Patient information: Complementary therapies for rheumatoid arthritis (Beyond the Basics)

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 [2].

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 appear to offer a chance to feel better and to 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 (Beyond the Basics)" and "Patient information: Rheumatoid arthritis treatment (Beyond the Basics)" and "Patient information: Disease-modifying antirheumatic drugs (DMARDs) (Beyond the Basics)" and "Patient information: Rheumatoid arthritis and pregnancy (Beyond the Basics)".)

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.

Certain experimental treatments such as immunoadsorption and stem cell transplantation are rarely, if ever, considered due to the small potential benefit and the significant potential for harm. However, some complementary treatments such as acupuncture, mind-body techniques, and exercise continue to have a place, alongside conventional treatment, for many people with RA; thus, while they are generally still called “complementary,” they are really mainstream medical therapy. The inclusion of such approaches together with conventional ones reflects what is now considered “integrative” medicine.

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 usually 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 might be used alongside conventional medical treatment. It is not meant to replace conventional RA treatment but may help to alleviate side effects or to 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 to be 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 to 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, can preserve muscle and normal joint motion, can minimize bone loss, and can improve pain control. Exercise may also have cardiovascular, psychological, and social benefits. (See "Patient information: Arthritis and exercise (Beyond the Basics)".)

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 [3]. (See "Patient information: Diet and health (Beyond the Basics)".)

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. 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).

These might be considered by patients during pregnancy or breast feeding, patients who need but are allergic to or who cannot tolerate nonsteroidal antiinflammatory drugs (NSAIDs), or individuals particularly wishing “natural” therapy for arthritis symptoms.

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 [4].

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 recommend the use of herbs, vitamins, or other dietary supplements.

Homeopathy — Homeopathy is a 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 with placebo, in reducing the symptoms of RA [5]. Although there may be a low risk of harm from homeopathic remedies, there is no scientific basis to recommend this for RA or for other rheumatic diseases. More information is available from the National Center for Complementary and Alternative Medicine (http://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. Review of these studies showed that acupuncture has no effect on the number of swollen and tender joints, on pain, or on the amount of pain medications required by people with RA [6].

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. Research does not show that people with RA derive much (if any) benefit from magnets, nor have electromagnetic treatments been shown to be helpful [7].

Mind-body techniques — Mind-body techniques include practices such as hypnosis, guided imagery, meditation, yoga, biofeedback, tai-chi, 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 in improving a person's overall psychological state, ability to cope, and belief in one's ability to handle difficult situations [8].

Other complementary therapies — There are many other such therapies (ranging from antibiotics to leeches to sitting in abandoned uranium mines), none of which can be recommended as having been scientifically demonstrated as consistently safe and effective for RA. Not using these complementary treatments does not deprive patients of clinically important or valuable therapy for their disease.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). 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 — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Rheumatoid arthritis (The Basics)
Patient information: Alternative medicine (The Basics)
Patient information: Probiotics (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

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

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

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
  (http://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)

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