New Review of Complemetary and Alternative Therapies for Arthritis

I’ve written extensively about alternative arthritis therapies, largely because that is one of the most common conditions for which complementary and alternative treatments are used. While a few are promising (such as fish oils), there is little good evidence to support most such practices. A detailed and very useful new review of alternative therapies for arthritis in humans has just been released. And while extrapolation from humans to pets has dangers and has to be viewed with some skepticism, this at least gives us some guidance as to whether such therapies have proven their value for people, a question for which the evidence is usually much greater in quantity and quality than we often get for veterinary uses.

The review, produced by the non-profit group Arthritis Research UK, is divided into two reports:

Complementary and alternative medicines for the treatment of rheumatoid arthritis, osteoarthritis and fibromyalgia

Practitioner-based complementary and alternative therapies for the treatment of rheumatoid arthritis, osteoarthritis, fibromyalgia and low back pain

I won’t go through all the findings, but in terms of the therapies I’ve covered before, the review pretty much confirms the evidence to date, with a couple of exceptions.

Glucosamine
The review assigns a score of 2/4 for glucosamine sulphate, which is defined as:

There’s only a little evidence to suggest the compound might work. The evidence in this category often comes from a single study which has reported positive results, and there are therefore important doubts about whether or not it works.

The evidence for glucosamine hydrochloride is not even as strong as this.

My own assessment is slightly more pessimistic that this based largely on these two findings:

There’s some evidence that more recent trials and those using higher?quality methods are less likely to show a benefit.Trials that used the best methods to make sure that participants didn’t know which treatment they were getting didn’t show significant benefits in pain relief and improved physical function.

So while there is some positive clinical trial evidence the better the controls for bias and error, the less likely positive results will be found, which is usually a signs that the therapy is not actually effective.

No significant risks appeared in the trials evaluated.

Chondroitin
This supplement, like glucosamine, is assigned a score of 2/4, indicating claims of a meaningful benefit are dubious.

Overall, evidence from trials with a good study design in allocating participants to treatment groups and trials that used the most appropriate statistical methods had lower estimates of effectiveness of chondroitin, particularly in terms of reduction in joint pain.In the most recent review, the authors concluded that chondroitin (or its combination with glucosamine) didn’t reduce joint pain to any clinically meaningful extent or change clinical aspects of the joint.

Chondroitin appears to have no significant risks.

Fish Oil
The evidence is limited, but it is pretty strong for a benefit of fish liver oil in treatment of rheumatoid arthritis. However, the evidence is not sufficient to determine if there is benefit from the more common fish body oil for non-rheumatoid osteoarthritis.

There’s good evidence that fish body oil can result in improvement in the symptoms of rheumatoid arthritis and some unconfirmed evidence that the combined treatment of fish body and liver oils might also be of long-term benefit, particularly in reducing daily NSAID use. Evidence for the use of fish liver oil for osteoarthritis is based on insufficient data.

Side effects appear to be mild, though high-dose or prolonged use of fish liver oil can lead to serious overdoses of Vitamin A.

Homeopathy
Despite the fact that there is no plausible reason to believe homeopathy could be an effective therapy for anything, this review took the slightly naïve approach of review the clinical trial research without regard to prior plausibility. Nevertheless, the score for arthritis was a 1/5 for both osteoarthritis and rheumatoid arthritis:

Overall, there’s no evidence to suggest that the compound works or only a little evidence which is outweighed by much stronger evidence that it doesn’t work.

The score for fibromyalgia was a 2/5, and detailed discussion of some of this research can be found here and here.

SAMe
The review only found a couple of studies looking at use of SAMe for osteoarthritis, but it found them to be consistently positive and of reasonable quality, earning a score of 4/5.

There’s some consistency to the evidence, which will come from more than one study, to suggest that the compound works. Although there are still doubts from the evidence that it works, on balance we feel that it’s more likely to be effective than not.Evidence from RCTs suggests that SAMe is effective in reducing functional limitations and, to a lesser extent, pain in osteoarthritis.

Generally, SAMe is believed to be safe, but severe side effects (mania and anxiety) have been seen in some individuals with depression.

Acupuncture
The report was very favorable for a positive effect of acupuncture on osteoarthritis. However, the authors based their conclusion mostly on a 2010 Cochrane Review which found < 5% difference in pain scores between real and fake acupuncture:

Pain after 8 weeks:-People who had acupuncture rated their pain to be improved by about 4 points on a scale of 0 to 20. -People who received sham acupuncture rated their pain to be improved by about 3 points on a scale of 0 to 20.-People who received acupuncture had a 1 point greater improvement on a scale of 0-20. (5% absolute improvement).Pain after 26 weeks:-People who had acupuncture rated their pain to be improved by slightly more than 3 points on a scale of 0 to 20. -People who received sham acupuncture rated their pain to be improved by slightly less than 3 points on a scale of 0 to 20.-People who received acupuncture had under a 1 point greater improvement on a scale of 0-20. (2% absolute improvement). Physical function after 8 weeks :-People who had acupuncture rated their function to be improved by about 11 points on a scale of 0 to 68. -People who received sham acupuncture rated their function to be improved by about 8 points on a scale of 0 to 68.-People who received acupuncture had about a 3 point greater improvement on a scale of 0-68. (4% absolute improvement) Physical function after 26 weeks :-People who had acupuncture rated their function to be improved by about 11 points on a scale of 0 to 68. -People who received sham acupuncture rated their function to be improved by about 10 points on a scale of 0 to 68.-People who received acupuncture had about a 1 point greater improvement on a scale of 0-68. (2% absolute improvement)

Not very compelling results. And the other studies the authors reviewed included one large trial, which showed no benefit, and 7 very small trials, two of admittedly poor quality, which showed small but inconsistent benefits. Given this evidence, the score seems excessively positive. And given the concern about significant placebo effects involved in acupuncture therapy, even if this tiny difference is real, it is unlikely to be of real benefit to veterinary patients but very likely to be subject to the caregiver placebo effect.

Chiropractic
Only 1 trial was identified, which was not well controlled, so this intervention received a score of 2/5, indicating no compelling evidence of effectiveness. And unlike most of the therapies reviewed, chiropractic received only an intermediate “amber” grade for safety:

Therapies with an amber rating have commonly reported side-effects (even if they’re mainly minor symptoms) or more serious side-effects.

 

 

 

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37 Responses to New Review of Complemetary and Alternative Therapies for Arthritis

  1. Art says:

    Can you add a link in the SAMe section linking to the RCTs that support it works for osteoarthritis?
    Art Malernee Dvm

  2. Pingback: Arthritis research updates | Gilgablog

  3. skeptvet says:

    The link to the report should take you to the .pdf. All of the studies are described and cited there.

  4. Art Malernee Dvm says:

    Does SAMe smell like the old dl methionine capsules we gave pets with liver enzyme elevations in the 70s? If so were the studies blinded so those in the study could not tell the difference due the smell of the drug? Dl methionine has a sauerkraut smell.
    Art

  5. John Duncan DVM says:

    Are polysulfated glycosaminoglycan injections considered mainstream or CAM? I noticed that they aren’t covered in this review.

  6. skeptvet says:

    Well, nutraceuticals fall into a grey area (not that CAM is ever sharply defined). They are biologically plausible and often have some legitimate researc evidence to support their use, but they are often promoted with claims far beyond anything supported by the evidence, or as necessarily safe and effective because they are “natural,” and this can make them more CAM than scientific medical therapies.

    Anyway, a 2007 systematic review (1) found one study in dogs (2) that was small and showed some benefit on purely subjective critria. A horse study, not reported completely, seemd to show little benefit (3). I’m not sure about the human data, but the veterinary data is limited and not very strong.

    1) Systematic review of clinical trials of treatments for osteoarthritis in dogs
    Carlos L. Aragon, Erik H. Hofmeister, and Steven C. Budsberg
    Journal of the American Veterinary Medical Association, February 15, 2007, Vol. 230, No. 4 , Pages 514-521

    2) Johnson SA. Osteoarthritis: joint anatomy, physiology, and pathobiology.
    Vet Clin North Am Small Anim Pract 1997;27:699–723.

    3) Evaluation of intra-articular polysulfated glycosaminoglycan and sodium hyaluronan for treatment of osteoarthritis using an equine experimental model.

    Author(s) Frisbie, D. D.; Kawcak, C. E.; Werpy, N. M.; McIlwraith, C. W. Proceedings of the 54th Annual Convention of the American Association of Equine Practitioners, San Diego, California, USA, 6-10 December 2008 2008 pp. 250-251

  7. gat says:

    These studies were done by Oxford..so already a bias. They have not been replicated and they appear to not be peer reviewed. So right there in the definition of legitmate research they fall short. Too many confounding variables will give false results. There are so many research studies done to support the use of natural remedies but none of those scientific studies are included here. What do you use to prevent and treat arthritis? It seems a skeptics life is a constant search for science to support a fear of the world of the unknown. Yet real security is only found within oneself not outside.

  8. skeptvet says:

    I’m afraid your comment doesn’t make a lot of sense. What bias exactly do you see in the authors? Given this is a non-profit group involved in helping arthritis patients, it’s hard to see why they would be inclined to reject effective therapies regardless of what kind they are. It is not published in a peer-reviewed journal, nor is it a systematic review with pre-determined exclusion and exclusion criteria, so certainly uncontrolle dbias is possible. But the evidence cited is clearly graded by Jadad score and available for review, so you can’t simply dismiss it because you don’t like the conclusion. If you have specific studies that support different conclusions, you need to identify those for your critique to be taken seriously.

    Speaking of bias, you completely mischaracterize skepticism. Fear is what drives blind belief in the unproven, desperate clutching at narratives that calm our fears. Skepticism is about evaluating the available evidence carefully and critically and witholding judgment until there is adequate evidence to support a claim. It is about fearflessly following the evidence rather than believing what we chose to believe and what comforts us.

    So instead of empty personal critiques based on your guesses about what others think, perhaps you’d like to talk about actual evidence?

  9. gat says:

    This makes no sense…everybody who knows about how research is conducted know the pitfalls. That is why one research studys are always changing depending on who does the study.one study says coffee is good for you and the next research study says coffee causes cancer. A vet that has a phd in nutrition is not the ultimate authority on pet food. The science they study is about the chemical composition of foods but not about nutritional value. So if corn gluten, or the leather sole from a shoe makes up x amount of protein that is what goes into a bag of kibble. So telling a client who’s dog has cancer to use IAMS is justified.

  10. gat says:

    I am sorry if I hit a nerve in you about my “obervational bias” unscientific comment about the inner workings of the skeptics mind. I might be projecting as I know myself to be an opened minded skeptic but do not completely rely on science and research to shape my world view. I use science and research more as as siggn post. I did take Research Methods class in college and it was the most informative course I took. We learned the roots of how research is done and we would take famous studies and would go over how the statistics etc. were flawed. I even broguht up the Pottengers Cat study and my professor said not legitimate study as it was never replicated..the controls were off..no peer review etc

  11. gat says:

    I was also a dietetics nutrition major but changed after I saw the food pyramind contained donuts and white flour in the grain group as being I part of a healthy diet!

  12. gat says:

    I also learned that there are thousands of people with advanced degrees backup by real research and yet humans are still not in agreement on what the correct diet should be. I know the texbooks that are studied by the animal phds and they do say a dog has no need for carbs yet the very pet food they promote are 75% carbs? How can this be? I think sometimes people can get swallowed up inscience and not see the forest for the trees…my family has always had dogs and my mom said they fed he dog table scaps..did not take to the vet yearly..and lived until 18..so I would love science to be geared towards learning what made this dog stay halthy as oppossed to how to treat illness

  13. skeptvet says:

    I’m fully aware of how to critically appraise research literature for risk of bias, confounding, chance, and other potential sources of error. But you aren’t doing that. You are saying, with no evidence whatsoever, that this review can be ignored because you believe the authors are biased. And what this has to do with pet nutrition is a mystery.

  14. skeptvet says:

    You didn’t hit a nerve, you just seem to prefer talking about motives and attitudes rather than facts, and I don’t see that as a productive way to evaluate medical therapies.

  15. skeptvet says:

    So you can think of a case that ate crap, got no medical care, and still lived a long time and we are supposed to take that as a reason to ignore the entire field of veterinary nutrition? And yet you dismiss an entire literature reviw based on your belief the authors are biased? It doesn’t seem to me that you are acknowledging the limitations of science so much as not really understanding what the role of controlled research is. You have entirely too much faith in your own ability to make judgments regardless of facts, evidence, or your own biases.

  16. gat says:

    Stop being so cranky or I am going to recommend a Bach Flower remedy for you to take….dogs have lived with humans for thousands of years..way before Petco and bags of moldy meat sitting on shelfs for years were created..why do you say my moms dog ate crap?..and yes I do think science should study health and not be so focused on disease..I think that sounds realistic? Is there anything in the Townsend Letter journal that you would consider as credible studies? I never said to throw out these studies you are referring to I said they have a bias..as does all research…including the holistic point ov view as well…fresh whole foods seems like a smart idea compared to dry food that has been processed..

  17. skeptvet says:

    Perhaps you should stop imputing attitudes and states of mind to me. I’m not cranky, just not impressed by the content or quality of your arguments. What we have been doing for thousands fo years is irrelevant to what is healthy or optimal. Poor nutrition compromises health and reduces both lifespan and well-being. Haphazard table scraps is poor nutrition, and the fact that your mother’s dog got away with eating it is not an argument against commercial pet, any more than your gratuitous and silly description of “bags of moldy meat” has any bearing on the facts. You seem really averse to talking about facts and evidence. You are free, of course, to toss around claims and opinions without these, but no one needs to take what you say seriously if you do.

  18. gat says:

    And yes you are right I do like to talk about motives..I find it so interesting the reasons why people do what they do..I like the emotions as well as the content on your blog. But that is my world view and why I got my degree in psychology. I seemed to have learned more about people though from life experiences. And I may not seem like I get what you are trying to say with all this..but I do understand your perspective, for what it worth I do see what you are trying to warn people about with magical holistic thinking…but I do think science is moving from biology and chemistry etc. into more psychics as being the new medical perspective. I enjoy chatting with you..thanks for the challenges..

  19. gat says:

    Ps so can I ask again how you would prevent a dog or cat etc from getting arthritis? And what you would do to heal that condition if a pet had it?

  20. gat says:

    Ps so can I ask again how you would prevent a dog or cat etc from getting arthritis? And what you would do to heal that condition if a pet had it? And you said something about neotany having a connection to anatomical changes in a dog so that would mean because a dogs head was bigger it therefore could digest kibble? Am I misreading that conclusion on another post?..

  21. gat says:

    I still think you are cranky…I am just trying to share my side…we can agree to disagree ok?..

  22. gat says:

    You remind me a lot of Dr. Wysong…it would be interesting to see you have a discussion with him…problem is you would both be right and not so right…and I was not trying to impress you..see you are doing to me what you are accusing me of doing to you…conjecture and assuming you know my motives…so do you think that is like that saying. “If you point a finger at someone remember there are 3 pointed back you”? ….I guess in the end I will stick with ” I would rather be happy or right?”..oh btw I did use an herb that removed a very large tumor on my dog…I put the herb on and the tumor fell off…I took pictures of the process..take care

  23. skeptvet says:

    I’ve reviewed a number of arthritis therapies from a veterinary perspective: http://skeptvet.com/Blog/2011/03/veterinary-arthritis-treatments/

    Prevention depends on the individual risk factors. Decreased calories and calcium levels for large breed puppies is important, for example. Breeding to avoid perpetuation of dysplasia is relevant for many breeds. Maintaining a healthy body condition (not overweight) and not forcing high-impact exercise nor prevention regular appropriate exercise are also important.

  24. skeptvet says:

    We can certainly agree to disagree, but you’re impression of my mood from these little exchanges depends as much, probably more, on you as on me.

  25. gat says:

    well saying my family fed their dog “crap” I don’t think it in the spirit of a healthy exchange of ideas on your blog. So yes I would consider that a cranky attitude. The food was fresh, they did not go to modern supermarkets stores like today where most of the foods are processed. They shopped locally at the butcher, the farm, fresh produce, fish, eggs, etc., daily. So that is what the dog ate. Variety and fresh cooked foods. Not proccessed food like kibble and canned pet food. But isn’t that what kibble is ? table scaps? I do not think there is some seperate place where they raise different animals, grow grains, fruits and veggies for pets…they eat the same things we do. Kibble and canned foods have been processed and then spayed with synthetic vitamins to get them back to be “complete and balanced”. The very thing you are not in favor of…vitamins? Yet these foods have them in them. On one hand you support the phds whose very own college textbooks of small clinical nutrition state “dogs do not need carbs”…yet that is what kibble is made of. So they turn around and sell these products that are not in line with their own science. So do you think dogs should have carbs? Yes? no? What is better for them? And you cannot say I am taking your inventory here and plead the fifth..I am asking a simple question to you so I can understand your position. Do you think, even in light of the science that says dogs do not need carbs, that carbs are a good source of nutrition for a dog? I am not trying to attack you, or accuse you of anything all I was looking for was for you to be accountable for a contraditory statement.

  26. skeptvet says:

    Fine, you can substitute “nutritionally poor” for “crappy” if that seems friendlier to you. The point is that a haphazard collection of random ingredients designed to suit the taste of humans is not equal to a well-balanced diet prepared with knowledge of the nutritional requirements of dogs. A fresh diet can be fine for dogs if it is properly formulated and balanced, but random table scraps is not nutritionally appropriate.

    As for what kibble is, you’re confusing ingredients with nutrients. The specific nutrient profile and digestibility of prepared commercial foods is well established. This is not the case for table scraps. The source of the nutrients is less important than the quantity and availability of those nutrients.

    As for carbs,dogs are functionally omnivores (as opposed to cats, who are obligate carnivores). And carbohydrates can be a perfectly digestible and appropriate source of calories for both species. The current hysteria about the negative health effects of carbs isn’t supported by any real evidence. It is an example of the appeal to nature fallacy to say that whatever an animal (or in the case of domestic animals, their ancesotrs) ate in the wild is the best diet for them. Wild animals adapt to eat what is available, but all animals, including humans, are healthier if they eat a nutritionally complete and appropriate diet. Exactly what that is is not completely understood for any species, but we know enough to know that the current irrational fads about raw foods, grain free diets, and so on, are based purely on speculation, and the conventional commercial diets are based on at least some reasonable empirical research. Not perfect, but a damn site better than just guessing.

  27. gat says:

    Ok I understand your perspective. I have used and tried almost every dog food out there…kibble canned dehydrated raw..all of them. I cooked for my lab for 7 yearrs and now she is 12 and had a check up and she is healthy except for lipoma…which I put an esseential oil on and it started to drain…but anyway I have 3 dogs now and it is harder to cook for them. They seem to do best on homecooked variety..but I do feed them Fromms now and is about the only company that has no recalls but I am not sure of the research behind their formulas..but your perspective is to look at the food from a point of the parts make the whole and I see food as more the whole is made up of parts if that makes any sense…

  28. Carol says:

    Thank you for the great website.
    What do you think of Marion Nestle’s book, “Feed Your Pet Right”? She refers to a simple formula, combining meat, cooked grains, cooked vegetables, bone meal, and a multivitamin to create meals at home for your pet. I frequently walk and sometimes feed a neighbor’s dog, and I roughly follow this formula using food I have at home. He loves what I feed him, and it saves me from storing dog food which would be used only occasionally. His owner also cooks for him, usually chicken, a grain mixture for pets and a few vegetables, which she cooks, combines, freezes and thaws out when it’s feeding time. I know feral dogs probably aren’t very healthy, but it seems that feeding your pet a variety of foods at home is unlikely to cause problems, skipping the sugar, of course, and things that might cause problems such as onions and garlic. What do you think of using this formula to feed a dog? (The quantities are 4 oz meat, 8 oz cooked grains–I usually use brown rice–and 2 oz cooked vegetables for a 40 pound dog.)

  29. skeptvet says:

    As you will see in another post on this site, several studies have found that most published recipes for unprovoked dog food are nutritionally inadequate, with either deficiencies or excesses of certain micronutrients. So I encourage anyone who wants to feed a unprovoked diet to consult a veterinary nutritionist for guidance. such diets may have health benefits, though no one has yet shown this to be the case.

    As for the specific book referenced, I haven’ t looked at it yet, so I can’t comment on the advice given in it.

  30. Anthro says:

    Oh! Please, please look at “Feed Your Pet Right” by Marion Nestle, PhD and Public Health Advocate (master’s degree in that too) and Malden Nesheim, PhD, of Cornell (emeritus I think) who has vast knowledge and experience with animal nutrition.

    The book is very down to earth, very science-based, and the recipes are very much in line with those principles. The commenter didn’t quite do them justice. The authors make is VERY clear, the supplements MUST be part of the homemade dog food and there is much, much more to the book than the recipe.

    Dr. Nestle has a blog–foodpolitics.com–that speaks to human nutrition and the politics thereof. Dr. Nesheim is her real life partner and more recent co-author. They are both excellent scientists, nutrition advocates for people and pets, and (having met one of them and corresponded with both) delightful human beings.

  31. skeptvet says:

    I’m not sure how this comment relates to this article, but I appreciate the recommendation.

  32. Anthro says:

    The comment relates directly to the comment above mine–which mentions the book “Feed Your Pet Right” and to which you reply that homemade dog food isn’t such a good idea. ??? Isn’t that obvious? Am I seeing something you are not?

    🙂

  33. skeptvet says:

    My mistake. The comments had gotten a bit off the original topic of the post, and the way new comments are displayed in the admin dashboard is chronological rather than grouped by post, so I wasn’t seeing the comments right before yours, just yours in isolation.

    As I said before, the research so far shows that recipes from books and web site are often nutritionally inadequate, but hopefully the book you’re talking about does a better job than most. It would be nice to have one I could confidently recommend, so I will try to get around to looking at it at some point. Thanks again.

  34. v.t. says:

    Also, Anthro, blog commenting “etiquette” would require us to quote the person we are addressing, (or, use “@-insert-name”), I’m guilty as sin for not doing that. So, yes, the posts can get confusing sometimes especially when there are tons of comments or time delays between posts and comments. It’s easy to wonder who’s posting to whom 🙂

  35. Anthro says:

    @v.t.

    I usually do the @ thing, but I don’t think this situation would have been clarified by my having put @skeptvet on my post. Will keep it in mind, though–the inner workings of comment postings being far beyond my expertise!

    @skepvet

    Re: Feed Your Pet Right

    I do hope you look at this book, as I detect your natural skepticism–which I ordinarily share.

    I would also refer you to foodpolitics.com which is Marion Nestle’s blog. There is a good summary of her qualifications there, information on her other books and further information on Dr. Nesheim. (It’s also a great resource on public health and human nutrition).

    I am thrilled to have this recipe (and the wealth of solid information in the book) due to my growing frustration with the ever-burgeoning marketing practices of dog food companies. It’s getting impossible to find some simple kibble that doesn’t make ridiculous health claims and add equally ridiculous supplements that make very dubious claims. I have been very disappointed in Science Diet in this vein, although after reading about their affiliation with vet schools, I now wonder if I have put way too much faith in vet’s recommendations for this brand. Nestle and Nesheim cover this issue in a very even-handed way to my mind, but would be interested in your thoughts. Perhaps you will review the book?

  36. Anthro says:

    @v.t.

    An afterthought: Where does one learn “blog commenting etiquette” anyway? I picked up the @ from reading them, but is there something more formal?

  37. v.t. says:

    Anthro, I don’t think there’s any hard and fast rules beyond being nice, no spamming, hit&run comments, link spamming, off-topic remarks, and of course, following rules the blog owner has set forth. That said, you can certainly google “blog commenting etiquette” for some basics.

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