Talk:Osteoarthritis/Archive 2

Reverted edits
This edit removed a bunch a reviews including a Cochrane review from 2009. Thus I reverted. Doc James (talk · contribs · email) (if I write on your page reply on mine) 19:47, 7 April 2013 (UTC)
 * Doc James, that is a heavy handed revert that removed tons of abbreviations and other edits. To simply restore the Cochrane review, let's do it more surgically.  Let me look closely at this single edit that you are trying to revert and see why I removed that info.Sthubbar (talk) 19:55, 7 April 2013 (UTC)
 * Doc James, this was near the start of my editing and I think I see the issue. My disagreement with that content is that as I mentioned in the edit comments, it violated NPOV to start listing every medication that has been shown to be ineffective for a particular disease.  Unless we also include a complete list of Western medications that have been shown to be ineffective for OA, then why include ineffective "Alt Med" treatments.  It appears clear that ineffective "Western" meds are ignored and only effective treatments are listed, so for "Alt Med" I would expect the same treatment.  If there is some controversy or extensive debate, like glucosamine, I'll let that slide for now, but from the mention of Vitamin C and stuff, I see no reason to include them.  Leave that out.Sthubbar (talk)
 * Doc James, that was in poor form. I put a comment in my I did the revert and further came here to explain.  You didn't even leave a comment when do did the revert a second time, or try to come to the talk page.  You are undoing tons of work, with no justification.Sthubbar (talk) 20:04, 7 April 2013 (UTC)
 * Justification was provided. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 20:19, 7 April 2013 (UTC)

Doc James, you provided some interesting input about glucosamine. I can't find that any of your data conflicts the statement that "1500mg cyrstalline glucosamine sulfate is effective" as stated by the 2012 review. Even the Cochrane mete-analysis can't rule out glucosamine sulfate, which supports the 2012 study. All other negative studies include glucosmaine HCL or heterogenous preperations of glucosamine.

Furthermore, as you made a mistake about the removal of the pmid:20847017 Cochrane review, I am reverting to where I left off. I appreciate your editing of the content and improving the quality.
 * You have removed a number of review articles again including: PMID:21220090 and this Cochrane review PMID:19821296. You have replaced the Cochrane review with an older non systematic review. You have removed the comments on there being a lack of good evidence which was supported by a 2010 review. I disagree with all these changes. The PMID to which you link is the BMJ article. The 2012 review is indeed contradicted by the other review you removed. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 23:28, 7 April 2013 (UTC)

Doc James, I'm going to assume good faith, so let me clear up what appears to be your confusion. Here is the situation:

1) I made several changes to OA 2)  You mistakenly assume I removed pmid:20847017 so you reverted most all of my changes 3) You added additional content, including PMID:21220090 that I wasn't aware of until just now 4)  I reverted to #1 to fix your mistake

The implication I hear in your comment is that I intentionally removed pmid:20847017 and PMID:21220090. We have already agreed that the former you were mistaken and the later, I wasn't aware because it was an addition after you made the massive revert.

As to PMID:19821296, this is for an di proven treatment. The implication is I removed a study disproving this treatment in order to support it. Instead I have completely removed the treatment because the treatment section is not to include every dis proven treatment. If a treatment doesn't work then completely remove it, or put it in the history section if you really want to have that in there.

Please stop the reverting. If you want to redo your edit, or I can even redo it for you of PMID:21220090, that's perfectly fine.Sthubbar (talk) 00:27, 8 April 2013 (UTC)
 * No that is not at all the case. But let see what a third opinion has to say. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 00:30, 8 April 2013 (UTC)

I reverted the latest change because generally the sourcing has been made worse in both recency and authority of works cited. Please discuss and get consensus for these proposed changes one at a time before replacing. 01:25, 8 April 2013 (UTC)

Adding - I understand some other good changes were in there like formatting or abbreviations. But the most important thing is the sourcing. Feel free to fix the small things while we discuss the sourcing changes. 01:33, 8 April 2013 (UTC)
 * I think most of the formatting changes he made are still there. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 01:42, 8 April 2013 (UTC)

I restored another removal of well-sourced and correctly-located content, including a 2010 Cochrane review. What could be the justification for the removal of such relevant, well-sourced content? 03:51, 8 April 2013 (UTC)
 * And he keeps removing what the refs say as in this edit  Doc James  (talk · contribs · email) (if I write on your page reply on mine) 15:02, 8 April 2013 (UTC)


 * Restored "many" after I confirmed that is what the source says.   15:23, 8 April 2013 (UTC)

Zad one more edit
Zad, for consistency, I suggest we remove curcumin from the second sentence of possible treatments and it conflicts with the stronger later study that says there is unclear evidence. OK?Sthubbar (talk) 17:40, 9 April 2013 (UTC)


 * Your suggestion is probably good. What's the later study's PMID?    17:54, 9 April 2013 (UTC)


 * The ref is already there talking about turmeric which curcumin is the active ingredient of turmeric. Sthubbar (talk) 18:03, 9 April 2013 (UTC)

Changes for 9 April
17:51, 9 April 2013 (UTC)
 * "Cat's claw" is a "practical treatment" - overstates what the source says. Source states "Three studies support cat's claw alone or in combination for OA" (Rosenbaum 2010).  Suggestion is to restore previous article content "Three studies support the use of cat's claw."
 * capsaicin and SAMe - study found them "effective in the management", but don't agree "practical" is a good paraphrase, suggest something like 'capsaicin and SAMe are effective in managing OA'.
 * vitamins and ginger, turmeric, omega-3, glucosamie: I'm OK with "There is insufficient evidence", I think it's an improvement.
 * chondroitin - "is not recommended", source says "discouraged", maybe we could make our statement a little stronger against


 * The remove of "three studies" is because this is a direct quote and as I've been told, plagiarism and copyright infringement. Also, I read the rules about using studies and if it is a single study then the language is "A 2010 study says X is a fact.", if it is a review article then it is "X is fact". DJ already reverted when I used the word "effective" and wrote on my talk page that I must paraphrase so I used thesaurus.com and practical is a synonym.  I don't see the problem with practical also for Cat's claw.  The review article supports the use, period.  You can make the chondroitin stronger.Sthubbar (talk) 18:01, 9 April 2013 (UTC)


 * I never said it didn't support, we just need to hammer out the wording. "Practical" is not a good synonym.  How about "There is evidence that cat's claw is effective in managing OA"?    18:18, 9 April 2013 (UTC)


 * Zad, that's fine. Feel free to edit at your leisure, I'm going to bed.  :)Sthubbar (talk) 18:20, 9 April 2013 (UTC)


 * Great! Have a good one.    18:25, 9 April 2013 (UTC)

So reverted back the edit that put cat's claw in the "effective" category... again, the review that covered it didn't go as far as to say 'effective', just that there's some evidence (three studies) to support. 01:58, 10 April 2013 (UTC)

Why single out cat's claw?
Zad, why do you want to single out cat's claw? The organization of the section I see is:
 * Treatments that are the most likely
 * Treatments that show some evidence and require more evidence

I am following the criteria "‘Weak evidence’ describes herbs with a single RCT with significant results; ‘promising evidence’ describes herbs with two trials that produced favourable outcomes; ‘moderately strong evidence’ describes herbs with three or more favourable trials." as specified here http://rheumatology.oxfordjournals.org/content/40/7/779.long, which is PMID:11477283, included in the article. We only use 2 categories instead of 3. Category 1 is 3 or more RCT. Category 2 is less than 3 RCT. Cat's claw has 3 RCT so that is why I include it in the first sentence with Capcaicin. Does that make sense?Sthubbar (talk) 02:00, 10 April 2013 (UTC)
 * How supportive evidence is of a treatment does not depend just on the number of RCTs done. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 05:31, 10 April 2013 (UTC)
 * Why is cat's claw being kept out of the first sentence? The abstract says clearly that it is supported as a treatment for OA, so I suggest it be added with the other treatments in the first sentence.  The abstract also says nothing about anti-inflammatory properties of cat's claw.  I though anti-inflammatory properties was generally associated with RA not OA.  Anyway, can we please change the first sentence to include cat's claw and remove the special clause?  — Preceding unsigned comment added by Sthubbar (talk • contribs) 03:49, 11 April 2013 (UTC)
 * Because De Silva didn't study cat's claw, and Rosenbaum only says "Three clinical trials support the use of cat's claw as an anti-oxidant/antiinflammatory agent". This is stopping short of saying there's enough evidence that it's hands-down effective.  I think the current article content reflects the source accurately, don't see a need to change it.    02:46, 12 April 2013 (UTC)
 * Zad68, where does Rosenbaum say "cat's claw as an anti-oxidant/antiinflammatory agent"? Do you have access to the complete document?Sthubbar (talk) 03:03, 12 April 2013 (UTC)
 * Yes sir, it is here. Whenever you find a document on PubMed, always search on the document title, you can often find an (illegal) copy of it somewhere to download.    03:07, 12 April 2013 (UTC)

Zad68, how dare you suggest I do anything illegal! I would never!! . I will agree to disagree. According to the reports: Phytodolor provides "significant improvement in grip strength", SAMe is "equal to or more effective and better tolerated than the NSAIDs" and SKI 306X provides "significantly lower levels of pain and better function".

To be fair I suggest these two choice: Which seems more reasonable to you?Sthubbar (talk) 03:57, 12 April 2013 (UTC)
 * 1) Put these statements along with each of the treatments to make them similar to the clarification for cat's claw.
 * 2) Leave out this clarification for all items, including cat's claw.

Added treatments are from full articles not from abstract
Before reverting the added treatments under dietary supplements, please review the complete articles and discuss here. There are 2 new references from Ernst in 2001 and 2011. This is where much of this info, though not all is coming from.

I realize there is still conflicting information to be clarified, for example stinging nettle is both listed as promising and not able to be recommended in the first and last paragraph of the section. I think there are other review articles for some of these conflict treatments that we can review.

I will also alphabatize these treatments when I have a mild confidence that these edits aren't just going to be blanket reverted.Sthubbar (talk) 02:27, 10 April 2013 (UTC)
 * We typically do not use reviews older than 10 years when newer stuff is available. Thus we should remove the 2001 review. Doc James (talk · contribs · email) (if I write on your page reply on mine) 04:33, 10 April 2013 (UTC)
 * Doc James, thank you for educating me about that rule. There is much overlap between the two studies, so I will remove anything that is only in the 2001 study and take the results from the 2011 study.Sthubbar (talk) 05:25, 10 April 2013 (UTC)
 * Have removed the 2001 ref. Not sure if there is still content there support by it though. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 05:30, 10 April 2013 (UTC)

Why a special page for knee osteoarthrits?
Doc James, I see you have created a special page for osteoarthritis of the knee. I'm curious why a special page. It seems like it will make it more difficult to maintain a consistent information if there is significant overlap with osteoarthritis. This page would make sense to me if on the osteoarthritis page there is a section "osteoarthritis of the knee" and with a link to the new page. Then this new page would only include additional clarification of this particular manifestation of OA and not include duplicate from OA. So, the general question is, why the special page and how to keep both pages in sync?Sthubbar (talk) 12:22, 13 April 2013 (UTC)
 * If mean this page knee osteoarthritis it was created by someone else in 2010 Jan . In fact in May of 2010 I tried to redirect it to the main page here and would still be supportive of this option with incorporation of the bit of good content into the main article.  Doc James  (talk · contribs · email) (if I write on your page reply on mine) 01:48, 14 April 2013 (UTC)
 * Doc James, I think I was looking at the history of the talk page that led me to believe you created the page. OK, so you have the same idea I have of putting in the redirect.  I guess next is to take it up on the talk page there.  Thanks.Sthubbar (talk) 11:36, 14 April 2013 (UTC)
 * I notice that there seems to be no activity on the talk page, so probably won't be helpful to start a discuss there. Do you recommend trying to put back in the redirect?Sthubbar (talk) 11:38, 14 April 2013 (UTC)
 * Best to mention it on the talk page first. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 11:56, 14 April 2013 (UTC)

OA vs. RA?
Shouldn't the article, including the introduction, define the difference between osteoarthritis and rheumatoid arthritis? (The link to Dorland's is dead.) --Nbauman (talk) 18:57, 22 April 2013 (UTC)
 * Yes they stopped offering a free copy of Dorlands a while ago. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 03:41, 23 April 2013 (UTC)
 * The simple explanation is that OA is a disease of mechanical wear, while RA is an autoimmune disease. That's arguably an oversimplification, but I think it's acceptable for the introduction. --Nbauman (talk) 17:10, 24 April 2013 (UTC)
 * I agree with the RA autoimmune bit. Do we have a ref for the mechanical wear? Doc James  (talk · contribs · email) (if I write on your page reply on mine) 11:04, 25 April 2013 (UTC)

Added massage therapy
I also reorganized under Alternative Medicine so the headings there are now: Dietary supplements, Manual therapies, Acupuncture, Electrical stimulation

I moved the content that was under Manual therapies into the two new headings (Acupuncture and E-stim), two sentences on the first and one on the other.

TBH this is the first time I've used journal citations, so please let me know if I did a poor job.

Derekawesome (talk) 20:25, 6 May 2013 (UTC)
 * Per WP:MEDRS we try to use secondary sources rather than primary sources. Thus reverted additions. Will look for secondary sources.  Doc James  (talk · contribs · email) (if I write on your page reply on mine) 07:11, 7 May 2013 (UTC)
 * The last one is a review of massage. As soon as I have internet that works I will look at it. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 07:46, 7 May 2013 (UTC)
 * Okay added summary. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 07:54, 7 May 2013 (UTC)
 * The last one is a review of massage. As soon as I have internet that works I will look at it. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 07:46, 7 May 2013 (UTC)
 * Okay added summary. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 07:54, 7 May 2013 (UTC)

Patient Reported Quality of Life Measures
Hi everyone, I was wondering if anyone thought that adding a section on osteoarthritis specific patient reported quality of life measures might be helpful? Measures commonly used to assess the impact of the disease on quality of life include: WOMAC,OAKHQoL,KOOS,OAQOL and AIMS. What is your opinion on this? Perhaps a paragraph in the Management section would be helpful? Thanks JamesOAdams (talk) 13:03, 10 February 2014 (UTC)

Reviews

 * Doc James (talk · contribs · email) (if I write on your page reply on mine) 13:14, 6 June 2013 (UTC)

Is before 2009 "older"
It is predictable that the two small and logical edits I have recently made are immediately reverted by Doc James, so let's address them one at a time.

The first one seems so blatantly biased that I'm looking forward to see how people justify reverting the improvement I made.

The term "Older" is used to refer to two studies, one in 2005 and one in 2009.

A quick look at the first 42 references shows 50% of them are from on or before 2009, some of them much earlier.

I will accept characterizing these two 2005 & 2009 studies as "older" if all of the other references from 2009 and before are also qualified as "old" or "older".

Do we have consensus to update this article and qualify every reference from 2009 and before as "old" or "older", or can we take the more rational step and remove this inflammatory characterization from the Dietary Supplements section?Sthubbar (talk) 13:16, 25 September 2013 (UTC)

Glucosamine Sulfate != Glucosamin Hydrochloride
I will assume good faith that Doc James is confused and maybe did not read closely the freely available full text of the reference PubMed 17599746. The current Wiki section says "some others have found it ineffective" where some others refers only to PubMed 17599746 and "it" refers to glucosamine SULFATE. The review article says "no definitive conclusion about efficacy is possible" in reference to glucosamine SULFATE. We have had this discussion before:

No conclusion does NOT equal ineffective No conclusion may mean is effective or is ineffective.

This statement of "ineffective" using PubMed 17599746 as the reference is strictly false. The edit I made removed this and simply moved the reference to the next sentence that says there seems to be a difference between Hydrochloride and Sulfate because this article clearly supports that conclusion as they conclude Hydrochloride "lacks efficacy" which is clearly different than "no conclusion" therefore is supports the idea that there may be a difference between hydrochloride and sulfate. Can we agree that No conclusion does NOT equal ineffective and again restore this edit as well?Sthubbar (talk) 13:24, 25 September 2013 (UTC)
 * It is time we remove the old reviews. I will update. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 13:32, 25 September 2013 (UTC)
 * What is the definition of "old reviews" and does that apply to the complete article or just to the Alt med section? I seem to remember you say before something like before 10 years, and I see references from much more than 10 years all over the article.  Are you going to be balanced and remove ALL reviews from the complete article from before a particular date?
 * BTW 2005 and 2009 are less than 10 years ago. What is your comment to the above section?Sthubbar (talk) 14:21, 25 September 2013 (UTC)
 * Furthermore, 17599746 is from 2007, hardly old. The point of this section has nothing to do with the age of the reference it has to do with your insistence that "no conclusion"="ineffective".  Please comment on this point.Sthubbar (talk) 14:22, 25 September 2013 (UTC)
 * 2007 is more than 3-5 years old and there is newer evidence. The ref stated "Glucosamine hydrochloride is not effective" which we summarized as "while some others have found it ineffective." Doc James  (talk · contribs · email) (if I write on your page reply on mine) 15:00, 25 September 2013 (UTC)
 * If there are newer reviews that incorporate newer study data or they are otherwise better reviews due to better review methodology, etc., then the older reviews should be removed and the newer reviews used, just as Doc is doing. In such a case it would not be that the older reviews are out of date because of when they were published, but rather that there's now better quality evidence to use.    14:36, 25 September 2013 (UTC)

You are completely removing references and changing the wording so let's just start a new section as I know we have to take whatever you write.Sthubbar (talk) 21:08, 25 September 2013 (UTC)
 * Have you read wp:MEDRS? There's a simple reason for using the more recent reviews than the older ones: the authors of the latter ones were themselves able to read the earlier ones and consider their results. Continuing to use the obsolete sources is in fact wp:UNDUE, except perhaps in a historical section. LeadSongDog  come howl!  21:58, 25 September 2013 (UTC)
 * LeadSongDog, what you say makes sense if we were talking about a building. So for example if we are designing the 7th floor, we don't have to talk about the existence of floors 1-6 as they must exist because they are supporting the 7th floor.  The assumption that because there is a 2012 review article that this 2012 review includes all previous review articles is false.  Authors, sometimes because of error, or bias miss or leave out previous review articles.  Review articles also can come to different conclusions.  Otherwise, only 1 review article would be allowed per topic and it would be whatever is the most recent review article.  Obviously, this is not the case, many review articles are used, not just the one with the most recent date.  If we allow review articles from 2012, 2008, and 2004, what is the logical reason to deny one from 2000?  Your argument sounds to me to be that since the 2000 review is "old" it is included in the more current reviews.  But, wait a minute, can't the same be said about the 2004 review?  It "must" be included in the 2012 and 2008, and to continue the logic, the 2008 review "must" be included in the 2012 review, so the only logical conclusion for me is either, 1) Only accept the most recent review in 2012 or 2) Do the laborious chore of actually reading all reviews, see if they are overlapping or not and don't choose some arbitrary deadline.Sthubbar (talk) 03:40, 26 September 2013 (UTC)
 * Generally you can look at a review or a systematic review and see the primary studies included and (possibly) the older reviews referenced. They may list all the primary studies they looked at, even if they didn't use them, or they might list everything, even stuff they didn't use.  Just because a review doesn't happen to mention an older study or review, that doesn't mean it wasn't considered, it just might mean that perhaps the authors didn't feel it was good enough to use.  I do not know of any other medical topic on Wikipedia where we go out of our way to use older reviews when there are newer, good-quality ones available.  In fact, "use up-to-date evidence" is in the WP:MEDRS guideline.  Unless a compelling reason can be given arguing for an exception here not to use the latest reviews, I can't see any policy-based reason to do so. What is so special about this particular topic that it'd be in the best interest of the article to do so?   04:24, 26 September 2013 (UTC)
 * Nothing more here. Next issue is fixing the mischaracterization of the 2012 review article.61.161.199.67 (talk) 06:31, 26 September 2013 (UTC)

Definition of "Most" and "recent"
Doc James, you have written "Most recent reviews do not show it to be better than placebo." That is a bold statement. My understand of the word most is that if there are x items then anything greater than x/2 could be considered "most". The items in question are "reviews". So, let's count, how many reviews are in that paragraph... Best Bets,, , , , , , , and. I count that as 9. So for your statement to be true, then 5 of them must conclude that Glucosamine equal or worse than Placebo. Let's check them out.
 * Best Best = "still controversy", so NO, they don't conclude it is equal to placebo. Evidence for effect and for placebo
 * = "mild symptomatic relief", so NO not equal to placebo, has effect if it only mild.
 * = "do not reduce joint pain or have an impact on narrowing of joint space", YES, one for your side.
 * = "may have function-modifying effects", so NO can't say it is equal to placebo
 * = "no clear difference between glucosamine and oral NSAIDs", so unless you say NSAIDs=placebo then another for my side.
 * = I can't find the full article
 * = "glucosamine sulfate 1500 mg once daily is therefore recommended" so very much on my side and NOT a placebo
 * = "recommendation...glucosamine and/or chondroitin sulphate for symptom relief; glucosamine sulphate, chondroitin sulphate and diacerein for possible structure-modifying effects " again very much NOT placebo.
 * = "viable option for the management of OA" so NOT placebo

I count that as 7 clearly show benefit, 1 says is equal to placebo and 1 I can't comment.

Hmm, If I had the power that you do, I would rewrite that as something like "There is overwhelming evidence that some formulations of glucosamine are effective in the treatment of OA."

What do you think?Sthubbar (talk) 21:41, 25 September 2013 (UTC)


 * Systematic reviews and meta analysis are a higher quality of evidence than just a plain review. Have changed it to "equal or only slight better than placebo". No one is claiming a large effect and no one finds "overwhelming evidence"


 * = " limited to mild symptomatic relief, while a disease-modifying agent for this disease remains elusive."
 * = "do not reduce joint pain or have an impact on narrowing of joint space", YES, one for your side.
 * = When papers say may this can equally mean may not "showed no pain-reduction benefits after 6 months of therapy."
 * = "evidence from a systematic review of higher-quality trials suggests that glucosamine had some very small benefits over placebo for pain"
 * = will look
 * = not listed as a review
 * = 2012 "not in the most recent NICE guidelines"
 * = old
 * Doc James (talk · contribs · email) (if I write on your page reply on mine) 22:37, 25 September 2013 (UTC)

I'm mostly satisfied with how it looks currently, but from 2013 (please post PMIDs like this so they can be clicked on) does not exactly conclude no better than placebo, as currently shown in the article. It says unequivocally that that GH (hydrochloride) is no better than placebo, but for sulfate it has a confusingly different message (I don't have access to the full paper): "Pooling data from studies with durations of more than 24 weeks presented a significant combined ES of -0.36 (95% CI: -0.56, -0.17) with an absence of heterogeneity" and concludes "GS may have function-modifying effects in patients with knee OA when administered for more than 6 months". Currently this is cited as [64] in "Most recent reviews found it to be equal to[63][64]", which appears to be an oversight. 0.36 is indeed a decent effect size and usually lack of heterogeneity is good but perhaps this just picked up the three Rottapharm studies, which may be affected by industry bias or, alternatively, by different formulations (according to Reginster 2007). II | (t - c) 01:51, 26 September 2013 (UTC)


 * Doc James, thanks for the balanced presentation. @ImperfectlyInformed, unfortunately the drop-down "cite journal" function does not work any more on my system and I don't enjoy memorizing wiki code.  BTW, from reading the research it seems absolutely clear to me that Sulfate and HCL are clearly separate treatments, as much as coffee and tea are separate beverages.  Most all reviews that show "confusing" results are because they mix the two treatments.  All research that I am aware of that clearly separates these two medications shows clear positive response to Sulfate and low or absent response to HCL.  The community here seems to think that this borders on "original research", so as long as it is mentioned like it is on the page, I'll leave it to other adventurous readers like myself to actually read the papers.Sthubbar (talk) 02:05, 26 September 2013 (UTC)


 * The experts seem mystified by why sulfate would cause a difference (maybe the sulfate itself?) but I dunnno. As far as PMIDs, just write it exactly as I did. PMID [number] and it will be linked (just did it with a couple of yours above). It's best not to get too worked up anyway as the truth comes out over time. II  | (t - c) 02:18, 26 September 2013 (UTC)


 * Isn't there an OS or RA treatment like sulfazine. It seems reasonable that maybe just taking sulfate, minus the glucosamine is actually what is having the positive affect.  I just looked up and sulfate is a salt of sulfuric acid.  Maybe we should be recommended OA suffers drink sulfuric acid.  Who wants to join that trial?!Sthubbar (talk) 02:34, 26 September 2013 (UTC)
 * Sulfur plays a biological role, including in joints. See e.g. Nimni et al 2007. II  | (t - c) 18:25, 26 September 2013 (UTC)
 * ImperfectlyInformed, great reference. Thank you.Sthubbar (talk) 14:43, 6 October 2013 (UTC)

"the National Institute of Clinical Excellence no longer recommends its use"??
Doc James, what am I missing here? I have checked the full text paper for and in the Conclusion section it says "it represents a viable option for the management of OA" and "we should consider the use of glucosamine as a combination therapy with other drugs or other nutraceuticals". How does that translate into a "no longer recommends" statement? Amy I looking at the wrong PMID?Sthubbar (talk) 02:16, 26 September 2013 (UTC)
 * Oh! I see if I just put PMID in all CAPS followed by the number then the Wiki software will make the link, no need to use the cite tool or memorize wiki code. Got it.Sthubbar (talk) 02:19, 26 September 2013 (UTC)


 * "Hence, glucosamine was at first recommended by EULAR and OARSI for the management of knee pain and structure improvement in OA patients, but not in the most recent NICE guidelines". In the abstract. :p Also you might want to move your comment above. II  | (t - c) 02:21, 26 September 2013 (UTC)
 * OK, I see the NICE guidelines are a different document here http://www.nice.org.uk/CG059 and this is definitely old and if included should be classified as such. These guidelines are being updated and should be released Feb 2014, according to http://www.nice.org.uk/guidance/index.jsp?action=byID&o=13505.
 * Please either specify the NICE is old and provide the correct reference, or remove completely as you have been doing for the other supportive old reviews and also update the include showing support for the use of glucosamine.Sthubbar (talk) 02:30, 26 September 2013 (UTC)

II, and please continue the quote "Consequently, the published recommendations for the management of OA require revision." This reference clearly says that the disagree with these guidelines and they should, and are being updated. It should be very clear that the most current review shows that these old recommendations are not supported by the reference.Sthubbar (talk) 02:38, 26 September 2013 (UTC)
 * This is a 2012 review So it is not old.  Doc James  (talk · contribs · email) (if I write on your page reply on mine) 02:39, 26 September 2013 (UTC)

Doc James, I think some more confusing going around. You are right, is from 2012 and a great review from my perspective as their conclusions are "it represents a viable option for the management of OA" and "we should consider the use of glucosamine as a combination therapy with other drugs or other nutraceuticals" as stated above. They also stress that the existing guidelines should be updated when they say " the published recommendations for the management of OA require revision." They clearly concluded the current recommendations are out of date and this 2012 is more authoritative. From this date, you decide to quote the 2008 NICE guidelines which this 2012 article clearly says are out of date. Please remove the NICE reference and reframe this reference a supporting the us of glucosamine.Sthubbar (talk) 03:33, 26 September 2013 (UTC)
 * But it doesn't support it. It says "At this time, glucosamine hydrochloride cannot be recommended based on the available clinical data. However, there are no clear indications that the effects of the two formulations can be distinguished from each other in terms of biological activity, posology or pharmacokinetics." (emphasis added) and "Therefore, the question of the benefit of glucosamine treatment remains largely unanswered." but also, "glucosamine has low and rare adverse effects". In summary, this article is saying there is no evidence to recommend its use, but because it doesn't appear harmful, it's safe to try it, and if you feel it works for you, great.  This is hardly a source that supports it.   04:35, 26 September 2013 (UTC)

Zad, we seem to have to go over this point many times. Hydrochloride != Sulfate. Of course they say Hydrochloride doesn't work. You are doing original research when you conclude "this article is saying there is no evidence to recommend its use" and you specifically contradict the conclusion further down in the Conclusion section. Again, I quote the ultimate conclusion above "[glucosamine]it represents a viable option for the management of OA." Period, end of story. This "viable option" is 100% against your original research of "no evidence to recommend its use." Sulfate and Hydrochloride have compelling evidence that they have different behavior with Sulfate showing effect.Sthubbar (talk) 05:03, 26 September 2013 (UTC)
 * The point is that the NICE recommendation is out of date. This reference specifically says, as quoted above, that the NICE recommendation is out of date.  This reference specifically says GS is a viable option.  The wiki page is using this reference to support a position that is 100% opposite of their conclusion.  Their conclusion is 1) viable option 2) NICE is out of date.Sthubbar (talk) 05:05, 26 September 2013 (UTC)
 * Although you state "Hydrochloride != Sulfate", Henrotin 2012 says (as I already mentioned) "there are no clear indications that the effects of the two formulations can be distinguished from each other in terms of biological activity, posology or pharmacokinetics." and they also state in their Pharmacokinetic studies section, "Glucosamine hydrochloride and sulfate are identical from a chemical and structural point of view. Indeed, both glucosamine sulfate and hydrochloride dissociate in the acidic milieu of the stomach, resulting in the release of glucosamine itself." There's nothing you've provided in your responses that is based in what the article actually says to allow a conclusion to be drawn other than what I stated above. Of the guidelines discussed in Henrotin 2012, ACR is very old (2000) and the EULARs are old (2003, 2005). NICE and the OARSIs are more up to date, with NICE published February 2008 and the OARSIs dated 2007, 2007, and the latest published 2010 says "update of research published through January 2009". NICE guidelines are influential and authoritative enough that I think we should keep mention of it in the article, and when the new NICE guidelines come out in 2014 we can update this article then. The point of Henrotin 2012's discussion of the evidence base and guidelines is that the guidelines are trending away from recommending glucosamine because the evidence is lacking.  They aren't even saying it definitely does not work; rather they are saying there isn't a sufficiently strong evidence base indicating that it does work to make a positive recommendation. But, I hear your point that those sources are aging; as a compromise how about we mention the dates of the OARSI and NICE guidelines in the article?  Proposed content change is:  "The Osteoarthritis Research Society International recommends in their 2007-10 guidelines that glucosamine be discontinued if no effect is observed after six months and the National Institute of Clinical Excellence no longer recommends its use in their 2008 guideline."   13:49, 26 September 2013 (UTC)

Zad, if you want to include the NICE study then just add a reference and leave the sentence as it is. My point is the current sentence is a gross distortion of this reference. One of the conclusions of this review is "glucosamine has low and rare adverse effects, it represents a viable option for the management of OA". Until we come up with a sentence that includes this information, I won't accept the characterization of this reference.Sthubbar (talk) 16:40, 26 September 2013 (UTC)
 * ?? There seems to be some disconnect here.  We already have a reference for NICE and it's already in the article, and cited appropriately.  I was just trying to work with you on the dates, but it sounds like you are now OK with the sources that are cited and their ages, correct? If so, great, we can move forward past that. The first and more important thing Henrotin states is that glucosamine "cannot be recommended based on the available clinical data" and Henrotin takes pains to point out that there are no important pharmacokinetic differences between the two preparations.  I stated all this previously.  Making sure you take into account that Henrotin states that the evidence is insufficient to recommend glucosamine, what is your proposal to summarize what the source states?   20:08, 26 September 2013 (UTC)

Zad68, where is the NICE reference? I only see the reference to this 2012 review which is not NICE. I have put the NICE URL above and I'll search again in the article and if I can't find it will put it in the page. Here is my suggestion and I'll go ahead and make the update. "Blah blah, NICE doesn't recommend glucosamine[NICE article reference]. Despite difficulty in determining the efficacy of glucosamine it remains a viable treatment option.[This 2012 reference]"  We agree, right? The article may still question the efficacy of glucosamine, but they clearly say it is a "viable treatment option".Sthubbar (talk) 01:43, 28 September 2013 (UTC)
 * Zad68, you are right, there already was a reference to NICE and I put that reference to the statement about NICE not recommending glucosamine. If any reverts that change with any comments like "better before".  I might die laughing on the floor.  How can putting a reference that is NOT the study be "better" than the actual study?!  Ok, then I added the sentence saying that despite the difficulty of determining the efficacy it is still a viable treatment option.Sthubbar (talk) 01:50, 28 September 2013 (UTC)

How can GH<TM<=GS and GH=GS?!
In reference to, who can explain the conclusions to me:

GH = Glucosamine Hydrochloride GS = Glucosamine Sulfate TM = Traditional Medicine (commonly used analgesic or nonsteroidal anti-inflammatory drugs)

GH<TM "glucosamine hydrochloride cannot be recommended based on the available clinical data"

TM<=GS "glucosamine sulfate shows an ES superior to (or at least equal to) the commonly used analgesic or nonsteroidal anti-inflammatory drugs"

GH=GS "no clear indications that the effects of the two formulations can be distinguished from each other in terms of biological activity, posology or pharmacokinetics"

Assumptions 1) TM is a recommended treatment 2) If any other treatment is equal to TM, then it is also recommended

So, how can it be that since GH is clearly not recommended, then we have to conclude it is less effective than TM, so GH=TM, then how in the world can GH=GS?!

At least one of the three conclusions must be wrong (I'm voting for GH=GS).Sthubbar (talk) 02:05, 28 September 2013 (UTC)
 * Well, the conclusions in that review are a bit confusing, but the key point to take away is that the quality of the primary clinical studies isn't good enough to draw significant conclusions from, "based on the available clinical data". It's not really surprising: when comparing tiny effects, it's hard to tell which is smaller without huge studies. LeadSongDog come howl!  05:31, 28 September 2013 (UTC)
 * LeadSongDog, I agree that the conclusions are confusing. How can you characterize the effects as "tiny" when the conclusion is that Sulfate has an ES (Effect Size) equal to or greater than analgesics or NSAIDS?  Do you believe the effect of NSAIDS is tiny?Sthubbar (talk) 00:34, 29 September 2013 (UTC)
 * What I believe doesn't enter into it, we use what the best sources say. The paper in question doesn't quantify the NSAID ES at all. It just compares NSAID ES to sulfate ES in one statement (in the conclusions), and there it neglects to say if it refers to ES for pain or ES for joint spacing. In earlier text it simply quantifies various ES ranges for the sulfate and for the HCl, each without reference to NSAIDS. LeadSongDog come howl!  07:11, 29 September 2013 (UTC)

Student sandbox

 * User:Madelynne Dudas/sandbox

No response from this editor to my query at her sandbox talk page, so I have removed the text for discussion. Sandy Georgia (Talk) 00:36, 6 November 2013 (UTC)

Removed text
The increased vulnerability of osteoarthritis in humans is potentially an evolutionary tradeoff of bipedalism. As early human ancestors evolved into bipeds, morphological changes occurred in the pelvis, hip joint and spine. This resulted in the center of gravity being closer to the hip joint increasing specific vulnerability that joint. Also, genetic morphological variations that predispose some humans to OA were likely not selected against because most often, the effects of variation only substantially decrease mobility after the reproductive life stage, therefore, not impacting reproductive success. Evolutionary constraints contribute to OA because the evolution of the basic bone and cartilage joint model evolved long before Homo sapiens. The cartilage did not evolve to last to the advanced age seen in Homo sapiens. An evolutionary understanding of why humans are vulnerable to OA can help improve our understanding of the original circumstances and needs (load, range of motion, etc.) of joints. This contributes to the understanding of what possible impacts behavioral actions many have on human joints which can be applied in a clinical setting.

Discussion
If we can straighten out the sourcing, the proposed text could use some (minor) copyediting, and the last few sentences in the proposed text above are more editorializing than encyclopedic in tone. Sandy Georgia (Talk) 01:21, 6 November 2013 (UTC)
 * User:Madelynne Dudas who added this is in user:Sanetti's Darwinian medicine class. I am happy with this article
 * being used as a source for the above content. The claims being made are in physiology and biology, so I see no reason that this needs to comply with Identifying reliable sources (medicine) as User:SandyGeorgia asserted. It definitely is a reliable source, and while it is not the review article which SandyGeorgia requested also there would not be any existing review articles for this kind of non-medical subject matter. The article itself is quite good as it reviews a lot of previous publication on the topic. I personally see two problems in this:
 * Every sentence should have a citation. On Wikipedia one never knows how content will be re-arranged, so put a citation at the end of every sentence so that the statements can always be matched to the source.
 * The author of the source presents his statements as candidate theories, as so much in evolution is. I feel like this material should be presented more as worthy of belief and the views of experts in the field, and less as the certain reality. I say this only because I feel that it would better match the source if it did.
 * Thanks, please respond to both my comments and Sandy's. I think with a bit of response this material could be re-integrated back into the article. Please also get feedback from your classmate here - I see that your class is reviewing each other's articles.  Blue Rasberry    (talk)   14:51, 20 November 2013 (UTC)
 * Thanks, please respond to both my comments and Sandy's. I think with a bit of response this material could be re-integrated back into the article. Please also get feedback from your classmate here - I see that your class is reviewing each other's articles.  Blue Rasberry    (talk)   14:51, 20 November 2013 (UTC)

I think the source is very weak. Bone Joint 360 is an obscure journal. That is not to say that there are no theories of evolutionary impact on lower limb osteoarthritis the same way there are sources for venous insufficiency and degenerative spinal disease. I would like to encourage the editor to find a stronger source in a textbook or review in an indexed journal. The current source has 42 sources, some of which might potentially be used to support this content. JFW &#124; T@lk  14:41, 21 November 2013 (UTC)

Thank you for feedback. It was incredibly helpful. I am in the process of placing my revised text in my sandbox. Madelynne Dudas (talk) 03:54, 26 November 2013 (UTC)

Revised Text for Evolutionary Considerations

The increased vulnerability of osteoarthritis in humans is potentially an evolutionary tradeoff of bipedalism along with other relatively recent evolved traits. This is represented in the prominence of osteoarthritis is a specific few joints such as the first metatarsophalangeal joint. As early human ancestors evolved into bipeds, morphological changes occurred in the pelvis, hip joint and spine. This resulted in the center of gravity being closer to the hip joint increasing specific vulnerability to the joint because the gait of modern Homo sapiens is more energy efficient then some recent ancestors. Also, genetic morphological variations that predispose some humans to osteoarthritis were likely not selected against because most often, the effects of variation only substantially decrease mobility after the reproductive life stage, therefore, not impacting reproductive success. Evolutionary constraints contribute to osteoarthritis because the evolution of the basic bone and cartilage joint model evolved long before Homo sapiens. Madelynne Dudas (talk) 18:05, 2 December 2013 (UTC)
 * Can you please format the refs in the same style as discussed at WP:MEDHOW. It will make it easier for us to look at the refs. Also they should generally be from the last 5 years. More than 10 years is too old. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 19:17, 2 December 2013 (UTC)

Removed again
I've removed the text again; please do not re-add it without gaining consensus. Both and  have expressed concern about the sourcing. Some are very old, others are weak, and if you would please format them correctly, the rest can be more easily evaluated. You can plug the PMID into this citation filling template to get a citation template. I corrected the citations for you in the version below; please view the text in edit mode so you can understand how to cite text. Sandy Georgia (Talk) 23:25, 2 December 2013 (UTC)

Evolutionary considerations
The increased vulnerability of osteoarthritis in humans is potentially an evolutionary tradeoff of bipedalism along with other relatively recent evolved traits. This is represented in the prominence of osteoarthritis is a specific few joints such as the first metatarsophalangeal joint. As early human ancestors evolved into bipeds, morphological changes occurred in the pelvis, hip joint and spine. This resulted in the center of gravity being closer to the hip joint increasing specific vulnerability to the joint because the gait of modern Homo sapiens is more energy efficient then some recent ancestors. Also, genetic morphological variations that predispose some humans to osteoarthritis were likely not selected against because most often, the effects of variation only substantially decrease mobility after the reproductive life stage, therefore, not impacting reproductive success. Evolutionary constraints contribute to osteoarthritis because the evolution of the basic bone and cartilage joint model evolved long before Homo sapiens.


 * I have summarized the content and added it here  Doc James  (talk · contribs · email) (if I write on your page reply on mine) 23:17, 2 December 2013 (UTC)

Glucosamine & Chondroitin Sulfate - new evidence
According to the recent Long-term Evaluation of Glucosamine Sulfate (LEGS) study it's looking more compelling that there is indeed a difference between the sulfate and hydrochloride preparations. Any way to include this in the article or do we need to wait for a review to come out that includes this study?Sthubbar (talk) 07:29, 11 March 2014 (UTC)
 * Need to wait for a review. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 23:28, 10 March 2014 (UTC)

Boswellia serrata
There was a slight difference of opinion in regard to how to word the summary of the Cochrane review of treatment of osteoarthritis using boswellia serrate. And that was due, in part, to seemingly contradictory assertions in the review itself, which stated fairly clearly that high quality evidence shows that boswellia serrate slightly improves pain and movement. So I emailed the author, who was kind enough to explain the seeming discrepancy and to suggest wording we can use in this article on osteoarthritis. Here's her explanation and suggested wording:

Thanks for your query. The question shows that you have thought carefully about what you are reading. The explanation as to why these statements are not contradictory requires some detail - please bear with me.

The note in the plain language statement that "There is high-quality evidence that in people with osteoarthritis Boswellia serrata slightly improved pain and function. Further research is unlikely to change the estimates." is generalised, but cuts across two key issues in Cochrane reviews: 1) the quality of the research and 2) the size of the effects.

Quality: Most of the studies on Boswellia serrata are well designed, randomised, controlled trials using reliable, validated outcome measures. When there are multiple trials of this type on a topic, the body of evidence may be deemed high quality. Sometimes we elected to downgrade the quality ranking to moderate because there was only one study, or the total number of participants was small, or there was some minor flaw in the study design. If combinations of these weaknesses in study quality were present, we downgraded the quality ranking further. Overall, however, the evidence for Boswellia serrata was of high quality.

Effect sizes: The effect sizes of Boswellia serrata on pain and function were fairly small (17% and 8% absolute improvements respectively). The effects, however, were consistent in direction across studies. Results were statistically significant, and numbers needed to treat were calculable, but larger than ideal. For example, NNTB for pain was 2, indicating that 2 people needed to be treated with Boswellia for one person to gain improvements in pain. Also, the effects did not always meet clinical significance. For example, a 15 point reduction in pain on a 100 point scale is considered to be the threshold for clinical significance (lesser reductions are probably noise in the testing instrument or baseline variance in "clinically stable" pain). The mean pain reduction using Boswellia was 17 points, but the 95% confidence interval ranged from 8 to 26 points, so quite a few people who reported improvements in pain with Boswellia might simply have improved regardless of what they did or did not do.

So, the evidence on Boswellia is generally of high quality. The effects of Boswellia are consistent, but mostly small, and not all of the improvement may be due to Boswellia. Hence I said "... extracts of Boswellia serrata, show trends of benefits that warrant further investigation in light of the fact that the risk of adverse events appear low."

As a summary for Wikipedia, I suggest you try to capture both the notions of quality studies and small, consistent effects. It is because the studies are mostly of high quality that we do not expect that further research will change our estimates of them (they will still be small), but a small, real, beneficial effect is still worthy of further investigation. There is still a good deal we don't know about Boswellia, and further studies could be helpful.

Putting these ideas together, I would suggest that you say something like this: A few high quality studies of Boswellia serrata show consistent, but small, improvements in pain and function among people with osteoarthritis.

I'll go ahead and add her suggested wording. TimidGuy (talk) 10:15, 11 July 2014 (UTC)

Glucosamine - replace unreferenced statement with multi-referenced statements.
The following text
 * " but there is no good evidence for its effectiveness. There have been multiple clinical trials testing glucosamine as a potential medical therapy for osteoarthritis, but the results have not supported its use."

has not a single reference to support that statement. It has been replaced by the previously, multi-referenced statement:
 * "The effectiveness of glucosamine is controversial. Most recent reviews found it to be equal to  or only slight better than placebo.  A difference may exist between glucosamine sulfate and glucosamine hydrochloride, with glucosamine sulfate showing a benefit and glucosamine hydrochloride not. The Osteoarthritis Research Society International recommends that glucosamine be discontinued if no effect is observed after six months and the National Institute of Clinical Excellence no longer recommends its use. Despite the difficulty in determining the efficacy of glucosamine, it remains a viable treatment option.

Massive problem with the "thumb" joint disablement
Its particularly problematic when its of the thumb, since affects a lot of f(x), including can't feed themselves, etc etc, it's terrible! 129.180.139.48 (talk) 12:59, 9 September 2014 (UTC)

Hyaluronic acid injects
Have trimmed one source with an impact factor of zero. We then have:


 * Annals of Intern Med which states "In patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit and an increased risk for serious adverse events."

Doc James (talk · contribs · email) 17:30, 7 December 2014 (UTC)
 * BioDrugs state "It is debatable whether this difference reaches the minimum clinically important difference."
 * I am fine with your edits. NW ( Talk ) 18:03, 23 December 2014 (UTC)

2014 Dietary Supplements review
This recent 2014 review article PMID has some interesting quotes like:


 * "Meta-analyses of all glucosamine studies found that when the results were pooled, glucosamine significantly reduced joint-space narrowing"
 * "To date, the best evidence for reducing joint-space narrowing is associated with glucosamine sulfate"

Further supporting the already discussed issue the Glucosamine Hydrochloride and Glucosamine Sulfate are different.Sthubbar (talk) 18:13, 26 January 2015 (UTC)


 * It than goes on to say "Overall, the best data exists for glucosamine sulfate for potentially reducing OA progression. However, these data are somewhat inconsistent and unclear. If there is a true effect of glucosamine sulfate on disease progression, the effect is likely modest" Doc James  (talk · contribs · email) 00:56, 27 January 2015 (UTC)

."
 * Doc James, so how about we update the article something like "Glucosamine Sulfate likely has a modest effect on OA progression, based on somewhat inconsistent and unclear data."Sthubbar (talk) 02:17, 27 January 2015 (UTC)
 * It is more the other way around. "The evidence for glucosamine sulfate having an effect on OA progression is unclear and if it does have a benefit it would likely be small" Doc James  (talk · contribs · email) 02:32, 27 January 2015 (UTC)

How about:


 * "The evidence for glucosamine sulfate having an effect on OA progression is somewhat unclear and likely modest."Sthubbar (talk) 03:49, 27 January 2015 (UTC)
 * How about "The evidence for glucosamine sulfate having an effect on OA progression is somewhat unclear and if present likely modest."? Doc James  (talk · contribs · email) 00:56, 28 January 2015 (UTC)

Agreed and added. Sthubbar (talk) 02:28, 28 January 2015 (UTC)

Lancet Seminar 2015
Also, the NICE guidance cited in the article has been updated. I can't figure out how to format a NICE guideline in the templates, but here it is:

Osteoarthritis: Care and management in adults http://www.nice.org.uk/guidance/cg177 NICE guidelines [CG177] February 2014 Clinical Guideline 177

--Nbauman (talk) 07:18, 7 March 2015 (UTC)
 * Here's the official citation style:
 * National Institute for Health and Care Excellence (YEAR) [TITLE OF GUIDANCE]. [No. OF GUIDANCE, e.g. CG55]. London: National Institute for Health and Care Excellence.
 * So that would be:
 * National Institute for Health and Care Excellence (2015) Osteoarthritis: Care and management in adults [CG177] London: National Institute for Health and Care Excellence. --Nbauman (talk) 17:36, 7 March 2015 (UTC)

stanford study
about this edit, where you introduced the following: "This view is challenged by a study from Stanford University School of Medicine, published online Nov. 6 2011 in Nature Medicine that 'have shown that the development of osteoarthritis is in great part driven by low-grade inflammatory processes.'(source Stanford)"

That source is a Stanford press release about this paper that published in 2011: (available free here.  Please read WP:MEDRS, especially the section about respecting secondary sources -- we do not source health content on press releases hyping primary sources like this.

That said, the paper was picked up in subsequent literature reviews, like (free text here)  and  (free text here) and  (free text here). None of those contradict the standard thinking that inflammation is secondary. Can you present a review that says otherwise? Thanks. Jytdog (talk) 22:54, 3 May 2015 (UTC)
 * thanks for the suggestion. I agree we poorly summarized that article and I have adjusted the text to reflect it better. Doc James  (talk · contribs · email) 04:08, 4 May 2015 (UTC)

, I suggest there are three ways to see the etiology of OA 1. The Stanford press release mention "simple wear and tear" without OA being driven by inflammatory processes. That, by their definition, is the prevailing view. As you said, inflammation is considered secondary. 2. They go on to say that the new paradigm is that OA "is in great part driven by low-grade inflammatory processes" (of unknown etiology) 3. There is a view that OA is driven by inflammation, the etiology of which is septic. When I posted what I did, I did so to inform the reader that there exist a view that differ from the prevailing, namely that inflammation is primary. You said "None of those contradict the standard thinking that inflammation is secondary", and that confuses me, because does so. I count it as one example. The already mentioned makes it two, known to you at the time you posted. You ask "Can you present a review that says otherwise?", and I answer; a. I do not think the onus is on me to find such a review. I do not have to present a proof that it is so, when my intention (and words) is to make the reader aware that differing views exist. The last word, needless to mention, has not been said about OA; the reader should be informed of dissent when relevant, and it strikes me as untimely that anyone should demand such proof. b. I did, after some pondering, find a review that says otherwise: from 2007. There may be more, as I have recently found it, and have not have time to look much further. When I posted, I did so with intention to at least begin the process of introducing the reader to the dissenting view that OA's etiology is sepsis. That was not well founded on my part, which was why I didn't do it at the time, but it is what I pursue. So to anyone it concerns, my wish is that the article on OA explicitly reflect the fact that these two dissenting views exist. You also said "Please read WP:MEDRS, especially the section about respecting secondary sources -- we do not source health content on press releases hyping primary sources like this". I admit that my experience in writing in Wikipedia is limited, so thank you for pointing things out for me, it is always appreciated. However, I do not quite agree. WP:MEDRS are guidelines, not law. And though I was not aware of the good advice at WP:MEDRS when I posted, in retrospect, the Stanford press release offers the senior author's own description of the implication of the article, which was just the point I was trying to make, and I could not have made that point by referring to, nor the full text PMC article. I have now searched in it, and I did not find anything like “It’s a paradigm change” (it only says; OA .. has long been viewed as the result of “wear and tear). I stand up for my use of source, not because I have a right to use it (I believe I do), but because I can defend it with an (I think) valid argument. It says in WP:MEDRS "..it is vital that the biomedical information in all types of articles be based on reliable, third-party, published secondary sources and accurately reflect current medical knowledge.", but that must apply when one is making statements as if they are facts; then your source should be the best (shouldn't it always :). Again, my objective is to inform the reader of a state of dissent, and the source I chose is respectable in that regard, as well as unique. I consider it untimely to state categorically "we do not source .. et.c.". My edit says "have shown that..", but within citation marks, so it doesn't state a fact, but cite a reference. I also stumbled over the advice in the beginning of the talk page; "PubMed provides review articles from the past five years (limit to free review articles or to systematic reviews)". Seemingly you again construe this as law when you ask me to find a *review* that says so and so (or am I wrong?). If I am right, you will reject the pubmed review I found on the grounds that it is older than five years: I hope not. I comment on this because I am concerned when advise is construed as law. Enough of that, I have stated the reasons for my addendum to the article, and I intend to edit accordingly in the near future, say before the end of August 2015, and if anyone has arguments or suggestions, I would appreciate it. Carystus
 * tl/dr, sorry. Jytdog (talk) 05:28, 26 July 2015 (UTC)
 * OK, I read it anyway. I have no idea what you are on about, with regard to "law".   The community created policies and guidelines for a reason, namely to solve disagreements about content.  So the worst thing to do when there is a disagreement is throw them away.  That makes no sense.  and btw, per the Terms of Use, every time you edit WP, you agree to abide by the policies and guidelines. Jytdog (talk) 05:31, 26 July 2015 (UTC)

I have read the reply; I don't see much if anything relevant to what I wrote, I don't think I am throwing guidelines away, if that is what is implied, I don't know what the disagreement is exactly. About guidelines, am I not in compliance, since you mention that? And sorry for what? Jytdog, you are not obliged to read what I post. All I want is a section about etiology in the article, that clearly state dissenting views, and since my last edit was deleted right away, and when I pointed out that a reference said the opposite of what it was quoted for, an, in my opinion, insufficient change was made in the article. I was not asked if I was happy with that; I am not, and I am obviously not happy with the way it was handled. In essence, I was kept from editing the OA article, and now I am back with fresh arguments, happy to discuss anything that is to the point, but not happy to accept a condescending style with no arguments. Carystus 3:34 PM, 26 July 2015 (UTC)
 * briefly, what secondary sources per MEDRS support the content you want to add? Thanks. Jytdog (talk) 20:30, 26 July 2015 (UTC)
 * Regarding "Conflicting etiology"; 1. In the case of "wear and tear" vs. "inflammation is primary", I was inclined to use the Stanford press release (not a secondary source), or I could use, which only indirectly mention the conflict. The press release is clear about it. 2. In the case of "wear and tear" vs. chronic infection, I could use . To make my position on sources clear: If I was trying to establish a medical "fact", a secondary source per MEDRS is preferred, I fully agree. If, e.g. I am trying to establish a state of dissenting views, I feel free to use the reliable sources that best illustrate it. In this case, both conflicting views are available from secondary sources, and I would gladly mention in connection with the press release. Carystus 21:39 July 27, 2015 (UTC)
 * One of the key things we use secondary sources for, is to assign weight when there is more than one view. Please read WP:WEIGHT which is part of the NPOV policy. The only secondary source you have brought is, which I will have a read of. I will also look at the most recent reviews.  Our sources in that section are all old. Jytdog (talk) 01:43, 28 July 2015 (UTC)

you said "The only secondary source you have brought is ", is not a secondary source? or do you mean I didn't bring it? Thanks for pointing to WP:WEIGHT; although I have read the NPOV before, it warrants attention. Example: in a naive interpretation of Mach's conjecture, motion is relative, I am free to say the sun moves around the earth, and if that creates epicycles of planets/moons, so be it. If a minority (e.g. the Catholic Church?, and should they be considered a minority?) literally holds that view, per WP:WEIGHT ("Generally, the views of tiny minorities should not be included at all"), ignore it in wikipedia. But it illustrates an important conundrum with regards to motion. Further to the point (if you don't find my example sufficient), Mach%27s_principle mention Gödel rotating universe. Gödel's view doesn't settle the question and he is a minority of one, so per WP:WEIGHT, why mention Gödel in that article? While I agree that one should give due consideration to NPOV, WP:WEIGHT and other policies, taking them as gospel is clearly not fruitful, it leads to dogma. You said "I have no idea what you are on about, with regard to "law".", does this illustrate my point better than I was able to before? I sure hope you will not be inspired to remove mention of Gödel in the article, because I love to be able to find bits like that on wikipedia, and if they are to be systematically excluded, I will loose one incentive to use wikipedia, really. So I don't think I should by default be barred from explicitly mention the dissenting view in the OA article that inflammation is primary, if I could not produce a secondary source. On the other hand, I of cause agree a secondary source is preferred in this case. Carystus (talk) 11:03, 28 July 2015 (UTC)
 * What text do you want to add / change based on what reference? Doc James  (talk · contribs · email) 13:16, 28 July 2015 (UTC)
 * Short answer: No, is not a secondary source. There are several ways to know this. First you can read it, in which case you will find wording such as "we used mass spectrometry", "We discovered that" and "we analyzed the expression". The authors are discussing their own research work rather than reviewing some other authors' work. Alternatively you can look at the PubMed abstract, where by clicking on "Publication Types, MeSH Terms, Substances, Secondary Source ID, Grant Support" you will not see "Review" listed as the publication type. Please, please, please, take the time to read and understand wp:MEDRS, as it is crucial to editors of medical topics here. LeadSongDog  come howl!  16:53, 28 July 2015 (UTC)

point taken, is not a secondary source. Thank you. I haven't written it yet, but I want a short section that informs the reader there are dissenting views when it comes to etiology, and I think this is so important that it warrant use of sources that are not secondary. It may not be true that there are other etiologies pertinent to OA than the prevailing view, and I am not trying to establish that. It is true that there are dissenting views, backed by the research of academics. I have seen in MEDRS "Controversies or areas of uncertainty in medicine should be illustrated with reliable secondary sources describing the varying viewpoints." If anyone can help me find such a reference, please do. If not, there could be a note, informing the reader of the nature of the reference. Carystus
 * Why is it so important that a non secondary source is needed? Doc James  (talk · contribs · email) 07:04, 29 July 2015 (UTC)

Nothing is more important in any field than dissenting views, it drives our understanding, and may change/rearrange the importance of known facts. To include those in a wikipedia article should be in a guideline. I have read MEDRS and it makes a lot of sense to me. WEIGHT is another story. Both are concerned with findings and how well a source support it. But a dissenting view is not a medical finding, although it presumably exist based on findings, so you may argue it should be treated just like other findings. More to the contra side, if the dissenting view is included in an article, the risk is that the reader perceive the prevailing view and the dissenting as equally possible although they are not, as the case may be. To the former I say history teach us how important it is not to suppress dissenting views. The role of wikipedia is to inform of how things are, so if a dissenting view exist, it should be mentioned, with a note on the gravity of the source. To the latter, the answer is the same, you walk in danger where you go. So if the gates are opened, dissenting views get a free ride with less stringent demands, and wikipedia medical articles are flooded with dissenting view remarks of dubious quality? Well, writing articles, like the medical profession, is an art, not science, and wikipedia peer review should work to keep a reasonable standard. Carystus (talk) 09:25, 30 July 2015 (UTC)
 * I see our role as that of following the best available sources rather than leading the best available sources. If there is a high quality secondary source which shows that that view has a decent following than we should include it. Doc James  (talk · contribs · email) 10:38, 30 July 2015 (UTC)

I was hoping for arguments as to why the best available sources criteria overrule the "report things as they are" approach (e.g. the dissent is real, and sufficiently documented by the Stanford press release alone, (with a note on the source and what it implies, to accommodate the context)). I realize this is a medical context. I also realize, if the best available sources criteria and WEIGHT was to be applied wikipediawide, most articles could not exist in their current form, and many could not exist. I ask what makes the medical context so special it must follow rules utterly foreign to wikipedia in general. Carystus (talk) 00:13, 2 August 2015 (UTC)
 * I do not see a press release as indicating that an idea has been picked up by the scientific community. Doc James  (talk · contribs · email) 10:48, 2 August 2015 (UTC)

You are right about that, so that is what the edit should say. I offered it as an example, my critique is generic. Carystus (talk) 15:21, 2 August 2015 (UTC)


 * , please read the policy wp:PSTS. The need to respect secondary sources does not just apply to medical assertions. Wikipedia is constantly subject to editors who wish to introduce primary-source material in ways contrary to policy. Anonymous editors cannot credibly determine which among many primary sources are significant, so we should not do so. We try to be more stringent about this on medical topics for the simple reason that there is an all too real possibility of harm. LeadSongDog come howl!  15:25, 2 August 2015 (UTC)

Disregarding the medical context for a moment, by PSTS the Stanford press release is considered a secondary source, right? If yes, and back to a medical context, is the unwillingness to accept the press release as a source based on MEDRS or WEIGHT or both? Carystus (talk) 17:57, 4 August 2015 (UTC)

External links modified
Hello fellow Wikipedians,

I have just added archive links to 1 one external link on Osteoarthritis. Please take a moment to review my edit. If necessary, add after the link to keep me from modifying it. Alternatively, you can add to keep me off the page altogether. I made the following changes:
 * Added archive https://web.archive.org/20110721225626/http://www.oarsi.org/pdfs/part_II_OARSI_recommendations_for_management_of_hipknee_OA_2007.pdf to http://www.oarsi.org/pdfs/part_II_OARSI_recommendations_for_management_of_hipknee_OA_2007.pdf

When you have finished reviewing my changes, please set the checked parameter below to true to let others know.

Cheers. —cyberbot II  Talk to my owner :Online 15:10, 19 October 2015 (UTC)

Hyaluronic acid injects
I have added the recommendations for ankle injects and differentiated them from the knee/hip injects. Kindly advise if you think it doesn't look okay/portray the idea correctly. Referenced Cochrane review:

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010643.pub2/abstract

amosabo''t@lk; 12:57, 10 February 2016 (UTC)

No mention of boron
Low boron intake seems a risk factor, and increased boron seems to alleviate symptoms. See Calcium fructoborate. Is there any reason not to mention boron in the appropriate places in this article ? - Rod57 (talk) 21:58, 9 April 2016 (UTC)
 * no - see talk page there. Jytdog (talk) 22:19, 9 April 2016 (UTC)

Update Glucosamine advice?
Looking at recent review articles, I ran across this recent review, which seems to advocate clearly for a pharmaceutical preparation of Glucosamine sulfate. This seems like a stronger recommendation than the current wording. Who can help confirm my understanding of the article?Sthubbar (talk) 08:47, 26 December 2016 (UTC)
 * The ref is not a systematic review and meta analysis.
 * Never heard of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis
 * The BMJ is a more respected journal. Doc James  (talk · contribs · email) 09:59, 26 December 2016 (UTC)
 * , in the full text here, a search for "meta-analys" show 16 matches with 4 of them in the text body and 12 of them from the titles of included sources. BTW, 3 of the referenced sources are from the BMJ.  Maybe one of them is the BMJ article you are referring to.  Doss any of this make a difference?Sthubbar (talk) 14:34, 26 December 2016 (UTC)
 * , as an alternative to changing the existing wording, can we add a new sentence, something like "Prescription glucosamine sulfate should be the first course of treatment according to the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO)." or "Prescription glucosamine sulfate is an effective OA treatment according to European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO)."Sthubbar (talk) 14:47, 26 December 2016 (UTC)
 * Must sleep. Will look at it in a few hours. Not sure this group ESCEO is notable? Doc James  (talk · contribs · email) 14:50, 26 December 2016 (UTC)
 * low quality source; there is no reason to use it Jytdog (talk) 20:05, 26 December 2016 (UTC)

, how is the quality of a source determined? The journal in which it is published? The authors? According to the journal's website, it is "ranked 5th out of 29 journals in the Rheumatology category on the 2011 Journal Citation Reports®, published by Thomson Reuters, and has an Impact Factor of 4.969." This sounds reputable to me. Is the Thomson Reuters ranking reputable? What is the cutoff for "reputable" sources?Sthubbar (talk) 12:32, 27 December 2016 (UTC)
 * your OP pretty much nails it. the advocacy is weird.  and looking at the "European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis" website they a) say that they are "dedicated to a close interaction between clinical scientists dealing with bone, joint and muscle disorders, pharmaceutical industry developing new compounds in this field, regulators responsible for the registration of such drugs and health policy makers, to integrate the management of Osteoporosis and Osteoarthritis within the comprehensive perspective of health resources utilization." and b) they don't disclose anything about their funding, the latter of which is concerning as well. looks like an astroturfing organization driven by Rottapharm. I would not use this ref.  User:Jytdog (talk) 18:59, 27 December 2016 (UTC)
 * , yes, it is clear that you do not recommend using this article. The point I'm trying to clarify is, isn't it the responsibility of the publishing journal to put their reputation on the line against such bias?  In particular, this is not the only review article that advocates for brand name, prescription medication.  Simply the fact that they recommend a particular brand name does not seem like significant enough evidence that they are biased.  So can you address:


 * Is Seminars in Arthritis and Rheumatism a reliable source?
 * , have you gotten enough sleep and can also chime in on this topic?
 * Thanks.Sthubbar (talk) 23:43, 27 December 2016 (UTC)
 * , BTW, to be clear, the current paragraph about glucosamine is thorough and well researched. I change my recommendation of modifying the paragraph, to simply request that this article be added as an additional reference after the sentence, "A difference may exist between glucosamine sulfate and glucosamine hydrochloride, with glucosamine sulfate showing a benefit and glucosamine hydrochloride not."  Is this article reliable enough to be included as a reference without changing any wording?Sthubbar (talk) 01:12, 28 December 2016 (UTC)
 * would rather not cite the article with its blatantly promo title at all. It brings no value to the encyclopedia; the topic is covered in other refs we have that are much higher quality. Jytdog (talk) 01:33, 28 December 2016 (UTC)

,, the author of the paper Professor Olivier Bruyère provided the following reply when asked if the paper had any connection to the manufacturer:
 * "The working group and this paper were fully funded by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO), a Belgian not-for-profit organisation. ESCEO was responsible for the selection of participants to the preliminary meeting and for the choice of the authors of the manuscript, covering all expenses related to the organisation of the preliminary meeting and the presentation of the outcomes of the working group at the World Congress on Osteoporosis, Osteoarthritis and Musculoskeletal Diseases. ESCEO also covered all expenses pertaining to the preparation, writing and submission of the manuscript. ESCEO received unrestricted educational grants from different non-governmental organisations, not-for-profit organisations and commercial partners; amongst them, Meda, which is a company interested in the development and marketing of glucosamine sufate. None of the partners were involved in the organisation of the ESCEO Working Group, which prepared this manuscript and were not part of the writing or review team of the manuscript.


 * Regarding Seminars in Arthritis and Rheumatism, I have no information that could jeopardise its neutrality."

Does this read like independent or biased?Sthubbar (talk) 00:13, 5 January 2017 (UTC)
 * Sorry but that means nothing. We have no way to verify that you received that email, that Bruyere sent it, nor what the email said is true. It all may be.  We just cannot know and ignoring stuff like that is baked into the foundations of Wikipedia.  We rely on published materials not private communications or personal knowledge. Jytdog (talk) 00:17, 5 January 2017 (UTC)
 * , I was taking guidance from 's entry above about Boswellia Serrata. He also could be a big fat liar.  BTW, I have attempted several times here and on your talk page to get some feedback on how the many sentences you added which have no relevance to OA should stay on the OA page.  Will you respond?Sthubbar (talk) 00:25, 5 January 2017 (UTC)
 * What part of what I wrote is unclear to you? I cannot help it if other people are incompetent here. Jytdog (talk) 00:45, 5 January 2017 (UTC)
 * Lots of non-organizations are simply fronts for marketing. They are funded by those who market the product so yes from the reply you received sounds biased. I guess the question is what percentage of their funding is from Meda? Doc James  (talk · contribs · email) 00:49, 5 January 2017 (UTC)
 * , thank you. Clear, simple, direct, polite, honest response.  That's all I was asking.Sthubbar (talk) 00:57, 5 January 2017 (UTC)

Edit conflicts?
, I'm not sure if we had an editing conflict. Here are the things I had corrected and now seem broken again after your recent edits. Is this intentional or may I put it back?Sthubbar (talk) 16:23, 26 December 2016 (UTC)
 * 1) Alphabetize Capcaicin, Chondroitin, ...
 * 2) No reference after Capsaicin.
 * Hello . There was an edit conflict while we were both working, but in reviewing the changes you made, I felt chondroitin should be mentioned first, since it is more widely used. The de Silva ref for capsaicin looks appropriate so can go back. Thanks. --Zefr (talk) 16:35, 26 December 2016 (UTC)
 * , ok. Is there an official policy that says a list of medications should be listed in order of wideness of use?  This would seem like a difficult rule to achieve consensus.  There are six medications in that list and I'm pretty sure SAMe is #1 or #2, so how do we get consensus on that?  It seems much more reasonable to just put all six in alphabetical order rather than trying to determine the wideness of use of each of the six.  Does that make sense?Sthubbar (talk) 21:52, 26 December 2016 (UTC)
 * As this is an alternative medicine/supplement section (not proven "medications"), with minor or dubious analgesic effects, it would be guesswork to assign an order for arthritis efficacy or popularity, and difficult to achieve WP:RS for published sales volumes (assumed). I mentioned chondroitin first because of its typical paired format with glucosamine, arguably the most common pseudoanalgesic supplement. If this seems important enough to develop, you could make your list here for editorial review, with sources if possible. --Zefr (talk) 23:15, 26 December 2016 (UTC)
 * , you lost me there. It seemed that you started supporting my position by saying "it would be guesswork to assign an order for arthritis efficacy or popularity" and then seem to contradict this by saying "the most common pseudoanalgesic supplement".  How did you determine "most common"?  Guessing?  Where are the sales volume of each?  There are 1.3 billion Chinese, how do the listed Chinese herbs compare to chondroitin?  My proposal is simply to alphabetize the already listed medications.  There is no need to put the proposed list here as it is already in the article.  Simple change the order of Capsacin gel and chondroitin and agree that alphabetize is most neutral presentation.  Do you agree?Sthubbar (talk) 23:30, 26 December 2016 (UTC)
 * It's too small a matter to debate. I'm ok with any order. --Zefr (talk) 02:06, 27 December 2016 (UTC)
 * Ok, alphabetization done.Sthubbar (talk) 04:29, 27 December 2016 (UTC)

I think listing the more common ones first is reasonable. Doc James (talk · contribs · email) 11:02, 27 December 2016 (UTC)

To OA or not to OA
Since, I'm feeling energetic these few days, here is another topic that was briefly touched on before, the consistency of abbreviating osteoarthritis as OA.

I propose replace all OA abbreviations with osteoarthritis for these reasons: Your thoughts?Sthubbar (talk) 01:19, 27 December 2016 (UTC)
 * 1) Wikipedia does not have the same space constraints as paper.Manual of Style/Abbreviations
 * 2) Conflicts with OA (WP:OA) – Office actions.Wikipedia_abbreviations#O
 * 3) A layperson may not know the meaning of OA if starting in middle of article.
 * 4) The page is inconsistent with some OA and some spelled out. Because of the above reasons, and to be consistent, it seems better to just always spell it out rather than to always use OA, or to have a mix.
 * I prefer the whole word. --Zefr (talk) 02:08, 27 December 2016 (UTC)
 * No preference personally. Doc James  (talk · contribs · email) 11:02, 27 December 2016 (UTC)

Paragraphing
, the first sentence in the Alternative Medicine section is a generic statement that applies to the following three paragraphs. I don't understand why you want to include it into the glucosamine paragraph. It makes more sense to either Why include it specifically with the glucosamine paragraph when every other sentence in that paragraph specifically references glucosamine?Sthubbar (talk) 13:29, 27 December 2016 (UTC)
 * 1) Remove this non-sourced, redudant, adds nothing to the article sentence
 * 2) Keep it on it's own at the beginning, which by coincidence highlights the points in the item above.
 * A single sentence by itself is not generally recommended. Removed per your suggestion. Doc James  (talk · contribs · email) 13:31, 27 December 2016 (UTC)