Arthritis and Complementary Health Approaches: What the Science Says
Clinical Guidelines, Scientific Literature, Info for Patients:
Arthritis and Complementary Health Approaches
Clinical practice guidelines issued by the American College of Rheumatology and the Arthritis Foundation recommend aerobic exercise and/or strength training, weight loss (if overweight), and a number of pharmacologic and nonpharmacologic modalities for treating osteoarthritis (OA) of the knee, hip, or hand. The guidelines strongly recommend tai chi, along with other nondrug approaches such as self-management programs, for managing knee and/or hip OA. Yoga is conditionally recommended for those with knee OA. Acupuncture is conditionally recommended for people with knee, hip, and/or hand OA. Massage therapy is conditionally recommended against use in people with knee and/or hand OA.
Despite extensive research, it’s still uncertain whether glucosamine and chondroitin have a meaningful impact on symptoms or joint structure in OA. The clinical practice guidelines strongly recommend against the use of glucosamine in people with hip, knee, and/or hand OA; however, the guidelines conditionally recommend chondroitin for people with hand OA. Topical capsaicin is conditionally recommended for people with knee OA and conditionally recommended against use in people with hand OA. 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. A 2023 systematic review and meta-analysis evaluated the effectiveness of acupuncture as an adjunctive therapy to oral pharmacologic medication in patients with knee OA and found that combined treatment of oral medication and adjuvant acupuncture showed statistically significant improvement in knee function and reduction in pain at the end of acupuncture treatment and short-term follow-up time (between 4 and 6 weeks after acupuncture).
- Massage therapy. A 2020 review found that massage or myofascial release yields a small improvement in hip and knee osteoarthritis. A 2017 systematic review of 7 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.
- Yoga. A 2019 systematic review of 9 studies (640 total participants) showed that yoga may be helpful for improving pain, function, and stiffness in people with osteoarthritis of the knee. However, the number of studies was small, and the research was not of high quality. The 2019 clinical practice guidelines from the American College of Rheumatology and the Arthritis Foundation conditionally recommends yoga for people with knee osteoarthritis based on similarities to tai chi, which has been better studied and is strongly recommended by the same guideline.
- Tai chi. A 2021 systematic review and meta-analysis of 11 randomized controlled trials involving a total of 603 participants found that tai chi was associated with improved walking function and posture control in older adults with knee osteoarthritis. A 2020 systematic review and meta-analysis of 20 randomized controlled trials and 2 case series found that compared to the controls groups, exercise (including tai chi and yoga) showed a small-to-high effect for improving pain, physical function, quality of life, and stiffness. 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 2021 systematic review and meta-analysis of 16 randomized controlled trials involving a total of 986 participants with knee osteoarthritis found that pain, physical function, dynamic balance, and physiological and psychological health were significantly improved for those practicing tai chi.
- Glucosamine and chondroitin. Studies of glucosamine and chondroitin 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 and chondroitin 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.
- In 2017, the American Academy of Orthopaedic Surgeons published a clinical practice guideline on management of osteoarthritis of the hip that concluded that moderate-strength evidence does not support the use of glucosamine sulfate for hip osteoarthritis. This conclusion was based on the one high-quality study, published in 2008, that included 222 participants, who received 2 years of treatment with glucosamine sulfate or a placebo. Glucosamine was no better than placebo in terms of effects on pain, joint function, or joint structure.
- Another study with 162 participants evaluated chondroitin for hand osteoarthritis and found that over 6 months, hand pain decreased and hand function improved to a greater extent in the chondroitin group than the placebo group.
- The 2019 guideline for osteoarthritis management from the American College of Rheumatology and the Arthritis Foundation conditionally recommends chondroitin for patients with hand osteoarthritis; however, it strongly recommends against the use of glucosamine in people with hip, knee, and/or hand OA
- 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.
- 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.
- No major safety problems have been identified in large studies of glucosamine and chondroitin for osteoarthritis. However, glucosamine may cause increases in blood glucose levels in some people, and glucosamine and chondroitin have been associated with an increased risk of bleeding in people who are taking the anticoagulant warfarin.
- 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.
Results from clinical trials suggest that some psychological and/or physical approaches—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 2005 Cochrane review of two studies—one on acupuncture and the other on electroacupuncture for RA—concluded that acupuncture has no effect on erythrocyte sedimentation rate, C-reactive protein, 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 electroacupuncture 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 2022 review of 23 studies found that mind and body therapies, including meditation, yoga, and mindfulness, had various effects on patient-reported outcomes, such as vitality, functioning, and mental health, as well as on disease activity markers. Mindfulness-based interventions mainly reduced the subjective disease activity parameters (e.g., joint tenderness, morning stiffness, and pain), rather than the objective disease activity parameters (e.g., swollen joints and C-reactive protein). A 2023 systematic review and meta-analysis of 57 studies had similar findings—psychological interventions such as cognitive behavioral therapy (CBT), mindfulness, relaxation techniques, and others are moderately effective in treating RA and can significantly contribute to the standard medical care of RA patients. 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.
- Tai chi. Only a few small studies have been conducted on tai chi for RA. A 2023 systematic review and meta-analysis of 9 controlled trials involving a total of 351 participants with RA found that tai chi did not improve physical function and pain. 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 OA and RA found that regular yoga training was helpful in reducing knee arthritic symptoms, promoting physical function, and general wellbeing in arthritic patients. In a 2023 systematic review and meta-analysis (27 studies were included for qualitative analysis and 18 for meta-analysis), yoga was favored to decrease depressive symptoms and improve sleep quality in patients with RA, OA, fibromyalgia, and chronic fatigue syndrome. 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 RA. 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.
- 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.
- 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.
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