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Knee Osteoarthritis: Thumbs Down for Acupuncture and Glucosamine

Osteoarthritis is the “wear and tear” kind of arthritis that many of us develop as we get older.  Cartilage becomes less resilient with age, collagen can degenerate, and inflammation and new bone outgrowths (osteophytes) can occur.  This leads to pain, crepitus (Rice Krispie type crackling noises with movement), swelling and fluid accumulation in the joints (effusion), and can severely limit activity for some patients.

Since knee osteoarthritis is such a ubiquitous annoyance, home remedies and CAM offerings abound.  Previously we have covered a number of CAM options on this blog, including glucosamine, acupuncture, and several others. The American Academy of Orthopaedic Surgeons (AAOS) has just issued a 1200 page report evaluating the evidence for various treatments for knee osteoarthritis short of total knee replacement surgery. A 13 page summary is available online. They have done the heavy lifting for us, reviewing all the available scientific studies for evidence of effectiveness. Here’s what the science says: (I’ve highlighted the ones where the evidence is strong.) 

  1. Exercise – strong evidence for effectiveness
  2. Weight loss – moderate evidence for
  3. Acupuncture – strong evidence against
  4. Physical agents (TENS, ultrasound, etc.) – inconclusive
  5. Manual therapy (chiropractic, massage) – inconclusive
  6. Valgus-directing force brace – inconclusive
  7. Lateral wedge insoles – moderate evidence against
  8. Glucosamine and chondroitin – strong evidence against
  9. NSAIDs – strong evidence for
  10. Acetaminophen, opioids, pain patches – inconclusive (this is particularly interesting since acetaminophen is the standard first-choice drug)
  11. Intraarticular corticosteroid injections – inconclusive
  12. Hyaluronic acid injections – strong evidence against (and if injections are ineffective, those oral diet supplements certainly don’t have a chance)
  13. Growth factor injections and/or platelet-rich plasma – inconclusive
  14. Needle lavage – moderate evidence against
  15. Arthroscopy with lavage and debridement – strong evidence against
  16. Partial meniscectomy in osteoarthritis patients with torn meniscus – inconclusive
  17. Valgus-producing proximal tibial osteotomy – limited evidence
  18. Free-floating interpositional device – no evidence; consensus against

They apparently didn’t think it was worthwhile even mentioning such things as copper bracelets, magnets, prayer, or supplements like boswellia. Or homeopathy!

Naturopaths and other critics of mainstream medicine claim that MDs don’t recommend lifestyle measures like exercise and weight loss, but here is a mainstream medical organization that clearly does, and even puts them first on its list. Critics who claim doctors are just out to make money, take note: if they were the evil money-grubbers some make them out to be, wouldn’t these surgeons want to promote income-generating arthroscopic lavage and debridement? Wouldn’t they want to suppress information about conservative treatments and keep patients in pain until they were desperate enough to consent to expensive joint replacement surgery? Gee, do you suppose maybe they really are just trying to do what’s best for their patients?

I was glad to see that the AAOS reached the same conclusions we did on SBM regarding acupuncture and glucosamine, but I wasn’t surprised. After all, we are looking at the same published evidence. Unbiased scientific minds think alike. Recommendations on other websites like WebMD and the Mayo Clinic still favor acupuncture and glucosamine. It will be interesting to see if they modify their websites in response to the AAOS report. I’m not holding my breath.

I was curious: if AAOS is an American Academy, why do they spell Orthopaedic the British way?  I looked it up: Orthopaedic is the correct medical spelling! So thanks to the AAOS, I learned something about spelling as well as about knees.

Posted in: Acupuncture, Herbs & Supplements, Surgical Procedures

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47 thoughts on “Knee Osteoarthritis: Thumbs Down for Acupuncture and Glucosamine

  1. Thor says:

    It was a given, perhaps ‘fact’. Glucosamine and, to a lesser extent chondroitin, were the supplements of choice, not only for knee arthritis but for the affliction body-wide. This was Supplements’ shining moment—a natural product that cures disease and eases the suffering of millions. Body workers, chiropractors, osteopaths, PTs, health food stores, vitamin companies, MLM companies, etc, just couldn’t sell enough of the stuff. Many MDs even joined the bandwagon. It started out fairly expensive; it’s cheap now-ha. It’s another one of those amazing SCAM success stories where all the needed pieces fit together to create a mass, (inter)national belief, almost ferver in a product that turns out to be, well, zilch, absolutely useless.
    The glucosamine bubble-burst is really the story of most great supplement hypes, although on a larger scale.

  2. goodnightirene says:

    @Thor

    I’d like to think the glucosamine bubble is burst, but it remains prominent in the Costco circular I just received. It’s also very much in evidence at the pet stores.

    This brings up a more general question: Is there any data on such questions? Surely someone knows whether Costco is selling more or less glucosamine than they were two (or whenever) years ago?

    1. calliarcale says:

      Well, if the bubble has burst, that doesn’t mean it’s gone. It just means it’s not something to massively overinvest in. And the backlog of stock means that Costco will be selling it cheap for quite a while yet.

  3. windriven says:

    @irene

    “Surely someone knows whether Costco is selling more or less glucosamine”

    I’m sure they do – but I doubt they’re telling. A tip-off is the amount of space Costco gives to various ‘supplements’ in its circulars. In one recent issue I calculated that roughly 10% of the total space was dedicated to supplements and other woo. Considering the broad array of products sold by Costco, devoting 10% suggests the volume and profitability of those items.

    I’m in the wrong business :-(

  4. WilliamLawrenceUtridge says:

    @windriven

    I’m in the wrong business

    Only in terms of money. If ethics are at all a concern to you, then you’re doing fine. You could always try surgical ablation of the parts of the brain responsible for giving a crap about other people, then take up homeopathy.

  5. - Their eagerness to endorse NSAID use is not taking into account the serious harm of this medication when taken long term. Education before medication!
    - The weightloss is obviously helpful – less weight less pressure on the knee joint.
    - Exercise – I need to add this is not running or football – avoid trauma of the knee. Low impact leg workout is helpful to strengthen the supporting muscles and will reduce pain.
    - I am a believer in therapeutic massage to go with the exercises, works for my patients.
    - Oral supplements – can help with weightloss, and pain control, but for structural repair – nothing that I know of that worked, it’s disappointing.

    1. calliarcale says:

      Personally, I see NSAIDs mostly as an aid to exercise. People stop exercising because it hurts; treat the pain and they start exercising again, the arthritis improves, and they can stop the NSAIDs (or at least stop taking them so much). I’m not a fan of long-term use of anything if you can help it, but honestly, for severe osteoarthritis long-term use of NSAIDs may be worthwhile if it keeps the patient from needing an artificial joint, as that can have some pretty serious repercussions too.

  6. It’s funny to see this. I’ve had numerous patient complaints why Glucosamine was no longer covered for them at the pharmacy. Doesn’t matter how many times you explain “there is no evidence for it and a decision was made not to cover it anymore”, the response is always “but it works wonders for me”. Observationally, these patients are usually overweight. Put the above guidelines together and it makes perfect sense (sub in exercise for glucosamine, lose some weight, strengthen supporting muscles and your pain will likely improve).

    I wish we actually had time in a busy pharmacy to actually explain everything to these patients. Undoubtedly some, turned away by a government plan, turn around and still buy this stuff.

  7. windriven says:

    @WLU

    ” If ethics are at all a concern to you, then you’re doing fine.”

    I wish my bank felt the same way ;-)

  8. Jeff says:

    I wonder what Dr. Hall thinks of undenatured type 2 collagen (not mentioned on the AAOS list). According to this article its effectiveness doesn’t require absorption into the body. The stuff merely has to remain intact while passing through the small intestine:

    http://www.lef.org/magazine/mag2012/jul2012_Hault-Auto-Immune-Attack-Of-Arthritis_01.htm

  9. WilliamLawrenceUtridge says:

    @FastBuckArtist

    Thanks for once again proving that CAM recommendations are either utterly redundant to mainstream recommendations, or based on unproven, but lucrative, supplements. While aspirin does indeed come with risks (and benefits, as it does prevent strokes at the cost of clotting), what is your alternative for a patient unwilling to lose weight or attempting to lose weight by exercising, but is limited by joint pain?

    That’s right, nothing. You’ve got nothing.

    Also, “works for my patients” is synonymous for “in my experience”, three worthless and dangerous words, particularly in medicine.

  10. Harriet Hall says:

    @Jeff,
    “I wonder what Dr. Hall thinks of undenatured type 2 collagen”

    I think the same thing the AAOS thought: there’s not enough evidence to seriously consider it. Only one small study in humans, with overlapping confidence intervals. There is at least one study showing that magnets were apparently effective, too, but the AAOS didn’t include magnets in their analysis either. I think they used good judgment.

  11. Thor says:

    @irene

    I hear you and it’s flabbergasting that selling snake oil to an unwitting public takes such prominence in ANY business model. The bottom line trumps ethics any day, most every time—even in stores we like, such as Costco, Whole Foods, and our pharmacies.
    Twenty-five years ago, a friend who owned a large health food store, pointed to his rows and rows of vitamins and other supplements and told me, “It’s all bullshit, but without selling these products, I wouldn’t be in business”.
    No, not even real food would keep him afloat. Fruits, vegetables, grains, cheeses, meats, just not lucrative enough. SCAM comes to the rescue for profit margins.
    In an ideal world, there should be an official public pronouncement by government that—NEWSFLASH—such and such a substance has been proven NOT to work.

  12. stanmrak says:

    Arthritis the result of “wear and tear”? Perhaps not. Maybe we can learn something from moose.

    Researchers found that osteoarthritis incidence increased in moose who were borne in times of population excess and nutritional hardship. Baby moose weaned on substandard amounts of food were more likely to develop osteoarthritis later in life.

    http://www.mtu.edu/news/files/ele_1504_Rev_EV.pdf
    http://www.marksdailyapple.com/malnutrition-diet-osteoarthritis/#ixzz2VveaTND7

    Statistics consistently show that the more active you are, the less osteoarthritis you have. Almost 44% of adults with doctor-diagnosed arthritis report no leisure time physical activity compared with 36% of adults without arthritis. Clearly not about wear and tear.

    Try eliminating wheat and grains from your diet – completely. Scoff if you will, but don’t tell me that’s it’s wear and tear.

    http://www.marksdailyapple.com/arthritis-diet/#axzz2VvcbvdMH

  13. WilliamLawrenceUtridge says:

    People aren’t moose. People live longer than moose. Moose are killed by predation and hunting, two things which humans generally aren’t vulnerable to. We tried to learn something about thalidomide from rats and the results were rather horrific.

    I scoff at your claims that wheat and grains will eliminate osteoarthritis.

    Hey, look at that – the site you linked to conveniently has a store that will sell you all the supplements you need! Wow, I can totally trust his advice!

  14. Mhops says:

    I apologize for being off a little off topic (but at least I’m not peddling my quack arthritis cure).

    Are there any decent skeptical documentaries about CAM (in general or specific subtypes)?

    Thanks!

  15. windriven says:

    @stanrnutz

    “Clearly not about wear and tear. Try eliminating wheat and grains from your diet – completely.”

    This isn’t simply a non sequitur, this fractal wrongness – pretty much what we’ve come to expect from you.

    First, you misconstrue wear and tear. The greatest damage comes from abuse; sitting on your fat keister in front of the vast wasteland for 6 hours a day, then chugging at full speed (such as it is) to catch the Good Humor man before he drives away. But athletes and others aren’t immune.

    As WLU pointed out above, humans and moose are both mammals but the similarities diverge pretty spectacularly beyond that. Moose in the wild* have a lifespan of 15-20 years. Humans, even those living in Somalia**, have a life span from 3 to 5 times as long. (squeaky hinge sound) all that walking and running and bending and jumping takes a toll. Except for you, Stan! You’ll live forever, supple and flexible as a ballerina.

    Next, you roll out some batsh|t crazy diet nonsense that has absolutely nothing to do with Dr. Hall’s post and that has no meaningful scientific support nor any prior plausibility. WTF is your fixation on grain? Bread, pizza, pasta, rice, tortillas; many of the things that bring joy to the table include one or another grain.

    Now Stan, I don’t actually believe you are actually as stupid as you pretend to be. You seem to be able to write sentences that have subjects and verbs and that order parts of speech appropriately. So what’s your game? Really? Why are you here and why do you open these cans of discount nonsense? Are you just a common garden troll like FBA or do you have some objective?

    *National Geographic, http://animals.nationalgeographic.com/animals/mammals/moose/
    ** CIA World Factbook places Somali life expectancy at 51.19 years

  16. morris39 says:

    The interesting question for me is why the “wear and tear” is repaired differentially across (sufficiently like) individuals and across time for the same individual. I have experienced measurable improvement in (one) knee symptoms (never more than mild discomfort under stress) as part of many other small improvements. I am assuming this is due to my experimentation which is 3 years long now but I do not know the mechanism. Diet was one of the interventions (not for reasons of excess fat). Crepitus I found correlates well with the degree of “arthritis” but I have not found a convincing explanation for the funny sounds . If someone here has a plausible one I would like to hear. Possible that water is being expelled form large glycoproteins/gels ( GAG’s, collagen) is one of the factors?

  17. DugganSC says:

    @morris39:
    Crepitus

    Short answer, it’s the bones rubbing together for the grinding sound, and the sound of air bubbles popping the cartilage for the popping sound.

  18. micwat says:

    I wish I’d read this 10 years ago. I had the arthroscopy with lavage and debridement treatment (I think). I know they took out the meniscus which was torn. It didn’t really seem to do me any good and I still get bad arthritis pain.
    I’d like to understand better exactly what kind of exercise is meant by “the Arthritis Self-Management Program (ASMP), which was modified to include an exercise component” and “The program in that study was based on the same theoretical framework as the ASMP, but included content that was specifically tailored to
    patients with knee osteoarthritis.”

    What do I have to do to actually start implementing this exercise program for my own benefit?

    (Whenever I go to a physio they want to try some pet theory – accupuncture style needles to “release” the muscles. electric shocks along the muscles etc

    What kind of exercises? Is it just something that will build up the muscle strength/bulk around the knee? Squats? Wall sits? or weight exercises? or what?

    Is there a link to the details of this that could be provided? With nearly 50 percent of people suffering knee osteoarthritis by the age of 85 (http://www.cdc.gov/arthritis/data_statistics/arthritis_related_stats.htm), there must be many on the web searching for this science based content. Linking to the actual advice about how to implement these conclusions would be great service to humanity.

  19. egstra says:

    “What kind of exercises? Is it just something that will build up the muscle strength/bulk around the knee? Squats? Wall sits? or weight exercises? or what?”

    I’d suggest that you keep shopping for a physical therapist, preferably one who works with a sports medicine MD. I’ve recently developed arthritic pain in my knee and the PT has me doing a variety of exercises (plus lots of ice) to strengthen the muscles around the knee and in the hip and abs. Maybe it’s the passage of time; maybe it’s the exercise, but it’s getting better.

    Woo is not helpful.

  20. JBarrettLMT says:

    I think you will agree this is a reasonably reliable source for information. http://www.sciencedaily.com/releases/2013/06/130611204534.htm These are literally news reports, so light on analysis and implications. However what I want to point out is that this is really a new way to think about what is happening with osteoarthritis. It is not just simple “wear and tear” as you assert in first sentence of article. If we want to take a science based approach to anything – medicine included, we have to keep in mind we really don’t have all the answers to how the body works, even on a basic physiological level. There are many things we don’t understand, but think we do. So if you start with the blanket statement about what osteoarthritis is [what you think it is] and then analyse the possibility of any treatment working – using logic – you may reach a false conclusion b/c you have unknowingly started with a false premise. How could massage help arthritis for instance if it is simple wear and tear damage inside a joint? Well it probably could not. But what if that is not what arthritis really is? What if it is more complicated? What if it is rather a shift in the balance in the ongoing damage we all do to joint tissue just doing normal activity and the body’s ability to repair that damage on an ongoing basis? Typical damage and less repair = arthritis, typical damage and more repair = healthy joint. What if massage helps improve sleep cycles and that helps “reset” cell clocks as mentioned in article and that helps tip balance of joint repair more favorably, so ongoing damage is repaired better and arthritis lessens? I’m not asserting that as true mind you, just pointing out that we don’t understand many of the basic mechanisms of disease, and so we lack the imagination to even conceive of how certain treatments may work. That does not mean they can’t or don’t work. It means we have heretofore lacked the ability to concieve of how to design an experiment to test if they work b/c we lacked a theory – a new idea – on which to base an experimental design. That is not to say every crackpot theory should be tested, just to say we have to stay humble and constantly remind ourselves how little we really know about how the body works and be willing to look for new information like this article and see how that might help increase understanding instead of just wholesale calling everything we dont understand “quackery”.

  21. stanmrak says:

    If moose don’t live long enough to get arthritis, why did the study find moose with arthritis?

  22. WilliamLawrenceUtridge says:

    @Stan

    That’s not really the issue. The issue is you can’t naively compare moose with people. The arthritis that moose get might be totally different than the arthritis people get (itself divided into something like 100 different types) because of many factors:
    - people live considerably longer than moose
    - moose outweigh people by probably an order of magnitude
    - the diets are totally different (assuming diet makes a difference)
    - the environments inhabited by both are totally different (present and evolutionarily)
    - the activities of both are totally different
    - locomotion styles are totally different
    - location, distribution and loading of stresses on joints are totally different

    Let’s take the first one – moose arthritis could be analogous to certain types of human arthritis developed at the same age (15-25 years). Moose arthritis could be analogous to the arthritis developed by elderly humans (i.e. 1 moose year is 3 human years). Moose may have a specific genetic factor which makes them more susceptible to nutrigenic arthritis. Humans may not be suceptible to nutrigenic arthritis at all. The rapid growth rate of moose relative to humans (two years to reach adulthood versus 20 years), or their massive nutritional requirements (10,000 calories per day) or their ruminent digestion may have an impact. And finally, with a lifespan three times that of moose, humans simply have more time to develop damage to their joints by banging them on walls, trees, stairs, cars, or whatever – there’s simply more time to develop trauma, which could lead to qualitatively different types of arthritis.

    So to say “moose have nutrigenic arthritis, therefore humans have nutrigenic arthritis” is, bluntly, stupid. The idea that even if humans get nutrigenic arthritis, that it can be “cured” by improved nutrition, is speculation on top of a stupid assumption. And further, since the main symptom of arthritis is pain, and pain is extremely liable and subject to all sorts of influences (two people could have the exact same tissue structure and damage, but feel totally different levels of pain), without very good research you have no idea what your risk of selection and confirmation bias is.

    Well, I know what your risk of confirmation bias is. Given your comments, it’s pretty much 100% – anything that makes real medicine look bad is remembered, as is anything that pretends food is a cure.

  23. Harriet Hall says:

    @ Stanmrak, How much wheat and grains do moose eat?

  24. scienceofpossibility says:

    Two of my dogs with arthritis that limited their abilities and doggie joy are on glucosamine/chondroitin supplements, and they now play and behave like happy puppies. I suspect most of you have seen this. For me, for an “untreatable, surgery-imminent” knee condition I had, I put together a regimen with the help and advice of my PCP and homeopath, and my condition is now remarkably reversed. My orthopedist shrugs his shoulders and calls it a fluke or a miracle. I’m not buying that, but I believe in what I did. Until it happens to you, you can’t. My personal jury is still out.

  25. D. C. Sessions says:

    Based on the usual N=1 study, I find that after synvisc stopped doing the job, switching to titanium did wonders.

  26. WilliamLawrenceUtridge says:

    @scienceofpossibility

    Snake Oil Science actually uses knee osteoarthritis as an example of why you need controls in order to attribute improvements to changes in diets, drugs or whatever. It’s course is variable.

    How do you think the glucosamine and chondroitin reach your knees, undigested, from your gut? You could probably get a cheaper dose by gnawing on pigs ears, the normal source for the latter. Ditto for glucosamine, just munch on the occasional cockroach (glucosamine is a constituent of chitin).

    Certainly your homeopath didn’t do anything to help, unless you were thirsty.

  27. Steve says:

    I would characterize your statement
    “Hyaluronic acid injections – strong evidence against” Is not really what the AAOS recommendation mean.

    “Fourteen studies assessed intra-articular hyaluronic acid injections,” said David S. Jevsevar, MD, MBA, chair of the AAOS Evidence Based Practice Committee which oversees the development of clinical practice guidelines. “Although a few individual studies found statistically significant treatment effects, when combined together in a meta-analysis the evidence did not meet the minimum clinically important improvement thresholds.”

    That is equivalent to saying that the the evidence is not strong enough to recommend as a treatment. Since there are positive studies and they are well structured.
    I have reviewed the meta-analysis and I am not convinced that the meta analysis methodology is strong. They included HIP OA injection research with Knee injections. Flawed since hip intra-articular injections as a whole have poor repeatable efficacy compared to knee in all inject-able treatments.

    I would not agree with your characterization. It makes it sound as if the injections are worsening OA.

    Full disclosure I have no relationship with any manufacturer, however I do recommend for knee OA.

  28. Harriet Hall says:

    @Steve,

    “I would not agree with your characterization. It makes it sound as if the injections are worsening OA.”

    Their summary says the evidence is strong supporting non-recommendation because of ineffectiveness. It also says “The strength of this recommendation was based on lack of efficacy, not on potential harm.”

    I don’t think I mischaracterized anything. I certainly didn’t suggest that any of the non-recommended treatments would “worsen” OA. Why would you think that?

    It is certainly understandable that someone who injects hyaluronic acid and has seen improvement would question the AAOS findings. The human mind finds experience more impressive than scientific evidence, but experience can be misleading. The only way to be sure the injections were the cause of the improvement is to do controlled studies.

  29. Art Malernee dvm says:

    Polysulfated glycosaminoglycan im injections are used a lot in dogs and horses. Care to comment about its use in humans?

  30. Walter Turner says:

    I have just received bandages for my knees because of “beginning osteoarthritis”.
    Yet the word “bandage” does not occur in the AAOS report, Dr. Hall’s article or the comments.
    Does that mean bandages are to be classed with magnets, acupuncture, etc.?

  31. I am not sure at what point I said that I personally find viscosupplementation effective.

    This is not a experiential claim of effectiveness, which I know is useless. I was pointing out that there are structural flaws in the meta analysis that was used in the decision. It includes intra-articular hip injections. This is a much more traumatic procedure. Far more likely to produce that painful joint flare noted as the downside to these injections. When you review the tables on the base data you will see a general pattern in the both efficacy and negative outcome(flare). Younger patients 40-60 range have much better outcomes and fewer flares than in the total numbers. In addition hip injections are universally poor.
    As I put before “the evidence did not meet the minimum clinically important improvement thresholds.” in my opinion is not the same as saying “Hyaluronic acid injections – strong evidence against”.

    Am I still going to give visco-supplementation to my patients? Honestly I am not convinced in the first place that they were ever of any benefit in elderly patients and I discouraged their use. My primary use previously was in severe knee OA patients that have exhausted physical therapy, NSAID’s, and corticosteroid injections. Mostly inoperable cases due to age, weight, and health issues.I will still consider them especially in younger patients that are poor candidates for replacement surgery and that have had good relief in the past. I am not yet convinced that the AAOS opinion based on the annals of internal medicine meta-study is convincing enough to give up and consider surgery or worse narcotics.
    This is no way an endorsement of oral preparations.

    I have had trouble logging in with the new webpage that is why it took so long to respond.

  32. enkidu says:

    “Glucosamine and chondroitin – strong evidence against”

    Why are there so many vets selling these to pet owners for their dogs’ arthritis? Seriously, it’s everywhere.

    1. Harriet Hall says:

      Because they are willing to rely on testimonial evidence instead of science.

      1. xtrocious says:

        Don’t quite agree with Harriet

        My dog (she’s coming to 10 this year) was wrecked by joint pain and even though I was skeptical at first, I gave her glucosamine.

        Guess what? She no longer has joint pains and is running around like she was a puppy.

        Not science maybe, but it works and I am definitely glad that it did

        1. Chris says:

          Didn’t do a thing for my late cat. We knew he was going downhill when he could no longer jump onto the bed, and was in pain. Despite the glucosamine prescribed by the vet.

          Though he was over fifteen years old, and then got to the point of having kitty dementia. We realized this as he meowed mournfully for his water dish that was only a couple of feet away. That was when he was nineteen years.

          We could tell he was in pain because that was the only time he wanted to sit in a lap. He spent much of his last couple of years in a lap being brushed. I miss him, he was a good cat. Don’t even get me started on the cats we had to get for two kids after he passed away.

  33. WilliamLawrenceUtridge says:

    Correct me if I’m wrong, but aren’t the symptoms of arthritis rather liable? Don’t they change from day to day? What kind of arthritis was it, did you get a diagnosis? Would it have gotten better irrespective what you did? “Joint pain” is quite nonspecific, it could have been due to something transitory like an injury or infection. This is why blinding and control groups are necessary.

  34. Steve says:

    How about 5-Loxin?
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2575633/?tool=pubmed

    Conclusion

    5-Loxin® reduces pain and improves physical functioning significantly in OA patients; and it is safe for human consumption. 5-Loxin® may exert its beneficial effects by controlling inflammatory responses through reducing proinflammatory modulators, and it may improve joint health by reducing the enzymatic degradation of cartilage in OA patients.

    1. WilliamLawrenceUtridge says:

      After skimming the article you link to and doing a bit of digging on pubmed, it certainly looks like a promising starting point (given my limited appreciation of biochemistry and pharmacognosy). The obvious limitations are the small number of actual studies (less than 10 for 5-Loxin though there are more for Boswellia, from which it appears to be extracted, which has been studied a fair bit though it is also associated with minor adverse effects) and small number of patients (from what I can tell, less than 100 have received the active ingredient in the two RCT that have occurred to date). Obviously a single group seems to be working a lot on this compound, so replication is an issue, but the work they are doing seems quite reasonable. It seems like a good starting point on a potentially promising compound.

      If you are thinking in terms of personally supplementing with this stuff, or recommending it to others, you might want to try a little test. If this were a novel drug synthesized by Pfizer, would you give a bottle of it to your mother or grandmother on the basis of these trials? If the answer is “no”, then perhaps you might want to hold off on taking the pills.

  35. frank brootal says:

    It would seem that despite there being no evidence of arthroscopy for OA of the knee being effective, it is still being performed frequently. https://www.mja.com.au/journal/2012/197/7/trends-elective-knee-arthroscopies-population-based-cohort-2000-2009
    Critics could surely say that surgeons who continue to perform this procedure are just out to make money. I expect the readers of this blog to reply with outrage that these surgeons are confidence tricksters, quacks, and charlatans, as they do with any practitioners of CAM therapies that aren’t backed by science.

    Fine to sceptical, but please apply your scepticism without prejudice.

    1. WilliamLawrenceUtridge says:

      sCan you point to any post on this website that says “more arthroscopy needs to be performed for arthritic knees”? I vaguely recall a couple posts disparaging that procedure for its lack of effectiveness, and several that explicitly support the “Choosing Wisely” campaign that actively discourages that procedure.

      You misunderstand the relationship between real medicine and CAM. Tissue debridement for OA of the knee had prior plausibility (it might have worked), whereas most SCAMs do not. Several studies of TB for the knee were conducted, and no benefit was found – it was tested and it failed. SCAMs usually are not tested. There is active criticism within the scientific community of this procedure and medical authorities are attempting to increase awareness of the futility of the procedure – you link to exactly such an effort. SCAMs are rarely officially abandoned or disparaged by authority figures within the SCAM community, no matter how many tests fail. Witness for instance, ongoing claims that homeopathy is effective, or that chiropractic care can treat otis media (or any hundreds of conditions beyond mere back pain).

      Finally, note that you are posing a false dilemma – the fact that tissue debridement is ineffective for OA of the knee means that that procedure should not be done. It doesn’t mean that SCAMs work. It’s not a zero-sum game with a winner and a loser – individual SCAMs either work or they don’t, irrespective the rest of medicine. Vitamin C either cures cancer, or it doesn’t (it doesn’t), no matter the effectiveness of chemotherapy. Homeopathy either cures diseases or it doesn’t, irrespective the effectiveness of antibiotics. By criticizing medicine, all you are proving is that medicine needs to improve further – you in no way justify quackery.

  36. frank brootal says:

    Your first question is irrelevant. The title of the article I responded to is ‘Thumbs down for Acupuncture and Glucosomine’. It could equally have been ‘Thumbs down for Arthroscopic Debridement’. I did not criticise medicine, promote quackery, or claim that any statement was made that more arthroscopy should be done. I responded to a specific article. It was based on a report that listed four treatments for which there was strong evidence against effectiveness: acupuncture, glucosomine, hyaluronic acid injections, and arthroscopic debridement. Of these four the author railed against only two. The author thought that the report’s approval of exercise and weight loss would show that surgeons were not evil money-grubbers promoting income-generating arthroscopic lavage and debridement. The Monash University study shows that whether they are promoting them or not, they are still doing a lot of them. While this treatment is ‘officially abandoned’ it is still being done. You say that a difference between conventional medicine and non-conventional is that the former abandons therapies that fail a test, I would suggest that in this case there is no difference.

    I made no statement that revealed my understanding of the relationship between ‘real medicine’ and CAM so I can’t see how you could say that I misunderstand it. Posts on science based medicine blogs frequently denigrate CAM practitioners as confidence tricksters, quacks, and charlatans. ‘Malfeasance’ crops up on this page. I assumed that was because their treatments were not thought to be science based. So I suggested that if surgeons were performing procedures that were not science based then advocates of science based medicine would also denigrate them. This says nothing about my understanding of the relationship between ‘real medicine’ and CAM, but does show that I think that crusaders for science based medicine determine the targets of their vitriol with unscientific criteria.

    What is this ‘initial plausibility’? It seems a little subjective to me. Plausible to whom? I don’t recall it being a part of the good old observation, hypothesis, experiment, analysis of scientific method. Anyhow, isn’t science based medicine what you’re after, not initial plausibility based medicine?

    You have imagined your false dilemma. There is no good evidence that tissue debridement effectively treats OA of the knee. I pointed out that despite this lack of evidence it is still frequently performed. How is this a claim that ‘SCAM’s’ work?

    1. Harriet Hall says:

      The reason the title wasn’t “Thumbs Down for Arthroscopic Debridement” is that that isn’t news. Doctors are aware of the research, and much has been written about it in the medical literature. Some doctors have stopped doing the procedure, and there is peer pressure for others to stop. Changes like this tend to take time, not so much because surgeons want to make money, but because of human psychological factors such as reluctance to abandon something that they were taught was the right thing to do by teachers they respected and that their grateful patients have been telling them really worked. I agree that that is wrong and could justify malpractice lawsuits for failing to follow the new standard of practice, but I wouldn’t call those doctors “confidence tricksters, quacks, and charlatans.” For that matter, I wouldn’t call doctors who prescribe glucosamine or refer patients for acupuncture those names either; I’d call them misguided. In fact, I wouldn’t call homeopaths “confidence tricksters” either; I think most of them sincerely believe they are helping their patients. Part of our mission on SBM is to try to understand the factors that lead even intelligent, educated people to use treatments that don’t work and have no basis in reality.

      The thumbs down on acupuncture and glucosamine IS news. There are a lot of doctors who believe they work and who have not evaluated the literature on the subject the way these orthopaedists did. Many of our colleagues are “shruggies” who don’t know much about CAM, and it’s important to educate them. My emphasis on acupuncture and glucosamine was in no way intended to condone arthroscopic debridement for knee osteoarthritis.

    2. WilliamLawrenceUtridge says:

      Meh, I assumed you were going to take this in the usual direction of most SCAM proponents, which is “if doctors are wrong then CAM works”. You didn’t, so that’s fine. But…

      What is this ‘initial plausibility’? It seems a little subjective to me. Plausible to whom? I don’t recall it being a part of the good old observation, hypothesis, experiment, analysis of scientific method. Anyhow, isn’t science based medicine what you’re after, not initial plausibility based medicine?

      Prior plausibility is the basic distinction between this site’s approach of “science-based medicine” and conventional “evidence-based medicine”. Knee debridement had prior plausibility – it used physical means in an attempt to solve a mechanical problem. While it might have worked, testing showed it didn’t and should be abandoned. SCAMs on the other hand, lack prior plausibility. There’s no reason to ever suspect homeopathy could or would work (and it doesn’t). SCAMs buck science- and evidence-based medicine by advocating testing of modalities that simply shouldn’t work on the basis of what we know about the body. Specifically, glucosamine (a supplement) lacks prior probability because it is simply digested when consumed, and there’s no reason it would be any more helpful than any other nutritional source of protein. Acupuncture lacks prior probability because we know qi (a type of vital energy, and vitalism failed testing several centuries ago) doesn’t exist, and there’s no reason to suspect that stabbing people with needles would be effective for anything.

      Science-based medicine is initial plausibility medicine. This site is harder on SCAMs because as a whole, they all lack prior plausibility yet they are still embraced by the medical community and treated with kid gloves in much the same way religious claims are given special standing in the political, scientific and historical communities despite being equally ridiculous. It’s not really that subjective – we know how a lot of things work in biology and chemistry so we would have a pretty good sense of whether something might work if tested. SCAM claims are so ridiculous, so contrary to what we know about the body, that they aren’t worth wasting money on for either testing or treatment. That’s why they are singled out for special criticism here – because they are unjustifiably treated as credible despite there being no reason to they they are anything but placebo.

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