Related Terms

• Anti-cyclic citrullinated peptide antibody, arthritis, arthroscopy, Becker's muscular dystrophy, computed tomography, connective tissue, convulsions, CT, depression, dermatomyositis, DEXA, dual-energy X-ray absorptiometry, Duchenne muscular dystrophy, Dupuytren's contracture, electromyography, epicondylitis, erythrocyte sedimentation rate, ESR, fibromyalgia, fibromyositis, fibrositis, gastroesophageal reflux disease, GERD, IBS, involuntary muscle, irritable bowel syndrome, joint noises, joint stiffness, magnetic resonance imaging, MD, MRI, MSDs, muscle atrophy, muscular dystrophy, myalgia, myofascial pain, myofascial release, osteoarthritis, osteomyelitis, PMS, polymyositis, premenstrual syndrome, proximal myopathy, rheumatoid arthritis, spinal muscular atrophy, synovial fluid, temporomandibular joint disorder, tendonitis, tenosynovitis, TMJ, voluntary muscle.

Background

• The musculoskeletal system is a type of organ system that allows for movement and stability of the body and consists of bones, muscles, joints, tendons, cartilage, ligaments, bursae (fluid-filled sacs), and other connective tissue. Complications arising when individual parts of this bodily system are injured can range from minor discomfort to serious medical conditions. Symptoms of musculoskeletal disorders (MSDs) can be acute or chronic and may include inflammation, swelling, pain, fatigue, weakness, joint noises and stiffness, limited range of motion, and lack of coordination.

• The skeletal system serves many important functions, including providing structure, shape, form, support, and protection for the body. The skeletal system also allows for bodily movement, produces blood for the body, and stores minerals. The skeletal system consists of 206 bones that form a rigid framework as well as protect soft tissues and vital organs of the body. For example, the brain is protected by the skull which surrounds it and the heart and lungs are enclosed in the sternum and rib cage.

• Bodily movement is made possible by the interaction of the muscular and skeletal systems. For this reason, they are often grouped together as the musculoskeletal system. Muscles are connected to bones by tendons. Bones are connected to each other by ligaments. Where bones meet one another is called a joint. Muscles that cause movement of a joint are connected to two different bones. The muscles contract and relax to cause movement. An example would be the contraction of the biceps and a relaxation of the triceps. This produces a bend at the elbow. The contraction of the triceps and relaxation of the biceps produces the effect of straightening the arm.

• Muscles are very specialized tissues that have the ability to contract and to conduct electrical impulses. Muscles are classified functionally as either voluntary or involuntary and structurally as either striated or smooth. From this organization, there are three types of muscles: smooth (involuntary) muscles, striated voluntary (skeletal) muscles, and striated involuntary (cardiac) muscles.

• Red blood cells are produced by the red marrow located in certain bones, including flat bones such as the hip bone, skull, and breastbone. An average of 2.6 million red blood cells is produced each second by the bone marrow to replace those damaged and destroyed by the liver.

• Bones also serve as a storage area for minerals such as calcium and phosphorus. When an excess of these minerals is present in the blood, a buildup of the mineral will occur within the bones. When the supply of these minerals within the blood is low, it will be withdrawn from the bones to replenish the supply.

Types of Musculoskeletal Problems

• Arthritis: Arthritis is a disorder that involves joint inflammation or swelling. More than 100 different diseases fall under the general category of arthritis. Arthritis conditions affect the joints, the tissues surrounding the affected joints, and other connective tissues. Common forms of arthritis include rheumatoid arthritis, osteoarthritis, and periarthritis.

• Muscular dystrophy: Muscular dystrophy (MD) is a group of rare inherited autoimmune muscle diseases in which muscle fibers are unusually susceptible to damage. Muscles, including primarily voluntary muscles, become progressively weaker due to muscle damage. In some types of muscular dystrophy, heart muscles, other involuntary muscles, and other organs are affected.

• The most common types of muscular dystrophy have been found to be due to a genetic deficiency of the muscle protein dystrophin. A cure for muscular dystrophy has not been found, but medications and therapy can slow the course of the disease.

• Fibromyalgia: Fibromyalgia, also known as fibromyositis or fibrositis, is a chronic (long-term) condition characterized by widespread, long-term pain in the muscles, ligaments, and tendons, as well as fatigue and multiple tender points (places on the body where slight pressure causes pain). In addition to muscular pain and fatigue, fibromyalgia can also cause sleep problems, depression, and an inability to think clearly.

• Although fibromyalgia affects about four million Americans, the vast majority of them are women in their mid-30s to late-50s. An estimate of the prevalence of fibromyalgia is as high as 3-5% of the population in the United States, or approximately six million people. Fibromyalgia symptoms may never completely resolve, and their intensity can vary. Although the symptoms of fibromyalgia may be hard to live with, the condition is not considered progressive or life-threatening.

• Joint stiffness: Joint stiffness is the feeling that motion of a joint is limited or difficult. Some people with joint stiffness are capable of moving the joint through its full range of motion, but some individuals cannot move the joint due to the pain they are experiencing. Joint stiffness is common with arthritis and usually occurs immediately when rising after lying or sitting still.

• Joint noises: Joint noises, such as creaks and clicks, are common and harmless in many individuals, but they can also occur with specific problems of the joints. For example, the base of the knee cap may creak when it is damaged by osteoarthritis.

• Temporomandibular joint disorder: Temporomandibular joint disorder (TMJD, TMJ, or TMD), or TMJ syndrome, is an umbrella term covering acute or chronic inflammation of the temporomandibular joint, which connects the lower jaw to the skull. TMJ can result in significant pain and impairment. TMJ may require surgical repair.

Causes and Risk Factors

• General:

• Individuals who are more susceptible to musculoskeletal problems tend to maintain fixed positions (such as sitting in a chair or standing), perform repetitive movements of the limbs (such as athletes or factory workers), overload particular muscle groups, apply pressure on body parts, and use forceful movements (such as in sports).

• Musculoskeletal problems and pain can be caused by damage or injury to bones, joints, muscles, tendons, ligaments, bursae, or nerves. If no injury has occurred or if pain persists for more than a few days, then another cause is often responsible.

• Bone pain is usually deep, penetrating, dull, or sharp. It commonly results from injury. Other less common causes of bone pain include bone infection (osteomyelitis), vitamin A toxicity, and tumors.

• Muscle pain is often less intense than that of bone pain but can be very unpleasant. For example, a muscle spasm or cramp (a sustained painful muscle contraction) in the calf is an intense pain that is commonly called a charley horse. Pain can occur when a muscle is affected by an injury, an autoimmune reaction (for example, polymyositis or dermatomyositis), loss of blood flow to the muscle, dehydration and resulting electrolyte imbalances, infection, or invasion by a tumor.

• Tendon and ligament pain is also often less intense than bone pain. This type of pain is often worse when the affected tendon or ligament is stretched or moved. Common causes of tendon pain include tendonitis, tenosynovitis, lateral and medial epicondylitis, and tendon injuries. Common causes of ligament pain include injuries (sprains).

• Arthritis:

• The exact causes of osteoarthritis and rheumatoid arthritis remain unknown. Most researchers believe that several factors, including obesity, age, joint injury or stress, genetics, and muscle weakness, may contribute to the development of osteoarthritis. Some researchers believe that cartilage damage may occur when too many enzymes that allow for the natural breakdown and regeneration of cartilage are released.

• Rheumatoid arthritis is considered an autoimmune disorder because the immune system does not function properly and attacks the body's own cells. Some researchers believe that this autoimmune process is triggered by an infection with a virus or bacterium. Heredity may also play a role in the development of rheumatoid arthritis.

• Periarthritis typically occurs after a joint becomes injured, which causes scarring, thickening, and shrinkage of the joint. It may also occur after exposure to cold temperatures. Periarthritis typically affects the shoulder. Individuals who have other types of long-term arthritis that affect the shoulders have an increased risk of developing periarthritis of the shoulder.

• Fibromyalgia:

• Gender: Although fibromyalgia may develop in men or women, statistics indicate that women are seven times more likely to develop the condition than men. Nine out of 10 fibromyalgia patients are women, and an estimated 3.4% of American women have the condition. Women's symptoms also tend to be more severe than men's. Women may be more prone to develop fibromyalgia during menopause.

• Age: Individuals between the ages of 20 and 60 are at the highest risk of developing fibromyalgia, although it may occur at any age.

• Genetic factors: There is some indication that genetic factors may be involved in the development of fibromyalgia. Studies have shown that individuals with family members who have fibromyalgia are at a higher risk of developing it themselves.

• Specific lifestyle factors: People who have recently experienced a traumatic physical or emotional event (such as a divorce, car accident, or death of a family member) may be at a higher risk of developing fibromyalgia.

• Psychiatric illness: While the majority of individuals with fibromyalgia report a history of psychiatric symptoms, such as depression or anxiety, many patients do not. There is no clear evidence that psychiatric illness causes fibromyalgia.

• Aggravating factors: Changes in weather, cold or drafty environments, infections, allergies, hormonal fluctuations (premenstrual and menopausal states), stress, depression, and anxiety may all contribute to fibromyalgia.

• Muscular dystrophy:

• Muscular dystrophy refers to a number of diseases that are caused by genetic mutations that involve progressive weakness, degeneration, and wasting of muscles. The Duchenne and Becker types of muscular dystrophy (DBMD) have similar signs and symptoms, are caused by the same genetic mutation (dystrophin mutation), and occur more frequently in males than in females.

• The particular gene that causes DBMD is found on the X chromosome, and so it is called "X-linked." Females carry two X chromosomes. Males carry one X chromosome and one Y chromosome. Because males have only one X chromosome, a male carrying a copy with a DBMD mutation will have the condition. However, because females have two copies of the X chromosome, a female can have one copy with a DBMD mutation and one functional copy. Because the functional copy is usually enough to compensate, a female with a DBMD mutation usually has few or no symptoms. However, because she can pass the mutation on to her children, she is called a "carrier."

• Each son born to a woman with the dystrophin mutation on one of her two X chromosomes has a 50% chance of inheriting the mutated gene and having DBMD. Each of her daughters has a 50% chance of inheriting the mutation and being a carrier. While most cases of DBMD occur by inheritance from the mother, in approximately one-third of boys with DBMD, there is a new mutation that forms in the egg, and so the mother is actually not the carrier of the mutation.

• Temporomandibular joint disorder:

• The cause of most TMJ disorders remains unknown. Some types of temporomandibular joint (TMJ) disorders appear to be caused by injury to the joint from a severe blow to the jaw or arthritis. Many behaviors, including frequently clenching the jaw or grinding the teeth (which may occur during sleep), poor posture that puts strain on the muscles and bones near the jaw, or other habits that overwork the jaw muscles (e.g. constantly chewing gum), may contribute to the development of TMJ disorders. However, further research is needed to definitively determine if these behaviors cause TMJ disorders.

Signs and Symptoms

• General:

• Pain is the chief symptom of most musculoskeletal disorders. The pain may be dull, sharp, radiating, or local and may be mild or severe. Although pain may be acute (short-lived), as is the case with most injuries, it may become chronic (ongoing) with illnesses such as rheumatoid arthritis. Muscle pain is known as myalgia.

• Arthritis:

• Common symptoms of osteoarthritis include joint pain, swelling and/or stiffness in a joint (especially after use), joint discomfort before or during a change in the weather, bony lumps on the fingers, and loss of joint flexibility. The joints that are most often affected by osteoarthritis include the fingers, spine, and weight-bearing joints, such as the hips, ankles, feet, and knees.

• Rheumatoid arthritis often affects many joints at the same time, and the severity of symptoms varies among patients. Symptoms, which may come and go, typically include pain and swelling in the joints (especially in the hands and feet), generalized aching or stiffness of the joints and muscles (especially after periods of rest), loss of motion of the affected joints, weakness in the muscles near the affected joints, low-grade fever, and general feeling of discomfort. Early in the disease, the joints in the hands, wrists, feet, and knees are most frequently affected. Over time, arthritis may develop in the shoulders, elbows, jaw, hips, and neck. In addition to the joints, rheumatoid arthritis may cause swelling in the tear ducts, salivary glands, the lining of the heart, the lungs, and occasionally, blood vessels.

• Periarthritis causes swelling and pain in the joints. Most patients develop periarthritis of the shoulder. When the shoulder is affected, the joint's mobility is significantly or completely reduced and aggressive treatment is started.

• Muscular dystrophy:

• Signs and symptoms of muscular dystrophy vary according to the type of muscular dystrophy. In general, they may include muscle weakness, apparent lack of coordination, and progressive crippling, resulting in contractures of the muscles around the joints and loss of mobility.

• Fibromyalgia:

• The primary symptoms of fibromyalgia include widespread musculoskeletal pain, severe fatigue (tiredness), and sleep disturbances. Fibromyalgia may cause pain in the muscles, tendons, or ligaments. The pain is usually in multiple locations and may be difficult to describe precisely.

• Most individuals with fibromyalgia complain of a total body "ache." Their muscles may feel like they were pulled or overworked or feel as if they are burning. Other symptoms associated with fibromyalgia include irritable bowel syndrome (IBS). Symptoms of IBS include fluctuations between constipation and diarrhea, frequent abdominal pain, abdominal gas, and nausea. Symptoms of IBS are frequently found in roughly 40 to 70% of fibromyalgia patients.

• Acid reflux, or gastroesophageal reflux disease (GERD), also occurs with the same high frequency. Recurrent migraine or tension-type headaches are seen in about 70% of fibromyalgia patients and can pose a major problem in coping for this patient group.

• Temporomandibular joint disorder (TMJ) causes tremendous jaw-related face and head pain in one-quarter of fibromyalgia patients.

• Other common symptoms of fibromyalgia include premenstrual syndrome (PMS) and painful periods, chest pain, morning stiffness, cognitive or memory impairment, numbness and tingling sensations, muscle twitching, irritable bladder, the feeling of swollen extremities (hands and feet), skin sensitivities, dry eyes and mouth, dizziness, and impaired coordination. Fibromyalgia patients are often sensitive to odors, loud noises, bright lights, and sometimes even the medications they are prescribed.

• Temporomandibular joint (TMJ) disorder:

• Common symptoms of TMJ disorders include pain and soreness of the jaw (which may worsen when the individual chews food, talks, or yawns), pain in and around the ear, facial pain, an uneven bite or change in the way the lower and upper teeth fit together, jaw muscle stiffness, a clicking sound or grating sensation when the mouth is opened and closed (sometimes called jaw clicking), headache, tired facial muscles, and locking of the joint, which may temporarily limit the movement of the jaw.

• It is important to note that jaw clicking affects many individuals who do not have TMJ disorders. Individuals who do not experience pain or limited movement of the jaw when the jaw clicks most likely do not have TMJ disorders.

Complications

• Depression: Some individuals with musculoskeletal problems may suffer from depression. This may happen if the musculoskeletal disorder interferes significantly with the patient's lifestyle, including causing pain. Individuals should consult their healthcare providers if they experience feelings of sadness, low self-esteem, loss of pleasure, apathy, and difficulty functioning for two weeks or longer with no known underlying cause. These may be signs of depression and suicidal thoughts.

• Joint damage: In some cases, musculoskeletal disorders can lead to severe joint damage. In such cases, surgery, such as a joint replacement, may be necessary. Individuals should regularly visit their healthcare providers to monitor their conditions.

• Limited mobility: Patients with musculoskeletal disorders may have limited mobility in their joints. Joint mobility decreases as the joint becomes more damaged.

Diagnosis

• A clinician can often diagnose a musculoskeletal disorder based on symptoms and the results of a physical examination. Laboratory tests, imaging tests, and other diagnostic procedures are sometimes necessary to help the clinician make or confirm a diagnosis.

• Physical examination: When a person complains of muscle weakness, the clinician checks muscles for bulk, texture, and tenderness. Muscles are also checked for twitches and involuntary movements, which may indicate a nerve disease rather than a muscle disease. Clinicians look for wasting away of muscle (atrophy), which can result from damage to the muscle or its nerves or from lack of use, as sometimes occurs with prolonged bed rest. Clinicians look for muscle enlargement (hypertrophy), which normally occurs with exercise such as weight lifting. However, when a person is ill, hypertrophy may result from one muscle working harder to compensate for the weakness of another. Muscles can also become enlarged when normal muscle tissue is replaced by abnormal tissue (increasing the size but not the strength of the muscle), which occurs in certain inherited muscle disorders, such as Duchenne's muscular dystrophy.

• Clinicians try to establish which (if any) muscles are weak as well as the degree of weakness involved. The muscles can be tested systematically, usually beginning with the face and neck, then the arms, and finally the legs. Normally, a person should be able to hold the arms extended, palms up, for one minute without them sagging, turning, or shaking. Downward drift of the arm with palms turning inward is one sign of weakness. Strength is tested by pushing or pulling while the clinician pushes and pulls in the opposite direction. Strength is also tested by having the person perform certain maneuvers, such as walking on the heels and tiptoes, rising from a squatting position, or getting up and down from a chair rapidly 10 times. To assess eye muscle strength, the person is asked to look in all directions; if double vision develops, one or more eye muscles may be weak.

• The clinician tests a joint's range of motion by moving the limb around a joint while the person is completely relaxed (passive movement). The clinician will check muscle tone by testing passive movement. Resistance to such movement (passive resistance) may be decreased when the nerve leading to the muscle is damaged. Resistance to such movement may be increased when the spinal cord or brain is damaged. If a person is weak, clinicians also tap the person's muscle tendon with a rubber hammer to assess reflexes. Reflexes may be slower than expected when the nerve leading to the muscle is damaged. Reflexes may be more rapid than expected when the spinal cord or brain is damaged.

• Laboratory tests: Laboratory tests are often helpful in making the diagnosis of a musculoskeletal disorder. A test called an erythrocyte sedimentation rate (ESR) test measures the rate at which red blood cells settle to the bottom of a test tube containing blood. The ESR is increased when inflammation is present. However, because inflammation occurs in so many conditions, the ESR alone does not establish a diagnosis. The level of creatine kinase (a normal muscle enzyme that leaks out and is released into the bloodstream when muscle is damaged) may also be tested. Levels of creatine kinase are increased when there is widespread and ongoing destruction of muscle. In rheumatoid arthritis, a blood test to identify rheumatoid factor or anti-cyclic citrullinated peptide (anti-CCP) antibody is helpful in making the diagnosis. In systemic lupus erythematosus (lupus), a blood test to identify autoimmune antibodies (antinuclear antibodies) is helpful in making the diagnosis.

• Nerve tests: Nerve conduction studies help determine whether the nerves supplying the muscles are functioning normally. Nerve conduction studies, together with electromyography, help indicate whether there is a problem primarily in the muscles (such as myositis or muscular dystrophy); in the nervous system, which supplies the muscles (such as a stroke, spinal cord problem, or polyneuropathy); or with the neuromuscular junction (such as myasthenia gravis). Electromyography, often performed at the same time as nerve conduction studies, is a test in which electrical impulses in the muscles are recorded to help determine how well the impulses from the nerves are reaching the connection between nerves and muscles (neuromuscular junction).

• X-rays: X-rays are most valuable for detecting abnormalities in bone and are taken to evaluate painful, deformed, or suspected abnormal areas of bone. Often, X-rays can help to diagnose fractures, tumors, injuries, infections, and deformities (such as congenital hip dysplasia). Also, X-rays may be helpful in showing changes that confirm a person has a certain kind of arthritis (for example, rheumatoid arthritis or osteoarthritis). X-rays do not show soft tissues such as muscles, bursae, ligaments, tendons, or nerves. To help determine whether the joint has been damaged by injury, a clinician may use an ordinary (non-stress) X-ray or one taken with the joint under stress (stress X-ray).

• Arthrography is an X-ray procedure in which a dye is injected into a joint space to outline the structures, such as ligaments inside a joint. Arthrography can be used to view torn ligaments and fragmented cartilage in the joint.

• Dual-energy X-ray absorptiometry (DEXA): The most accurate way to evaluate bone density, which is necessary when screening for or diagnosing osteoporosis, is with dual-energy X-ray absorptiometry (DEXA). In this test, low-dose X-rays are used to examine bone density at the lower spine, hip, wrist, or entire body. Measurements of bone density are very accurate at these sites. To help differentiate osteoporosis (the most common cause of an abnormal DEXA scan) from other bone disorders, doctors may need to consider the person's symptoms, medical conditions, medication use, and certain blood or urine test results as well as the DEXA results.

• Computed tomography (CT) and magnetic resonance imaging (MRI): Computed tomography (CT) and magnetic resonance imaging (MRI) give much more detail than conventional X-rays. CT and MRI may be performed to determine the extent and exact location of musculoskeletal damage. These tests can also be used to detect fractures that are not visible on X-rays. MRI is especially valuable for imaging muscles, ligaments, and tendons. MRI can be used if the cause of pain is thought to be a severe soft-tissue problem (for example, rupture of a major ligament or tendon or damage to important structures inside the knee joint). The amount of time a person spends undergoing CT is much less than for MRI.

• Bone scanning: Bone scanning is an imaging procedure that is occasionally used to diagnose a fracture, particularly if other tests, such as plain X-rays and CT or MRI, do not reveal the fracture. Bone scanning involves the use of a radioactive substance (technetium-99m-labeled pyrophosphate) that is absorbed by any healing bone. The technique can also be used when a bone infection or a metastasis (from a cancer elsewhere in the body) is suspected. The radioactive substance is given intravenously and is detected by a bone-scanning device, creating an image of the bone that can be viewed on a computer screen.

• Joint aspiration: Joint aspiration is used to diagnose certain joint problems. A needle is inserted into a joint space and fluid (synovial fluid) is drawn out (aspirated) and examined under a microscope. A doctor can often make a diagnosis after analyzing the fluid. For example, a sample of synovial fluid may contain bacteria, which confirms a diagnosis of infection. Joint aspiration is usually performed in a doctor's office and is generally quick, easy, and relatively painless. The risk of joint infection is minimal.

• Arthroscopy: Arthroscopy is a procedure in which a small (diameter of a pencil) fiber optic scope is inserted into a joint space, allowing the doctor to look inside the joint and to project the image onto a television screen. The skin incision is very small. A person receives local, spinal, or general anesthesia. During arthroscopy, doctors can take a piece of tissue for analysis (biopsy) and, if necessary, perform surgery to correct the condition. Disorders commonly found during arthroscopy include inflammation of the synovium lining a joint (synovitis); ligament, tendon, or cartilage tears; and loose pieces of bone or cartilage. Such conditions affect people with arthritis or previous joint injuries, as well as athletes. All of these conditions can be repaired or removed during arthroscopy. There is a very small risk of joint infection with this procedure.

Treatment

• General: Musculoskeletal problems are generally managed with medications that reduce pain and inflammation. In severe cases, surgery may be necessary to repair damage.

• In order to properly manage pain and prevent joint damage, individuals should take their medications as prescribed by their healthcare providers. Individuals with musculoskeletal problems should also tell their healthcare providers if they are taking any other drugs (prescription, over-the-counter, or dietary supplements) because they may interfere with treatment.

• Corticosteroids: Corticosteroids, such as prednisone (Deltasone®) and methylprednisolone (Medrol®), are occasionally used to reduce inflammation and pain and slow joint damage caused by musculoskeletal problems. These drugs are generally very effective when used short-term. However, if used for many months to years, these drugs may become less effective and serious side effects may develop. Side effects may include easy bruising, thinning of bones, cataracts, weight gain, a "moon" face, and diabetes.

• Corticosteroids are usually prescribed for a certain amount of time, and then the individual is gradually tapered off the medication. Individuals should not stop taking corticosteroids suddenly or change their dosages without first consulting their healthcare providers.

• Nonsteroidal anti-inflammatory drugs (NSAIDs): Nonsteroidal anti-inflammatory drugs (NSAIDs) have been used to relieve pain and inflammation caused by musculoskeletal problems. Commonly used over-the-counter NSAIDs include ibuprofen (Advil® or Motrin®) and naproxen sodium (Aleve®). Higher doses of these drugs are also available by prescription. Commonly prescribed NSAIDs include diclofenac (Cataflam® or Voltaren®), nabumetone (Relafen®), and ketoprofen (Orudis®). NSAIDs may be taken by mouth, injected into a vein, or applied to the skin. These medications are generally taken long term to manage symptoms.

• The frequency and severity of side effects vary among NSAIDs. The most common side effects include nausea, vomiting, diarrhea, constipation, decreased appetite, rash, dizziness, headache, and drowsiness. The most serious side effects include kidney failure, liver failure, ulcers, heart-related problems, and prolonged bleeding after an injury or surgery. About 15% of patients who receive long-term NSAID treatment develop ulcers in the stomach or duodenum.

• Pain relievers: Over-the-counter (OTC) pain relievers used in the treatment of musculoskeletal disorders include acetaminophen (Tylenol®). Prescription pain relievers, including tramadol (Ultram®), have been used to reduce pain caused by musculoskeletal problems. Although this drug, which is available by prescription, does not reduce swelling, it has fewer side effects than NSAIDs. Tramadol is generally taken as a short-term treatment to reduce symptoms of flare-ups.

• Narcotic pain relievers, such as acetaminophen/codeine (Tylenol with Codeine®), hydrocodone/acetaminophen (Lorcet®, Lortab®, or Vicodin®), or oxycodone (OxyContin® or Roxicodone®), may be prescribed to treat severe musculoskeletal pain. However, they do not reduce swelling. These medications are only used short-term to treat flare-ups. Common side effects include constipation, drowsiness, dry mouth, and difficulty urinating. Narcotic pain relievers should be used cautiously because individuals may become dependent upon them.

• Selective COX-2 inhibitors: Celecoxib (Celebrex®) has been taken by mouth to reduce pain and inflammation caused by musculoskeletal problems such as osteoarthritis. Celecoxib is currently the only COX-2 inhibitor that is approved by the U.S. Food and Drug Administration (FDA). Celecoxib is generally taken long-term to manage symptoms.

• COX-2 inhibitors have been linked to an increased risk of serious heart-related side effects, including heart attack and stroke. Selective COX-2 inhibitors have also been shown to increase the risk of stomach bleeding, fluid retention, kidney problems, and liver damage. Less serious side effects may include headache, indigestion, upper respiratory tract infection, diarrhea, sinus inflammation, stomach pain, and nausea.

• Topical pain relievers: Topical pain relievers are creams, ointments, gels, and sprays that are applied to the skin. Many over-the-counter (OTC) pain relievers may temporarily help reduce pain caused by osteoarthritis. Products such as Aspercreme®, Sportscreme®, Icy Hot®, and Ben-Gay® may help reduce arthritis pain. Capsaicin cream, which is made from the seeds of hot peppers, may reduce pain in joints that are close to the skin surface, such as the fingers, knees, and elbows. Lidocaine patches (Lidoderm®) may also be used. Lidocaine is an anesthetic when applied topically and may decrease pain associated with musculoskeletal problems.

• Antidepressants: Some individuals with musculoskeletal problems may also suffer from depression. Commonly prescribed anti-depressants for arthritis patients include amitriptyline, nortriptyline (Aventyl®, Pamelor®), and trazodone (Desyrel®). These drugs may also help with nerve pain associated with musculoskeletal disorders. Side effects of antidepressant medications include drowsiness, fatigue (excessive tiredness), constipation, dry mouth, and blurred vision.

• Lifestyle changes: Many lifestyle changes, including regular exercise, weight management, and consumption of a healthy diet may help reduce symptoms of musculoskeletal problems. A healthcare provider may recommend a physical therapist, nutritionist, or registered dietician to help determine the best treatment plan for the individual.

• Individuals with musculoskeletal problems such as osteoarthritis or rheumatoid arthritis should wear comfortable footwear that properly supports their weight. This may reduce the amount of strain put on the joints during walking.

• Individuals with musculoskeletal problems may require canes, walkers, or other devices to help them get around. If the hands are severely affected, braces may be beneficial. Individuals should talk to their healthcare providers about assistive devices that are available.

• Individuals with musculoskeletal problems should maintain good posture. This allows the body's weight to be evenly distributed among joints.

• Cool compress or ice pack: Applying a cool compress or ice pack to the affected joint during a flare-up may help reduce swelling and pain.

• Heat: Applying a hot pack to affected joints may help reduce pain, relax muscles, and increase blood flow to the joint. It may also be an effective treatment before exercise. Alternatively, individuals may take a hot shower or bath before or after exercise to help reduce pain.

• Fusing bones: If there is serious joint damage, the bones of a joint, such as the ankle, may be surgically fused together in a procedure called arthrodesis. This surgery helps increase stability and reduces pain. However, the joint no longer has any flexibility and cannot bend or move.

• Joint replacement surgery: In some cases, individuals with osteoarthritis suffer from permanent joint damage. In such instances, joint replacement surgery may be necessary. During the procedure, the damaged joint is surgically removed, and it is replaced with a plastic or metal device called a prosthesis. The most commonly replaced joints are the hip and knee, but other joints, including the elbow, shoulder, finger, or ankle joints can be replaced as well.

• Joint replacement surgeries are generally most successful for large joints, such as the hip or knee. Researchers estimate that hip or knee replacements last at least 20 years in 80% of patients. After a successful surgery and several months of rehabilitation, individuals are able to use their new joints without pain.

• As with any major surgery, there are risks associated with joint replacements. Patients should discuss the potential health risks and benefits of surgery with their healthcare providers.

Integrative Therapies

• Strong 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. There has been substantial research into the efficacy of acupuncture in the treatment of osteoarthritis (OA). Most studies focus on knee, cervical, and hip OA symptoms. In recent years, the evidence has improved and is now considered strong enough to recommend trying acupuncture in OA of the knee, which is one of the most common forms of this condition.

• Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders, medical conditions of unknown origin, neurological disorders, or if taking anticoagulants. Avoid on areas that have received radiation therapy and during pregnancy. Avoid electroacupuncture with irregular heartbeat or in patients with pacemakers. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics or with a history of seizures.

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

• Avoid with prostate cancer or an increased risk of prostate cancer. Use cautiously if allergic or hypersensitive to chondroitin sulfate products or with shellfish allergy. Use cautiously with bleeding disorders or if taking blood-thinners like warfarin (like Coumadin®). Avoid if pregnant or breastfeeding.

• Glucosamine: Glucosamine is a natural compound that is found in healthy cartilage. Based on human research, there is strong 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 for the effect 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.

• Willow bark: Willow (Salix alba) bark 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 studied have confirmed this finding. Additional study comparing willow bark to conventional medicinal agents for safety and effectiveness is warranted.

• Avoid if allergic/hypersensitive to aspirin, willow bark (Salix spp.), or any of its constituents, including salicylates. Avoid operating heavy machinery. Avoid in children with chickenpox and any other viral infections. Avoid with blood disorders or kidney disorders. Avoid if taking other NSAIDs, acetazolamide or other carbonic anhydrase inhibitors. Avoid with elevated serum cadmium levels. Use cautiously with gastrointestinal problems, such as ulcers, hepatic disorders, diabetes, gout, high blood pressure, hyperlipidemia, history of allergy or 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 predisposed to headaches. Use cautiously with tannin-containing herbs or supplements. Avoid if pregnant or breastfeeding.

• Good scientific evidence:

• 5-HTP (5-hydroxytryptophan): 5-HTP is the precursor of the neurotransmitter serotonin. It is obtained commercially from the seeds of the plant Griffonia simplicifolia. There is a small amount of research evaluating the use of 5-HTP for fibromyalgia, and early evidence suggests that 5-HTP may reduce the number of tender points, anxiety, and intensity of pain and may improve sleep, fatigue, and morning stiffness.

• 5-HTP may cause drug interaction with medications such as antidepressants and sleep medicines. 5-HTP is not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor.

• Acupuncture: There is evidence from several studies suggesting acupuncture may help with pain relief in fibromyalgia. More high quality studies would help to confirm these study results.

• Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders, medical conditions of unknown origin, neurological disorders, or if taking anticoagulants. Avoid on areas that have received radiation therapy and during pregnancy. Avoid electroacupuncture with irregular heartbeat or in patients with pacemakers. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics or with a history of seizures.

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

• Avoid if allergic or hypersensitive to avocado, banana, chestnut, or natural rubber latex. Avoid with monoamine oxidase inhibitors (MAOIs). Use cautiously with anticoagulants (like warfarin). Doses greater than found in a normal diet is not recommended if pregnant or breastfeeding. Some types of avocado may be unsafe when breastfeeding.

• Borage seed oil: Preliminary evidence suggests that gamma linolenic acid (GLA) may have anti-inflammatory effects that may make it beneficial in treating rheumatoid arthritis. Additional 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. Use cautiously in patients with bleeding disorders or in those taking warfarin or other anticoagulant or antiplatelet (blood thinning) agents. Use cautiously in patients with epilepsy or in those taking anticonvulsants. Avoid in patients with compromised immune systems or similar immunological conditions. Avoid during pregnancy and breastfeeding.

• Chlorella: A randomized controlled trial and one case series indicate that chlorella may reduce the tenderness associated with fibromyalgia's tender points. Although the results are promising, more high quality studies are needed to confirm these studies' findings.

• Avoid in patients with known allergy/hypersensitivity to chlorella, its constituents, mold, or members of the Oocystaceae family. Use cautiously in patients with hypotension, altered immune function, cancer, or taking antihypertensives, or immunomodulators. Use cautiously in patients with photosensitivity, taking photosensitizers, or exposed to the sun. Avoid long-term supplementation or with manganese supplementation. Avoid in patients using warfarin or other anticoagulant therapy.

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

• Avoid if allergic to devil's claw or to plants in the Harpagophytum procumbens family. Use cautiously with stomach ulcers or with a history of bleeding disorders, diabetes, gallstones, gout, heart disease, stroke, ulcers, or with prescription drugs used for these conditions. Stop use two weeks before and immediately after surgery/dental/diagnostic procedures with bleeding risks. Avoid if pregnant or breastfeeding.

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

• 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, fish oil, alpha-linolenic acid: Multiple randomized controlled trials report improvements in rheumatoid arthritis, including morning stiffness and joint tenderness, with the regular intake of fish oil supplements for up to three months. Benefits have been reported as additive with anti-inflammatory medications such as NSAIDs (like ibuprofen or aspirin). However, because of weaknesses in study designs and reporting, better research is necessary before a strong favorable recommendation can be made. Effects beyond three months of treatment have not been well evaluated.

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

• Physical therapy: The goal of physical therapy is to improve mobility, restore function, reduce pain, and prevent further injuries. Several techniques, including exercises, stretches, traction, electrical stimulation, and massage, are used. Physical therapy for osteoarthritis of the knee may provide short-term benefits, but long-term benefits do not appear better than standard treatments. Physical therapy, either as an individually delivered treatment or in a small group format, appears effective. Limited available study compared physical therapy to a sham group (sub therapeutic ultrasound) and found that a combination of manual physical therapy and supervised exercise was beneficial for patients with osteoarthritis of the knee.

• 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. 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. Physical therapy has been used in pregnancy, and although reports of major adverse effects are lacking in the available literature, caution is advised nonetheless. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician/gynecologist before initiation.

• Psychotherapy: 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 worsen 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 stir up strong emotional feelings.

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

• Avoid if allergic to rose hips, rose pollen, their constituents, or members of the Rosaceae family. Use cautiously if taking anticoagulant or antiplatelet agents, anticancer agents, anti-HIV medications, anti-inflammatory agents, antilipemics, aluminum-containing antacids, antibiotics, salicylates or salicylate-containing herbs, or laxatives. Use cautiously in patients who are avoiding immune system stimulants.

• SAMe: S-adenosyl-L-methionine (SAMe) is a naturally occurring molecule that is found in humans. SAMe is present in almost every tissue and fluid in the body, and has been studied extensively in the treatment of osteoarthritis. SAMe reduces the pain associated with osteoarthritis and is well tolerated in this patient population. Although an optimal dose has yet to be determined, SAMe appears as effective as non-steroidal anti-inflammatory drugs (NSAIDS). Additional study is warranted to confirm these findings.

• Avoid if allergic or hypersensitive to SAMe. Avoid with bipolar disorder. Avoid during the first trimester of pregnancy or if breastfeeding. Use cautiously with diabetes, anxiety disorders, or during the third trimester of pregnancy.

• 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 knee osteoarthritis 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.

• Trigger point therapy: There have been several studies that addressed the therapeutic potential of trigger point therapy. The results of the higher-quality studies show slight, albeit not significant, improvement of myofascial pain. Many of the medium-quality studies illustrate more pronounced improvement and statistical differences. Overall, the studies indicate that trigger point therapy may be effective for myofascial pain. However, future studies need to be performed before any definitive conclusions can be drawn.

• Use cautiously with local or systemic infection, anticoagulation or bleeding disorders, or acute muscle trauma. Avoid aspirin ingestion within three days of injection. Avoid with extreme fear of needles, large bruises, phlebitis, varicose veins, undiagnosed lumps, or open wounds. Avoid if allergic to anesthetic agents (mainly caused by aminoester agents). Use cautiously during pregnancy.

• Yoga: There is promising early evidence that yoga therapy may help treat rheumatoid arthritis. More research is needed to confirm these results.

• Yoga is generally considered to be safe in healthy individuals when practiced appropriately. Avoid some inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, risk for blood clots, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, or cervical spondylitis. Certain yoga breathing techniques should be avoided in people with heart or lung disease. Use cautiously with a history of psychotic disorders. Yoga techniques are believed to be safe during pregnancy and breastfeeding when practiced under the guidance of expert instruction (the popular Lamaze techniques are based on yogic breathing). However, poses that put pressure on the uterus, such as abdominal twists, should be avoided in pregnancy.

• Unclear or conflicting scientific evidence:

• Acupuncture: Further research is needed before acupuncture can be recommended for the treatment of rheumatoid arthritis, temporomandibular joint disorder (TMJ), or myofascial pain.

• Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders or with drugs that increase the risk of bleeding (anticoagulants), medical conditions of unknown origin, or neurological disorders. Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers.

• Alexander technique: The Alexander technique is an educational program that teaches movement patterns and postures, with an aim to improve coordination and balance, reduce tension, relieve pain, alleviate fatigue, improve various medical conditions, and promote well-being.Early case series data suggest that Alexander technique instruction may reduce symptoms of temporomandibular joint disorder (TMJ) chronic pain. More human research is needed before a clear recommendation can be made.

• Serious side effects of the Alexander technique have not been reported. It has been suggested that the technique may be less effective with learning disabilities or mental illnesses. The Alexander technique has been used safely in pregnant women.

• Alpinia: Alpinia, also known as Chinese ginger, has been studied in combination with another ginger species for the treatment of osteoarthritis. Although alpinia shows promise for the reduction in knee pain, more studies using alpinia alone would strengthen the evidence for this indication.

• Avoid if allergic/hypersensitive to alpinia, ginger, or other members of the Zingiberaceae family. Use cautiously with diabetes or if taking hypoglycemic agents. Use cautiously with electrolyte imbalance and low blood pressure. Avoid if pregnant or breastfeeding.

• Aromatherapy: Aromatherapy refers to many different therapies that use essential oils. The oils are sprayed in the air, inhaled or applied to the skin. Essential oils are usually mixed with a carrier oil (usually a vegetable oil) or alcohol. There is not enough scientific evidence to determine if aromatherapy improves wellbeing in arthritis patients.

• Essential oils should be administered in a carrier oil to avoid toxicity. Avoid with a history of allergic dermatitis. Avoid consuming essential oils. Avoid direct contact of undiluted oils with mucous membranes. Use cautiously if driving/operating heavy machinery. Use cautiously if pregnant.

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

• Avoid if allergic or hypersensitive to arnica or any member of the Asteraceae or Compositae families (sunflowers, marigolds, or any related plants like daisies, ragweed, or asters). Use cautiously with blood thinners, protein-bound drugs, cholesterol or heart medications, or diabetes drugs. Use cautiously with a history of stroke. Avoid contact with open wounds or near the eyes and mouth. Avoid if pregnant or breastfeeding.

• Ash: The use of ash as an herbal remedy can be traced to Native Americans and the early settlers of the Americas. Ash has been historically noted for its anti-inflammatory and pain-relieving properties. There is currently little scientific evidence currently available to support its use for gouty arthritis. Future randomized, placebo controlled studies are necessary to confirm these initial results.

• Avoid if allergic or hypersensitive to ash (Fraxinus species), its constituents, or to members of the Oleaceae family. Reviews note ash pollen allergic cross-reactivities with pollen from the Fagales order (birch, alder, hazel, hornbeam, oak, and chestnut), Scrophulariales order (olive, ash, plantain, privet, and lilac), Coniferales order (cedar, cypress, and pine), and fruits and vegetables. Use cautiously if sensitive to anticoagulants (blood thinners). Use cautiously if susceptible to hypouricemia (condition where the level of uric acid is below a certain threshold), including but not limited to hyperthyroidism, inflamed kidneys, multiple sclerosis, and Fanconi syndrome. Avoid if immunocompromised. Avoid if pregnant or breastfeeding.

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

• Avoid if allergic or hypersensitive to ashwagandha. Dermatitis (allergic skin rash) has been reported.There are few reports of adverse effects associated with ashwagandha, but there are few human trials using ashwagandha and most do not report the doses or standardization/preparation used.Avoid with peptic ulcer disease. Ashwagandha may cause abortion based on anecdotal reports. Avoid if pregnant or breastfeeding.

• Astaxanthin: More well-designed clinical trials are necessary before astaxanthin can be recommended for the treatment of rheumatoid arthritis.

• Avoid if allergic/hypersensitive to astaxanthin, related carotenoids, or astaxanthin algal sources. Use cautiously if taking 5-alpha-reductase inihibitors, hypertensive agents, asthma medications, cytochrome P450 metabolized agents, menopause agents or oral contraception, or Helicobacter pylori agents. Use cautiously with hypertension, parathyroid disorders, and 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: 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 (gugulla), 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 rheumatoid arthritis. More studies are needed to determine efficacy of these treatments for rheumatoid arthritis.

• There is early evidence that an Ayurvedic formula containing roots of Withania somnifera, the stem of Boswellia serrata, rhizomes of Curcuma longa, and a zinc complex (Articulin-F®) may significantly improve symptoms of osteoarthritis. Other research suggests that taking guggul (Commiphora mukul) daily as a powder capsule supplement may reduce pain and improve functioning in OA. Further research is needed before a recommendation can be made.

• 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 can interact with other herbs, foods and drugs. A qualified healthcare professional should be consulted before taking.

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

• Avoid if sensitive to beta-carotene, vitamin A, or any other ingredients in beta-carotene products.

• Beta sitosterol: Beta-sitosterol and beta-sitosterol glucoside have been observed to lower blood levels of IL-6 and, therefore, have been studied as a treatment for rheumatoid arthritis. Larger populations of patients with rheumatoid arthritis should be evaluated in well-conducted clinical study if conclusions are to be made.

• 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 (like Parkinsonism or Alzheimer's disease), diverticular disease (bulging of the colon), short bowel syndrome, celiac disease and sitosterolemia. Use cautiously with a history of gallstones. Avoid if pregnant or breastfeeding.

• Black cohosh: There is not enough human research to make a clear recommendation regarding the use of black cohosh for rheumatoid arthritis pain.

• Use cautiously if allergic to members of the Ranunculaceaefamily such as buttercups or crowfoot. Avoid with hormone conditions (breast cancer, ovarian cancer, uterine cancer, endometriosis). Avoid if allergic to aspirin products, non-steriodal anti-inflammatories (NSAIDs, Motrin®, ibuprofen, etc.), blood-thinners (like warfarin) or with a history of blood clots, stroke, seizures, or liver disease. Stop use before surgery/dental/diagnostic procedures with bleeding risk and avoid immediately after these procedures. Avoid if pregnant or breastfeeding.

• Black currant: Early study shows promise for the use of black currant seed oil in reducing the signs and symptoms of rheumatoid arthritis. However, additional study is needed to confirm these findings.

• Avoid if allergic or hypersensitive to black currant, its constituents, or plants in the Saxifragaceae family. Avoid in patients with hemophilia or those on blood thinners unless otherwise recommended by a qualified healthcare provider. Use cautiously with venous disorders or gastrointestinal disorders. Use cautiously if taking MAOIs (antidepressants) or vitamin C supplements. Avoid if pregnant or breastfeeding.

• Boron: Boron is a trace element, which is found throughout the global environment. Based on human population research, individuals who eat foods rich in boron (including green vegetables, fruits, and nuts) appear to have fewer joint disorders. It has also been proposed that boron deficiency may contribute to the development of osteoarthritis. However, there is a lack of human evidence that supplementation with boron is beneficial as prevention against or as a treatment for osteoarthritis.

• Avoid if allergic or sensitive to boron, boric acid, borax, citrate, aspartate, or glycinate. Avoid with a history of diabetes, seizure disorder, kidney disease, liver disease, depression, anxiety, high blood pressure, skin rash, anemia, asthma, chronic obstructive pulmonary disease (COPD), or hormone-sensitive conditions (e.g., breast cancer or prostate cancer). Avoid if pregnant or breastfeeding.

• Boswellia: Boswellia has been noted in animal and laboratory studies to possess anti-inflammatory properties. Based on these observations, boswellia has been suggested as a potential treatment for rheumatoid arthritis and osteoarthritis. However, data is conflicting, and combination products were used in some studies. Therefore, there is currently insufficient evidence to recommend for or against the use of boswellia for rheumatoid arthritis.

• Avoid if allergic to boswellia. Avoid with a history of stomach ulcers or stomach acid reflux disease (GERD). Use cautiously if taking lipid-soluble medications, agents metabolized by the liver's cytochrome P450 enzymes, or sedatives. Use cautiously with impaired liver function or liver damage or lung disorders. Use cautiously in children. Avoid if pregnant due to potential abortifacient effects or if breastfeeding.

• Bowen therapy: Bowen therapy is a technique that involves gentle but precise soft tissue manipulation. Early research suggests that Bowen therapy may improve the range of motion in patients with frozen shoulder.

• Bowen therapy is generally believed to be safe in most people. However, safety has not been thoroughly studied. Bowen therapy should not be used for severe conditions or in place of more proven treatments. Use cautiously in patients with cancer or in those who are undergoing surgery.

• Bromelain: Results of a study found a combination supplement called ERC (enzyme-rutosid combination -rutosid, bromelain, trypsin) may be considered as an effective and safe alternative to prescription anti-inflammatory drugs (NSAIDs), such as diclofenac, in the treatment of knee pain associated with osteoarthritis. Further well-designed clinical trials of bromelain alone are needed to confirm these results. Bromelain also cannot be recommended for the treatment of rheumatoid arthritis until further research is conducted.

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

• Cat's claw: Several laboratory and animal studies suggest that cat's claw may reduce inflammation, and this has led to research of cat's claw for conditions such as rheumatoid arthritis. Early research also suggests that cat's claw may reduce pain from osteoarthritis of the knee. Large, high-quality human studies are needed 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. Use cautiously with bleeding disorders or with a history of stroke, or if taking drugs that may increase the risk of bleeding. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Cat's claw may be contaminated with other Uncaria species. Reports exist of a potentially toxic Texan grown plant, Acacia gregii, being substituted for cat's claw. Avoid if pregnant, breastfeeding, or trying to become pregnant.

• Chiropractic: Chiropractic is a healthcare discipline that focuses on the relationship between musculoskeletal structure (primarily the spine) and body function (as coordinated by the nervous system), and how this relationship affects the preservation and restoration of health. Further research is needed to determine if chiropractic therapy is an effective treatment for hip pain, osteoarthritis, fibromyalgia, or temporomandibular joint (TMJ) disorders.

• Avoid with symptoms of vertebrobasilar vascular insufficiency, aneurysms, unstable spondylolisthesis, or arthritis. Avoid with agents that increase the risk of bleeding. Avoid in areas of para-spinal tissue after surgery. Avoid if pregnant or breastfeeding due to a lack of scientific data. Use extra caution during cervical adjustments. Use cautiously with acute arthritis, conditions that cause decreased bone mineralization, brittle bone disease, bone softening conditions, bleeding disorders, or migraines. Use cautiously with the risk of tumors or cancers.

• Chlorophyll: 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 antidiabetes agents. Avoid if pregnant or breastfeeding.

• Copper: 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 use of copper supplements during the early phase of recovery from diarrhea. Avoid with hypercupremia, occasionally observed in disease states, including cutaneous leishmaniasis, sickle-cell disease, unipolar depression, breast cancer, epilepsy, measles, Down syndrome, and 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 6mg/L. Use cautiously with anemia, arthralgias, or myalgias. Use cautiously if taking oral contraceptives. Use cautiously if at risk for selenium deficiency. The U.S. Recommended Dietary Allowance (RDA) is 1,000 micrograms for pregnant women. The U.S. RDA is 1,300 micrograms for nursing women.

• DHEA: Preliminary evidence suggests that DHEA (dehydroepiandrosterone) may not offer benefit to individuals with rheumatoid arthritis or fibromyalgia. Further research is needed in this area.

• Avoid if allergic to DHEA. Avoid with a history of seizures. Use with caution in adrenal or thyroid disorders or anticoagulants, or drugs, herbs or supplements for diabetes, heart disease, seizure or stroke. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Avoid if pregnant or breastfeeding.

• DMSO (dimethyl sulfoxide): Applying DMSO to the skin may help treat rheumatoid arthritis. More research is needed before a conclusion can be drawn.

• Avoid if allergic or hypersensitive to DMSO. Use caution with urinary tract cancer or liver and 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 unknown. Long-term studies of side effects are lacking. Avoid if allergic/hypersensitive to Dong quai or members of the Apiaceae/Umbelliferae family (like anise, caraway, carrot, celery, dill, parsley). Avoid prolonged exposure to sunlight or ultraviolet light. Avoid before dental or surgical procedures. 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 (like breast cancer, uterine cancer or ovarian cancer). Avoid if pregnant or breastfeeding.

• Eucalyptus oil: Aromatherapy using eucalyptus has been studied for its effects on pain, depression, and feelings of satisfaction in life in arthritis patients. Aromatherapy may help reduce pain and depression, but does not appear to alter the feeling of satisfaction in life. Additional study is needed to clarify these findings.

• Avoid if allergic to eucalyptus oil or with a history of seizures, diabetes, asthma, heart disease, abnormal heart rhythms, intestinal disorders, liver disease, kidney disease, or lung disease. Avoid with a history of acute intermittent porphyria. Use cautiously if driving or operating machinery. Avoid if pregnant or breastfeeding. A strain of bacteria found on eucalyptus may cause infection. Toxicity has been reported with oral and inhaled use.

• Evening primrose oil: Benefits of evening primrose oil in the treatment of rheumatoid arthritis have not clearly been shown. More research is needed before a conclusion 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 with mental illness drugs. Stop use two weeks before surgery with anesthesia. Avoid if pregnant or breastfeeding.

• Feldenkrais Method®: In early studies of patients with nonspecific musculoskeletal disorders, Body Awareness Therapy® and Feldenkrais seemed to improve health-related quality of lifeThe Feldenkrais Method® is popularly considered a useful treatment for chronic pain. However, clinical evidence of the efficacy of Feldenkrais in fibromyalgia is limited. There is currently a lack of available scientific studies or reports of safety of the Feldenkrais Method®.

• Feverfew: There is currently not enough evidence to support the use of feverfew for rheumatoid arthritis. Further research is warranted.

• Avoid if allergic to feverfew and other plants of the Compositaefamily (chrysanthemums, daisies, marigolds, ragweed). Stop use prior to surgery and dental or diagnostic procedures. Avoid with drugs that increase bleeding risk. Avoid stopping feverfew use all at once. Avoid if history of heart disease, anxiety or bleeding disorders. Caution is advised with a history of mental illness, depression and headaches. Avoid if pregnant or breastfeeding.

• Gamma linolenic acid (GLA): Several clinical studies indicate significant therapeutic improvements in rheumatoid arthritis symptoms with use of gamma linolenic acid (GLA). Additional study is needed before a conclusion can be made.

• Use cautiously with drugs that increase the risk of bleeding like anticoagulants and anti-platelet drugs. Avoid if pregnant or breastfeeding.

• Ginger: Well-designed clinical trials are necessary before ginger can be recommended for the treatment of rheumatoid arthritis or osteoarthritis.

• Avoid if allergic to ginger or other members of the Zingiberaceaefamily. Avoid with anticoagulation therapy. Avoid large quantities of fresh cut ginger with inflammatory bowel disease or a history of intestinal obstruction. Use cautiously prior to surgery and with gastric or duodenal ulcers, gallstones, cardiovascular disease, and diabetes. Use cautiously long-term and in underweight patients. Use cautiously if taking heart medications or sedatives and if driving or operating heavy machinery. Use cautiously if pregnant or breastfeeding.

• Glucosamine: Preliminary human research reports benefits of glucosamine in the treatment of joint pain and swelling in rheumatoid arthritis patients. However, additional research is needed before a conclusion can be made. There is currently a lack of sufficient evidence to recommend for or against the use of glucosamine (or the combination of glucosamine and chondroitin) in the treatment of temporomandibular joint (TMJ) disorders.

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

• Green lipped mussel: The green-lipped mussel is native to the New Zealand coast and is a staple in the diet of the indigenous Maori culture. There is conflicting evidence of the effect of green-lipped mussel supplementation for treating osteoarthritis. Reliable evidence is needed to determine whether green-lipped mussel is effective for this use.

• Green-lipped mussel is generally considered safe. Avoid with allergy or sensitivity to green-lipped mussel or other shellfish. Avoid with liver disease. Use cautiously with anti-inflammatory agents. Use cautiously with asthma. 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: There is currently insufficient evidence to support the use of guggul or guggul derivatives for the management of rheumatoid arthritis or osteoarthritis.

• 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: Cognitive-behavioral interventions for pain may be an effective adjunct to standard pharmacologic interventions for pain in patients with osteoarthritis or juvenile rheumatoid arthritis. Initial research for fibromyalgia also suggests possible reductions in pain and improvements in functioning. Further research is needed to confirm these results.

• Guided imagery is usually intended to supplement medical care, not to replace it, and should not be relied on as the sole therapy for a medical problem. Contact a qualified health care 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. Speak with a qualified health care provider before practicing guided imagery if feeling unusually anxious while practicing guided imagery, or with a history of trauma or abuse.

• Hops: Early clinical research suggests that a combination formula containing hops may help reduce symptoms of rheumatic diseases. However, well-designed human trials using hops alone are needed to determine if these positive effects are specifically the result of hops.

• Avoid if allergic to hops, its constituents, members of the Cannabaceae family, peanuts, chestnuts, or bananas. Use cautiously if driving or operating heavy machinery. Use cautiously with hormone-sensitive conditions (e.g. breast cancer, uterine cancer, cervical cancer, prostate cancer, or endometriosis) and diabetes. Use cautiously if taking hormonal agents (e.g. contraceptives or fertility agents). Use cautiously if pregnant or breastfeeding; some hops preparations contain high levels of alcohol and should be avoided during pregnancy.

• 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 like 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 treatment with more proven techniques or therapies and should not be used as the sole approach to illnesses. Patients with known illnesses should consult their physicians before starting hydrotherapy.

• Hypnotherapy: 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. There is inconclusive evidence from preliminary research regarding use of hypnotherapy for fibromyalgia. Additional study is needed before a firm conclusion can be drawn.

• Use cautiously with mental illnesses like psychosis/schizophrenia, manic depression, multiple personality disorder or dissociative disorders. Use cautiously with seizure disorders.

• Lavender: Early human studies have found conflicting results on the use of massage with lavender aromatherapy for rheumatoid arthritis pain. More research is needed to make a conclusion.

• Avoid if allergic or hypersensitive to lavender. Avoid with a history of seizures, bleeding disorders, eating disorders (anorexia, bulimia) or anemia (low levels of iron). Avoid if pregnant or breastfeeding.

• Magnet therapy: Initial evidence has failed to show improvements in pain from rheumatoid arthritis or osteoarthritis with the use of magnet therapy. However, due to methodological weaknesses of this research, the conclusions cannot be considered definitive. The effectiveness of magnet therapy as an additive treatment for fibromyalgia has been assessed in preliminary studies (including the use of magnetic sleep pads). Results of recent research suggest that magnetic fields may not be helpful for this condition. Better study is necessary before a firm conclusion can be drawn.

• Avoid with implantable medical devices like 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 or treatment with more proven methods. Patients are advised to discuss magnet therapy with a qualified healthcare provider before starting treatment.

• Massage: Massage may be of benefit for rheumatoid arthritis, but there is currently not enough scientific data on which to base a strong conclusion for this indication. A small number of studies report that massage may improve pain, depression, and quality of life in fibromyalgia patients. Early evidence suggests that massage may reduce the number and intensity of painful trigger points. More studies are needed regarding use of massage for myofascial pain.

• Avoid with bleeding disorders, low platelet counts, or if on blood-thinning medications (such as heparin or warfarin/Coumadin®). Areas should not be massaged where there are fractures, weakened bones from osteoporosis or cancer, open/healing skin wounds, skin infections, recent surgery, or blood clots. Use cautiously with a history of physical abuse or if pregnant or breastfeeding. Massage should not be used as a substitute for more proven therapies for medical conditions. Massage should not cause pain to the client.

• Meditation: It has been suggested that mindfulness meditation may help improve symptoms in patients with fibromyalgia. Better quality research is necessary before a conclusion can be formed.

• Use cautiously with underlying mental illnesses. People with psychiatric disorders should consult with their primary mental healthcare professionals before starting a program of meditation and should explore how meditation may or may not fit in with their current treatment plans. Avoid with risk of seizures. The practice of meditation should not delay the time to diagnose or treat the condition with more proven techniques or therapies. Meditation should not be used as the sole approach to illnesses.

• 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 a 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 to any of its constituents. Anaphylactic reactions (life threatening, shock) have 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: 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 conclusions.

• Use cautiously over large blood vessels and thin or weak skin. Avoid with aneurysms, any kind of "heat syndrome," cardiac disease, convulsions or cramps, diabetic neuropathy, extreme fatigue and/or anemia, fever, inflammatory conditions, over allergic skin conditions or ulcerated sores, or skin adhesions. Avoid if pregnant or breastfeeding. Avoid areas with an inflamed organ, contraindicated acupuncture points, face, genitals, head, inflamed areas in general, nipples, and skin adhesions. Avoid in patients who have just finished exercising or if taking a hot bath or shower. Caution with elderly people with large vessels. It is advised to not bathe or shower for up to 24 hours after a moxibustion treatment.

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

• Avoid if allergic or hypersensitive to MSM. Long-term effects of supplementation with MSM are unknown. Avoid if pregnant or breastfeeding.

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

• Avoid niacin/vitamin B3 if allergic to niacin or niacinamide. Avoid with a history of liver disease or dysfunction, irregular heartbeats, heart disease, bleeding disorders, asthma, anxiety, panic attacks, thyroid disorders, stomach ulcers, gout, or diabetes. Avoid if pregnant or breastfeeding.

• Pantothenic acid (vitamin B5): It has been reported that pantothenic acid levels are lower in the blood of rheumatoid arthritis patients than healthy individuals. However, it is not clear 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.

• Pantothenic 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.

• Papain: Review study found that proteolytic enzymes, including papain, may reduce pain and inflammation in rheumatic disorders. Additional research is needed to confirm these results.

• Use cautiously in patients sensitive to papain, being treated for prostatitis, with bleeding disorders or taking anticoagulants or antiplatelets. Use cautiously as an adjuvant to radiation therapy. Avoid in patients with gastroesophageal reflux disease or in those using immunosuppressive therapy.

• Peony: Peony's anti-inflammatory effects may benefit patients with rheumatoid arthritis. However, there is currently not enough evidence for or against this use of peony.

• Avoid if allergic or sensitive to peony. Avoid with bleeding disorders or if taking drugs, herbs, or supplements that increase bleeding risk. Use cautiously with estrogen-sensitive cancers or if taking drugs, herbs, or supplements with hormonal activity. Avoid if pregnant or breastfeeding.

• Physical therapy: Several studies have indicated that treatment of rheumatoid arthritis with physical therapy may help improve morning stiffness and grip strength. Some experts have suggested a long-term, high-intensity exercise program. Beneficial effects may last up to one year. Despite promising early evidence, better-designed studies are needed to draw a firm conclusion. More research is also needed to determine if physical therapy is an effective treatment for frozen shoulder, hip pain, joint problems (including rotator cuff and sacroiliac joint dysfunction), or osteoarthritis.

• Early research indicates that a self-management based program of pool exercises and education may improve the quality of life of patients with fibromyalgia and their satisfaction with treatment. In one study, physical therapy did not show better effects when compared with hypnotherapy. Additional study is needed to make a firm recommendation for use of physical therapy for myofascial pain.

• Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with a qualified healthcare professional before beginning any treatments. 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 physical therapy literature although causality is unclear. Erectile dysfunction has also been reported. Physical therapy has been used in pregnancy and although reports of major adverse effects are lacking the available literature, caution is advised nonetheless. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician/gynecologist before initiation.

• Podophyllum: 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 oral podophyllum. Additional research is needed before a firm conclusion can be drawn.

• 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, and neurologic disorders, psychosis, or kidney insufficiency. Use cautiously if taking antimiotic agents like vincristine, anti-psychotic agents, or laxatives. Avoid if pregnant or breastfeeding.

• Prayer, distant healing: Initial research suggests that in-person intercessory prayer (praying by others in the presence of patients) may reduce pain, fatigue, tenderness, swelling and weakness in rheumatoid arthritis when it is used in addition to standard care. Better quality research is necessary before a firm conclusion can be drawn.

• Prayer is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time it takes to consult with a healthcare professional or receive established therapies. Sometimes religious beliefs come into conflict with standard medical approaches, and require an open dialog between patients and caregivers. Based on limited clinical study, patients certain that they were receiving intercessory prayer had a higher incidence of complications following cardiac bypass surgery than those who did not know they were being prayed for.

• Probiotics: In limited study, Lactobacillus GG was associated with improved subjective well-being, as well as reduced symptoms of rheumatoid arthritis. However, these findings were not statistically significant. More studies on the effects of probiotics in rheumatoid arthritis are needed.

• Probiotics are generally considered safe and well-tolerated. Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant. Caution is advised when using probiotics in neonates born prematurely or with immune deficiency.

• Propolis: Based on anti-inflammatory action observed in laboratory research, propolis has been proposed as a possible treatment for rheumatic diseases. However, there is currently not enough scientific human study to make a conclusion.

• Avoid if allergic or hypersensitive to propolis, black poplar (Populas nigra), poplar bud, bee stings, bee products, honey, and Balsam of Peru. Severe allergic reactions have been reported. Use cautiously with asthma or gastrointestinal disorders. Avoid if pregnant or breastfeeding because of the high alcohol content in some propolis products.

• Qi gong: There is mixed evidence regarding the usefulness of Qi gong in treating fibromyalgia. More research is needed before a conclusion can be made.

• Qi gong is generally considered to be safe in most people when learned from a qualified instructor. Use cautiously with psychiatric disorders.

• Reishi mushroom: A combination of reishi mushroom and San Miao San (a mixture of several Chinese herbs) may help reduce the pain of rheumatoid arthritis. However, these herbs did not reduce swelling. More research with reishi mushroom alone is needed.

• Avoid if allergic or hypersensitive to any constituents of Ganoderma lucidum or any member of its family. Use cautiously with diabetes, blood disorders (including hemophilia), low blood pressure, or ulcers. Avoid if pregnant or breastfeeding.

• Relaxation therapy: 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.

• 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.

• Relaxation has been reported to reduce fibromyalgia pain. However, results from other studies are conflicting, and therefore further research is needed before a clear recommendation can be made.

• Avoid with psychiatric disorders like schizophrenia/psychosis. Jacobson relaxation (flexing specific muscles, holding that position, then relaxing the muscles) should be used cautiously with illnesses like heart disease, high blood pressure, or musculoskeletal injury. Relaxation therapy is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time to diagnosis or treatment with more proven techniques.

• SAMe: Since fibromyalgia is characterized by chronic pain and depressive symptoms, there is an increased interest in studying SAMe for this indication. Current available evidence, however, does not appear to show any benefit of SAMe over placebo in reducing the number of tender points and in alleviating depression. Additional study is needed to confirm these findings.

• Avoid if allergic or hypersensitive to SAMe. Use cautiously with diabetes and anxiety disorders, or women in their third trimester of pregnancy. Avoid with bipolar disorder. Avoid during first trimester of pregnancy or if breastfeeding.

• Selenium: 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 history of nonmelanoma 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: Chondroitin sulfate, a component of shark cartilage, has been shown to benefit patients with osteoarthritis. However, the concentrations of chondroitin in shark cartilage products may be too small to be helpful. The ability of shark cartilage to block new blood vessel growth or reduce inflammation is suggested to be helpful in rheumatoid arthritis. However, there is limited research in these areas, and more studies are needed before a recommendation can be made.

• 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 (like asthma), cancers that raise calcium levels (like breast, prostate, multiple myeloma or squamous cell lung cancer) and diabetes. Avoid if pregnant or breastfeeding.

• Soy: It is unclear if soy is an effective treatment for rheumatoid arthritis or osteoarthritis. Additional research is warranted in this area.

• Avoid if allergic to soy. Breathing problems and rash may occur in sensitive people. Soy, as a part of the regular diet, is traditionally considered to be safe during pregnancy and breastfeeding, but there is limited scientific data. The effects of high doses of soy or soy isoflavones in humans are not clear, and therefore are not recommended. There has been a case report of vitamin D deficiency rickets in an infant nursed with soybean milk (not specifically designed for infants). People who experience intestinal irritation (colitis) from cow's milk may experience intestinal damage or diarrhea from soy. It is not known if soy or soy isoflavones share the same side effects as estrogens, like increased risk of blood clots. The use of soy is often discouraged in patients with hormone-sensitive cancers, such as breast, ovarian, or uterine cancer. Other hormone-sensitive conditions such as endometriosis may also be worsened. Patients taking blood-thinning drugs like warfarin should check with a doctor and pharmacist before taking soy supplements.

• Spiritual healing: There is currently not enough evidence that spiritual healing adds any benefit to conventional treatment in rheumatoid arthritis or temporomandibular joint pain (TMJ). Spiritual healing should not be used as the only treatment approach for medical or psychiatric conditions, and should not delay the time it takes to consider more proven therapies.

• Stinging nettle: Stinging nettle is widely used as a folk remedy to treat arthritis and rheumatic conditions throughout Europe and Australia. Pre-clinical evidence suggests that certain constituents in the nettle plant have anti-inflammatory and/or immunomodulatory activity and may be of benefit in rheumatoid arthritis. Well-designed, randomized controlled trials are needed to further support its use in humans.

• Avoid if allergic or hypersensitive to nettle, members of 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.

• Tai chi: There is not enough scientific evidence showing that tai chi reduces rheumatoid arthritis symptoms, although tai chi may help improve range of motion of the lower extremities. A small trial in women with osteoarthritis reported that treatment with tai chi significantly decreased pain and stiffness compared with a sedentary lifestyle. Women in the tai chi group also reported fewer perceptions of difficulties in physical functioning. More research is needed in this area. Tai chi may also aid quality of life in fibromyalgia patients, but additional study is needed to make a strong recommendation.

• Avoid with severe osteoporosis or joint problems, acute back pain, sprains, or fractures. Avoid during active infections, right after a meal, or when very tired. Some believe that visualization of energy flow below the waist during menstruation may increase menstrual bleeding. Straining downwards or holding low postures should be avoided during pregnancy, and by people with inguinal hernias. Some tai chi practitioners believe that practicing for too long or using too much intention may direct the flow of chi (qi) inappropriately, possibly resulting in physical or emotional illness. Tai chi should not be used as a substitute for more proven therapies for potentially serious conditions. Advancing too quickly while studying tai chi may increase the risk of injury.

• TENS (Transcutaneous Electrical Nerve Stimulation): Preliminary studies of TENS in patients with rheumatoid arthritis, fibromyalgia, and temporomandibular joint pain (TMJ) 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, like defibrillators, pacemakers, intravenous infusion pumps, or hepatic artery infusion pumps. Use cautiously with decreased sensation, like neuropathy, and with seizure disorders. Avoid if pregnant or breastfeeding.

• Therapeutic touch: Preliminary research suggests that therapeutic touch may be an effective treatment option in relieving pain in patients with fibromyalgia. Further research is needed before a recommendation can be made.

• Therapeutic touch is believed to be safe for most people. Therapeutic touch should not be used for potentially serious conditions in place of more proven therapies. Avoid with fever or inflammation, and on body areas with cancer.

• 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 the 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 hormonal therapy or immunosuppressants. Avoid if pregnant or breastfeeding; thymic extract increases human sperm motility and progression.

• Turmeric: Turmeric has been used historically to treat rheumatoid arthritis and osteoarthritis. Laboratory and animal studies show anti-inflammatory activity of turmeric and its constituent curcumin, however, reliable human research is lacking.

• Avoid if allergic or hypersensitive to turmeric, curcumin, yellow food colorings, or plants belonging to the Zingiberaceae (ginger) family. Use cautiously with a history of bleeding disorders, immune system deficiencies, liver disease, diabetes, hypoglycemia, or gallstones. Use cautiously with blood-thinners, such as warfarin (like Coumadin®), and blood sugar-altering medications. Avoid in medicinal amounts if pregnant or breastfeeding. Turmeric should be stopped prior to scheduled surgery.

• Zinc: The majority of trials do not show significant improvements in rheumatoid 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 definitive conclusion 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. Avoid with kidney disease. Use cautiously if pregnant or breastfeeding.

• Fair negative scientific evidence:

• Green lipped mussel: There is conflicting evidence of the effect of green-lipped mussel supplementation for treating rheumatoid arthritis. Overall, the evidence does not support this use.

• Green-lipped mussel is generally considered safe. Use cautiously with anti-inflammatory agents. Use cautiously with asthma. Avoid in patients with liver disease. Avoid with allergy or sensitivity to green-lipped mussel or other shellfish. Avoid if pregnant or breastfeeding.

• Selenium: Selenium-ACE, a formulation containing selenium with three vitamins, has been promoted for the treatment of arthritis. Research has failed to demonstrate significant benefits, with a possible excess of side effects compared to placebo.

• 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.

• Vitamin E: Vitamin E exists in eight different forms ("isomers"): alpha, beta, gamma and delta tocopherol; and alpha, beta, gamma and delta tocotrienol. Alpha-tocopherol is the most active form in humans. Vitamin E does not appear to reduce symptoms or prevent cartilage loss in osteoarthritis.

• Avoid if allergic or hypersensitive to vitamin E. Avoid with retinitis pigmentosa (loss of peripheral vision). Use cautiously with bleeding disorders or if taking blood thinners. Avoid doses greater than the recommended daily level in pregnant women and breastfeeding women.

• Willow bark: Based on limited clinical study, willow bark extract has not shown efficacy in treating rheumatoid arthritis. More high-quality studies of larger design are needed to make a 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, hepatic disorders, diabetes, gout, hypertension, hyperlipidemia, history of allergy or 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. Avoid operating heavy machinery. Avoid in children with chickenpox and any other viral infections. Avoid with blood disorders, and renal disorders. Avoid if taking other NSAIDs, acetazolamide or other carbonic anhydrase inhibitors. Avoid with elevated serum cadmium levels. Avoid if pregnant or breastfeeding.

• Zinc: In limited study, zinc supplementation did not seem to have a beneficial effect on symptoms of patients with chronic inflammatory rheumatic disease.

• 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. Avoid with kidney disease. Use cautiously if pregnant or breastfeeding.

Prevention

• Preventing sports injury: Some musculoskeletal problems associated with injuries may be preventable. Care should be taken in sports and physical activities to prevent injuries, sprains, and the overuse of joints, such as in the ankle, wrist, knee, shoulder, and spine. Individuals participating in sports activities such as football, swimming, gymnastics, baseball, basketball, tennis, skiing, wrestling, and soccer may be at a greater risk of developing musculoskeletal problems.

• Preventing occupational injury: Any job or activity that requires a fixed position over a long period of time can cause musculoskeletal discomfort. Poor job and workplace design appears to contribute to many reported discomforts. Important methods of preventing such discomfort include assuming a range of comfortable positions and having adjustable furniture, such as chairs, tables, and keyboard supports. However, the degree of adjustability for any furniture and visual display depends on how long and for what purpose they will be used. Prolonged work in the same position, whether seated or standing, can cause discomfort. Where possible, movement should be incorporated into the task to prevent discomfort and fatigue.

• It is best to avoid standing still in one place for long periods of time. The activity of the leg muscles acts as a pump and assists the veins in returning blood to the heart. Prolonged standing stops this pumping action and this may cause swelling of the lower extremities. Using a rubber or padded mat where prolonged standing cannot be avoided is recommended by healthcare providers. Mats help reduce fatigue and improve comfort. For those individuals who sit for long periods of time, a well-designed chair is very important.

• Dietary modification: Nutritional changes, along with the addition of supplements (vitamins, minerals and herbs), may be effective in reducing symptoms associated with musculoskeletal problems.

• It is best to limit caffeine and other stimulants, as well as alcohol, and to stop smoking. It may also be beneficial to eliminate potential food allergens, including dairy (milk, cheese and sour cream), eggs, nuts, shellfish, wheat (gluten), corn, preservatives, and food additives (such as dyes and fillers). Additionally, it may be helpful to avoid refined foods such as white breads and pastas and foods with high levels of sugar or refined sugar, such as donuts, pastries, candy, and soft drinks.

• Exercise: Maintaining physical fitness is important to those suffering from musculoskeletal problems. Those with musculoskeletal problems who exercise according to their healthcare professional's recommendations tend to do better, with less symptoms and a slower disease progression, than those who do not. A daily regimen of exercise can help the person feel better physically and mentally. Individuals should walk as much as possible, even if assistance is necessary.

• Regular exercise may also help individuals control their weight and decrease stress on the musculoskeletal system. There are many ways for people to exercise including gardening, walking, sports activities, and dancing. Individuals who are beginning an exercise program should choose activities that fit their levels of strength and endurance. The type of exercise is not as important as a consistent exercise schedule. Most experts today agree that burning calories should not be the goal of exercise. Exercise that causes extreme pain or discomfort is considered by many experts as unhealthy, and may even cause permanent damage to the body.

• Pilates is a body conditioning routine that seeks to build flexibility, strength, endurance, and coordination without adding muscle bulk. In addition, pilates may increase circulation and may help to sculpt the body and strengthen the body's "core" (torso). People who engage in pilates regularly report that they have better posture, are less prone to musculoskeletal injury, and experience better overall health.

• It is recommended for the patient to consult with their healthcare providers before beginning any exercise program.

Author Information

• This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography

Natural Standard developed the above evidence-based information based on a thorough systematic review of the available scientific articles. For comprehensive information about alternative and complementary therapies on the professional level, go to www.naturalstandard.com. Selected references are listed below.

1. Centers for Disease Control and Prevention. www.cdc.gov.

2. Barr KP. Review of upper and lower extremity musculoskeletal pain problems. Phys Med Rehabil Clin N Am. 2007;18(4):747-60. View Abstract

3. Chakrabarty S, Zoorob R. Fibromyalgia. Am Fam Physician. 2007;76(2):247-54. View Abstract

4. Clark KL. Nutritional considerations in joint health. Clin Sports Med. 2007;26(1):101-18. View Abstract

5. Cossu G, Sampaolesi M. New therapies for Duchenne muscular dystrophy: challenges, prospects and clinical trials. Trends Mol Med. 2007; [Epub ahead of print]. View Abstract

6. National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). www.niams.nih.gov.

7. Natural Standard: The Authority on Integrative Medicine. www.naturalstandard.com.

8. Staud R. Treatment of fibromyalgia and its symptoms. Expert Opin Pharmacother. 2007;8(11):1629-42. View Abstract