Arthritis alternative
Patients taking alternative medicine treatments for arthritis are much more likely than previously thought to be discussing the alternative therapy with their physicians, according to a new study. In addition, very few are afraid their doctors will disapprove. "The literature would have you believe that most patients won't tell the doctor," said Dr. Jaya K. Rao, lead author of the study of more than 200 arthritis patients in six different clinical settings in Indianapolis.
However, the study found that many patients were concerned about potential interactions between conventional medicines and alternative treatments, such as herbs or large doses of vitamins.
"People would want to know, 'Is this going to interact with the therapies that I'm taking?'," said Rao, whose findings were published in the Sept. 21 issue of the Annals of Internal Medicine, a Philadelphia-based medical journal.
Dr. Robert C. Atkins, the founder of the Atkins Center for Complementary Medicine and an advocate of alternative medicine, said he doubts that patients would be as open about talking to their doctors about alternative treatments for other conditions.
"The perception is, 'My oncologist wouldn't want to hear anything about alternative treatments for cancer,"' Atkins said.
Herbs sold in health-food stores to treat arthritis are being used widely, he said. "When it's something that has gained fairly widespread acceptance, they're all too willing to talk about it," Atkins said.
Dr. Michael Janson, the president of the American College for Advancement in Medicine in Laguna Hills, Calif., agreed with Atkins. "Cancer is somehow more of a hot-button issue for doctors because there is very little that does treat it well," including alternative medicine, Janson said. He said conventional treatments work well for a few types of cancers but for many types, no treatment is a good cure.
But Janson said that is no reason for conventional doctors to speak ill of alternative treatments. "If you don't have anything better to offer, you really should be cautious about making remarks that demean the other treatment," he said.
Rao's study examined 232 patients who saw rheumatologists at six different clinical settings in Indianapolis: a municipal hospital that cares for the poor, a veterans' hospital, a fee-for-service specialty-care practice and three private rheumatology practices. It found that about two-thirds of the patients had used some form of alternative medicine at least once.
"I think what most surprised us was that 56 percent of the two-thirds were using it at the time of the survey," Rao said. Another surprise was that many were using multiple forms of alternative medicine. The study found that 24 percent had used at least three different forms of alternative treatment. Of those who did not tell their doctor about the alternative treatments, only 15 percent said it was because they feared the doctor would disapprove, the study found. It also found 55 percent said the doctor did not ask and 49 percent said they meant to tell the doctor but forgot.
Among those who did tell their doctor, 71 percent said their doctors told them it was acceptable to keep using the alternative treatments, while 14 percent said their doctors told them to stop.
The study also found that college-educated patients were more likely to use alternative treatments than those without degrees. Rao said she did not know for certain why this would be so, but said, "They might have more access to other kinds of information." For example, more educated people might be reading more about alternative treatments on the Internet.
Atkins said it was also his experience that more educated people turn to alternative medicine.
"It is a very intelligent and knowledgeable decision to scrutinize what all of your options are," Atkins said, adding that college-educated people are more likely to have that intelligence and knowledge.
One limitation of the study was that it did not examine the attitudes of people who rely exclusively on alternative healing and avoid physicians altogether. Rao said she did not know of any studies conducted on such people.
The most common complementary and alternative remedies are discussed below
Acupuncture, a part of Traditional Chinese Medicine (TCM), has been around for thousands of years, but only recently has been introduced to the American public as a possible treatment for disease. Acupuncture appears to be a safe method of pain relief for osteoarthritis, and may give even greater pain relief when combined with NSAIDs or narcotics. However, patients should be sure to consult a reputable physician who practices this art. Honey bee venom therapy (BVT), has been anecdotally used for treatment of a variety of conditions, including osteoarthritis. It involves either having an actual bee placed near a painful joint and stinging the patient or injecting purified bee venom near the joint. Bee venom contains phospholipase A and melittin, as well as hylauronidase, apamin, mast cell-degranulating peptide, and adolapin. It has been shown to inhibit neutrophil superoxide and hydrogen peroxide formation, which has been postulated to garner an anti-inflammatory effect by inhibiting oxygen free radial formation. Rat studies in adjuvant-induced arthritis show improvement in symptoms with BVT, but this would provide tenuous support for rheumatoid arthritis, not osteoarthritis treatment. The most severe effect is anaphylaxis, given that some individuals are allergic to bee stings. Anyone engaging in this type of therapy should have an Epi-pen within reach in case an allergic reaction begins. BVT, apart from simple anecdotal evidence, has no research to support its use in osteoarthritis, especially given the wide variety of clinically proven traditional Western and alternative therapies available. Given the serious risks of anaphylaxis, including death, BVT should be avoided. Used for many years in Germany and other parts of Europe, glucosamine has rapidly gained popularity in the United States. Recent research supports its effectiveness. A study of more than 200 patients with osteoarthritis published in the British journal Lancet in January 2001 reported that people treated with glucosamine had fewer symptoms and exhibited less progressive damage on X-rays than did people treated with placebo. Some experts believe, however, that the improved X-ray findings resulted from flawed radiology techniques. Although glucosamine's effect on joint damage is still debated, many medical experts believe this supplement reduces pain and is safe. The usual dose is 500 milligrams three times a day. Twice this amount may be recommended for the first few weeks. It may take four to eight weeks to get significant benefit, and like most remedies, glucosamine does not work for everyone. Consider stopping after eight to 10 weeks if you do not experience any improvement. Two other supplements on the market, chondroitin and S-adenosylmethionine (SAM-e), are not as well studied or accepted in the United States as glucosamine. Most studies of these agents are of insufficient quality to draw firm conclusions. One study of SAM-e found the agent to have similar benefits as naproxen (Naprosyn, Aleve), used to relieve pain and inflammation. DMSO and MSM are two common substances that are available commercially for the treatment of osteoarthritis. Notably, MSM is an oxidation product of DMSO and is therefore closely related to it.
DMSO was originally created in the 1800's, but had little use until the 1940's, where it became popular as an industrial solvent. Used in the 1960's for a veterinary ointment as well as a popular "cure all", it is today used only as a treatment for interstitial cystitis (bladder infection) in an FDA-approved method. DMSO today is also found in paint thinners and antifreeze, and is NOT available in a preparation suitable for human use (except by prescription as above); it is only available in industrial form and is therefore impure. It has been postulated that DMSO may increased free radial scavenging and reduce prostaglandin production, but this has only been shown to work in vitro, not in vivo. In addition, animal models may show reduced C fiber nerve conduction, which would then increase analgesia. Regardless, there is scarce laboratory evidence of anti-inflammatory or immunomodulatory effects Two studies of DMSO for treatment of a wide variety of conditions were done in the 1960's and published in the Annals of the New York Academy of Sciences. Neither of these trials had standardized outcomes and overall were poorly designed.
MSM is an oxidation product of DMSO and is therefore postulated to have many of the same properties as DMSO. MSM is synthesized from DMSO and is available in many commercially prepared compounds. MSM may have similar properties to DMSO, but does not have the possible free-radial scavenging effects of DMSO; regardless, there is scarce laboratory evidence of anti-inflammatory or immunomodulatory effects. MSM was studied in one trial conducted by RM Lawrence in The International Journal of Anti-Aging Medicine, which was placebo controlled, and pain reduction was 80% at six weeks in the MSM group and 18% in the placebo group. The dose of MSM was 1225 mg twice per day. The adverse effects seen with DMSO (used topically) is skin redness and warmth, which may be severe. Also, even with topical use, one may develop a foul taste in the mouth and a body odor similar to garlic or oysters. MSM's adverse effects include gastrointestinal upset and diarrhea.
DMSO is only available in industrial grade solutions, and, given the paucity of data on it along with possible impurities, it should be avoided. MSM requires more long-term and laboratory data to determine its exact effects, and therefore should not be used until more data are made available Some herbs, including evening primrose, ginger, stinging nettle and curcumin, are sold as remedies for arthritis pain, but there is not enough evidence to support their use. Always discuss the use of herbs or other supplements with your doctor to check for interactions and side effects. Before seeking an herbal therapy practitioner, first consult with your doctor. Another source of information is the National Center for Complementary and Alternative Medicine. Search their Web site to find research centers at universities and medical schools throughout the United States that are conducting studies on complementary and alternative therapies. Try to find the name of a researcher near you who is conducting an herbal study; find out if that person provides guidance to patients as well. Homeopathy is based on administering tiny (often undetectable) amounts of a substance that in higher doses might cause symptoms or disease in healthy persons. Scientific evidence of benefit is lacking. A recent review in a British homeopathic journal identified only four methodologically sound studies and concluded that the available studies "do not allow a firm conclusion as to the effectiveness of homeopathic remedies in the treatment of patients with osteoarthritis." Evidence that antioxidant vitamins can prevent arthritis is lacking. Fish oil capsules (containing omega-3 fatty acids) may decrease pain and swelling in some people with rheumatoid arthritis. Fish oil for osteoarthritis cannot be recommended. Omega-3 fatty acids have other health benefits, most notably related to heart disease. Fish that are especially rich in omega-3 fatty acids include salmon, mackerel, herring and sardines. But there is no proof that eating more fish to treat rheumatoid arthritis makes any difference. Acupuncture is an ancient Chinese practice. By inserting hair-fine needles into the skin along defined tracts called meridians, practitioners believe they can stimulate the flow of "qi," or vital life energy. Acupressure and shiatsu, a Japanese form of acupressure, use no needles. Instead intense local pressure is applied to certain points on the body. Although medical experts do not understand how acupuncture and acupressure work, some people experience less joint pain with these techniques. A large National Institutes of Health-funded multisite clinical trial will evaluate the efficacy, safety and cost-effectiveness of acupuncture for osteoarthritis. Magnet therapy has gained popularity, but again the scientific evidence of its benefit is lacking. Magnets are sold in various strengths, but there is no proof that one strength is better than the next. Or if any strength magnet really helps. A word of caution, keep them away from your computer! Efforts to find food allergies that cause arthritis have not yielded definitive results. The most common approach is to eliminate vegetables from the nightshade family: white potatoes, tomatoes, peppers and eggplant. Tobacco also belongs to this family. (Of course, there are more compelling reasons to avoid tobacco than its effect on arthritis.) Some people with arthritis also feel that dairy products aggravate their symptoms. If you suspect food allergies may be affecting your arthritis (for example, if your symptoms become worse after you eat certain foods), keep a record of what you eat for several weeks, along with notes about your arthritis symptoms. Eliminate from your diet foods that seem to cause trouble; after a period of time, gradually reintroduce these foods one at a time, noting any change in symptoms. Research-based evidence on the value of this approach is lacking, but diet therapy still may be worth a try. Exercise and weight control are among the most effective self-help measures for alleviating the symptoms of osteoarthritis (and perhaps other types of arthritis). The objective is to improve or maintain cardiovascular fitness, range of motion and muscle tone while avoiding excessive stress or injury to joints. Walking, biking, cross-country skiing and swimming are the best choices. Water offers support and gentle resistance; if possible, water temperature should be 83 to 88 F or warmer. In one study, 33 adults with arthritis reported being better able to manage their disease symptoms and enjoyed better health after a three-month tai chi program; another study found improved balance and abdominal muscle strength. Other studies of moderate, low-impact exercise have suggested a benefit in arthritis symptoms. Guidelines for appropriate exercise may be obtained from the Arthritis Foundation (800-283-7800). If you have arthritis, consider setting up an exercise program with the advice of a physician or physical therapist. He or she can also suggest effective weight control measures if needed. Many arthritis sufferers find that warm showers and baths -- particularly whirlpool baths -- are often helpful in reducing pain and stiffness, especially first thing in the morning. For arthritis in the hands, the simple act of squeezing a sponge in a basin or sink full of warm water provides gentle exercise and relief of stiffness. Warm, wet compresses, especially castor oil compresses (available where specialty health products are sold), may provide comfort for sore joints. Helpful suggestions abound in books and magazines and on the Internet about joint-sparing techniques for ordinary activities. For example: Pick up a coffee cup with both hands instead of thumb and finger. Massage by an expert in therapeutic massage can contribute to an overall feeling of relaxation and well-being. There are many types of massage, including Western, Swedish, deep-tissue and neuromuscular. A massage therapist can teach you some do-it-yourself techniques. Massage therapists are required to be licensed in at least 28 states and the District of Columbia. You can find a qualified practitioner by asking your physician or by contacting a professional massage therapy association. Yoga originates with the teachings of Patanjali, an eastern philosopher who stated that health is achieved through harmony of mind, body, and spirit; yoga then prepares the body for spiritual cleansing through balanced body positions. In Westernized yoga, the focus is on strength, flexibility, and relaxation, not necessarily the Eastern ideals. In one randomized controlled trial (i.e. a good study) conducted by Garfinkel, et al in The Journal of Rheumatology, yoga performed for hand osteoarthritis regularly for 10 weeks yielded statistically significant decreases in finger joint tenderness, range on motion, and hand pain with activity. Notably, this study was very small (30 patients total) and lacked an active intervention control (i.e. "sham yoga"). Adverse effects are rare, but cervical spine movements at the extremes of the neck range of motion have been noted to cause various neck artery occlusions. Anyone starting a new exercise program should be thoroughly evaluated by their physician; those with osteoarthritis should make special note to tell the physician which joints are affected and what exercises they are doing that may affect these joints. Cervical spine extreme movements should be avoided as outlined above. Special caution should be used for bikram yoga (done in a very hot room) for those with heart conditions or previous heat cramps or heat stroke.
Like any person with a chronic disease, a person with osteoarthritis may be more prone to depression. You may worry about becoming increasingly unable to perform activities of daily living or doing things you enjoy. The capacity to adapt, cope and continue full function varies greatly among patients. Some patients feel disabled by their symptoms, but only a very small percentage will ever become severely disabled. A positive outlook, focusing on what you are able to do rather than what you are unable to do, can be immensely helpful. Some people find that meditation and other stress-reduction techniques help them to relax and better adjust the pace of their lives to the limitations imposed by their arthritis. Recognize that for many unproven approaches, uncertainty about benefit and risk must be accepted before pursuing treatment. For example, small studies may find benefit for a particular approach, but if the patients in the study were highly selected (for example, taking no other medications and having no other major health problems besides their arthritis), that same approach may not work for others. A particular source of concern is that the treatment may interact with another medication, something the small studies cannot predict. Finally, keep in mind that herbs and supplements such as glucosamine are not regulated by the Food and Drug Administration; active ingredients, purity and quality may vary greatly. Studies now underway should shed light on which treatments are helpful and which are a waste of time, money and faith. In addition, the reasons a treatment may work -- including the possibility of a placebo effect -- may also be sorted out in the next few years when the results of carefully performed studies are published. Even if it turns out that patients are better because of a placebo effect (in which the expectation of benefit from an inactive treatment somehow induces improvement), learning how to harness that effect may prove highly useful and safe.
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