Alternative treatment options—also known as complementary therapies—can be a good adjunct to medication when it comes to managing arthritis symptoms. Some of the options address physical causes of pain, but don’t forget that chronic pain is complicated. In arthritis, tissue inflammation, bone erosion, and nerve impingement can combine to “rewire” your nervous system, making it hypersensitive. This means that the way you perceive and react to pain may become a major factor in how you cope with your disease. Not only can alternative treatment modalities ease pain, they also can alter the way you experience pain, making you more resilient and reducing the stress that accompanies chronic disease. However, you shouldn’t forgo conventional treatment in favor of alternative approaches, particularly in the case of rheumatoid arthritis (RA).
Dietary Supplements for Arthritis
Dietary supplements include vitamins, minerals, herbs, spices, amino acids, and enzymes. They are available as tablets, capsules, softgels, gelcaps, powders, and liquids. Some supplements can help you increase your intake of vital substances the body needs to function, while others may help reduce the risk of disease.
In the United States, dietary supplement manufacturers are not permitted to claim that their products prevent or cure diseases. However, beyond this requirement the Food and Drug Administration does not regulate dietary supplements, and this means there is no standardization of manufacturing quality or dosage. Previous research into popular supplements has revealed that many either do not contain the active ingredients listed on the label, or contain unlisted ingredients and/or harmful substances, such as heavy metals, insecticides, and pesticides.
Be aware that supplements contain biologically active ingredients that influence the function of cells, organs, or systems in the body, and, just like pharmaceuticals, should be taken with care.
Problems may occur:
- When combining different types of supplements
- When combining supplements with medicines or recreational drugs
- When taking too high a dose (for example, with vitamin A, vitamin D, or iron)
- When pregnant, as the fetus may be affected
- When taken around the time of surgery
- When taking supplements from a disreputable source.
If you are at all unsure about the safety of a dietary supplement, you can check at the Office of Dietary Supplements website (see the Resources section at the back of this report).
Glucosamine/Chondroitin
One of the most common supplements used today for managing arthritis symptoms is a combination of glucosamine and chondroitin. The Cochrane Database supports its use, reporting that glucosamine may reduce pain and improve physical function, while chondroitin may improve all pain slightly in the short term, improve knee pain by 20 percent, slightly improve quality of life, and slow down the narrowing of the joint space.
The National Institute of Health’s 24-week Glucosamine/Chondroitin Arthritis Intervention Trial (GAIT) randomly assigned 1,583 osteoarthritis (OA) patients to one of five treatment groups: glucosamine alone; chondroitin alone; glucosamine and chondroitin in combination; the nonsteroidal anti-inflammatory drug (NSAID) celecoxib (Celebrex); or a placebo. Study participants were evaluated at the beginning of the study, and again at four, eight, 16, and 24 weeks.
Some 70 percent of those taking the NSAID reported a 20 percent or greater reduction in pain compared to about 60 percent for placebo and the other treatments. However, in the subset with moderate-to-severe pain, glucosamine/chondroitin provided statistically significant pain relief compared with placebo: 79 percent had a 20 percent or greater reduction in pain compared to 54 percent who took the placebo.
Another study, this time in people with RA, showed 17 percent reduction in the inflammatory marker C-reactive protein with glucosamine, 22 percent with chondroitin, and 16 percent with fish oil supplements.
Side effects are rare with glucosamine/chondroitin, but if they occur they may include mild gastrointestinal upset. Glucosamine/chondroitin may interact with NSAIDS and blood thinners, such as warfarin (Coumadin), so check with your doctor about its safety alongside other medications you take. If you are allergic to shellfish, you will need to check the source of the glucosamine, as some brands use lobster shells. Diabetics will need to monitor its effect on blood sugar.
Many clinicians recommend that patients try a three- to six-month trial of glucosamine/chondroitin. The suggested dosage is 1,500 milligrams (mg) per day, taken in three doses.
Fish Oils
Fish oil supplements are popular in arthritis management due to claims that they reduce inflammation. Fish oil contains omega-3 fatty acids, including eicosapaentanoic acid (EPA) and docosahexaenoic acid (DHA), both of which have been shown to block inflammatory chemicals. They also lower harmful triglycerides (fats that circulate in the blood), and may reduce the risk of cardiovascular disease.
The National Center for Complementary and Integrative Health (NCCIH), the federal government’s lead agency for scientific research on complementary and integrative health approaches, concludes 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 statistically significant (a common problem with small trials).
Fish oils come from fatty fish, such as herring, mackerel, salmon, tuna, halibut, and cod. Health experts recommend that people eat only two to three servings of fish per week due to heavy metal poisoning of the oceans. It is difficult to get enough omega-3 fatty acids in only three portions of fish, so it is recommended that patients with RA take fish oil capsules with at least 30 percent EPA/DHA.
Pregnant women and people taking blood thinners should not take fish oils. Fish oils should be stopped at least five days before any surgery, as they increase the risk of bleeding.
Herbals
Many arthritis patients faced with chronic pain and disability turn to herbal remedies in the hope they will find relief. There often is a lack of convincing evidence as to the efficacy of herbals. However, while scientific research may fail to prove that a herbal remedy works on a population level, it may be effective in an individual. This is a reflection of the fact that our bodies work in unique ways.
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. In fact, many modern medicines have their roots in herbal medicine—for example, today’s NSAIDs, including aspirin, began as willow bark tea in ancient Egypt.
Check with your pharmacist or doctor for possible interactions with conventional medications before starting any herbal remedy. As with dietary supplements, the quality of herbal remedies varies, so consider consulting a herbalist for the best chance of getting good herbals.
In 2016, the NCCIH produced a review of evidence for the use of natural products in musculoskeletal inflammation. Here’s a summary of what it found regarding some popular herbals:
Turmeric (Curcuma longa)
A plant related to ginger, turmeric contains a group of biologically active chemicals known as curcuminoids. Research suggests that curcuminoids may have anti-inflammatory effects, and preliminary studies have found that they may control knee pain from OA as well as the NSAID ibuprofen (Advil, Motrin). 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 taken in large doses, and also may interact with blood thinners.
Devil’s Claw (Harpagophytum)
Derived from an African herb, devil’s claw is sometimes used for arthritis, gout, general muscle pain, tendonitis (inflammation of a tendon), and other musculoskeletal conditions. The NCCIH concludes that there is some 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 and diabetes medications.
Thunder God Vine (Tripterygium Wilfordii)
Thunder god vine is a perennial vine native to China, Japan, and Korea, and is not widely available in the United States. The NCCIH concludes that there is some evidence thunder god vine may reduce some RA symptoms. However, it comes with a range of gastrointestinal side effects, and can be toxic if not properly prepared.
Gamma Linolenic Acid
Gamma linolenic acid (GLA) is an omega-6 fatty acid found in seed oils, including evening primrose, borage, and black currant. In the body, GLA may be converted into inflammation-reducing substances. The NCCIH concludes that there is some preliminary evidence that GLA is beneficial for RA, noting that more rigorous studies suggest it may relieve joint pain, stiffness, and tenderness. In some cases, GLA led to a decreased need for NSAID medication to manage arthritis pain. Since GLA thins the blood, it 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. The NCCIH points to preliminary evidence suggesting that ASU may have a modest beneficial effect on OA symptoms.
SAMe
S-Adenosyl-L-methionine, or SAMe (pronounced sam-ee), is categorized as a dietary supplement in the United States but is considered a drug in much of Europe. The NCCIH concludes that 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.
Antioxidant Vitamins
Antioxidants are substances that prevent or delay cell damage and inflammation due to free radicals: harmful molecules that occur naturally in the body. According to the NCCIH, diets 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, and there is much evidence that they are effective only when consumed via dietary sources. Popular antioxidant vitamins include vitamins C and D.
- Vitamin C is essential for the formation and health of collagen and other connective tissue. The recommended daily amount for vitamin C is 90 grams (g) for men, and 75 g for women. Evidence suggests that 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 is manufactured in the skin with exposure to sunlight, and also can be ingested via fortified cereals, milk and fruit juice, fish, and eggs, or taken as a supplement. The Institute of Medicine recommends people get 600 International Units (IUs) of vitamin D per day, but many experts recommend 800-1,000 IUs. Vitamin D is essential in the metabolism of calcium, but while there is some evidence it may help in osteoporosis, fibromyalgia, and multiple sclerosis, there is conflicting evidence of any benefit in arthritis.
Acupuncture
There is fairly robust research supporting the use of acupuncture—a form of ancient Chinese medicine—to ease pain.
Ancient Chinese medicine theorizes that health and wellbeing depend on balancing the body’s vital energy (called “qi”). Qi is believed to run through specific points in the body called meridians. In acupuncture, very thin needles are inserted into the skin at these meridians to clear blockages in the flow of qi. This is believed to restore energy balance and alleviate pain. One theory of how acupuncture relieves pain is that the needles stimulate the body to secrete endorphins and anti-inflammatory substances.
The NCCIH endorses acupuncture as a treatment for chronic pain, including low back, neck, and OA knee pain. Acupuncture performed by a licensed therapist following a high standard of hygiene standards is very safe. However, people with bleeding disorders, HIV/AIDS, hepatitis B, skin infections, valvular heart disease, pacemakers, or cardiac arrhythmias and those on blood thinners should avoid acupuncture.
Spinal Manipulation
Between 8 and 14 percent of Americans use spinal manipulation for low back pain due to arthritis and other causes.
Chiropractors, osteopaths, naturopaths, and some medical doctors practice spinal manipulation. The practitioner applies controlled force to specific joints in the spine, with the aim of restoring spinal alignment, improving function, and relieving pain.
A 2017 review suggests that spinal manipulation can provide modest pain relief, and the American College of Physicians includes the practice in its recommendations for non-drug pain relief. Research suggests it is relatively safe when performed by a trained and licensed practitioner. However, you should consult your doctor before undergoing spinal manipulation if you suffer from severe pain, nerve involvement, herniated disc, osteoporosis, or significant bony abnormalities. Common side effects of spinal manipulation include mild tiredness and temporary soreness.
Tai Chi
Originating in China as a form of martial art, tai chi—dubbed “moving mediation” by practitioners—incorporates the Chinese concepts of yin and yang (opposing forces within the body) and qi (a vital energy or life force). Practicing tai chi is said to support a healthy balance of yin and yang, thereby aiding the flow of qi.
Tai chi involves slow gentle movements (called “forms”) that can help relieve joint pain and stiffness as well as ease stress. An analysis published in the Cochrane Review found that tai chi improves range of motion in people who have RA of the hip, knee, and ankle. Other research suggests that the practice improves arthritis sufferers’ ability to carry out activities of daily living, such as dressing, bathing, and household tasks.
In a 2016 study, 204 people with knee osteoarthritis were randomized into two groups: tai chi (twice a week for 12 weeks) or standard physical therapy (twice a week for six weeks, followed by six weeks of monitored home exercise). Arthritis symptom scores decreased significantly in both groups and there was significant improvement in most secondary outcomes (physical function, depression, medication use, and quality of life). The benefits were maintained over several months.
Yoga
Yoga involves gentle stretches that can increase the range of motion in arthritic joints as well as strengthen the muscles that support your joints. Research also suggests that the practice eases stress, and benefits cardiovascular and brain health.
A 2017 study found that people with low back pain who engaged in yoga reported less pain after 12 weeks. The improvements persisted for more than a year, and some of the participants were able to stop taking painkillers. The yoga poses used in the study were easy, with chairs and other props used for support, and the participants were also shown a simple meditation and relaxation breathing routines.
If you decide to give yoga a try, stick to gentle forms and be sure to inform the instructor that you have arthritis so that he or she can show you modified poses if necessary. Each pose should feel comfortable and strong—never push your joints beyond the point of comfort.
Thermal Therapy
Low temperatures relax tense muscles, numb nerves, and reduce inflammation, swelling, pain, and stiffness. Cold therapy is particularly useful in acute inflammatory episodes and after exercise. If a joint is not actively inflamed, heat therapy may give you temporary relief from arthritis symptoms by enhancing blood flow, relaxing tense muscles, and improving flexibility. It also may be useful for warming muscles before exercise.
Cold therapy for arthritic joints includes cold packs, ice massage, over-the-counter ointments or sprays, and even a bag of frozen peas (don’t apply it directly to your skin—wrap it in a towel). Use cold packs for 20 minutes at a time, and repeat several times a day. Follow the instructions when using cooling sprays and ointments.
- Heat therapy. Try heat packs, a hot water bottle, warmed towels, a bath, or a shower.
- Balneotherapy. For centuries, people have been using balneotherapy (essentially spa therapies) to relieve pain and stress, and improve circulation. There is anecdotal evidence that a warm mudpack, or a warm bath containing Epsom salts, may be beneficial in arthritis, but this is not supported by scientific evidence.
Mind/Body Techniques
There is a vicious cycle in arthritis: Chronic pain causes stress, negative thinking, hopelessness, anxiety, depression, and sleep disturbance—all of which increase pain perception and inflammation, making the pain worse. As such, mind/body techniques can be useful for easing discomfort. Try mindfulness meditation, cognitive behavioral therapy (CBT), biofeedback, and reiki. All can be used in addition to traditional treatments, in combination, or alone.
Mindfulness Meditation
Mindfulness meditation is increasingly used for pain management, and there is much research pointing to its effectiveness (see “Mindful People Feel Less 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.
A simple mindfulness meditation you can try involves sitting on a chair or lying down on your bed and simply focusing on each breath you take. Be aware of the sensation of air flowing into and out from your body, and how it feels in your nostrils, your shoulders, your ribcage, and belly, as they expand and relax. If anything distracts you, simply acknowledge the distraction without judging it or getting annoyed by it, and then return to focusing on your breathing.
In a 2016 study funded by the NCCIH, adults with chronic low back pain received mindfulness-based stress reduction (MBSR) training, CBT (see below), 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 CBT reported a “meaningful” improvement in their back pain and function, compared with 44 percent of people who received usual care.
Cognitive Behavioral Therapy
CBT is a problem-focused, goal-directed therapy that aims to help you learn how to recognize and modify negative thoughts and behaviors along with your psychological and physical responses to these. The underlying idea is that examining the way you think about yourself helps you learn to restructure your thinking in positive ways that will result in healthier behaviors and less anxiety and stress.
CBT techniques include cognitive restructuring, which, for example, might call on you to try thinking about tackling a challenge one step at a time to be successful, rather than deciding that there is no way to manage a seemingly overwhelming and complicated problem. A 2016 review in the Journal of Pain Research found that CBT was the psychosocial approach with the strongest evidence base for relieving RA pain.
Biofeedback
Biofeedback is a relaxation technique that teaches you to monitor and control certain autonomic body functions, such as pulse, muscle tension, and skin temperature.
During a biofeedback session, you’re connected to electrical sensors that pick up body signals and transmit them to a special computer. The computer displays the signals via images or sounds that indicate your stress levels, skin temperature, blood pressure, heart rate, and brain waves. You are then guided in how to vary your thoughts and emotions so that you see a change in the signal display. The idea is that you learn how to consciously control your body’s responses—including its response to arthritis symptoms.
Reiki
This ancient Japanese technique for stress reduction and relaxation involves the “laying on” of hands (alternatively, the practitioner may simply hold his or her hands over specific points on your body). As with acupuncture, the practice 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. The healing touch of the reiki practitioner corrects underlying imbalances, restoring the flow of energy.
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 it may be helpful for increasing a person’s sense of wellbeing while reducing their stress levels.
Therapeutic Massage
Massage can provide temporary relief from pain, stiffness, and tight muscles by increasing blood flow, stimulating the body to release painkilling endorphins, lowering the stress hormone cortisol, and releasing knotted muscle fibers. Massage also may increase levels of the hormone serotonin, which is involved in mood and sleep, and has been found to reduce inflammatory cytokines (toxic chemicals implicated in RA). A 2017 review of medical literature reported the combined results of seven randomized control trials with 352 patients, and concluded that there was low-to-moderate quality evidence that massage therapy is superior to non-active therapies for reducing pain and improving functional outcomes in people with arthritis. Other 2017 research suggested that massage therapy has better results in people age 50 and older.
It is essential that you find a therapist who understands your condition and will adapt the massage accordingly—an inexperienced massage therapist may do more harm than good. Be particularly careful if you are experiencing a flare-up, or if you have eroded joints, significant osteoporosis, high blood pressure, and/or varicose veins.
As a precaution, check with your doctor before undergoing massage. If you find massage beneficial, it can be repeated two or three times a week if your budget allows.
Transcutaneous Electrical Nerve Stimulation
Transcutaneous electrical nerve stimulation (TENS), which also is known as electroanalgesia, is commonly used for pain relief. It involves low-level electrical pulses that are delivered via electrodes placed on the skin near the site of the pain. It is believed that the electrical pulses block pain signals from traveling along the spinal cord to the brain and also trigger endorphin release. The electrical pulses are not painful, but you will feel a slight tingling sensation.
Research into the effectiveness of TENS has produced conflicting results. The American Academy of Neurology does not recommend TENS in its guidelines for chronic lower back pain, but the American College of Rheumatology “conditionally recommends” that people with knee OA try TENS as part of their treatment.
TENS machines were once available only through a clinician but are now more widely available without a prescription. It is sensible, however, to consult your doctor before commencing treatment with TENS.
Magnet Therapy
Studies suggest that many people with arthritis try wearing magnetic bracelets to ease their discomfort. Proponents of magnets claim they boost the flow of oxygen-rich blood to the tissues, but decades of research have failed to make any connection between these bracelets and symptom relief. It is possible that any perceived benefits could be due to the placebo effect (a phenomenon in which a placebo—fake treatment—can sometimes improve a patient’s condition simply because the person has the expectation that it will be helpful). Electromagnet therapy—which uses magnets that have an electrical charge—also has been widely marketed for pain control. A handful of small studies have suggested that it may be beneficial, but most rigorous trials have found they have no effect on pain.
Magnet therapy is not safe for people who use defibrillators, pacemakers, insulin pumps, or medicated patches, or those who have been treated for an aneurysm with a metal clip.
Dimethyl Sulfoxide
Another controversial treatment for arthritis is dimethyl sulfoxide (DMSO), a colorless, sulfur-containing organic by-product of wood pulp processing that has analgesic and anti-inflammatory properties. DMSO 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.
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