Naturopathic Interventions for Reduction of Perceived Pain in Patients Suffering from Arthritis: A Systematic Review and Meta-Analysis

Arthritis affects millions of lives with its pervasive effects on physical health and quality of life. Addressing the complexities of managing symptoms such as swelling, inflammation, and pain requires prolonged treatment. Naturopathy is a treatment method that enhances the body's innate ability to restore optimal health through a holistic approach including natural products and lifestyle modifications. This systematic review addresses the intersection of naturopathy and arthritis treatment to provide current evidence about its potential benefits. Four databases (PubMed, AYUSH Research Portal, Web of Science, and Google Scholar) were searched with the keywords "Naturopathy" AND "Arthritis". Randomized, non-randomized, and cross-over studies in English were included. Studies reporting perceived pain using a visual analogue scale (VAS) were selected for meta-analysis. A total of 15 studies were included in the systematic review. The studies were from Denmark, Egypt, France, Hungary, Israel, Italy, Spain, and Turkey, and the study periods ranged from 1992 to 2017. They suggested that naturopathic treatment modalities like exercise, mud compress, sand bath, or hydrotherapy may be used in addition to conventional modes of treatment for added benefit. There was a diversity of naturopathic treatment modalities and outcome evaluation methods. Most studies used mud compress or mud baths with reported improvement of symptoms. The meta-analysis of 10 studies (11 sets of data) showed a significant improvement in pain measured by VAS. The studies included in the review have a high level of heterogenicity. There is a need for more studies and uniform assessment methods with standardization of interventions for robust evidence. More clinical trials from countries where naturopathy is approved treatment modalities are needed.


Introduction And Background
Arthritis manifests as joint pain, swelling, stiffness, and decreased range of motion.It frequently leads to considerable functional impairment [1].The effects of arthritis extend beyond the joints, impacting various aspects of an individual's life.Chronic pain is a hallmark feature that alters daily routines and diminishes the ability to engage in optimum levels of activities [2].The relentless nature of arthritis pain not only affects the mobility of the patients but also takes a toll on their psychological and emotional well-being [3].
Effective management and treatment strategies for arthritis play a crucial role in mitigating these adverse effects.By addressing pain, preserving joint function, and improving overall well-being, healthcare interventions aim to enhance the quality of life for individuals living with arthritis [4,5].Modern medicine treatment modalities may fail in many cases and a holistic approach including physical therapy and lifestyle modifications can be tried in conjunction with other treatment methods [6,7].
Among holistic and complementary therapeutic approaches, naturopathy has emerged as a promising avenue for the management of arthritis.Naturopathic treatments for arthritis often focus on incorporating various natural therapies including food modification (e.g., consumption of fresh fruits containing antioxidants, fish enriched with omega-3 fatty acids, foods containing calcium and vitamin D like yoghurt, and avoiding foods containing saturated fats, refined carbohydrates, sugar), massage, and compression with natural substances like mud.It emphasizes the body's innate ability to heal [8].While some patients report relief, it's essential to note that scientific evidence supporting the efficacy of naturopathic treatments for arthritis is limited compared to conventional medical approaches [9].There is no previous study that systematically evaluated the effect of naturopathic treatment for both upper limb and lower limb arthritis.
With this background, this systematic review aimed to review the literature on the treatment of arthritis by naturopathy therapies and a meta-analysis was done to find if the therapies help in the reduction of perceived pain after the therapy.

Results
A total of 11 items from PubMed, 12 from Web of Science, nine from AYUSH Research Portal, 68 from Google Scholar were initially identified, and seven were obtained from cross-references.After removing duplicates, non-English studies, and excluding studies according to inclusion and exclusion criteria, a total of 15 studies were included in the final analysis.The PRISMA flow chart is shown in Figure 1.The characteristics of the included studies with their major finding are summarized in Table 1.The studies in the list from 1992 to 2017 are from Denmark, Egypt, France, Hungary, Israel, Italy, Spain, and Turkey [11][12][13][14][15][16].The studies suggested that naturopathic treatment modalities like exercise, mud compress, sand bath, or hydrotherapy may be used in addition to conventional modes of treatment for added benefit.
Among the studies, 10 studies (one study had two intervention groups; hence, a total of 11 sets of data) were selected for meta-analysis as they reported the mean and standard deviation of VAS for pain severity.The forest plot of the intervention groups in pre-therapy and post-therapy VAS scores is shown in Figure 2.There was a significant decrease in perceived pain after the therapy in the intervention group.However, the studies were significantly heterogeneous.The perceived pain VAS score before the therapy in the intervention and control groups is shown in Figure 3.There was no evidence of a difference in the level of perceived pain in the intervention and control groups before starting the therapy.The studies had moderate heterogeneity.The pain score after the therapy in the intervention and control groups is shown in Figure 4.There was significantly lower perceived pain in the intervention groups after the therapy when compared with controls.The heterogeneity was considerably high.

Discussion
The findings from the included studies suggest a potential role for naturopathy in the management of pain related to arthritis.The majority of the studies reported significant positive outcomes, including improvements in pain levels and joint function by reducing the swelling, redness, and number of painful joints.However, naturopathic therapy was used as an additional therapy to the routine treatment the patient was undergoing [27].Hence, the therapies used in those trials do not suggest replacing the ongoing treatment but suggest additional measures that can help reduce the pain of arthritis.Diverse therapeutic approaches were used in the trials like Siwan therapy, involving sand bathing and olive oil massage, stimulating massage, spa therapy combined with exercises, and mineral-rich mud compresses and packs.
Overall, the efficacy of these interventions was context-specific, emphasizing the need for tailored approaches in arthritis management.
Despite the overall positive results reported in the individual studies, it is crucial to acknowledge the heterogeneity in study designs and methodological quality among the included articles.Even for mud therapy, the mineral content in mud may be different according to countries and regions.Hence, uniform therapies were lacking.The variation in outcome measures, duration of interventions, and participant characteristics poses challenges in drawing definitive conclusions.
Among the studies, 10 studies were included in the meta-analysis and the result suggested significant improvement in perceived pain level as measured by VAS in the intervention group.This supports an earlier review by Hou et al. of mud therapy in knee osteoarthritis [28].We combined the lower, upper, and wholebody therapies in the meta-analysis [14,24].However, studies for upper limbs and the whole body are scarce and need further exploration.In addition to mud packs and other methods found in this review (Table 1), other naturopathic methods to control inflammation are yet to be explored [29,30].
When the therapy was started, baseline characteristics showed that the pain levels in both groups were similar (Figure 3).However, after treatment, the pain in the intervention groups significantly reduced (Figure 4).However, at this point, with different modes of naturopathic intervention, the synthesized evidence needs further exploration for a more robust and definite conclusion.
This systematic review has limitations.The restriction to English-language articles and the limited number of articles from Google Scholar may introduce selection bias.The risk of bias was not assessed.Furthermore, the keywords used in this study were selected to find the naturopathic therapies and studies that did not include the term "naturopathy" were excluded.For example, chiropractic therapy, which has similarities to naturopathy might not appear in the literature search [31].Future research should aim for more extensive inclusion of diverse sources and languages.Additionally, well-designed randomized controlled trials are needed in countries where naturopathic treatments are approved therapy and are in the academic sphere to strengthen the evidence base and establish the sustainability of naturopathic interventions for arthritis [32].

Conclusions
There was diversity of naturopathic treatment modalities and outcome evaluation methods.Mud packing was the most common method.Most studies showed improved disease severity when naturopathy is combined with other treatment methods.There was a significant improvement in perceived pain measured by VAS immediately after the therapy.There is a need for more studies with uniform therapy and

FIGURE 1 :
FIGURE 1: PRISMA flow chart showing the identification, screening, and inclusion steps PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Author, year Place Sample in intervention (n), age (years) (mean±SD) Sample in control (n), age (years) (mean±SD) Region of body Therapy in the intervention group Therapy in the control group Duration Outcome Summary of finding
2024 Mondal et al.Cureus 16(2): e54589.DOI 10.7759/cureus.545893 of 8