Complementary Health Approaches for Chronic Pain: What the Science Says

Nutritional Approaches

• 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.  

• A 2022 systematic review of vitamin D supplementation for treatment of fibromyalgia and chronic musculoskeletal pain suggests it may alleviate pain, especially in vitamin D–deficient individuals. 

Psychological and/or Physical 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. A 2020 update to a systematic review by the Agency for Healthcare Research and Quality (AHRQ) largely supports previous findings—namely that exercise, multidisciplinary rehabilitation, acupuncture, cognitive behavioral therapy, mindfulness practices, massage, and mind-body practices most consistently improve function and/or pain beyond the course of therapy for specific chronic pain conditions. 

• Tai chi. A 2018 randomized controlled trial involving 226 adults with fibromyalgia found that high-intensity and frequent tai chi (i.e., two times a week) reduced symptom severity at 24 weeks more than supervised aerobic exercise. In addition, the study found that patients are more likely to attend tai chi classes than aerobic exercise sessions.
• Biofeedback/mindfulness/relaxation techniques. A 2015 Cochrane review of 61 trials involving 4,234 predominantly female participants with fibromyalgia concluded that the effectiveness of biofeedback, mindfulness, movement therapies, and relaxation techniques remains unclear as the quality of evidence was low or very low.

• Mindfulness-based stress reduction (MBSR). A 2019 randomized controlled trial involving 70 female participants found that mindfulness training was efficacious in reducing clinical severity of patients with fibromyalgia. The results of the trial also suggest that MBSR has significant immune regulatory effects in patients with fibromyalgia, while immune-inflammatory pathways may in part predict the clinical efficacy of MBSR.
• Acupuncture. A 2020 update to a systematic review by the Agency for Healthcare Research and Quality (AHRQ) found that acupuncture was associated with a small improvement in function compared with sham acupuncture as evaluated by the Fibromyalgia Impact Questionnaire (FIQ) Total Score at short-term and intermediate-term follow-up. (The strength of evidence was considered moderate.) The updated review also found no effect of acupuncture versus sham acupuncture on pain in the short term or intermediate term. (The strength of evidence was considered low.) A 2019 systematic review and meta-analysis of 12 randomized controlled trials with sample sizes ranging from 20 to 164 participants found that acupuncture was significantly better than sham acupuncture for relieving pain and improving the quality of life with low- to moderate-quality evidence in the short term. The long-term follow-up showed the effect of acupuncture was also superior to that of sham 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.

Nutritional Approaches

• Except for people with soy allergies, soy is considered to be a safe food. In research studies, soy protein supplements and soy extracts rich in isoflavones have been used safely on a short-term basis; the safety of long-term use is uncertain.
• The most common side effects of soy are digestive upsets, such as constipation and diarrhea.
• Soy may alter thyroid function in people who are deficient in iodine.
• Very high levels of vitamin D (greater than 375 nmol/L or 150 ng/mL) can cause nausea, vomiting, muscle weakness, confusion, pain, loss of appetite, dehydration, excessive urination and thirst, and kidney stones. 
• Vitamin D may interact with some medications, including statins, steroids such as prednisone, and thiazide diuretics. 

Psychological and/or Physical Approaches

• 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.
• A 2019 review found no apparent negative effects of mindfulness-based interventions and concluded that their general health benefits justify their use as adjunctive therapy for patients with anxiety disorders.
• Biofeedback generally does not have harmful side effects.
• Relaxation techniques generally don’t have side effects. However, rare harmful effects have been reported in people with serious physical or mental health conditions.
• 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.

Nutritional Approaches

• Butterbur. Butterbur appears to help reduce the frequency of migraines in adults and children. However, the American Academy of Neurology stopped recommending butterbur in 2015 because of serious concerns about possible liver toxicity. 
• Coenzyme Q10. A 2021 systematic review and meta-analysis of 6 studies (371 total participants) which compared coenzyme Q10 with a placebo showed that coenzyme Q10 may help reduce the duration and frequency of migraines but not their severity. Because both the amount of evidence and the size of the effects observed in the studies were small, there are still uncertainties about whether coenzyme Q10 is helpful for migraines.
• Feverfew. A 2015 Cochrane review of 6 studies involving 561 participants found a difference in effect between feverfew and placebo of 0.6 migraine attacks per month. However, the reviewers noted that this constitutes low-quality evidence, which needs to be confirmed in larger rigorous trials with stable feverfew extracts and clearly defined migraine populations before firm conclusions can be drawn. A 2019 review on migraine headache prophylaxis found that feverfew is probably effective.
• Magnesium. A 2018 systematic review of five studies found “possibly effective” (Grade C) evidence for prevention of migraine with magnesium. However, a 2021 review concluded that even if the preliminary results are very promising, more rigorous studies must be designed to confirm the efficacy of magnesium for headache. A 2009 review found that three of four small, short-term, placebo-controlled trials showed modest reductions in the frequency of migraines in patients given up to 600 mg/day of magnesium. The reviewers noted that the typical dose of magnesium used for migraine prevention exceeds the Tolerable Upper Intake Level (UL), and this treatment should be used only under the direction and supervision of a health care provider.
• Riboflavin. A 2020 review concluded that overall, results of studies to date have found that riboflavin has similar efficacy to valproate for migraine prophylaxis but has a more tolerable side effect profile. A 2017 review of 9 studies (546 participants) of riboflavin supplementation to prevent migraine found it to be effective in reducing migraine frequency in some adults. Riboflavin supplementation seemed to be more useful in adults than in children.
• Omega-3 fatty acid supplementation. Diets high in omega-3 fatty acids may be helpful for migraines; however, omega-3s in supplement form have not been shown to reduce the frequency or severity of migraines. There is a small amount of evidence that suggests that omega-3 supplements might reduce the duration of migraine attacks. In a 2021 study of 182 adults with frequent migraines, researchers from the National Institutes of Health in cooperation with other investigators assigned participants to one of three groups for 16 weeks comparing a diet high in omega-3 fatty acids from high-fat fish and low in linoleic acid, a diet high in omega-3s but with as much linoleic acid as in the average U.S. diet, and a control diet containing omega-3s and linoleic acid in the amounts found in the average U.S. diet. Participants in the two groups receiving higher amounts of omega-3s had fewer hours of headaches and fewer hours of moderate-to-severe headaches per day, as well as fewer days per month with headaches compared to the control group. The greatest decrease in headache days per month was seen in the group that received a diet high in omega-3s and low in linoleic acid. A 2021 analysis of the VITamin D and OmegA-3 TriaL (VITAL) showed that omega-3 supplementation did not affect migraine frequency or severity among the 1,032 study participants with a reported a history of probable migraine. A 2018 review of 5 small studies involving a total of 382 participants found that while omega-3s did not affect the frequency of migraines, there was a reduction in duration of migraine attacks.

Psychological and/or Physical Approaches

• Acupuncture. Results from studies indicate that acupuncture may help relieve headache pain, but that much of its benefit may be due to nonspecific effects including expectation, beliefs, and placebo responses rather than specific effects of needling. A 2018 update to a 2012 meta-analysis (of 39 studies involving a total of 20,827 participants) concluded that acupuncture is effective for the treatment of 4 chronic pain conditions, including migraine, with treatment effects lasting over time. A 2016 Cochrane review of 22 randomized trials found that acupuncture was more effective than no acupuncture, was slightly more effective than sham, and may be similarly effective as preventative drug treatment for chronic pain. A 2021 systematic review of 8 studies involving 3,846 participants found evidence that acupuncture and manual therapy can be valuable nonpharmacologic treatment options for tension-type headaches. A 2022 systemic review of 15 randomized controlled trials compared acupuncture to sham acupuncture, and acupuncture to medical treatment. In 7 out of 10 trials comparing acupuncture to sham, reviewers found acupuncture showed a more significant reduction in the frequency of migraine attacks and headache intensity. 

• Massage. Only a small number of studies of massage for headache have been completed, and their results are not consistent. A 2016 study with 64 participants evaluated lymphatic drainage and traditional massage (once a week for 8 weeks) in patients with migraine and found that the frequency of migraines decreased in both groups, compared with people on a waiting list. A 2015 study of 56 people with tension headaches found that those who received either massage or the inactive treatment had a decrease in the frequency of headaches, but there was no difference between the two groups. A 2011 study of 83 participants evaluated the effect of adding hand massage to multimodal behavior treatment of migraine and found that hand massage had no effect on migraine frequency.
• Relaxation techniques. In a 2018 review of 6 studies involving a total of 274 participants, 5 of the studies found that autogenic training or biofeedback-assisted autogenic training helped to reduce headache pain; however, because of the small sample size and study limitations, the review authors noted that the findings should be viewed cautiously. In a 2018 review, five of eight studies found that hypnosis—usually self-hypnosis and often paired with guided imagery—resulted in less headache activity in people diagnosed with migraine or chronic headache disorder; however, none of the studies in this review were rated high quality. In a 2016 review of 19 studies (2,600 total participants) on psychological interventions for migraine and tension-type headache, including relaxation training, cognitive behavioral therapy, biofeedback, or a combination of interventions, participants in 15 of the studies reported a decrease in daily headache frequency ranging from 20 to 67 percent. While relaxation training paired with cognitive behavioral therapy appeared to have the most supportive research, the review authors said that the overall research was lacking in quality.
• Spinal manipulation. Spinal manipulation may be one of several complementary health approaches (including massage therapy) that’s as helpful as medications used for migraine prevention, but the research isn’t conclusive. The AHRQ systematic review of noninvasive, nonpharmacologic treatment for chronic pain reported spinal manipulation therapy was associated with slight-to-moderate improvements in function compared to usual care on the Headache Impact Test and the Headache Disability Inventory (scale 0–100) and in pain over the short term (i.e., 1–6 months) in one trial. The standard of evidence was rated as low.
• Tai chi. One small, randomized study has evaluated tai chi for tension headaches and found some evidence of improvements in headache status and health-related quality of life among patients on the tai chi program compared to others on a wait list. However, these data are too limited to draw meaningful conclusions about whether this practice is helpful for tension headaches.

Nutritional Approaches

• Some butterbur products contain chemicals called pyrrolizidine alkaloids (PAs). PAs can damage the liver, lungs, and blood circulation, and possibly cause cancer. Only butterbur products that have been processed to remove PAs and are labeled or certified as PA-free should be considered for use.
• No serious side effects of coenzyme Q10 have been reported. Coenzyme Q10 may interact with some medications, including the anticoagulant (blood-thinning) medication warfarin and the diabetes drug insulin.
• Side effects of feverfew may include digestive disturbances, skin rash, and inflammation of the mouth. Feverfew may interact with medications.
• High doses of magnesium from dietary supplements or medicines can cause diarrhea, nausea, and stomach cramps, and very large doses can cause serious toxicity. Magnesium can interact with medicines, including some antibiotics, diuretics, and drugs used to treat osteoporosis. Because the amounts of magnesium people take for migraines are greater than the largest daily intake of magnesium from supplements and medicines that is considered safe, magnesium supplements for migraine should be used only under the supervision of a health care provider.
• No harmful effects from the use of riboflavin have been reported, and riboflavin is not known to interact with drugs.
• Omega-3 supplements usually produce only mild side effects, if any. There’s conflicting evidence on whether omega-3 supplements might influence the risk of prostate cancer. If you’re taking medicine that affects blood clotting or if you’re allergic to fish or shellfish, consult your health care provider before taking omega-3 supplements.

Psychological and/or Physical Approaches

• Acupuncture is generally considered safe when performed by an experienced practitioner using sterile needles. Improperly performed acupuncture can cause potentially serious side effects.
• Biofeedback generally does not have harmful side effects.
• Massage therapy appears to have few risks when performed by a trained practitioner. However, people with health conditions and pregnant women may need to avoid some types of massage and should consult their health care providers before having massage therapy.
• Relaxation techniques generally don’t have side effects. However, rare harmful effects have been reported in people with serious physical or mental health conditions.
• Side effects from spinal manipulation can include temporary headaches, tiredness, or discomfort in the area that was manipulated. There have been rare reports of strokes occurring after manipulation of the upper (cervical) spine, but whether manipulation actually caused the strokes is unclear.
• Tai chi is generally considered to be a safe practice.

Nutritional Approaches

• Probiotics. Clinical guidelines issued in 2021 by the American College of Gastroenterology recommends against the use of probiotics for the treatment of global IBS symptoms. (The recommendation is conditional, with “very low level of evidence.”) Authors of the guidelines noted that there are challenges in interpreting the existing literature because of small studies, the multiple types and strains of probiotics, the inconsistent benefits on individual symptoms, and the lack of rigorous trials based on U.S. Food and Drug Administration (FDA) endpoints. A 2022 systematic review and meta-analysis of 10 randomized controlled trials involving 757 patients with constipation-predominant IBS (IBS-C) found that compared to placebo, probiotics significantly improved stool consistency and increased the number of fecal Bifidobacteria and Lactobacillus; however, no significant differences were found in abdominal pain scores, bloating scores, or quality-of-life scores. It is important to note that only three studies included in the review were rated as having low risk of bias. A 2021 systematic review and meta-analysis of 9 randomized controlled trials involving 651 pediatric patients found that probiotics significantly reduced the abdominal pain score, increased the rate of abdominal pain treatment success and abdominal pain relief, and reduced the frequency of abdominal pain. A 2019 systematic review of 11 studies evaluating the effects of probiotics on IBS symptoms found mixed results. Seven of the studies included in the review reported that probiotics significantly improved IBS symptoms compared with placebo, whereas the other four studies did not report any significant improvement in IBS symptoms after taking probiotics. 

• Peppermint oil. There is some evidence that enteric-coated peppermint oil capsules may be modestly efficacious, in the short term, in reducing several common symptoms of IBS, in particular abdominal pain, bloating, and gas. Long-term efficacy has not been established. Clinical guidelines issued in 2021 by the American College of Gastroenterology recommend the use of peppermint to provide relief of global IBS symptoms. (The recommendation is conditional, with “low quality of evidence.”) A 2020 randomized, double-blind trial of 190 patients in the Netherlands found that neither small-intestinal-release nor ileocolonic-release peppermint oil, administered over 8 weeks, produced statistically significant reductions in abdominal pain response or overall symptom relief, when using U.S. FDA/European Medicines Agency recommended endpoints. However, the small-intestinal-release peppermint oil did produce significant reductions in abdominal pain, discomfort, and IBS severity. A 2020 systematic review and network meta-analysis of 51 randomized controlled trials involving 4,644 patients evaluated soluble fiber, antispasmodic drugs, peppermint oil, and gut-brain neuromodulators for IBS. The reviewers found peppermint oil was ranked first for efficacy regarding improvement in global IBS symptoms, based on data from six trials. However, the reviewers also noted that only 13 trials included in the review were at low risk of bias, and therefore, there is likely to be considerable uncertainty around these findings.
• Herbal remedies. There is evidence to suggest some herbal remedies may improve IBS symptoms. However, much of the data available is based on studies with inadequate methodology and small sample populations. A 2017 double-blind, randomized, placebo-controlled trial involving 99 participants found that those who received an herbal remedy (IQP-CL-101) containing a mixture of curcuminoids and essential oils from different Curcuma species, besides fish oil, peppermint oil, caraway oil, and vitamins B1, B9, and D3, had a significant reduction in IBS symptoms compared to placebo. A 2019 randomized trial of 240 women who had IBS with diarrhea (IBS-D) found that crofelemer, an active compound from the latex of the plant Croton lechleri, had no significant effect compared with placebo on the number of days without pain and discomfort. However, in an analysis conducted after the trial ended, crofelemer did improve abdominal pain compared with placebo based on the FDA abdominal pain monthly responder endpoint, which suggests that crofelemer may have a role in the management of pain in IBS-D.

Psychological and/or Physical Approaches

• Gut-directed hypnotherapy. Some studies have suggested benefits of gut-directed hypnotherapy for IBS symptoms, including gastrointestinal symptoms, anxiety, depression, disability, and health-related quality of life. Significant relief from pain-related functional gastrointestinal pain disorders in children has been reported after hypnotherapy compared with standard care or waitlist approaches. Clinical guidelines issued in 2021 by the American College of Gastroenterology recommend that gut-directed psychotherapies, such as gut-directed hypnotherapy, be used to treat global IBS symptoms. (The recommendation is conditional, with “very low quality of evidence.”) A 2020 systematic review and network meta-analysis of 41 randomized controlled trials involving a total of 4,072 participants found that gut-directed hypnotherapy was more efficacious than either education and/or support or routine care in adults with IBS. However, other psychological therapies were analyzed as well, and none were superior to another; cognitive behavioral therapy and gut-directed hypnotherapy had the largest evidence base and were the most efficacious over the long term. A 2022 systematic review and meta-analysis of 33 randomized controlled trials involving a total of 2,657 children with functional abdominal pain disorders found that hypnotherapy may be considered as a treatment for these disorders in childhood. 
• Acupuncture. In sham-controlled, randomized trials, acupuncture was found to be no better than placebo for IBS symptom severity or health-related quality of life. In other studies, acupuncture appeared to provide greater benefits than two antispasmodic drugs, although the studies could not rule out that these benefits may have been due to patient preferences or expectations of improvement. A 2019 meta-analysis of 41 studies involving a total of 3,440 participants showed that acupuncture was no more effective than sham acupuncture for symptoms of IBS, but there was some evidence that acupuncture could be helpful when used in addition to other forms of treatment.

Nutritional Approaches

• In healthy people, probiotics usually have only minor side effects, if any. However, in people with underlying health problems, serious complications, such as infections, have occasionally been reported.
• Most research about the safety of probiotics comes from studies of Lactobacillus and Bifidobacterium; less is known about other probiotic strains.
• Non-enteric coated forms of peppermint oil may cause or worsen heartburn symptoms, but otherwise appear to be generally safe over the short term.
• Herbal supplements may contain dozens of compounds and all of the ingredients may not be known.

• Some herbs can interact with medications. For example, St. John’s wort is a potent inducer of both cytochrome P-450 enzymes and intestinal P-glycoprotein. Clinically significant interactions have been documented with St. John’s wort and cyclosporine, the antiretroviral agent indinavir, oral contraceptives, coumadin, digoxin, and benzodiazepines, among others.
• Some herbs can cause serious side effects. For example, comfrey and kava can cause liver toxicity.

Psychological and/or Physical Approaches

• Gut-directed hypnosis is generally considered safe and tolerable among children and adults when led by licensed hypnotherapists with special training in this technique.

• Relatively few complications from using acupuncture have been reported. Still, complications have resulted from use of nonsterile needles and improper delivery of treatments. When not delivered properly, acupuncture can cause serious adverse effects, including infections, bleeding, pneumothorax, and injury to the central nervous system.

Nutritional Approaches

• Herbal products. A 2016 Cochrane review of 14 randomized controlled trials (2,050 participants) showed that capsicum frutescens (cayenne) reduced pain more than placebo, and that Harpagophytum procumbens (devil’s claw), Salix alba (white willow bark), Symphytum officinale L. (comfrey), Solidago chilensis (Brazilian arnica), and lavender essential oil also seemed to reduce pain more than placebo. However, evidence for these substances was of moderate quality at best. 
• Vitamin D. A 2017 review of 29 studies (27,764 participants) showed that people with low-back pain were more likely to be deficient in vitamin D. This association was particularly noticeable in people under age 60, especially women. However, a 2018 review of 8 studies of vitamin D supplementation (747 participants) did not find vitamin D to be helpful in improving low-back pain.

Psychological and/or Physical Approaches

• Acupuncture. A 2020 Cochrane review evaluated 33 studies (8,270 participants) of acupuncture for chronic low-back pain and found that when compared with no treatment, acupuncture produced greater pain relief and improvement of back function. However, when compared with usual care, acupuncture improved function, but it did not reduce pain to an extent that would be clinically meaningful to patients. Further, when acupuncture was compared with sham acupuncture, no clinically meaningful difference was observed in effects on pain or function. A systematic review supporting the 2017 American College of Physicians clinical practice guidelines evaluated 32 randomized controlled trials involving more than 6,000 participants and found modest, short-term effects on pain. A 2018 update to a 2012 meta-analysis (39 randomized controlled trials with 20,827 patients) concluded acupuncture is effective for the treatment of low-back pain, with treatment effects lasting over time. A 2020 review by the Agency for Healthcare Research and Quality (AHRQ) found that acupuncture was associated with slightly greater effects on pain and function at 1 to 6 months when compared to controls, such as sham (simulated) acupuncture or usual care. One study also found a greater reduction in pain after more than 12 months. 
• Massage therapy. A 2015 review of 25 studies of massage for low-back pain, with about 3,000 participants, found that it may produce short-term improvements in pain. The quality of the evidence was low to very low. A 2020 AHRQ review that looked at the impact of therapies for chronic low-back pain at least 1 month after the end of treatment found that massage therapy was associated with slightly greater effects on pain and function after 1 to 6 months, compared to sham (simulated) massage or usual care. There was no evidence of an effect at 6 to 12 months. The American College of Physicians clinical practice guideline for low-back pain treatment includes massage as a treatment option for acute/subacute low-back pain (based on low-quality evidence). It does not recommend massage therapy as an option for chronic low-back pain.
• Spinal manipulation. A 2017 analysis examined data from 15 randomized controlled trials with almost 1,700 participants. The researchers concluded that spinal manipulative therapy can modestly improve pain and function in people with acute low-back pain. Results of a 2018 study with 750 active-duty U.S. military personnel with low-back pain found that those who received chiropractic care in addition to usual care had better short-term improvements in low-back pain intensity and pain-related disability than those who only received usual medical care. A 2018 combined analysis of 9 studies (1,176 participants) found moderate-quality evidence that manipulation and mobilization are likely to reduce pain and improve function in people with chronic low-back pain. Manipulation appeared to produce a larger effect than mobilization. A 2018 AHRQ review that looked at the impact of therapies for chronic low-back pain at least 1 month after the end of treatment found that spinal manipulation had slightly greater benefits on function after 1 to 6 months and 6 to 12 months and on pain after 6 to 12 months, when compared to sham (simulated) manipulation or other controls.
• Tai chi. A 2016 review of 3 studies of tai chi for low-back pain (385 participants), all of which involved at least 10 weeks of tai chi, found it was helpful. In two additional studies, not included in the review, tai chi was at least as helpful as some other treatments for low-back pain and better than no treatment. The American College of Physicians clinical practice guideline for low-back pain treatment includes tai chi as an option for initial treatment of chronic low-back pain (based on low-quality evidence).
• Yoga. A 2020 review of 25 randomized controlled trials examined the effects of yoga for back pain and found that 20 studies reported positive outcomes in variables such as pain or psychological distress, including depression and anxiety, or energy. However, no significant difference in treatment effect on pain and disability was seen between yoga and physical therapy at 6 weeks. A 2018 report by AHRQ evaluated 8 trials of yoga for low-back pain (involving 1,466 total participants) and found that yoga improved pain and function both in the short term (1 to 6 months) and intermediate term (6 to 12 months). The effects of yoga were similar to those of exercise. A systematic review supporting the 2017 American College of Physicians clinical practice guidelines evaluated 14 randomized controlled trials and found that yoga was associated with lower pain scores, although the effects were small and were not always statistically significant. A 2017 Cochrane review of 12 trials involving 1,080 participants found low- to moderate-certainty evidence that yoga compared to nonexercise controls results in small-to-moderate improvements in back-related function at 3 and 6 months. Yoga may also be slightly more effective for pain at 3 and 6 months, however the effect size did not meet predefined levels of minimum clinical importance. A 2017 randomized controlled trial involving 320 predominantly low-income, racially diverse adults showed that yoga and physical therapy offer similar pain-relief and functional benefits to people with low socioeconomic status who had chronic low-back pain. These improvements were greater than self-education; however, they were not considered significant.

 Nutritional Approaches

• Herbal supplements may contain dozens of compounds and all of the ingredients may not be known.
• Some herbs can interact with medications. For example, taking capsicum (cayenne) might lower blood sugar levels. Taking capsicum along with diabetes medications might cause blood sugar to drop too low.
• Some herbs can cause serious side effects. For example, comfrey can cause liver toxicity.
• Very high levels of vitamin D (greater than 375 nmol/L or 150 ng/mL) can cause nausea, vomiting, muscle weakness, confusion, pain, loss of appetite, dehydration, excessive urination and thirst, and kidney stones. Vitamin D may interact with some medications, including statins, steroids such as prednisone, and thiazide diuretics. 

Psychological and/or Physical Approaches

• 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 or thrombocytopenia, as well as 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.
• 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. 
• 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.
• Tai chi is generally considered safe. It may lead to minor aches and pains but is unlikely to cause serious injury.

Psychological and/or Physical Approaches

• Acupuncture. A 2018 Agency for Healthcare Research and Quality systematic review of noninvasive nonpharmacological treatment of chronic pain concluded that exercise, low-level laser, Alexander Technique, and acupuncture improved function and/or pain rating for at least one month. A 2018 update to a 2012 meta-analysis (39 randomized controlled trials with 20,827 patients) concluded acupuncture is effective for the treatment of low-back pain, with treatment effects lasting over time. 
• 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. 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 2012 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. The authors concluded that no recommendations for practice can be made at this time because the effectiveness of massage for neck pain remains uncertain.

Psychological and/or Physical Approaches

• 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.

• Side effects from spinal manipulation can include temporary headaches, tiredness, or discomfort in the parts of the body that were treated. A type of spinal manipulation that focuses on the neck has been linked to cervical artery dissections (CAD). The available evidence suggests that the incidence of CAD in people getting spinal manipulation is low, but patients need to be informed of this potential risk.
• The risk of harmful effects from massage therapy appears to be low. However, there have been rare reports of serious side effects, such as a blood clot, nerve injury, or bone fracture. Some of the reported cases have involved vigorous types of massage, such as deep tissue massage, or patients who might be at increased risk of injury, such as older people. 

Nutritional Approaches

• 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 2019 by the American College of Rheumatology as well as 2022 guidelines by the American Academy of Orthopaedic Surgeons recommend not using glucosamine or chondroitin for OA. 

• Herbs. A 2014 Cochrane review concluded that while a few herbs such as ginger, avocado-soybean unsaponifiables (ASUs), and the Ayurvedic herb Boswellia serrata, taken orally, may 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. 
• DMSO (Dimethyl sulfoxide) and MSM (methylsulfonylmethane) DMSO and MSM are two chemically related substances that have been used for OA, although little research has been done. A 2011 meta-analysis of 7 high-quality studies with 326 patients did not show significant reduction of pain. 
• SAMe (S-Adenosylmethionine). SAMe may be a treatment option for OA but the evidence about its effectiveness and safety is unclear. A 2009 Cochrane review of 4 trials with 656 participants that compared SAMe with placebo was inconclusive. 

Psychological and/or Physical Approaches

• Acupuncture. In a 2018 review, data from 10 studies (2,413 participants) showed acupuncture was more effective than no treatment for osteoarthritis pain, and data from 9 studies (2,376 participants) showed acupuncture was more effective than sham acupuncture. A 2019 overview of 12 systematic reviews suggested that acupuncture has more total effective rate, more short-term effective rate, and less adverse reactions than western medicine as a treatment for knee OA. The authors concluded that acupuncture may have some advantages in treating knee OA; however, some risk of bias and reporting deficiencies need to be improved. A 2014 Australian clinical study involving 282 men and women over age 50 showed that needle and laser acupuncture were modestly better at relieving knee pain from OA than no treatment, but not better than simulated (sham) laser acupuncture. The authors concluded that in people over age 50 neither laser nor needle acupuncture was more beneficial than sham for pain or function. 
• Massage therapy. A 2017 systematic review of 7 randomized controlled trials with 352 participants found low-to-moderate–quality evidence that massage therapy is superior to nonactive therapies for reducing pain and improving certain functional outcomes. A 2018 clinical trial of 222 adults with knee OA found that weekly massage improved symptoms such as pain, stiffness and physical function compared to light-touch and usual care. The researchers concluded the efficacy of symptom relief and safety of weekly massage make it an attractive short-term treatment option for knee OA. 
• Tai chi. A 2016 randomized, 52-week, single blind comparative effectiveness study involving 204 participants, found that tai chi produced beneficial effects similar to those of a standard course of physical therapy in the treatment of knee OA. A 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. 

Nutritional Approaches

• Glucosamine and chondroitin supplements may interact with the anticoagulant drug warfarin (Coumadin). Overall, studies have not shown any other serious side effects.
• Side effects of SAMe are uncommon and usually mild. However, little is known about the long-term safety of SAMe because most studies have been brief. SAMe may have special risks for people with bipolar disorder as it may provoke mania, and in those who are HIV positive or immunocompromised, it increases the risk of Pneumocystis carinii infection, by enhancing the growth of this microorganism. SAMe also may interact with drugs, including some antidepressants and the drug levodopa.
• Not all herbs have been studied or prepared in a consistent way. There is also a general lack of safety data available for many herbs.
• DMSO can cause digestive upset, skin irritation, and a garlic-like taste, breath, and body odor. 
• MSM can cause allergic reactions, digestive upsets, and skin rashes.

Psychological and/or Physical Approaches

• 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.
• 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.

Nutritional Approaches

• Omega-3 fatty acids. A 2018 systematic review and meta-analysis of 20 randomized controlled trials (717 participants in the intervention group and 535 participants patients in the control group) found that consumption of omega-3 fatty acids significantly improved 8 disease-activity–related markers. A 2017 review of 22 studies (956 total participants) that tested supplements of long-chain omega-3s found a favorable effect on pain in patients with RA.
• GLA (gamma-linolenic acid). There is some preliminary evidence that GLA may be beneficial for RA; however, the quality of the studies on GLA has been inconsistent. 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.

Psychological and/or Physical Approaches

• Acupuncture. Acupuncture has been studied for a variety of pain conditions, but very little acupuncture research has focused on RA. A 2018 review of 7 systematic reviews included 20 studies, which were randomized controlled trials. Of those, only two randomized trials evaluated if acupuncture was superior to sham acupuncture. The researchers concluded the use of acupuncture probably has little or no impact on RA. 
• Massage. A 2017 systematic review of 7 randomized controlled trials with 352 participants found low-to-moderate–quality evidence that massage therapy is superior to nonactive therapies for reducing pain and improving certain functional outcomes. The authors concluded that more rigorous randomized controlled trials are needed. A single study with 42 participants, conducted in 2013, indicated that moderate pressure massage therapy may reduce pain and increase grip strength in people who have RA that affects their arms and shoulders.
• Mindfulness, biofeedback, and relaxation training. A 2017 review of three randomized controlled trials found that although there is increasing evidence linking the practice of mindfulness techniques to improved immune function, there haven’t been enough large, high-quality studies to determine long-term effects in rheumatic disease. A 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 were 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 2019 Cochrane review of 7 controlled trials with a total of 345 participants (mostly women with RA) concluded that it is uncertain whether tai chi has any effect on clinical outcomes (joint pain, activity limitation, function) in RA, and important effects cannot be confirmed or excluded, since all outcomes had very low‐quality evidence. 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 follow-up; 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 2018 meta-analysis of 13 trials involving a total of 1,557 participants with knee osteoarthritis and rheumatoid arthritis found that regular yoga training was helpful in reducing knee arthritic symptoms, promoting physical function, and general wellbeing in arthritic patients. A 2017 review of two studies found some beneficial effect on pain, but due to the high risk of bias in both studies, the reviewers gave a weak recommendation for yoga in rheumatoid arthritis. 

Nutritional Approaches

• 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.
• 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.

Psychological and/or Physical Approaches

• 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.
• Mindfulness, biofeedback, and relaxation training are generally considered to be safe. 
• 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. 

Psychological and/or Physical Approaches

• Acupuncture. A 2021 review of 5 studies (189 patients) found acupuncture may be an effective and safe treatment for pain relief in palliative care of cancer patients. A 2022 meta-analysis of 9 randomized controlled trials involving 592 breast cancer patients showed that acupuncture can relieve the pain caused by aromatase inhibitors. A 2022 systematic review of 33 trials of 3,002 lung cancer patients showed acupuncture significantly improved some quality-of-life symptoms, including pain, compared with the control group. A 2020 systematic review of 31 randomized controlled trials with a total of 2,031 patients found acupuncture and/or acupressure were associated with reduced cancer pain and decreased use of analgesics, although the evidence level was moderate. 
• Hypnotherapy. A 2022 systematic review and meta-analysis of 8 studies involving 1,242 patients with breast cancer undergoing surgery found that hypnosis before surgery reduced the degree of preoperative anxiety and postoperative pain. A 2007 study of 200 patients scheduled to undergo excisional breast biopsy or lumpectomy found that those who were randomly assigned to 15-minutes of presurgery hypnosis required less propofol and lidocaine than patients in the control group. 
• Massage. A 2016 systematic review and meta-analysis of 16 studies of 1,247 patients with cancer showed that massage therapy is effective for treating pain compared to no treatment and active comparators. In 2020, a small randomized controlled trial of 42 patients with breast cancer undergoing breast reconstruction compared massage only to massage with acupuncture for reducing post operative stress, pain, anxiety, muscle tension, and fatigue. The researchers concluded no additional benefits were seen with the addition of acupuncture to massage for pain, anxiety, relaxation, nausea, fatigue, and mood. Further, the combination of massage and acupuncture was not as effective in reducing stress as massage alone, although both groups had significant stress reduction. 

Psychological and/or Physical Approaches

• 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.
• Hypnosis is considered safe when performed by a health professional trained in hypnotherapy. Self-hypnosis also appears to be safe for most people. There are no reported cases of injury resulting from self-hypnosis.
• Massage therapy and reflexology appear to have few risks if it is used appropriately and provided by a trained massage professional.