Article Review: Alternative and Complementary Therapies in Osteoarthritis and Cartilage Repair
Osteoarthritis (OA) is very prevalent within the global population and is becoming a growing socioeconomic and public health issue. OA is when joints undergo changes in which cartilage becomes thin and sometimes can be lost which can create bony changes in the joints and cause pain and functional weaknesses. The most common body parts that OA occurs in are the knees, distal interphalangeal joints (fingers), and hips. Clinically, OA can cause joint pain, stiffness, functional deficits, and reduced quality of life. There are multiple interventions for joint OA, however there are is no direct advice on “alternative” treatments including autologous chondrocyte implantation (ACI), autologous/heterologous mesenchymal stem cells (MSCs), platelet rich plasma (PRP), Vitamin D supplements, and other therapies. This study reviewed the current literature on the above mentioned “alternative” therapies to evaluate the research that has been done and make conclusions to determine the effectiveness of them.
Autologous Chondrocyte Implantation (ACI):
ACI is a surgical intervention where cartilage is removed from the affected area, cells of that cartilage (chondrocytes) are cultured, and then injected back into the affected cartilage location under a flap or membrane that is sutured into the defect.
Early trials found no benefit of ACI, however ACI has improved to include matrix assisted ACI (MACI). MACI has shown to have better outcomes than microfracture in terms of clinical and functional outcomes, however no differences with MRI or histological outcomes. ACI is also considered a high cost treatment and although there may be short term clinical benefits, the long term benefits are unknown. It is concluded that MACI may be a good use for symptomatic therapy in early cartilage disease and traumatic cartilage lesions, though may not be beneficial in OA.
Autologous Mesenchymal Stem Cells (MSCs)
Mesenchymal stem cells (MSCs) are cells from the bone marrow that can help facilitate the repair of chondral defects, or joint cartilage defects. MSCs can be directly injected into a joint where they can differentiate into either cartilage, bone, or fat and display anti-inflammatory properties. Based off the research, MSCs can be effective with lowering pain related to chondral defects or joint OA. However, there is limited evidence to suggest improvements with structural/ tissue repair. There are also multiple sources where autologous MSCs can be derived from including bone marrow, adipose (fat) tissue, synovial membrane, umbilical cord MSCs, and peripheral blood and there are various techniques to prepare the MSCs. Also, MSCs seem to have a greater positive impact on individuals who are younger in age, male, low BMI and have a small lesion/defect at mild to moderate OA severity. Despite potential benefits of MSCs to help decrease pain, there are multiple factors limiting stem cell efficacy and a standardization of MSC interventions is needed to obtain a better understanding and a clearer conclusion.
Platelet-rich Plasma (PRP)
Platelets are part of our blood that play an important role in inflammation. Platelet rich plasma is a fluid that helps stimulate cell growth, cell migration, and synthesis of our extracellular matrix. PRP is derived from centrifuging our blood so that the plasma component which is rich in platelets is separated from the other components of our blood. This plasma component is then extracted and injected back into our affected joint to help stimulate cell growth. PRP varies widely in regards to preparations and formulations making it challenging to determine effectiveness of PRP when injected into joints with OA, though some trial studies support a symptomatic benefit.
There are receptors for Vitamin D on chondrocytes and Vitamin D stimulates proteoglycan synthesis which are both important for cartilage health. Vitamin D deficiency influences bone remodeling which may predispose joints to the development of OA. Based on this info above, it is believed that increasing Vitamin D may improve cartilage structure and help slow down progression of joint OA. However, studies conducted demonstrate no structural or symptomatic benefit in OA.
Collagens: Oral and intra-articular
Oral and intra-articular collagens are a rich source of amino acids and can be helpful in OA to stimulate the joint to produce collagens. Even though this is widely used across the world, the current data does not support a positive recommendation to treat OA patients, however may have a mild effect on pain and function.
This is a dietary supplement found in plants, fruits, and vegetables. Only small trials have researched the effectiveness of MSM and although MSM is a safe supplement, larger, better designed trials are needed to make more conclusive recommendations.
This is produced in the liver and has been researched on the effectiveness for treating hip and knee OA. The research showed a minor improvement with pain and function when treating OA with SAMe compared to placebo. However, the quality of the studies were poor suggesting it is difficult to make accurate conclusions.
Curcuma is an extract of turmeric which has roots in Ayurvedic and Chinese medicine as an anti-inflammatory agent. In a meta-analysis from 2016, improvements in symptoms and NSAID consumption were observed for individuals that used curcuma vs placebo, however curcuma did no better when compared to Ibuprofen or when added to Dicflofenac. Another meta analysis published in 2018 concluded that curcuma improved pain and function when compared to placebo, however evidence was not enough at the time to be considered a recommendation to clinically treat OA.
This is an African plant thought to have anti-inflammatory properties. A systematic review concluded there was moderate evidence to help treat low back pain and joint OA. However, there were only three studies included and additional research is needed before it can be recommended in clinical practice.
This is another therapy that is thought to have an anti-inflammatory effect. A systematic review and meta-analysis of the studies performed found a significant reduction in pain and disability when using ginger vs placebo. However, there were high rates of discontinuation when taking ginger and may have increased risk of mild gastro-intestinal adverse effects.
It is challenging to make accurate conclusions of the clinical effectiveness of these interventions on symptomatic OA due to issues with study design and limited amount of research. Some interventions may be beneficial and there is insufficient evidence to declare them completely ineffective. Therefore, all of these interventions need to be further researched with larger, more appropriately designed studies.
Fuggle NR, Cooper C, Oreffo ROC, et al. Alternative and Complementary Therapies in Osteoarthritis and Cartilage Repair. Aging Clinical and Experimental Research. 2020, 32:547-560