Rheumatoid arthritis (RA) is a chronic condition that is a major cause of disability and occurs in around 1% of the population. Approximately 600 000 people in the UK suffer from RA. Prevalence increases with age in both males and females, with RA being three times more common in women than in men (McIntosh, 1996). In 1992/93, the economic burden of RA in the UK was estimated to be £1.256 billion (McIntosh, 1996), with just over half of this comprising production losses through the inability of those affected to work.
RA represents a significant proportion of health-care spending and results in economic loss for individuals and society. Scott et al (1998) estimate that a district general hospital servicing a population of 250 000 would see between 80 and 100 new cases of RA every year and 1200 to 1500 cases with established RA.
Many RA patients are seen regularly as both inpatients and outpatients, and nurses are frequently in the position of giving information and advice about disease management. Because of the inability of conventional medicine to provide a cure for this disease, many patients turn to complementary and/or alternative medicines alongside their conventional medical care.
A recent study by Osborne (2000) on the use of complementary medicines by patients attending Barnsley District General Hospital Rheumatology Outpatient Clinic showed that, of 119 patients involved in the study, over a third had used complementary medicine, of whom the majority had RA. Acupuncture was identified as the most widely used therapy, with 13 patients having tried it.
With this in mind, it seemed appropriate to examine the evidence from other studies that have addressed the use of complementary and alternative medicine (CAM), particularly acupuncture, among patients with RA, in order to establish the extent of its use and evidence of its effectiveness. It is also of interest to establish the patients’ knowledge of and attitude towards CAM and their experiences of it. It is particularly important for nurses to understand the contribution of acupuncture to the management of RA because NHS physiotherapists in this and other districts use this therapy. Nurses also need to be aware of the professional implications of its use.
Box I provides a definition of CAM.
Use of acupuncture and other CAMs in the treatment of rheumatoid arthritis
It is clear from the definition of CAM given in Box 1 that it encompasses a diverse range of health practices, some of which are based on belief systems that are at variance with conventional biomedical traditions. Yet patients in specialties such as rheumatology are making increasing use of such therapies, and it is important for nurses to understand the implications of such use.
Rheumatological patients are among the most frequent users of complementary therapies (Resch et al, 1997). The questionnaire-based research on which this study was founded examined the use of complementary therapies by individuals with arthritis and found that, of the 1020 respondents, one-third had received at least one treatment from a complementary practitioner. They also found that sessions spent with the therapist were seen as more satisfying than those with GPs. A study by Vecchio (1994) to determine the number of rheumatology outpatients who sought alternative medicine treatment (and their satisfaction with this versus conventional services) found that, of the 280 completed questionnaires analysed, 114 patients (40%) had attended one or more alternative practitioners at some stage during their rheumatic illness, with acupuncture being one of the most popular therapies sought.
Chandola et al (1999) looked at the use of complementary therapies by patients attending musculoskeletal clinics. In total, 166 patients were interviewed, with the predominant diagnosis being RA. Of these, 47 patients had tried a complementary therapy, with 26 saying they felt that they had benefited from doing so. Acupuncture, homoeopathy, osteopathy and herbal therapy were found to be the most popular types and it emerged that female patients, and patients who were dissatisfied with conventional treatments, were those seen in the study as most likely to consider using complementary medicine.
Effectiveness of acupuncture in RA
It is apparent from the literature that acupuncture seems to be effective for some arthritic conditions but not others. It has also been noted that many studies examining the effectiveness of acupuncture for pain have had methodological flaws that cast doubt on the results (Berman et al, 1999). For example, it is difficult to construct randomised controlled trials to test the effectiveness of acupuncture because of the need to provide a placebo therapy. ‘Sham acupuncture’, using needling at points known not to be acupoints, has been used in some studies (David et al, 1999).
A randomised, placebo-controlled crossover study by David et al (1999), which evaluated the effect of acupuncture treatment as an adjunct in the management of patients with RA, concluded that it cannot be considered as a useful adjunct. The patients involved in the study, however, had established erosive disease, which may have been less responsive than less advanced disease. It is also suggested in this study that the outcome measures used may not have been sensitive enough for this particular type of study. A positive subjective response is seen as difficult to quantify.
Strong evidence that real acupuncture is more effective than sham acupuncture in treating osteoarthritis (OA) knee pain was suggested in a systematic review by Ezzo et al (2001). The review looked at the use of acupuncture for OA of the knee and found three high-quality studies that compared real acupuncture with sham acupuncture; two of these showed positive results for pain.
Berman et al (2000) summarise the evidence as follows: ‘Although there is not yet definitive evidence from large-scale randomised controlled trials that acupuncture is effective for treating rheumatic conditions, there is moderately strong evidence from controlled trials to support the use of acupuncture as an adjunctive therapy for both osteoarthritis and fibromyalgia… the only randomised controlled trial of acupuncture for rheumatoid arthritis employed too small a sample size for any statistically significant results to emerge’ (Berman et al, 2000).
These findings make the high degree of use of acupuncture as an adjunct in the treatment of rheumatoid arthritis questionable from a scientific perspective if the evidence required on which to base practice is the gold-standard clinical trial. However, surveys of patient satisfaction with and perceived benefits from acupuncture suggest that these clinical trials may be failing to capture the holistic nature of any benefit. It is worth noting that lack of evidence does not mean lack of effect.
It is difficult to accurately quantify adverse effects of acupuncture, as there is no reporting system in place for acupuncturists at present. Events that have been reported include mild events, such as needle pain and feeling faint, to rare, serious events such as systemic infection and pneumothorax. It has been suggested (Berman et al, 2000) that the more serious side-effects are more commonly reported in patients seen by practitioners who have had a very brief training in acupuncture. Furthermore, it is also recommended that an orthodox diagnosis be made before treatment in case the diagnosis determines that another treatment is more appropriate (Berman et al, 2000). Recent research indicates that adverse events are, however, rare (Vincent, 2001).
Professional issues for nurses
In its position statement on complementary therapies the UKCC states: ‘In using complementary therapies, a registered nurse, midwife or health visitor must consider the council’s standards as set out in the code of professional conduct and apply the principles set out in the council’s document The Scope of Professional Practice at paragraphs 8 to 11’ (UKCC, 2000).
The Guidelines for the Administration of Medicines (UKCC, 2000) state that registered nurses, midwives and health visitors who practise the use of complementary therapies must have successfully undertaken training and be competent in this area. It is the responsibility of the individual practitioner to judge whether his or her qualification in a therapy has achieved a satisfactory level of competence. The practitioner must consider the appropriateness of the therapy to both the condition of the patient and any co-existing treatments and ensure that the patient is aware of the therapy and gives informed consent.
Clearly, nurses using CAM or advising patients on its use must adhere to evidence-based principles and ensure informed consent is obtained. As in other areas of practice, adequate training and supervision are required.
Patients’ knowledge, attitudes and experience
In a recent US study that investigated factors seen as possible predictors of using alternative health care, Astin (1998) concluded that users were those who found it to be congruent with their beliefs and values, but that its use did not generally indicate dissatisfaction with traditional or conventional medicine. Indeed, patients indicate more confidence and satisfaction with conventional therapies but still use CAMs as an additional aid to managing their disease.
Many studies have been undertaken to examine patient satisfaction with alternative treatments. As part of a Dutch study by Visser et al (1992), a selection of rheumatology patients were invited to complete a questionnaire, part of which referred to the patients’ attitudes towards alternative medicine and their experience of it. The majority of patients suffered from rheumatoid arthritis and one of the three most frequently used therapies was acupuncture.
In an Australian study, Vecchio (1994) undertook a questionnaire survey of 280 rheumatology outpatients to determine how many of them had sought alternative medicine treatment and how satisfied they were with the service provided in comparison to that provided by conventional clinics. It concluded that ‘a significant number of patients attending hospital clinics will try or have tried alternative medicine for their rheumatic disease and this, at least for a substantial number, helps to reinforce their attendance, perception and satisfaction with conventional care’.
A House of Lords select committee report (2000) suggests that there is a high level of patient satisfaction with CAM treatment and it is felt that this may well partly account for a significant proportion of its high level of use. The authors go on to discuss work carried out by Ernst and White (1997) which looked at satisfaction levels with CAM compared with conventional medicine in arthritis sufferers who had personal experiences of both types of treatment. This suggested that many of the CAM therapists were more friendly, gave information more readily and spent more time with them. The report highlights the fact that practitioners of CAM feel it may function better in the private sector, suggesting that when patients pay directly for their health care it not only increases their own involvement in recovery but also gives them extra motivation, and in turn may lead to a higher degree of satisfaction.
It is apparent from the evidence that rheumatology patients are frequent users of complementary and alternative medicines but that, as yet, we still have limited knowledge of their effectiveness. It has been suggested by many researchers that there is a need to test the efficacy of these therapies by carrying out further clinical trials on their use in rheumatic diseases (Ernst and White, 1999). However, the continued use of such therapies by patients with chronic diseases such as arthritis suggests that we should not dismiss their use as unscientific; rather we should investigate further the benefits obtained.
Ernst (1999) suggests that, in the current climate, in which evidence-based medicine is considered the gold standard, complementary therapists need to demonstrate the efficacy, safety and cost-effectiveness of their therapy for the conditions they are treating. Physicians should be adequately informed about complementary therapies in order to offer guidance to their patients, and patients are best to be cautious and to remember that if a therapy sounds ‘too good to be true’, it most probably is. The most realistic way forward may be the conducting of research by experienced researchers in collaboration with CAM therapists, who will complement each other’s skills and expertise.
Nurses giving advice and support to patients should understand the need for symptom relief and the psychological benefit that many derive from alternative and complementary therapies, but they also need to be able to explain the ambiguous evidence base for many CAMs.
Studies have suggested that increasing a patient’s involvement in the management of his or her disease tends to have a positive effect on outcome. Practitioners of CAMs are identified as actively involving patients, and this may explain some of the perceived benefits of these therapies. Research into acupuncture also demands a wider range of methodologies, including surveys and qualitative methods alongside randomised controlled trials. The randomised controlled trial may well be the method of choice in the attribution of biomedical cause and effect in CAM research but is less useful in capturing the holistic experience of patients seeking alternative therapies.
The authors are grateful for the help and support of Dr A.O. Adebajo, Consultant Rheumatologist, Barnsley District General Hospital, and Caroline Osborne, Researcher, Physiotherapy Subject Group, Coventry University, in the development of this work.
Astin, J.A. (1998) Why patients use alternative medicine: results of a national study. Journal of the American Medical Association 279: 19, 1448-1553.
Berman, B.M., Singh, B.B., Lao, L. et al. (1999) A randomised trial of acupuncture as an adjunctive therapy in osteoarthritis of the knee. Rheumatology 38: 346-354.
Berman, B.M., Swyers, J.P., Ezzo, J. (2000) The evidence for acupuncture as a treatment for rheumatologic conditions (Complementary and Alternative Therapies for Rheumatic Diseases II). Rheumatic Disease Clinics of North America 26: 1.
Chandola, A., Young. Y., McAlister. J., Axford, J.S. (1999) Use of complementary therapies by patients attending musculoskeletal clinics. Journal of the Royal Society of Medicine 92: 13-16.
David, J., Townsend, R., Sathanathan, S., Dore, C.J. (1999) The effect of acupuncture on patients with rheumatoid arthritis: a randomised, placebo-controlled cross-over study. Rheumatology 38: 864-869.
Ernst, E. (1999) Complementary medicine: too good to be true? Journal of the Royal Society of Medicine 92: 1, 1-2.
Ernst, E. (2000) Complementary and alternative medicine in rheumatology. Baillieres Clinical Rheumatology 14: 4, 731-749.
Ernst, E., White, A. (1997) A review of problems in clinical acupuncture research. American Journal of Chinese Medicine 25: 1, 3-11.
Ezzo, J., Hadhazy, V., Birch, S. et al. (2001) Acupuncture for osteoarthritis of the knee: a systematic review. Arthritis and Rheumatism 44: 819-825.
House of Lords Select Committee on Science and Technology. (2000) Science and Technology Sixth report (Chapters one and three) (HL(123) (1999-2000). London: House of Lords.
McIntosh, E. (1996) The cost of rheumatoid arthritis. British Journal of Rheumatology 35: 8, 781-900.
Osborne, C. (2000) The Use of Complementary Medicine by Patients Attending Rheumatology Outpatient Clinics (unpublished PhD thesis). Coventry: University of Coventry.
Resch, K.L., Hill, S., Ernst, E. (1997) Use of complementary therapies by individuals with arthritis. Clinical Rheumatology 16: 4, 391-395.
Scott, D.L., Shipley, M., Dawson, A. et al. (1998) The clinical management of rheumatoid arthritis and osteoarthritis: strategies for improving clinical effectiveness. British Journal of Rheumatology 37: 546-554.
UKCC. (2000) Guidelines for the Administration of Medicines. London: UKCC.
UKCC. (2000) The Scope of Professional Practice. London: UKCC.
Vecchio, P.C. (1994) Attitudes to alternative medicine by rheumatology outpatient attenders. Journal of Rheumatology 21: 2.
Vincent, C. (2001) The safety of acupuncture. British Medical Journal 323: 467-468.
Visser, G.J., Peters, L., Rasker, J.J. (1992) Rheumatologists and their patients who seek alternative care: an agreement to disagree. British Journal of Rheumatology 31: 485-490.