Achondroplasia

Note: Currently, there is a lack of scientific data on the use of integrative therapies for the treatment or prevention of achondroplasia. However, some therapies have been studied as a way to treat or prevent arthritis, a common complication of achondroplasia. It is important to note that these studies did not include patients with achondroplasia. The integrative therapies listed below should be used only under the supervision of a qualified healthcare provider and should not be used in replacement of other proven therapies.

A Strong scientific evidence

• 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 used products other than glucosamine sulfate. The evidence supporting the use of glycosaminoglycan polysulphate is conflicting and merits further investigation. 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 that contains salicin has been used to treat many different kinds of pain. Willow bark is a traditional analgesic (pain relieving) therapy for osteoarthritis. Several studies have confirmed this finding. Additional study comparing the safety and efficacy of willow bark to conventional medicinal agents 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), liver disorders, diabetes, gout (foot inflammation), high blood pressure, or high cholesterol. Use cautiously with a history of allergy, asthma, or leukemia. Use cautiously if taking protein-bound medications, antihyperlipidemia agents, alcohol, leukemia medications, beta-blockers, diuretics, phenytoin (Dilantin®), probenecid, spironolactone, sulfonylureas, valproic acid, or methotrexate. Use cautiously if pre-disposed to headaches. Use cautiously with use of tannin-containing herbs or supplements. Avoid operating heavy machinery. Avoid in children with chickenpox and any other viral infections. Avoid with blood 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.

B Good scientific evidence

• 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 arthritis. A few human studies have generally found positive results and no side effects were 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.
• Glucosamine : Glucosamine is a natural compound that is found in healthy cartilage. Several human studies and animal experiments report benefits of glucosamine in treating osteoarthritis of various joints of the body. However, 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.
• 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.
• Omega-3 fatty acids : Multiple studies report improvements in morning stiffness and joint tenderness with the regular intake of fish oil supplements for up to three months. Additive benefits have been reported 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. The Environmental Protection Agency (EPA) recommends that fish intake be limited in pregnant/nursing women to a single six-ounce meal per week and in young children to less than two ounces per week. For farm-raised, imported, or marine fish, the U.S. Food and Drug Administration (FDA) recommends that pregnant/nursing women and young children avoid eating types with higher levels of methylmercury and less than 12 ounces per week of other fish types. Women who might become pregnant are advised to eat seven ounces or less per week of fish with higher levels of methylmercury or up to 14 ounces per week of fish types with about 0.5 parts per million (such as marlin, orange roughy, red snapper, or fresh tuna).
• 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 outcome measures would be helpful in this area.
• 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. Physical therapy may increase the duration of pain or cause limitation of motion. Pain and anxiety may occur during the rehabilitation of patients with burns. Both morning stiffness and bone erosion have been reported in the literature, although causality is unclear. Erectile dysfunction has also been reported. 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 behaviors to help with problem solving. Although group therapy may somewhat decrease pain in people with rheumatoid arthritis and depression, individual therapy coupled with anti-depressants may be more effective.
• Psychotherapy cannot always fix mental or emotional conditions. Psychiatric drugs are sometimes needed. In some cases, symptoms may get worse if the proper medication is not taken. Not all therapists are qualified to work with all problems. Use cautiously with serious mental illness or some medical conditions because some forms of psychotherapy may provoke strong emotional feelings and expression.

C Unclear or conflicting scientific evidence

• 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. Some studies of weak design have reported that acupuncture may relieve pain associated with rheumatoid arthritis (RA). However, a well-designed trial was unable to confirm this. More evidence is needed to clarify if or when acupuncture is beneficial in RA.
• Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders, medical conditions of unknown origin, or neurological disorders. Avoid on areas that have received radiation therapy and during pregnancy. Avoid if taking drugs that increase the risk of bleeding (anticoagulants). Use cautiously with pulmonary disease (such as asthma or emphysema). Use cautiously in medically compromised patients, diabetics, or the elderly. Use cautiously with a history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers.
• 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 astaxanthin from algal sources. Use cautiously if taking 5-alpha-reductase inhibitors, hypertensive agents, asthma medications, drugs that are broken down by the liver, menopause agents, birth control pills, or Helicobacter pylori agents. 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.
• Ayurveda : Ayurveda is a form of natural medicine that originated in ancient India more than 5,000 years ago. Ayurveda is an integrated system of techniques that uses diet, herbs, exercise, meditation, yoga, and massage or bodywork to achieve optimal health on all levels (physical, psychological, and spiritual). There is some evidence that a traditional Ayurvedic herbal formula RA-1 may reduce joint swelling but not other symptoms in rheumatoid arthritis. RA-1 contains Withania somnifera (ashwagandha), Boswellia serrata (gugul), Zingiberis officinale (ginger), and Curcuma longa (turmeric). A resin that is extracted from Boswellia serrata (H15, indish incense) is regarded in Ayurvedic medicine as having anti-inflammatory properties. However, evidence from one study showed no benefit in patients with RA. More studies are needed to determine efficacy of these treatments in RA.
• Ayurvedic herbs should be used cautiously because they are potent and some constituents can be potentially toxic if taken in large amounts or for a long time. Some herbs imported from India have been reported to contain high levels of toxic metals. Ayurvedic herbs may interact with other herbs, foods, or drugs; consult with a qualified healthcare professional before taking. Avoid Ayurveda with traumatic injuries, acute pain, advanced disease stages, or medical conditions that require surgery.
• 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 : Black cohosh is a popular alternative for menopausal hormonal symptoms, such as hot flashes, migraine headache, mood changes, sleep changes, sweating, fast heartbeat, and vaginal dryness. The exact action of black cohosh is unclear. Although it has been suggested that black cohosh may help relieve joint pain associated with rheumatoid arthritis and osteoarthritis, further research is needed.
• Use cautiously if allergic to members of the Ranunculaceae family, such as buttercups 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. Stop use two weeks before and immediately after surgery/dental/diagnostic procedures with bleeding risks.
• Black currant : The black currant shrub grows naturally in Europe and parts of Asia. Traditionally, black currant fruit has been cultivated mainly for dietary and confectionary purposes. Black currant may help reduce inflammation and morning stiffness associated with arthritis. However, additional research is needed before a firm conclusion can be made.
• Avoid if allergic or hypersensitive to black currant, its constituents, or plants in the Saxifragaceae family. Avoid with bleeding disorders or if taking blood thinners, unless otherwise recommended by a qualified healthcare provider. Use cautiously with venous disorders or gastrointestinal disorders. Use cautiously if taking antidepressants or vitamin C supplements. Avoid if pregnant or breastfeeding.
• Boswellia : Boswellia (Boswellia serrata) is an herb that has been shown to have anti-inflammatory properties. Therefore, boswellia has been suggested as a potential treatment for rheumatoid arthritis (RA) and osteoarthritis. However, data are conflicting and sometimes combination products have been used. Therefore, there is currently insufficient evidence to recommend for or against the use of boswellia for arthritis.
• Avoid if allergic or hypersensitive to boswellia. Avoid with a history of stomach ulcers or stomach acid reflux disease. Avoid if pregnant or breastfeeding.
• Bromelain : Bromelain is an herb that contains a digestive enzyme that comes from the stem and the fruit of the pineapple plant. 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 an effective and safe alternative to prescription anti-inflammatory drugs (NSAIDs), such as diclofenac, in the treatment of painful episodes of osteoarthritis of the knee. Further well-designed clinical trials of bromelain alone are needed to confirm these results.
• Bromelain has also been suggested as a possible treatment for rheumatoid arthritis. Further research is needed before a firm conclusion can be made.
• 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; 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 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. Stop use two weeks before and immediately after surgery/dental/diagnostic procedures with bleeding risk. Avoid if pregnant or breastfeeding. Cat's claw may be contaminated with other Uncaria species. Reports exist of the potentially toxic Texan grown plant Acacia gregii being substituted for cat's claw.
• Chlorophyll : Chlorophyll is responsible for the green pigment in plants. It can be obtained from green leafy vegetables (broccoli, Brussels sprouts, cabbage, lettuce, and spinach), algae (Chlorella and Spirulina), wheat grass, and numerous herbs (alfalfa, damiana, nettle, and parsley). Diets high in chlorophyll have been hypothesized to modify intestinal flora, resulting in improved management of immune disorders, including rheumatoid arthritis. More evidence is needed to support the use of chlorophyll in autoimmune diseases.
• Avoid if allergic or hypersensitive to chlorophyll or any of its metabolites. Use cautiously with photosensitivity, compromised liver function, diabetes, or gastrointestinal conditions or obstructions. Use cautiously if taking immunosuppressant agents or anti-diabetes agents. Avoid if pregnant or breastfeeding.
• Copper : Copper is a mineral that occurs naturally in many foods, including vegetables, legumes, nuts, grains, fruits, shellfish, avocado, beef, and animal organs, such as liver and kidney. The use of copper bracelets in the treatment of arthritis has a long history of traditional use, with many anecdotal reports of effectiveness. There are research reports suggesting that copper salicylate may reduce arthritis symptoms more effectively than either copper or aspirin alone. Further study is needed before a recommendation can be made.
• Avoid if allergic/hypersensitive to copper. Avoid the use of copper supplements during the early phase of recovery from diarrhea. Avoid with hypercupremia (an abnormally high concentration of copper in the blood), which occasionally occurs in disease states, including cutaneous leishmaniasis, sickle-cell disease, unipolar depression, breast cancer, epilepsy, measles, Down's syndrome, or controlled fibrocalculous pancreatic diabetes (a unique form of secondary diabetes mellitus). Avoid with genetic disorders affecting copper metabolism, such as Wilson's disease, Indian childhood cirrhosis, or idiopathic copper toxicosis. Avoid with HIV/AIDS. Use cautiously with water-containing copper concentrations greater than six milligrams per liter. Use cautiously with anemia, arthralgias (joint pains), or myalgias (muscle pains). Use cautiously if taking oral contraceptives. Use cautiously if at risk for selenium deficiency. The Recommended Dietary Allowance (RDA) is 1,000 micrograms for pregnant women. The RDA for nursing women is 1,300 micrograms.
• DHEA : DHEA (dehydroepiandrosterone) is a hormone that is produced by the adrenal glands. Preliminary evidence from a case series suggests that DHEA likely offers no benefit to individuals with rheumatoid arthritis. Well-designed human studies are needed before firm conclusions can be made.
• Avoid if allergic to DHEA. Avoid with a history of seizures. Use cautiously with adrenal or thyroid disorders. Use cautiously if taking anticoagulants or drugs, herbs, or supplements that treat diabetes, heart disease, seizure, or stroke. Stop use two weeks before and immediately after surgery/dental/diagnostic procedures with bleeding risks. Avoid if pregnant or breastfeeding.
• DMSO (dimethyl sulfoxide) : DMSO (dimethyl sulfoxide) is naturally found in vegetables, fruits, grains, and animal products. DMSO is available for both non-medicinal and medicinal uses. Applying DMSO to the skin may help treat symptoms of rheumatoid arthritis. More research is needed before a conclusion can be drawn.
• Avoid if allergic or hypersensitive to DMSO. Use cautiously with urinary tract cancer, liver disorders, or kidney dysfunction. Avoid if pregnant or breastfeeding.
• Dong quai : Dong quai (Angelica sinensis), also known as Chinese angelica, has been used for thousands of years in traditional Chinese, Korean, and Japanese medicine. Dong quai is traditionally used to treat arthritis. However, there is insufficient reliable human evidence to recommend the use of Dong quai alone or in combination with other herbs for osteoarthritis or rheumatoid arthritis.
• Although Dong quai is accepted as being safe as a food additive in the United States and Europe, its safety in medicinal doses is not known. There are no reliable long-term studies of side effects available. Avoid if allergic or hypersensitive to Angelica radix or members of the Apiaceae (Umbelliferae) family (such as anise, caraway, carrot, celery, dill, and parsley). Avoid prolonged exposure to sunlight or ultraviolet light. Use cautiously with bleeding disorders or if taking drugs that may increase the risk of bleeding. Use cautiously with diabetes, glucose intolerance, or hormone sensitive conditions (such as breast cancer, uterine cancer, or ovarian cancer). Do not use before dental or surgical procedures. Avoid if pregnant or breastfeeding.
• 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 if allergic to plants in the Onagraceae family (willow's herb, enchanter's nightshade) or gamma-linolenic acid. Avoid with seizure disorders. Use cautiously if taking medications to treat mental illness. Stop use two weeks before surgery with anesthesia. Avoid if pregnant or breastfeeding.
• Feverfew : Feverfew (Tanacetum parthenium) is an herb native to Asia Minor. It is unclear if feverfew is an effective treatment for rheumatoid arthritis symptoms, such as joint stiffness or pain.
• Avoid if allergic to feverfew and other plants of the Compositae family (such as chrysanthemums, daisies, marigolds, and ragweed). Stop use before and immediately after surgery and dental or diagnostic procedures. Avoid with drugs that increase bleeding risk. Avoid stopping feverfew use all at once; instead, slowly take progressively smaller doses over several days. Avoid with a history of heart disease, anxiety, or bleeding disorders. Use cautiously with a history of mental illness, depression, or headaches. Avoid if pregnant or breastfeeding.
• Gamma linolenic acid : Gamma linolenic acid (GLA) is a dietary fatty acid. It is found in many plant oil extracts. A limited amount of GLA is found naturally in human breast milk, cold-water fish, and organ meats, such as liver. GLA is commonly sold as a dietary supplement either in the form of capsules or oil. Several human studies indicate significant therapeutic improvements in rheumatoid arthritis symptoms, including decreased joint tenderness, joint swelling, and pain. Some studies also suggest that GLA may be a more tolerable alternative to standard pain-reduction therapies, such as COX2 inhibitors and NSAIDs. However, there is some concern on dosage control and additional study is needed to make a strong recommendation in this area.
• Use cautiously with drugs that increase the risk of bleeding, such as anticoagulants and anti-platelet drugs. Avoid if pregnant or breastfeeding.
• Ginger : The underground stems of ginger, called rhizomes, as well as the above ground stems, have been used in Chinese, Japanese, and Indian medicine for hundreds of years. It is unclear if ginger can improve joint and muscle pain caused by rheumatoid arthritis or osteoarthritis.
• Avoid if allergic to ginger or other members of the Zingiberaceae family (such as red ginger, Alpinia purpurata, shell ginger, Alpinia zeru, green cardamom, and Balsam of Peru). Use cautiously if driving or operating machinery. Stop use two weeks before and immediately after surgery/dental/diagnostic procedures due to a risk of bleeding. Avoid with a history of irregular heartbeat (arrhythmia). Use cautiously with a history of ulcers, acid reflux, heart conditions, inflammatory bowel disease, blocked intestines, or bleeding disorders. Use cautiously if pregnant or breastfeeding.
• Glucosamine : Glucosamine is a natural compound that is found in healthy cartilage. Preliminary human research reports benefits of glucosamine in the treatment of joint pain and swelling in rheumatoid arthritis. However, this is early information and additional research is needed before a conclusion can be drawn. The treatment of rheumatoid arthritis can be complicated and a qualified healthcare provider should follow people with this disease.
• 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.
• Green tea : Green tea is made from the dried leaves of Camellia sinensis, an evergreen shrub. Research indicates that green tea may benefit arthritis by reducing inflammation and slowing cartilage breakdown. Further studies are required before a recommendation can be made.
• Avoid if allergic or hypersensitive to caffeine or tannins. Use cautiously with diabetes or liver disease.
• 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 juvenile rheumatoid arthritis. 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.
• Hydrotherapy : Hydrotherapy is broadly defined as the external application of water in any form or temperature (hot, cold, steam, liquid, ice) for healing purposes. It may include immersion in a bath or body of water (such as the ocean or a pool), use of water jets, douches, application of wet towels to the skin, or water birth. Historically, hydrotherapy has been used to treat symptoms related to rheumatoid arthritis and osteoarthritis. Multiple studies have been published, largely based on therapy given at Dead Sea spa sites in Israel. Although most studies report benefits in pain, range of motion, or muscle strength, due to design flaws, there is not enough reliable evidence to draw a firm conclusion.
• Avoid sudden or prolonged exposure to extreme temperatures in baths, wraps, saunas, or other forms of hydrotherapy, particularly with heart disease, lung disease, or if pregnant. Avoid with implanted medical devices, such as pacemakers, defibrillators, or hepatic (liver) infusion pumps. Vigorous use of water jets should be avoided with fractures, known blood clots, bleeding disorders, severe osteoporosis, open wounds, or during pregnancy. Use cautiously with Raynaud's disease, chilblains, acrocyanosis, erythrocyanosis, or impaired temperature sensitivity, such as neuropathy. Use cautiously if pregnant or breastfeeding. Hydrotherapy should not delay the time to diagnosis or replace treatment with more proven techniques or therapies. Hydrotherapy should not be used as the sole approach to illnesses. Patients with known illnesses should consult their physicians before starting hydrotherapy.
• Hypnosis, hypnotherapy : Hypnosis is a trance-like state in which a person becomes more aware and focused and is more open to suggestion. Hypnotherapy has been used to treat health conditions or to change behaviors. Although multiple trials report diminished pain levels or requirements for pain-relieving medications after hypnotherapy, there is limited research for rheumatoid arthritis pain specifically. Other signs of rheumatoid arthritis, such as joint mobility or blood tests for rheumatoid factor, have not been adequately assessed.
• Use cautiously with mental illnesses like psychosis/schizophrenia, manic depression, multiple personality disorder, dissociative disorders, or seizure disorders.
• 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 of 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.
• Mistletoe : Once considered a sacred herb in Celtic tradition, mistletoe has been used for centuries for high blood pressure, epilepsy, exhaustion, anxiety, arthritis, vertigo (dizziness), and degenerative inflammation of the joints. According to one retrospective case study, mistletoe injections may help manage arthritis. Further research is needed before a firm conclusion can be made.
• Avoid if allergic or hypersensitive to mistletoe or any of its constituents. A life-threatening allergic reaction called anaphylaxis has been described after injections of mistletoe. Avoid with acute highly febrile inflammatory disease, thyroid disorders, seizure disorders, or heart disease. Use cautiously with diabetes, glaucoma, or if taking cholinergics.
• Moxibustion : Moxibustion is a therapeutic method used in traditional Chinese medicine (TCM), classical acupuncture, and Japanese acupuncture. During moxibustion therapy, an herb, usually mugwort, is burned above the skin or on acupuncture points to introduce heat into the acupuncture point to relieve symptoms. There is preliminary evidence suggesting that patients suffering from rheumatoid arthritis may experience improved immune function as a result of acupuncture and moxibustion. However, evidence is insufficient at this time for making firm recommendations.
• Use cautiously over large blood vessels and thin or weak skin. Avoid with aneurysms, any kind of "heat syndrome," heart disease, convulsions, cramps, diabetic neuropathy, extreme fatigue and/or anemia, fever, or inflammatory conditions. Avoid using over allergic skin conditions, ulcerated sores, or skin adhesions. Avoid areas with an inflamed organ, contraindicated acupuncture points, face, genitals, head, inflamed areas in general, and nipples. Avoid in patients who have just finished exercising or while taking a hot bath or shower. Avoid if pregnant or breastfeeding. Use cautiously with elderly people, or on areas with large blood vessels. It is considered not advisable to bathe or shower for up to 24 hours after a moxibustion treatment.
• 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.
• 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 has been used in the treatment of gonarthritis, hand, hip, and knee osteoarthritis. Manual therapy has sometimes shown better outcomes on pain, stiffness, hip function, and range of motion, although it is unclear whether sham treatment or other modalities would be comparable to physical therapy. Additional study is needed in this area.
• 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. Physical therapy may increase the duration of pain or cause limitation of motion. Pain and anxiety may occur during the rehabilitation of patients with burns. Both morning stiffness and bone erosion have been reported in the literature, although causality is unclear. Erectile dysfunction has also been reported. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician/gynecologist before initiation.
• Podophyllum : Podophyllum rhizomes have a long history of medicinal use among native North American tribes who used the rhizome powder as a laxative or to treat infections with worms or parasites. A topical poultice of the powder was also used to treat warts and tumorous growths on the skin. Preliminary research suggests that podophyllum may be helpful for rheumatoid arthritis. Research is limited due to the possible adverse effects like severe diarrhea associated with taking podophyllum by mouth. However, additional research is needed before a firm conclusion can be made.
• Avoid if allergic/hypersensitive to podophyllum or to members of the Berberidaceae family. Podophyllum, when applied topically, may be absorbed through the skin and cause irritation of the stomach and intestines. Podophyllum toxicity may cause heart palpitations and blood pressure changes, muscle paralysis, difficulty walking, confusion, and convulsions. Using podophyllum and laxatives may result in dehydration and electrolyte depletion. Use cautiously with arrhythmia, Crohn's disease, cardiovascular problems, gallbladder disease or gallstones, high blood pressure, irritable bowel syndrome, liver insufficiency, muscular disorders, neurologic disorders, psychosis, and kidney insufficiency. Use cautiously if taking antimiotic agents (e.g. vincristine), anti-psychotic agents, or laxatives. Avoid if pregnant or breastfeeding.
• Prayer, distant healing : Prayer can be defined as a "reverent petition," the act of asking for something while aiming to connect with God or another object of worship. Prayer on behalf of the ill or dying has played a prominent role throughout history and across cultures. Initial research suggests that praying for others in the presence of patients may reduce pain, fatigue, tenderness, swelling, and weakness when it is used in addition to standard care. Better-quality research is necessary before a firm conclusion can be made.
• Prayer is not recommended as the sole treatment approach for potentially serious medical conditions, and it should not delay the time it takes to consult with a healthcare professional or to receive established therapies. Sometimes religious beliefs come into conflict with standard medical approaches and require an open dialog between patients and caregivers.
• 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. Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant.
• Propolis : Bees make propolis to form their hives. Propolis is made of the buds of conifer and poplar trees and it is combined with beeswax and other bee secretions. Based on anti-inflammatory action observed in laboratory research, propolis has been proposed as a possible treatment for rheumatic and other inflammatory diseases. However, there is currently not enough scientific human study to make a clear recommendation.
• Avoid if allergic or hypersensitive to propolis, black poplar (Populus nigra), poplar bud, bee stings, bee products, honey, and Balsam of Peru. Severe allergic reactions have been reported. There has been one report of kidney failure with the ingestion of propolis that improved upon discontinuing therapy and deteriorated with re-exposure. Avoid if pregnant or breastfeeding because of the high alcohol content in some propolis products.
• 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, Jacobson relaxation 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. Jacobson relaxation, 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.
• Selenium : Selenium is a mineral found in soil, water, and some foods. Selenium supplementation has been studied in rheumatoid arthritis patients with mixed results. Additional research is necessary before a clear conclusion can be drawn.
• Avoid if allergic or sensitive to products containing selenium. Avoid with a history of non-melanoma skin cancer. Selenium is generally regarded as safe for pregnant or breastfeeding women. However, animal research reports that large doses of selenium may lead to birth defects.
• Shark cartilage : Shark cartilage is one of the most popular supplements in the United States, with more than 40 brand-name products sold. Shark cartilage has been suggested as a possible treatment for inflammatory conditions, including rheumatoid arthritis and osteoarthritis. However, additional research is needed to determine if this treatment is safe and effective in humans.
• Avoid if allergic to shark cartilage or any of its ingredients (including chondroitin sulfate and glucosamine). Use cautiously with sulfur allergy. Avoid with a history of heart attack, vascular disease, heart rhythm abnormalities (arrhythmias), or heart disease. Use cautiously with a history of liver or kidney disorders, tendency to form kidney stones, breast cancer, prostate cancer, multiple myeloma, breathing disorders (such as asthma), cancers that raise calcium levels (such as breast, prostate, multiple myeloma, or squamous cell lung cancer), or diabetes. Avoid if pregnant or breastfeeding.
• Stinging nettle : Stinging nettle is found in Africa, Europe, the United States, and Canada. It is a perennial plant that has been used as a medical treatment since ancient times. Nettle is widely used as a folk remedy to treat arthritic and rheumatic conditions throughout Europe and in Australia. Preliminary evidence suggests that certain constituents in the nettle plant have anti-inflammatory and/or immunomodulatory activity. More study is needed to confirm these findings.
• Nettle has historically been used in several different forms to treat pain of varying origins, including arthritis. However, there is a lack of available scientific evidence to confirm this use and additional study is needed.
• Avoid if allergic or hypersensitive to nettle, the Urticaceae family, or any ingredient of nettle products. Use cautiously with diabetes, bleeding disorders, or low sodium levels in the blood. Use cautiously with diuretics and anti-inflammatory drugs. The elderly should also use nettle cautiously. Avoid if pregnant or breastfeeding.
• 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 with paste 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 a lack of safety evidence.
• 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 : Turmeric is a perennial plant native to India and Indonesia. It is often used as a spice in cooking. Laboratory and animal studies show anti-inflammatory activity of turmeric and its constituent curcumin, which may be beneficial in people with osteoarthritis or rheumatoid arthritis. Reliable human research is lacking.
• Avoid if allergic or hypersensitive to turmeric (curcumin), yellow food colorings, or plants belonging to the Curcuma and Zingiberaceae (ginger) families. Use cautiously with a history of bleeding disorders, immune system deficiencies, liver disease, or gallstones. Use cautiously if taking blood-thinners, such as warfarin (Coumadin®). Use cautiously if pregnant or breastfeeding.
• Zinc : Zinc formulations have been used since ancient Egyptian times to enhance wound healing. The majority of trials do not show significant improvements in arthritis symptoms following zinc treatment. Interpretation of some data is difficult because patients in the studies were permitted to continue their previous arthritis medication and most studies used a small number of participants. Well-designed clinical trials are needed before a decision can be made.
• Zinc is generally considered safe when taken at the recommended dosages. Avoid zinc chloride since studies have not been done on its safety or effectiveness. While zinc appears safe during pregnancy in amounts lower than the established upper intake level, caution should be used since studies cannot rule out the possibility of harm to the fetus.

D Fair negative scientific evidence

• Willowbark : Willowbark that contains salicin has been used to treat many different kinds of pain. 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 make a firm conclusion.
• Avoid if allergic/hypersensitive to aspirin, willow bark (Salix spp.), or any of its constituents, including salicylates. Use cautiously with gastrointestinal problems such as ulcers, liver disorders, diabetes, gout (foot inflammation), high blood pressure, or high cholesterol. Use cautiously with a history of allergy, asthma, and leukemia. Use cautiously if taking protein-bound medications, antihyperlipidemia agents, alcohol, leukemia medications, beta-blockers, diuretics, Phenytoin (Dilantin®), probenecid, spironolactone, sulfonylureas, valproic acid, or methotrexate. Use cautiously if pre-disposed to headaches. Use cautiously with use of tannin-containing herbs or supplements. Avoid operating heavy machinery. Avoid in children with chickenpox and any other viral infections. Avoid with blood and kidney disorders. Avoid if taking other NSAIDs, acetazolamide, or other carbonic anhydrase inhibitors. Avoid with elevated serum cadmium levels. Avoid if pregnant or breastfeeding.

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