|Acupuncture for pain relief in patients with rheumatoid arthritis: a systematic review
|Wang C, de Pablo P, Chen X, Schmid C, McAlindon T
The review concluded that, despite some favourable results in active-controlled trials, there was conflicting evidence in placebo-controlled trials concerning the efficacy of acupuncture for rheumatoid arthritis. The authors' conclusions should be interpreted with some degree of caution due to the possibility of publication bias and limitations in the analysis.
To determine the efficacy of acupuncture for pain relief in patients with rheumatoid arthritis.
MEDINE, PsycINFO, CAB, Health Star, EMB Reviews, Cochrane Database of Systematic Reviews, ACP Journal Club, DARE, CINAHL, Global Health and Alt Health Watch, China Hospital Knowledge database, China National Knowledge Infrastructure, Wanfang Data and Traditional Chinese Medical Database System were searched from inception to March 2008. Search terms were reported. A handsearch was conducted of the Traditional Chinese Medicine libraries of Beijing, including the Beijing Chinese Academy of Traditional Medicine and Nanjing Medical Universities. Bibliographies of retrieved articles and reviews were scanned for additional articles. Only studies published in English and Chinese were eligible for inclusion.
Randomised controlled trials (RCTs) that compared acupuncture with placebo or active therapies for the treatment of patients with rheumatoid arthritis were eligible for inclusion. The main outcome of interest was pain measured by tender joint count. Other outcomes were pain measured by a pain scale, morning stiffness, erythrocyte sedimentation rate and C-reactive protein level.
The interventions used electroacupuncture and traditional acupuncture. The number of acupuncture sessions ranged from one to 180. Duration of needle insertion ranged from four to 40 minutes. Control groups received either placebo (sham, superficial acupuncture or placebo needles) or an active comparator including methotrexate, topical Votalin ointment and nonsteroidal anti-inflammatory drugs (NSAIDS). The age of participants ranged from 18 to 75 years. Disease duration ranged from one to more than 10 years. Outcomes were assessed using a range of scales, including tender joint count, visual analogue scale, American College of Rheumatology, swollen joint count, Health Assessment Questionnaire, General Health Questionnaire, Disease Activity Score in 28 joints (DAS28), erythrocyte sedimentation rate and C-reactive protein. The studies were conducted in Canada, UK, Brazil and China.
The authors stated neither how papers were selected for the review nor how many reviewers performed the selection.
Assessment of study quality
Validity was assessed using the Jadad score, which assessed randomisation, double blinding and withdrawals to a maximum score of 5 points. Validity was assessed in duplicate. Discrepancies were resolved through discussion.
Data on relevant pain outcomes were extracted from individual studies and the differences in means or medians between treatment groups were calculated. Data were extracted in duplicate. Discrepancies were resolved through discussion.
Methods of synthesis
Studies were combined in a narrative synthesis with additional data provided in tables.
Results of the review
Eight RCTs (n=536) were included in the review: four placebo-controlled trials (including parallel and crossover designs) and four active control trials. Average study duration was 11 weeks. Three studies scored 5 points, three studies scored 3 points and two studies scored 2 points for validity assessment. Randomisation was adequately described in all studies; method of randomisation and blinding were adequately described and appropriate in four studies; and reasons for withdrawals were adequately described in seven studies.
RCTs with placebo control (four RCTs, n=160): One high-quality RCT reported significant improvements in tender joint count for both intervention groups compared to placebo groups (p<0.05). One modest-quality RCT reported improvements on a pain scale for the acupuncture group compared to no change in the control group, but due to lack of baseline data the effect was estimated. Two high-quality RCTs reported no significant differences between groups.
RCTs with active comparator (four RCTs, n=407): All four RCTs, said to be of modest quality, reported that acupuncture was associated with a significant decrease in tender joint count compared with active comparator. Three RCTs reported a reduction in erythrocyte sedimentation rate compared to active comparator, although this was only statistically significant for one RCT (data not reported). Two RCTs reported a reduction in C-reactive protein level, but this was only statistically significant for one RCT (data not reported).
Despite some favourable results in active-controlled trials, there was conflicting evidence in placebo-controlled trials of the efficacy of acupuncture for rheumatoid arthritis.
The review question was clear and supported by detailed inclusion criteria. Several relevant sources were searched. No efforts were made to reduce the potential for publication bias. By including studies in English and Chinese, the authors made some attempts to reduce language bias. Appropriate methods were used to reduce reviewer error and bias in the extraction of data and validity assessment, but it was unclear whether similar steps were taken in the selection of studies. Validity was assessed using published criteria and results of the assessment were reported. The synthesis was largely narrative. Although some summary means were reported, it was unclear how these were calculated and they were reported without corresponding confidence intervals, which made interpretation difficult. The results presented in the table were difficult to interpret. The authors' conclusions should be interpreted with some degree of caution due to the possibility of publication bias and limitations in the analysis.
Implications of the review for practice and research
Practice: The authors did not state any implications for practice.
Research: The authors stated that further research was needed, in particular large RCTs that used rigorous methodology and appropriate control groups (physiologically inactive yet credible shams). Studies should use validated long-term outcome measures for rheumatoid arthritis. Future studies should aim to determine an effective evidence-based dose and intensity, including number of acupuncture points, frequency of acupuncture sessions and duration of treatment for rheumatoid arthritis. The level of qualifications and experience of acupuncture practitioners should be compared and recorded. The mechanisms of the physiologic and biologic effects of acupuncture in rheumatoid arthritis needed to be determined. Studies should be conducted in western and eastern regions to address potential reporting and publication biases.
American College Rheumatology Health Professional Award.
Wang C, de Pablo P, Chen X, Schmid C, McAlindon T. Acupuncture for pain relief in patients with rheumatoid arthritis: a systematic review. Arthritis and Rheumatism (Arthritis Care and Research) 2008; 59(9): 1249-1256
Subject indexing assigned by NLM
Acupuncture Analgesia; Arthritis, Rheumatoid /complications /therapy; Databases, Bibliographic; Humans; Medicine, Chinese Traditional; Pain /etiology /prevention & control; Pain Measurement; Randomized Controlled Trials as Topic; Treatment Outcome
Database entry date
This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.