Rheumatoid arthritis & Complementary and Alternative Medicine

Gharate M.K

Many CAM therapies for arthritis are heavily advertised and make attractive claims, often based on personal stories (testimonials). However, it is important to find out whether any high-quality scientific research has been done on a CAM therapy. Some CAM therapies discussed in this review-such as thunder god vine (which is not currently available in a safe American-made product), gamma-linolenic acid, fish oil, and mind-body therapies--have shown some possibility of benefit for RA.

The claims for many CAM therapies can be attractive, ranging from enhancing well-being, to helping with difficult chronic conditions, to achieving unbelievable results. It is important to know whether scientific research has proven that a therapy works and, if so, why. It is important for people with RA to have their condition followed by a rheumatologist.

Introduction:

Rheumatoid arthritis (RA) is a chronic disease of unknown cause affecting over 2 million adults in the USA ⁽¹⁾. An inflammatory disease of the synovium, it results in pain, stiffness, swelling, deformity and, eventually, loss of function in the joints. Because there is currently no known cure or means of preventing RA, the American College of Rheumatology recommends the earliest possible diagnosis and treatment with disease modifying anti-rheumatic agents to limit the degree of irreversible joint damage⁽¹⁾.  Despite early detection, current treatment medications are limited in their efficacy and are frequently toxic.

Many patients look for complementary and alternative medicine (CAM) options in coping with this debilitating disease. Research has indicated that people suffering from chronic pain, as in RA, and those dissatisfied with current treatment are very likely to seek alternative treatments, and an estimated 60–90% of persons with arthritis use CAM ⁽²⁾. Among the most widely used treatments are chiropractic and herbal therapies ⁽²⁾. This growing interest in alternative medical practices clearly indicates the need for more thorough investigation into the safety and efficacy of CAM. An earlier review ⁽³⁾ conducted in 2000 was limited in that it excluded trials of herbal preparations against active comparators.

Rheumatoid arthritis (RA) is an autoimmune disease. In this type of disease, a person's immune system (the system in the body responsible for fighting disease) mistakenly attacks the person's own body. In RA, the parts attacked are the linings of the joints (places in the body where two bones connect). RA causes pain, swelling, and stiffness in a person's joints and problems with functioning. However, RA affects different people in different ways, in terms of the symptoms they have, how serious the symptoms are, and how long the symptoms last. RA is different from other types of arthritis (such as osteoarthritis). For example:

·RA usually occurs in a symmetrical pattern; for example, if one hand is affected, usually the other will be, too.

·RA often affects the wrists and fingers, though it can affect other parts of the body.

·RA is an autoimmune disease affecting the entire body. A person with RA may feel tired and weak, have fevers at times, lose appetite, lose weight, and generally not feel well ⁽⁴⁾.

Conventional treatment of rheumatoid arthritis:

There are many proven treatments in conventional medicine for RA. They are used to relieve pain, reduce swelling, slow down or stop the damage to joints, help the person function better, and improve the person's sense of well-being. Medications include nonsteroidal anti-inflammatory drugs (NSAIDs), disease-modifying antirheumatic drugs (DMARDs), biological response modifiers, and corticosteroids. Non-drug treatments include physical therapy; modified exercise programs; devices such as canes, special shoes, and splints (rigid supports that keep a part of the body from moving while it heals); and lifestyle changes--such as balancing activity with rest, eating a healthy diet, and reducing stress.

Complementary and Alternative Medicine (CAM):

Among the many reasons that some people use CAM for RA are:

·Because conventional treatment is not working as well as they would like

·A wish for greater relief of symptoms and/or disability

·Issues with side effects of drug treatment

·A desire to reduce some of the stress that comes from living with a chronic illness and to cope better

·A belief that CAM therapies are safer and more "natural"

·Widespread advertising and attractive claims for many CAM products

CAM therapies for rheumatoid arthritis:

Many types of CAM are tried for RA, such as:

1.Preparations made from botanicals (plants and their products, including herbs)

2.Vitamins and minerals in unconventional amounts

3.Other products taken by mouth, such as fish oil

4. Dietary approaches

5.Preparations applied to the skin, such as balms and liniments

6. Hydrotherapy

7.Items that are worn (for example, magnetic clothing or copper bracelets)

8.Mind-body therapies such as relaxation techniques, meditation, and tai chi.

9.Whole medical systems, such as Ayurveda (a traditional medicine of India), traditional Chinese medicine, homeopathy, and chiropractic

10. Other therapies delivered by CAM practitioners--for example, acupuncture or massage

It is beyond the scope of this review to discuss the scientific evidence about all CAM therapies used for RA. The therapies listed below were selected because they are among those most frequently discussed in the scientific literature.

Therapies Discussed in This Review:

1.Botanical supplements and other dietary supplements

1.1.Thunder god vine

1.2.Gamma-linolenic acid (GLA)

1.3.Fish oil

1.4.Valerian

1.5.Four Other Botanicals

1.5.1. Ginger

1.5.2. Curcumin

1.5.3. Boswellia

1.5.4. Feverfew

1.6.Glucosamine and chondroitin

2.Special diets

3.Acupuncture

4.Magnets

5.Hydrotherapy

6.Homeopathy

7.Selected mind-body techniques

8.Chiropractic

1. Botanical Supplements and Other Dietary Supplements

Overall, there is not much rigorous research available on the effectiveness and safety of botanical and other supplements that people try for RA. It is also important to know that while supplements are regulated by the U.S. Food and Drug Administration (FDA) as a category of foods, supplements made from plants and used for medicinal purposes (sometimes referred to as herbal medicines) can have effects as powerful as those of drugs. In fact, many conventional drugs first came from plants, such as digitalis (from the foxglove plant), used to treat heart failure and heart rhythm, and paclitaxel (from the yew tree), a cancer chemotherapy drug.

1.1 Thunder God Vine (TGV) ⁽⁵⁾

Thunder god vine (botanical name Tripterygium wilfordii Hook F) is a perennial vine native to China, Japan, and Korea. Preparations made from the skinned root of TGV have been used in traditional Chinese medicine to treat inflammatory and autoimmune diseases.

Effectiveness and safety

·Some anti-inflammatory and immune-system-suppressing activity for TGV has been seen in laboratory and animal studies. The first clinical trial on TGV in the United States (the earlier ones were done in China) was carried out at the University of Texas Southwestern Medical Center and the National Institutes of Health (NIH).

·Parts of the TGV plant are dangerous. The leaves, the flowers, the main stem, and the skin covering the root are poisonous, to a point that they could cause death. People should never try to make TGV medications themselves.

·If taken for a long time (for more than 5 years), TGV may decrease the density of the minerals in women's bones, which would be of special concern for women who have osteoporosis or are at risk for it. If taken at high doses, TGV could suppress the immune system and increase the effects of immune-suppressing drugs.

·Side effects can occur and may include stomach upset, diarrhea, skin rash, changes in menstrual periods, and hair loss.

1.2 Gamma-Linolenic Acid (GLA)

GLA is an omega-6 fatty acid that is found in the oils of some plant seeds, including evening primrose (Oenothera biennis L.), borage (Borago officinalis L.), and black currant (Ribes nigrum L.). GLA can be used by the body to make substances that reduce inflammation.

Effectiveness and safety

There are potential side effects and risks to know about with GLA. First, these plant seed oils may affect certain medical conditions and interact with prescription medications. Specifically:

·Some borage seed oil preparations contain ingredients called PAs (for pyrrolizidine alkaloids) that can harm the liver or worsen liver disease. Only preparations that are certified and labeled as "PA-free" should be used.

·Borage oil and evening primrose oil might increase the risk of bleeding and bruising, especially in people taking blood-thinning drugs, such as aspirin, clopidogrel, NSAIDs, or warfarin.

·Evening primrose oil may cause problems for people taking a class of psychiatric drugs called phenothiazines, such as chlorpromazine or prochlorperazine.

·Side effects of these oils can include nausea, diarrhea, soft stool, intestinal gas, burping, and stomach bloating.

1.3 Fish Oil ^{(7, 8, 9)}

Fish oil contains high amounts of two omega-3 fatty acids: EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid). As with GLA, the body can use omega-3s to make substances that reduce inflammation.

Effectiveness and safety

·Fish oil or omega-3 supplementation can be used effectively for various aspects of RA--such as the number of tender joints, morning stiffness, and the need for NSAIDs.

·In some people, the high amounts of omega-3s that are present in fish oil can increase the risk of bleeding or affect the time it takes blood to clot. If a person is taking drugs that affect bleeding or is going to have surgery, this is of special concern. Fish oil supplements interact with medicines for high blood pressure, so taking them together might lower a person's blood pressure too much.

·Certain species of fish can contain high levels of contaminants, such as mercury, from the environment ex. shark, swordfish, king mackerel, and tilefish. Thus, their oils could pose a health risk, especially for pregnant or nursing women and for children. People who decide to use fish oil should look for products made from fish with lower mercury levels.

·Another point to note about safety is that a product called fish liver oil can contain more vitamin A than the recommended daily dosage, which could cause problems.

·Generally, for low doses of fish oil supplements, the side effects are mild and can include a fishy aftertaste, belching, stomach disturbances, and nausea.

1.4 Valerian ^{(10, 11,12, 13)}

The herb valerian has a history of use for sleep problems and anxiety disorders. Disrupted sleep has been called a common and often neglected symptom of arthritis. Valerian has also been taken for other reasons, such as the intent to relieve muscle and joint pain. The species of valerian most used in American supplements is Valeriana officinalis.

Effectiveness and safety

The valerian has at least mild benefits for sleep problems in the general population, including insomnia. Valerian may have benefit for people with sleep problems from RA.

There is not much evidence on how long it is safe to take valerian and which dose to use.

·There is not enough reliable evidence to declare whether valerian is effective for muscle and joint pain, including pain from RA. There may be some biological basis for the theory that valerian could be beneficial for musculoskeletal pain.

·Valerian is considered generally safe. However, it should not be taken with sedative drugs (for example, alcohol, benzodiazepines, or narcotics) or other sedative herbs (such as melatonin, SAMe, or St. John's wort). Valerian will increase sedative effects. People who are taking antifungal drugs, statins, or certain anti-arrhythmia drugs should not take valerian. Valerian may not be safe for people who have a liver disorder or are at risk for one. After taking valerian, caution should be used in driving or using dangerous machinery. Side effects of valerian can include drowsiness in the morning, headache, stomach problems, excitability or anxiety, and sleeplessness.

1.5 Four Other Botanicals

Three of the other botanicals marketed with claims to benefit arthritis pain are:

·Ginger ⁽¹⁴⁾

·Curcumin (a component of the spice turmeric) ⁽¹⁵⁾

·Boswellia (also called Indian frankincense, made from the resin of a tree that grows in India) ⁽¹⁶⁾

These three botanicals have a history of use in Ayurveda to treat inflammatory conditions.

A fourth botanical, feverfew, has been used in folk medicine with an intent to treat arthritis, migraine, and other conditions. ⁽¹⁷⁾

Safety

·Ginger's possible side effects include stomach upset, diarrhea, and irritation to the mouth and throat. Ginger is not recommended for people who have a bleeding disorder, a heart condition, or diabetes. Ginger may further slow blood clotting when combined with other herbs and drugs that slow blood clotting; add to the blood-pressure-lowering effects of drugs for high blood pressure and heart disease; and add to the blood-sugar-lowering effects of diabetes drugs.

·Curcumin can have side effects of stomach problems, including nausea and diarrhea. Curcumin could add to the effects of other herbs and drugs that slow blood clotting. Curcumin can cause gallbladder contractions and should not be used by people with gallbladder disease or gallstones.

·Boswellia can have side effects of stomach pain, stomach upset, nausea, and diarrhea. It is not known whether boswellia interacts with any drugs, supplements, or diseases and conditions.

·Feverfew appears to be safe for short-term use, but the safety of long-term use is not known. Feverfew can cause an allergic reaction, especially in people who are allergic to the daisy family. Side effects can include diarrhea and other stomach upsets. Chewing fresh leaves of feverfew may cause mouth irritation and sores. Feverfew might interact with medications broken down by the liver and increase the actions of drugs that slow blood clotting. Pregnant women should not take feverfew.

1.6Glucosamine and Chondroitin ^{(18, 19)}

Glucosamine sulfate and chondroitin sulfate are popular dietary supplements for arthritis. They are sold separately, in combination with each other, and in other combinations.

Glucosamine is a substance found in the fluid around the joints. It can also be obtained from the shells of shrimp, lobster, and crabs, or made in the laboratory. The body uses glucosamine to make and repair cartilage, a firm but flexible tissue that covers the ends of bones, keeps them from rubbing against each other, and absorbs the force of impact.

Chondroitin is a substance found in the cartilage around joints. As a supplement, it is obtained from sources such as sharks and cattle.

Effectiveness and safety

·Both glucosamine and chondroitin have shown anti-inflammatory effects in animal studies. In humans, they have been studied only for osteoarthritis so far, not for RA. Osteoarthritis is a different form of arthritis than RA, with different causes, although the symptoms are similar (such as joint pain and problems with function).

·Glucosamine appears to be safe for most people. However, it might worsen asthma through an allergic reaction. Also, glucosamine might cause higher blood sugar and insulin levels in people with diabetes, and those who decide to use it need to carefully monitor their blood sugar. Glucosamine could possibly decrease the effectiveness of certain medications--acetaminophen, some anticancer drugs, and antidiabetes drugs. Generally, side effects of glucosamine can include mild stomach problems and nausea; less commonly, there can be sleepiness, a skin reaction, or a headache. Some people who are allergic to shellfish are concerned about an allergic reaction to glucosamine. However, most shellfish allergies are to proteins in the meat, not to the shell material from which glucosamine supplements are made.

·Chondroitin appears to be safe for most people. However, chondroitin may possibly worsen asthma (through an allergic response), blood clotting disorders, and prostate cancer. The side effects of chondroitin can include stomach pain and nausea; less commonly, diarrhea, constipation, swelling, and problems with heart rate.

·Both supplements could affect the action of the drug warfarin, but this is not definite.

2. Special Diets ^{(20, 21, 22, 23)}

Many people with RA are interested in whether certain foods can affect their symptoms. Examples of foods that are believed to possibly worsen the symptoms of arthritis (including RA) are the nightshade family of plants (white potatoes, tomatoes, eggplant, and peppers), dairy, citrus fruits, acidic foods, sweets, coffee, and animal protein. There are various theories about how foods may affect RA, including:

·The foods one eats and how the digestive system handles them are known to affect the immune system. Because RA is a disease of the immune system, a connection between diet and the disease has been proposed.

·Certain fats (mostly from animal sources, but also from corn and sunflower oils) break down in the body into substances that can cause inflammation.

·RA and/or medications to treat it may affect the way a person's digestive system handles foods.

·RA can affect a person's ability to prepare and eat food, leading to nutritional problems.

Effectiveness and Safety

·There is no strong, reproducible evidence that any foods or diets have a specific role in causing or treating RA.

·It is important for people who have RA to eat a healthy, balanced diet.

·If one or more foods are eliminated from the diet, it is possible to miss key nutrients and not get enough calories.

·A true food allergy may exist in a small percentage of patients with RA.

3.Acupuncture ^{(24, 25, 26)}

Acupuncture is a practice that developed as a part of traditional Chinese medicine. Some people try acupuncture to treat RA pain or to treat the RA itself. Acupuncture is the stimulation of anatomical points on the body by a variety of methods, including the insertion and manipulation of thin steel needles or the use of pressure from the practitioner's hands. It is intended to remove blockages in the flow of qi.

Effectiveness and Safety

·Good research studies have shown that acupuncture can help relieve pain associated with osteoarthritis. However, not much is known about its effectiveness for symptoms of RA. More and better research is needed.

·Acupuncture tends to have minimal side effects, if any. Relatively few complications from acupuncture have been reported to the FDA. If a person decides to use acupuncture, it is important to find a licensed and certified practitioner, as any complications have usually occurred from inadequate practitioner training and experience.

4. Magnets ^(27,28)

Magnets are objects that produce a type of energy called magnetic fields. The term "magnets" is also used to refer to consumer products that contain magnets. Examples include shoe insoles, clothing, wraps for parts of the body, and mattress pads. These are of a type called static magnets, because their magnetic fields are unchanging.

Effectiveness and Safety: Static Magnets

·The research so far does not firmly support claims that static magnets are effective for treating pain, including pain from RA. In those cases where some benefit was seen it may be due to a placebo effect.

·Static magnets should not be used by pregnant women; people who have a condition--such as an acute sprain, inflammation, infection, or wound--that could be affected by dilation of the blood vessels; and people who use a device such as a pacemaker, defibrillator, or insulin pump, or who use a medication patch.

The second type of magnets used for health purposes are called electromagnets (EMs), because they produce magnetic fields only when electric current flows through them. EMs are used in conventional medicine to treat bone fractures that have not healed well, and they are being studied in research settings for a number of other conditions (including cancer, epilepsy, RA, and mental disorders).

Effectiveness and Safety: Electromagnets

·EMs are being studied because there have been some encouragingearly findings indicating the possibility of benefits for pain, physical function, and stiffness.

·EMs should not be used by pregnant women; people who have a condition--such as an acute sprain, inflammation, infection, or wound--that could be affected by dilation of the blood vessels; and people who use a device such as a pacemaker, defibrillator, or insulin pump, or who use a medication patch. It may be advisable for people who have a history of cancer or seizure disorder to avoid using EMs until more is known about their effects on these medical conditions.

5.Hydrotherapy ^{(29, 30)}

Hydrotherapy is the use of water for therapeutic purposes. A few examples of hydrotherapy include bathing in heated water, as from hot springs or the sea; mineral baths; and water-jet massages. Another term used for hydrotherapy baths is balneotherapy.

Hydrotherapy dates back to ancient Greece and Rome. Some forms of hydrotherapy are used in conventional medicine in the United States, such as whirlpool baths for athletic injuries and ice for sprains. As CAM, hydrotherapy is often combined with other treatments, such as exercises, massage, diets, herbs, and/or mud packs. It is used with the intent to benefit arthritis, circulation, and various other health issues, and to enhance feelings of relaxation and well-being. Some also claim that hydrotherapy "detoxifies" the body. Here, the term hydrotherapy refers to external water treatments and not to internal treatments using water, such as colon irrigation or drinking specially treated water.

Effectiveness and Safety

• A small number of controlled studies have been done on hydrotherapy for RA, most based on sea-bath treatments given in Israel's Dead Sea area. Most of these studies reported benefit.
• The safety of hydrotherapy has not been well studied. Overall, it appears to be a low-risk practice for most people if common-sense precautions are taken, such as not exposing the body to too much heat or cold or for too long a time, and being sure to drink enough fluid. However, hydrotherapy is riskier and could even be dangerous for certain people:

ØThose who have a condition that could be worsened by exposure to extremes of heat or cold (for example, heart disease, lung disease, circulation disorder, Raynaud's phenomenon, or chilblains) or by strong motions from water jets

ØThose who have difficulty perceiving temperature (for example, from neuropathy, or damage to the nerves)

ØWomen who are pregnant

ØPeople who have implanted medical devices such as pacemakers or pumps

·Some people may get a skin irritation or infection from hydrotherapy water, either as a reaction to something in the water or if the water is not in sanitary condition.

6. Homeopathy^{(31, 32, 33)}

Homeopathy is a whole medical system that was developed in Germany and brought to the United States in the 19th century. Homeopathy involves giving very small doses of substances called remedies that would produce the same or similar symptoms of illness in healthy people when given in larger doses. This approach is called "like cures like." The remedies are diluted very highly, often to a point where not one molecule of the original substance remains.

Effectiveness and Safety

• Little rigorous research has been done on homeopathy for RA. It appears from some studies that homeopathy might be more effective than a placebo for rheumatic diseases and syndromes (including RA), but this evidence is not strong.
• Homeopathic remedies are considered safe and unlikely to cause severe side effects. Homeopathic remedies are not known to interfere with conventional drugs.

7. Selected Mind-Body Techniques ^{(34, 35, 36, 37)}

Mind-body techniques draw upon the interactions that exist in health and disease between the mind, the emotions, the body as a whole, and various body systems (such as the immune, nervous, and endocrine systems). Some mind-body techniques are part of ancient healing traditions, others have emerged in recent times. Examples of mind-body techniques include meditation, tai chi, relaxation techniques, and spirituality for health purposes.

Effectiveness and Safety

• Mind-body therapies have been applied to and studied for various types of pain. Results from clinical trials indicate that mind-body therapies may be effective additions to the treatment and management of arthritis, including RA and its pain.
• Mind-body practices led to significant improvements in RA pain, disability, overall psychological state (psychological status), coping, and belief in one's own ability to handle situations (self-efficacy). Mind-body therapies appeared to be more helpful for people who had RA for a shorter period of time, not a longer period.
• Spirituality may help people with RA in their quality of life, coping, and how they feel about their health, although the research so far has been limited, and often it has not looked at RA only. A 2003 study at Johns Hopkins University of people with moderate RA found that those who had "spiritual transcendence had more happiness, joy, and positive perceptions of their own health. This was regardless of how severe their RA was or how well they could function.
• Tai chi is a practice from traditional Chinese medicine that uses specific postures along with gentle, slow movements; meditation; and coordinated breathing. These studies on RA have had conflicting results; some found improvement in daily functioning and certain symptoms, others did not. Tai chi is a relatively safe practice. It is done slowly and at low impact to the body.
• In mind-body therapies, there are relatively few physical and emotional risks, if any. A helpful aspect of most mind-body therapies is that they can be taught to users and practiced by them at times and places of their choice.

In this study, spirituality was described as something "often viewed as an intrinsic quality of the individual, a desire for personal connectedness with a transcendence reality." This was different from religiousness, "an outward practice of a particular spiritual understanding and/or the framework of beliefs, values, and rituals," although the authors noted that this distinction is difficult. Spirituality was measured using a scale designed to evaluate "the capacity of an individual to stand outside of his/her immediate sense of time and place and to view life from a larger, more detached perspective."

8. Chiropractic⁽³⁸⁾

A whole medical system based on the concept that the body has a powerful self-healing ability, and its structure (primarily the spine), function, and health are closely related. The goal of therapy is to correct structural alignment problems and allow the body to heal itself.

References:

1.American College of Rheumatology. Ad Hoc Committee on Clinical Guidelines. Guidelines for the management of rheumatoid arthritis. Arthritis Rheum. 1996; 39:713–22.      

2.Rao J, Mihaliak K, Kroenke K, Bradley J, Tierney W, Weinberger M. Use of complementary therapies for arthritis among patients of rheumatologists. Ann Intern Med. 1999; 131:409–16.

3.Little C, Parsons T. Herbal therapy for treating rheumatoid arthritis (Cochrane Review). The Cochrane Library, Issue 1. Oxford: Update Software, 2002.

4.Berman JD, Straus SE. Implementing a research agenda in complementary and alternative medicine. Annual Review of Medicine. 2004; 55:239-254.

5.Balick MJ, Lee R. Digging in the herb garden: responding to a patient's query about thunder god vine.* Alternative Therapies in Health and Medicine. 2001;7(6):100-103.

6.Natural Medicines Comprehensive Database. Gamma-Linolenic Acid. Web site (www.naturaldatabase.com).

7.Ariza-Ariza R, Mestanza-Peralta M, Cardiel MH. Omega-3 fatty acids in rheumatoid arthritis: an overview.* Seminars in Arthritis and Rheumatism. 1998;27(6):366-370.

8.Berbert AA, Kondon CR, Almendra AL, et al. Supplementation of fish oil and olive oil in patients with rheumatoid arthritis.* Nutrition. 2005;2:131-136.

9.Oh R. Practical applications of fish oil (omega-3 fatty acids) in primary care. Journal of the American Board of Family Practice. 2005; 18 (1):28-36.

10. Natural Medicines Comprehensive Database. Valerian. Web site (www.naturaldatabase.com).

11.Natural Standard Database. Valerian (Valeriana officinalis L.). Web site (www.naturaldatabase.com).

12. Office of Dietary Supplements. Questions and Answers About Valerian for Insomnia and Other Sleep Disorders. Web site (www.ods.od.nih.gov)

13.Taibi, DM, Bourguignon C, Taylor AG. Valerian use for sleep disturbances related to rheumatoid arthritis. Holistic Nursing Practice. 2004;18(3):120-126.

14. Natural Medicines Comprehensive Database. Ginger. Web site (www.naturaldatabase.com).

15.Natural Medicines Comprehensive Database. Turmeric. Web site (www.naturaldatabase.com).

16. Natural Medicines Comprehensive Database. Indian Frankincense. Web site (www.naturaldatabase.com).

17.Pattrick M, Heptinstall S, Doherty M. Feverfew in rheumatoid arthritis: a double blind, placebo controlled study. Annals of the Rheumatic Diseases. 1989. 48(7):547-549.

18. Natural Medicines Comprehensive Database. Glucosamine Sulfate. Web site (www.naturaldatabase.com).

19. National Center for Complementary and Alternative Medicine. Questions and Answers: NIH Glucosamine/Chondroitin Arthritis Intervention Trial (GAIT). Web site. (www.nccam.nih.gov)

20. Henderson CJ, Panush RS. Diets, dietary supplements, and nutritional therapies in rheumatic diseases. Rheumatic Disease Clinics of North America. 1999;25(4):937-968.

21.Capriotti T. Any science behind the hype of "natural" dietary supplements? Medsurg Nursing. 2004; 13 (5):339-350.

22. Danao-Camara TC, Shintani TT. The dietary treatment of inflammatory arthritis: case reports and review of the literature. Hawaii Medical Journal. 1999; 58 (5):126-131.

23.Knoops KT, de Groot LC, Kromhout D, et al. Mediterranean diet, lifestyle factors, and 10-year mortality in elderly European men and women: the HALE project. Journal of the American Medical Association. 2004; 292 (12):1433-1439.

24.Berman BM, Lao L, Langenberg P, et al. Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: a randomized, controlled trial. Annals of Internal Medicine. 2004; 141 (12):901-910.

25. Casimiro L, Brosseau L, Milne S, et al. Acupuncture and electroacupuncture for the treatment of RA. Cochrane Database of Systematic Reviews. 2004; (3):CD003788.

26.National Center for Complementary and Alternative Medicine. Acupuncture. Web site. Web site (www.nccam.nih.gov).

27. National Center for Complementary and Alternative Medicine. Questions and Answers About Using Magnets To Treat Pain. Web site  (www.nccam.nih.gov)

28. Schlaepfer TE, Kosel M, Nemeroff CB. Efficacy of transcranial magnetic stimulation (rTMS) in the treatment of affective disorders. Neuropsychopharmacology. 2003; 28 (2):201-205.

29.Verhagen AP, Bierma-Zeinstra SM, Cardoso JR, et al. Balneotherapy for rheumatoid arthritis. Cochrane Database of Systematic Reviews. 2005; (2):CD00518.

30.Natural Medicines Comprehensive Database. Hydrotherapy. Web site (www.naturaldatabase.com).

31.Fisher P, Scott DL. A randomized controlled trial of homeopathy in rheumatoid arthritis. Rheumatology (Oxford). 2001; 40 (9):1052-1055.

32. Fisher P, Scott DL. A randomized controlled trial of homeopathy in rheumatoid arthritis. Rheumatology (Oxford). 2001; 40(9):1052-1055.

33. Jonas WB, Linde K, Ramirez G. Homeopathy and rheumatic diseases. Rheumatic Disease Clinics of North America. 2000; 26 (1):117-123.

34.Astin JA. Mind-body therapies for the management of pain. Clinical Journal of Pain. 2004;20 (1):27-32.

35.National Center for Complementary and Alternative Medicine. Mind-Body Medicine: An Overview. Web site.

1. Han A, Robinson V, Judd M, et al. Tai chi for treating rheumatoid arthritis. Cochrane Database of Systematic Reviews. 2004; (3):CD004849. Accessed on July 21, 2004.

37.Wang C, Roubenoff R, Lau J, et al. Effect of tai chi in adults with rheumatoid arthritis. Rheumatology (Oxford). 2005; 44 (5):685-687.

38.www.holisticonline.com/Remedies/Arthritis/arth_RA_herbal_med.htm

About Authors:

Gharate M.K.
Lecturer, Dept of Pharm. Chemistry, MGV’s Pharmacy College, Panchavati, Nashik - 422 003.
Mobile: 9881669753, manishatayde@rediffmail.com

Mrs. Rupali a. Patil, Lecturer, Dept of Pharmacology, MGV’s Pharmacy College, Panchavati, Nashik – 422 003.