COMMENTARY

CAM for Arthritis: Is There a Role?

Nathan Wei, MD; Jonathan Kay, MD

Disclosures

September 25, 2013

In This Article

Editor's Note:
The Centers for Disease Control and Prevention estimates that up to 50 million US adults have some form of arthritis, including one half of those older than 65 years. With lifestyle modification and pharmacotherapies often only providing partial relief, many patients turn to complementary and alternative medicine (CAM) therapies, despite limited efficacy and safety data on many such approaches. Medscape recently asked rheumatologists Nathan Wei, MD, and Jonathan Kay, MD, to participate in the following email debate exploring what CAM data do exist and addressing the role of alternative treatments in the management of arthritic conditions.

Your Patient's Taking What?

Dr. Wei: My patients ask me about any number of CAMs on a daily basis. The ones they ask about most frequently are glucosamine sulfate/chondroitin sulfate, chiropractic, anti-inflammatory herbs, yoga, and acupuncture. 

The data on glucosamine sulfate/chondroitin sulfate are mixed, and its use remains controversial. Nonetheless, many patients continue to take it, and many report excellent outcomes. Although some assume the National Institutes of Health (NIH) GAIT trial[1,2] might have put the nail in the coffin of this preparation, after looking at the results of the study (particularly in the moderate to severe cases), I'm not so sure. I am probably not the best person to refute its benefits, because I take it myself -- hedging my bets, so to speak.

Chiropractic is a CAM that the American Medical Association called "snake oil" -- until a Supreme Court ruling came down in favor of the chiropractors. There's little question in my mind that chiropractic works, particularly for acute musculoskeletal pain. Also, chiropractors know musculoskeletal anatomy better than most rheumatologists.

The beneficial effects of anti-inflammatory herbs and supplements have been demonstrated in multiple studies.[3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43] Although these effects appear to be relatively modest, they seem to be effective.

Yoga is an excellent CAM that I would refer to as a "body/mind experience." In addition to flexibility, stretching, and breathing, there is also a mental aspect to it that seems to trigger endorphin release.[44] My wife got me into yoga 2 years ago, and I look forward to each session. It complements vigorous exercise, which I engage in regularly.

Acupuncture is another CAM that has its advocates. Although acupuncture has yielded mixed results in studies,[45,46,47,48] I think that it is helpful in some cases of musculoskeletal pain. In the hands of a skilled practitioner, acupuncture appears to be less toxic than the pharmaceutical alternative.

I know I haven't delved into other CAMs, but I think this is a good start.

Dr. Kay: Many of my patients also inquire about CAMs. Some patients new to my practice are already taking glucosamine sulfate/chondroitin sulfate, irrespective of their underlying diagnosis. Although it is more often recommended for patients with osteoarthritis (OA), many patients with rheumatoid arthritis (RA) also take glucosamine sulfate/chondroitin sulfate because it is advertised as a remedy for "arthritis," without mention of the specific type.

Recently, I saw a physician who works in medical research. Despite his regular adherence to evidence-based science and medicine, he told me that he takes glucosamine sulfate/chondroitin sulfate to treat degenerative arthritis of his fingers and that he has perceived an improvement in his symptoms since beginning to take this nutritional supplement.

As you point out, the NIH-sponsored GAIT trial demonstrated no significant benefit of glucosamine sulfate/chondroitin sulfate as a treatment to reduce pain in patients with symptomatic OA of the knee who had radiographic evidence of osteophytes.[1,2] However, a subgroup analysis of this large, well-designed, randomized, controlled clinical trial found this nutritional supplement to be significantly better than placebo in reducing pain among participants with moderate to severe pain at baseline. A limitation of this study was that it did not include patients with milder degrees of knee OA, among a greater proportion of whom one might expect glucosamine sulfate/chondroitin sulfate to be beneficial. Regardless, as for any medication, we cannot confirm its benefit until positive results have been achieved when studied directly in the population of interest.

A skilled chiropractor who performs appropriate manipulation to treat back pain might be as effective as some physical therapists. However, I am not aware of any large, well-designed clinical trials in which chiropractic treatment of back pain has been compared with conservative medical management using physical therapy modalities. There is little credible scientific basis to support chiropractic manipulation as treatment for systemic diseases, such as diabetes mellitus.

I am unaware of any well-controlled study of yoga in pain amplification syndromes, such as the fibromyalgia syndrome, or in other conditions that might be encountered by a rheumatologist. However, disciplined meditation and stretching exercises certainly would benefit patients with pain amplification syndromes.

Acupuncture has been shown to stimulate the release of endorphins into cerebrospinal fluid.[49,50] Thus, this traditional Chinese therapy triggers analgesia by a mechanism that has been validated using the scientific method.

Many patients eat cherries or take cherry extract to prevent and treat attacks of gout. A recent Internet-based study, published in Arthritis & Rheumatism in 2012, found that patients experienced fewer attacks of gout over a 2-day period during which they consumed more cherries or used cherry extract, compared with a 2-day period during which they did not.[51] Cherry consumption may have a urate-lowering effect, but this would not explain a reduction in acute attacks with short-term increased cherry intake. Cherries contain anthocyanins, which exert anti-inflammatory effects. Thus, there is a plausible scientific basis for the efficacy of this alternative approach to treating gout. However, until this therapy is subjected to a prospective, controlled clinical trial, its potential efficacy can only be surmised.

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