Acupuncture and electroacupuncture for the treatment of rheumatoid arthritis: Cochrane systematic review
Assessed as up to date: 2005/08/21
Acupuncture has been used by rehabilitation specialists as an adjunct therapy for the symptomatic treatment of rheumatoid arthritis (RA). Acupuncture is a traditional Chinese medicine where thin needles are inserted in specific documented points believed to represent concentration of body energies. In some cases a small electrical impulse is added to the needles. Once the needles are inserted in some of the appropriate points, endorphins, morphine-like substances, have been shown to be released in the patient's system, thus inducing local or generalised analgesia (pain relief). This review is an update of the original review published in July 2002.Objectives
To evaluate the effects of acupuncture or electroacupuncture on the objective and subjective measures of disease activity in patients with RA.Search strategy
A comprehensive search of MEDLINE, EMBASE, PEDro, Current Contents , Sports Discus and CINAHL, initially done in September 2001, was updated in May 2005.The Cochrane Field of Rehabilitation and Related Therapies and the Cochrane Musculoskeletal Review Group were also contacted for a search of their specialized registries. Handsearching was conducted on all retrieved papers and content experts were contacted to identify additional studies.Selection criteria
Comparative controlled studies, such as randomized controlled trials and controlled clinical trials in patients with RA were eligible. Trials published in languages other than French and English were not analyzed. Abstracts were excluded unless further data could be obtained from the authors.Data collection and analysis
Two independent reviewers identified potential articles from the literature search and extracted data using pre-defined extraction forms. Consensus was reached on all the extracted data. Quality was assessed by two reviewers using a five point validated tool that measured the quality of randomization, double-blinding and description of withdrawals.Main results
After the updated searches were conducted, five further potential articles were identified; however, these did not meet the inclusion criteria. Two studies involving a total of 84 people were included. One study used acupuncture while the other used electroacupuncture. In the acupuncture study, no statistically significant difference was found between groups for erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), visual analogue scale for patient's global assessment (VAS G), number of swollen joints and tender joints, general health questionnaire (GHQ), modified disease activity scale (DAS) or for the decrease in analgesic intake. Although not statistically significant, pain in the treatment group improved by 4 points on a 0-100mm visual analogue scale versus no improvement in the placebo group.
In the second study, using electroacupuncture, a significant decrease in knee pain was reported in the experimental group, 24 hours post treatment, when compared to the placebo group (WMD: -2.0 with 95% CI -3.6,-4.0). A significant decrease was found also at four months post-treatment (WMD -0.2, 95% CI: -0.36, -0.04)
Although the results of the study on electroacupuncture show that electroacupuncture may be beneficial to reduce symptomatic knee pain in patients with RA 24 hours and 4 months post treatment, the reviewers concluded that the poor quality of the trial, including the small sample size preclude its recommendation. The reviewers further conclude that acupuncture has no effect on ESR, CRP, pain, patient's global assessment, number of swollen joints, number of tender joints, general health, disease activity and reduction of analgesics. These conclusions are limited by methodological considerations such as the type of acupuncture (acupuncture vs electroacupuncture), the site of intervention, the low number of clinical trials and the small sample size of the included studies.
Casimiro Lynn, Barnsley Les, Brosseau Lucie, Milne Sarah, Welch Vivian, Tugwell Peter, Wells George A
Acupunture and electroacupuncture for rheumatoid arthritis
Does acupuncture work for treating rheumatoid arthritis?
Two studies of low to medium quality were reviewed and provide the best evidence we have today. The studies tested 84 people who had rheumatoid arthritis. The studies compared acupuncture to a placebo (fake therapy) or a steroid injection. Improvement was measured after one treatment or after five treatments given once per week.
What causes shoulder pain and how can acupuncture help?
Rheumatoid arthritis (RA) is a disease in which the body's immune system attacks its own healthy tissues. The attack happens mostly in the joints of the hands and feet and causes redness, pain, swelling and heat around the joints. Drug and non-drug treatments are used to relieve pain and/or swelling.
Acupuncture is a non-drug therapy being in which thin needles are inserted into the body at specific spots. It is thought that acupuncture works either by releasing chemical compounds in the body that relieve pain, by overriding pain signals in the nerves or by allowing energy (Qi) or blood to flow freely through the body. It is not known whether acupuncture works or is safe.
What do the studies show?
In one study, people had acupuncture or fake therapy for five weeks, once per week. Pain, number of swollen and tender joints, disease activity, overall well-being, lab results, or amount of pain medication needed was about the same whether they had acupuncture or fake therapy.
In the other study, people had acupuncture with an electric current going through the needles at specific or real acupuncture spots in the knee or at fake spots in the knee. Knee pain while at rest, while moving or while standing decreased more in the people who had the real acupuncture. The improvement lasted up to 4 months after acupuncture. Unfortunately, the authors of this review believe that this trial was of low quality and may overestimate how well acupuncture works.
How safe is it?
Side effects were not measured in the studies.
What is the bottom line?
The quality of the evidence is 'silver'.
From the little evidence that there is, acupuncture does not appear to improve the symptoms of rheumatoid arthritis.
Implications for practice
Although the results of the Man study show that electroacupuncture may be beneficial to reduce symptomatic knee pain in patients with RA , the authors of this systematic review note that there is insufficient evidence to support this conclusion. The poor quality of the trial, including the small sample size preclude its recommendation. Acupuncture has not yet been shown in the literature to have an effect on ESR, CRP, pain, patient's global assessment, number of swollen joints, number of tender joints, general health, disease activity and reduction of analgesics. These conclusions are limited by methodological considerations such as the site of intervention, the low number of clinical trials and the small sample size of the included studies.
Finally, with a silver level of evidence, we conclude that there is little evidence that acupuncture relieves RA symptoms.
Implications for research
This review has not clearly proven efficacy of acupuncture or electroacupuncture in the symptomatic treatment of RA. The conclusions are limited by the methodological considerations such as poor quality of the trials, the high methodological variability, the low number of clinical trials and the small sample size of the included studies. No harmful side effects were reported. More sensitive and valid clinical outcomes should be used in studies on the use of acupuncture to reflect the physiological effects found in the scientific literature. More focus should be made on the optimal characteristics of the therapeutic application of acupuncture on different human RA joints. If sufficient studies were ever available on this subject it is recommended that acupuncture and electroacupuncture be reviewed separately.Get full text at The Cochrane Library
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