Alternative and Integrative Therapies for Musculoskeletal Problems

Strong Scientific Evidence:

Chondroitin: Multiple clinical trials have examined the use of oral chondroitin in patients with osteoarthritis of the knee and other locations (spine, hips, and finger joints). Most of these studies have reported significant benefits in terms of symptoms (such as pain), function (such as mobility), and reduced medication requirements (such as anti-inflammatories). The weight of scientific evidence points to a beneficial effect when chondroitin is used for six to 24 months. Longer-term effects are not clear. Preliminary studies of topical chondroitin have also been conducted.

Chondroitin is frequently used with glucosamine. Glucosamine has independently been demonstrated to benefit patients with osteoarthritis (particularly of the knee). It remains unclear if there is added benefit of using these two agents together compared to using either alone. Chondroitin is currently manufactured from natural sources (shark/beef cartilage or bovine trachea) or by synthetic means.

Glucosamine: Glucosamine is a natural compound that is found in healthy cartilage. Based on human research, there is good evidence to support the use of glucosamine sulfate in the treatment of mild-to-moderate knee osteoarthritis. Most studies have used glucosamine sulfate supplied by one European manufacturer (Rotta Research Laboratorium), and it is not known if glucosamine preparations made by other manufacturers are equally effective. Although some studies of glucosamine have not found benefits, these have either included patients with severe osteoarthritis or have used products other than glucosamine sulfate. More well-designed clinical trials are needed to confirm safety and effectiveness and to test different formulations of glucosamine.

Avoid if allergic or hypersensitive to shellfish or iodine. Some reports suggest a link between glucosamine/chondroitin products and asthma. Use cautiously with diabetes or with a history of bleeding disorders. Avoid if pregnant or breastfeeding.

Willowbark: Willowbark (Salix alba) contains salicin and has been used to treat many different kinds of pain. Willow bark is a traditional analgesic (pain relieving) therapy for osteoarthritis and musculoskeletal disorders. Several studies have confirmed this finding. Additional study comparing willow bark to conventional medicinal agents for safety and effectiveness is warranted.

Avoid if allergic/hypersensitive to aspirin, willow bark (Salix spp.), or any of its constituents, including salicylates. Use cautiously with gastrointestinal problems (e.g. ulcers), hepatic disorders, diabetes, gout, hypertension, or hyperlipidemia. Use cautiously with a history of allergy, asthma, or leukemia. Use cautiously if taking antihyperlipidemia agents, alcohol, leukemia medications, beta-blockers, diuretics, phenytoin (Dilantin ®), probenecid, spironolactone, sulfonylureas, valproic acid, or methotrexate. Use cautiously if taking tannin-containing herbs or supplements. Avoid use when operating heavy machinery. Avoid in children with chickenpox and any other viral infections. Avoid with blood disorders and renal disorders. Avoid if taking other NSAIDs, acetazolamide, or other carbonic anhydrase inhibitors. Avoid with elevated serum cadmium levels. Avoid if pregnant or breastfeeding.

Good Scientific Evidence:

5-HTP: There is a small amount of research evaluating the use of 5-HTP for fibromyalgia and early evidence suggests that 5-HTP may reduce the number of tender points, anxiety, and intensity of pain and may improve sleep, fatigue, and morning stiffness. Additional studies with larger numbers of people are needed to determine what dose may be safe and effective.

Acupuncture: Acupuncture is commonly used throughout the world. According to Chinese medicine theory, the human body contains a network of energy pathways through which vital energy, called chi, circulates. These pathways contain specific "points" that function like gates, allowing chi to flow through the body. Needles are inserted into these points to regulate the flow of chi. There has been substantial research into the efficacy of acupuncture in the treatment of osteoarthritis (OA). Most studies focus on knee, cervical, and hip OA symptoms. In recent years, the evidence has improved and is now considered strong enough to recommend trying acupuncture in OA of the knee, which is one of the most common forms of this condition. There is also evidence from several studies suggesting that acupuncture may help with pain relief in fibromyalgia.

Avocado: A combination of avocado/soybean unsaponifiables (ASU) has been found beneficial in osteoarthritis of the knee and hip. Additional study using avocado (Persea Americana) alone in OA is needed.

Borage seed oil: Borage (Borago officinalis) is an herb native to Syria that has spread throughout the Middle East and Mediterranean. Borage flowers and leaves may be eaten and borage seeds are often pressed to produce oil that is very high in gamma-linolenic acid (GLA). GLA has known anti-inflammatory effects that may make it beneficial in treating rheumatoid arthritis. A few human studies have generally found positive results, and side effects were not reported. However, more research is needed to determine the optimal dose and administration.

Avoid if allergic or hypersensitive to borage, its constituents, or members of the Boraginaceae family. Avoid with a weakened immune system. Use cautiously with bleeding disorders, epilepsy, or if taking drugs used to treat these disorders. Avoid if pregnant or breastfeeding.

Chlorella: Clinical evidence indicates that chlorella may reduce the tenderness associated with fibromyalgia. Although the results are promising, more high quality studies are needed to confirm these findings.

Devil's claw: Devil's claw (Harpagophytum procumbens) originates from the Kalahari and Savannah desert regions of South and Southeast Africa. There is increasing scientific evidence suggesting that devil's claw is safe and beneficial for the short-term treatment of pain related to degenerative joint disease or osteoarthritis (taken for 8-12 weeks) and may be equally effective as drug therapies such as non-steroidal anti-inflammatory drugs like ibuprofen (Advil ®, Motrin ®) or may allow for dose reductions or discontinuation of these drugs in some patients. However, most studies have been small with flaws in their designs. Additional well-designed trials are necessary.

Glucosamine: Several human studies and animal experiments report benefits of glucosamine in treating osteoarthritis of various joints of the body, although the evidence is less plentiful than that for knee osteoarthritis. Some of these benefits include pain relief, possibly due to an anti-inflammatory effect of glucosamine and improved joint function. Overall, these studies have not been well-designed. Although there is some promising research, more study is needed in this area before a firm conclusion can be made.

Omega-3 fatty acids (fish oils): Multiple studies report improvements in morning stiffness and joint tenderness in patients with rheumatoid arthritis with the regular intake of fish oil supplements for up to three months. Benefits have been reported as additive with anti-inflammatory medications, such as nonsteroidal anti-inflammatory drugs (such as ibuprofen). However, because of weaknesses in study designs and reporting, better research is necessary before a strong, favorable recommendation can be made. Effects beyond three months of treatment have not been well evaluated.

Avoid if allergic or hypersensitive to fish, omega-3 fatty acid products that come from fish, nuts, linolenic acid, or omega-3 fatty acid products that come from nuts. Avoid during active bleeding. Use cautiously with bleeding disorders, diabetes, low blood pressure, or if taking drugs, herbs, or supplements that treat any such conditions. Use cautiously before surgery. Pregnant and breastfeeding women should not consume doses of omega-3 fatty acids that exceed the Recommended Dietary Allowance (RDA).

Physical therapy: The goal of physical therapy is to improve mobility, restore function, reduce pain, and prevent further injuries. Several techniques, including exercises, stretches, traction, electrical stimulation, and massage, are used. Physical therapy for osteoarthritis of the knee may provide short-term benefits, but long-term benefits do not appear better than standard treatments. Physical therapy, either as an individually delivered treatment or in a small group format, appears effective. Only one available study compared physical therapy to a sham group (subtherapeutic ultrasound) and found that a combination of manual physical therapy and supervised exercise was beneficial for patients with osteoarthritis of the knee. One method of physical therapy, infrared, short-wave diathermy-pulsed patterns and interferential therapy, showed more effectiveness than intra-articular hyaluronan drugs in two studies. More research using consistent treatment protocols and outcomes measures are needed.

Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with their qualified healthcare professionals before beginning any treatments. Based on the available literature, physical therapy appears generally safe when practiced by a qualified physical therapist. Physical therapy may aggravate pre-existing conditions. Persistent pain and fractures of unknown origin have been reported. Both morning stiffness and bone erosion in patients have been reported, although the cause is unclear. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician/gynecologist before initiation.

Psychotherapy: Psychotherapy is an interactive process between a person and a qualified mental health professional. The patient will explore thoughts, feelings, and behavior to help with problem solving. Although group therapy may somewhat decrease pain in people with rheumatoid arthritis and depression, individual therapy coupled with antidepressants may be more effective.

Rose hips: Rose hips have traditionally been used by herbalists as an anti-inflammatory and antiarthritic agent. A constituent isolated from dried and milled fruits of Rosa canina has demonstrated anti-inflammatory properties, and Hyben Vital ®, a standardized rose hips extract, has been shown to have anti-oxidant properties. Rose hip extracts have been studied in patients with osteoarthritis, with some evidence of benefit. Additional high quality clinical research is needed in this area to confirm these results.

SAMe: SAMe has been studied extensively in the treatment of osteoarthritis. SAMe reduces the pain associated with osteoarthritis and appears to be well tolerated in this patient population. Although an optimal dose has yet to be determined, SAMe appears as effective as non-steroidal anti-inflammatory drugs (NSAIDS). Additional study is warranted to confirm these findings.

TENS (transcutaneous electrical nerve stimulation): Transcutaneous electrical nerve stimulation (TENS) is a non-invasive technique in which a low-voltage electrical current is delivered through wires from a small power unit to electrodes located on the skin. Electrodes are temporarily attached in various patterns, depending on the specific condition and treatment goals. Preliminary studies of TENS in rheumatoid arthritis report improvements in joint function and pain. However, most research is not well designed or reported, and better studies are necessary before a clear conclusion can be reached.

Avoid with implantable devices, such as defibrillators, pacemakers, intravenous infusion pumps, or hepatic artery infusion pumps. Use cautiously with decreased sensation (such as neuropathy) or with seizure disorders. Avoid if pregnant or breastfeeding due to insufficient evidence of safety.

Unclear or Conflicting Scientific Evidence:

Arnica: Arnica (Arnica montana) gel has been used on the skin for osteoarthritis pain and stiffness, due to its anti-inflammatory constituents. Although early study is promising, additional study is needed.

Ashwagandha: The use of ashwagandha in osteoarthritis has been suggested based on its reported anti-inflammatory and anti-arthritic properties. Well-designed human research is needed to confirm these results.

Astaxanthin: Astaxanthin is found in microalgae, yeast, salmon, trout, krill, shrimp, crayfish, crustaceans, and the feathers of some birds. Astaxanthin has been suggested as a possible treatment for rheumatoid arthritis. However, further research is warranted.

Avoid if allergic or hypersensitive to astaxanthin or related carotenoids, including canthaxanthin or an astaxanthin algal source. Use cautiously if taking 5-alpha-reductase inhibitors (used in prostate conditions), hypertensive agents, asthma medications, drugs that are broken down by the liver, menopausal agents, birth control pills, or medications that are used to treat Helicobacter pylori infections. Use cautiously with high blood pressure, parathyroid disorders, or osteoporosis. Avoid with hormone-sensitive conditions, immune disorders, or if taking immunosuppressive therapies. Avoid with previous experience of visual changes while taking astaxanthin and with low eosinophil levels. Avoid if pregnant or breastfeeding.

Beta carotene: Beta-carotene is a member of the carotenoid family, which contains highly pigmented (red, orange, yellow), fat-soluble compounds naturally present in many fruits, grains, oil and vegetables (green plants, carrots, sweet potatoes, squash, spinach, apricots, and green peppers). Beta-carotene supplementation does not appear to prevent osteoarthritis, but it might slow progression of the disease. Well-designed clinical trials are needed before a conclusion can be drawn.

Supplemental beta-carotene may increase the risk of lung cancer, prostate cancer, intracerebral hemorrhage, and cardiovascular and total mortality in people who smoke cigarettes or have a history of high-level exposure to asbestos. Beta-carotene from foods does not seem to have this effect.

Preliminary study has found that synthetic beta-carotene may increase cardiovascular mortality in people who smoke. In men who smoke and have had a prior myocardial infarction (MI), the risk of fatal coronary heart disease increases by as much as 43% with low doses of beta-carotene. There is some evidence that beta-carotene in combination with selenium, vitamin C, and vitamin E might lower high-density lipoprotein 2 (HDL2) cholesterol levels. HDL levels are protective so this is considered to be a negative effect. Dizziness, reversible yellowing of palms, hands, or soles of feet and to a lesser extent the face (called carotenoderma) can occur with high doses of beta-carotene. Loose stools, diarrhea, unusual bleeding or bruising, and joint pain have been reported.

Beta-sitosterol: Beta-sitosterol is found in plant-based foods, such as fruits, vegetables, soybeans, breads, peanuts, and peanut products. It is also found in bourbon and oils, such as olive oil, flaxseed, and tuna. Beta-sitosterol has been shown to reduce inflammation and it has therefore been suggested as a possible treatment for rheumatoid arthritis. Further research is needed to confirm these claims.

Avoid if allergic or hypersensitive to beta-sitosterol, beta-sitosterol glucoside, or pine. Use cautiously with asthma or breathing disorders, diabetes, primary biliary cirrhosis (destruction of the small bile duct in the liver), ileostomy, neurodegenerative disorders (such as Parkinson's disease or Alzheimer's disease), bulging of the colon, short bowel syndrome, celiac disease, or sitosterolemia. Use cautiously with a history of gallstones. Avoid if pregnant or breastfeeding.

Black cohosh: Although it has been suggested that black cohosh (Actaea racemosa) may help relieve joint pain associated with rheumatoid arthritis and osteoarthritis, further research is needed. High doses of black cohosh may cause frontal headache, dizziness, perspiration, or visual disturbances.

Use cautiously if allergic to members of the Ranunculaceae family, such as buttercup or crowfoot. Avoid with hormone conditions (e.g. breast cancer, ovarian cancer, uterine cancer, endometriosis). Avoid if allergic to aspirin products, nonsteroidal anti-inflammatory drugs (such as ibuprofen), or blood-thinners (such as warfarin). Avoid with a history of blood clots, stroke, seizures, or liver disease. It is recommended to stop use of black cohosh two weeks before and immediately after surgery/dental/diagnostic procedures with bleeding risks.

Boron: Boron is a trace element that is found throughout the environment. Based on human population research, in a boron-rich environment, people appear to have fewer joint disorders. It has also been proposed that boron deficiency may contribute to the development of osteoarthritis. However, there is no clear human evidence that supplementation with boron is beneficial as prevention against or as a treatment for osteoarthritis.

Boswellia: Resin extracts from the Boswellia serrata tree have been found to have anti-inflammatory effects. Due to boswellia's potential anti-inflammatory properties, boswellia has been suggested as a potential treatment for osteoarthritis. Further research is needed in this area. Boswellia may increase bleeding in sensitive individuals, such as those taking blood thinning medications including warfarin (Coumadin ®).

Bromelain: Bromelain is an herb that contains a digestive enzyme that comes from the stem and the fruit of the pineapple plant (Ananus comosus). When taken with meals, bromelain may aid in the digestion of proteins. When taken on an empty stomach, it acts as an anti-inflammatory agent. In one study of the combination product ERC (enzyme-rutosid combination; rutosid, bromelain, trypsin), results showed that ERC may be considered as an effective and safe alternative to prescription anti-inflammatory drugs (NSAIDs), such as diclofenac, in the treatment of painful episodes of OA of the knee. Further well-designed clinical trials of bromelain alone are needed to confirm these results.

Avoid if allergic to bromelain, pineapple, honeybee, venom, latex, birch pollen, carrots, celery, fennel, cypress pollen, grass pollen, papain, rye flour, wheat flour, or other members of the Bromeliaceae family. Use cautiously with a history of bleeding disorders, stomach ulcers, heart disease, liver disease, or kidney disease. Use cautiously before dental or surgical procedures or while driving or operating machinery. Avoid if pregnant or breastfeeding.

Cat's claw: Cat's claw is widely used in the United States and Europe, and it is one of the top herbal remedies sold despite a lack of high-quality human evidence. In Germany and Austria, cat's claw is only available by prescription. Several laboratory and animal studies suggest that cat's claw may reduce inflammation and this has led to research of cat's claw for inflammatory conditions, such as arthritis. Early research also suggests that cat's claw may reduce pain from knee osteoarthritis. Large, high-quality human studies are needed comparing the effects of cat's claw alone vs. placebo before a conclusion can be drawn.

Avoid if allergic to Cat's claw, Uncaria plants, or plants in the Rubiaceae family (such as gardenia, coffee, or quinine). Avoid with a history of conditions affecting the immune system (such as AIDS, HIV, some types of cancer, multiple sclerosis, tuberculosis, or lupus). Use cautiously with bleeding disorders or with a history of stroke. Use cautiously if taking drugs that may increase the risk of bleeding. It is recommended to stop use of cat's claw two weeks before and immediately after surgery/dental/diagnostic procedures with a bleeding risk. Avoid if pregnant or breastfeeding. Cat's claw may be contaminated with other Uncaria species. Reports exist of a potentially toxic, Texan-grown plant, Acacia gregii, being substituted for cat's claw.

Chiropractic: Chiropractic is a healthcare discipline that focuses on the relationship between musculoskeletal structure (primarily the spine) and body function (as coordinated by the nervous system), and how this relationship affects the preservation and restoration of health. Promising results were obtained in the treatment of osteoarthritis using manual physical therapy and exercise. However, presently there is insufficient evidence to support the use of chiropractic manipulation for this condition.

Evening primrose oil: Evening primrose oil contains an omega-6 essential fatty acid called gamma-linolenic acid (GLA), which is believed to be the active ingredient. Benefits of evening primrose oil in the treatment of arthritis have not been clearly shown. More information is needed before a recommendation can be made.

Avoid with seizure disorders. Use cautiously if taking mental illness drugs. It is recommended to stop use two weeks before surgery with anesthesia. Avoid if pregnant or breastfeeding.

Guggul: Guggul (gum guggul) is a resin produced by the mukul mirth tree. There is insufficient evidence to support the use of guggul or guggul derivatives for the management of rheumatoid arthritis. Avoid if allergic to guggul. Avoid with a history of thyroid disorders, anorexia, bulimia, or bleeding disorders. Signs of allergy to guggul may include itching and shortness of breath. Avoid if pregnant or breastfeeding.

Guided imagery: Guided imagery refers to a number of techniques, including metaphor, storytelling, fantasy, game playing, dream interpretation, drawing, visualization, active imagination, and direct suggestion using imagery. Therapeutic guided imagery may be used to help patients relax and focus on images associated with personal issues they are confronting. Cognitive-behavioral interventions for pain may be an effective adjunct to standard pharmacologic interventions for pain in patients with osteoarthritis. Further research is needed to confirm these results.

Guided imagery is usually intended to supplement medical care, not to replace it, and guided imagery should not be relied on as the sole therapy for a medical problem. Contact a qualified healthcare provider if mental or physical health is unstable or fragile. Never use guided imagery techniques while driving or doing any other activity that requires strict attention. Use cautiously with physical symptoms that can be brought about by stress, anxiety, or emotional upset because imagery may trigger these symptoms.

Magnet therapy: Magnetic fields play an important role in Western medicine. For instance, they are used for magnetic resonance imaging (MRI), pulsed electromagnetic fields, and experimental magnetic stimulatory techniques. Several studies have evaluated the use of magnetic field therapy applied to areas affected by osteoarthritis or degenerative joint disease. In particular, this research has focused on knee osteoarthritis. However, most studies have been small or poorly designed or reported. Efficacy remains unclear. Notably, one promising small study published in 2004 by Wolsko et al. reported some benefits. Larger and better quality studies are needed before a recommendation can be made in this area.

Initial evidence has failed to show improvements in knee pain with the use of magnet therapy. However, due to methodological weaknesses with this research, the conclusions cannot be considered definitive.

Avoid with implantable medical devices, such as heart pacemakers, defibrillators, insulin pumps, or hepatic artery infusion pumps. Avoid with myasthenia gravis or bleeding disorders. Avoid if pregnant or breastfeeding. Magnet therapy is not advised as the sole treatment for potentially serious medical conditions and should not delay the time to diagnosis a condition. It should not replace treatment with more proven methods. Patients are advised to discuss magnet therapy with their qualified healthcare providers before starting treatment.

MSM: Methylsulfonylmethane, or MSM, is a form of organic sulfur that occurs naturally in a variety of fruits, vegetables, grains, and animals. MSM is a normal oxidation product of dimethyl sulfoxide (DMSO). Preliminary study has used MSM, alone or in combination with glucosamine, in the treatment of osteoarthritis. The combination may provide pain relief and reduction in inflammation. Further studies on MSM and its effects on patients with osteoarthritis are warranted.

Niacin: Vitamin B3 is made up of niacin (nicotinic acid) and its amide, niacinamide, and can be found in many foods, including yeast, meat, fish, milk, eggs, green vegetables, and cereal grains. Preliminary human studies suggest that niacinamide may be useful in the treatment of osteoarthritis. Further research is needed.

Pantothenic acid (vitamin B5): Pantothenic acid is found in many foods including meats, liver, kidney, fish/shellfish, chicken, vegetables, legumes, yeast, eggs, and milk. It has been reported that pantothenic acid levels are lower in the blood of patients with rheumatoid arthritis compared to healthy individuals. However, it is unclear if this is a cause, effect, or a beneficial adaptive reaction. There is currently insufficient scientific evidence in this area in order to form a clear conclusion.

Panthothenic acid has also been suggested as a possible treatment for osteoarthritis. However, further research is needed to determine whether or not this treatment is effective.

Avoid if allergic or hypersensitive to pantothenic acid or dexpanthenol. Avoid with gastrointestinal blockage. Pantothenic acid is generally considered safe in pregnant and breastfeeding women when taken at recommended doses.

Probiotics: Probiotics are beneficial bacteria that are sometimes called friendly germs. They help maintain a healthy intestine and aid in digestion. They also help keep harmful bacteria and yeasts in the gut under control. Most probiotics come from food sources, especially cultured milk products. Probiotics can be taken as capsules, tablets, beverages, powders, yogurts, and other foods. In a small study, Lactobacillus GG was associated with improved subjective well-being and trends in reduced symptoms of rheumatoid arthritis. However, the results were not statistically significant. More studies on the effects of probiotics on rheumatoid arthritis are needed.

Probiotics are generally considered safe and well-tolerated, but may cause diarrhea in sensitive individuals. Use cautiously if lactose intolerant.

Relaxation therapy: Relaxation techniques include behavioral therapeutic approaches that differ widely in philosophy, methodology, and practice. The primary goal is usually non-directed relaxation. In a randomized study of patients with osteoarthritis pain, relaxation therapy was reported to lower the level of subjective pain over time. The study concluded that relaxation might be effective in reducing the amount of analgesic medication taken by participants. Further well-designed research is needed to confirm these results.

Limited preliminary research reports that muscle relaxation training may improve function and well-being in patients with rheumatoid arthritis. Additional research is necessary before a conclusion can be reached.

Avoid with psychiatric disorders, such as schizophrenia or psychosis. Relaxation therapy, which involves flexing and relaxing specific muscles, should be used cautiously with illnesses, such as heart disease, high blood pressure, or musculoskeletal injury. Relaxation therapy is not recommended as the sole treatment approach for potentially serious medical conditions, and it should not delay the time to diagnosis or treatment with more proven techniques

Tai chi: Tai chi is a system of movements and positions believed to have developed in 12th Century China. Tai chi techniques aim to address the body and mind as an interconnected system and are traditionally believed to have mental and physical health benefits to improve posture, balance, flexibility and strength. A small trial in women with osteoarthritis reported that treatment with tai chi significantly decreased pain and stiffness compared with a sedentary lifestyle. Women in the tai chi group also reported fewer perceptions of difficulties in physical functioning. Additional research is needed in this area.

Thymus extract: Thymus extracts for nutritional supplements are usually derived from young calves (bovine). Thymus extract is commonly used to treat primary immunodeficiencies, bone marrow failure, autoimmune disorders, chronic skin diseases, recurrent viral and bacterial infections, hepatitis, allergies, chemotherapy side effects, and cancer. Further research is needed to determine whether or not thymus extract can effectively treat symptoms of rheumatoid arthritis.

Avoid if allergic or hypersensitive to thymus extracts. Use bovine thymus extract supplements cautiously due to potential for exposure to the virus that causes "mad cow disease." Avoid use with an organ transplant or other forms of allografts or xenografts. Avoid with thymic tumors, myasthenia gravis (neuromuscular disorder), or untreated hypothyroidism. Avoid if taking immunosuppressants or hormonal therapy. Avoid if pregnant or breastfeeding. Thymic extract increases human sperm motility and progression.

Turmeric: The rhizome (root) of turmeric (Curcuma longa Linn.) has long been used in traditional Asian medicine. Turmeric has been used historically to treat rheumatic conditions. Laboratory and animal studies show anti-inflammatory activity of turmeric and its constituent curcumin, which may be beneficial in people with osteoarthritis. Reliable human research is lacking. Turmeric may increase bleeding in sensitive individuals, such as those taking blood thinning medications including warfarin (Coumadin ®).

Yoga: Yoga is an ancient system of relaxation, exercise, and healing, with origins in Indian philosophy. Yoga is often practiced by healthy individuals with the aim to achieve relaxation, fitness, and a healthy lifestyle. Based on a pilot study, yoga may help reduce pain and disability caused by knee osteoarthritis (OA) in some patients. Further research is needed.

Fair Negative Evidence:

Arnica: Homeopaths believe that arnica may be effective in relieving pain due to delayed onset muscle soreness, which is defined by exercise to which subjects are unaccustomed. Currently, it is not recommended to give arnica for this indication, although it does not appear to be unsafe for use.

Chondroitin: Chondroitin sulfate is often used as an anti-inflammatory and pain reliever for osteoarthritis, so chondroitin was thought to be beneficial for delayed onset muscle soreness. However, early research does not support this use. More research is needed in this area to confirm these results.

DHEA: DHEA does not seem to improve quality of life, pain, fatigue, cognitive function, mood, or functional impairment in postmenopausal patients with fibromyalgia.

Phenylalanine: In clinical study, D-phenylalanine has not been shown to affect symptoms in patients with chronic pain. Additional high quality clinical research is needed to confirm these results.

Selenium: Selenium is a trace mineral found in soil, water, and some foods. It is an essential element in several metabolic pathways. Selenium-ACE, a formulation containing selenium with three vitamins, has been promoted for the treatment of arthritis. Research has failed to demonstrate significant benefits, with a possible excess of side effects compared to placebo.

Willowbark: There is good evidence that willow bark may be effective in treating chronic pain from osteoarthritis; however, willow bark extract did not show efficacy in treating rheumatoid arthritis. Additional study is needed to confirm these results.

Traditional or Theoretical Uses Lacking Sufficient Evidence:

Integrative therapies used in pain or related conditions causing pain and that have historical or theoretical uses but lack sufficient clinical evidence include: homeopathic aconite (Aconitum napellus), acupressure (shiatsu), black currant (Ribes nigrum), black tea (Camellia sinensis), celery (Apium graveolens), chelation (EDTA) therapy, hellerwork, horse chestnut (Aesculus hippocastanum), kundalini yoga, licorice (Glycyrrhiza glabra), mangosteen (Garcinia mangostana), massage, meadowsweet (Filipendula ulmaria), polarity therapy, rhubarb (Rheum officinale, Rheum palmatum), rutin, shark cartilage, and vitamin E.

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