If you are suffering from what medicine calls 'arthritis', you could have any one of a hundred different kinds of illness, including everything from the most common - osteoarthritis and the crippling rheumatoid arthritis - to gout and fibromyalgia. While organisations such as the Arthritis Foundation pooh-pooh all but the most widely used conventional treatments, the sheer pandemic proportions of arthritis - one in three in America and one in five in Britain - and the wide variety of different kinds of arthritis make it clear that considering other solutions is necessary and desirable.

Front-line drug therapy, which includes the use of aspirin and NSAIDs, used to reduce inflammation in the joints, can produce side-effects such as bleeding in the stomach. Likewise, second-line treatment in the form of slow-acting antirheumatic drugs (SAARDs) such as gold, methotrexate and sulphasalazine, traditionally prescribed to advanced rheumatoid arthritis sufferers to slow the progress of the disease, bring with them a host of side-effects, including ulcers and life-threatening gastrointestinal problems.

The official line is that there are no other 'cures' for arthritis, that anything other than the accepted pathway is just quackery. The Arthritis Foundation believes that nine out of 120 arthritis sufferers have tried at least one form of alternative therapy and that most of these have failed to find relief. Their attitude assumes two things: 1) that copper bracelets, motor oil and bee venom can happily be lumped in with acupuncture, yoga and herbs; and 2) that conventional medicine is some sort of haven for sufferers to return to. These views fail to acknowledge that perhaps 90 per cent of sufferers feel in some way let down by the conventional approach and its myriad unpleasant side-effects. Of course, it also ignores those studies which show that arthritis sufferers can find relief from pain, stiffness and inflammation through a variety of alternative methods, either singly or in combination.

At present, the numbers of patients enrolled in studies of alternative arthritis treatments are small. Since these small studies show many positive outcomes, it is worth asking why they have not been followed up with larger studies. Are our doctors as hopeless about arthritis as the sufferers?

Acupuncture
Several studies show that acupuncture can help reduce pain. In one study, a group of 42 patients with osteoarthritic knees were randomised into two groups: either acupuncture (group A) or no treatment (group B). After nine weeks, those receiving no treatment were treated with acupuncture as well. Investigators who were 'blind' as to which individuals belonged to which group concluded that, in the treatment group, there was a significant reduction in pain, analgesic consumption and most other objective measures. When groups A and B were combined, there was an 80 per cent subjective improvement, including a significantly increased knee-range movement, even in the most immobile knees. Those who had not been ill for a long time showed the greatest improvement - emphasising the need for early treatment - and improvements were maintained over time (Acta Anaesthesiol Scand, 1992; 36: 519-25). Another study showed that acupuncture is at least as effective as diazepam for relieving the pain of osteoarthritis (Am J Chin Med, 1991; 19(2): 95-100).

Similar results were found in one study of patients with fibromyalgia (G Ital Riflessot Agopunt, 1995; 7(2): 33-7), although results have been mixed. In one study, 40 patients with osteoarthritis were randomly assigned to two groups. One received acupuncture at genuine points, the other at placebo points. Both groups showed improvement in tenderness and the subjective assessment of pain (N Engl J Med, 1975; 293: 375-8). This finding has been repeated elsewhere (Z Physiother, 1990; 42: 375-8), although some analysts remain sceptical (J Clin Epidemiol, 1990; 43:1191-9).

Electronic stimulation
Electroacupuncture via the Codetron machine has also been shown to be highly beneficial (Acupunct Electrother Res, 1992; 17: 95-105) and as equally effective as other forms of acupuncture (Pain Clin, 1991; 4: 155-61), though less effective than Transcutaneous Electronic Nerve Stimulation (TENS) (Altern Ther Clin Pract, 1996; 3: 33-5).

A group of 70 patients with fibromyalgia was randomised to receive either electroacupuncture treatment or a sham procedure. Outcome parameters were pain threshold, analgesic use, regional pain scores, pain recorded on a visual analogue scale, sleep quality and morning stiffness, and also by the assessment of the patients themselves and evaluating physicians. In the treatment group, seven of the eight outcome parameters showed a significant improvement, whereas none of the patients in the sham group showed any improvement (BMJ, 1992; 305: 1249-52).

In another double-blind placebo-controlled trial, patients suffering from pain due to osteoarthritis of the hip and knee received either genuine Codetron treatment or a sham treatment. Of the Codetron group, 74 per cent showed improvement in pain levels (as measured by a visual analogue scale), while only 28 per cent of the sham treatment group showed improvement (Clin J Pain, 1989; 5: 137-41).

Another trial compared mock electroacupuncture with local heat from an infrared gun. In the treatment group, 75 per cent of patients received significant pain relief, compared to 31 per cent in the mock treatment group (Acup Electrother Res, 1981; 6: 277-84).

Mind and body
It is now recognised that patients' emotional or psychological state may affect the course and perception of their disease, and that intervention, in the form of group therapy, may help perceptions of pain (Arthr Rheum, 1986; 29: 1203-9).

The effectiveness of short, intensive programmes of patient education has been evaluated in several studies. In one, individuals with ankylosing spondylitis showed improvement in rates of depression and self-esteem, and severity of the disorder at three weeks, and this improvement continued until the end of the trial at six months. The researchers noted, however, that motivating the patients to continue their home exercise programme past the six-month mark remained one of the biggest prob-lems (Patient Educ Couns, 1996; 27: 257-67).

Another study looked at the effect of group treatment on chronic pain and the emotions linked with it - anger, anxiety and depression - on a group which included sufferers of low-back pain, tension headache, rheumatoid arthritis and ankylosing spondylitis. A cognitive behavioural programme that included components of relaxation, cognitive restructuring and the promotion of wellbeing was used, and the effect on the different groups assessed. Subjects with inflammatory rheumatoid diseases showed improvement on all fronts (Patient Educ Couns, 1993; 20: 167-75).

Patients with rheumatoid arthritis may also benefit from a cognitive behavioural programme. In one 12-month trial, subjects showed greater confidence in using coping strategies to deal with pain as well as improvements in their emotional state (Arthr Rheum, 1988; 31: 593-601).

A further randomised clinical trial to evaluate a psychological treatment and a social-support programme compared with a control programme of no treatment showed that psychological intervention produced significant reductions in pain, anxiety and disease activity post-treatment. The effect was still detectable at the six-month follow-up. The social-support programme also showed a reduction in anxiety (Arthr Rheum, 1987; 30: 1105-14).

One study looked at the efficacy of several treatments: pain-management education, relaxation training and visualisation compared with no treatment. Those participating in the pain management and visualisation groups showed improvements, while relaxation on its own proved to be little better than no treatment at all.

The authors noted that patient attitude was important and that simply attending the groups was not enough. Those who were able to take on board the methods used and practise them fully showed the greatest improvement (Zeitschr Klin Psychol Psychopathol Psychother, 1994; 42: 319-38).

Of course what one person finds relaxing, another might not. One small study supports the idea that we must choose methods of relaxation carefully. Thirty women with rheumatoid arthritis were told to relax while listening to music of their choice, and researchers studied the effect which this had on their perceptions of pain. The results of the study, based on questionnaires completed before, during and after listening to music, showed that this kind of relaxation can be a valid way to help chronic pain (Adv Nurs Sci, 1993; 15: 27-36).

Hypnotherapy may also be useful. In a controlled study of patients with fibromyalgia, 40 patients were randomised either into hypnotherapy or physical therapy groups for 12 weeks. Follow-up was at 24 weeks. In the hypnotherapy group, the subjective scores of pain, morning fatigue and sleep patterns all showed improvement, though objective assessment of the disease progression showed no change (J Rheumatol, 1991; 18: 72-5).

In another trial, hypnotherapy with guided images was compared with two control groups - a relaxation group and a waiting-list group receiving no treatment. Self-assessment during therapy and at three and six months was used, as were blood tests to measure erythrocyte sedimentation rates (ESR), C-reactive protein, haemoglobin and leukocyte levels. The hypnosis group showed a decrease in joint pain both during and after the therapy period. The relaxation group also showed a decline in joint pain during therapy, but this state stabilised at follow-up. The hypnosis group also showed improvements in ESR (Psychol Beitr, 1994; 36: 205-12).

A meta-analysis of trials on massage for relief of symptoms of arthritis provided some support for the idea that manipulation may help improve pain and flexibility (Spine, 1985; 10: 833-7), though the results were not encouraging.

Herbs
Several herbs have proven anti-inflammatory effects. In an experimental, double-blind, crossover study, 42 patients with osteoarthritis randomly received a combination formula, Articulin-F (comprising the stem of Boswellia serrata, Curcuma longa rhizome, Withania somnifera root and zinc), or a matching placebo for three months and then, after a 15-day 'wash-out period', the patients changed places with the other treatment group for a further period of three months. After three months, those taking the combination treatment had a significant reduction in pain and disability. The authors emphasise that this was a subjective assessment since radiological assessment failed to show any signs of improvement (J Ethnopharmacol, 1991; 33: 91-5).

An over-the-counter remedy, Reumalex, has been shown in a double-blind study to have a mild analgesic effect and thus improve pain for those with chronic symptoms (Br J Rheumatol, 1996; 35: 874-8).

Devil's claw (Harpagophytum procumbens) is a herb native to Africa that has a long history in the treatment of arthritis, and there is some evidence that it may be useful as an anti-inflammatory (Schweiz Apothek-Zeitung, 1976; 114: 337-42). In one experimental study over 60 days, 86 per cent of patients noted decreased morning stiffness. Improvement was reported
after just eight days on the treatment and gradually improved (J Med Actuelle, 1985; 12: 65-7). Another study also showed positive results (J Pharm Belg, 1980; 35: 143-9).

Feverfew (Tanacetum parthenium) has a long history as a remedy for rheumatoid arthritis. It has been shown to inhibit the release of blood vessel-dilating substances and to inhibit the production of inflammatory substances. Most of the research, however, has been confined to in-vitro (Lancet, October 25,1980) and animal studies (Planta Med, 1992; 58: 117-23; Planta Med, 1993; 59: 20-5). Select the best quality feverfew that you can since many commercial preparations vary in the amount of parthenolide, the active component of feverfew, contained within them (J Pharm Pharmacol, 1992; 44: 319-5). In about 10 per cent of individuals, chewing the leaves can result in small ulcerations of the mouth, and swelling of the lips and tongue (Can Pharm J, 1989; 122: 266-70).

The root of Tripterygium wilfordii may also be helpful, but should be used with caution in children and women of childbearing age since it can lead to amenorrhoea and impaired spermatogenesis (both of these side-effects eventually disappear once treatment has stopped). It has been shown useful in rheumatoid arthritis and ankylosing spondylitis (Chin Med J, 1989; 102: 327-32; J Trad Chin Med, 1983; 3: 125-9).

Homoeopathy
There have been several studies which show a positive effect of homoeopathic preparations on arthritic conditions. In one trial, patients with fibromyalgia showed improvement (BMJ, 1989; 299: 365-6).

In a randomised, controlled trial to evaluate the effectiveness of homoeopathy in rheumatoid arthritis, 44 patients were assigned either homoeopathic remedies or placebo. At six months, the treatments were generally equally effective in most assessments, with those taking homoeopathic remedies reporting slightly better results (Scand J Rheumatol, 1991; 20: 204-8).

In another double-blind trial, 23 patients with rheumatoid arthritis took first-line anti-inflammatory treatment plus homoeopathy, while a similar group of 23 took first-line anti-inflammatory treatment plus placebo. There was a significant improvement in subjective pain, stiffness and grip strength in the homoeopathy group, and perhaps most important, there were no side-effects observed (Br Homeop J, 1986; 75: 148-57).

The homoeopathic preparation Rheumaselect was tested on patients with rheumatoid arthritis against a placebo over a 12-week period in a randomised double-blind, controlled trial. Although both groups improved, the improvement was more marked in the Rheumaselect group (Erzt Akt Rheumatol, 1991; 16: 1-9).

Movement and exercise
Yoga has been shown to be effective in a randomised trial to improve pain, strength, motion, joint circumference, tenderness and hand function in patients with osteoarthritis (J Rheum, 1994; 21: 2341-3).

In another controlled study of the effect of Tai Chi as opposed to a traditional exercise programme, the Tai Chi group showed a greater range of motion, better rest and greater enjoyment of daily activities than those in the traditional exercise group. These results were maintained at the four-month, post-trial follow-up (Am J Occup Ther, 1987; 41: 90-5). These results are interesting because analysis showed that, although the traditional exercise group exercised more frequently, they seemed to gain less benefit from it.

In another study, aerobic exercise was compared with stress management and treatment-as-usual for those with fibromyalgia (Scand J Rheumatol, 1996; 25: 77-86). Those who engaged in aerobic exercise showed the greatest improvement in pain levels, sleep patterns and feelings of depression as well as increased energy. The authors expressed surprise at this conclusion since the subjects in the aerobic exercise group were the most sceptical about exercise as a form of treatment. Yet, at the four-year follow-up, the aerobic group was the one most likely to have carried on using exercise as a form of treatment.

Hydrotherapy
The difference between hydrotherapy in a mineral bath and hydrotherapy in a normal hospital exercise bath was evaluated in one study. The researchers concluded that morning stiffness was significantly improved in both groups, though objective measures such as ESR rate showed no improvement (Ned Tijdschr Geneesk, 1992; 136: 173-6).

Sulphur baths and mud pack treatments singly or in combination have been shown to improve symptoms of rheumatoid arthritis in a controlled randomised trial over two weeks. Patients had daily treatment and the improvements lasted for up to three months (Ann Rheum Dis, 1990; 49: 99-102).

In another trial, the efficacy of Dead Sea bath salts used in a warm bath were assessed in a double-blind study. One group received genuine Dead Sea bath salts, the other simple table salt. Each group had a daily bath for two weeks. The Dead Sea salt bath group showed a significant improvement over the table salt group, and the effects lasted for up to one month after the end of the treatment period (Clin Exp Rheumatol, 1990; 8(4): 353-7).

There is, as yet, no 'cure' for arthritis. What the evidence shows us is that many alternative methods for relieving the symptoms, both physical and emotional, of arthritis can be at least as effective as conventional therapy and that these methods carry with them the promise of fewer debilitating side-effects. Perhaps, as with any chronic disease, the individual's belief that one system or another is right for them is the most potent factor in finding relief.

Conventional medicine has yet to answer this question convincingly, which is why controlling symptoms is the best it has to offer most patients. Dr John Mansfield takes a different line from some other practitioners and does not believe that arthritis is caused by a virus nor, he says, is it an autoimmune disease. Instead, he believes that the body is reacting against allergens and not against itself.

It is still controversial to some to suggest that arthritis may be linked to food allergy, the environment or even nutrition. And yet it is in these areas where alternative practitioners are having the greatest successes in effecting cures.

Arthritis is a multifactorial disease, and its causes can vary a great deal from one patient to another. A programme which involves dietary and environmental changes along with one or more of the alternative therapies outlined in the main article may show the greatest positive effect.

In his book Arthritis: Allergy, Environment and Nutrition (Thorsons, £6.99), Dr Mansfield outlines case studies from his own practice at the Burghwood Clinic in Banstead, Surrey, where he specialises in allergy and nutrition, as well as from the growing body of evidence showing nutritional and environmental links with arthritis.

Clearly, some arthritis sufferers with simple food allergies are helped by simple dietary manipulation. Those who do not respond to minor changes may have more complex food allergies, which are further complicated by inhaled allergens of ingested chemicals. Dr Mansfield cites the evidence, from both the UK and the US, of arthritis patients who entered environmental control clinics (totally allergy-free environments) and who, after a few days of fasting and despite the absence of medication, lost most and sometimes all of their arthritis symptoms. Those who do not respond are long-term sufferers whose joints have been irreversibly damaged. Were our physicians to work in such clinics, he concludes, they 'could hardly fail to conclude that arthritis is a condition in which food and environmental factors play a huge part.'

What's more, Mansfield is confident that 'the vast majority of people do not need the attention of an environmental control unit and its attendant expense. They can normally be helped by attending an outpatient clinic specialising in this approach. In-depth history taking will often yield clues as to whether the problems are related to food, chemicals, inhaled allergens or nutrients.'

The time to consider nutritional and environmental causes is early on in the disease, and before your body has become battered and compromised by years of taking NSAIDs and potent cortisone-derived drugs, concludes Dr Mansfield.

There is no single dietary change which will help all arthritis sufferers and, even if an individual is allergic to certain foods, this may not always be linked to a worsening of arthritis symptoms (Clin Exp Rheum, 1995; 13: 167-72). Unfortunately, because conventional medicine has mostly ignored any links between diet and arthritis, research has been confined mostly to smallish studies and the work of dedicated practitioners like Dr Mansfield. Although the point continues to be debated by many doctors and researchers, it has been known for some time that altering the diet can help alleviate arthritic symptoms (Lancet, 1986; i: 236-8).

* Fasting and diet changes. Dr Jens Kneldsen-Kragh and his colleagues as the University of Oslo have led the way with some excellent studies into arthritis and diet. They have found that there may be benefits from a short fast followed by dietary changes (Lancet, 1991; 338: 899-902; Scand J Rheumatol, 1995; 24: 85-93). Like all 'cures', patient belief in a system of dietary change can influence its success and how well an individual sticks to the regime (Br J Rheumatol, 1994; 33: 569-75). In one two-year study, clinical improvement was noted in sufferers of rheumatoid arthritis after they fasted and then embarked on an individually adjusted vegetarian diet for a year. Follow-up one year after the trial showed that the benefits remained for those who had stuck to the vegetarian diet (Clin Rheumatol, 1994; 13: 475-82).

* Eliminate allergens. The most common allergens are dairy, soya, wheat and the nightshade family (potatoes, peppers, tomatoes and tobacco). In one study of 5000 arthritis patients, 70 per cent reported gradually increasing relief after the elimination of nightshades (J Int Acad Prev Med, November 1982). It may be worth having a specialist arrange for food allergy testing.
One of the biggest-ever trials of diet took place in three environmental control units in the US. The first arm involved a water-only fast of six days, at the end of which improvements were reported in the vast majority of cases. The second revealed that patients reacted more frequently to wheat, corn and animal proteins than fruit or vegetables. A third revealed by first introducing organic foods, then commercially prepared foods, that chemical sensitivity was also linked to arthritic symptoms (J Clin Ecol, II: 137-45; J Clin Ecol, II: 181-9).

* Increase B vitamins. Both B5 (pantothenic acid) and B3 (niacinamide) have been shown to be beneficial at doses of 25 mg. They should be taken within a balanced B-complex supplement and should not be taken at night. Niacinamide has been shown to reduce inflammation and increase joint flexibility, and may help sufferers reduce the amount of first-line anti-inflammatories they need to take (Imflam Res, 1996; 45: 330-4). In addition, for those on methotrexate, folic acid supplements have been shown to reduce the toxicity of this powerful drug (Arth Rheum, 1990; 33: 9-18).

* More oils for healthy joints. Omega-3 fatty acids may help to reduce morning stiffness (J Rheumatol, 1992; 19: 1531-6), as can a diet which is high in polyunsaturated fats and low in saturated fat (Lancet, 1985; i: 184-7). Blackcurrant seed oil, rich in gamma-linolenic acid (GLA) and alpha-linolenic acid (ALA), can help alleviate inflammation in patients with rheumatoid arthritis (Br J Rheumatol, 1994; 33: 847-52). But the problem is that sufferers need to take several large capsules a day of whatever supplement they choose, and this puts some off the regime.

* Other nutrients. Selenium-ACE failed to show significant efficacy over placebo at three or six months in one trial (Br J Rheumatol, 1990; 29: 211-3). Nevertheless, the Institute of Optimum Nutrition recommends that arthritis sufferers should consider taking combined antioxidants vitamins C, E and selenium. Daily doses of vitamin C can be as high as 3000 mg, and 400 IU of vitamin E and 200 mcg of selenium could also be taken every day for optimum effect, the Institute recommends.