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.
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.
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).
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).
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.
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.
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.
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.