Osteoarthritis (OA) is the most common form of arthritis, especially among
older people. It is a joint disease caused by the breakdown of
cartilage—the firm, rubbery tissue that cushions bones
at joints. Healthy cartilage allows bones to glide over one another and
cartilage absorbs energy from the shock of physical movement. In OA cartilage
breaks down and wears away. As a result, the bones rub together, causing pain,
swelling, and stiffness. OA may also limit the range of motion in affected
joints. Most often, OA develops in the hands, knees, hips, and spine. The
disease affects men and women nearly equally. More than 20 million people in the
United States have OA. Symptoms tend to appear when individuals are in their 50s
Signs and Symptoms
Signs and symptoms of OA may include the following:
Joint pain (often a deep, aching pain) that is worsened by movement
and improved with rest (in more severe cases, a person may experience constant
Stiffness in the morning or after being inactive for more than 15
Joints that are warm to the touch
Crunching or crackling noise when the joint moves
Limited range of motion
Abnormal growth of bony knobs near joints causing deformities (such as
Heberden's nodes, in which bumps appear on the outermost finger
OA is also often called degenerative joint disease because this condition
involves the destruction of cartilage, which normally protects the joint.
Although there are
risk factors that may predispose a
person to developing OA, it is usually not entirely clear what initiates the
damage and loss of cartilage. Once the cartilage becomes somewhat damaged,
however, it is more likely for further injury to ensue from repetitive use or
another injury. Less commonly, OA is due to a fracture, mechanical abnormalities
(such as unequal lower limb lengths), other bone and joint disease (such as
gout), or an underlying metabolic or hormonal disorder.
Risk factors for OA include:
Injury to the joint
History of inflammatory joint disease
Metabolic or hormonal disorders (such as hemochromatosis and
Bone and joint disorders present at birth
Repetitive stressful joint use (such as with certain occupations like
baseball, ballet dancing and construction work)
Deposits of crystals in joints, such as happens with gout
Because no single test can diagnose OA, most healthcare practitioners use a
combination of the following methods to diagnose the disease and rule out the
possibility of other causes of arthritis:
Medical history—the doctor assesses symptoms
by asking when they started and how they changed over time, including which
joints are currently involved and have been affected previously. He or she will
also ask about other medical conditions that may be contributing to current
joint symptoms, and whether any factors (such as a fall or injury) could have
caused these symptoms. The doctor will also determine whether the you are taking
might interact with drugs that he or she is considering prescribing.
Physical exam—each of the affected joints is
examined for redness and swelling, crepitations (a crackling noise that may be
heard and sensation felt when bone is rubbing on bone due to lack of cartilage),
the presence of fluid in the joint, and the strength and range of motion of the
X-rays—can detect cartilage loss (which is
indicated by narrowing of the joint space on x-ray) and bone damage such as bone
spurs or erosions.
Blood tests—are performed to look for general
signs of inflammation, to help eliminate the possibility of other types of
arthritis such as rheumatoid or Lyme's disease, and to check for possible
markers of OA such as hyaluronic acid, a substance that normally provides
lubrication for joints but breaks down in the case of OA.
Joint aspiration - if fluid is present, it
can be withdrawn from the joint for evaluation using a needle and syringe;
normally with OA, there is not an adequate amount of fluid in the joint space to
aspirate; therefore, evaluation of fluid may reveal another cause of arthritis
such as gout or an infection.
The following measures may reduce the risk of developing OA:
Protecting an injured joint from further damage
Avoiding excessive repetitive
The goals of OA treatment are to relieve symptoms, maintain mobility, and
minimize disability. A combination of conventional treatment and complementary
and alternative medicine (CAM) may be most effective.
It is possible, if not preferable, to treat OA without the use of
medications. Pain-killers and anti-inflammatory
medications should not be used as the
primary treatment for OA—they should be used only in
addition to other forms of treatment.
Lifestyle approaches, including exercise,
and many alternative medical therapies are becoming more popular and are
considered safe and effective for the treatment OA. Several natural remedies are
at least as effective as conventional medication for symptom relief, and may
diminish the progression of the disease. Various surveys conducted in 1997 found
that anywhere from 26% to 100% of patients with rheumatologic disorders (painful
conditions of the muscles, tendons, joints, and bones) had tried some form of
complementary and alternative medicine.
Some of the most promising complementary approaches for treating OA include
Reducing physical stress on the joint (such as by losing weight or
Lifestyle changes (particularly
S-adenosylmethionine (SAMe), glucosamine and/or chondroitin, and
Herbs with anti-inflammatory properties,
including devil's claw, willow bark, and capsaicin (cream)
Physical therapy and magnet
Exercise to strengthen, stretch, and relax muscles around affected joints is
almost always included in a treatment plan for OA. Several studies support the
value of exercise for people with OA. One recent study, for example, found that
people with OA of the knee who participated in a home exercise program
experienced a 23% reduction in pain compared with only 6% reduction in people
who did not exercise. Other studies also suggest that in addition to reduction
of pain and disability, exercise improves strength, range of motion, balance and
coordination, endurance, and posture.
The following medications may be used in addition to lifestyle approaches
(such as exercise) and alternative therapies (such as herbs and supplements) to
Acetaminophen—reduces pain; the American
Geriatrics Society recommends trying this medication first to alleviate pain.
Aspirin and other nonsteroidal anti-inflammatory drugs
(NSAIDs)—reduce pain and swelling. These include
numerous over-the-counter drugs, such as ibuprofen, ketoprofen, and naproxen
sodium, as well as prescription medications, such as diclofenac, diflunisal,
etodolac, fenoprofen, indomethacin, nabumetone, oxaprozin piroxicam, sulindac,
salsalate, and tolmetin as well as stronger versions of the OTC drugs. Studies
indicate that NSAIDs used for extended periods may cause stomach ulcers and
other gastrointestinal problems. Some evidence even suggests that NSAIDs may
accelerate the progression of OA because they appear to inhibit cartilage
repair. Further studies are needed about this controversial issue.
Cyclooxygenase 2 (COX-2) inhibitors (such as celecoxib and
rofecoxib)—reduce pain and are less likely to cause the
gastrointestinal side effects that sometimes accompany NSAIDs
Tramadol—for pain that does not improve with
Hyaluronic acid—may restore lubrication to
the joints. The medication is injected into affected joints once per week for 3
to 5 weeks and the effects may last up to one year. After each injection,
weight-bearing activity should be avoided for about 48 hours.
Glucocorticoids—injected in or around
affected joints to relieve symptoms; no more than two to three injections should
be administered in one year.
Misoprostol or omeprazole—taken together with
an NSAID may reduce ulcers and gastrointestinal bleeding associated with NSAID
Surgery and Other Procedures
Surgery is usually only considered as a last resort for OA. Surgical options
Arthroscopic debridement and lavage (using a lighted instrument to
examine the interior of a joint, remove dead tissue, and wash the joint) may
Osteotomy (removal of all or part of the bone; loose fragments that
may be causing symptoms are removed at the same time) may alleviate pain and
inflammation in people with moderately advanced knee or hip OA.
Arthrodesis (fusion of joints) may be considered for the spine and
small joints of the wrist, hand, and foot to reduce pain. Fusion of the bone,
however, eliminates movement of that joint.
Arthroplasty (joint replacement) is used for people with severe and
advanced OA who have not improved from any other treatments. This procedure
works best for older people because artificial joints typically last only 20
Nutrition and Dietary Supplements
Glucosamine and Chondroitin
Glucosamine and chondroitin are compounds that occur naturally in human
cartilage. For use in supplements, they are derived from bovine and calf
cartilage. They have been widely used in Europe for more than a decade and have
also recently gained popularity in the United States. Both compounds have been
shown to inhibit inflammation in laboratory experiments. To evaluate the
long-term effectiveness and possible toxic effects of these substances, the
National Center for Complementary and Alternative Medicine (NCCAM) of the
National Institutes of Health (NIH) has funded a large clinical trial comparing
glucosamine, chondroitin, and a combination of the two agents, to placebo. The
study is projected to be complete by March 2005.
Several reviews of clinical trials examining either glucosamine or
chondroitin for OA concluded that these agents showed a number of benefits.
Glucosamineis administered orally or by injection into
a joint or muscle. In its most commonly used form, glucosamine sulfate, it has
been shown to:
Decrease pain more effectively than placebo or NSAIDs (particularly
Take longer to begin working than ibuprofen but alleviate pain for a
longer period of time
Have significantly fewer adverse effects than ibufrofen
Significantly improve pain and range of motion compared to both
placebo and the NSAID piroxicam
Have longer-lasting improvement of symptoms compared to piroxicam
Although encouraging, these studies did not examine the long-term safety and
effectiveness of this supplement. In one long-term study in which 212 patients
with OA received either glucosamine sulfate or placebo for 3 years, those in the
glucosamine group experienced a 25% improvement in symptoms as well as
diminished narrowing of the joint space, suggesting that the supplement slowed
the progression of the disease. Participants in the glucosamine group reported
no more adverse effects than those in the placebo group.
Some experts believe that another form of glucosamine known as glucosamine
hydrochloride may be absorbed more readily by the body than glucosamine sulfate.
Since most research to date has been conducted on glucosamine sulfate, this is
the form generally recommended for OA.
Chondroitin is also administered orally or by injection into a
joint or muscle. It has been found to produce the following results in several
well-designed clinical trials:
Reduce the need for NSAIDs and other pain relievers
Alleviate pain (sometimes more effectively than conventional
medications; this effect even lasts up to 3 months after chondroitin
supplementation is discontinued)
Reduce amount of fluid in the joint
Enhance walking pace
Slow the progression of the disease
Although glucosamine and chondroitin have been studied separately,
accumulating evidence suggests that taking both supplements together may be a
safe and effective treatment for OA. As mentioned earlier, a large NIH-funded
study comparing glucosamine, chondroitin, and a combination of the two agents to
placebo is currently underway. The study is expected to be completed by March
Medical experts caution that glucosamine and chondroitin supplements sold
over the counter in the United States are not regulated by the U.S. Food and
Drug Administration, meaning that there is no standardization nor any guarantee
that a product contains what is listed on the label.
Laboratory and animal studies suggest that SAMe may reduce pain and
inflammation, but researchers are not clear how this works. Clinical trials with
humans (although generally small in size and of short duration) have also shown
favorable results for SAMe when used to relieve OA symptoms.
In several short-term studies (ranging from 4 to 12 weeks), SAMe supplements
(1200 mg/day) compared favorably to NSAIDs in adults with knee, hip, or spine
osteoarthritis in the following ways:
Diminished morning stiffness
Improved range of motion
Increased walking pace
In an extensive review of studies conducted with SAMe (collectively
representing over 20,000 people), including trials of longer duration (namely, 2
years), the supplement was associated with the following
Few side effects
No negative influences on cartilage production (unlike
Reduced risk for relapse
Vitamin D is essential to bone and cartilage health. Studies evaluating
vitamin D use for OA have found the following:
Vitamin D prevents breakdown of cartilage
Lower intake of vitamin D may be linked to greater risk of hip OA in
older women and OA-related joint changes (visible on X-rays) in both men and
Antioxidants appear to significantly ease oxidative stress and inflammation
caused by free radicals and may therefore slow the progression of OA. Free
radicals can be produced in the joints and have been implicated in many
degenerative changes in the aging body, including destruction of cartilage and
connective tissue. Antioxidants appear to offset the damage caused by free
radicals. Although further evidence is needed to substantiate these claims,
studies of groups of people observed over time suggest that the following
antioxidants may help to reduce the symptoms of OA:
Vitamin A and beta-carotene
In addition, more extensive research on vitamin E revealed that people with
OA experienced a significant reduction in pain after taking 600 mg of vitamin E
per day, compared with those who received placebo. Those who took 600 mg of
vitamin E three times a day experienced significantly less pain than those who
took the NSAID diclofenac.
In one preliminary study, 72 patients with OA were randomly assigned to
receive niacinamide, a form of vitamin B3, or placebo. Participants
in the niacinamide group experienced a 30% improvement in symptoms compared to a
10% worsening of symptoms experienced by those in the placebo group. People
taking niacinamide reported the following:
Improved joint mobility
Reduced need for anti-inflammatory medications
The study authors speculate that niacinamide may aid cartilage repair and
suggest that it may be used safely with NSAIDs to reduce inflammation. Further
research is needed to fully understand how niacinamide benefits people with OA
and to determine whether the results apply to all people with the condition. It
does appear, however, that niacinamide must be used for at least 3 weeks before
the benefits described are seen. Experts also suggest that long-term use (1 to 3
years) may slow the progression of the disease.
Omega-3 Fatty Acids
Omega-3 fatty acids are found in coldwater fatty fish (such as salmon,
mackerel, and herring), flaxseed, rapeseed, and walnuts. Research regarding the
use of omega-3 fatty acid supplements for inflammatory joint conditions has
focused almost entirely on rheumatoid arthritis. Based on laboratory studies,
however, many researchers suggest that diets rich in omega-3 fatty acids (and
low in omega-6 fatty acids) may benefit people with other inflammatory
disorders, such as OA. In fact, several laboratory studies of
cartilage-containing cells have found that omega-3 fatty acids decrease
inflammation and reduce the activity of enzymes that break down cartilage.
Another potential source of omega-3 fatty acids is the New Zealand green
lipped mussel (Perna canaliculus), used for centuries by the Maori people
for good health. In a trial involving 38 people with OA, nearly 40% of those who
received P. canaliculus extracts experienced the
Decreased joint stiffness and pain
Increased grip strength
Enhanced walking pace
It is also important to note, however, that 10% of participants experienced a
temporary worsening of symptoms when first taking the supplement. In addition,
it is better to use lipid extracts of P. canaliculus rather than powder
as there is less chance of an allergic reaction. P. canaliculus should be
avoided by people who are allergic to seafood.
Manganese is among the substances that the body needs to build cartilage. In
a clinical trial studying glucosamine, choindroitin, and manganese, 72 people
with mild to moderate OA of the knee showed significant improvement in symptoms
after taking these supplements in combination compared to those taking placebo.
No serious side effects were reported. People with more severe forms of the
disease did not show improvement as a result of taking the combination, however.
Although earlier studies have indicated that low levels of manganese may
contribute to degenerative joint conditions and bone loss, it is not clear from
this trial what role manganese (as opposed to chondroitin and glucosamine) may
have played in the results. Interestingly, however, an estimated 37% of
Americans have low levels of manganese in their diets.
According to anectodal reports and preliminary studies, other supplements
that may potentially alleviate the symptoms of OA include:
(Ananascomosus)—compared favorably to
NSAIDs for pain reduction
Boron—population, animal, and preliminary
human studies suggest that this trace element may reduce occurrence of symptoms
Collagen hydrolysate—may stimulate cells to
make collagen, although this theory is currently being
Herbal remedies are among the most popular alternative therapies used by
individuals with arthritis. Scientific evidence suggests that the following
herbs are most effective for treating OA:
Devil's claw (Harpagophytum procumbens)
Willow bark (Salix spp.)
Stinging nettle (Urtica dioica)
A combination of aspen (Populus tremula), ash
(Fraxinus excelsior), and goldenrod (Solidago
An Ayurvedic herbal mixture containing extracts of ashwagandha
(Withania somnifera), boswellia (Boswellia serrata), and
turmeric (Curcuma longa)
A combination of willow bark (Salix spp.), black cohosh
(Cimicifuga racemosa), sarsaparilla (Smilax spp.), guaiacum
(Guaiacum officinale) resin, and poplar bark (Populus tremuloides)
Other herbs that have shown promise in the treatment of OA include:
Capsaicin (Capsicum frutescens)
Capsaicin is the main component in hot chili peppers (also known as cayenne).
Applied to the surface of the skin, it is believed to deplete stores of a
substance that contributes to inflammation and pain in arthritis. Several
studies have shown that capsaicin cream provided much better pain relief than a
placebo but no improvement in joint swelling, grip strength, or function for
people with OA. Pain reduction generally begins 3 to 7 days after applying the
capsaicin cream to the skin.
Laboratory studies suggest that avocado/soybean extracts stimulate the growth
of collagen (the principal protein of the skin, tendons, cartilage, and bone) in
cartilage cells. In a study of 164 people with OA of the knee or hip,
researchers found that participants who received avocado/soybean extracts for 6
months experienced the following improvements with few or no side
Reduction in pain and disability
Increase in mobility
Reduced need for NSAIDs
Cat's claw (Uncaria tomentosa)
In astudy of 45 people with OA of the knee, those who received cat's claw
reported a significant reduction in knee pain compared to those who received
Ginger (Zingiber officinale)
Ginger extract has long been used in traditional medical practices (such as
Ayurvedic and Chinese) to decrease inflammation. Although there have been a few
case reports of the benefit of ginger for OA in medical literature, one recent
trial found that the herb was no more effective than ibuprofen or placebo in
reducing symptoms of OA.
Kava kava (Piper methysticum)
Kava has traditionally been used as a pain reliever, but few scientific
studies have evaluated kava for this purpose. In support of this traditional
use, animal studies have also shown that kava reduces pain. Research in humans
Several controlled trials suggest that the ancient Chinese practice of
acupuncture is an effective treatment for pain associated with OA, as well as
for other aspects of the condition, including diminished joint function and
reduced walking ability. In fact, a few studies have shown that people with OA
experience better pain relief and improvement in function from acupuncture than
from NSAIDs such as aspiroxicam. For example, a group of 29 people awaiting
surgery for OA of the knee demonstrated significant improvement in their ability
to climb stairs and in their walking pace after receiving acupuncture compared
to those who were not treated with acupuncture.
The National Institutes of Health is funding a large multicenter clinical
trial due to be completed in 2001 to fully evaluate efficacy and safety of
acupuncture for OA.
Although there is no evidence that chiropractic care can reverse the joint
degeneration that causes OA, some studies indicate that spinal manipulation
increase range of motion
restore normal movement of the spine
relax the muscles
improve joint coordination
In fact, a comprehensive review of the scientific literature suggests that
chiropractic, especially when combined with glucosamine supplements and
rehabilitative stretches and exercise, is an effective supplemental treatment
for OA. Chiropractors will avoid using direct thrusts or pressure on red,
Massage and Physical Therapy
Manual therapy and supervised exercise may decrease or delay the need for
surgery in individuals with OA. In a trial evaluating physical therapy and
exercise in people with OA of the knee, participants who received manual therapy
to the lumbar spine, hip, ankle, and knees showed the following
Improved functional ability
Improved walking distance
Less need for knee surgery one year later
Exposure to electromagnetic fields has been shown to boost the number of
cartilage-building cells and substances in laboratory experiments. One important
study found that low-energy AC and DC magnetic fields stimulated the production
of cartilage. For therapeutic purposes, magnets can be applied one of two ways:
directly to the skin surface over the bone or joint (Capacitive coupling) or via
pulsed electromagnetic fields (PEMFs) which induce an electrical current in the
target tissue without making direct contact to the body (Inductive
Studies using either type of magnet therapy for arthritis are limited, and
the few that exist have mainly used poor methods that make it difficult to draw
any definite conclusions. However, in one study of 78 people with OA of the
knee, magnet therapy (applied to the knee for 6 to 10 hours per day over a
period of one month) significantly reduced pain as compared with placebo.
Balneotherapy (Hydrotherapy or spa therapy)
Balneotherapy is one of the oldest forms of therapy for pain relief for
people with arthritis. The term "balneo" comes from the Latin word for bath
(balneum) and refers to bathing in thermal or mineral waters. Sulfur-containing
mud baths, for example, have been shown to relieve symptoms of arthritis.
However, hydrotherapy, which can be performed under the guidance of certain
physical therapists, is occasionally used interchangeably with the word
balneotherapy. The goals of balneotherapy for arthritis include:
Improving range of joint motion
Increasing muscle strength
Eliminating muscle spasm
Enhancing functional mobility
Although balneotherapy is most often used for psoriatic or rheumatoid
arthritis, some medical experts believe that it may be beneficial for OA as
well. However, one large review of many trials found little evidence to support
Ice Massage, Transcutaneous Nerve Stimulation (TENS), and
In a well-designed trial comparing the effectiveness of TENS,
electroacupuncture, and ice massage for the treatment of knee OA, each of these
methods were found to:
Reduce pain at rest
Boost walking speed
Increase quadriceps muscle strength
Increase knee range of motion
TENS is a technique used by many physical therapists. When the nerve
stimulation of TENS is applied to acupuncture points, it is called
A variety of mechanical devices, called orthoses, are available for people
with OA to help support and protect joints. Made from lightweight metal leather,
elastic, foam, and plastic, orthoses allow some movement within the affected
joint and do not restrict nearby joints. For example, splints or braces help
align joints and properly distribute weight. Shock-absorbing soles in shoes can
help in daily activities and during exercise. These mechanical aids are used
most frequently to treat arthritic hands, wrists, knees, ankles, and feet.
Orthoses should be custom-fitted by a physical or occupational
Although people with OA are best treated with an individualized homeopathic
remedy chosen by a professional homeopath, several trials have found that some
common homeopathic combinations may be at least as effective as conventional
medications for OA. Potential remedies include:
A topical homeopathic gel containing comfrey (Symphytum
officinale), poison ivy (Rhus toxicodendron), and marsh-tea (Ledum
A combination homeopathic preparation containing R. toxicodendron.,
Arnica Montana (arnica), Solanum dulcamara (climbing nightshade),
Sanguinarra Canadensis (bloodroot), and Sulphur
A liquid homeopathic preparation containing R. toxicodendron,
Causticum (potassium hydrate), and Lac vaccinum (cow's
Other common homeopathic remedies for OA include:
Calcarea carbonica (carbonate of lime or calcium
Bryonia (wild hops)
Chronic pain and disability can make daily functioning difficult. A holistic
approach to care in these clinical circumstances may positively affect both
lifestyle and how one feels overall. Many people report that relaxation
techniques, such as guided imagery and meditation, are an important part of
comprehensive, holistic care, and help to alleviate pain and other symptoms of
This ancient Indian practice is well known for its physical, psychological,
emotional, and spiritual benefits and is often recommended in the West to
relieve musculoskeletal symptoms. In one clinical trial studying OA of the hand,
the group practicing yoga showed significant decrease in pain and improved range
of motion compared to those participating in non-yoga stretching and
strengthening sessions. Certain yoga "asanas" (postures) strengthen the
quadriceps and emphasize stretching, both of which benefit people with OA of the
knee. People with arthritis should begin asanas slowly and they should be
performed only after a warm up. Yoga is best performed under the careful
guidance of a reputable instructor.
Two recent trials comparing Ayurvedic herbal remedies with placebo found that
participants who consumed the Ayurvedic herbs experienced significant
improvement (with only mild side effects) compared to those in the placebo
group. An Ayurvedic combination containing the following herbs significantly
reduced pain and disability in people with OA:
Winter cherry (Withania somnifera)
Boswellia (Boswellia serrata)
Turmeric (Curcuma longa)
Side effects of these herbs include nausea, dermatitis, and stomach
Traditional Chinese Medicine
This ancient form of classical conditioning practiced in China for centuries
has been shown to produce a number of benefits, including the following:
Increased muscular strength
Reduced percentage of body fat
Diminished risk of falls in the elderly
In a trial of subjects with OA of the knee or hip (ranging in age from 49 to
81), those who practiced tai chi twice a week for 3 months showed significant
improvement compared to those in the control group in the following
Overall sense of quality of life
Diminished feelings of stress/tension
Increased satisfaction with general health
Easier self management of arthritis
Most women who become pregnant are too young to have OA. Many of the herbs
used in treatment for OA have not been tested on pregnant women and some are
known to be unsafe for women who are pregnant. For this reason, pregnant women
should only take substances for pain and other symptoms that are approved by
Prognosis and Complications
Complications of OA include:
Inability to walk due to very advanced hip or knee OA
Gastrointestinal bleeding and decreased kidney function resulting from
long-term NSAID and aspirin use
Many people are able to control OA and prevent the condition from worsening
over time. Joint deterioration in OA tends to be slower than that of rheumatoid
arthritis, but knee OA is still the number one cause of disability in
industrialized countries such as the United States. Increased fluid in joints
and joint enlargement occur later in the course of the disease. In the most
advanced stages, OA can cause full cartilage loss. In some cases joint
replacement may become necessary. While OA can be a debilitating condition,
current treatments have shown great promise in reducing pain and improving
Acevedo E, Castaneda O, Ugaz M, et al. Tolerability profiles of rofecoxib
(Vioxx) and Arthrotec. A comparison of six weeks treatment in patients with
osteoarthritis. Scand J Rheumatol. 2001;30(1):19-24.
Berman BM, Swyers JP, Ezzo J. The evidence for acupuncture as a treatment for
rheumatologic conditions. Rheum Dis Clin North Am.
Bliddal H, Rosetzsky A, Schlichting P, et al. A randomized,
placebo-controlled, cross-over study of ginger extracts and ibruprofen in
osteoarthritis. Osteoarthritis Cartilage. 2000;8:9-12.
Blumenthal M, Goldberg A, Brinckman J, eds. Herbal Medicine: Expanded
Commission E Monographs. Newton, Mass: Integrative Medicine Communications;
Bradley JD, Flusser D, Katz BP, et al. A randomized, double blind, placebo
controlled trial of intravenous loading with S-adenosylmethionine (SAM) followed
by oral SAM therapy in patients with knee osteoarthritis. J Rheumatol.
Brandt KD. Osteoarthritis. In: Fauci AS, Braunwald E, Isselbacher KJ, et al,
eds. Harrison's Principles of Internal Medicine. 14th ed. New York, NY:
Chopra A. Ayurvedic Medicine and arthritis. Rheum Dis Clin North Am.
Corvol MT, Dumontier MF, Tsagris L, Lang F, Bourguignon J. Cartilage and
vitamin D in vitro. Ann Endocrinol. 1981;42:482-487.
Curtis CL, Hughes CE, Flannery CR, Little CB, Harwood JL, Caterson B. N-3
fatty acids specifically modulate catabolic factors involved in articular
cartilage degradation. J Biol Chem. 2000;275(2):721-724.
da Camara CC, Dowless GV. Glucosamine sulfate for osteoarthritis. Ann
Danao-Camara TC, Shintani TT. The dietary treatment of inflammatory
arthritis: case reports and review of the literature. Hawaii Med J.
Das A, Hammad TA. Combination of glucosamine and chondroitin in knee OA.
Osteoarthritis Cartilage. 2000;8(5):343-350.
Davis GC, Cortez C, Rubin BR. Pain management in the older adult with
rheumatoid arthritis or osteoarthritis. Arthritis Care Res.
Deal CL, Moskowitz RW. Nutraceuticals as therapeutic agents in
osteoarthritis: the role of glucosamine, chondroitin sulfate, and collagen
hydrolysate. Rheum Dis Clin North Am. 1999;25(2):379-395.
Dean DD, Boyan BD, Muniz OE, Howell DS, Schwartz Z. Vitamin D metabolites
regulate matrix vesicle metalloproteinase content in a cell maturation dependent
manner. Calcif Tissue Int. 1996;59:109-116.
Delafuente JC. Glucosamine in the treatment of osteoarthritis. Rheum Dis
Clin North Am. 2000;26(1):1-11.
Deyle GD, Henderson NE, Matekel RL, Ryder MG, Garber MB, Allison SC.
Effectiveness of manual physical therapy and exercise in osteoarthritis of the
knee. A randomized, controlled trial. Ann Intern Med.
di Pavoda C. S-adenosylmethionine in the treatment of osteoarthritis. Review
of clinical studies. Am J Med. 1987;83(suppl 5A):60-65.
Domljan Z, Vrhovac B, Durrigl T, Pucar I. A double-blind trial of
ademetionine vs naproxen in activated gonarthrosis. Int J Clin Pharmacol Ter
Eberhardt R, Zwingers T, Hofmann R. DMSO in patients with active
gonarthrosis. A double-blind placebo controlled phases III study. Fortshr
Elkayam O, Ophir J, Brener S, et al. Immediate and delayed effects of
treatment at the Dead Sea in patients with psoriatic arthritis. Rheumatol Int.
Ernst E, Chrubasik S. Phyto-anti-inflammatories. A
systematic review of randomized, placebo-controlled, double-blind trials.
Rheum Dis Clin North Am. 2000;26(1):13-27.
Felson DT, Lawrence RC, Hochberg MC, et al. Osteoarthritis: new insights.
Part 2: treatment approaches. Ann Intern Med. 2000;133(9):726-737.
Gaby AR. Natural treatments for osteoarthritis. Altern Med Rev.
Garfinkel M, Schumacher HR, Jr. Yoga. Rheum Dis Clin North Am.
Garfinkel MS, Schumacher HR, Husain A, Levy, M, Reshetar RA. Evaluation of a
yoga based regimen for treatment of osteoarthritis of the hands. J Rheumatol.
Gibson SL, Gibson RG. The treatment of arthritis with a lipid extract of
Perna canaliculus: a randomized trial. Complement Ther Med.
Gottlieb MS. Reviews of the literature. Conservative management of spinal
osteoarthritis with glucosamine sulfate and chiropractic treatment. JMPT.
Haldeman S, Chapman-Smith D, Peterson DM. Guidelines for Chiropractic Quality
Assurance and Practice Parameters: Proceedings of the Mercy Center Consensus
Conference. Gaithersburg, Maryland. Aspen Publishers, 1993:173.
Halpern G-M. Anti-inflammatory effects of a stabilized lipid extract of Perna
canaliculus (Lyprinol). Allerg Immunol (Paris). 2000;32(7):272-278.
Hartman CA, Manos TM, Winter C, Hartman DM, Li B, Smith JC. Effects of T'ai
Chi training on function and quality of life indicators in older adults with
osteoarthritis. JAGS. 2000;48:1553-1559.
Jamieson DD, Duffield PH. The antinociceptive actions of kava components in
mice. Clin Exp Pharmacol Physiol. 1990;17(7):495-507.
Jonas WB, Rapoza CP, Blair WF. The effect of niacinamide on osteoarthritis: A
pilot study. Inflamm Res. 1996;45:330-334.
Klein G, Kullich W. Short-term treatment of painful osteoarthritis of the
knee with oral enzymes. A randomized, double-blind study versus diclofenec.
Clin Drug Invest. 2000;19(1):15-23.
Kremer JM. N-3 fatty acid supplements in rheumatoid arthritis. Am J Clin
Nutr. 2000;(suppl 1):349S-351S.
Kulkarni RR, Patki PS, Jog VP, Gandage SG, Patwardhan B. Treatment of
osteoarthritis with a herbomineral formulation: a double-blind,
placebo-controlled, cross over study. J Ethnopharmacol. 1991;33:91-95.
Lane NE, Gore R, Cummings SR, et al. Serum vitamin D levels and incident
changes of radiographic hip osteoarthritis. A longtitudinal study. Arthritis
Leeb BF, Schweitzer KM, Smolen JS. A metaanalysis of chondroitin sulfate in
the treatment of osteoarthritis. J Rheumatol. 2000;27(1):205-211.
Long L, Ernst E. Homeopathic remedies for the treatment of osteoarthritis: A
systematic review. Br Homeopath J. 2001;90:37-43.
Machtey I, Ouaknine L. Tocopherol in osteoarthritis: a controlled pilot
study. J Am Geriatr Soc. 1987;26(7):328-330.
Maccagno A, di Giorio EE, Caston OL, Sagasta CL. Double-blind controlled
clinical trial of oral S-adenosylmethionine versus piroxicam in knee
osteoarthritis. Am J Med. 1987;83(suppl 5A):72-77.
Machtey I, Ouaknine L. Tocopherol in osteoarthritis: a controlled pilot
study. J Am Geriatr Soc. 1978;26:328.
Maheu E, Mazières B, Valat J-P, et al. Symptomatic efficacy of
avocado/soybean unsaponifiables in the treatment of osteoarthritis of the knee
and hip. Arthritis Rheum. 1998;41(1):81-91.
McAlindon T. Glucosamine for osteoarthritis: dawn of a new era? Lancet.
McAlindon TE, LaValley MP, Gulin JP, Felson DT. Glucosamine and chondroitin
for treatment of osteoarthritis: a systematic quality assessment and
meta-analysis. JAMA. 2000;283(11):1469-1475.
McAlindon TE, Felson DT, Zhang Y, et al. Relation of dietary intake of serum
levels of vitamin D to progression of osteoarthritis of the knee among
participants in the Framingham study. Ann Intern Med.
McAlindon TE, Jacques P, Zhang Y. Do antioxidant micronutrients protect
against the development and progression of knee osteoarthritis? Arthritis
Morrison R. Desktop Companion to Physical Pathology. Nevada City, Nev:
Hahnemann Publishing; 1998.
Müller-Fassbender H. Double-blind clinical trial of s-adenosylmethionine
versus ibuprofen in the treatment of osteoarthritis. Am J Med.
Newnham RE. Essentiality of boron for healthy bones and joints. Environ
Health Perspect. 1994;102(suppl 7):83-85.
O'Reilly SC, Muir KR, Doherty M. Effectiveness of home exercise on pain and
disability from osteoarthritis of the knee: a randomised controlled trial.
Ann Rheum Dis. 1999;58:15-19.
Piscoya J, Rodriguez Z, Bustamante SA, Okuhama NN, Miller MJ, Sandoval M.
Efficacy and safety of freeze-dried cat's claw in osteoarthritis of the knee:
mechanisms of action of the species Uncaria guianensis. Inflamm Res.
Rains C, Bryson HM. Topical Capsaicin. A review of its pharmacological
properties and therapeutic potential in post-herpetic neuralgia, diabetic
neuropathy and osteoarthritis. Drugs and Aging. 1998;7(4):317-328.
Reginster JY, Deroisy R, Rovati LC, et al. Long-term effects of glucosamine
sulphate on osteoarthritis progression: a randomised, placebo-controlled
clinical trial. Lancet. 2001;357:251-256.
Rosenstein ED. Topical agents in the treatment of rheumatic disorders.
Rheum Dis Clin North Am. 1999;25(4):899-913.
Schwartz ER, Leveille CR, Stevens JW, et al. Proteoglycan structure and
metabolism in normal and osteoarthritic cartilage of guinea pigs. Arthritis
Shealy CN, Thomlinson RP, Cox RH, Bormeyer V. Osteoarthritic pain: a
comparison of homeoapthy and acetaminophen. American Journal of Pain
Shipley M, Berry H, Broster G, Jenkins M, Clover A, Williams I. Controlled
trial of homeopathic treatment of osteoarthritis. The Lancet. 1983:97-99.
Simopoulos AP. Essential fatty acids in health and chronic disease. Am J
Clin Nutr. 1999;70(30 Suppl):560S-569S.
Sowers MF, Lachance L. Vitamins and arthritis: The roles of vitamins A, C, D,
and E. Rheum Dis Clin North Am. 1999;25(2):315-331.
Srivastava KC, Mustafa T. Ginger (Zingiber officinale) in rheumatism
and musculoskeletal disorders. Medical Hypotheses. 1992;39:343-348.
Sukenik S. Balneotherapy for rheumatic diseases at the Dead sea area. Isr
J Med Sci. 1996;32Suppl:S16-19.
Sukenik S, Buskila D, Neumann L, Kleiner-Baumgarten A, Zimlichman S, Horowitz
J. Sulphur bath and mud pack treatment for rheumatoid arthritis at the Dead Sea
area. Ann Rheum Dis. 1990;49(2):99-102.
Sukenik S, Flusser D, Codish S, Abu-Shakra M. Balneotherapy at the Dead Sea
area for knee osteoarthritis. Isr Med Assoc J. 1999;1(2):83-85.
Sukenik S, Giryes H, Halevy, et al. Treatment of psoriatic arthritis at the
Dead Sea. J Rheumatol. 1994;21:1305-1309.
Sukenik S, Neumann L, Flusser D, Kleiner-Baumgarten A, Buskila D.
Balneotherapy for rheumatoid arthritis at the Dead Sea. Isr J Med Sci.
Towheed TE, Anastassiades TP. Glucosamine and chondroitin for treating
symptoms of osteoarthritis: evidence is widely touted but incomplete.
Trock DH. Electromagnetic fields and magnets. Investigating treatment for
musculoskeletal disorders. Rheum Dis Clin North Am.
Van Baar ME, Assendelft WJ, Dekker J, Oostendorp RA, Bijlsma JW.
Effectiveness of exercise therapy in patients with osteoarthritis of the hip or
knee. A systematic review of randomized clinical trials. Arthritis Rheum.
van Haselen RA, Fisher PAG. A randomized controlled trial comparing topical
piroxicam gel with a homeopathich gel in osteoarthritis of the knee.
Verhagen AP, de Vet HC, de BIE RA, Kessels AG, Boers M, Knipschild PG.
Balneotherapy for rheumatoid arthritis and osteoarthritis (Cochrane Review). In:
The Cochrane Library, Issue 4, 2000. Oxford: Update Software.
Vetter G. Double-blind comparative clinical trial with S-adenosylmethionine
and indomethacin in the treatment of osteoarthritis. Am J Med.
Yurtkuran M, Kocagil T. TENS, electroacupuncture and ice massage: comparison
of treatment for osteoarthritis of the knee. Am J Acupunct.
Zhang WY, Li Wan Po A. The effectiveness of topically applied capsaicin.
Eur J Clin Pharmacol. 1994;46:517-522.
Review Date: June 2001
Reviewed By: Participants in the review process include: Ruth Debusk, RD, PhD, Editor,
Nutrition in Complementary Care, Tallahassee, FL; Gary Guebert, DC, DACBR,
(Chiropractic section October 2001) Login Chiropractic College, Maryland
Heights, MO; Jacqueline A. Hart, MD, Department of Internal Medicine,
Newton-Wellesley Hospital, Harvard University and Senior Medical Editor
Integrative Medicine, Boston, MA; Joseph Lamb, MD, The Integrative Medicine
Works, Alexandria, VA; Joseph Trainor, DC, (Chiropractic section October 2001)
Integrative Therapeutics, Inc., Natick, MA; Dana Ullman, MPH, Homeopathic
Educational Services, Berkeley, CA.
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