Use of complementary and alternative medicine among patients with radiographic-confirmed knee osteoarthritis

Use of complementary and alternative medicine among patients withradiographic-confirmed knee osteoarthritis K.L. Lapane y, M.R. Sands zx, S. Yang y, T.E. McAlindon k, C.B. Eaton zx{y Department of Epidemiology and Community Health, Virginia Commonwealth University, 800 East Main Street, 8th Floor, Richmond, VA 23298, USAz Department of Community Health, Warren Alpert Medical School, Brown University, Providence, RI, USAx Center for Primary Care and Prevention, Memorial Hospital of Rhode Island, 111 Brewster Street, Pawtucket, RI, USAk Department of Rheumatology, Tufts Medical School, Boston, MA, USA{ Department of Family Medicine, Warren Alpert Medical School, Brown University, RI, USA Objective: To examine use of complementary and alternative medicine (CAM) among individuals with radiographic-confirmed osteoarthritis (OA) of the knee.
Methods: We included 2679 participants of the Osteoarthritis Initiative with radiographic tibiofemoralknee OA in at least one knee at baseline. Trained interviewers asked a series of specific questions relating to current OA treatments including CAM therapies (seven categories e alternative medical systems, mind-body interventions, manipulation and body-based methods, energy therapies, and three types of biologically based therapies) and conventional medications. Participants were classified as: (1) conven- tional medication users only, (2) CAM users only; (3) users of both; and (4) users of neither. Polytomouslogistic regression identified correlates of treatment approaches including sociodemographics andclinical/functional correlates.
Results: CAM use was prevalent (47%), with 24% reporting use of both CAM and conventional medicationapproaches. Multi-joint OA was correlated with all treatments (adjusted odds ratios (aOR) conventionalmedications only: 1.62; CAM only: 1.37 and both: 2.16). X-ray evidence of severe narrowing (OARSI grade3) was associated with use of glucosamine/chondroitin (aOR: 2.20) and use of both (aOR: 1.98). TheWestern Ontario and McMaster Universities (WOMAC)-Pain Score was correlated with conventionalmedication use, either alone (aOR: 1.28) or in combination with CAM (aOR: 1.41 per one standarddeviation change). Knee Outcomes in Osteoarthritis Survey (KOOS)-Quality of Life (QOL) and Short Form(SF)-12 Physical Scale scores were inversely related to all treatments.
Conclusion: CAM is commonly used to treat joint and arthritis pain among persons with knee OA. Theextent to which these treatments are effective in managing symptoms and slowing disease progressionremains to be proven.
Ó 2011 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.
weight loss, pharmacologic approaches) for pain relief, as well asminimizing functional limitations of symptoms and to attempt to By the year 2020, 59.4 million persons in the United States will be slow disease progressi. In additional to conventional medications, affected by arthritiOsteoarthritis of the knee (OAK) is the leading complementary and alternative medicine (CAM) (including herbal cause of disability in the United Statand population-based remedies, acupuncture, supplementsincreasingly are used. Indeed, projections of the probable need for total knee arthroplasty indi- arthritis is among the top six conditions for which CAM is use cate steady increases in all age grou. Patients suffering from OAK Previous reports have demonstrated that CAM use differs by age seek effective treatments (e.g., physical or occupational therapy, grougende, race/ethnicieducational attainmenannualhousehold income, employment stat, and health insurance status.
However, the extent to which the existing literature on CAM use(based on self-report) extends to a population with radiographic * Address correspondence and reprint requests to: Kate L. Lapane, Department of confirmation of OAK is unknown. Also, standardized measures of Epidemiology and Community Health, Virginia Commonwealth University, 800 East performance, function, quality of life and pain are frequently absent Main Street, 8th Floor, Richmond, VA 23298, USA. Tel: 1-804-628-2506.
from studies of CAM among persons with OAK. Lastly, most studies of 1063-4584/$ e see front matter Ó 2011 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.
K.L. Lapane et al. / Osteoarthritis and Cartilage 20 (2012) 22e28 CAM use describe correlates of CAM use only, and have not differ- glucosamine. A series of questions specifically asked about the use entiated the use a combination of CAM and conventional medical of CAM approaches for arthritis or joint pain during the past year, as approaches. Thus, we examined the use of CAM and conventional well as how frequently practitioners were seen. Responses from medication approaches in a large number of participants of the these questions were used to classify participants as: conventional medication users only, CAM users only, both CAM and conventionalusers, and users of neither.
Medications often used in the management of OAK included use of acetaminophen, over-the-counter NSAIDs (e.g., aspirin, ibuprofen, The Institutional Review Boards of Virginia Commonwealth naproxen), NSAIDs requiring a prescription (e.g., ibuprofen at higher University and the Memorial Hospital of Rhode Island approved the doses, diclofenac, naproxen), COX-2 selective inhibitors (e.g., valde- coxib, rofecoxib, celecoxib), hyaluronic acid, steroids/injected corti-costeroids, and calcitonin. To differentiate from CAM, we labeled these treatments as conventional medications. We considered CAas anyindication of use of: (1) alternative medical systems (acupuncture, We used publicly available data from the OAI ( acupressure, homeopathy and others); (2) mind-body interventions (#AllClinical00, V0.2.2). The OAI began enrolling people (yoga/Tai Chi/Chi Gong/pilates, spiritual activities, relaxation therapy, aged 45 through 79 years in 2004 and followed them annually for meditation, deep breathing or visualization); (3) manipulation and the development or progression of OAK. The clinical sites involved body-based methods (Chiropractic and massage); (4) energy thera- were Baltimore, MD; Columbus, OH; Pittsburgh, PA; and Pawtucket, pies (copper bracelets or magnets); (5) topical biologically based RI. Participants were ineligible if any of the following were present: therapies including rubs, lotions, liniments, creams or oils (tiger balm, (1) rheumatoid arthritis or inflammatory arthritis; (2) severe joint horse liniment), capsaicin; (6) biologically based diet; or (7) biologi- space narrowing in both knees or unilateral total knee arthroplasty cally based supplements (e.g., herbals, glucosamine, chondroitin, and severe joint space narrowing in the contralateral knee; vitamins/minerals, methylsulfonylmethane (MSM), S-adenosylme- (3) inability to undergo 3.0 T magnetic resonance imaging (MRI) thionine (SAME)). Because glucosamine and chondroitin are not examination of the knee; (4) a positive pregnancy test; (5) inability considered as CAM in some countries, we also separated the use of to provide a blood sample; (6) use of ambulatory aids aside from the glucosamine and chondroitin from other CAM treatments.
use of a single straight cane for 50% of ambulation time or more;(7) co-morbid conditions that might interfere with ability to participate in a study with a 4-year follow-up time; or (8) unlike-lihood to reside in the clinic area for at least 3 yThe overall Based on a non-systematic literature review, we considered several conceptual domains as potential correlates of treatmentapproach for OA: sociodemographic indicators, body mass index (BMI), overall measures of mental and physical wellbeing, and clin-ical indices of OAK. We hypothesized that CAM use would be different For the current study, we included individuals with radiographic by age grougen, race/ethnicity, educational attainment tibiofemoral OAK in at least one knee at baseline (N ¼ 2679).
annual household income, employment status, and health insur- Readers from each clinical site were trained to assess baseline fixed ance status. Gender, age, and race/ethnicity were based on self- flexion knee X-rays for osteophytes and joint space narrowing.
report. Participants were considered employed if they reported Training consisted of a didactic and interactive components using currently working or planning to return to work within 6 months.
a web-based system that included scoring a training set of knee Health insurance coverage status was identified as “currently having X-rays. Radiographic tibiofemoral OAK was defined as the presence private health insurance, prepaid plans, Preferred Provider Organi- of an Osteoarthritis Research Society International (OARSI) atlas zations or any government-sponsored plans”. Participants were also osteophyte grade 1e3 (equivalent to Kellgren and Lawrence classified as having insurance that covered prescription medications.
grade  2) on a fixed flexion radiograph based on the readings In the general population, obesity is inversely related to use of results provided by the individual clinical site.
. Trained examiners measured height (mm) twice duringheld inspiration. BMI was calculated from measured height and weight [weight (kg)/height (m2)]. Participants with a BMI between25 and less than 30 were defined as overweight, 30 to less than 35 We decided to create a four level variable to simultaneously as obese, and 35 and over as morbidly .
categorize participants according to their CAM and conventional The Medical Outcomes Study Short Form 12 (SF-12) was used to medication use. Previously, reports have focused on correlates of assess general physical health status. The SF-12 consists of 12 ques- CAM use, without regarding use of conventional medications. Yet, tions covering eight health domains (physical functioning, social we speculated that use of both strategies were common and that the functioning, role-physical, role-emotional, mental health, energy/ factors associated with monotherapy (CAM or conventional), may vitality, pain, and general health perceptio. The questions were be different to those associated with use of combined therapies.
combined, scored, and weighted to create the Physical Health Scale Participants were asked “During the past 30 days, have you used and Mental Health Score (ranging from 0 (lowest level of health) to any of the following medications for joint pain or OA on most days? 100 (highest level)). The Center for Epidemiologic Studies Depression By most days, we mean more than half the days of the month.” (CES-D) 20 item Scawas used to evaluate the depression status Participants were asked separate questions for: acetaminophen, and participants with scores above 16 were considered to have over-the-counter non-steroidal anti-inflammatory agents (NSAIDs), We also considered indicators of symptoms and severity of OAK inhibitors, doxycycline and prescription “strong pain” medications including pain, quality of life, performance and function, and disease such as opioids. Interviewers asked “During the past 6 months, did severity. For the measure of pain, we used the Western Ontario and you use the following health supplements for joint pain or McMaster Universities (WOMAC) Osteoarthritis Index (Likert Version arthritis?” with separate questions for chondroitin sulfate and 3.1). Although the WOMAC measures three separate dimensio, K.L. Lapane et al. / Osteoarthritis and Cartilage 20 (2012) 22e28 we only used the pain scale. Each of the five items of the pain scale five Likert responses, ranging from ‘0 ¼ none’ to ‘4 ¼ extreme’, which were summed to produce the pain subscale The majority of the sample was white, well educated, and scores (maximum score 20 indicating the worst pain). We also used covered by health insurance. Use of CAM was common (47%, 95% the Knee Outcomes in Osteoarthritis Survey (KOOS) as an indicator of confidence interval (CI): 45e49%). Sixteen percent (95% CI: 15e18%) knee related quality of life. The KOOS assesses knee symptoms and used conventional medications only, 23% (95% CI: 21e25%) used function during more demanding activities (e.g., during sport and CAM only, and 24% (95% CI: 22e26%) used both CAM and conven- recreation. The KOOS quality of life scale was estimated by tional medications. shows the specific types of CAM used.
summing the responses to four items with five Likert responses, Forty-seven percent reported use of at least one CAM method. Of ranging from 0 to 4 and computing a normalized score ranging from these, 32% (95% CI: 29e35%) reported use of at least two CAM 0 to 100 (100 indicating no symptoms and 0 indicating extreme approaches. The use of biologically based supplements was the symptoms). For the WOMAC and KOOS measures, we evaluated the most often used method (68%), followed by biologically based right and left knees separately and used the knee with worse topical agents (28%), and mind-body interventions (23%). Of CAM measures. For measures of performance and function we used a 20-m users, 54% used chondroitin, 59% used glucosamine, 12% used MSM, walk to measure walking ability and endurancThe average dura- and 13% used vitamins/minerals nearly every day. Almost 8% re- tion (seconds) of completing the 20-m walk was calculated based on ported use of energy therapies. Use of mind-body interventions was two trials. The chair stand test was used as a direct assessment of common (23%), with 12% of CAM users reporting use of methods like integrated physical performance involving leg strength and knee yoga or Tai Chi, w8% reporting techniques such as meditation or . The chair stand time was defined as the time duration visualization, and 8% reporting spiritual activities. The distributions (seconds) of standing up and sitting down five times as quickly as were similar regardless of conventional medication use except for possible. Disease severity was measured in two ways. First, we clas- spiritual activities which were more common among users of CAM sified participants by the X-ray joint space narrowing as determined and conventional medications (26%) than CAM only users (19%).
by the OARSI atlas osteophyte grade 1e3 (equivalent to Kellgren and shows the characteristics of the participants by treatment Lawrence grade  2) on a fixed flexion radiograpThe worst approaches: conventional only, CAM only, both, or neither. The age measure of two knees was used. Second, to capture multiple-joint OA distribution was similar across categories of CAM and conventional symptoms we considered: low back pain in previous 30 days, OA in medication use, while differences in the gender distribution were hand, hip symptoms, hip replacement and knee injury history present. Women were more likely to use any treatment (including knee injury and knee surgery) as reported at baseline.
(60% conventional medication only users, 61% CAM (only users, 67%both and 51% neither). The distribution of race/ethnicity was similar among those reporting use of both conventional and CAMapproaches to those reporting use of neither approach. Those We compared the sociodemographic and clinical characteristics of users in each group (conventional medication use only, CAM useonly, use of both CAM and conventional medications) to the referent group e non-users of CAM/conventional medications by conducting Characteristics of CAM use by category* (N ¼ 1259) chi-square tests for categorical data and t-tests for continuous vari- ables. Rather than overall chi-square tests, each group was compared to the referent group. Next, we used polytomous logistic regression modeling to identify correlates of treatment approaches by comparing the odds of using conventional medications only, using CAM approaches only, using both CAM and conventional approaches with non-users. In our polytomous logistic regression model, the outcome variable represented four categories. The models for each (three models for four categories) are simultaneously fit by using maximum likelihood to estimate adjusted odds ratios (aOR) for each group compared with a common reference grouBefore modeling we evaluated (and ruled out) the potential for multicollinearity amongst the potential correlate variables under study by checking correlations between the covariates. When two variables werecorrelated (e.g., education and income), we elected to include only one of the variables (e.g., education) in our final model. During the modeling process, the standard errors for the variables were alsoevaluated for indications of multicollinearity. If inflated standard Energy therapies (copper bracelets or magnets) Biologically based therapies: topical agent errors were apparent, we dropped one of the collinear variables from the model. We used an iterative, but not computer driven approach to develop the final model of correlates. To provide more clinically meaningful results for the SF-12 Physical Scale, WOMAC-Pain, and KOOS-Quality of Life (QOL), we provide odds ratios for a one standard Biologically based therapies: supplements deviation change in each variable. To further differentiate correlates amongst the different CAM approaches, we created a separate pol- ytomous logistic regression model with the following outcome variable: use of glucosamine/chondroitin only, use of other CAM approaches only, using both CAM and conventional approaches and non-users. The same modeling strategies described above were * As defined by the National Center for Complementary and Alternative Medicine.
y CIs were calculated based on asymptotic Gaussian approximation.
K.L. Lapane et al. / Osteoarthritis and Cartilage 20 (2012) 22e28 reporting use of conventional medications only were more likely to be Black/African American (29%), whereas users reporting only CAM conventional and CAM treatment approaches (N ¼ 2679) use were less likely to report being Black/African American (14%) relative to non-users of either group (18%).
Relative to non-users of CAM and conventional medications, those reporting only the use of conventional medications had less education, and were less likely to report being employed. Most reported health insurance coverage, with no differences in the percent with health insurance providing prescription medication coverage by treatment approach. The distribution of BMI differed between the conventional medication only group and those reporting use of CAM and conventional medications compared to non-users of either approach. Physical summary scores were less in each treatment group relative to the group using neither approach.
shows the clinical and functional characteristics of the participants stratified by treatment group. Compared to participants not using any CAM therapies or conventional medications, each of the other treatment groups had higher pain scores and lower quality of life indices. While CAM only users had functional and performance indicators similar to the no treatment group, users of conventional medications and users of CAM and conventional medications took longer on the functional tests. Correspondingly, all treatment groups had worsening X-ray evidence of joint space narrowing relative to participants who reported no CAM or conventional medication use.
Users of both CAM and conventional medications (29%), CAM only users (23%), conventional medication users (22%) were more likely to have severe joint space narrowing relative to non-users of CAM and conventional medicines (14%). Although overall total hip replace- ment was infrequent (<3%), its occurrence was greater in the conventional medication users only and in the CAM and conventional medication use group relative to the non-users. Hand OA was twice as prevalent in each of the exposure groups relative to the non-users.
Hip symptoms in the past 12 months were most often reported in users of CAM and conventional medications (w36%) followed by conventional medication users only (28%), CAM only users (25%), and non-users (15%). While history of knee injury was only more * May not total 100% due to rounding.
common in CAM only users relative to non-users (51% vs 45%),history of knee surgery was more prevalent among conventionalmedication users (32%) and CAM and conventional medicationusers (33%) relative to non-users (26%).
Table IIIClinical characteristics of participants with radiographic-confirmed knee OA by conventional and CAM treatment approaches (N ¼ 2679) Joint space narrowing: X-ray evidence of knee severity K.L. Lapane et al. / Osteoarthritis and Cartilage 20 (2012) 22e28 shows the correlates of treatment approaches among participants with radiographic-confirmed knee OA. Women were Sociodemographic and clinical correlates* of glucosamine/chondroitin use, otherCAM use among participants with radiographic-confirmed knee OA more likely than men to use any method (CAM or conventionalmedications). Black participants were less likely than non-Hispanic Whites to use CAM therapies either alone (aOR: 0.71; 95% CI: 0.51e1.00) or in combination (aOR: 0.54; 95% CI: 0.38e0.76). Rela-tive to participants with a high school education or less, those who graduated from college were more likely to use strategies that included CAM (aOR CAM only: 1.64; aOR Both: 1.48). Those with higher scores on the SF-12 (physical summary) and the KOOS-QOL were less likely to receive any treatments. Total hip replacement more than tripled the likelihood of use of conventional medications, either with or without CAM. X-ray evidence of severe narrowing (OARSI grade 3) was associated with strategies using CAM (aOR CAM only: 1.63; 95% CI: 1.16e2.29; aOR Both: 1.98; 95% CI: 1.39e2.82).
The analyses in further refine the classification of CAM into: (1) glucosamine or chondroitin users (with most participantsreporting use of both therapies); and (2) other CAM therapies.
When classified this way, women are twice as likely to report use of Sociodemographic and clinical correlates* of treatment use among participants with radiographic-confirmed knee OA (N ¼ 2679) * Reference group for the outcome includes patients who did not report use of CAM or conventional medications for OA treatment. Odds ratios shown are adjusted for all variables shown on the table. Results for conventional medications only and users of both CAM and conventional medications are not shown as the odds ratios are virtually the same as those shown in y Odds ratios are per one standard deviation change in SF-12 Physical Scale (standard deviation ¼ 9.5), WOMAC-Pain scale (standard deviation ¼ 4.0), and KOOS-QOL scale (standard deviation ¼ 23.1).
X-ray evidence of joint space narrowing.
other CAM therapies relative to men (aOR: 2.25; 95% CI: 1.61e3.14).
While Black participants were no more or less likely to report use of other CAM treatments, they were much less likely to report use of glucosamine or chondroitin (aOR: 0.39; 95% CI: 0.24e0.65). Further, those with at least a college education were twice as likely to report glucosamine/chondroitin use relative to those with a high school education or less, but education did not correlate with use of other CAM therapies. Severity of disease also did not correlate with other CAM use, but was associated with a greater likelihood of glucos- We found use of CAM approaches to be common. Forty-seven percent of participants of the OAI with radiographic-confirmed OAK reported use of at least one CAM approach, which is lower * Reference group for the outcome includes patients who did not report use of than previous report, but similar as other studies with specific CAM or conventional medications for OA treatment. Odds ratios shown are adjusted focus on OAEstimates of CAM use from other studies vary widely for all variables shown on the table.
(34e90) owing to differences in the operational expression of y Odds ratios are per one standard deviation change in SF-12 Physical Scale CAM use (e.g., including prayer), differences in the time referent (e.g., (standard deviation ¼ 9.5), WOMAC-Pain scale (standard deviation ¼ 4.0), and ever use, use in past month), population included (e.g., all conditions KOOS-QOL scale (standard deviation ¼ 23.1).
z X-ray evidence of joint space narrowing.
vs OAK), as well as geographic differences.
K.L. Lapane et al. / Osteoarthritis and Cartilage 20 (2012) 22e28 This study documents that persons with OAK commonly use on a 30 day and 6 month recall so it is possible that participants did multiple treatment approaches. Indeed, 24% reported use of at least not accurately report the use of treatments. These concerns may one CAM approach in addition to conventional pharmacologic have introduced misclassification in assignment of participants to medicines and 32% of CAM users reported recent use of multiple the treatment approaches which would have diluted any observed CAM approaches. The most common CAM approach was use of associations. The OAI data do not provide information regarding biologically based supplements. Despite widespread use, patients whether or not CAM treatments and conventional medications may not disclose their use of CAM to physiciansand even if dis- were actually covered by the participants’ health insurance. We cussed, CAM use is not frequently documented in the medical were unable to evaluate the impact of insurance coverage on use of recorThe extent to which herbal remedies and supplements may these treatments. As with other studiesour findings are not interact with conventional medications is non-triviaUnless CAM generalizable to all persons with OAK owing to selective partici- use is integrated into electronic medical records, averting such pation in research. In particular, most of the people in our sample interactions is unlikely. Given the extent of dual use of approaches, were employed, had health insurance, and were well educated. The physicians should be encouraged to ask patients about CAM use and sample also excluded persons with severe OAK.
document use. Electronic medical record systems allowing elec- Our study demonstrates that CAM use (with or without conven- tronic prescribing should have the ability to check for such drug- tional medication use) is common in persons with radiographic- herb or drug-supplement interactions at the point of prescribing, confirmed OAK, and that frequently multiple CAM approaches are as this may be the only place in the pharmacy-care process where used either alone or in conjunction with conventional medication use. Our finding that use of treatments is associated with severity of We found that participants with greater physical wellbeing as disease and pain indicators suggests that management of OAK may measured with standardized tools including the KOOS-QOL and SF- not be optimal. Sociodemographic, as well as functional and clinical 12 had reduced use of any treatment. Indication of clinical factors related to pain and quality of life are correlated to choice of depression was not associated with OA treatment. Although there treatment options. Physicians caring for persons with OAK should are many accepted CAM approaches to treatment of depression understand their patients’ CAM practices, educate patients of the increased use of CAM among persons with depression was not latest understanding of the usefulness of CAM approaches, and observed in previous reseaor in the current study. Indeed, discuss the potential risks associated with CAM and conventional persons with depression were half as likely to report glucosamine/ treatments. While previous research has documented the potential chondroitin use. Our findings contradict previous research linking adverse effects of both conventional and CAM approaches, more depression among persons with OA to greater health care utiliza- evidence is needed to demonstrate the effectiveness of these treat- tion (e.g., greater contacts with primary care providers, orthopedic ment approaches either alone or in combination with other CAM doctors, and CAM practitioners)These important differences approachesor conventional medicatioas the costs of treat- between CAM and non-CAM users in co-morbid conditions, phys- ment equal to costs of traditional mediciOur data demonstrate ical functioning and severity of illness will likely lead to con- the need for improved overall management, and potentially greater founding by indication when evaluating the benefits of CAM use access to total knee replacements if non-surgical approaches do not using non-experimental paradigms. As such, novel analytic sufficiently address the patients’ needs.
approaches to address such confounding in comparative effec-tiveness research of CAM must be employed.
Our study confirmed several important associations between treatment approaches and sociodemographic factors. We confirmed Kate L. Lapane: conception and design; drafting the article. She previous reports between gender and treatment options, with had full access to all the data in the study and final responsibility for greater associations noted with CAM use (either alone or in the decision to submit it for publication.
conjunction with conventional medications). As others have sho M.R. Sands and Shibing Yang: analysis and interpretation of persons with more education were more likely to select treatment options including CAM. In our study, more education was associated Charles B. Eaton and T.E. McAlindon: critical revision of the with increased reported use of glucosamine/chondroitin. Relative to article for important intellectual content.
non-Hispanic Whites, Blacks were less likely to use CAM treatments All authors gave final approval of the article.
(either alone or in conjunction with conventional medications) rela-tive to no treatments. The lack of CAM use by Blacks was owing to decreased use of glucosamine/chondroitin. This finding contradicts This study was funded by the National Institute of Arthritis and previous reports showing that Black persons with OA are more likely Musculoskeletal and Skin Disease (Project number 268201000020C- to use CAM and conventional medicatio. The extent to which our 1-0-1 entitled TAS::75 0888::TAS to Charles Eaton).
findings are subject to information bias, as others suggeremainsunknown. Persons with greater levels of obesity were more likely to report use of conventional medications than those with BMI < 25 k/ Dr. Eaton has received grants and has served as a consultant to Pfizer.
m2. Previous researchnoted that adults with higher BMIs were no Dr. Lapane has served as a consultant to Pfizer and Ortho McNeil more likely to use each of the individual CAM therapy and less likely to use supplements relative to normal weight adults. This is consistentwith the finding in our study that morbidly obese persons were almost half as likely to report use of glucosamine/chondroitin.
Our findings must be considered with limitations in mind. The The OAI is a publiceprivate partnership comprised of five data on treatments were obtained at the same time the measures of function and pain were collected. No questions were asked about N01-AR-2-2261; N01-AR-2-2262) funded by the National Institutes omega-3 or seal oil. This cross-sectional study precludes state- of Health, a branch of the Department of Health and Human ments of predictors of use and associations are confounded by Services, and conducted by the OAI Study Investigators. Private potential treatment effects. Recall bias of treatments among funding partners include Pfizer, Inc.; Novartis Pharmaceuticals persons with OAK has been documentTreatments were based Corporation; Merck Research Laboratories; and GlaxoSmithKline.
K.L. Lapane et al. / Osteoarthritis and Cartilage 20 (2012) 22e28 Private sector funding for the OAI is managed by the Foundation for 19. Greidanus N, Peterson R, Masri B, Garbuz D. Quality of life the National Institutes of Health. This manuscript has received the outcomes in revision versus primary total knee arthroplasty.
approval of the OAI Publications Committee based on a review of its scientific content and data interpretation.
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RBMOnline - Vol 7. No 2. 194–199 Reproductive BioMedicine Online; on web 16 June 2003 Premature LH and progesterone rise inintrauterine insemination cycles: analysis ofrelated factorsJoão Sabino Cunha-Filho obtained his MD degree (1993) and the speciality degree inObstetrics and Gynecology (1997) at the Faculty of Medicine (Hospital de Clínicas de PortoAlegre

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