The manuscript by Witt et al. intends to analyze the effectiveness of conventional Western medicine in comparison with traditional Indian Ayurvedic (TIA) medicine in treating osteoarthritis (OA) symptoms in patients with knee OA. Patients randomized through TIA diagnosis to the TIA intervention group will receive 15 treatment sessions up to a maximum of 90 minutes each, composed of an individualized combination of manual treatments and massages, nutritional advice, specific consideration of selected food items and nutritional supplements, general and specific lifestyle advice, yoga posture advice for the knee, and daily self-applied home knee massage. Patients randomized through TIA diagnosis to the conventional care intervention group will receive 15 sessions with a duration of 45 minutes, composed of an individualized combination of quadriceps muscle strengthening exercises, local physiotherapy including manual therapy and friction massage, occupational therapy, advice for individual knee exercise, and weight loss counseling if indicated. The Western Ontario and McMaster University Osteoarthritis Index (WOMAC) will be used to assess OA symptomology with 80% power after the 12-week study period.

The content of the manuscript is appropriately represented through the title and the abstract of the manuscript. The construction of the manuscript is operative, the methods are thoughtful, and the discussion is, predominantly, well-developed. I recommend that this manuscript be accepted following minor revisions to the discussion section and figures present within the manuscript.

Comments

1.) Background Section: The discussion of TIA medicine as a complex and comprehensive medical model, and the juxtaposition by the authors of this manuscript of TIA medicine with Western medicine, is useful to the reader and serves to develop a sense of importance for the intention of the study described in the manuscript.

2.) Figures: Figures 1-3 are appropriately utilized in this manuscript and aid the accessibility of processes described within the methods section. Figure 4, named “placement of the trial in the efficacy/effectiveness continuum” is confusing and unnecessary to the description of the multidimensional construct of the trial. It is recommended that this figure be either modified to serve as an aid to understanding the multidimensional construct of the trial or be removed from the manuscript prior to publication.

3.) Methods: The true appropriateness and generalizability of the designed multi-modal complex conventional care intervention is uncertain, as the consistent and systematic delivery of a complex OA intervention across the continuum presents as a relevant challenge within the Western health care environment. There is potential for the creation of a larger effect size in the conventional care intervention group, as well as for the detraction from the results of TIA intervention when examined in comparison. It is recommended that this be communicate in the discussion section of the manuscript prior to publication.

4.) Suggestions for Future Research: In the conventional care intervention group, participants received a multi-modal complex conventional care intervention that was developed in concordance with both guideline- and evidence-based consensus. As discussed prior, however, the consistent and systematic delivery of a complex OA intervention across the continuum presents as a relevant challenge within the Western health care environment. It is suggested that a future study examine the effectiveness of a simple conventional care intervention for OA and a complex TIA intervention.