Usage of complementary therapies in rheumatology: a systematic review

Natural Product Dietary Supplement Use by Individuals With Rheumatoid Arthritis: A Scoping Review

OBJECTIVE

Natural product dietary supplements (NDS), defined as non-mineral, non-vitamin, ingested, natural product-derived, substances, are the most frequently used complementary and alternative medicine modality in the US, with musculoskeletal disease being the most frequent reason for their use. Because NDS usage is frequently unreported, and patients with RA may be at higher risk for NDS-related side effects due the underlying nature of the disease and frequent use of complex pharmaceutical regimens, a scoping review of the literature was undertaken to examine population-based patterns of NDS use for RA self-management.

METHODS

Using guidelines for scoping reviews, Allied and Complementary Medicine, the Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, Embase, Ovid/Medline, and Web of Science databases were searched to identify references presenting primary data related to the prevalence or patterns of use of NDS in RA populations.

RESULTS

Twenty-three studies, which were published between 1980 and 2015 and conducted in 11 countries, met the inclusion criteria. The overall prevalence of NDS use in patients with RA was 47% worldwide and did not differ by geographic region. On average, 47% of patients found NDS to be effective and 13% reported adverse side effects, with only 30% informing their physicians about the use of NDS, which in a majority of cases were used concomitantly with RA pharmaceuticals. Marine oils, glucosamine, vinegar, and chondroitin were among the most commonly reported NDS worldwide.

CONCLUSION

Given the apparent communication gap between patients and providers regarding NDS use and higher potential risks associated with this usage in RA, ongoing surveillance of population-based practices may help facilitate RA management and direct future NDS research.

Traditional and Complementary Medicine Use in Knee Osteoarthritis and its Associated Factors Among Patients in Northeast Peninsular Malaysia

Objectives

We sought to determine the prevalence of traditional and complementary medicine (TCM) use for knee osteoarthritis and its associated factors among patients attending a referral hospital in an eastern coastal state of Malaysia.

Methods

This cross-sectional study included 214 patients with knee osteoarthritis. A universal sampling method was applied to patients who attended the outpatient clinic in Hospital Universiti Sains Malaysia from May 2013 to October 2013. Participants were given a questionnaire to determine their sociodemographic information and a validated Bahasa Malaysia version of the Western Ontario and McMaster Universities Arthritis Index (WOMAC). This questionnaire was used to assess the severity of knee osteoarthritis (i.e., pain, stiffness, and disturbances in daily activity).

Results

Over half (57.9%) of patients reported using TCM to treat knee osteoarthritis. Factors associated with TCM use were gender (odd ratio (OR) = 2.47; 95% confidence interval (CI): 1.28-4.77), duration of knee osteoarthritis (OR = 1.51; 95% CI: 1.03-2.23), and the severity of knee pain (OR = 2.56; 95% CI: 1.71-3.86).

Conclusions

The prevalence of TCM use among eastern Malaysian patients with knee osteoarthritis was high. Physicians caring for these patients should be aware of these findings so that inquiries regarding TCM use can be made and patients can be appropriately counseled.

Self-reported use of natural health products among rheumatology patients: A cross-sectional survey

OBJECTIVES

To describe the self-reported use of natural health products (NHPs) and identify characteristics that predict selected NHP use in rheumatology patients.

METHODS

We conducted a cross-sectional survey of consecutive rheumatology patients in two major clinics in Edmonton, Alberta. Survey items included demographic data, rheumatologic diagnoses, prescribed medications, NHPs, and information regarding patients' use of NHPs. Selected NHPs of interest - defined to include joint-specific products, oils with putative joint benefits, and other non-vitamin, non-mineral products - were classified by 2 reviewers. The characteristics of selected NHP users and non-users were compared using chi-squared and ANOVA tests, followed by multivariable-adjusted logistic regression.

RESULTS

1063 patients completed the survey (response rate = 36%, mean age 53 [sd 15], 70% female). 36% of respondents reported using one or more of a wide range of selected NHPs (mean 1.8, range 1-9). The most common source of NHP recommendations for selected NHP users were physicians (42%). Significant predictors of selected NHP use were: being female (aOR 1.41, 95%CI [1.05-1.90], p = 0.02), having a post-secondary degree (aOR 1.60 [1.15-2.22], p = 0.005), and the number of non-rheumatic medications (aOR 1.08 [ 1.00-1.15], p = 0.03) and NSAIDs (aOR 1.32 [1.06, 1.63], p = 0.01). Similar findings were observed among only inflammatory arthritis patients.

CONCLUSIONS

Our study confirms the frequent use of selected NHPs, possibly to mitigate persistent symptoms of rheumatologic illness. Rheumatologists appear to be trusted sources of advice and recommendations on NHP use and should provide balanced counselling for their patients.

Alternative Medicine or “Alternative” Patients: A Qualitative Study of Patient-Oriented Decision-Making Processes with Respect to Complementary and Alternative Medicine

Background. Theory and clinical practice suggest that complementary and alternative medicine (CAM) decisionmaking processesmaydiffer from those used in conventional medicine. If so, understanding the differences could improve patient-provider communication around treatment options. Objectives. To examine patient-oriented decision-making processes relative to CAM use. Population. Adults with chronic rheumatological disorders who utilize allopathic medicine only, CAM only, or both. Method. An exploratory, cross-sectional naturalistic design with thematic and content analyses. Results. Three distinct decision paths were developed, differing substantially on the importance of provider trust, disease severity/prognosis, willingness to experiment, intuitive/spiritual factors, and outcomes evidence. Conclusions. These divergent decision paths indicate the possibility of “alternative patients,” not just “alternative therapies.” Since informed decisions, tailored to the patient, would likely lead to sustainable improvements in health care outcomes, the findings may facilitate providers’ capacity to effectively advise patients about treatment alternatives and CAM use.

Complementary medicine use in rheumatology: A review

Complementary and alternative medicine (CAM) use is increasing worldwide; specifically it appears that these treatment modalities are popular among rheumatology patients. The most commonly reported CAM therapies are herbal medicines, homeopathy, chiropractic, acupuncture and reflexology. Despite high reported rates of CAM use, the number of patients disclosing use to their rheumatologists remains low. This review highlights rates of current CAM use in rheumatology in studies performed worldwide, and discusses potential reasons for nondisclosure of CAM use to clinicians.

Patient experiences with intensive combination-treatment strategies with glucocorticoids for early rheumatoid arthritis

OBJECTIVES

To investigate patients' experiences with intensive combination-treatment strategies with glucocorticoids (ICTS-GCs) in the early phase of early rheumatoid arthritis (ERA) treatment.

METHODS

We interviewed 26 participants individually, 4-6 months after initiation of ICTS-GCs (t1). Fourteen participants from the same sample took part in one of three focus groups at least 1 year after treatment initiation (t2). Each interview was audio-recorded, literally transcribed and thematically coded.

RESULTS

The participants described concerns and feelings about ICTS-GCs that changed over time; for example, a fear of side effects diminished when the treatment effects were beneficial or expected side effects did not materialize. Moreover, participants indicated additional information needs at t1 and t2. The most used sources of information were healthcare professionals, relatives, and the Internet. Furthermore, participants reported on their relationship with healthcare professionals and the need for trust and reassurance, especially at t1. Lastly, participants described their personal self-management strategies.

CONCLUSION

Despite their concerns at treatment initiation, most participants had positive experiences with ICTS-GCs.

PRACTICE IMPLICATIONS

Healthcare professionals should be aware that, in the early phase of treatment, they can address patients' concerns, they are the most important information source, they need to create a relationship of trust, and guide patients in self-management strategies.

A randomized, double-blind, sham-controlled study of static electric field therapy by high voltage alternating current for active rheumatoid arthritis

Static electric field therapy by high voltage alternating current (EF-HVAC) is a traditional complementary Japanese medicine used for headache, shoulder stiffness, chronic constipation and insomnia. Open-label studies and clinical experience in Japan have suggested that this electric field therapy is safe and effective in treating chronic arthritis. We evaluated the efficacy of EF-HVAC therapy in a randomized, double-blinded, sham-controlled trial in patients with active rheumatoid arthritis (RA) in community-based general physician centers. Thirty patients fulfilling American College of Rheumatology (ACR) criteria for RA were treated with EF-HVAC therapy with the LEGACIS PLUS System (COCOROCA Corp., Tokyo, Japan) or sham therapy for 12 weeks and followed for 4 weeks without treatment. The disease activity score 28 (DAS28-CRP), visual analogue scale for pain (VAS), modified health assessment questionnaire (MHAQ), and inflammatory parameters were used as the outcome variable. Twenty four patients (n = 12 in each group) were analyzed by a per protocol analysis. Although a significant reduction in DAS28-CRP was observed in EF-HVAC group at 8 and 12 weeks compared to before treatment, there were no significant differences in DAS28-CRP scores during treatment between two groups. The scale of VAS was also significantly decreased by the treatment with EF-HVAC compared to before treatment, in addition, the scale of VAS in EF-HVAC group was significantly lower than sham group at 8 and 12 weeks. Changes in another parameters including MHAQ were not significant between before and after treatment, or by all comparative study between two groups. There were no adverse events related the treatment. In conclusion, the EF-HVAC therapy has a beneficial effect on the improvement to subjective pain of RA.

Use of complementary and alternative therapy among patients with rheumatoid arthritis and osteoarthritis

AIMS AND OBJECTIVES

We wanted to assess the prevalence of complementary and alternative therapy use among patients suffering from rheumatoid arthritis or osteoarthritis in the Lebanese population and to determine the perceived efficacy and side effects of complementary and alternative therapy in the treatment of these diseases.

BACKGROUND

Complementary and alternative therapy has become popular among patients with chronic illnesses because of its widespread use. Rheumatoid arthritis and osteoarthritis are two diseases associated with severe pain, inflammation and limited activity. Although both are quite common in Lebanon, no studies were conducted in our country to portray complementary and alternative therapy use in their treatment.

DESIGN

Descriptive cross-sectional study.

METHODS

Conducted individualised questionnaire-based interviews among 250 adult patients, ranging between the ages of 20-90 years and diagnosed with either rheumatoid arthritis or osteoarthritis. The questionnaire included demographic information, clinical information, use of conventional therapies and complementary and alternative therapy, and the disease status before and after complementary and alternative therapy use.

RESULTS

Fifty-eight (23·2%) patients used complementary and alternative therapy in addition to their conventional medications in the treatment of either rheumatoid arthritis or osteoarthritis. Most herbal medicine users (63·8%) believed that complementary and alternative therapy was beneficial. The disease status measured by the intensity of pain, sleeping pattern and level of activities was significantly improved after using complementary and alternative therapy (p =0·01). Forty-eight (82·75%) patients were using herbals as complementary and alternative therapy, 14 (24·1%) of whom have sought medical care because of potential concomitant drug-complementary and alternative therapy side effects. However, these side effects were not serious and reversible.

CONCLUSION AND RECOMMENDATIONS

Although complementary and alternative therapy might have beneficial effects in rheumatoid arthritis and osteoarthritis, patients should be cautious about their use and should necessarily inform their health care providers about the consumption of any products other than their conventional medicines.

RELEVANCE TO CLINICAL PRACTICE

It is quite essential for health care professionals to be knowledgeable about the use of complementary and alternative medicine therapies when providing medical care to patients with arthritis.

Evidence for the efficacy of complementary and alternative medicines in the management of rheumatoid arthritis: a systematic review

OBJECTIVE

To critically evaluate the evidence regarding complementary and alternative medicine (CAM) taken orally or applied topically (excluding fish oil) in the treatment of RA.

METHODS

Randomized controlled trials (RCTs) of RA using CAMs, in comparison with other treatments or placebo, published in English up to August 2010, were eligible for inclusion. They were identified using systematic searches of bibliographic databases and manual searching of reference lists. Information was extracted on outcomes and statistical significance, in comparison with alternative treatments, and reported side effects. The methodological quality of the primary studies was determined using the Jadad scoring system.

RESULTS

Reported RCTs were available for 18 CAMs in the management of RA. There was no consistent evidence available for any of the reviewed substances to suggest that they were efficacious as complementary medicines to standard treatment. Nevertheless, the studies conducted on borage seed oil (n = 2) and thunder god vine (n = 3) have been positive and may warrant further investigation. Not all CAM compounds studied were free of major adverse effects.

CONCLUSION

The major limitation in reviewing the evidence for CAMs is the paucity of RCTs in the area. The available evidence does not support their current use in the management of RA.

Evidence for the efficacy of complementary and alternative medicines in the management of osteoarthritis: a systematic review

Objectives. To critically evaluate the evidence regarding complementary and alternative medicine (CAM) taken orally or applied topically (excluding glucosamine and chondroitin) in the treatment of OA. Methods. Randomized clinical trials of OA using CAMs, in comparison with other treatments or placebo, published in English up to January 2009, were eligible for inclusion. They were identified using systematic searches of bibliographic databases and manual searching of reference lists. Information was extracted on outcomes, and statistical significance, in comparison with alternative treatment of placebo, and side effects were reported. The methodological quality of the primary studies was determined. Results. The present review found consistent evidence that capsaicin gel and S-adenosyl methionine were effective in the management of OA. There was also some consistency to the evidence that Indian Frankincense, methylsulphonylmethane and rose hip may be effective. For other substances with promising evidence, the evidence base was either insufficiently large or the evidence base was inconsistent. Most of the CAM compounds studied were free of major adverse effects. Conclusion. The major limitation in reviewing the evidence is the paucity of randomized controlled trials in the area: widening the evidence base, particularly for those compounds for which there is promising evidence, should be a priority for both researchers and funders.

Use of complementary and alternative medicine by patients with arthritis

AIMS AND OBJECTIVES

The aims of this study were to determine the prevalence of complementary and alternative medicine use in patients with arthritis, the types of complementary and alternative medicine used, pertinent socio-demographic factors associated with complementary and alternative medicine use and its perceived efficacy.

BACKGROUND

Arthritis is a major health issue, and the use of complementary and alternative medicine among patients with arthritis is common.

DESIGN

This is a descriptive cross-sectional study.

METHODS

Data were obtained from 250 patients with arthritis at the physiotherapy and immunology clinics Atatürk University Hospital in eastern Turkey between May-July 2005 using a questionnaire developed specifically for this study. The instrument included questions on socio-demographic information, disease specifics and complementary and alternative medicine usage.

RESULTS

Seventy-six per cent of participants reported use of at least one form of complementary and alternative medicine in the previous year. Complementary and alternative medicine users and non-users were not significantly different in most socio-demographic characteristics including age, gender, marital status and education level with the exception of economic status. We categorised treatment into six complementary and alternative medicine categories: 62.6% of patients used thermal therapies; 41.5% used oral herbal therapies; 40.5% used hot therapies; 32.6% used externally applied (skin) therapies; 28.4% used massage and 12.6% used cold therapies. All forms of complementary and alternative medicine except thermal and oral herbal therapies were perceived as very effective by more than half of study participants.

CONCLUSIONS

Complementary and alternative medicine therapy is widely used by patients with arthritis and has perceived beneficial effects.

RELEVANCE TO CLINICAL PRACTICE

It is important for nurses and other health care professionals to be knowledgeable about the use of complementary and alternative medicine therapies when providing care to patients with arthritis because of possible interactions with other treatments, delays in seeking care and the potential for poor quality products. It is also essential for health professionals to discuss treatment options with patients and to monitor treatment efficacy.

Rheumatic disease and complementary-alternative treatments: a qualitative study of patient's experiences

BACKGROUND

Complementary-alternative medicine (CAM) has been widely used by rheumatic patients for many years, but doctors are often unaware of the actual use.

OBJECTIVES

This study aimed at patients' experience and perceptions of CAM as a way for long-term coping with illness.

METHODS

Fifteen in-depth interviews were conducted with patients sampled by contact with voluntary patient-driven rheumatic disease societies, outside of any treatment settings. Strategically, the sampling included a variety of rheumatic diseases and CAM-treatments, but strived otherwise to be typical of CAM-users. Interviews were taped and fully transcribed; coding and analysis of themes were assisted by computer software.

RESULTS

Rheumatic disease patients expressed use of CAM as methods of regulation of discomforts, the feeling of the body, and self-empowerment, not for unrealistic healing of their rheumatic disease. They experienced a variety of effects, most often expressed in terms of mind-body interrelated experiences, such as "lightness of the body" rather than relief in specific symptoms. They expressed the feeling of "have been helped" when leaving a CAM-session and appreciated to have more than 1 way to understand their disease and symptoms. They were usually not naive, but were critical consumers. The patients typically believed in the alternative viewpoints of "natural is best" and in "energy meridians," but they were otherwise not believers in any alternative, "new age"-type worldview.

CONCLUSION

These findings suggest that clinical practice may be enriched by listening to or asking rheumatic disease patients' CAM-experiences in a nonpatronizing way.

Prospective investigation of complementary and alternative medicine use and subsequent hospitalizations

Background

The prevalence of complementary and alternative medicine (CAM) use has been estimated to be as high as 65% in some populations. However, there has been little objective research into the possible risks or benefits of unmanaged CAM therapies.

Methods

In this prospective study of active duty US Navy and Marine Corps personnel, the association between self-reported practitioner-assisted or self-administered CAM use and future hospitalization was investigated. Cox regression models were used to examine risk of hospitalization due to any cause over the follow-up period from date of questionnaire submission, until hospitalization, separation from the military, or end of observation period (June 30, 2004), whichever occurred first.

Results

After adjusting for baseline health, baseline trust and satisfaction with conventional medicine, and demographic characteristics, those who reported self-administering two or more CAM therapies were significantly less likely to be hospitalized for any cause when compared with those who did not self-administer CAM (HR = 0.38; 95% CI = 0.17, 0.86). Use of multiple practitioner-assisted CAM was not associated with a significant decrease or increase of risk for future hospitalization (HR = 1.86; 95 percent confidence interval = 0.96-3.63).

Conclusion

While there were limitations to these analyses, this investigation utilized an objective measure of health to investigate the potential health effects of CAM therapies and found a modest reduction in the overall risk of hospitalization associated with self-administration of two or more CAM therapies. In contrast, use of practitioner-assisted CAM was not associated with a protective effect.

[Physiotherapeutic and rehabilitation therapy for ankylosing spondylitis. Status quo and are they still necessary in the age of anti-cytokine therapy?]

Ankylosing spondylitis (AS) is one of the most common chronic inflammatory rheumatic diseases characterized by erosions and bone proliferation with consecutive morphologic and functional deficits. Physiotherapeutic and rehabilitation measures are often necessary for AS patients for their whole life. In recent years, biologicals have substantially improved the outcome in AS patients, but their positive influence on vertebral and joint functions still requires differential indicative physiotherapeutic strategies and rehabilitation, in most cases in combination with effective analgesic and anti-inflammatory medication. Although physical therapy and rehabilitation have not been investigated in large controlled trials, they are essential for the multimodal therapeutic concept of AS.

The use of CAM and conventional treatments among primary care consulters with chronic musculoskeletal pain

Background

Chronic musculoskeletal pain is the single most cited reason for use of complementary and alternative medicine (CAM). Primary care is the most frequent conventional medical service used by patients with pain in the UK. We are unaware, however, of a direct evidence of the extent of CAM use by primary care patients, and how successful they perceive it to be.

Methods

Aims and objectives

To determine CAM use among patients with chronic musculoskeletal pain who have consulted about their pain in primary care.

Study design

Face-to-face interview-based survey.

Setting

Three general practices in North Staffordshire.

Participants

Respondents to a population pain survey who had reported having musculoskeletal pain in the survey and who had consulted about their pain in primary care in the previous 12 months as well as consenting to further research and agreeing to an interview. Information was gathered about their pain and the use of all treatments for pain, including CAM, in the previous year.

Results

138 interviews were completed. 116 participants (84%) had used at least one CAM treatment for pain in the previous year. 65% were current users of CAM. The ratio of over-the-counter CAM use to care from a CAM provider was 3:2. 111 participants (80%) had used conventional treatment. 95 (69%) were using a combination of CAM and conventional treatment. Glucosamine and fish oil were the most commonly used CAM treatments (38%, 35% respectively). Most CAM treatments were scored on average as being helpful, and users indicated that they intended to use again 87% of the CAM treatments they had already used.

Conclusion

We provide direct evidence that most primary care consulters with chronic musculoskeletal pain have used CAM in the previous year, usually in combination with conventional treatments. The high prevalence and wide range of users experiences of benefit and harm from CAM strengthen the argument for more research into this type of medicine to quantify benefit and assess safety. The observation that most users of conventional medicine also used CAM suggests a continuing need for more investigation of effective pain management in primary care.

Why do patients with rheumatoid arthritis use complementary therapies?

OBJECTIVES

(1) to develop an understanding as to how the use of complementary therapy (CT) affects a patient's perspective of health and well-being, (2) to offer the rheumatology professional insight and understanding as to why a patient chooses to use a CT, and (3) to raise awareness as to the forms of CT most commonly used by patients with rheumatoid arthritis.

METHODS

This qualitative study was based on phenomenological principles applied through focused inquiry to develop an understanding of the lived experience of the study participants. The inclusion criteria of an established diagnosis of rheumatoid arthritis and known use of CT were applied to a convenience sample of patients attending a rheumatology outpatient department clinic on two consecutive days. Of the 15 eligible patients identified, five were randomly selected for inclusion in the study. Narrative data were collected through analysis of transcripts taken from audiotape recordings of unstructured interviews with study participants. A manual indexing system was used to develop four significant categorisation themes to reflect the findings: (1) incentives to use CT, (2) perceived benefits of CT use, (3) the choice of CT used, and (4) perceived disadvantages and risks of CT use.

RESULTS

Incentives to use CT included dissatisfaction with conventional treatment, often in the form of side effects, and drug ineffectiveness. Social factors, such as loss of employment and social activities, were also indicated, as were psychological changes in the form of depression, hopelessness and fear. Perceived benefits were categorised as either physical or psychological with associated aspects of choice and control viewed as important elements of personal empowerment. The choice of CT used fell into three categories; physical, spiritual and herbal. The most commonly used of these were herbal remedies and supplements, closely followed by aromatherapy massage. Disadvantages and risks were identified as physical (pain and discomfort), psychological (fear and uncertainty), and/or material (cost).

CONCLUSIONS

This study suggests that regular use of CT by patients with rheumatoid arthritis offers holistic benefits. Compared to conventional treatments, CT is seen to have advantages in terms of a lower incidence of adverse reactions, greater patient choice, psychological comfort and an increased quality of the patient/therapist relationship. The use of CT by patients with rheumatoid arthritis indicates a need for evidence-based information about its use and safety in order to direct practice within a rheumatology department.

Exploring acupuncturists' perceptions of treating patients with rheumatoid arthritis

AIMS

To outline acupuncturists' perceptions of treating patients with rheumatoid arthritis (RA), exploring the impact of practitioner affiliation to a traditional or western theoretical base.

METHODS

Qualitative study utilising Grounded Theory Method. Nineteen acupuncturists were chosen via theoretical sampling. In-depth semi-structured interviews were tape-recorded and transcribed. Field notes were also taken. Emerging categories and themes were identified.

RESULTS

Inter-affiliatory differences were identified in the treatments administered and the scope and emphasis of intended therapeutic effects. Limited divergence was found between acupuncturists' perceptions of treatment outcomes. Factors perceived as impacting on treatment outcomes were identified.

CONCLUSIONS

Clinical trials of acupuncture in RA may have failed to administer a treatment which reflects that administered in clinical practice. Outcome measures employed in clinical trials of acupuncture in RA, as well as established outcome indices for RA, may lack the necessary breadth to accurately assess acupuncture's efficacy. Acupuncturist affiliation has demonstrable implications for the practice and research of acupuncture.

Characteristics associated with reported CAM use in patients attending six GP practices in the Tayside and Grampian regions of Scotland: a survey

OBJECTIVES

To study the nature of CAM use in primary care attenders, the involvement of their NHS healthcare professionals in their CAM care and differences in characteristics between CAM users and non-users.

DESIGN

Postal questionnaire for primary care attenders and analysis of practice leaflets.

SETTING

Six Scottish GP practices with a range of practice size, CAM provision within practice, deprivation and rurality.

RESULTS

Five hundred and fourteen primary care attenders described 1194 incidences of CAM use and gave details about their main therapy. 37% had contact with a practitioner, the rest mainly self-prescribed. The perceived effectiveness of CAM was high. Patients used CAM for a variety of health problems, mainly as an adjuvant to orthodox medicine rather than an alternative. The involvement of the NHS in CAM delivery was small but there is a significant role to ensure patient safety, especially regarding herb-drug interactions. Disclosure rate of CAM use was low. CAM offered options in areas where the provision in the NHS is difficult, including musculo-skeletal and mental health problems. Provision of CAM by the GP is associated with higher CAM use in primary care attenders.

CONCLUSIONS

It is recommended that healthcare professionals include patients' use of CAM in history taking and clinical decision making.

Complementary and Alternative Approaches to the Treatment of Persistent Musculoskeletal Pain

OBJECTIVE

To review common complementary and alternative treatment modalities for the treatment of persistent musculoskeletal pain in older adults.

METHODS

A critical review of the literature on acupuncture and related modalities, herbal therapies, homeopathy, and spinal manipulation was carried out. Review included 678 cases within 21 randomized trials and 2 systematic reviews of herbal therapies: 798 cases within 2 systematic reviews of homeopathy; 1,059 cases within 1 systematic review of spinal manipulation for low back pain, and 419 cases within 4 randomized controlled trials for neck pain. The review of acupuncture and related modalities was based upon a paucity of well-controlled studies combined with our clinical experience.

RESULTS

Insufficient experimental evidence exists to recommend the use of traditional Chinese acupuncture over other modalities for older adults with persistent musculoskeletal pain. Promising preliminary evidence exists to support the use of percutaneous electrical nerve stimulation for persistent low back pain. While some herbals appear to have modest analgesic benefits, insufficient evidence exists to definitively recommend their use. Drug-herb interactions must also be considered. Some evidence exists to support the superiority of homeopathic remedies over placebo for treating osteoarthritis and rheumatoid arthritis. The benefits of spinal manipulation for persistent low back and neck pain have not been convincingly shown to outweigh its risks.

DISCUSSION

While the use of complementary and alternative modalities for the treatment of persistent musculoskeletal pain continues to increase, rigorous clinical trials examining their efficacy are needed before definitive recommendations regarding the application of these modalities can be made.

Use of complementary and alternative medicine by arthritis patients in a university hospital clinic serving rheumatology patients in Korea

There is a paucity of data regarding the use of and attitudes toward complementary and alternative medicine (CAM) among arthritis patients in Asia. This study was performed to assess the use of CAM, related demographic and clinical factors, and attitudes among Korean arthritis patients. We conducted a survey of patients in rheumatology clinics affiliated with a university hospital. One hundred fifty patients (68.5%) reported using at least one form of CAM during the previous 12 months. Herbal remedies and acupuncture were the most frequently used categories of CAM. Among the parameters analyzed, income level was significantly and negatively associated with frequent or regular use of CAM. Dialogue about CAM use with Korean patients does not seem to have been initiated yet, as the main reason given for not discussing CAM use with physicians was "not being asked."

Quality, efficacy and safety of complementary medicines: fashions, facts and the future. Part I. Regulation and quality

This is the first of two papers which review issues concerning complementary medicines. The first reviews the extent of use of complementary medicines, and issues related to the regulation and pharmaceutical quality of these products; the second considers evidence for the efficacy of several well-known complementary medicines, and discusses complementary-medicines pharmacovigilance. The term complementary medicines describes a range of pharmaceutical-type preparations, including herbal medicines, homoeopathic remedies, essential oils and dietary supplements, which mainly sit outside conventional medicine. The use of complementary medicines is a popular healthcare approach in the UK, and there are signs that the use of such products is continuing to increase. Patients and the public use complementary medicines for health maintenance, for the treatment or prevention of minor ailments, and also for serious, chronic illnesses. The pervasive use of complementary medicines raises several concerns. Many of these arise because most complementary medicines are not licensed as medicines, and therefore evidence of quality, efficacy and safety is not required before marketing. The regulatory framework for herbal medicines and dietary supplements is currently under review. A new system for registration of traditional herbal medicines will ensure that marketed products meet standards for quality and safety. At present, the pharmaceutical quality of many complementary medicines is a cause for concern.

Surveys of complementary and alternative medicine: part IV. Use of alternative and complementary therapies for rheumatologic and other diseases

This fourth review in the series covers eight recent U.S. surveys on complementary and alternative medicine (CAM) use by patients with rheumatologic and other autoimmune conditions, and summarizes seven studies of other disease categories. Regarding the previous reviews, the acronym CAM is used unless it is possible to refine the concepts. This reflects the problem that most survey questionnaires do not differentiate between adjunct or complementary therapies and alternative approaches to treatment.

Rise in popularity of complementary and alternative medicine: reasons and consequences for vaccination

Complementary and alternative medicine (CAM) has become a popular form of healthcare and the predictions are that, it will increase further. The reasons for this level of popularity are highly diverse, and much of the motivation to turn to CAM pertains to a deeply felt criticism of mainstream medicine - many people (are led to) believe that conventional interventions, including immunisation, are associated with the potential to do more harm than good. Thus, it is hardly surprising that CAM also lends support to the "anti-vaccination movement". In particular, sections of the chiropractors, the (non-medically trained) homoeopaths and naturopaths tend to advise their clients against immunisation. The reasons for this attitude are complex and lie, at least in part in the early philosophies which form the basis of these professions. The negative attitude of some providers of CAM towards immunisation constitutes an important example of indirect risks associated with this form of healthcare. The best way forward, it seems, would be a campaign to clarify the risk-benefit profile of immunisations for both users and providers of CAM.

Which complementary and alternative therapies benefit which conditions? A survey of the opinions of 223 professional organizations

With the increasing demand and usage of complementary/alternative medicine (CAM) by the general public, it is vital that healthcare professionals can make informed decisions when advising or referring their patients who wish to use CAM. Therefore they might benefit from advice by CAM-providers as to which treatment can be recommended for which condition.

AIM

The primary aim of this survey was to determine which complementary therapies are believed by their respective representing professional organizations to be suited for which medical conditions.

METHOD

223 questionnaires were sent out to CAM organizations representing a single CAM therapy. The respondents were asked to list the 15 conditions they felt benefited most from their CAM therapy, the 15 most important contra-indications, the typical costs of initial and any subsequent treatments and the average length of training required to become a fully qualified practitioner. The conditions and contra-indications quoted by responding CAM organizations were recorded and the top five of each were determined. Treatment costs and hours of training were expressed as ranges.

RESULTS

Of the 223 questionnaires sent out, 66 were completed and returned. Taking undelivered questionnaires into account, the response rate was 34%. Two or more responses were received from CAM organizations representing twelve therapies: aromatherapy, Bach flower remedies, Bowen technique, chiropractic, homoeopathy, hypnotherapy, magnet therapy, massage, nutrition, reflexology, Reiki and yoga. The top seven common conditions deemed to benefit by all twelve therapies, in order of frequency, were: stress/anxiety, headaches/migraine, back pain, respiratory problems (including asthma), insomnia, cardiovascular problems and musculoskeletal problems. Aromatherapy, Bach flower remedies, hypnotherapy, massage, nutrition, reflexology, Reiki and yoga were all recommended as suitable treatments for stress/anxiety. Aromatherapy, Bowen technique, chiropractic, hypnotherapy, massage, nutrition, reflexology, Reiki and yoga were all recommended for headache/migraine. Bowen technique, chiropractic, magnet therapy, massage, reflexology and yoga were recommended for back pain. None of the therapies cost more than ł60 for an initial consultation and treatment. No obvious correlation between length of training and treatment cost was apparent.

CONCLUSION

The recommendations by CAM organizations responding to this survey may provide guidance to health care professionals wishing to advise or refer patients interested in using CAM.

Herbal medicines for the treatment of osteoarthritis: a systematic review

OBJECTIVE

Limitations in the conventional medical management of osteoarthritis indicate a real need for safe and effective treatment of osteoarthritis patients. Herbal medicines may provide a solution to this problem. The aim of this article was to review systematically all randomized controlled trials on the effectiveness of herbal medicines in the treatment of osteoarthritis.

METHODS

Computerized literature searches were carried out on five electronic databases. Trial data were extracted in a standardized, predefined manner and assessed independently.

RESULTS

Twelve trials and two systematic reviews fulfilled the inclusion criteria. The authors found promising evidence for the effective use of some herbal preparations in the treatment of osteoarthritis. In addition, evidence suggesting that some herbal preparations reduce consumption of non-steroidal anti-inflammatory drugs was found. The reviewed herbal medicines appear relatively safe.

CONCLUSIONS

Some herbal medicines may offer a much-needed alternative for patients with osteoarthritis.

Complementary and alternative medicine in rheumatology

Complementary and alternative medicine (CAM) has become an important subject for rheumatologists. This article is an attempt to provide an introduction to this subject. It will provide definitions of, and define the prevalence of, CAM. The emphasis of the article is on evaluating the efficacy of CAM treatment modalities. This is achieved by referring to systematic reviews of clinical trials of acupuncture for low back pain, osteo-arthritis, fibromyalgia, inflammatory rheumatoid disease and neck pain. Further areas addressed in this way are herbal remedies, fish oil and glucosamine. Moreover, massage therapy and spinal manipulation for back pain are discussed. The final sections of this review deal with the safety and cost of CAM. It is concluded that, in view of the popularity of CAM with rheumatological patients, rigorous research into CAM is the best way forward.

The prevalence of complementary and alternative medicine use among the general population: a systematic review of the literature

OBJECTIVE

To conduct a systematic review of published research investigating the prevalence of complementary and alternative medicine (CAM) use in the general population.

DESIGN

A protocol was developed for a systematic review of survey literature identified using two bibliographic databases and citation tracking. The protocol specified criteria for: 1) database searches; 2) selection of studies for review; and 3) description of methodological and substantive aspects of the studies.

RESULTS

Twelve studies were reviewed. These estimated the prevalence of CAM use in Australia, Canada, Finland, Israel, the UK, and the USA. The most rigorous studies, conducted in Australia and the USA, showed that a high proportion of the population was using CAM. There was evidence from the USA that CAM use increased significantly among the general population during the 1990s.

CONCLUSION

CAM is used by substantial proportions of the general population of a number of countries, but differences in study design and methodological limitations make it difficult to compare prevalence estimates both within and between countries.

The costs of rheumatoid arthritis: an international long-term view

OBJECTIVES

To review the literature on the measurable direct and indirect costs of rheumatoid arthritis (RA) in industrialized countries from a societal perspective and to develop a template for international use.

METHODS

A literature search using MEDLINE and other sources identified 153 relevant published articles, press releases, and so forth on the costs of RA and rheumatism from the major Organization for Economic Cooperation and Development (OECD) countries in English and other languages. Sixty-eight publications provide some economic data for analysis and are included in the bibliography. Twelve publications provide sufficiently detailed and robust information for inclusion in country overview tables. The concept of varied costs at different disease stages measured by years since diagnosis and Health Assessment Questionnaire (HAQ) scores is used to guide rational decisions in the allocation of scarce health care resources.

RESULTS

Direct costs increase overproportionately during the course of the disease. The most important driver of direct costs is hospitalization, especially in moderate and severe RA. Costs of medication represent a comparatively small proportion of direct costs. Indirect costs caused by work disability can be substantially higher than direct costs, particularly in working-age patients. The total costs of RA to society, and the different cost components such as direct and indirect costs, are broadly comparable in industrialized countries by their order of magnitude. Major confounding factors for international comparison are different study methodologies and patient samples.

CONCLUSIONS

The cost template developed in this article can be used to estimate the likely costs of RA to society for industrialized countries. It probably will underestimate indirect costs because of their incomplete coverage in the studies examined. A long-term perspective is needed for chronic diseases such as RA to assess the future effects of early interventions. Treatment in the early stages of RA that effectively reduces long-term disability has the potential to save substantial costs to society.

Phyto-anti-inflammatories. A systematic review of randomized, placebo-controlled, double-blind trials

Herbal treatments are often used to treat rheumatic symptoms. This systematic review is aimed at determining the clinical efficacy of this approach. Computer literature searches are carried out to locate all placebo-controlled, double-blind, randomized trials in this area. Nineteen studies meet the inclusion criteria. They are heterogeneous in terms of remedies tested, patients treated, and trial methodology applied. Most of the studies suggest that herbal remedies can have symptomatic effects beyond placebo. It is concluded that phyto-anti-inflammatories have considerable, albeit under-researched, potential in the symptomatic treatment of rheumatic disorders.

Complementary medicine: too good to be true?

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