Complementary and alternative medicine (known as “CAM”) covers medical  treatment that falls outside of mainstream/conventional healthcare.

The US National Center for Complementary and Integrative Health uses this distinction:

• when a non-mainstream practice is used together with conventional medicine, it’s considered “complementary“
• when a non-mainstream practice is used instead of conventional medicine, it’s considered “alternative”.

Often, both conventional and complementary and alternative medicine approaches are used side by side  to treat diseases – this approach is called “Integrated medicine”.

A variety of CAM treatments  have been suggested to help patients with musculoskeletal disorders and CAM enjoys popularity amongst  patients with musculoskeletal issues.

However, the availability of CAM on the NHS is limited and  generally the NHS does not provide CAM  therapies. Some private  health insurers may cover CAM treatments.

Are they completely safe?

It is a misconception that CAM therapies are completely natural and harmless, as CAM products can be dangerous due to many factors, including contaminants,  interactions with other medications and products and direct side effects.

Many CAM therapies are considered relatively safe, although you should always talk to your doctor before you start a CAM treatment. There are some risks associated with specific therapies, e.g. some herbal therapies may have significant side-effects or may interact with prescribed and other medication and affect various blood tests. The  risks that can associated with a CAM may be due to the therapist rather than the therapy. This is why it’s important for you to go to a legally registered qualified therapist, whose profession has an ethical code and who is fully insured.

Versus Arthritis recommend you consider several key points if  you’re considering using CAM:

• What am I hoping to achieve? e.g. pain relief, energy, improved sleep
• Who is the therapist? Are they qualified, registered and insured?
• Am I happy with the therapy and will I realistically be able to use it ?
• Are there any risks? Are they safe?
• What are the financial costs?
• Is there any evidence for their effectiveness?

CAM Therapies of NO clinical benefit

Copper bracelets. Copper bracelets can be bought online in the hope they reduce  symptoms of arthritis. Studies  involving osteoarthritis and  rheumatoid arthritis patients found that copper bracelets worked no better than dummy devices (placebos). The use of copper bracelets may cause  rashes, skin discoloration and  irritation.

Magnets. Magnetic fields are caused by placing magnets on the skin or by incorporating them into jewellery, belts or shoes. There’s scant evidence that magnet therapy is effective, and stronger magnets can adversely affect electronic devices and medical devices such as pacemakers.

Homeopathy. This  has not been found to be of value for musculoskeletal disorders.

Therapies with limited but inadequate or inconsistent evidence

Acupuncture.  Acupuncture involves having thin needles inserted into the skin in different places. The needles usually do not hurt, or they hurt very little. However, it is not a risk-free treatment. Acupuncture has not been found to be effective in patients with Rheumatoid Arthritis, and a few well-designed clinical trials have found that both acupuncture and sham acupuncture are more effective than standard treatments for low back pain, suggesting a strong placebo effect. In patients with knee osteoarthritis, the improvement in studies have been too small to be clinically meaningful.

Ayurveda.  Ayurveda is an ancient Indian medical system utilizing a variety of products and practices. Some Ayurvedic mixtures have been studied in osteoarthritis and Rheumatoid Arthritis, but satisfactory evidence of efficacy was not shown.

Cannabis and cannabinoids.  The use of cannabis and cannabinoids for chronic pain is controversial and studies have given mixed results in the management of  chronic pain. The  rate of side effects is high and there are concerns about standardisation of the dose and compound between various products.

Diet and nutritional therapies.  Food, diet, and nutrition have been of considerable interest  for millennia.

Dietary interventions do not have a clear role in therapy for most patients with chronic inflammatory or autoimmune musculoskeletal disease. An exception arises  in  patients with gout where dietary consumption of  specific foods and drinks  are well established as risk factors, the  modification of which  can affect  the course of disease.

Obesity has been associated with higher disease activity in inflammatory arthritis as well as a poor response to medications so obese patients should attempt to lose weight.

The gut microbiome is a topic of increasing interest, and it’s thought that the balance of certain organisms that live normally in our gut may influence the development of rheumatic disease, although it remains to shown whether this is a cause or effect.

There is no compelling evidence that any diet other than a healthy, balanced one is consistently helpful to patients with arthritis. A ‘Mediterranean diet’ is associated with a lower risk of developing Rheumatoid Arthritis. Compared to a typical ‘Western’ diet, a Mediterranean diet derives fewer calories from animal fat and involves eating less red meat and processed foods, focusing more on poultry, fish, fruit, vegetables, wholegrain cereals, olive oil, peas and beans, nuts and seeds.

Nutritional supplements

Nutritional supplements e.g. oral zinc, L-histidine, vitamin C  have been reported to be helpful for patients with arthritis, but the evidence supporting their use is lacking.

Glucosamine and chondroitin sulfate.  These supplements have been the subject of many trials, which have given conflicting results in knee osteoarthritis,  although there is some evidence that their use may delay the progression of knee osteoarthritis.

Chondroitin is found naturally in the body and is an important part of cartilage, giving it elasticity by helping it retain water.

Glucosamine is made from shellfish or prepared in the laboratory. It’s widely available over the counter as glucosamine sulphate and glucosamine hydrochloride. Side-effects, which are usually mild and infrequent, include stomach upsets, constipation, diarrhoea, headaches and rashes. Glucosamine shouldn’t be taken by people who are allergic to shellfish, although shellfish free options are available.  There have been cases of it interacting with  diabetic medication and control of diabetes. It also may interact with chemotherapy and cholesterol lowering drugs.

Evening Primrose oil. This  is rich in polyunsaturated omega-6 fatty acids that play a part in the control of pain and inflammation. Evidence for its use in  reducing joint pain in rheumatoid arthritis isn’t conclusive, but it may help reduce stiffness.

Herbal remedies

These are usually taken as  pills that  contain substances derived from  plants. Even though herbal remedies are natural, they are not always safe. Plants sometimes have chemicals that can damage the  body or cause problems when used along with regular medicines

Curcumin (Turmeric)  Turmeric is a plant native to southern Asia. It’s widely grown both for culinary and medicinal purposes. Some studies suggest Turmeric  has anti inflammatory and analgesic properties. You can buy ground Turmeric over the counter. We don’t know yet whether it’s effective in osteoarthritis as there’s only limited  evidence from  studies so larger trials are needed to determine the clinical relevance of these findings. It appears to only have minor side-effects.

Boswellia serrata. Boswellia serrata is a plant extract and may help relieve pain, stiffness, and function but the studies evaluating it have been of poor quality.

Capsaicin. This is extracted from chilli peppers and is  available on prescription as  gel, cream and plasters. It works mainly by its ability to reduce Substance P, a pain signal transmitter. It has no major safety problems and can help in hand and knee osteoarthritis.

Green tea extract. This has been evaluated in patients with Lupus, but high doses have been linked to liver damage.

Other  herbal supplements including blackcurrant, feverfew (from sunflowers) and green-lipped mussel extract  have been studied in patients with rheumatoid arthritis but they did not yield any clinical improvement,

Other herbal preparations have been promoted as treatments for osteoarthritis but the studies have not shown unequivocal benefit ginger extract, willow or pine  bark, Rose hip, nettle, Devil’s claw.

Massage.  Massage involves rubbing or kneading muscles and joints to relieve pain and tension. Some side-effects have been reported, although these are mostly minor, and it’s considered safe. A small beneficial effect of whole-body massage was suggested in small study of patients with knee  osteoarthritis. While there’s only a little evidence that massage is effective in osteoarthritis, there’s consistent evidence from a number of trials to suggest that it’s effective in treating some of the symptoms of fibromyalgia and low back pain.

Therapies that haven’t  been studied

Several possible CAM treatments currently lack scientific evidence of benefit and neither have the nature of their side effects been properly evaluated e.g.  shark cartilage, ginger root.

Therapies thought to be of proven value

Exercise.  Exercise is widely accepted as part of a comprehensive management program for most patients with arthritis,  for physical and mental health benefits.

Fish and botanic oils. Fish and botanic oils seem to exert their beneficial effects through their impact on inflammation pathways and might improve clinical outcomes in patients with inflammatory arthritis when used in conjunction with standard treatments.

There are two types of fish oil:

fish body oil (from fatty fish tissue) and

fish liver oil (from pressed fish livers).

Fish body oil and fish liver oil are rich in omega-3 essential  fatty acids, which are involved in the regulation of the body’s immune system and joint inflammation. Fish liver oil is also a rich source of vitamin A.

Side-effects at recommended doses are usually minor and uncommon. The most common is stomach upsets.  It’s important not to take large amounts of fish liver oil because you may exceed the recommended dietary allowance of vitamin A and this in turn, can lead to  liver problems and hair loss. Fish liver oil and vitamin A supplements should be avoided during pregnancy.

Useful resources

https://www.nhs.uk/conditions/complementary-and-alternative-medicine

https://www.versusarthritis.org/about-arthritis/complementary-and-alternative-treatments/what-are-complementary-and-alternative-treatments

https://www.versusarthritis.org/media/1337/complementary-and-alternative-medicines-report.pdf

https://www.versusarthritis.org/media/12780/complementary-and-alternative-therapies-report-2013.pdf

https://www.versusarthritis.org/media/23186/eating-well-with-arthritis-information-booklet.pdf