Chronic Recurrent Multifocal Osteomyelitis (CRMO)

What is Chronic Recurrent Multifocal Osteomyelitis?

Chronic recurrent multifocal osteomyelitis (CRMO) is an autoinflammatory bone disorder in which bones become inflamed without infection. It is the severe, multifocal form of chronic nonbacterial osteomyelitis (CNO), a condition that most often affects children and adolescents.^[1]

Because it usually begins in childhood, diagnosis and treatment are normally directed by pediatric specialists, although the condition can also appear in adults.^{[1, 2]}

Common symptoms

The main symptom is bone pain, often first mistaken for growing pains, an infection or a tumor, which can delay diagnosis.^[3] The long bones near the growth plates (especially the thigh and shin), the pelvis, spine, collarbone and jaw are the usual sites.^[4]

• Bone pain that comes and goes in episodes
• Swelling or tenderness over a bone
• Less commonly, fever, tiredness or limited movement

The course is waxing and waning, and the pain can be severe enough to affect quality of life and psychosocial development.^[1]

Causes and risk factors

The cause is not fully understood. Research suggests an imbalance of inflammatory signals in immune cells that leads to increased inflammasome activity and bone inflammation.^{[1, 5]} Infection is not the cause, which is why bone cultures are sterile. Some people also have skin conditions such as acne or palmoplantar pustulosis, and CRMO overlaps with SAPHO syndrome in adults.^{[2, 6]}

How it is diagnosed and treated conventionally

There are no accepted diagnostic criteria or blood markers, so CNO is a diagnosis of exclusion, made after infection and cancer are ruled out.^[1] MRI is considered the gold standard, and whole-body MRI can find lesions that cause no symptoms.^{[3, 4]}

Most patients respond at least partly to nonsteroidal anti-inflammatory drugs. Others need corticosteroids, cytokine-blocking agents or bisphosphonates, and no drug is licensed specifically for CNO.^[1] A pediatric consensus plan for NSAID-resistant disease or spinal lesions lists methotrexate or sulfasalazine, TNF inhibitors, or bisphosphonates.^[7] With an experienced team the outlook is good, but some people have lasting effects such as vertebral compression fractures, and the disease may relapse over years.^{[1, 3]}

Why Chronic Recurrent Multifocal Osteomyelitis calls for a whole-person approach

CRMO is an immune-driven bone disease, but living with it involves more than the bones. Pain, missed activities, worry and the effects of long-term drugs all affect daily life, and each needs its own attention.

Supportive care may have a role in some of these areas once the disease is under specialist management. Research in CRMO itself is missing, so what follows is drawn from related conditions.

Inflammation

CNO is described as a disorder of imbalanced inflammatory signaling in innate immune cells.^[5] This explains why anti-inflammatory and immune-modifying drugs are the mainstay.^[1] No herb or acupuncture has been shown to correct this imbalance.

Chronic pain

Severe, long-lasting pain can reduce quality of life and psychosocial development in people with CNO.^[1] Acupuncture has been studied for chronic pain in other conditions, as described below.^[8]

Stress and emotional health

Chronic pain, missed school or work, and repeated tests are stressful. Stress has been studied as a target for some Ayurvedic herbs, discussed below.^{[9, 10]}

Bone health

Spinal lesions can lead to vertebral compression fractures, and bisphosphonates are used to protect vulnerable bone.^{[1, 3]} Decisions about bone protection belong with your physicians.

Acupuncture as supportive care in Chronic Recurrent Multifocal Osteomyelitis

What the research shows

No clinical studies of acupuncture for CRMO were found, so there is no evidence that it affects the bone inflammation.

For chronic pain in general, an individual patient data meta-analysis of 39 trials (about 20,800 patients) found acupuncture superior to sham and no-acupuncture controls for musculoskeletal pain, osteoarthritis, headache and shoulder pain, with effects that persisted for a year.^[8] These were adult trials in other conditions and may not apply to inflammatory bone disease.

In children, a systematic review of acupuncture for chronic pain found only 5 studies, including one randomized trial. They reported less pain and better school attendance, but the authors called the evidence weak because of design limits and small samples.^[11]

How acupuncture may work

How acupuncture might act is not established. The individual patient data analysis of chronic pain found that decreases in pain cannot be explained by placebo effects alone, but this does not show a mechanism.^[8] No mechanism studies in CRMO were found.

What treatment involves

Treatment uses fine, sterile, single-use needles, usually left in place for about 20 to 40 minutes, with a short course of visits and reassessment. Needles are not placed over a painful, inflamed or recently fractured bone.

In prospective studies, about 9 in 100 patients had a minor reaction such as soreness or bleeding at a needle site, and serious events occurred in about 1 in 10,000 patients.^[12] Tell the practitioner first if you take blood thinners, have a bleeding disorder, are pregnant or have a pacemaker. People taking steroids or other immune-suppressing drugs should say so, because infection risk matters.

Ayurvedic medicine as supportive care in Chronic Recurrent Multifocal Osteomyelitis

The Ayurvedic view

Ayurveda has no classical name for CRMO. A practitioner might describe recurring bone pain and swelling as a disturbance of Vata, linked to bone tissue (asthi), sometimes with aggravated Pitta where there is heat and inflammation. These are traditional frameworks, not biomedical diagnoses.

Therapies that may be used

Care is individualized and traditionally includes:

• Diet and daily routine aimed at regular meals, rest and steady sleep
• Gentle warm oil massage away from painful or swollen bones, and relaxation or breathing practices
• Herbs prescribed individually by a qualified practitioner, after review of your medicines

Panchakarma is not appropriate during pregnancy, acute illness or frailty, and strong cleansing procedures are generally unsuitable for people on high-dose steroids or immune-suppressing drugs or with active flares.

What the research shows

No clinical studies of Ayurvedic treatment for CRMO were found. Turmeric (curcumin) is an Ayurvedic herb that has been studied in arthritis. A meta-analysis of 29 trials in 5 types of arthritis found it may improve symptoms and inflammation, but the authors judged the trials to be few and of low quality.^[13] Those trials did not include CRMO.

Ashwagandha has been studied for stress and anxiety. A meta-analysis of 9 trials found lower stress, anxiety and cortisol scores than placebo, with limited long-term safety data, and another pooling 12 trials rated the certainty as low.^{[9, 10]} The participants were adults without CRMO.

Herbal medicine as supportive care in Chronic Recurrent Multifocal Osteomyelitis

Herbs and formulas that have been studied

A recent narrative review of SAPHO syndrome, which overlaps with CRMO, lists traditional Chinese medicine among non-drug approaches to be considered, without evidence of benefit in the abstract.^[2] Beyond this, the plant compound curcumin has been studied in arthritis.^[13]

What the research shows

No clinical trials of herbal medicine for CRMO were found. The curcumin evidence is from arthritis, is of low quality, and cannot be applied to CRMO.^[13]

Safety and herb-drug interactions

Methotrexate, sulfasalazine, TNF inhibitors and steroids affect the immune system and liver, so herb choices need review by your specialist. Herb-drug interaction reports include St John's wort lowering ciclosporin and tacrolimus levels, and cases of organ rejection followed.^[14] Herbal and dietary supplements account for about 20% of drug-induced liver injury in the United States.^[15]

About one fifth of Ayurvedic medicines bought online contained detectable lead, mercury or arsenic.^[16] Tell us about all medicines and supplements, and whether you are pregnant or breastfeeding. Herbs for a child need particular caution and a pediatric specialist's agreement.

Translating traditional medicine into modern biological language

This section is interpretation, not equivalence. Chinese medicine might describe recurring bone pain with swelling as obstruction of qi and blood, sometimes with heat. Ayurveda would describe disturbed Vata affecting bone tissue. Researchers describe inflammasome activation and an imbalance of pro- and anti-inflammatory cytokines in innate immune cells.^[5]

The overlap is in symptoms such as pain and stress, which can be studied directly, for example with acupuncture trials for chronic pain or ashwagandha trials for stress in other groups.^{[8, 9]}

How this care fits with your medical care

CRMO needs diagnosis and ongoing care from a specialist, usually in rheumatology. Our care is supportive only, does not treat the bone inflammation, and does not replace anti-inflammatory drugs, methotrexate, biologics, bisphosphonates or other prescribed treatment. For a condition like this, we ask that you are under a physician's care for it and that your treating team knows you are receiving complementary care.

Do not stop or change any prescribed medicine without your prescriber. Please bring your diagnosis, imaging reports, a full list of medicines and supplements, and your specialist's name.

When to seek urgent medical care

CRMO can cause fractures and mimics serious conditions such as infection, so new or changing symptoms need prompt assessment.^{[1, 3]}

• Sudden severe back pain, especially after minor strain, which could signal a spinal fracture
• Bone pain with high fever, chills or a hot, red, swollen area
• New weakness, numbness or trouble walking or controlling the bladder or bowels
• A limb that cannot bear weight or looks deformed
• Fever or signs of infection while taking steroids or immune-suppressing drugs

If any of these occur, call 911 or go to the nearest emergency department.