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NCCIH Clinical Digest

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Arthritis and Complementary Health Approaches : What the Science Says

July 2020

Clinical Guidelines, Scientific Literature, Info for Patients: 
Arthritis and Complementary Health Approaches

older man with cane walking with caregiver

Osteoarthritis

Clinical practice guidelines issued by the American College of Rheumatology recommend aerobic exercise and/or strength training, weight loss (if overweight), and a number of pharmacologic and non-pharmacologic modalities for treating osteoarthritis (OA) of the knee, hip, or hand. The guidelines conditionally recommend tai chi, along with other non-drug approaches such as self-management programs and walking aids, for managing knee OA. Acupuncture is also conditionally recommended for those who have chronic moderate-to-severe knee pain and are candidates for total knee replacement but can’t or won’t undergo the procedure.

Despite extensive research, it’s still uncertain whether glucosamine and chondroitin have a meaningful impact on symptoms or joint structure in osteoarthritis. The evidence on other natural products is too limited for any conclusions to be reached.

What Does the Research Show?

  • Acupuncture. A 2016 meta-analysis of 10 randomized controlled trials concluded that acupuncture can improve short and long-term physical function, but it appears to provide only short-term pain relief in patients with chronic knee pain due to arthritis. A 2012 meta-analysis concluded that acupuncture can be helpful and a reasonable referral option for OA pain. The authors of the meta-analysis also noted that significant differences between true (actual) and sham acupuncture indicate that acupuncture is more than a placebo; however, these differences are relatively modest. Findings suggest that factors other than the specific effects of needling contribute to the therapeutic effects of acupuncture. In a 2008 systematic review of 10 randomized controlled trials of acupuncture for OA of the knee in 1,456 patients, the authors concluded that these studies provide evidence that acupuncture is an effective treatment for pain and physical dysfunction associated with OA of the knee. A 2010 systematic review of 16 trials of 3,498 patients examined the effects of acupuncture for OA in peripheral joints and found that although acupuncture, when compared to a sham treatment, showed statistically significant, short-term improvements in OA pain, the benefits were small and not clinically relevant. In contrast, acupuncture, when compared to a waiting list control, showed statistically significant and clinically relevant benefits in people with peripheral joint OA.
  • Massage therapy. A 2017 systematic review of seven randomized controlled trials involving 352 participants with arthritis found low- to moderate-quality evidence that massage therapy is superior to nonactive therapies in reducing pain and improving functional outcomes. A 2013 review of two randomized controlled trials found positive short-term (less than 6 months) effects in the form of reduced pain and improved self-reported physical functioning. Results of a 2006 randomized controlled trial of 68 adults with OA of the knee who received standard Swedish massage over 8 weeks demonstrated statistically significant improvements in pain and physical function.
  • Tai chi. A 2016 randomized, 52-week, single blind comparative effectiveness study involving 204 participants, found that tai chi produced beneficial effects similar to those of a standard course of physical therapy in the treatment of knee osteoarthritis. A 2013 meta-analysis of 7 randomized controlled trials involving 348 participants found that a 12-week course of tai chi provides benefits of improvement in arthritic symptoms and physical function in patients with OA; however, any long-term benefits of tai chi on OA symptoms has not yet been investigated. A 2013 systematic review and meta-analysis of 5 randomized controlled trials involving 252 participants found moderate evidence for short-term improvement of pain, physical function, and stiffness in patients with OA of the knee who practiced tai chi. A 2009 prospective, single-blind, randomized controlled trial of 40 participants found that tai chi demonstrated significantly greater improvement in pain and physical function, as well as improvement in depression, self-efficacy, and quality of life.
  • Glucosamine and chondroitin. Studies of glucosamine for pain in knee OA have had conflicting results. Some, including a major National Institutes of Health (NIH)-sponsored study, found little or no evidence that glucosamine can relieve pain, but several other studies indicated that it can. Studies of chondroitin for pain from OA of the knee have had inconsistent results, but in general, the largest, highest quality studies have not shown an effect. There isn’t enough evidence to show whether glucosamine or chondroitin lessens pain from OA in other joints. A few studies have looked at whether glucosamine or chondroitin or the combination can have beneficial effects on joint structure in people with OA. Some but not all of these studies found evidence that chondroitin or a glucosamine/chondroitin combination might help, but the improvements seen in most studies may be too small to make a difference to patients. There’s little evidence that glucosamine alone has beneficial effects on joint structure.
  • DMSO and MSM. Dimethyl sulfoxide (DMSO) and methylsulfonylmethane (MSM) are two chemically related substances that have been studied for OA. DMSO is applied to the skin. MSM is used as a dietary supplement. Very little research has been done on DMSO and MSM, so it’s uncertain whether they’re helpful for OA symptoms.
  • SAMe. S-Adenosyl-L-methionine (SAMe) is a molecule that is naturally produced in the body. It’s also sold in the United States as a dietary supplement. Studies of SAMe for OA have had inconsistent results. In some studies, SAMe appeared to be as effective as nonsteroidal anti-inflammatory drugs (NSAIDs) in relieving symptoms associated with OA, but in others it was no more helpful than a placebo.

Safety

  • There are few complications associated with acupuncture, but adverse effects such as minor bruising or bleeding can occur; infections can result from the use of nonsterile needles or poor technique from an inexperienced practitioner.
  • Massage therapy appears to have few risks if it is used appropriately and provided by a trained massage professional.
  • Tai chi is considered to be a safe practice.
  • Glucosamine and chondroitin supplements may interact with the anticoagulant (blood-thinning) drug warfarin (Coumadin). Overall, studies have not shown any other serious side effects.
  • Both DMSO and MSM can have side effects. DMSO can cause digestive upset, skin irritation, and a garlic-like taste, breath, and body odor. MSM can cause allergic reactions, digestive upsets, and skin rashes.
  • Side effects of SAMe are uncommon and usually mild. However, little is known about the long-term safety of SAMe because most studies have been brief. SAMe may have special risks for people with bipolar disorder as it may provoke mania, and in those who are HIV positive or immunocompromised, it increases the risk of Pneumocystis carinii infection, by enhancing the growth of this microorganism. SAMe also may interact with drugs, including some antidepressants and the drug levodopa.

Rheumatoid Arthritis

Results from clinical trials suggest that some mind and body practices—such as relaxation, mindfulness meditation, tai chi, and yoga—may be beneficial additions to conventional treatment plans, but some studies indicate that these practices may do more to improve other aspects of patients’ health than to relieve pain. Supplements containing omega-3 fatty acids, gamma-linolenic acid (GLA), or the herb thunder god vine may help relieve rheumatoid arthritis symptoms.

What Does the Research Show?

  • Acupuncture. Acupuncture has been studied for a variety of pain conditions, but very little acupuncture research has focused on RA. A 2017 review identified several studies that have indicated a positive role for acupuncture in the treatment of rheumatoid arthritis, but others have failed to show positive outcomes. A 2010 Cochrane review of two studies—one on acupuncture and the other on electroacupuncture for RA—concluded that acupuncture has no effect on ESR, CRP, pain, patient's global assessment, number of swollen joints, number of tender joints, general health, disease activity, and reduction of analgesics. Although findings from the study on electroacupuncture showed that electro-acupuncture may reduce symptomatic knee pain, the review noted that the poor quality of the trial, including the small sample size, preclude its recommendation.
  • Mindfulness, biofeedback, and relaxation training. A 2017 review of three randomized controlled trials found that although there is increasing evidence linking the practice of mindfulness techniques to improved immune function, there haven’t been enough large, high-quality studies to determine long-term effects in rheumatic disease. A 2010 systematic review of 31 studies in 2,021 patients looked at the benefits of mind and body practices such as mindfulness meditation, biofeedback, and relaxation training on the physical and psychological symptoms associated with RA. There was some evidence that these techniques may be helpful, but overall, the research results have been mixed.
  • Tai chi. A few small studies have been conducted on tai chi for RA. A 2007 systematic review concluded that tai chi has not been shown to be effective for joint pain, swelling, and tenderness, although improvements in mood, quality of life, and overall physical function have been reported. A small 2010 study of 15 participants found that tai chi improved lower-limb muscle function post-treatment and at the 12-week follow up; however, there was no evidence that it reduced disease activity or pain.
  • Yoga. A 2018 meta-analysis of 13 trials involving a total of 1,557 participants with knee osteoarthritis and rheumatoid arthritis found that regular yoga training was helpful in reducing knee arthritic symptoms, promoting physical function, and general wellbeing in arthritic patients. A 2017 review of two studies found some beneficial effect on pain, but due to the high risk of bias in both studies, the reviewers gave a weak recommendation for yoga in rheumatoid arthritis. Yoga incorporates several elements of exercise that may be beneficial for arthritis, including activities that may help improve strength and flexibility. A 2013 systematic review of 8 randomized controlled trials involving a total of 559 participants found very low evidence on the effects of yoga on pain associated with RA.
  • Fish oil. Clinical trials on RA have found that fish oil supplements may help alleviate tender joints and morning stiffness, while other studies have found that fish oil may reduce the daily nonsteroidal anti-inflammatory drug (NSAID) requirement of RA patients. 
  • Gamma-Linolenic Acid (GLA). GLA is an omega-6 fatty acid found in the oils from some plants, including evening primrose (Oenothera biennis), borage (Borago officinalis), and black currant (Ribes nigrum). Oils containing GLA may have some benefit in relieving RA symptoms; however, only a few studies have been conducted on each of the oils.
  • Thunder God Vine. Thunder god vine (Tripterygium wilfordii) is an herb used in traditional Chinese medicine. There have been only a few high-quality studies of oral thunder god vine for RA. These studies indicate that thunder god vine may improve some RA symptoms. In two studies, thunder god vine was at least as helpful as a conventional drug. Promising results have also been seen in studies in China where thunder god vine was used in combination with a conventional drug.

Safety

  • Acupuncture is considered safe when performed by a qualified and competent practitioner using sterile needles. Few complications have been reported. Serious adverse events related to acupuncture are rare, but include infections and punctured organs.
  • Some people have reported soreness, but most studies have found that tai chi is relatively safe for people with RA.
  • People with RA who have limited mobility or spinal problems should perform yoga exercises with caution. People with RA may need assistance in modifying some yoga postures to minimize joint stress and may need to use props to help with balance.
  • Omega-3 supplements usually produce only mild side effects, if any. There’s conflicting evidence on whether omega-3 supplements might influence the risk of prostate cancer. People who take anticoagulants and those who are allergic to fish or shellfish should consult their health care provider before taking omega-3 supplements.
  • In short-term studies, oils containing GLA produced only mild side effects, such as upset stomach or headache. The long-term safety of GLA supplements is uncertain. Some borage products may contain pyrrolizidine alkaloids that can harm the liver.
  • Thunder god vine can have serious side effects, including loss of bone density and male infertility. Thunder god vine can be extremely poisonous if the extract is not prepared properly. The risks of using this herb may exceed its benefits.

References

Osteoarthritis

Rheumatoid Arthritis

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