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NCCIH Clinical Digest

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Complementary Health Approaches for Chronic Pain:
What the Science Says

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September 2016
pain photo collage
Clinical Guidelines, Scientific Literature, Info for Patients: 

Fibromyalgia

In general, research on complementary health approaches for fibromyalgia must be regarded as preliminary. However, recent systematic reviews and randomized clinical trials provide encouraging evidence that practices such as tai chi, qi gong, yoga, massage therapy, acupuncture, and balneotherapy may help relieve some fibromyalgia symptoms.

The Evidence Base

  • The evidence base on efficacy of complementary health approaches for fibromyalgia consists of mostly preliminary research. More recent systematic reviews and randomized clinical trials provide encouraging evidence that practices such as tai chi, qi gong, yoga, acupuncture, mindfulness, and biofeedback may help relieve some fibromyalgia symptoms. There is insufficient evidence that any natural products can relieve fibromyalgia pain, with the possible exception of vitamin D supplementation, which may reduce pain in people with fibromyalgia who have vitamin D deficiencies. Current diagnostic criteria are available from the American College of Rheumatology. Treatment often involves an individualized approach that may include both pharmacologic therapies (prescription drugs, analgesics, and NSAIDs) and nonpharmacologic interventions such as exercise, muscle strength training, cognitive-behavioral therapy, movement/body awareness practices, massage, acupuncture, and balneotherapy.

Efficacy

  • Natural products. Small studies have examined various natural products—such as topical creams containing capsaicin or dietary supplements like S-adenosyl-L-methionine (SAMe) or soy—for fibromyalgia. A 2010 systematic review concluded that there is not enough evidence to determine whether these products provide a health benefit.
  • Mind and body approaches. Findings from some studies of tai chi, yoga, mindfulness training, and biofeedback for fibromyalgia symptoms suggest beneficial effects, but the evidence is too limited to draw definitive conclusions about whether these approaches are helpful.
  • Acupuncture. A 2013 Cochrane review of 9 studies involving a total of 395 participants found low-to-moderate evidence that acupuncture improves pain and stiffness in people with fibromyalgia, compared with no treatment and standard therapy. The reviewers also found moderate-level evidence that the effect of acupuncture does not differ from sham acupuncture in reducing pain or fatigue, or improving sleep or global well-being. 

Safety

  • Acupuncture is considered safe when performed by a qualified and competent practitioner using sterile needles. Few complications have been reported. Serious adverse events related to acupuncture are rare, but include infections and punctured organs.
  • Tai chi is a relatively safe practice; however, some patients should modify or avoid certain tai chi postures due to acute back pain, knee problems, bone fractures, sprains, and osteoporosis.

Headache

Several dietary supplements, including riboflavin, coenzyme Q10, and the herbs butterbur and feverfew, have been studied for migraine, with some promising results in preliminary studies. Results of research on mind and body practices such as relaxation training, biofeedback, acupuncture, and spinal manipulation for headaches suggest that these approaches may help relieve headaches and may be helpful for migraines.

The Evidence Base

  • The evidence base on efficacy of natural products for relieving headaches comes from small randomized controlled trials. A 2012 update to an evidence-based guideline from the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society provides recommendations on some dietary supplements for episodic migraine prevention in adults based on a review of 15 studies.
  • The evidence base on efficacy of mind and body practices such as relaxation training, acupuncture, and spinal manipulation for headaches consists of reviews of data from randomized controlled trials, and the evidence base for biofeedback, tai chi, and massage therapy for headaches consists of only a few small, randomized controlled trials.

Efficacy

  • Natural products. The Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society issued an update in 2012 to existing evidence-based guidelines on NSAIDs and other complementary health approaches for episodic migraine prevention in adults. The review supporting these recommendations found:
    • In two studies, butterbur (petasites) significantly reduced the frequency of migraines compared with placebo. In the first study, butterbur reduced the frequency of attacks by 3.3 ± 1.5 to 1.8 ± 0.8 attacks/month after 4 weeks, to 1.3 ± 0.9 attacks/month after 8 weeks, and to 1.7 ± 0.9 attacks/month after 12 weeks (p ≤ 0.05). In the second study, two separate dosages of butterbur (75 mg BID and 50 mg BID) reduced the frequency of migraines (48 percent and 36 percent, respectively) compared with placebo (26 percent). Based on these studies, the guidelines state that butterbur “should be offered to patients with migraine to reduce the frequency and severity of migraine attacks.”
    • Riboflavin, magnesium, and feverfew are probably effective for migraine prevention.
    • In one small study, coenzyme Q10 was more effective than placebo in reducing frequency of migraines from baseline to 4 months post-treatment. Based on this single study, the guidelines indicate that coenzyme Q10 is “possibly effective” for migraine prevention.
  • Biofeedback. The efficacy of biofeedback has been evaluated in numerous studies for tension headaches, with positive results. However, a 2009 systematic review of 11 randomized controlled trials concluded that there is conflicting evidence on the effectiveness of biofeedback compared with placebo to prophylactic drugs or any other treatment. Several studies have shown biofeedback decreased the frequency of migraines. A 2007 meta-analysis of 55 studies found a modest effect for biofeedback interventions and was seen lasting over an average followup phase of 17 months. However, a 2008 review concluded that biofeedback has beneficial clinical effects for migraine but whether those effects are specific or non-specific remains unclear.
  • Relaxation techniques. There is limited evidence to support the efficacy of relaxation techniques for tension-type headaches. A 2009 systematic review of eight studies comparing relaxation training to wait list conditions found inconsistent results. Authors of the review concluded that there is no indication, based on current evidence, that relaxation training is better than no treatment or a placebo. A 2008 meta-analysis of 53 studies suggests that relaxation training is less effective than biofeedback. The US Headache Consortium guidelines (85KB PDF) for management of migraines include behavioral and physical treatment recommendations based on evidence from 39 controlled trials. The guidelines indicate that relaxation training, thermal biofeedback combined with relaxation training, EMG biofeedback, and cognitive-behavioral therapy may be considered as treatment options for prevention of migraine and combined with preventive drug therapy to achieve additional clinical improvement for migraine relief.
  • Tai chi. Data are too limited to draw meaningful conclusions about whether tai chi is effective for tension-type headaches. One small clinical trial (n=47) suggested that a 15-week program of tai chi was effective in reducing the impact of tension-type headaches when compared to a wait-list control group.
  • Acupuncture. The combined results from studies evaluating the efficacy of acupuncture for headaches indicate that acupuncture may provide beneficial clinical effects, but whether those effects of acupuncture treatment are specific or non-specific has not been determined, and is under active investigation. A 2012 individual patient data meta-analysis concluded that acupuncture can be a reasonable referral option for chronic pain conditions, including headache.
  • Massage therapy. Limited evidence from two small studies suggests massage therapy is possibly helpful for migraines, but clear conclusions cannot be drawn. A 2011 systematic review of these two studies concluded that massage therapy might be equally effective as propranolol and topiramate in the prophylactic management of migraine.
  • Spinal manipulation. Findings from numerous systematic reviews on spinal manipulation for headaches are contradictory. A 2011 review concluded that higher-quality systematic reviews are needed before the benefit of spinal manipulation for headaches can be defined.

Safety

  • Riboflavin and coenzyme Q10 are generally well tolerated, but magnesium supplements may cause diarrhea.
  • In clinical trials, use of feverfew was associated with mild adverse effects such as open sores in the mouth and upset stomach. Butterbur is generally well tolerated but may cause mild gastrointestinal upset. Some butterbur products contain the potentially harmful chemicals pyrrolizidine alkaloids (PAs). Butterbur products labeled or certified as PA-free are also available.
  • Riboflavin supplements, feverfew, and butterbur are not recommended for pregnant women.
  • Relaxation techniques are generally considered safe for healthy people; however, there have been rare reports that certain relaxation techniques might cause or worsen symptoms in people with epilepsy or certain mental illnesses, or with a history of abuse or trauma.
  • Acupuncture is considered safe when performed by a qualified and competent practitioner using sterile needles. Few complications have been reported. Serious adverse events related to acupuncture are rare, but include infections and punctured organs.
  • Tai chi is a relatively safe practice; however, some patients with acute back pain, knee problems, bone fractures, sprains, and osteoporosis may need to  modify or avoid certain tai chi postures.
  • Side effects from spinal manipulation can include temporary headaches, tiredness, or discomfort in the parts of the body that were addressed. Although there have been rare reports of serious complications such as stroke, a large 2009 study did not find a relationship between spinal manipulation and vertebrobasilar artery stroke. Safety remains an important part of ongoing research.

Irritable Bowel Syndrome (IBS)

Although no complementary health approach has definitively been shown to be helpful for irritable bowel syndrome (IBS), some studies on hypnotherapy and probiotics have been promising.

The Evidence Base

  • The evidence base on efficacy of complementary health approaches for IBS comes from a 2014 American College of Gastroenterology monograph; a few, large, well-designed studies; and other studies with methodological flaws.

Efficacy

  • Hypnotherapy. A 2014 American College of Gastroenterology monograph found evidence that a variety of psychological therapies, including hypnotherapy, may be effective in improving IBS symptoms; however, the quality of evidence is very low. Findings from a 2013 systematic review indicated that hypnotherapy may provide beneficial clinical effects for managing IBS symptoms; however, the studies were of poor quality. Another 2013 systematic review of three randomized controlled trials in children showed benefits of hypnotherapy over standard medical care. 
  • Herbal medicine. Much of the research on herbal remedies for IBS has been done in China. A 2006 Cochrane review of 71 herbal remedies compared to placebo or conventional pharmacologic treatment found limited evidence suggesting that a few of these herbal remedies might help improve IBS symptoms including abdominal pain, constipation, and diarrhea. However, the review emphasizes that the studies were generally of poor quality.
  • Peppermint oil. Results from studies on peppermint oil for IBS are mixed, but there is some evidence that enteric-coated peppermint oil capsules may be modestly effective in reducing several common symptoms of IBS—especially abdominal pain, bloating, and gas. The 2014 American College of Gastroenterology monograph on the management of IBS and idiopathic constipation identified 5 randomized controlled trials involving a total of 482 participants and gave a “weak” recommendation, based on moderate quality of evidence, for the use of peppermint oil for IBS. A 2011 Cochrane review of 56 studies found statistically significant benefits of antispasmodics, including peppermint oil. The review concluded that there is evidence to support the use of antispasmodics, such as peppermint oil, for the treatment of IBS.
  • Probiotics. Probiotics have been associated with an improvement in IBS symptoms compared with placebo. A 2010 systematic review of 19 randomized controlled trials in 1,650 patients found that probiotics were statistically significantly better than placebo; however, the authors concluded that the magnitude of benefit and the most effective species and strain are uncertain. The 2014 American College of Gastroenterology monograph on the management of IBS and idiopathic constipation found that aggregated data do indicate that probiotics improve global symptoms, bloating, and flatulence in IBS; however, quality of evidence is low and recommendations regarding individual species, preparations, or strains cannot be made because of insufficient and conflicting data. Recommendations regarding individual species, preparations, or strains cannot be made at this time because of insufficient and conflicting data.
  • Acupuncture. A few small studies have indicated that acupuncture has some positive effect on quality of life in people with IBS, but in general, systematic reviews have concluded that there is no convincing evidence to support the use of acupuncture for the treatment of IBS symptoms. A 2012 Cochrane review of 17 randomized controlled trials found no benefits of acupuncture relative to a credible sham acupuncture control for IBS symptom severity or IBS-related quality of life. However, in comparative effectiveness Chinese trials, patients reported greater benefits from acupuncture than from two antispasmodic drugs (pinaverium bromide and trimebutine maleate), both of which have been shown to provide a modest benefit for IBS.
  • Other approaches. Evidence for other complementary health approaches sometimes tried in treating IBS—including melatonin, meditation, reflexology, yoga, and herbal remedies such as artichoke—is too limited to draw any conclusions about effectiveness.

Safety

  • Non-enteric coated forms of peppermint oil may cause or worsen heartburn symptoms.
  • Acupuncture is considered safe when performed by a qualified and competent practitioner using sterile needles. Few complications have been reported. Serious adverse events related to acupuncture are rare, but include infections and punctured organs.
  • Most people do not experience side effects from probiotics or have only mild gastrointestinal side effects such as gas. But some case reports exist of serious adverse events, and research on safety is ongoing. A 2008 review of probiotics safety noted that Lactobacillus rhamnosus GG has been widely studied in clinical trials for a variety of conditions and generally found to be safe. However, a recent review of Lactobacillus and Bifidobacterium noted that the long-term, cumulative effects of probiotics use, especially in children, are unknown, and also pointed to evidence that probiotics should not be used in critically ill patients. A 2011 Agency for Healthcare Research and Quality assessment of the safety of probiotics, partly funded by NCCIH, concluded that the current evidence does not suggest a widespread risk of negative side effects associated with probiotics. However, the data on safety, particularly long-term safety, are limited, and the risk of serious side effects may be greater in people who have underlying health conditions.

Low-Back Pain

Evidence-based clinical practice guidelines from the American College of Physicians and the American Pain Society (ACP/APS) provide a useful algorithm for diagnosis and treatment of patients with chronic low-back pain. In general, the guidelines recommend a conservative approach to diagnosis and treatment, except when patients have progressive neurologic deficits or cauda equina syndrome, or are suspected of having underlying conditions requiring urgent intervention (e.g., vertebral infection or cancer with impending spinal cord compression).

  • The systematic review supporting these recommendations (Chou and Huffman, Ann Intern Med. 2007;147(7):492–504) found:
    • Good evidence that cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation are all moderately effective for chronic or subacute (>4 weeks’ duration) low-back pain.
    • Fair evidence that acupuncture, massage, yoga (Viniyoga), and functional restoration are also effective for chronic low-back pain.
  • The guidelines recommend that practitioners consider these non-pharmacologic interventions as appropriate options when treating patients whose low-back pain does not improve with more conservative self-care.
  • It is important to know that interpreting and summarizing current evidence about diagnosis and treatment of chronic low-back pain is particularly challenging because of major differences in patient populations, eligibility criteria, diagnostic studies, treatments, and outcome measures across different studies, and the variety of health care professions involved in care of patients.
  • Read more on the current evidence about spinal manipulation, acupuncture, massage, and yoga—the complementary approaches most often used by people for chronic low-back pain.

The Evidence Base

  • The evidence base on efficacy of several mind and body approaches such as spinal manipulation, acupuncture, massage, and yoga consists of several independent systematic reviews and meta-analyses, and inclusion of recommendations into independent clinical practice guidelines.

Efficacy

  • Spinal manipulation. The systematic review supporting the 2007 clinical practice guidelines from the ACP/APS found good evidence that spinal manipulation (as well as cognitive-behavioral therapy, exercise, and interdisciplinary rehabilitation) are all moderately effective for chronic or subacute (>4 weeks’ duration) low-back pain. A 2010 Agency for Healthcare Research and Quality (AHRQ) systematic review concluded that spinal manipulation was more effective than placebo and as effective as medication in reducing low-back pain intensity. The researchers did not find consistent differences when they compared spinal manipulation with massage or physical therapy. A 2011 Cochrane review of 26 clinical trials looked at the effectiveness of different treatments, including spinal manipulation, for chronic low-back pain. The authors concluded that spinal manipulation is as effective as other interventions for reducing pain and improving function.
  • Acupuncture.  A rigorous 2012 patient data meta-analysis found clear evidence that acupuncture is useful in treating chronic back and neck pain, and the investigators concluded that it is therefore a reasonable referral option. While they found evidence of acupuncture-specific effects attributable to needling, suggesting that acupuncture is more than an elaborate placebo, they noted that these effects are relatively modest and that other non-acupuncture-specific factors are major contributors to the clinical benefit. Findings from a 2016 review of evidence suggest that acupuncture can help some patients manage low-back pain.
  • Massage. A 2015 Cochrane review found evidence that massage may provide short-term relief from low-back pain, but the evidence is not of high quality. The long-term effects of massage for low-back pain have not been established.
  • Yoga.  In a 2011 study, researchers compared yoga (a protocol developed using the principles of viniyoga) with conventional stretching exercises or a self-care book in 228 adults with chronic low-back pain. The investigators concluded that yoga classes were more effective than a self-care book, but not more effective than stretching classes, in improving function and reducing symptoms due to chronic low-back pain, with benefits lasting at least several months. Conclusions from another 2011 study of 313 adults with chronic or recurring low-back pain suggested that 12 weekly yoga classes resulted in better function than usual medical care.
  • A systematic review supporting the 2007 ACP/APS clinical practice guidelines found fair evidence that acupuncture, as well as massage, yoga, and functional restoration are effective for chronic low back pain and included them as options physicians should consider when patients with chronic low-back pain do not respond to conventional treatment.
  • Natural products. A 2014 Cochrane review of 14 randomized controlled trials involving 2,050 participants found preliminary evidence that devil’s claw and white willow bark (taken orally) may be helpful for low-back pain over the short-term. Topical preparations of cayenne, comfrey, Brazilian arnica, and lavender essential oil may provide some pain relief, although evidence for these natural products was of moderate quality at best. 

Safety

  • Many reviews have concluded that spinal manipulation for low-back pain is relatively safe when performed by a trained and licensed practitioner. The most common minor side effects include feeling tired and temporary soreness. There have been a few reports of cauda equina syndrome (CES), a significant narrowing of the lower part of the spinal canal in which nerves become pinched and may cause pain, weakness, loss of feeling in one or both legs, and bowel or bladder problems, following spinal manipulation. However, the vast majority of cases of CES are not associated with previous spinal manipulation, and in the few cases that are, it is unclear whether this is a complication of manipulation or an underlying disease condition which is causing back pain.
  • In people whose pain is caused by a herniated disc, manipulation of the low back appears to have a very low chance of worsening the herniation. For risks associated with spinal manipulation affecting the upper (cervical) spine, see the NCCIH fact sheet Chiropractic: An Introduction.
  • Acupuncture is generally considered safe when performed by an experienced practitioner using sterile needles. Reports of serious adverse events related to acupuncture are rare, but include infections and punctured organs.
  • Massage therapy appears to have few risks when performed by a trained practitioner. However, massage therapists should take some precautions with certain health conditions. In some cases, pregnant women should avoid massage therapy.  People with conditions such as bleeding disorders, thrombocytopenia and those taking anticoagulant medications should avoid forceful and deep tissue massage. Massage should not be done in any potentially weak area of the skin, such as wounds.
  • Overall, clinical trial data suggest yoga as taught and practiced in these research studies under the guidance of skilled teacher has a low rate of minor side effects. However, injuries from yoga, some of them serious, have been reported in the popular press. People with health conditions should work with an experienced teacher who can help modify or avoid some yoga poses to prevent side effects.

Neck Pain

Available evidence indicates that acupuncture for neck pain may provide better pain relief compared to no treatment. There is some evidence that spinal manipulation may help relieve neck pain, but much of the research on has been of low quality.

The Evidence Base

  • The evidence base on efficacy of spinal manipulation and acupuncture for neck pain consists of several systematic reviews. The evidence base on efficacy of massage for neck pain is based on several small studies of poor quality and a 2013 systematic review.

Efficacy

  • Manual therapies. Reviews of research on manual therapies (primarily manipulation or mobilization) and acupuncture for chronic neck pain have found mixed evidence regarding potential benefits and have emphasized the need for additional research. A 2015 Cochrane review of 51 randomized controlled trials involving a total of 2,920 participants concluded that there is some evidence to support the use of thoracic manipulation versus control for neck pain, function, and quality of life; however, results for cervical manipulation and mobilization are few and diverse. The reviewers noted that these findings suggest that manipulation and mobilization present similar results for each outcome at immediate-, short-, and intermediate-term followup. Multiple cervical manipulation sessions may provide better relief of pain and improvement in function than certain medications at immediate-, intermediate-, and long-term followup. Because there is risk of rare but serious adverse events for manipulation, more rigorous research is needed on mobilization, and comparing mobilization and manipulation versus other treatment options. A 2007 review noted that clinical guidelines often endorse the use of manual therapies for neck pain, although there is no overall consensus on the status of these therapies.
  • Massage therapy. A 2016 review of four randomized controlled trials found that massage therapy may provide short-term benefits from neck pain. However, a 2013 Cochrane review of 15 trials on massage therapy for neck pain showed “very low level evidence” that certain massage techniques may have been effective in reducing pain and improving function. Authors of the review concluded that no recommendations for practice can be made at this time because the effectiveness of massage for neck pain remains uncertain.

Safety

  • Side effects from spinal manipulation can include temporary headaches, tiredness, or discomfort in the parts of the body that were treated. Although there have been rare reports of serious complications such as stroke, a large 2009 study did not find a relationship between spinal manipulation and vertebrobasilar artery stroke, which involves the arteries that supply blood to the back of the brain. Safety remains an important part of ongoing research.
  • Acupuncture is considered safe when performed by a qualified and competent practitioner using sterile needles. Few complications have been reported. Serious adverse events related to acupuncture are rare, but include infections and punctured organs.

Osteoarthritis

Clinical practice guidelines issued by the American College of Rheumatology recommend aerobic exercise and/or strength training, weight loss (if overweight), and a number of pharmacologic and non-pharmacologic modalities for treating osteoarthritis (OA) of the knee, hip, or hand. The guidelines conditionally recommend tai chi, along with other non-drug approaches such as self-management programs and walking aids, for managing knee OA. Acupuncture is also conditionally recommended for those who have chronic moderate-to-severe knee pain and are candidates for total knee replacement but can’t or won’t undergo the procedure.

The Evidence Base

  • The evidence base on efficacy of various complementary health appraches for osteoarthritis consists of several independent systematic reviews and meta-analyses, and inclusion of recommendations into independent clinical practice guidelines.

Efficacy

  • Glucosamine and chondroitin. The preponderance of evidence on glucosamine and chondroitin sulfate—taken separately or together—indicates little or no meaningful effect on pain or function. Independent clinical practice guidelines published in 2012 by the American College of Rheumatology (ACR) (95KB PDF), and in 2010 by the American Academy of Orthopaedic Surgeons (AAOS) recommend not using glucosamine or chondroitin for OA. Recommendations from Osteoarthritis Research Society International (OARSI) published in 2014 conclude that current evidence does not support use of glucosamine or chondroitin in knee OA for disease-modifying effects, but leave unsettled the question of whether either may provide symptomatic relief.
  • DMSO and MSM. DMSO and MSM are two chemically-related dietary supplements that have been used for arthritic conditions. However, evidence does not suggest that DMSO and MSM are helpful for OA symptoms.
  • SAMe. SAMe is a molecule that is naturally produced in the body and is often taken as a dietary supplement. There is not enough evidence to support the use of SAMe for OA of the knee or hip.
  • Herbs. Although some results suggest that a few herbs such as ginger, avocado-soybean unsaponifiables (ASUs), and the Ayurvedic herb Boswellia serrata, taken orally, may be have modest benefits for OA symptoms, the overall evidence is weak. There is some evidence that topical arnica gel and comfrey gel may also be helpful. In addition, not all herbs have been studied or prepared in a consistent way, and conclusions among reviews of the literature provide conflicting interpretations. There is also a general lack of safety data available for many herbs. 
  • Acupuncture. A 2012 meta-analysis concluded that acupuncture can be helpful and a reasonable referral option for OA pain. The authors of the meta-analysis also noted that significant differences between true (actual) and sham acupuncture indicate that acupuncture is more than a placebo; however, these differences are relatively modest. Findings suggest that factors other than the specific effects of needling contribute to the therapeutic effects of acupuncture. In a 2008 systematic review of 10 randomized controlled trials of acupuncture for OA of the knee in 1,456 patients, the authors concluded that these studies provide evidence that acupuncture is an effective treatment for pain and physical dysfunction associated with OA of the knee. A 2010 systematic review of 16 trials of 3,498 patients examined the effects of acupuncture for OA in peripheral joints and found that although acupuncture, when compared to a sham treatment, showed statistically significant, short-term improvements in OA pain, the benefits were small and not clinically relevant. In contrast, acupuncture, when compared to a waiting list control, showed statistically significant and clinically relevant benefits in people with peripheral joint OA.
  • Massage therapy.2013 review of two randomized controlled trials found positive short-term (less than 6 months) effects in the form of reduced pain and improved self-reported physicial functioning. Results of a 2006 randomized controlled trial of 68 adults with OA of the knee who received standard Swedish massage over 8 weeks demonstrated statistically significant improvements in pain and physical function. 
  • Tai chi.2013 meta-analysis of 7 randomized controlled trials involving 348 participants found that a 12-week course of tai chi provides benefits of improvement in arthritic symptoms and physical function in patients with OA; however, any long-term benefits of tai chi on OA symptoms has not yet been investigated. A 2013 systematic review and meta-analysis of 5 randomized controlled trials involving 252 participants found moderate evidence for short-term improvement of pain, physical function, and stiffness in patients with OA of the knee who practiced tai chi. A 2009 prospective, single-blind, randomized controlled trial of 40 participants found that tai chi demonstrated significantly greater improvement in pain and physical function, as well as improvement in depression, self-efficacy, and quality of life.

Safety

  • There are few complications associated with acupuncture, but adverse effects such as minor bruising or bleeding can occur; infections can result from the use of nonsterile needles or poor technique from an inexperienced practitioner.
  • Massage therapy appears to have few risks if it is used appropriately and provided by a trained massage professional.
  • Tai chi is considered to be a safe practice.

Rheumatoid Arthritis

While conventional medical therapies such as biologic agents or disease-modifying antirheumatic drugs (DMARDs) are able to modify the disease course of rheumatoid arthritis (RA) and prevent erosions, no natural product has been shown to alter the course of the disease. Omega-3 fatty acids found in fish oil may have modest benefits in relieving RA pain symptoms. No other dietary supplement has shown clear benefits for RA, but there is preliminary evidence for a few, particularly fish oil, gamma-linolenic acid, and the herb thunder god vine. However, serious safety concerns have been raised about thunder god vine. Results from clinical trials suggest that some mind and body practices—such as relaxation, mindfulness meditation, tai chi, and yoga—may be beneficial additions to conventional treatment plans, but some studies indicate that these practices may do more to improve other aspects of patients’ health than to relieve pain.

The Evidence Base

  • The evidence base on the efficacy of natural products such as fish oil and Gamma-Linolenic Acid (GLA ) for rheumatoid arthritis consists of several randomized controlled trials. The evidence base on efficacy of other natural products—thunder god vine, boswellia, ginger, green tea, and turmeric—are from laboratory studies. 
  • The evidence base on efficacy of mind and body practices such as mindfulness meditation, biofeedback, and relaxation training for rheumatoid arthritis symptoms consists of a 2010 systematic review. Only a few small randomized controlled trials have been conducted on acupuncture, tai chi, and yoga for RA.

Efficacy

  • Fish oil. Clinical trials on RA have found that fish oil supplements may help alleviate tender joints and morning stiffness. Other studies have found that fish oil may reduce the daily NSAID requirement of RA patients. Results of a 2008 randomized, controlled trial found that compared with placebo, participants who received a blend of cod liver oil and fish oil over a 9-month period reduced their NSAID intake by more than 30 percent.
  • GLA. There is some preliminary evidence that GLA (gamma linolenic acid) may be beneficial for RA; however, the quality of the studies on GLA has been inconsistent. The more rigorous studies suggest that GLA may relieve symptoms such as joint pain, stiffness, and tenderness; in some cases, GLA led to a decreased need for NSAID medication. A 2011 Cochrane review found evidence from seven studies indicating potential benefits of GLA from evening primrose oil, borage seed oil, or blackcurrant seed oil, in terms of reduced pain intensity; improved disability; and an increase in adverse events that was not statistically different.
  • Thunder god vine. Findings from laboratory and animal studies suggest that Tripterygium wilfordii (thunder god vine) may fight inflammation and suppress the immune system. A 2011 Cochrane review examined three human studies of oral thunder god vine and one study of topical thunder god vine for RA and concluded that Tripterygium wilfordii products may reduce some RA symptoms, however, oral use may be associated with several side effects.
  • Acupuncture. Acupuncture has been studied for a variety of pain conditions, but very little acupuncture research has focused on RA. A 2010 Cochrane review of two studies—one on acupuncture and the other on electroacupuncture for RA—concluded that acupuncture has no effect on ESR, CRP, pain, patient’s global assessment, number of swollen joints, number of tender joints, general health, disease activity, and reduction of analgesics. Although findings from the study on electroacupuncture showed that electro-acupuncture may reduce symptomatic knee pain, the review noted that the poor quality of the trial, including the small sample size, preclude its recommendation.
  • Mindfulness, biofeedback, and relaxation training.2010 systematic review of 31 studies in 2,021 patients looked at the benefits of mind and body practices such as mindfulness meditation, biofeedback, and relaxation training on the physical and psychological symptoms associated with RA. There was some evidence that these techniques may be helpful, but overall, the research results have been mixed. A 2008 study of 144 patients compared cognitive-behavioral therapy emphasizing pain management with mindfulness meditation for RA. Findings from the study indicated that mindfulness meditation improved participants’ ability to cope with pain. Participants with a history of depression responded better than others to mindfulness meditation.
  • Tai chi. A few small studies have been conducted on tai chi for RA. A 2007 systematic review concluded that tai chi has not been shown to be effective for joint pain, swelling, and tenderness, although improvements in mood, quality of life, and overall physical function have been reported. A small 2010 study of 15 participants found that tai chi improved lower-limb muscle function post-treatment and at the 12-week followup; however, there was no evidence that it reduced disease activity or pain.
  • Yoga. Yoga incorporates several elements of exercise that may be beneficial for arthritis, including activities that may help improve strength and flexibility. A 2013 systematic review of 8 randomized controlled trials involving a total of 559 participants found very low evidence on the effects of yoga on pain associated with RA.  

Safety

  • Omega-3 fatty acid supplements usually do not have serious adverse effects, but may extend bleeding time. People taking anticoagulants or NSAIDs should use caution. Products made from fish liver oils may contain vitamins A and D as well as omega-3 fatty acids, which can be toxic in large doses.
  • Side effects of GLA may include headache, soft stools, constipation, gas, and belching. Some borage oil preparations contain chemicals called pyrrolizidine alkaloids that may harm the liver.
  • A systematic review on thunder god vine for RA concluded that serious side effects occurred frequently enough that the risk of using it outweighs its benefits. Depending on the dose and type of extract, thunder god vine may cause serious side effects. Thunder god vine can affect the reproductive system, possibly causing menstrual changes in women and infertility in men. Long-term use may decrease bone mineral density in women, potentially increasing the risk of osteoporosis. Other side effects can include diarrhea, upset stomach, hair loss, headache, and skin rash.
  • Acupuncture is considered safe when performed by a qualified and competent practitioner using sterile needles. Few complications have been reported. Serious adverse events related to acupuncture are rare, but include infections and punctured organs.
  • Some people have reported soreness, but most studies have found that tai chi is relatively safe for people with RA.
  • People with RA who have limited mobility or spinal problems should perform yoga exercises with caution. People with RA may need assistance in modifying some yoga postures to minimize joint stress and may need to use props to help with balance.

References

Fibromyalgia

Headaches

Irritable Bowel Syndrome

Low-Back Pain

Neck Pain

Osteoarthritis

Rheumatoid Arthritis

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NCCIH Clinical Digest is a service of the National Center for Complementary and Integrative Health, NIH, DHHS. NCCIH Clinical Digest, a monthly e-newsletter, offers evidence-based information on complementary health approaches, including scientific literature searches, summaries of NCCIH-funded research, fact sheets for patients, and more.

The National Center for Complementary and Integrative Health is dedicated to exploring complementary health products and practices in the context of rigorous science, training complementary health researchers, and disseminating authoritative information to the public and professionals. For additional information, call NCCIH's Clearinghouse toll-free at 1-888-644-6226, or visit the NCCIH Web site at nccih.nih.gov. NCCIH is 1 of 27 institutes and centers at the National Institutes of Health, the Federal focal point for medical research in the United States.

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Content is in the public domain and may be reprinted, except if marked as copyrighted (©). Please credit the National Center for Complementary and Integrative Health as the source. All copyrighted material is the property of its respective owners and may not be reprinted without their permission.

This page last modified March 27, 2018