**1. Introduction**

350 Rheumatoid Arthritis – Treatment

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> Treatment of rheumatoid arthritis, a systemic, diverse and dynamic disorder, has made major progress over the past few decades. Early active treatment with disease-modifying anti-rheumatic drugs and biological agents can be highly beneficial for controlling inflammatory activity and preventing disability in many patients. However, the most effective new drugs are expensive and many patients with rheumatoid arthritis continue to have significant pain, restricted mobility, reduced muscle strength and low endurance. In addition, it is increasingly recognized that co-morbid conditions play a pivotal role in rheumatoid arthritis outcomes. For example, cardiovascular complications are the leading contributor to mortality in rheumatoid arthritis, accounting for approximately one half of all deaths. Osteoporosis, resulting in bone fractures, also represents a major source of morbidity in rheumatoid arthritis. Complementary and alternative medicine treatment and lifestyle behavioral modification may play a role in preventing rheumatoid arthritisassociated comorbidities and their complications.

> Rheumatoid arthritis is characterized by synovial inflammation that leads to joint destruction, resulting in substantial long-term disability and a significantly shorter life expectancy. Many patients with rheumatoid arthritis experience high levels of pain, functional impairment, psychological distress and negative emotions, but these symptoms have limited pharmacological therapeutic options. Given the complexity of the therapeutic armamentarium used in rheumatoid arthritis, non-pharmacological therapies are increasingly attractive to those with chronic rheumatic pain conditions. Recently, complementary and alternative medicine therapies for arthritis have been heavily advertised and increasing numbers of chronic pain patients report utilizing alternative therapies. At the same time, clinical trials and observational studies have provided encouraging evidence that Acupuncture, Mind-body Therapy, Chinese herbs and Tibetan Medicine have some benefits for patients with rheumatoid arthritis. Indeed, integrative approaches combine the best of conventional medicine and the wisdom of complementary and alternative medicine. Thus, this chapter synthesizes the current body of knowledge on the therapeutic benefits of several types of Complementary and Alternative Medicine on pain and symptom relief in patients with rheumatoid arthritis to better inform clinical decision-making for our patients.

Complementary and Alternative Medicine in the Treatment of Rheumatoid Arthritis 353

1999; Jiang & Fan, 2003; Liu et al., 2003; Tam et al., 2007; Wang, 2002; Zanette Sde et al., 2008; Zhou & Zhu, 2000), two used electroacupuncture, (EA) (Man & Baragar, 1974; Tam et al., 2007) and one used both (Tam et al., 2007). Four trials used placebo needles (sham acupuncture orincorrectly placed needles) as the control (David et al., 1999; Man & Baragar, 1974; Tam et al., 2007; Zanette Sde et al., 2008). The other five studies published in China used a variety of active interventions in the control groups, including methotrexate, topical

The four placebo-controlled trials involved 160 participants. Of those, two had optimal quality and two had moderate quality (David et al., 1999; Man & Baragar, 1974; Tam et al., 2007; Zanette Sde et al., 2008). Two high quality double-blind randomized, placebocontrolled trials and two moderate quality trials evaluated the effects of either traditional or electroacupuncture versus sham acupuncture. Tam et al (2007) conducted a trial in Hong Kong among 36 patients with RA and a disease duration of 9.3 years. Patients were randomly assigned to three groups: traditional acupuncture (TA), electroacupuncture (EA), and sham acupuncture (placebo needles). Patients received a total of 20 sessions for 10 weeks using six acupuncture points. The authors found that tender joint count improved for both EA and TA groups compared with the control group (tender joint count 5.5 vs. 0.5, p<0.05 and tender joint count 4 vs. 0.5, p<0.05, respectively). Physician's global score significantly improved for the EA group while patient's global score significantly improved for the TA group. Of note, the pain score remained unchanged in all three groups. The ACR core disease measures and DAS 28 score were

In a contemporaneous high quality study conducted by Zanette Sde et al (2008), 40 patients with long-standing RA were randomized to traditional acupuncture or a control group using superficial acupuncture at non-acupuncture points. All participants received a total of 10 sessions, twice a week for five consecutive weeks. Tender joint count improved for the TA group compared with the control group (tender joint count 8.35 vs. 2.45, p=0.145). There was no significant difference between groups regarding ACR 20 improvement criteria (primary outcome) after the 5th and 10th sessions. At the last visit, there was a trend in favor of the acupuncture intervention compared with the control group (40% vs. 10% of each group achieved ACR20 criteria, p=0.07, respectively). In addition, there was a significant difference favoring the TA group on physician's global assessment of the treatment (p=0.012), and patient's (p=0.003) and physician's global assessment of disease activity (p=0.011), but there was no difference for other endpoints. The authors concluded that the negative result could be related to the small sample size, selection of patients, type of acupuncture protocol applied, and difficulties in establishing

A double-blind randomized placebo-controlled trial conducted by David et al (1999) used a six-week crossover design comparing traditional acupuncture with sham acupuncture in 64 patients. There was a total of five weekly sessions. After a washout period of six weeks, participants were crossed-over into the other intervention arm (acupuncture or control) for an additional five weeks. The tender joint count, swollen joints count, pain scale, patient's and physician's global assessments, modified DAS, ESR, and C-reactive protein were assessed at baseline and at the end of both intervention periods. The authors found no

Votalin ointment, and non-steroidal anti-inflammatory drugs.

**2.1.1 Placebo-controlled trials** 

not achieved at week 10.

an appropriate control group.
