Arthritis and Complementary Health Approaches: What the Science Says

Clinical practice guidelines issued by the American College of Rheumatology and the Arthritis Foundation recommend aerobic exercise and/or strength training, weight loss (if overweight), and a number of pharmacologic and nonpharmacologic modalities for treating osteoarthritis (OA) of the knee, hip, or hand. The guidelines strongly recommend tai chi, along with other nondrug approaches such as self-management programs, for managing knee and/or hip OA. Yoga is conditionally recommended for those with knee OA. Acupuncture is conditionally recommended for people with knee, hip, and/or hand OA. Massage therapy is conditionally recommended against use in people with knee and/or hand OA.

Despite extensive research, it’s still uncertain whether glucosamine and chondroitin have a meaningful impact on symptoms or joint structure in OA. The clinical practice guidelines strongly recommend against the use of glucosamine in people with hip, knee, and/or hand OA; however, the guidelines conditionally recommend chondroitin for people with hand OA. Topical capsaicin is conditionally recommended for people with knee OA and conditionally recommended against use in people with hand OA. The evidence on other natural products is too limited for any conclusions to be reached.

What Does the Research Show?

• Acupuncture. A 2016 meta-analysis of 10 randomized controlled trials concluded that acupuncture can improve short and long-term physical function, but it appears to provide only short-term pain relief in patients with chronic knee pain due to arthritis. A 2012 meta-analysis concluded that acupuncture can be helpful and a reasonable referral option for OA pain. The authors of the meta-analysis also noted that significant differences between true (actual) and sham acupuncture indicate that acupuncture is more than a placebo; however, these differences are relatively modest. Findings suggest that factors other than the specific effects of needling contribute to the therapeutic effects of acupuncture. A 2023 systematic review and meta-analysis evaluated the effectiveness of acupuncture as an adjunctive therapy to oral pharmacologic medication in patients with knee OA and found that combined treatment of oral medication and adjuvant acupuncture showed statistically significant improvement in knee function and reduction in pain at the end of acupuncture treatment and short-term follow-up time (between 4 and 6 weeks after acupuncture).  
• Massage therapy. A 2020 review found that massage or myofascial release yields a small improvement in hip and knee osteoarthritis. A 2017 systematic review of 7 randomized controlled trials involving 352 participants with arthritis found low-to-moderate–quality evidence that massage therapy is superior to nonactive therapies in reducing pain and improving functional outcomes. A 2013 review of two randomized controlled trials found positive short-term (less than 6 months) effects in the form of reduced pain and improved self-reported physical functioning.
• Yoga. A 2019 systematic review of 9 studies (640 total participants) showed that yoga may be helpful for improving pain, function, and stiffness in people with osteoarthritis of the knee. However, the number of studies was small, and the research was not of high quality. The 2019 clinical practice guidelines from the American College of Rheumatology and the Arthritis Foundation conditionally recommends yoga for people with knee osteoarthritis based on similarities to tai chi, which has been better studied and is strongly recommended by the same guideline.
• Tai chi. A 2021 systematic review and meta-analysis of 11 randomized controlled trials involving a total of 603 participants found that tai chi was associated with improved walking function and posture control in older adults with knee osteoarthritis. A 2020 systematic review and meta-analysis of 20 randomized controlled trials and 2 case series found that compared to the controls groups, exercise (including tai chi and yoga) showed a small-to-high effect for improving pain, physical function, quality of life, and stiffness. A 2016 randomized, 52-week, single blind comparative effectiveness study involving 204 participants, found that tai chi produced beneficial effects similar to those of a standard course of physical therapy in the treatment of knee osteoarthritis. A 2021 systematic review and meta-analysis of 16 randomized controlled trials involving a total of 986 participants with knee osteoarthritis found that pain, physical function, dynamic balance, and physiological and psychological health were significantly improved for those practicing tai chi. 
• Glucosamine and chondroitin. Studies of glucosamine and chondroitin for pain in knee OA have had conflicting results. Some, including a major National Institutes of Health (NIH)-sponsored study, found little or no evidence that glucosamine and chondroitin can relieve pain, but several other studies indicated that it can. 
  • Studies of chondroitin for pain from OA of the knee have had inconsistent results, but in general, the largest, highest quality studies have not shown an effect. There isn’t enough evidence to show whether glucosamine or chondroitin lessens pain from OA in other joints. 
  • A few studies have looked at whether glucosamine or chondroitin or the combination can have beneficial effects on joint structure in people with OA. Some but not all of these studies found evidence that chondroitin or a glucosamine-chondroitin combination might help, but the improvements seen in most studies may be too small to make a difference to patients. 
  • In 2017, the American Academy of Orthopaedic Surgeons published a clinical practice guideline on management of osteoarthritis of the hip that concluded that moderate-strength evidence does not support the use of glucosamine sulfate for hip osteoarthritis. This conclusion was based on the one high-quality  study, published in 2008, that included 222 participants, who received 2 years of treatment with glucosamine sulfate or a placebo. Glucosamine was no better than placebo in terms of effects on pain, joint function, or joint structure.
  • Another study with 162 participants evaluated chondroitin for hand osteoarthritis and found that over 6 months, hand pain decreased and hand function improved to a greater extent in the chondroitin group than the placebo group. 
  • The 2019 guideline for osteoarthritis management from the American College of Rheumatology and the Arthritis Foundation conditionally recommends chondroitin for patients with hand osteoarthritis; however, it strongly recommends against the use of glucosamine in people with hip, knee, and/or hand OA
• DMSO and MSM. Dimethyl sulfoxide (DMSO) and methylsulfonylmethane (MSM) are two chemically related substances that have been studied for OA. DMSO is applied to the skin. MSM is used as a dietary supplement. Very little research has been done on DMSO and MSM, so it’s uncertain whether they’re helpful for OA symptoms.
• SAMe. S-Adenosyl-L-methionine (SAMe) is a molecule that is naturally produced in the body. It’s also sold in the United States as a dietary supplement. Studies of SAMe for OA have had inconsistent results. In some studies, SAMe appeared to be as effective as nonsteroidal anti-inflammatory drugs (NSAIDs) in relieving symptoms associated with OA, but in others it was no more helpful than a placebo.

Safety

• There are few complications associated with acupuncture, but adverse effects such as minor bruising or bleeding can occur; infections can result from the use of nonsterile needles or poor technique from an inexperienced practitioner.
• Massage therapy appears to have few risks if it is used appropriately and provided by a trained massage professional.
• Tai chi is considered to be a safe practice.
• No major safety problems have been identified in large studies of glucosamine and chondroitin for osteoarthritis. However, glucosamine may cause increases in blood glucose levels in some people, and glucosamine and chondroitin have been associated with an increased risk of bleeding in people who are taking the anticoagulant warfarin. 
• Both DMSO and MSM can have side effects. DMSO can cause digestive upset, skin irritation, and a garlic-like taste, breath, and body odor. MSM can cause allergic reactions, digestive upsets, and skin rashes.
• Side effects of SAMe are uncommon and usually mild. However, little is known about the long-term safety of SAMe because most studies have been brief. SAMe may have special risks for people with bipolar disorder as it may provoke mania, and in those who are HIV positive or immunocompromised, it increases the risk of Pneumocystis carinii infection, by enhancing the growth of this microorganism. SAMe also may interact with drugs, including some antidepressants and the drug levodopa.