Complementary medicine- or what used to be called alternative medicine- is gaining more acceptance as an option for people with arthritis.
A recent study showed that Whole-body Swedish massage proved safe and effective in reducing pain and improving function in osteoarthritis of the knee.
Osteoarthritis is a chronic condition that affects 21 million Americans and causes more physical limitation than lung disease, heart disease and diabetes mellitus, according to the Centers for Disease Control and Prevention (CDC).
Conventional treatment for knee osteoarthritis includes pain medication, exercises, hot and cold therapy, corticosteroid injections, and, eventually, surgery to repair the joint. Many forms of complementary therapy including yoga, herbal therapies, chiropractic, acupuncture, and others have also demonstrated effectiveness in treating osteoarthritis.
In a randomized controlled crossover trial, 68 men and women, patients with radiographically confirmed osteoarthritis of the knee were assigned to twice-weekly hour-long sessions of standard Swedish massage in weeks one through four and once-weekly sessions in weeks five through eight.
Participants in the massage intervention group received a standard one-hour Swedish massage twice a week for four weeks, followed by Swedish massage once a week for the next four weeks at the Siegler Center for Integrative Medicine at the Saint Barnabus Ambulatory Care Center in Livingston, New Jersey. After the first eight weeks of massage therapy, participants had improved flexibility, less pain and improved range of motion.
This study, reported the Archives of Internal Medicine (Archives of Internal Medicine, Vol. 166, No. 22 (December 11, 2006), suggested that the popular Swedish technique seems to diminish symptoms and improve the course of osteoarthritis by increasing local circulation to the affected joint, said Adam I. Perlman, M.D., MPH, of the University of Medicine and Dentistry of New Jersey and colleagues at Yale.
Massage also improved the tone of supportive musculature, enhancing joint flexibility, and relieving pain.
Massage therapy has been found effective for various painful musculoskeletal conditions, "but to our knowledge, this is the first prospective, randomized trial assessing the efficacy of massage for osteoarthritis," said Dr. Perlman and colleagues.
Patients were at least 35 years old, and were recruited from January to July 2003 at the St. Barnabas Ambulatory Care Center in Livingston, N.J. Those getting the massage were compared with a group of controls, who were all crossed over to massage after eight weeks -- called delayed intervention. Both groups were encouraged to continue previously prescribed medications and treatments.
Massage therapists used a standard full-body massage technique and a standard protocol.
The control group continued to receive conventional care during the initial eight-week intervention period and then at the ninth week, the controls crossed over to receive massage.
Primary outcomes were changes in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and functional scores, and the visual analog scale (VAS (0 mm to 100 mm) for pain assessment.
Measures of pain, stiffness, and functional ability were all significantly improved by the intervention as compared to the control group.
Those who only continued with their usual care without massage showed no changes in symptoms. During weeks nine through 16, they received the massage intervention and experienced benefits similar to those receiving the initial massage therapy. When reassessed eight weeks after completion of the massage intervention, the benefits of massage persisted and remained significant, although the magnitude of effect was somewhat reduced.
The findings were unchanged in multivariable models controlling for demographic factors, the researchers said.
Possible study limitations included the use of a wait-list control design because there is no validated method of performing placebo massage. However, the researchers said, this resulted in increased contact between the groups during the eight-week intervention.
In addition, using intention-to-treat analysis and carrying forward baseline values may have biased the results toward the null. The treatment effects observed were stronger when limited to only those subjects returning for follow-up, suggesting that the findings are a conservative estimate.
Another limitation pointed out by the authors was demographic homogeneity. The study participants were all from northern New Jersey and most were white women.
However, the results remain intriguing.
The potential importance of massage as an adjunct to or even an alternative to pharmacotherapy is "self-evident," Dr. Perlman said.
"Massage is free of any known side effects and according to our results, clearly shows therapeutic promise," said senior investigator of the study David L. Katz, M.D., associate adjunct professor in the Department of Epidemiology & Public Health at Yale School of Medicine and director of Yale's Prevention Research Center. "So-called 'alternative' treatments like massage are most important when conventional treatments are far from ideal. Currently available non-steroidal anti-inflammatory drugs are often not well-tolerated by older adults with osteoarthritis. Cox-II inhibitors like Vioxx were developed as substitutes for traditional anti-inflammatory drugs, but pose highly-publicized toxicity problems of their own."
"Our results suggest that massage therapy can be used in conjunction with conventional treatment for osteoarthritis," said Perlman. "Ultimately, massage may be shown to lessen a patient's reliance on medications and decrease health care costs."
Perlman and Katz say that further study of the cost-effectiveness and the lasting impact of the intervention is warranted. They have begun collaborating on a follow-up study.
"Our hope is to show that this treatment is not only safe and effective, but cost-effective," said Perlman. "That could serve to change practice standards so that massage is a more common option for the many patients with osteoarthritis of the knee."
Further study of massage, even other types of massage, to determine optimal treatment protocols, absolute efficacy, cost-effectiveness, and generalization to other patients groups is clearly warranted, Dr. Perlman's team concluded.
In addition to Katz and Perlman, other authors on the study included Alyse Sabina, Anna-leila Williams and Valentine Yanchou Njike, M.D., all of the Yale Prevention Research Center.
