Research Database -
International Updates

Arthritis and Fibromyalgia

Issue 75

FIECHTNER and BRODEUR, Division of Rheumatology, Michigan State University, Colleges of Osteopathic and Human Medicine, East Lansing, Michigan, USA, jfiechtner@pol.net, reviewed (67 references) clinical studies investigating the usefulness of manipulation in treating musculoskeletal disorders and arthritis.
Discussion: Many people seek out therapists who perform manual and manipulation techniques to relieve pain and improve function, despite the fact that few third-party payers cover such therapies. If it could be confirmed that manipulative techniques were effective for treating musculoskeletal conditions, it is likely that third-party payers would be willing to reimburse the costs of these treatments. A review of relevant clinical studies revealed mixed results for several conditions and that most studies had both methodological strengths and weaknesses. The most powerful studies showed manual techniques to be beneficial for back and neck pain in comparison with no treatment or ‘placebo’. However, clear superiority of manual therapy in relation to other techniques such as physical therapy, education or exercise has not been demonstrated.
Conclusion: Manual techniques are useful, but primarily as adjuncts to a comprehensive treatment programme. Manual techniques are particularly useful to help break the cycle of pain and to increase tolerance to exercise and other educational approaches. The available clinical studies do not provide any information on how manual techniques aid the healing process, and thus further study is needed in this area, for example, to determine the mechanisms by which manipulation affects pain and motion. Such information should help to improve the design of future studies in this area.
Fiechtner JJ, Brodeur RR. Manual and manipulation techniques for rheumatic disease. The Medical Clinics of North America 86 (1): 91-103. Jan 2002.

Issue 72

FISHER and SCOTT, Royal London Homoeopathic Hospital, Great Ormond Street, London, UK, investigated whether a homeopathic medicines series was effective in reducing the symptoms of joint inflammation in rheumatoid arthritis (RA).
Methods: This 6-month, randomized, cross-over design, double-blind, placebo-controlled, single-centre clinical trial involved 112 patients with definite or classical RA who were seropositive for rheumatoid factor and were receiving either stable doses of single non-steroidal anti- inflammatory drugs (NSAIDs) for up to 3 months or single disease- modifying antirheumatic drugs (DMARDs) with or without NSAIDs for up to 6 months. Patients were excluded if they were severely disabled, had taken systemic steroids in the previous 6 months or had withdrawn from DMARD therapy in the previous 12 months. Trial subjects received either a series of 42 homeopathic medicines used to treat RA in 6cH (10(-12)) and/or 30cH (10(-30)) dilutions (a total of 59 preparations) manufactured to French National Pharmacopoeia standards, or a series of identical matching placebos, for 3 months, after which they were ‘crossed over’ to the opposite treatment series for a further 3 months. Main outcome measures were: visual analogue scale (VAS) pain scores; Ritchie articular index; duration of morning stiffness; and erythrocyte sedimentation rate (ESR).
Results: 58 patients (51.8%) completed the trial. 54 withdrew before completing the trial. 31 changed to conventional medicine, 10 had serious intercurrent illness or surgery, 12 failed to attend, and 3 withdrew consent. For those patients who completed, mean pain scores, articular indices and ESRs decreased significantly over the 6-month trial period by 18%, 24% and 11% respectively (p<0.01, Wilcoxon rank sum tests). Mean pain scores were significantly lower after 3 months’ placebo therapy than after 3 months’ homeopathic treatment (p=0.032, Wilcoxon rank sum test). Articular index, ESR and morning stiffness were similar with placebo and homeopathic treatment.
Conclusion: There was no evidence that the series of homeopathic medicines used in this trial improved symptoms of RA over 3 months in patients attending a routine clinic who were stabilized on NSAIDs or DMARDs.
Fisher P, Scott DL. A randomized controlled trial of homeopathy in rheumatoid arthritis. Rheumatology 40 (9): 1052-5. Sep 2001.

Comment from Dr Peter Fisher: This clinical trial was essentially an attempt to replicate two clinical trials of homeopathy for rheumatoid arthritis, reported by Robin and Sheila Gibson of the Glasgow Homoeopathic Hospital, in the early 1980s. The 3-month treatment period and crossover design were the same as in their work. The trial ran into serious problems, in particular that nearly half the patients were withdrawn from the study, mostly because their conventional medication was changed or because of other illnesses. Both the active treatment and placebo groups seemed to improve, but this probably reflects the fact that the patients who were deteriorating had their medication changed and were withdrawn. The main conclusion is that, for us at least, the trial design simply did not work. Given the short treatment period, the large proportion of withdrawals and cross-over design, very little can be said about the effectiveness of homeopathy for rheumatoid arthritis. In retrospect, perhaps we should have abandoned it. But having done the study it was important to publish it, if only to prevent others from making the same mistakes. It is by no means the end of the road; we have done other, positive studies of homeopathy in rheumatic conditions, and are planning more, much better designed trials. Certainly we have learned some important lessons about trial design, if not about homeopathy!

PERETZ and colleagues, Rheumatology, CHU Brugmann, Institute of Pharmacy, Free University of Brussels, Belgium, anne.peretz@chu-brugmann.be, investigated the effects of selenium supplementation in rheumatoid arthritis (RA).
Background: Selenium is an essential trace element with antioxidant properties. Trials with selenium have been conducted in RA to correct impaired selenium status and increase defences against deleterious oxidant species.
Methods: In this double-blind, placebo-controlled, multicentre study, 55 patients with moderate RA received capsules containing selenium-enriched yeast (200 g/day) or placebo over 90 days.
Results: Visual analogue scales scores, Ritchie index, the number of swollen and painful joints, and morning stiffness all decreased significantly with time in both the active and placebo treatment groups (p<0.001). No difference between groups was identified. Selenium-treated patients showed significant improvements on qualify of life measures (arm movements and health feeling) (p<0.01).
Conclusion: The authors reported that selenium treatment for 90 days did not show a clinical benefit in RA. [However, selenium treatment did appear to benefit patients on some quality of life measures.] The results demonstrated a significant placebo effect of the intervention trial.
Peretz A et al. Selenium supplementation in rheumatoid arthritis investigated in a double blind, placebo-controlled trial. Scandinavian Journal of Rheumatology 30 (4): 208-12. 2001.

Issue 53

BRODERICK, Department of Psychiatry and Behavioral Sciences, State University of New York at Stony Brook USA reviews (68 references) the research over the last 20 years in Mind-Body Medicine.
Results and Conclusions: The author writes the Mind-Body Medicine has made significant contributions to the treatment of rheumatic disease. The approach is based upon the concept that patients have the ability to influence their experience of illness via direct modification of thoughts, emotions and behaviours. The review finds that Mind-Body approaches results in significant, incremental symptom relief, improvement in disability status and well-being beyond that achieved with routine medical care. Furthermore, evidence demonstrates that such interventions reduce utilization of health care services, despite continuing progression of disease, a finding which has major economic implications for health policy.
Broderick JE. Mind-body medicine in rheumatologic disease. Rheumatic Diseases Clinics of North America 26(1): 161-76. Feb 2000.

YOCUM and colleagues, Arizona Arthritis Center, University of Arizona, Tucson USA writes that stress and pain mechanism pathways are complex and share many central nervous system pathways. These are critical issues for patients with rheumatoid arthritis and other connective tissue diseases. Links between stress and neuroendoimmune function suggests that alternative therapies which focus upon improved psychological and metabolic function may significantly change pain outcomes for patients. The author reviews (54 references) programmes using alternative therapies such as tai chi and meditation in combination with traditional medications, which appear to be beneficial for patients with arthritis. These people appear to live better lives and may have better long-term outcomes.
Yocum DE et al. Exercise, education, and behavioral modification as alternative therapy for pain and stress in rheumatic disease. Rheumatic Diseases Clinics of North America 26(1): 145-59. Feb 2000.

CHOPRA, Center for Rheumatic Diseases, Bharati Hospital, Pune, India. archopra@pn2.VSNL.net in reviews (22 references) the fundamental principles of Ayurveda. The author describes the ancient classification of arthritis along with comparisons to the modern system. Though the diagnosis is historical and clinical, it is based upon the tridosha hypothesis; Ayurvedic pathogenesis links arthritis to the gut and management consists chiefly of diet and lifestyle changes, panchakarma process and herbal remedies. The author introduces the rasayana concept of immunomodulation.
Conclusions: Clinical ethno-validation of the ancient therapy is required to meet modern requirements and establish an interface with modern medicine.
Chopra A. Ayurvedic medicine and arthritis. Rheumatic Diseases Clinics of North America 26(1): 133-44. Feb 2000.

GARFINKEL and colleagues, BKS Iyengar Yoga Studio of Philadelphia, Pennsylvania USA review (29 references) yoga as an ancient tradition which has been westernized and often practised for its proposed health benefits. Traditional texts describe its benefits for many types of arthritis. The authors describe two limited studies of yoga for osteoarthritis of the hands and carpal tunnel syndrome, which showed greater improvement in pain than in control group. Yoga uses stretching and improves strength so that it theoretically should be beneficial for certain musculoskeletal problems.
Conclusions: Yoga deserves further study into the basis for its cellular and physiological effects.
Garfinkel M and Schumacher HR Jr. Yoga. Rheumatic Diseases Clinics of North America 26(1): 125-32. Feb 2000.

JONAS and colleagues, Uniformed Services University of the Health Sciences, Bethesda, Maryland USA. wjonas@mxa.usuhs.mil write that despite a growing interest in discovering the basic mechanisms underlying arthritis, medical treatment remains symptomatic and do not consistently halt the long-term progression of these diseases. Surgery may still be required to restore mechanical function in large joints. Patients with rheumatic syndromes often seek alternative therapies, homoeopathy being one of the most frequently used complementary therapies worldwide.
Jonas WB et al. Homeopathy and rheumatic disease. Rheumatic Diseases Clinics of North America 26(1): 117-23. Feb 2000.

FIECHTNER and BRODEUR, Division of Rheumatology, Michigan State University, Colleges of Osteopathic and Human Medicine, East Lansing USA reviews (67 references) manipulation, as practised mainly by chiropractors and osteopaths, as one of the most commonly used alternative treatments for rheumatic diseases. Low back and neck pain are the most frequently treated disorders; however, manipulation is also used to treat a broad range of rheumatic diseases. Manipulation has been demonstrated to decrease joint pain and normalize function. Its mechanisms of action, however are not well understood, with current theories proposing an imbalance of muscle activity a source of pain which can be relieved by manipulation via reflexive actions. Such muscle imbalances would exacerbate rheumatic and arthritic conditions, suggesting that manipulation may be an important therapy which is appropriate for early conservative care as part of a comprehensive treatment regimen.
Fiechtner JJ and Brodeur RR. Manual and manipulation techniques for rheumatic disease. Rheumatic Diseases Clinics of North America 26(1): 83-96. Feb 2000.

ERNST and CHRUBASIK, Department of Complementary Medicine, School of Postgraduate Medicine and Health Sciences, University of Exeter, United Kingdom. E.Ernst@ex.ac.uk review (58 references) the literature regarding herbal treatments for rheumatic symptoms.
Methods: The authors conducted a systematic review of randomized, placebo-controlled, double-blind trials.
Results: 19 studies met the inclusion criteria. These were heterogeneous with respect to remedies tested, patients treated and trial methodology applied. Most of the studies suggested that herbal remedies have symptomatic effects beyond placebo.
Conclusions: Phyto-anti-inflammatories have considerable, albeit under-researched potential for the symptomatic treatment of rheumatic disorders.
Ernst E and Chrubasik S. Phyto-anti-inflammatories. A systematic review of randomized, placebo-controlled, double-blind trials. Rheumatic Diseases Clinics of North America 26(1): 13-27. Feb 2000.

DELAFUENTE, Department of Pharmacy, School of Pharmacy, Medical College of Virginia, Virginia Commonwealth University, Richmond, USA review (21 references) the use of glucosamine sulphate, a constituent of cartilage, in the treatment of osteoarthritis.
Results: The available data suggest that glucosamine decreases pain and improves function in osteoarthritis. Most of the studies using glucosamine have methodological flaws or have used parenteral formulations, which make their data difficult to extrapolate into clinical practice. Glucosamine sulphate is shown to be as good as ibuprofen for osteoarthritis of the knee.
Conclusions: Better designed clinical trials of glucosamine are required in order to identify its role in the pharmacotherapy of osteoarthritis.
Delafuente JC. Glucosamine in the treatment of osteoarthritis. Rheumatic Diseases Clinics of North America 26(1): 1-11. Feb 2000.

Comments: The above group of studies is a demonstration of the wide-ranging nature of alternative approaches being clinically researched for arthritis and rheumatic diseases.

Issue 24

GIO-FITMAN, Columbia Michael Reese Hospital, Chicago, IL USA reviews (22 references) the effects of psychological stress upon the immune system and how stress is linked to onset of disease and exacerbation in rheumatoid arthritis patients. Flare-ups of disease may be preceded by stress. The author writes that adult health and advanced practice nurses should focus upon assessing patients for symptoms of stress, identify methods of coping with stress and implement a number of stress-reduction techniques.
Gio-Fitman J. The role of psychological stress in rheumatoid arthritis. Medsurg Nurs 5(6): 422-6. Dec 1996.

KEEFE and colleagues, Management Programme, Duke University Medical Center, Durham, North Caroline 27710 USA analysed pain coping processes in patients with rheumatoid arthritis.
METHODS: 53 people recorded in daily diaries the pain coping strategies they used each day for 30 consecutive days, rating the efficacy of their coping, joint pain and mood - positive and negative. Variables were examined across- persons and within-persons over time.
RESULTS: With regard to across-persons level of analysis 1) daily coping efficacy was not related to pain coping or pain intensity; and 2) more frequent daily use of a wide variety of pain coping strategies was correlated with greater pain. Within-person analyses provided information regarding the relationships among coping, pain and mood not apparent in the across-persons results. These analyses demonstrated that increases in daily coping efficacy were not only related to decreases in pain, but also to decreases in negative mood and increased positive mood. Time-lagged effects of coping and coping efficacy were also discovered. People who reported high levels of coping efficacy on one particular day experienced lower pain levels on the following day. Daily use of pain reduction and relaxation strategies also contributed to improvement in next-day pain and enhancement of positive mood.
CONCLUSIONS: The implications of these findings regarding pain assessment and coping in patients with rheumatoid arthritis are discussed.
Keefe FJ et al. Pain coping strategies and coping efficacy in rheumatoid arthritis: a daily process analysis. Pain 69(1-2): 35-42. Jan 1997.

SHAPIRO and colleagues, Department of Epidemiology, University of Washington, Seattle USA note that it has been hypothesised by researchers that omega-3 fatty acids found mainly in fish oils, may be protective against rheumatoid arthritis.
METHODS: The authors conducted a case-control study in women, comparing 324 rheumatoid arthritis cases with 1,245 control cases. A food frequency questionnaire was used to determine diet during a 1-year period 5 years prior to a reference date – the first visit to the physician with joint symptoms.
RESULTS: Consumption of broiled or baked, but not other types of fish was associated with a decreased risk of rheumatoid arthritis. Compared to eating less than one serving of broiled or baked fish per week, the adjusted odds ratios (OR) for eating 1-2 servings per week were 0.78 and for eating more than 2 servings were 0.57. There was also an association of protein as a percentage of calories, with the adjusted OR for the top quartile compared with the bottom quartile = 0.65 and total calories – adjusted OR for the top quartile = 1.62. The associations with broiled or baked fish, protein and calories became stronger when the analysis was restricted to cases positive for rheumatoid factor.
CONCLUSIONS: These data support the hypothesis that omega-3 fatty acids may help to prevent rheumatoid arthritis.
Shapiro JA et al. Diet and rheumatoid arthritis in women: a possible protective effect of fish consumption. Epidemiology 7(3): 256-63. May 1996.

COMMENTS: Rheumatoid arthritis is a complex disease. The above research studies indicate that psychological factors including stress, coping strategies and dietary practices – consumption of fish - may all influence the degree of pain and quality of life for sufferers of rheumatoid arthritis. Clinically, as with asthma, heart disease and HIV, an integrative treatment approach for RA shouldn’t just involve throwing steroids at the problem - it should combine careful individual assessments of psychological, emotional, nutritional and physical treatment modalities.

Issue 19

LINDBERG and colleagues, National Institute for Psychosocial Factors and Health, Stockholm, Sweden applied the clinical use of psychoneuroimmunological approaches to rheumatoid arthritis (RA). METHODS: 15 patients with RA were treated with analytical insight therapy for 60-90 minutes per week throughout a period of 10 months to 4.5 years (median period 3.3 years).
RESULTS: Of the 15 patients, 6 patients demonstrated great and largely continuous improvement, both psychological and physical, throughout the psychotherapy treatment and often for a long time thereafter. In another 5 patients, improvements in psychological state and joint disease occurred over a period of 1-2 years. Later, when the emotional channels to childhood traumas had been opened, these 5 patients relapsed and the course of their disease became more variable. In 4 other cases, the associations between psychological state and the course of joint disease were more varied throughout the period of psychotherapy. In this studied group, the correlation between psychological state and the course of rheumatic disease was highly significant.
CONCLUSIONS: The probability of the study's outcome being due to chance alone is considered to be very small, especially taking into account the fact that RA is a chronic progressive disease.
Lindberg NE et al. Psychotherapy in rheumatoid arthritis - a parallel process study of psychic state and course of theumatic disease. Z Rheumatol 55(1): 28-39. Jan-Feb 1996.

PIORO-BOISSET and colleagues investigated patients with fibromyalgia syndrome (FMS), and determined the prevalence, extent, cost and satisfaction with the use of alternative medicine therapies compared to control rheumatology patients.
METHODS: 220 consecutive rheumatology and 80 FMS patients completed an interviewer-based questionnaire.
RESULTS: Alternative medicine interventions were used extensively by rheumatology patients and by FMS patients in particular. Compared to controls, all categories of alternative therapies were used more by FMS patients - overall use 91% versus 63% for controls; spiritual practices 48% versus 37%; and alternative practitioners 26% versus 12%. Two-thirds of patients using alternative therapies were concurrently using multiple intereventions and patient satisfaction was highest for spiritual approaches.
CONCLUSIONS: Almost all FMS patients were using alternative medicine therapies, which may indicate that conventional medical therapies are inadequate in providing symptomatic relief to sufferers of FMS.
Pioro-Boisset M et al. Alternative medicine use in fibromyalgia syndrome. Arthritis Care Res 9(1): 13-7. Feb 1996.

COMMENTS: Again there are similar sentiments as expressed following Begbie et al (see Alternative Medicine). Because most FMS patients use alternative therapies, the authors feel this is a reflection upon the inadequacy of conventional medical care. The authors do not choose to conclude that FMS patients use alternative approaches because they may provide therapeutic benefit, nor to point out the potentially positive aspects of these alternative therapies.

MILLS and colleagues, Centre for Complementary Health Studies, University of Exeter, UK conducted a double-blind study to investigate the therapeutic efficacy of a licensed herbal medicine for the relief of chronic arthritic pain.
METHODS: 82 people with chronic pain from arthritis were randomly assigned, without cross-over, to 2 months' treatment either with Reumalex, a licensed over-the-counter (OTC) herbal medicine or a placebo. Characteristics at entry were determined by a previous survey of customers with arthritis who shopped at pharmacies and healthfood stores. The AIMS2 questionnaire was for 2 months prior to the trial and monthly throughout; a modified Ritchie Index provided clinical scores. The people also kept a diary of their use of self-prescribed pain-relief medication and events they considered significant.
RESULTS: A small, but statistically significant improvement occurred regarding pain symptoms, less so with osteoarthritis patients. There were no other significant changes in any other measures nor in the use of other self-prescribed analgesics. Few side-effects were noted.
CONCLUSIONS: Reumalex has a mild analgesic effect in chronic arthritis at a level appropriate to self-medication.
Mills SY et al. Effect of a proprietary herbal medicine on the relief of chronic arthritic pain: a double-blind study. Br J Rheumatol 35(9): 874-8. Sep 1996.

KAIPIAINEN-SEPPANEN and colleagues, Department of Medicine, Kuopio University Hospital, Finland obtained information regarding the incidence of rheumatoid arthritis (RA) and on its recent trends in Finland.
METHODS: The people in the study included those entitled to receive specially reimbursed medication for RA under the national sickness insurance scheme from 5 out of 21 central hospital districts in Finland (population basis approx. 1 million adults) during the 3 years 1980, 1985 and 1990.
RESULTS: The annual incidence of RA in 1980 and 1985, according to the American Rheumatism Association 1987 classification criteria, was 39/100,000 of the population, 16 years of age or older. The combined incidence of rheumatoid factor (RF) factor positive arthritis and RF negative polyarthritis was 46/100,000. Compared with the earlier years, in 1990 there was a decline of 40% in the number of RF negative RA cases. This declining trend was statistically significant.
CONCLUSIONS: The decline in the incidence of RF negative RA in Finland may reflect environmental changes specifically affecting the risk of RF negative disease.
Kaipiainen-Seppanen O, et al. Incidence of rheumatoid arthritis in Finland during 1980-1990. Ann Rheum Dis. 55(9): 608-11. Sep 1996.