9.2COMPLEMENTARTY THERAPIES (CAM)

ReferenceStudy type
Evidence level
Number of patientsPatient characteristicsInterventionComparisonLength of follow-upOutcome measuresSource of funding
L. Casimiro, L. Barnsley, L. Brosseau, S. Milne, V. A. Robinson, P. Tugwell, and G. Wells. Acupuncture and electroacupuncture for the treatment of rheumatoid arthritis.[update of Cochrane Database Syst Rev. 2002;(3):CD003788; PMID: 12137715]. [Review] [24 refs]. Cochrane Database of Systematic Reviews (4):CD003788, 2005.

ID 3424
MA: 1++
RCT’s of MA: 1+ to 1++

SR and MA included: N=2 trials with suitable data

Trials were similar in terms of:
  • Study design (RCTs)
  • Blinding (not mentioned)
  • Comparison group (placebo)
Trials differed with respect to:
  • Intervention [N=1 RCT used acupuncture (needles manipulated); N=1 RCT used electroacupuncture]
  • Study size (range N=20 and N=64)
  • Study quality – max score of 5 (N=1 study good quality; n=1 study reasonable quality)
  • Study duration – length of intervention (N=1 RCT 5 weeks; N=1 RCT 3 months)
Tests for heterogeneity and quality assessment performed.
Total N=84.Inclusion criteria: RCTs; Adult patients with classic or definite RA treated with acupuncture or electroacupuncture; any joint except the spine.

Search was up to 2005.

Exclusion criteria: Trials which used patients as their own control.
Acupuncture or electroacupuncture Using any combinations of parameters (eg. use of electric current, stimulation of various points or types of needles employed)PlaceboTreatment ranged from 5 weeks to 3 monthsPain; tender and swollen joints; Patients and Physicians global assessment; functional status.Partial funding by Laing Foundation, Southampton University Hospital, UK.
Effect size
Electroacupuncture vs placebo
  • Electroacupuncture was significantly better than placebo for:
    • Pain (0–4 scale) at end of treatment-24 hours (1 RCT, N=20; effect size WMD −2.0, 95% CI −3.6 to −0.4; p=0.01) and at 4 month follow-up (1 RCT, N=20; effect size WMD −0.2, 95% CI −0.36 to −0.04; p=0.01)
Acupuncture vs placebo Author’s conclusions:
The results of the electroacupuncture study show that electroacupuncture may be beneficial to reduce symptomatic knee pain in patients with RA 24hrs and 4 months post-treatment; however the trial was poor quality and small sample size so this may preclude its recommendation. Acupuncture trial had no effect on ESR, CRP, Pain, Patient’s global assessment, number of tender and swollen joints, disease activity, General Health Questionnaire and reduction in analgesics. These conclusions are limited by methodological considerations such as the type of acupuncture (acu vs electracu), the site of the intervention, the low number of clinical trials and the small sample size of the included studies.
ReferenceStudy type
Evidence level
Number of patientsPatient characteristicsInterventionComparisonLength of follow-upOutcome measuresSource of funding
T. Field, M. Diego, Reif M. Hernandez, and J. Shea. Hand arthritis pain is reduced by massage therapy. Journal of Bodywork and Movement Therapies 11 (1):21–24, 2007.

ID 3439
RCT: 1+
Single centre trial: USA
  • Randomised (method not mentioned
  • No mention of blinding
  • No mention of ITT analysis, however no dropouts
  • Power study
Total N=22 randomised

Drop-outs: None mentioned
Inclusion criteria: adults already diagnosed with wrist/hand arthritis.

Exclusion criteria: none given.

Baseline characteristics: mean age 47 years; Female 93%; Duration of RA = not mentioned; Pain (VAS) mean 3.0.

There were NS differences between the randomised groups for baseline characteristics.
Massage therapy

Massage (15 mins) of the affected wrist/hand by a therapist once/week for 4 weeks. Also patients were taught self-massage on the wrist/hand that was to be done daily at home prior to bedtime.
Control group (standard treatment)

Patients received the same assessments as the massage group but did not receive massage therapy during the study. They were taught the self-massage routine at the end of the study.
4 weeks treatment (assessments every week)Pain (VAS); Perceived grip strength (10-point scale); STAI (State anxiety inventory); POMS (profile of mood states – 5 point Likert scale including helpless or gloomy feelings, depression and anxiety).Grants from Johnsonand Johnson Paediatric Institute and Biotone, USA.
Effect size

Hand massage vs Control (standard treatment) – ANIOVA group interaction effects
  • Hand massage was significantly better than control (standard treatment) at 4 weeks (end of treatment) for:
    • Pain (VAS, change from baseline) mean change −0.8 and −0.1 respectively, p<0.01;
    • Anxiety (STAI, change from baseline) mean change −4.5 and −0.6 respectively, p<0.05;
    • Depression (POMS, change from baseline) mean change −1.1 and −0.2 respectively, p<0.01;
    • Grip strength (change from baseline) mean change +0.8 and −0.2 respectively, p<0.05.
ReferenceStudy type
Evidence level
Number of patientsPatient characteristicsIntervention and ComparisonLength of follow-upOutcome measuresSource of funding
E. Freye and L. Latasch. Analgesic therapy of rheumatoid arthritis - Part II: A study of combined allopathic and homeopathic therapy. Biomedical Therapy 18 (2):193–196, 2000.

ID 3440
Case-series (prospective): 3

Germany
Total N=30Inclusion criteria: Patients with classic symptoms of RA, rheumatic pain and inflammation; patients who sought more effective or alternative treatment due to persistent pain or excessive AEs of current medication and a resulting decline in QoL.

Exclusion criteria: not mentioned

Baseline characteristics: Age mean 57 years; female 70%; disease duration mean 12 years (established RA).
Plant-based homeopathic preparations + antioxidants (Vitamin C 1000 mg and Vitamin E 800 mg intramuscularly)

2 treatments/week for 5 weeks

Nerve block injections were administered concurrently to relieve acute pain and prevent sensitisation and the development of chronic pain syndrome.
5 weeks (2 treatments/week)Patients were questioned about pain during movement (VAS), degree of restriction of movement (scale 1–3) and general level of well-being (VAS).Not mentioned
Effect size*
  • At 5 weeks (end of study), patients treated with Plant-based homeopathic preparations + antioxidants had decreased Pain (VAS) change from baseline −1.5, increased level of well-being (VAS) change from baseline +8.0 and decreased restriction of movement, change from baseline −8.0.
  • Reduction of drugs patients’ had been previously taking was successful (all causing AEs were immediately eliminated – NSAIDs, MTX and/or paracetamol)
Author’s conclusions:
Over the course of treatment with homeopathic therapy + vitamin supplements + allopathic therapy, gradual improvement in pain, movement and well-being was noted and standard allopathic therapy was reduced or eliminated.

*values are approximate and have been taken from graphs published in the paper
ReferenceStudy type
Evidence level
Number of patientsPatient characteristicsInterventionComparisonLength of follow-upOutcome measuresSource of funding
R. G. Gibson, S. L. Gibson, A. D. MacNeill, and W. W. Buchanan. Homoeopathic therapy in rheumatoid arthritis: evaluation by double-blind clinical therapeutic trial. British Journal of Clinical Pharmacology 9 (5):453–459, 1980.

ID 3432
RCT (cross-over): 1−
Single centre trial: UK
  • Divided into groups (patients were assigned into the 2 groups so that as far as possible there were equal numbers of U and R patients in each group) – method of assignment not mentioned
  • Double blind
  • Allocation concealment
  • No mention of ITT analysis
  • No washout period between cross-over treatments
Total N=46 Divided into 2 groups (N=23 in each)

Drop-outs: N=2 placebo; N=1 homeopathy
Inclusion criteria: RA (ARA criteria).

Patients were divided into 2 groups: those with good prescribing symptoms (R) and those with poor prescribing symptoms (U). Patients with good prescribing symptoms have 3 or more of the following: onset of symptoms following a sudden fright, breavement, physical injury or other profound emotional or physical trauma; complaint affected by climatic conditions; complaint markedly affected by other factors such as movement, rest or time of day; outstanding factors affecting the patient not necessarily associated with the disease, such as marked craving or aversion for certain foods.

Exclusion criteria: none given.

Baseline characteristics:
Homeopathy: mean age 54 years; Female 70%; Duration of RA = established RA (mean 7 years).

Placebo: mean age 52 years; Female 65%; Duration of RA = established RA (mean 9 years).

The 2 groups were similar for all baseline characteristics.
HomeopathyPlacebo3 monthsPain (VAS); Articular Index; Grip strength; Morning stiffness (limbering up time)Not mentioned
Effect size

Authors’ conclusions:
There was significant improvement in pain, articular index, stiffness and grip strength in those patients receiving homeopathic remedies whereas there was NS change in the patients who received placebo. However, there were NS differences between the 2 groups. No side-effects were observed with the homeopathic remedies..
ReferenceStudy type
Evidence level
Number of patientsPatient characteristicsInterventionComparisonLength of follow-upOutcome measuresSource of funding
R. G. Gibson, S. L. M. Gibson, A. D. MacNeill, and W. W. Buchanan. The place for non-pharmaceutical therapy in chronic rheumatoid arthritis: A critical study of homoeopathy. British Homoeopathic Journal 69 (3):121–133, 1980.

ID 3434
RCT (cross-over): 1−
Single centre trial: UK
  • Divided into groups (patients were assigned into the 2 groups so that as far as possible there were equal numbers of U and R patients in each group) – method of assignment not mentioned
  • Double blind
  • Allocation concealment
  • No mention of ITT analysis
  • No washout period between cross-over treatments
Total N=46 Divided into 2 groups (N=23 in each)

Drop-outs: N=2 placebo; N=1 homeopathy
As for ID 3432 HomeopathyPlacebo3 months followed by 3 months cross-overPain (VAS); Articular Index; Grip strength; Morning stiffness (limbering up time)Not mentioned
Effect size

Authors’ conclusions:
There was significant improvement in patients receiving homeopathic remedies whereas there was NS change in those who received placebo. No side-effects were observed with the homeopathic remedies.

From: Evidence Tables

Cover of Rheumatoid Arthritis
Rheumatoid Arthritis: National Clinical Guideline for Management and Treatment in Adults.
NICE Clinical Guidelines, No. 79.
National Collaborating Centre for Chronic Conditions (UK).
Copyright © 2009, Royal College of Physicians of London.

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