Note to the Editor, I am not an expert on statistics nor do I have expertise in the treatment of arthritis.

Abstract, Title, and References

1. The study's aim is clearly stated in the Abstract and Introduction.

2. The title is concise and direct. It stimulates interest and informs the readers of the article's contents.

3. The references are thorough and relevant. The oldest resource, a book, was dated the year 2000. The second oldest, resources dated 2005 and 2007, include questionnaires that served as a foundation for data collection in the research. The references are cited correctly within parenthesis throughout the text.

Introduction and Background

1. The presentation of the study aim and identification of knowledge gaps convince the reader of the necessity of the study.

2. The authors identified current knowledge and provided a need for urgency for these types of complementary studies on arthritis by describing the aging population and the negative impacts of the disease process.

3. The inclusion of best practices in the Introduction shows the reader that the authors acknowledge current practice. Even though the list of best practices appeared thorough, the researchers identified areas for improvement in the subject matter by stating the following in the 3rd paragraph on page 2:

“Despite best practice recommendations, the integration of complementary therapies in OA management may be controversial, depending on the healthcare context, and there is no international consensus regarding if, when or how to integrate complementary therapies into OA management.”

1. The research topic is justified in order to establish how complementary treatment options are perceived and which regimens patients choose to integrate into their care.

Methods

1. The goal to have the focus groups led by the patients was purposeful in order to have the participants acknowledge and generate new data. It was helpful from the reader’s perspective to have the authors' rationale included in the article.

2. The size of the sample group was an intentional number determined by the researchers. The rationale in determining the 4 to 8 participant limit was also described and is useful for the reader.

3. The subject selection was clear with a rationale for the proposed subjects. The authors state the number of participants and accounted for those who did not participate in the study.

4. Achieving "data saturation" in the focus groups allowed the researchers to determine the data collection was complete and thorough. The five main themes identified in the study were acknowledged by the participants and demonstrated reliability.

5. The group interview questions were included in the article in Table 1. The content presented in the table is organized and easy to read.

6. Quantitative data was obtained utilizing several tools to allow the participant to rate their physical and psychosocial status. This inclusion of detail allows for the replication of the study.

7. Table 2 is organized and identifies the demographic information about the participant. This table is easy to read. The decision to change the orientation to landscape and to delineate the lines between grey and white contributes to the clear presentation of the data.

8. The description leading up to Table 3 allows for a natural flow of data and facilitates an understanding of the content.

9. Table 4 included the main themes discovered through the focus interviews and elaborated with appropriate quotations from the participants.

10. The included tables are appropriate and their placement and inclusion further enhance the content of the study.

11. The data is presented with headings to clearly identify the main points. The article flows well and is reader-friendly.

12. The study discusses the participant perception of complementary medicine and therapies (CMT). Some of the participants did not practice CMT and believed the positive benefits experienced by others were the result of a placebo effect. Their opinion is important to the study in order to identify a range of views toward complementary medicine. This also provided reasons as to why some participants do not include complementary interventions in their health practices.

13. The data presented in the article support the study's aim.

14. 1. Future research topics discussed in the article

• The Discussion section identifies the need for clarification and consistent terminology of the interventions as a way to encourage dialogue between patients and providers.

• Concerns from the medical community regarding the quality and regulation of supplements was also raised. Identifying the knowledge and perceptions of the health care provider is an area proposed for future research.

• A screening checklist was proposed as a way to identify patients who are currently participating in CMT. This can also be used as a tool for providers to encourage dialogue, and to promote the safe integration of CMT.

• Another topic of future research is the cost of complementary treatment. Some forms of treatment are viewed as expensive, and the availability of CMT to patients with limited access to financial resources was identified as another topic of future research.

1. The conclusions are supported by references, which are appropriately integrated into the context.

2. Limitations identified in the article included a potential bias and the acknowledgment of a portion of participants with recent joint replacement surgery. The authors stated the participants' who received surgery experienced the symptoms of osteoarthritis within the past 24 months, and their perceptions remained valuable to the research results.

3. Study design

• The study design was thorough in its approach to the topic. • The interviews aide in identifying the need for consistent terminology and education regarding various complementary approaches. • The researchers discussed the major themes of CMT perspectives identified in the focus groups. The inclusion of both the participants who excluded and integrated CMT into their care provides valuable insight into perceived barriers and means of promoting dialogue with providers.

1. Questions I considered when reading the following statement on page 6, 3rd paragraph: "Participants generally had a limited view of a complementary medicine as only referring to an oral-based product, and were unaware of the breadth of products and therapies that the term 'complementary' covered."

• How did the researchers clarify the definition of complementary therapy to include both oral medication and "applied therapy"? It would be helpful to determine if the explanations provided in the discussion broadened their view of CMT from "home remedies" to a comprehensive understanding of the various modalities.

• Acknowledging the participant-lead discussion, did the researchers provide a list of CMT for osteoarthritis to the participants after the study or did the open discussion identify all of the available options?

Overall, this is an informative, well-researched article. The researchers evaluated the study aim and used the patient’s perspective as a tool to gain a complete picture of the most common themes. The article impacts both the patient and the provider approach to CMT. Establishing perspectives from the patient's point of view allows the provider to bridge the gap to provide a comprehensive plan of care.

Thank you for allowing me to review this beneficial article.