by Steffany Haaz, MFA, CYT
Rheumatoid Arthritis (RA) is a chronic, inflammatory, autoimmune disease that impacts joints and connective tissue. It is often painful and disabling, and usually requires lifelong pharmacological management. Patients are usually diagnosed between the ages of thirty and fifty, although RA affects all ages. Common co-morbidities include cardiovascular disease, cachexia (muscle wasting), depression and impairments to quality of life (1;2). Although they have greatly improved the general course of RA, drugs that are commonly used to manage the disease carry some notable side effects as well.
For all of these reasons, patients with RA often look to Complementary and Alternative Medicine (CAM) for additional sources of relief. In fact, joint pain and arthritis are among the top five most common reasons that Americans seek CAM (3). Usually, CAM is sought in addition to allopathic (standard medical) treatment to ease symptoms of the disease and side effects of drug therapy. Below is an outline of the currently available research for treatments that are commonly used by RA patients, as well as a synopsis of what may be recommended as safe and possibly effective for this population.
Dietary and Botanical Supplements
When working with an RA population, fish oil is probably the most frequently mentioned supplement. The standard western diet contains a low proportion of omega-3 type essential fatty acids (EFAs), which are said to have anti-inflammatory properties. Two EFAs in fish oil are eicosapentaenoic acide (EPA) and docosahexanoic acid (DHA). The body can actually convert EPA to DHA, but individuals vary with regard to the efficiency of that conversion. EPA and DHA can also be found in vegetable sources, such as flax and algae, respectively. In a report by the National Center for Complementary and Alternative Medicine (NCCAM) within the National Institutes of Health (NIH), it was concluded that evidence for the use of fish oil (or other omega-3 supplements) for the treatment of RA is promising, as a result of several laboratory, animal and clinical studies (4). Some effect has been noted for symptoms such as tender joints, morning stiffness and use of non-steroidal anti-inflammatory drugs (NSAIDs). What is uncertain, however, is how much of this effect is placebo, as results from randomized controlled trials (RCTs) are inconsistent.
Patients must be prudent with the use of fish oil, however, as it can reduce the ability for some individuals to clot, leading to a greater risk of bleeding. This is particularly important if patients are on other blood thinners, blood pressure medication, or if they might undergo surgery. Because the risk of mercury contamination in fish is high, a concentrated extract from fish also carries some risk. Unfortunately, dietary and herbal supplements are not regulated by the FDA for content, so without diligent research into a particular manufacturer, it is difficult to know what mercury levels are present. For this same reason, label accuracy cannot be guaranteed, and patients should be wary about whether the supplement contains the desired ingredients, without any unknown additives.
Gamma Linolenic Acid (GLA). Unlike EPA and DHA, GLA is an omega-6 fatty acid. The standard western diet has a higher proportion of omega-6 fats, and they are often associated with higher levels of inflammation. However, evidence for anti-inflammatory properties of GLA, in particular, seems to be strong. It is not naturally occurring in the diet, but can be found in several plant seeds, including borage, evening primrose and black currant. A 2000 review by the diligent and reputable Cochrane Collaboration investigated several RCTs that suggested a beneficial effect for pain, joint tenderness and morning stiffness (5).
As with many supplements, however, the risk for drug interaction should be considered. Borage oil may contain pyrrolizidine alkaloids, which can be harmful for patients at risk of liver damage. The risks of bleeding with GLA are similar to those noted for fish oil. Evening primrose should not be taken along with some psychiatric drugs (phenothiazines), and there is some risk of minor GI side effects (nausea, gas, bloating, etc.) with large quantities of these supplements.
Glucosamine and chondroitin.
These are two different substances that are often combined in supplement form. Both are usually isolated from shellfish, but are naturally found in human joint tissue. Both are commonly used for osteoarthritis (OA), which is a degenerative form of arthritis with a very different etiology from RA. While these supplements have shown anti-inflammatory effects in animals, clinical trials have only been conducted in OA. These have been quite inconsistent and controversial, with some finding improvements on X-ray, others finding improvements in symptoms only, and still others finding no effect (6;7). There is no evidence at all, however, that these supplements would be helpful for RA patients.
Glucosamine and chondroitin are generally safe, however, they might pose risk for those with asthma, diabetes, blood clotting disorders, or shellfish allergies. Some mild GI symptoms may occur as well.
Tumeric, ginger, valerian. These are three supplements that are thought to have anti-inflammatory properties. Tumeric, which contains circumin, has been associated with decreased inflammation in animals, and one small, double-blind crossover trial found improvements in walking time, swelling and morning stiffness in RA (8). One small trial found that a ginger supplement was associated with decreased pain and discomfort for patients with RA (9). Valerian root is commonly used as a sleep aid, due to its relaxing properties. Because poor sleep is common among RA patients, valerian may be helpful. However, there is no research evidence of its efficacy for this population. Valerian should not be combined with sedatives or other sleep aids (4).
The composition of an individual’s diet can be an important aspect of health promotion, barring the complications of a chronic condition. For those with a diagnosis of RA, dietary choices may have added significance for a variety of reasons:
- it may be more difficult to eat a well-balanced diet
- drug therapy may change nutrient absorption
- foods perceived as allergens may contribute to inflammation. All individuals, and especially those with RA, should make efforts to consume a well-balanced diet, full of nutrient-dense foods and limited in additives and processed foods. However, some special diets have been investigated specifically for their potential to aid patients with RA.
Fasting for a brief period may bring some relief of symptoms for patients with RA, possibly due to the elimination of some foods that are perceived as allergens (10). These effects are not necessarily long lasting, however, and symptoms may return when patients return to a normal diet (11). Fasting may be dangerous for some patients, and should certainly not be done without close medical supervision. If a normal diet is not resumed, but sensitive foods are eliminated, effects may be longer lasting. There appears to be a subset of RA patients who are highly sensitive to certain foods, and for whom eliminating these foods can have beneficial effects (12). It should be noted, however, that there are no scientific data supporting the concept that RA is caused by allergies to foods or to other substances.
Several European trials have examined the efficacy of vegan (no animal products at all) or vegetarian (includes eggs and dairy) diets for RA patients, sometimes following a period of fasting. These trials have shown some benefits, including less inflammation, lower disease activity, reduced pain and stiffness. These diets are not always well-tolerated, however, resulting in a high drop-out rate (13).
One RCT of a Mediterranean diet found improvements to clinical and psychological parameters in patients with RA (14). Two other observational trials are underway, and will hopefully lead to more investigation in this area.
In a Cochrane review, only one clinical trial of acupuncture met inclusion criteria for rigor of study design (15). There were no statistically significant differences found between intervention and control groups. A prior review of published studies was broader in its inclusion criteria, but due to mixed results, the review still concluded that nothing can be determined from the trials conducted so far in this area (6). There may be some improvement in symptoms, but further research will be necessary to provide a clearer picture of acupuncture’s efficacy for RA.
Many patients with arthritis use magnets as a complementary treatment for pain. A review of the use of magnets for pain cites one trial in RA patients with unremitting knee pain (16), in which significant pain reduction was found with two different types of magnetic treatment. There was not a third group without magnet treatment for comparison. Magnets have been effective for treating other types of pain (17), but further research is needed to ensure safety and efficacy for the RA population.
A 2008 Cochrane review by Verhagen et al(18) found seven trials of hydrotherapy (also called balneotherapy) for RA patients, which generally included mineral baths using varying minerals and concentrations. (This is to be distinguished from water aerobics or therapies in the field of physical therapy that involve the use of water, which are not considered CAM.) Positive findings were reported by most studies, but flaws in the methodology hindered conclusiveness. Results were mixed for pain and quality of life (QOL), while some improvements were noted in morning stiffness and grip strength. Often, studies were poorly powered and/or did not include sufficient data to determine statistically significant differences. Although hydrotherapy may be beneficial for RA patients, a large and well-conducted trial is in order.
Homeopathy is based on the tenant that “like cures like.” Substances that would produce a certain symptom in larger quantities (such as swelling) are diluted to such an extreme that they may actually relieve such symptoms. Two recent trials have been conducted using homeopathy compared to a placebo for RA patients(19;20). Neither found evidence of an effect. An RCT in 1980 found improvements in pain, stiffness and grip strength for the treatment group, but not for controls (21), while a pilot two years prior was unable to make conclusions based on the confounding effects of pharmaceuticals and/or non-specific aspects of physician interaction. (22).
Collectively, this evidence does not support the use of homeopathy for RA, although larger and better designed studies would be useful to crystallize that conclusion.
A 2007 systematic review reported on 5 trials using t’ai chi for RA patients (23). Some measures, such as disability, mood and vitality showed improvement. No change was seen for any markers of pain or functional assessment, and results were mixed for fatigue and swollen joints. Only two of these trials were randomized. T’ai chi may offer some benefits for RA patients, but clarity regarding its effects will require further review.
Two trials have shown significant improvements in grip strength for yoga as compared to non-active controls (24;25). Unfortunately, broader outcomes were not assessed. A more comprehensive RCT is currently underway, and has only assessed preliminary data for changes in quality of life (QOL) and tender/swollen joints (26). Improvements were seen in a variety of QOL areas, as well as both joint measures. A full examination of these data will be important for helping to determine the efficacy of yoga for this population.
Complementary and alternative medicine is a very broad category, including mind-body therapies, herbs, energy medicine, and any other modalities that are not considered part of standard allopathic care. In fact, some treatments that were formerly considered CAM have moved into the realm of standard care (ie. some vitamin and mineral supplementation). Due to its heterogeneous nature, it is not appropriate to make broad conclusions about CAM’s efficacy as a whole. As expected, some CAM modalities seem to show more promise for patients living with RA. Some natural supplements have been known for their anti-inflammatory properties, and when side effects are of little concern, they may be beneficial for this population. Special diets, if acceptable to the patient and sufficient in nutrient content, may also provide some relief. CAM forms of physical activity may be the most promising, as this population would benefit from anything that increases their activity levels safely. Overall, CAM methods that help patients to relax and balance physical/emotional stress can be beneficial by a variety of mechanisms. As is generally the case in this emerging field of scientific inquiry, more research is necessary to bolster such findings.
A variety of lifestyle recommendations are generally accepted for ongoing management of rheumatoid arthritis. These include: 1) eating a healthy, balanced diet for adequate nutrition; 2) participating in regular physical activity; 3) reducing sources of stress and finding ways to better manage stress; 4) relying on sources of social support; 5) openly communicating with care providers; and 6) taking an active role in disease management. The complexities of a systemic autoimmune disease, such as RA, require an approach that addresses all aspects of the individual’s wellbeing, beyond pharmacotherapy alone. Psychoneuroimmunology suggests that immune function is impacted by a variety of factors that must all be considered.
While these aspects of lifestyle may not seem like CAM, they all involve taking an active role in disease management, and many address stress, involve social support, or increase patient’s attention to healthful choices, such as diet and exercise. For those that do no harm, there may be benefits on a variety of levels that are not measured, or are inadequately assessed by objective measurement criteria. In many cases, too little research has been done to allow for recommendations regarding participation or avoidance. It is important for patients and providers to be informed about the nature of these modalities, and for researchers and funders to continue the search for more information about their safety, efficacy and mechanisms.
- Walsmith J, Roubenoff R. Cachexia in rheumatoid arthritis. Int J Cardiol 2002; 85(1):89-99.
- Bair MJ, Robinson RL, Katon W, Kroenke K. Depression and pain comorbidity: a literature review. Arch Intern Med 2003; 163(20):2433-2445.
- Barnes PM, Powell-Griner E, McFann K, Nahin RL. Complementary and alternative medicine use among adults: United States, 2002. Adv Data 2004;(343):1-19.
- National Center for Complementary and Alternative Medicine. Research Report: Rheumatoid Arthritis and Complementary and Alternative Medicine. http://nccam.nih.gov/health/RA/ [ 2008 [cited 2008 Feb. 17];
- Little C, Parsons T. Herbal therapy for treating rheumatoid arthritis. Cochrane Database Syst Rev 2001;(1):CD002948.
- Soeken KL. Selected CAM therapies for arthritis-related pain: the evidence from systematic reviews. Clin J Pain 2004; 20(1):13-18.
- Distler J, Anguelouch A. Evidence-based practice: review of clinical evidence on the efficacy of glucosamine and chondroitin in the treatment of osteoarthritis. J Am Acad Nurse Pract 2006; 18(10):487-493.
- Ahmed S, Anuntiyo J, Malemud CJ, Haqqi TM. Biological basis for the use of botanicals in osteoarthritis and rheumatoid arthritis: a review. Evid Based Complement Alternat Med 2005; 2(3):301-308.
- Srivastava KC, Mustafa T. Ginger (Zingiber officinale) in rheumatism and musculoskeletal disorders. Med Hypotheses 1992; 39(4):342-348.
- Palmblad J, Hafstrom I, Ringertz B. Antirheumatic effects of fasting. Rheum Dis Clin North Am 1991; 17(2):351-362.
- Kjeldsen-Kragh J, Haugen M, Borchgrevink CF, Laerum E, Eek M, Mowinkel P et al. Controlled trial of fasting and one-year vegetarian diet in rheumatoid arthritis. Lancet 1991; 338(8772):899-902.
- Darlington LG, Ramsey NW. Review of dietary therapy for rheumatoid arthritis. Br J Rheumatol 1993; 32(6):507-514.
- Stamp LK, James MJ, Cleland LG. Diet and rheumatoid arthritis: a review of the literature. Semin Arthritis Rheum 2005; 35(2):77-94.
- Skoldstam L, Hagfors L, Johansson G. An experimental study of a Mediterranean diet intervention for patients with rheumatoid arthritis. Ann Rheum Dis 2003; 62(3):208-214.
- Casimiro L, Barnsley L, Brosseau L, Milne S, Robinson VA, Tugwell P et al. Acupuncture and electroacupuncture for the treatment of rheumatoid arthritis. Cochrane Database Syst Rev 2005;(4):CD003788.
- Segal NA, Toda Y, Huston J, Saeki Y, Shimizu M, Fuchs H et al. Two configurations of static magnetic fields for treating rheumatoid arthritis of the knee: a double-blind clinical trial. Arch Phys Med Rehabil 2001; 82(10):1453-1460.
- Eccles NK. A critical review of randomized controlled trials of static magnets for pain relief. J Altern Complement Med 2005; 11(3):495-509.
- Verhagen AP, Bierma-Zeinstra SM, Boers M, Cardoso JR, Lambeck J, de Bie RA et al. Balneotherapy for osteoarthritis. Cochrane Database Syst Rev 2007;(4):CD006864.
- Andrade LE, Ferraz MB, Atra E, Castro A, Silva MS. A randomized controlled trial to evaluate the effectiveness of homeopathy in rheumatoid arthritis. Scand J Rheumatol 1991; 20(3):204-208.
- Fisher P, Scott DL. A randomized controlled trial of homeopathy in rheumatoid arthritis. Rheumatology (Oxford) 2001; 40(9):1052-1055.
- Gibson RG, Gibson SL, MacNeill AD, Buchanan WW. Homoeopathic therapy in rheumatoid arthritis: evaluation by double-blind clinical therapeutic trial. Br J Clin Pharmacol 1980; 9(5):453-459.
- Gibson RG, Gibson SL, MacNeill AD, Gray GH, Dick WC, Buchanan WW. Salicylates and homoeopathy in rheumatoid arthritis: preliminary observations. Br J Clin Pharmacol 1978; 6(5):391-395.
- Lee MS, Pittler MH, Ernst E. Tai chi for rheumatoid arthritis: systematic review. Rheumatology (Oxford) 2007; 46(11):1648-1651.
- Dash M, Telles S. Improvement in hand grip strength in normal volunteers and rheumatoid arthritis patients following yoga training. Indian J Physiol Pharmacol 2001; 45(3):355-360.
- Haslock I, Monro R, Nagarathna R, Nagendra HR, Raghuram NV. Measuring the effects of yoga in rheumatoid arthritis. Br J Rheumatol 1994; 33(8):787-788.
- Haaz S, Bathon J, Bartlett S. Initial Findings of an RCT of Yoga on Physical and Psychological Functioning in RA and OA. Arthritis and Rheumatism Supplement. 2007.
Ref Type: Abstract
Receive the Latest News from Johns Hopkins Rheumatology
Join our mailing list to receive the latest news and updates from Johns Hopkins Rheumatology.