Complementary therapies for rheumatoid arthritis

Patient information: Complementary therapies for rheumatoid arthritis

Author
Richard S Panush, MD, MACP, MACR
Section Editor
RN Maini, BA, MB BChir, FRCP, FMedSci, FRS
Deputy Editor
Paul L Romain, MD

Disclosures

COMPLEMENTARY THERAPY OVERVIEW — Rheumatoid arthritis (RA) is a chronic inflammatory condition. The condition can affect many tissues throughout the body, although the joints are usually most severely affected. Medications and other conventional therapies, such as physical therapy, are the mainstays of treatment for people with RA. However, treatment for RA remains far from ideal for many patients, leading them to search for other approaches that might improve outcomes.

Complementary and alternative medicine (CAM) has been defined by the National Center for Complementary and Alternative Medicine as “a group of diverse medical and healthcare systems, practices, and products that are not presently considered to be part of conventional medicine [1]. For some CAM practices, there is scientific evidence that a treatment is both beneficial and safe. For many other practices, evidence is lacking or inconclusive.

Most patients who use complementary and alternative medicine treatments are not dissatisfied with conventional or established medical treatments, but find that complementary medicine appeals to their values and beliefs about health and life. Being diagnosed with RA and living with the disease can be a frightening, exhausting, and demanding experience. CAM appeals to many people because these treatments offer a chance to feel better and decrease uncomfortable symptoms such as pain and fatigue.

A number of other topics about RA are available separately. (See “Patient information: Rheumatoid arthritis symptoms and diagnosis” and “Patient information: Rheumatoid arthritis treatment” and “Patient information: Disease modifying antirheumatic drugs (DMARDs)” and “Patient information: Rheumatoid arthritis and pregnancy”.)

CONVENTIONAL TREATMENT OF RA — Conventional treatments for RA have improved significantly since the late 1990s, when advances in molecular biology led to a variety of new treatment approaches for RA. These new treatments are known as biologic agents, which interfere with the body’s production of inflammatory chemicals. Biologic agents are often used with disease modifying antirheumatic drugs (DMARDs) such as methotrexate. When DMARDs and biologic agents are used in combination, up to 85 percent of patients have a moderate to good response to treatment.

Experimental treatments such as immunoadsorption and stem cell transplantation are rarely, if ever, considered due to the small potential benefit and significant potential for harm. However, complementary treatments such as acupuncture, mind-body techniques, and exercise continue to have a place, alongside conventional treatment, for many people with RA.

Placebo effect — When discussing complementary treatments for RA, it is important to understand the placebo effect. A placebo is an inactive medication or treatment. Well-designed studies include a placebo treatment as well as a real treatment so that the two may be compared. The placebo effect is the positive or negative result that occurs when a patient believes they have been given a treatment, when in fact they have been given none (or a look-alike substitute). For example, a complementary treatment that claims to improve symptoms of fatigue in 50 percent of patients is of little benefit if a placebo treatment also improves fatigue in 50 percent of patients.

The placebo effect is not well understood, although it has a strong influence on the results of any research study, whether in conventional or complementary medicine.

COMPLEMENTARY THERAPIES — Complementary medicine is a treatment, practice, or product that is used alongside conventional medical treatment. It is not meant to replace conventional RA treatment, but may help to alleviate side effects or improve a patient’s sense of well-being.

Complementary therapies are attractive because they are perceived to be safe and

“natural”, and because conventional medical treatments can have limited effectiveness and significant side effects. However, it is not clear how most complementary treatments work, many are marketed with unproven claims, and certain therapies have even been proven harmful.

Several complementary therapies may play a useful role in the treatment of RA, although the safety and effectiveness of most of these therapies are still uncertain. Thus, people with RA who are considering complementary therapies should discuss these therapies with their healthcare provider first. Furthermore, therapies that have proven benefits should only be used to complement, not replace, conventional medical treatment.

Exercise — Studies suggest that exercise is both safe and beneficial in people with RA. Regular exercise can build endurance and strength, preserve muscle and normal joint motion, minimize bone loss, and improve pain control. Exercise may also have cardiovascular, psychological, and social benefits. (See “Patient information: Arthritis and exercise”.)

People with rheumatoid arthritis should have an exercise program designed by an experienced physical therapist. The program should be tailored to the severity of the person’s condition, body build, and activity level. Exercise should never cause increased pain and should never push the joints past their normal range of motion.

Foods and diets — There is no evidence that food allergies or sensitivities cause or worsen RA in most people. However, some people notice that their symptoms improve when they fast or eliminate certain foods from their diet, leading the person to believe that an allergy or sensitivity is contributing to arthritis. However, elimination diets are difficult to maintain long-term and can lead to malnutrition. Thus, it is important to involve an experienced healthcare provider in decisions regarding diet. In some cases, a consultation with a dietitian will be recommended.

For most people with RA, a healthy, balanced diet is a sensible component of the treatment plan [2]. (See “Patient information: Diet and health”.)

Fish oils and plant oils — Fish oil contains high amounts of two omega-3 fatty acids, which the body can use to make substances that reduce inflammation. Plant oils (such as primrose oil, borage, black currant, and flaxseed oil) contain omega-3 and omega-6 fatty acids.

Both fish and plant oils have been shown to modestly reduce symptoms of rheumatoid arthritis and may be helpful in some people. Further studies are needed to establish their benefit and determine the optimal dosage. However, fish oils can interact with blood pressure medications (potentially lowering blood pressure too much) and can increase the risk of bleeding, especially in people who take aspirin or warfarin (Coumadin®). In addition some fish oils have high levels of contaminants such as mercury.

Plant oils also have potentially dangerous side effects, including increased bleeding (with borage seed and primrose oil), interactions with psychiatric medications (with primrose oil), and worsened liver function (with borage seed oil).

Herbs, vitamins, and dietary supplements — Combinations of herbs (also called botanicals) are often promoted as treatments for medical problems. Herbal medicines may come in the form of a powder, liquid, or pill. Examples of herbal treatments for RA include Thunder god vine (botanical name Tripterygium wilfordii Hook F), valerian, ginger, curcumin, and boswellia [3].

However, the evidence in support of such claims is scant, standardized and high quality preparations are not available, and some of these herbs can cause dangerous side effects. In addition, some herbal products can interact with conventional treatments, making them less effective. We do not currently recommend the use of herbs, vitamins, or other dietary supplements.

Homeopathy — Homeopathy is a complementary therapy that uses small quantities of highly diluted substances to relieve symptoms of a condition or illness. A few studies have evaluated the benefit of homeopathy in the treatment of RA, although most studies were small. One well designed study failed to show a clear benefit of homeopathy, compared to placebo, in reducing the symptoms of RA [4]. Although there may be a low risk of harm from homeopathic remedies, further studies are needed before homeopathy is recommended. Further information about homeopathy is available from the National Center for Complementary and Alternative Medicine (file://nccam.nih.gov/health/homeopathy/).

Acupuncture — Acupuncture involves inserting hair-thin, metal needles into the skin at specific points on the body. It causes little to no pain. Electrical stimulation is sometimes applied to the acupuncture needle. There have been a few studies of acupuncture’s benefit for RA, most of which were small and poorly designed. The most recent review of these studies show that acupuncture has no effect on the number of swollen and tender joints, pain, or amount of pain medications required by people with RA [5].

Magnets — Magnets produce a type of energy known as a magnetic field, which is theorized to improve pain caused by a number of conditions, including RA. Magnets have been used in bracelets, body wraps, mattresses, and shoe inserts. Current research does not show that people with RA derive much (if any) benefit from magnets, although research is ongoing [6].

Mind-body techniques — Mind-body techniques include practices such as hypnosis, guided imagery, meditation, yoga, biofeedback, and prayer. Mind-body techniques are based upon the interactions between the body, mind, emotions, and overall state of health. These techniques may be useful to control anxiety or pain. Patients of any age can learn mind-body techniques.

Studies of mind-body techniques in people with RA show that most techniques are of some benefit, when used along with conventional treatments, in reducing pain and disability and improving a person’s overall psychological state, ability to cope, and belief in one’s ability to handle difficult situations [7].

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

 

Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient Level Information:

Patient information: Rheumatoid arthritis symptoms and diagnosis
Patient information: Rheumatoid arthritis treatment
Patient information: Disease modifying antirheumatic drugs (DMARDs)
Patient information: Rheumatoid arthritis and pregnancy
Patient information: Arthritis and exercise
Patient information: Diet and health

Professional Level Information:

Acupuncture for rheumatic conditions
Complementary and alternative remedies in rheumatic disorders

The following organizations also provide reliable health information.

National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)

National Institute of Arthritis and Musculoskeletal and Skin Diseases
(301) 496-8188
(www.nih.gov/niams/)

National Center for Complementary and Alternative Medicine
(file://nccam.nih.gov/)

American College of Rheumatology/Association of Rheumatology
(404) 633-3777
(www.rheumatology.org)

The Arthritis Foundation
(800) 283-7800
(www.arthritis.org)

REFERENCES
NIH Consensus Conference. Acupuncture. JAMA 1998; 280:1518.
Henderson CJ, Panush RS. Diets, dietary supplements, and nutritional therapies in rheumatic diseases. Rheum Dis Clin North Am 1999; 25:937.
Little C, Parsons T. Herbal therapy for treating rheumatoid arthritis. Cochrane Database Syst Rev 2001; :CD002948.
Fisher, P, Scott, DL. A randomized controlled trial of homeopathy in rheumatoid arthritis. Rheumatology 2001; 40:1052.
Casimiro L, Barnsley L, Brosseau L, et al. Acupuncture and electroacupuncture for the treatment of rheumatoid arthritis. Cochrane Database Syst Rev 2005; :CD003788.
Johnson MT, Waite LR, Nindl G. Noninvasive treatment of inflammation using electromagnetic fields: current and emerging therapeutic potential. Biomed Sci Instrum 2004; 40:469.
Astin JA, Beckner W, Soeken K, et al. Psychological interventions for rheumatoid arthritis: a meta-analysis of randomized controlled trials. Arthritis Rheum 2002; 47:291.
Rose G. Why do patients with rheumatoid arthritis use complementary therapies? Musculoskeletal Care 2006; 4:101.