American Academy of Orthropaedic Surgeons Evidence-Based Review of Arthritis Treatments

I have previously reviewed a number of common alternative therapies for arthritis. The evidence concerning veterinary use specifically is often limited, but for common therapies, like glucosamine and acupuncture, there is often extensive research data in humans. While extrapolation from one species to another should always be viewed with caution, if something is shown by extensive evidence to be useless in humans, this is reason to be skeptical about its value for our pets.

Harriet Hall, at Science-Based Medicine, has recently reported on an extensive evidence review of arthritis therapies published by the American Academy of Orthopedic Surgeons (AAOS).  This review evaluates common therapies, both conventional and alternative, and reinforces the conclusions I have previously come to regarding several of these. In particular, the evidence is clear and strong against the value of both glucosamine and acupuncture. And lest advocates of these immediately assume these conclusions are simply evidence of bias in favor of surgery, since the review was conducted by an organization of surgeons, I will point out that the report is equally critical of conventional surgical treatments that clearly don’t work either. They even cast doubt on the most common pharmaceutical therapy used, simply following where the evidence leads.

While this review by itself is not, of course, the sole and final word on any subject, it is part of a consistent and continually growing body of evidence which shows that several commonly recommended arthritis therapies simply do not work. At some point, hope and the placebo effect will have to give way to reality and we will have to start redirecting our resources away from studying and using such worthless treatments and into more promising therapies.

 

  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

 

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23 Responses to American Academy of Orthropaedic Surgeons Evidence-Based Review of Arthritis Treatments

  1. Art says:

    Anyone know about the use of Adequan use in Europe for people with arthritis? If it really works for horses and dogs and is FDA approved where are the FDA quality human studies that support it’s use for arthritis in humans?

    Art Malernee Dvm

  2. RumpyDog! says:

    Thank you so much for this post! I have a dog and a cat suffering from arthritis. The dog was offered Vetprofen, glucosamine and cold laser therapy. The cat was offered short-term pain meds and then glucosamine. I think I will decline the cold therapy. I bought a joint supplement. I’ll probably not use it past this first bottle.

  3. v.t. says:

    Skeptvet and Art, do you have an opinion on the use of Adequan in cats? Are you using it in practice for felines?

  4. Art says:

    I do not use it. Would love to know whatDavid Remey dvm says about it for horses. I used it for about ten years in dogs when it first came out. FDA studies saying it works looked good to me but the arthritic cases bad enough to justify the cost did not impress the client like a shot of cortisone did. Have never heard why if it works so well there is no FDA adequan human label.
    Art

  5. Anthro says:

    Hopefully, this will reach the pet food companies (including “vet recommended” Science Diet) and they will stop marketing food with added supplements for arthritis/joint pain. I am so disgusted by this practice. You cannot find a dog food anymore that does NOT make some ridiculous and unsupported health claim.

    SkepVet, I hope you’ll get around to reading “Feed Your Pet Right” sometime. It’s the only sensible source I’ve found for pet food advice.

  6. skeptvet says:

    There is, as Art points out, limited evidence to support it. There are not, unfortunately, a lot of good options for cats with chronic arthritis, so in cases that seem to warrant some intervention, I do discuss it along with meloxicam and other analgesics. I have used it in a few cases and have not been blown away but a subjective impression that it works, but of course I’m not confident that is a reliable guide anyway. As always, I believe the urgency of treatment and the uncertainty about the treatment need to be balanced, and in the case of arthritis in cats when the urgency is high enough, I don’t think it’s inappropriate to try therapies with poor supporting evidence so long as the client is made aware of the uncertainty involved.

  7. skeptvet says:

    Yes, the inclusion of such clearly worthless supplements as glucosamine in these diets is pure marketing triumphing over science.

    I have ordered the book, so hopefully I’ll get to reading it soon.

  8. Art says:

    There are randomized prospective studies using adequan as a arthritis prevention.

    38. Lust G, Williams AJ, BurtinWurster N, et al. Effects of intramuscular administration of glycosaminoglycans polysulfates on signs of incipient hip dysplasia in growing pups. Am J Vet Res 1992;53: 1836-1843.

  9. v.t. says:

    Thanks, skeptvet and Art, for your input on Adequan use in cats. I’ve seen a lot of (anecdotal) reports from vets and clients that it does seem to be helpful, for what it’s worth – is there perhaps a better safety margin rather than long-term use of metacam?

  10. Art says:

    V.T, I got this off the FDA website
    ” NO veterinary NSAIDs approved for long-term use in cats in US”
    Art

  11. v.t. says:

    Art, I understand the problems with NSAIDs of any type for use in cats, hence the off-label uses. Just wondering if the Adequan has a better safety margin than metacam (I know, so far, only anecdotal “evidence”).

  12. Diane says:

    Skeptvet, thank you for this invaluable site, which I stumbled across two days ago and can’t stop reading! A couple questions for you:
    –You have a lot of content throughout your site about different modalities for arthritis–would you consider consolidating your conclusions into a list like this article does? It’s SO helpful to see it succinctly laid out.
    –What are your thoughts on Hill’s j/d? My understanding is that it has been shown to improve clinical signs of arthritis, and that the primary active agent is very high EFA content.
    –Are you familiar with phycocyanin, an extract from the blue-green algae spirulina? The maker of “Phycox” (a supplement that contains it) says it is a COX-2 inhibitor and antioxidant. They have some publications on their site, http://www.phycox.com. I would be very interested in your opinion.
    Thank you!!

  13. skeptvet says:

    Thanks for the comment. I have an article which collects my various posts on osteoarthritis under Veterinary Arthritis Treatments, so hopefully that will help a bit.

    There is a little bit of evidence to support some value to J/D, but it’s tricky because there are a lot of different ingredients in it, and it’s difficult to sort out what exactly might be helping or to account for possible complicating factors such as weight loss, more close monitoring and veterinary care, and other changes that often occur when a dog is in a clinical trial. There is some independent evidence for fish oils (though I think it’s still pretty weak), so that could plausibly be the component that is helpful. Certainly, the glucosamine in it isn’t going to be helpful. So it’s not unreasonable to try it, but I’d like to see more detailed and, ideally independent, research before I had great confidence in it as a treatment.

    I am not familiar wwith phycocyanin, so I’ll try to take a look at some point. Thanks for the suggestion.

  14. Diane says:

    Thanks for the insights and the pointer to your other article. I’m learning a lot from this site…the biggest eye-opener is how personal experience is not nearly as reliable as I’ve been considering it…

  15. Art says:

    J/D has a prospective study showing it works with purina dog chow as the placebo. They need to randomize the study better so those reporting cannot tell just by looking at the food which dogs got j/d and which dogs got purina.
    Art

  16. skeptvet says:

    Diane,

    So I took a quick look at Phycox. It contains many different ingredients in addition to the phyocyanin (depending on which formula you use). Some are well-established to be useless (e.g. glucosamine), most haven’t been properly tested. The phycocyanin has been examined in lab animals and in vitro and modulates the expression of the genes that produce COX-2. It does NOT block COX-2 activity the way NSAID drugs do, so it is misleading to call it a COX-2 inhibitor. The effect, if any, of this gene regulation is unknown. It could potentially provide some clinical relief from arthritis pain, but it might not. I have not found a single clinical study in any species evaluating this as a treatment for arthritis, so all we have is a plausible potential mechanism and anecdotes.

  17. Anthro says:

    Sorry if I missed it, but what is J/D?

  18. Anthro says:

    Welcome Diane! You will love this blog and learn a lot from SkepVet. He’s a really wonderful writer who explains logic and its fallacies in a very readable way.

    You also might like:

    sciencebasedmedicine.org

    for the same approach to people!

  19. v.t. says:

    Anthro, J/D is Hills Prescription Diet J/D feline or canine food:

    http://www.hillspet.com/mobility/mobility-nutrition-canine.html

  20. Pingback: Veterinary Arthritis Treatments | The SkeptVet

  21. Shane Jakober, DVM says:

    Intraarticular HA (e.g., Legend) is a mainstay of treatment for horses with OA. It works great intravenously, too. There is lots of evidence to demonstrate its analgesic and anti-inflammatory effects, used with or without corticosteroids. I’ve also used intramuscular PSGAGs (e.g., Adequan) with positive effects noted, though less impressive. Chondroitin and Glucosamine have been shown to improve objective measures of lameness (force-plate studies) in dogs. When combined with ASU, there is a synergistic effect (as in the Nutramax product for both horses and dogs). I’ve had incredible luck using essential fatty acid supplementation (fish oil) in my dog for moderate OA due to hip dysplasia. That alone had a better effect than a daily NSAID, not only ameliorating her grade 3/5 lameness (obvious at a trot in all conditions), but also improving her attitude and hip range of motion. And it avoids the side effects known of daily NSAID use. I know many DVMs who only perform acupuncture, and have many happy equine and canine patients with chronic pain conditions. I know most of what I am relating is anecdotal, but I chose all those therapies because they were evidence-based. I can’t believe that all you’ve based your recommendations is from a group of human orthopedic surgeons. There is a lot of evidence in the veterinary literature in support of therapies you condemn. And a lot of happy pets.

  22. skeptvet says:

    I notice that despite your claims for “lots of evidence,” you don’t actually provide or cite any, only anecdotes. You also haven’t noticed the veterinary systematic review of nutraceuticals for arthritis I have written about, or all the other articles discussing the evidence regarding specific therapies for arthritis that I have posted. It isn’t enough to say that you are making evidence-based choices, you have to actually back this up with relevant, critically appraised evidence.

    In terms of specifics, I agree there is some evidence for IA hyaluronic acid, though not high-level controlled clinical trials. There is also some promising evidence concerning fish oils, though again it has pretty significant limitations. The evidence, however, absolutely does not support your claim that fish oils are superior to NSAIDs, which again you base entirely on anecdote. As for acupuncture, the fact people believe in it is irrelevant. The evidence is unconvincing, as I have discussed in detail before.

    I am happy to discuss specific therapies, but when you say there is evidence, you ought to show some. And when you refer to anecdotes as if they proved anything at all, you illustrate one of the main beliefs that impedes the development of truly evidence-based veterinary medicine. Here is a collection of resources discussing some of the many reasons such anecdotes are not reliable.

    Why We’re Often Wrong

    The Role of Anecdotes in Science-Based Medicine

    Why We Need Science: “I saw it with my own eyes” Is Not Enough

    Don’t Believe your Eyes (or Your Brain)

    Medical Miracles: Should We Believe?

    Testimonials Lie

    Alternative medicine and placebo effects in pets

    Medical Practices Once Widely Accepted that Proved Ineffective or Harmful when Studied Scientifically

  23. Jonos says:

    I can only add a personal experience with Adequan ( I am RN, and no vet experience except for taking care of my own pets for 15+ years. I was very skeptical of Adequan when my vet suggested it. I researched it until there was nothing more to read. Then decided to give it a try on an overweight, arthritic, 11 year old Golden Ret. (post TPLO one year ago) In 3 week I have seen a very obvious positive change in her overall gait, decrease in pain (as evidenced by her increase and interest in activity) and all of this with little to no side effect (for about 12 hrs after the injection she is gassy, I can deal with that) We are going into wk 4 of loading does of 1.5 ml (100mg/ml) with high hopes that this improvement continues and can be sustained with injections continuing every 3 to 4 weeks as maintenance. Just wanted to give an actual experience which has been a very good one with Adequan.

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