, research is needed to understand why femalesare more adherent to disease-related exercise programs ingeneral. Females may have a stronger preference fornon-pharmacological treatments than males, or theymay be generally more adherent to physicians’ OA-relatedtreatment recommendations. Our results suggest thattailoring interventions to reach males with OA may be ap-propriate, especially in traditionally male-dominated en-vironments such as VA medical centers.

Participants who reported currently using exercisewere significantly more likely to perceive exercise as be-ing somewhat or very helpful. This highlights the im-portance of educating patients about the benefits of ex-ercise for OA. However, a high proportion of non-exer-cisers also believed exercise was helpful (72%). This in-dicates that factors other than perceived efficacy are alsoimportant in determining use of exercise among patientswith OA, and additional research is needed to clarify

these issues. Factors such as low self-efficacy, perceivedlack of time, fear of injury, or not knowing appropriate ex-ercise techniques may play an important role (31). Physi-cian recommendations were also a significant predictor ofpatients’ use of exercise, highlighting the importance ofphysician involvement in future interventions. Yet al-most half of the patients who were not currently exercisingreported that a physician had recommended that they ex-ercise. This indicates that physicians’ recommendations,although helpful, may not be a sufficient stimulus to pro-mote patient physical activity in some patients. Moreintensive counseling and intervention may be needed.

About 11% of participants reported current use ofPT to treat their OA. There is little prior research re-garding the frequency of use of PT among patients withOA, and further research is warranted. Participants in thissample who were currently using PT had significantly high-er WOMAC scores than those who were not. PT is oftenprescribed during acute flares of OA-related pain andother symptoms, and this is one probable reason forthe relationship of WOMAC score to PT use in ourstudy. Patients currently using PT were also significantlymore likely to believe it was helpful than those who werenot. However, similar to results regarding exercise, alarge proportion of individuals not currently using PT(71%) also believed that it is a helpful treatment. These re-sults are encouraging, and support the efficacy of PT forOA treatment. We also found that patients with olderphysicians tended to make greater use of PT. This may bedue to older physicians’ level of experience in treating OAor to differences in medical training between older andyounger physicians. Not surprisingly, physician recom-mendation for PT was a strong predictor of patients’use of it. Because of this close association, further un-derstanding of factors related to physicians’ recommen-dations for PT are important. Approximately 34% ofindividuals who reported a physician recommendation forPT were not currently using it. However, they may havereceived formal PT in the past and were simply not undera physical therapist’s care at the time of the survey.

Only 12% of patients in this study reported using di-etary supplements or herbs. In another study, 18% of sub-jects used herbal therapies, 14% diet supplements, and10% minerals or megavitamins (12). One possible reasonfor the slightly lower proportion of users in our study isthat our sample was primarily male, whereas the priorstudy sample was primarily female. Studies have shownthat use of dietary/herbal supplements is more commonamong females than males (12, 32).

Among participants using dietary/herbal supplements,82% perceived them being helpful, whereas only 37% ofthose not using them believed these therapies to be help-ful. Such a difference in perceived helpfulness was not aspronounced among users and non-users of the othertwo therapies. This indicates that general public percep-




tion of dietary/herbal supplements may still not be as fa-vorable as other more traditional non-pharmacologicaltreatments such as exercise and PT. Other research hasalso found that fewer patients perceive dietary treat-ments to be helpful compared with behavioral treat-ments such as exercise and PT (8). While there are stillquestions about the efficacy of some dietary supplementsand herbs, positive evidence is increasing for some, suchas glucosamine and chondroitin (18, 19). Should otherstudies confirm the efficacy of these supplements, in-creased efforts to educate the public may be warranted.

There are several limitations to this study that should beconsidered. First, participants were initially identified on thebasis of ICD-9 codes for OA, and there are known inac-curacies in these codes. Studies have reported the sensi-tivity of ICD-9 codes for OA to be between 0.32 and 1.0(33, 34) and the positive predictive value to be between0.67 and 0.83 (34). Sensitivity and positive predictivevalues are greater when codes are used to identify OA ingeneral (as was done in this study), rather than site-specificOA. Among all patients screened for this study, about 9%indicated that they did not have OA and were excluded.This reduced the number of false positive cases in thestudy. However, since we did not require radiographic ev-idence of OA for entry, it is possible that some individualsincluded in this sample may have been experiencing paindue to other joint problems, or non-specific jointpain/symptoms, without a definite diagnosis of OA.

Second, participants were taken from a conveniencesample rather than a random sample, and therefore thesample may be biased with respect to measured or un-measured characteristics (i.e., OA severity, socio-eco-nomic status). Third, this sample included patients fromone VA medical center, and additional research is need-ed to examine these patterns in other patient populations.Fourth, the sample included a small proportion of females.This may have limited our ability to detect gender differ-ences due to lack of statistical power. In addition, this maylimit the generalizability of the results to the generalpopulation of older adults. Fifth, this study sample wasgenerally a “young-old” sample (mean age approximately64 years), and findings may not generalize to the oldestsegment of the population. Our data indicate that exercise,in particular, may be used even more infrequently amongolder individuals. Because these patterns may differ for in-dividuals in older age categories, further research is need-ed to study non-pharmacological therapy use in this agegroup more specifically. Sixth, this study examined the useof dietary/herbal supplements generally but did not queryspecific treatments. This is important, since both the ef-ficacy and costs of specific dietary and herbal supplementsdiffer. Lastly, participants were not asked about some fair-ly common non-pharmacological treatments for OA, in-cluding occupational therapy, walking aids, braces, jointprotection strategies, and weight loss.

CONCLUSIONSIn conclusion, this study found relatively low use of ex-

ercise, physical therapy, and dietary/herbal supplementsamong a group of patients under care for OA. We foundthat patient and physician demographic characteristicswere generally not strong predictors of use in this sample.Patients’ perceptions of treatment helpfulness and physicianrecommendations were the strongest predictors of use, sig-naling the importance of patient education about these treat-ments. Given the potential value of these treatment strate-gies, interventions aimed at educating both patients andphysicians about these therapies are warranted.

ACKNOWLEDGEMENTSThis research was partly supported by the Department of Veterans

Affairs, Veterans Health Administration, HSR&D Service, Program 824Funds to the first author. The views expressed in this manuscript arethose of the authors and do not necessarily represent the views of theDepartment of Veterans Affairs.

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