Even people who have traditionally sought the care of a mainstream physician or health-care provider are likely to have used a complementary or alternative approach at some point. In fact, more than half of Americans are currently using some form of medicine that is not mainstream.
The line between mainstream “Western” medicine and complementary/alternative medicine has become increasingly blurred—and now there is another form of health care, referred to as “integrative.” To make sure everyone is on the same page when talking or reading about the various kinds of treatment available to people who have arthritis, try the “Health Care Choices: What’s the Difference?” matching test on the next page.
The information in this chapter highlights some of the most popular complementary and alternative methods of treatment. Be warned that while there is evidence that some work, some don’t!
Acupuncture
This form of traditional Chinese medicine is based on the theory that health and well-being depend on a harmonious balance between “yin” and “yang,” which are the two extremes of “qi,” or life force. Qi is believed to flow 
through pathways in the body called meridians, which can be accessed via more than 300 acupuncture points. Inserting fine needles into these points is believed to rebalance yin and yang. There also is a scientific explanation behind the therapy: Stimulation of the points with fine needles may cause your body to release more of its own natural painkillers.
Acupuncture is endorsed as a treatment for arthritis pain by the American College of Physicians. According to the American Academy of Orthopaedic Surgeons, when acupuncture is combined with traditional pain-relief methods, it may be helpful for low back pain, fibromyalgia, and osteoarthritis (OA). A review of 44 trials concluded that acupuncture can enhance standard care by reducing the severity of pain associated with a variety of conditions and diseases. However, acupuncture is not recommended for people who are taking certain drugs—for example, blood thinners like warfarin (Coumadin)—or those who are extremely anxious. It also is inappropriate for conditions such as head injuries, herniated discs, or unstable joints.
If you decide to try acupuncture, consult a practitioner certified by the American Academy of Medical Acupuncture (see the Resources section at the back of this report).
Antioxidants
Antioxidants are substances that prevent or delay cell damage and inflammation due to free radicals (harmful molecules that occur naturally in the body). Popular antioxidants include vitamins C and D, resveratrol, and compounds in tea.
According to the National Center for Complementary and Integrative Health (NCCIH), diets that are high in fruits and vegetables (which are good sources of antioxidants) have been found to be healthy. However, research has not shown antioxidant supplements to be beneficial at preventing diseases.
- Vitamin C is essential for the formation and health of collagen and other connective tissue. The recommended daily amount for vitamin C is 90 milligrams (mg) for men, and 75 mg for women. Taking vitamin C supplements may have a counterproductive effect in OA, and there also is conflicting evidence as to whether it has a protective effect for gout.
- Vitamin D. Vitamin D is essential for the metabolism of calcium. It is manufactured in the skin with exposure to sunlight and also can be consumed via fortified cereals, milk and fruit juice, fish, and eggs, or taken as a supplement. The Institute of Medicine recommends that people get 600 International Units (IUs) of vitamin D per day, but many experts recommend 800 to 1,000 IUs. While there is some evidence vitamin D may help in osteoporosis and fibromyalgia, there is conflicting evidence of any benefit in arthritis.
- Resveratrol. This antioxidant is present in berries, grapes, and wine, and it may decrease inflammatory markers. In a 2018 study, people with RA who were given resveratrol along with conventional drugs experienced improvements in clinical markers of RA disease activity compared to those treated with drugs alone.
- Green tea. In one study, people with RA who were treated with green tea for six months alone or in combination with the biologic drug infliximab (Remicade) or an exercise program showed significant improvement in disease activity. Benefits also may be seen with black tea.
Aromatherapy/Essential Oils
Aromatherapy is the use of essential oils from plants to improve the mind, body, and spirit, according to the National Cancer Institute, which has conducted or sponsored most of the current research on aromatherapy.
Aromatherapy may be used with other complementary treatments, such as massage and acupuncture. Among the oils used are those from Roman chamomile, geranium, lavender, tea tree, lemon, and cedarwood. They are thought to stimulate scent receptors, which send messages through the nervous system to the part of the brain that controls emotions.
Aromatherapy is used in three ways:
- Indirect inhalation. Breathing in the oil via a room diffuser, which spreads the oil through the air, or by placing drops of oil nearby.
- Direct inhalation. Breathing in the oil through an inhaler.
- Massage. Massaging diluted oil into the skin through lotions or bath salts.
The U.S. Food and Drug Administration (FDA) considers essential oils cosmetic, so manufacturers are not required to prove their product’s effectiveness, purity, or potency. Any advertising claim that an essential oil can treat a health condition is illegal.
Studies of aromatherapy massage and inhalation have had mixed results. There have been reports of improved mood, anxiety, sleep, nausea, and pain levels, but nothing specifically about arthritis. The Mayo Clinic found that patients who tried aromatherapy after surgery had better pain management and higher overall satisfaction with their care. Another study suggested that lavender oil may help reduce pain for people with OA of the knee. A review of several small studies published in Pain Research and Treatment indicated that aromatherapy can successfully treat pain when combined with conventional treatment.
Side effects are rare when essential oils are used according to directions, but they are possible and include allergic reactions, skin irritation, and sensitivity to sunlight. You should never apply undiluted essential oils to your skin; they are potent and should be added to a neutral carrier oil or lotion before use. Never ingest essential oils.
Biofeedback
Biofeedback measures body functions that are related to emotional stress and chronic pain. Awareness of the physical changes that take place when you are under stress or feel pain can help you manage those variables.
Electrodes placed on the body measure functions such as breathing rate, heart rate, blood pressure, skin temperature, and muscle tension. A monitor displays the results for you and the person administering the process. He or she will show you which body function levels indicate abnormalities, and will then teach you how to lower those indicators using techniques such as controlled breathing, imagery, and exercises. The goal is for you to gain control over these body functions and, in the process, self-treat a variety of physical problems, including your arthritis pain.
Cognitive Behavioral Therapy
Cognitive behavioral therapy—a type of “talk therapy”—is one of the most common psychological interventions for people with arthritis pain. If you decide to try it, you will attend a pre-determined number of in-person or online sessions with a mental health counselor. He or she will attempt to help you identify and correct ingrained patterns of negative thoughts and behaviors. The process is most effective in people who can quickly identify a specific concern and learn how to cope with it, even if the level of pain they are experiencing remains unchanged.
Cognitive behavioral therapy is considered a mainstream pain-management treatment by some people and a complementary technique by others. It’s traditional because it has been recommended by physicians for more than a decade. It’s complementary (or integrative) because it almost always is used in combination with one or more additional mainstream strategies.
Copper Bracelets
Copper bracelet manufacturers claim that tiny amounts of copper move from the bracelets through the surface of the skin and neutralize molecules that can damage cells in and around joints. The bracelets have strong support among those who believe that they relieve pain. However, there is no evidence that they have any meaningful therapeutic effect beyond that of a placebo (an inert substance or “fake” treatment).
Dimethyl Sulfoxide (DMSO)
DMSO is a colorless, sulfur-containing organic byproduct of wood pulp processing that has analgesic and anti-inflammatory properties. It can be taken orally or applied to the skin and is used in wound healing, burns, and arthritis. However, evidence of its effectiveness is mixed.
When taken orally, DMSO may cause side effects including headaches, dizziness, vomiting, diarrhea, constipation, drowsiness, nausea, and anorexia. Topically it may lead to skin irritation.
Do not use DMSO if you have diabetes, asthma, or liver, kidney, or heart conditions. Industrial-grade DMSO should not be used under any circumstances.
Fish Oil
Fish oil from fatty fish (such as herring, salmon, tuna, halibut, sardines, and cod) contains the omega-3 fatty acids eicosapaentanoic acid (EPA) and docosahexaenoic acid (DHA), both of which have been shown to block inflammatory chemicals.
The NCCIH has concluded that there is some evidence omega-3s from fish oil and seafood may be modestly helpful in relieving RA symptoms. A 2017 meta-analysis of 42 trials found considerable variation in the results, but 22 trials suggested that fish oil eased pain in RA. (Only five trials looked at OA, and the improvements were not significant.)
Health experts recommend that people eat two to three servings of fish per week, but you should avoid some types (including tilefish, swordfish, shark, and king mackerel) due to their high mercury content. Since it is difficult to get enough omega-3 fatty acids in only three portions of fish, you may want to consider taking fish oil supplements. It is recommended that people with RA take fish oil capsules with at least 30 percent EPA/DHA.
The U.S. National Academy of Sciences has established a minimum daily requirement for omega-3 fatty acids: 1.1 grams (g) per day for adult women, and 1.6 g per day for adult men. Don’t exceed these dosages, since too much fish oil may cause nausea and diarrhea and also may increase the risk of bleeding in people who take blood thinners such as warfarin (Coumadin).
Glucosamine and Chondroitin
Research on glucosamine and chondroitin is perennially inconsistent. The two supplements may be beneficial for certain populations, but the evidence is not at all conclusive. A 2018 study published in Advances in Rheumatology found that a fixed-dose formulation (two drugs in a single capsule or tablet) of glucosamine and chondroitin was effective in treating OA. However, according to a 2018 NCCIH report, chondroitin was not helpful for pain caused by OA of the knee or hip, and it was unclear whether glucosamine helps with knee OA, or if either substance lessens OA pain in other joints. In 2017, Arthritis & Rheumatology published data indicating that 164 knee OA patients who took a combination of glucosamine and chondroitin daily for six months did no better when it came to pain or daily function than those who took a placebo.
If you and your doctor decide that it’s worth you giving glucosamine and chondroitin a try, the most commonly recommended dosages are 1,500 mg of glucosamine and 800 to 1,200 mg of chondroitin daily. Thirty to 90 days of use are needed to get an accurate assessment of their effectiveness.
Heat, Cold Applications
Cold therapy—also known as cryotherapy—can relax tense muscles, numb nerves, and reduce inflammation, swelling, pain, and stiffness. It is particularly useful in acute inflammatory episodes and after exercise. Cold therapy for arthritic joints includes cool packs, ice massage, and over-the-counter ointments or sprays. You also can use a bag of frozen peas or corn, but don’t apply it directly to your skin—wrap it in a towel.
If a joint is not actively inflamed, heat therapy may provide temporary relief from arthritis symptoms by enhancing blood flow, relaxing tense muscles, and improving flexibility. Heat also may be useful for warming your muscles before an exercise session. Heat therapy includes heat packs, a hot water bottle, warmed towels, a bath, or a shower.
Herbals
There is a lack of convincing evidence regarding the effectiveness of herbals, but while scientific research may fail to prove that herbal remedies work for the general population, they may be effective for an individual.
Herbal remedies promoted for the treatment of arthritis include turmeric, ginger, Chinese thunder god vine, willow bark extract, feverfew, cat’s claw, and stinging nettle. These and other herbal remedies contain a complex mix of biologically active ingredients that impact processes in the body and have side effects, interactions, and contraindications, just like pharmaceutical drugs. Check with your pharmacist or doctor for possible interactions with conventional medications before starting any herbal remedy.
A review of evidence carried out by the NCCIH focused on the following popular supplements:
Turmeric (Curcuma Longa). Turmeric contains a group of biologically active chemicals known as curcuminoids. Curcuminoids are believed to have anti-inflammatory effects, and preliminary studies have found that they may work as well as the nonsteroidal anti-inflammatory drug (NSAID) ibuprofen (Advil, Motrin) when it comes to controlling knee pain from OA. However, the NCCIH concludes that there are no really strong study data supporting claims that turmeric helps to reduce inflammation. The herb may cause gastrointestinal issues if it is taken in large doses and also may interact with the blood thinner warfarin.
Devil’s Claw. Devil’s claw sometimes is used for arthritis, gout, general muscle pain, tendinitis, and other musculoskeletal conditions. The NCCIH concludes that there is limited evidence that devil’s claw may provide modest improvements for low back pain and OA of the spine, hip, and knee. Devil’s claw may lower blood pressure as well as interact with blood thinners, statins, and diabetes drugs, among others.
Thunder God Vine. Thunder god vine is a perennial vine native to China, Japan, and Korea, and is not widely available in the United States. The NCCIH says the vine may reduce some RA symptoms. However, it comes with a range of gastrointestinal side effects and can be toxic if it is not properly prepared.
Gamma Linolenic Acid. An omega-6 fatty acid, gamma linolenic acid (GLA) is found in seed oils, including evening primrose, borage, and black currant. In the body, GLA may be converted into inflammation-reducing substances. Preliminary evidence suggests that GLA is beneficial for RA. More rigorous studies suggest it may relieve joint pain, stiffness, and tenderness. GLA should not be used if you take blood thinners.
Avocado-Soybean Unsaponifiables. Avocado-soybean unsaponifiables (ASU) is a natural vegetable extract made from one-third avocado oil and two-thirds soybean oil. Preliminary evidence suggests that ASU may have a modest beneficial effect on OA symptoms.
SAMe. S-Adenosyl-L-methionine, or SAMe, is categorized as a dietary supplement in the United States, but it is considered a drug in much of Europe. Results of research on SAMe for OA are mixed. In general, studies that compared SAMe with NSAIDs showed that each provided a similar degree of pain relief and improved joint function, with fewer side effects in people taking SAMe. However, other studies have shown no such benefits from SAMe.
Magnet Therapy
Magnet manufacturers claim their products are effective in treating fibromyalgia, back pain, headaches, neck pain, knee pain, and foot pain, but the science to prove these claims does not exist.
Magnet use in specific populations (people with polio, degenerative knee pain, or diabetes, and women with low back pain) has shown the treatment to be therapeutic. Other studies have shown no benefit, however, and it may be that positive findings are a result of the placebo effect (a phenomenon in which people respond positively to a placebo due to a psychological benefit).
No research specifies how strong the magnets should be, how long they should be applied, whether they could be harmful, or exactly how they work.
Massage Therapy
According to the American Massage Therapy Association, therapeutic massage promotes health and well-being by way of soft tissue manipulation and movement of the body. Massage can reduce pain, boost circulation, reduce muscle tension, and improve a joint’s range of motion. However, it can’t cure or reverse the course of any disease.
Research suggests that massage therapy may result in significantly less pain, anxiety, and depression among fibromyalgia patients. It also may reduce pain, improve function, and increase flexibility in patients with knee OA (see “Massage May Provide Short-Term Improvement in Knee Osteoarthritis”).
Other trials have suggested that massage might be helpful in treating low back pain. However, it also appears that these effects are short term and that people need to keep getting massages for the benefits to continue.
Medical Marijuana
Medical marijuana is administered in various forms: as an oil, transdermal patch, pill, vaporized liquid, nasal spray, dried leaves and buds, and the plant itself.
The primary active component of marijuana is a compound called delta-9-tetrahydrocannabinol (THC). THC is responsible for marijuana’s psychoactive effects; it stimulates the release of a “feel-good” brain chemical called dopamine. It also may decrease pain and inflammation. Cannabidiol (CBD), which is another component of marijuana, is non-psychoactive and also may have pain-relieving and inflammation-reducing effects.
Medical marijuana is being studied as a treatment for several health conditions, including arthritis pain. A 2018 study in the journal Pain found that people with chronic pain who used marijuana reported health benefits including improved pain management and sleep. A study published in the European Journal of Internal Medicine found that marijuana therapy was safe and effective, particularly for neuropathic (nerve) pain. A 2019 study published in Cannabis and Cannabinoid Research used simulated data to conclude that marijuana appears to be a cost-effective option for treating several medical conditions, including neuropathic pain.
The FDA is aware of considerable interest in using marijuana to treat a number of medical conditions, including some forms of arthritis. However, as of July 2019, the FDA had not approved marijuana as a safe and effective drug for treating pain. Bottom line: Multiple studies suggest that medical marijuana has benefits when it comes to relieving neuropathic pain, but there is very little evidence supporting its use specifically for arthritis or arthritis pain.
Mindfulness Meditation
Mindfulness meditation is increasingly used for arthritis pain. Mindfulness means paying attention to the moment at hand without judging or interpreting it. Acquiring this skill may help you purposefully avoid dwelling on the negative aspects of your life, including your arthritis pain. Training yourself to choose how you respond to the pain can help give you back the sense of control you may have lost when it comes to your health.
In a study funded by the NCCIH, adults with chronic low back pain received mindfulness-based stress reduction (MBSR) training, cognitive behavioral therapy, or “usual care” (painkillers and stretching exercises). At the end of one year, 60 percent of participants who attended MSBR sessions and 58 percent of those who received cognitive behavioral therapy reported a “meaningful” improvement in their back pain and function, compared with 44 percent of people who received usual care.
Reiki
As with acupuncture, reiki—which originated in Japan in the 1800s—is based on the idea that an unseen “life force energy” flows through us, giving us life and healing what ails us. But if that life force is blocked, the resulting imbalance may impact physical and emotional health. A reiki practitioner attempts to correct this underlying imbalance and restore the flow of energy by simply placing his or her hands on or over the recipient.
A reiki session lasts about one hour, and proponents report that it leaves them feeling relaxed. While there isn’t much solid evidence for its effectiveness, some research suggests that reiki may be helpful for increasing a person’s sense of well-being while reducing stress levels. The take-home message is that it probably won’t hurt but is not likely to help.
Spinal Manipulation
Between 8 and 14 percent of Americans use spinal manipulation for low back pain caused by arthritis and other conditions. A 2017 review suggests that the therapy can provide modest pain relief, and the American College of Physicians includes the practice in its recommendations for non-drug pain relief.
Chiropractors, osteopaths, naturopaths, and some medical doctors practice spinal manipulation. It involves applying controlled force to specific joints in the spine, with the aim of restoring spinal alignment, improving function, and relieving pain.
Spinal manipulation is relatively safe when performed by a licensed practitioner, but you may experience side effects, such as mild tiredness and temporary soreness. Consult your doctor before undergoing spinal manipulation if you suffer from severe pain, nerve involvement, a herniated spinal disc, osteoporosis, or significant bony abnormalities.
Tai Chi
Tai chi combines relaxation, meditation, and deep breathing with slow, gentle, continuous, and structured exercises called forms. “Standing, graceful postures,” “achieving harmony between body and mind,” and “meditation in motion” are some of the phrases used to describe tai chi movements.
The NCCIH offers a cautiously optimistic summary of tai chi research. Tai chi may improve balance and stability in older people, reduce pain from knee OA, and help people cope with fibromyalgia and back pain. Tai chi is especially effective in older adults because it can be practiced at different intensity levels.
Indirectly, exercise of any kind seems to reduce pain, so tai chi qualifies in that respect. However, anyone who has acute chest pain with minimal exertion, severe shortness of breath, dizziness or fainting spells, or uncontrolled blood pressure should seek the advice of a physician before starting tai chi, as should people who have osteoporosis, acute back pain, or active infections.
Transcutaneous Electrical Nerve Stimulation
Transcutaneous electrical nerve stimulation (TENS) lies somewhere between traditional and alternative medicine.
A TENS device is a small, portable, battery-powered unit with adhesive electrodes that are placed on the skin over the painful area. The unit transmits a mild electrical current through the skin that lasts a fraction of a second, followed by a pause, and then the next wave of current. It can be adjusted to deliver intermittent waves.
Exactly how TENS therapy works is a mystery. It may stimulate the production of substances in the body that diminish pain, or it may simply serve as a distraction from pain.
TENS units are used in clinical settings by physical therapists, but patients can purchase them for home use. There are also over-the-counter TENS devices available without a prescription. Keep in mind that the American Academy of Neurology warns that TENS is ineffective at treating lower back pain that has persisted for three months or longer.
Yoga
Yoga uses movement, meditation, relaxation, and gentle breathing, all of which contribute to a sense of self-awareness. For some people, yoga is more of a spiritual experience that enhances their mood. For others, it’s an alternative exercise that promotes flexibility, strength, and endurance.
An important component of yoga is breathing technique. Specific breathing exercises are thought to serve as mood elevators, as well as tools to calm the central nervous system. At Arizona State University, yoga-type slow breathing techniques reduced pain intensity in women with fibromyalgia.
Under certain conditions, yoga has been shown to relieve pain caused by OA of the hands. Researchers writing in the Journal of Family Practice and Archives of Internal Medicine have highlighted its benefits for back pain, while a study funded by the NCCIH found that it may help relieve low back pain and neck pain. Studies reviewed in the Journal of Evidence-Based Complementary and Alternative Medicine showed that yoga reduced pain and morning stiffness, improved physical function, and was associated with lower levels of depression in people with OA.
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