Alternatives Therapies for RA

Complementary and Alternative Medicine (CAM), a collection of medical interventions or treatments that lie beyond the scope of allopathic or mainstream Western medicine, have become more widely accepted. CAM services are provided by specialists who have been trained in different treatment modalities not typically covered in medical school. Practitioners of CAM modalities may or may not be certified in their area of expertise. Most CAM treatments have not been systematically evaluated in randomized, controlled clinical trials (RCTs). Therefore, it is often difficult to determine the effectiveness and safety of some CAM treatments. Examples of CAM modalities which have gained wide social acceptance include yoga, herbal supplements, acupuncture, meditation, and chiropractic care.

Various CAM treatments are commonly used by people with arthritis and other conditions affecting the joints. For example, one study conducted in 2007 found that adults in the US used CAMs most often to treat musculoskeletal problems, including back pain, neck pain, joint pain or stiffness, and other joint conditions such as arthritis. The most popular CAMs used included natural products (herbal and other supplements, deep breathing, meditation, and chiropractic care.1

The US National Institutes of Health (NIH) has categorized Complementary and Alternative Medicine into four main groups, as shown in the table below, including biologically-based treatments, alternative medicine systems, mind-body medicine, and manipulative and body-based treatments.1,2

 

Complementary and alternative medicine: NIH categories

Category
Interventions
Biologically-based treatments
  • Diet-based therapies (eg, vegetarian, macrobiotic, Mediterranean, vegan)
  • Vitamins, minerals
  • Natural products (eg, herbal and other non-vitamin, non-mineral supplements)
Alternative medicine systems
  • Acupuncture
  • Traditional Chinese medicine
  • Ayurveda
  • Homeopathy
  • Naturopathy
  • Traditional healing
Mind-body medicine
  • Biofeedback
  • Hypnosis
  • Guided imagery
  • Meditation
  • Deep breathing
  • Music therapy
  • Prayer and spirituality
  • Yoga, Tai Chi
  • Energy field therapies (eg, qi gong, Reiki)
Manipulative and body-based systems
  • Chiropractic
  • Osteopathic
  • Massage
  • Movement therapies (Feldenkreis, Pilates, Trager)
  • Electromagnetic therapy
  • Physiotherapy (heat and cold, electrical nerve stimulation, hydrotherapy)

 

What do the terms ‘complementary’ and ‘alternative’ refer to?

CAM approaches can be divided into two broad groups,  those that are complementary, or used alongside conventional medical treatments, and those that are alternative, or used instead of conventional treatments. Some complementary approaches, such as dietary interventions, are commonly recommended by physicians to promote general health in complement to prescribed medications or treatments. Alternative approaches, which replace conventional medicine, are less common in the US and have not been rigorously studied. Integrative medicine is another term which refers to treatments provided by physicians or medical centers that combine allopathic and alternative or complementary medicine. As healthcare evolves, the distinction between different categories of care begins to blur.

 

Importance of letting your doctor know about CAMs

You may be hesitant to discuss a CAM intervention that you are using or interested in trying with your doctor. However, you should always let your doctor know about ALL the treatments you are considering, including supplements, vitamins, herbal products, body work, and alternative medicine approaches. It is important for your care team to have a complete picture of the treatments you are using. This is especially true with substances that may react inside your body with the drugs that you are taking. So, keep your doctor in the loop about any and all treatments you are trying.

 

Why is there so much disagreement about the benefits of certain CAMs?

The gold standard in testing the effectiveness and safety of any medication used to treat a disease, including treatments for RA, is the randomized, controlled clinical trial (RCT. Typically, an RCT compares a medicine or treatment with a placebo which is often an inert pill containing no medicine or, in the case of an injection or infusion, a liquid such as a saline solution. In a clinical trial, the comparison between a treatment and placebo is made in groups of patients who are randomly assigned to receive either the drug or placebo. If the groups are large enough and the effects of the test medication are strong enough, a statistically significant difference in the effectiveness of the medication versus the placebo.

This statistical difference demonstrates that a medication works. Just to make sure that the results of one study are not a fluke, multiple RCTs that replicate or repeat the results are typically needed. For many CAMs, there have not been sufficient well-designed studies including enough people to determine with any confidence that the CAM being studied works. (This is not true for all CAMs, so check individual treatments to see what the study results show.)

RCTs are needed to provide evidence that there is a real difference in effectiveness between a medication or placebo to avoid the placebo effect. Placebo effect is something that is seen in studies, where a certain percentage of patients who get placebo instead of active treatment will experience an improvement. It may be their belief that they are receiving real treatment, or their confidence in their doctor, or just the power of positive thinking, but results from studies show that in some patients, placebo treatment results in a real, measurable health improvement.

Because of placebo effect and because of the rising popularity of CAMs, the US NIH established the National Center for Complementary and Alternative Medicine (NCCAM) to promote the systematic study and dissemination of study results of various CAM approaches.

 

How can I tell if claims about a CAM are trustworthy?

There are many CAM approaches that provide clear benefits for people with RA. While these approaches may not be effective in the same way disease-modifying anti-rheumatic drugs (DMARDs) are in terms of slowing or preventing the progression of joint damage, they may contribute positively to your general health and well-being. Here are some principles that you should follow if you are considering a CAM.

 

Principles to keep in mind when considering CAMs

Be skeptical
  • If it sounds too good to be true, it probably is
Look for scientific evidence of efficacy and safety
  • If you have not read about it in the scientific literature, it is not scientifically validated
  • It is especially important with CAMs to determine whether the treatment is proven safe: there are many instances in which supplements (herbal or chemical) can do considerable harm
Beware popular claims
  • If you first heard about it from the media, it is not scientifically validated
Beware of the word “Breakthrough”
  • To date, there have been no “breakthroughs” in RA linked to CAM therapies
Ask “why?” before you ask “why not?”
  • It is important to make your treatment decisions on the basis of scientific evidence (including proof of efficacy and safety)
  • So, always ask about what evidence supports a treatment, rather than just trying something for the sake of trying it

Adapted from Panush RS. Complementary and alternative remedies in rheumatic disorders.  In: Furst DE, Romain PL, eds. UptoDate. Wolters Kluwer Health. Accessed at: www.uptodate.com. 2013.

Written by: Jonathan Simmons | Last reviewed: September 2013.
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