Criticism for CAM
I usually read The Rheumatologist with pleasure, but September’s issue had an unpleasant surprise on the front page: the article “CAM & RA” featuring an overview of complementary therapies that may benefit patients with RA by Professor Wang of the Center for Integrative Medicine at Tufts University, and supported by the National Center for Complementary and Alternative Medicine of the National Institutes of Health.
I think this article is misleading and does both physicians and patients a disservice. Its publication suggests that the ACR and ARHP promote services and therapies that are at best of uncertain benefit, at worst quackery, harmful, and usually costly.
The leader on p. 31 claims that the literature in the past two decades “has consistently recognized the potential therapeutic benefits of Tai Chi mind–body exercise for chronic conditions.” Apart from Tai Chi, the overview features acupuncture, Trypterygium Wilfordii Hook F, and Tibetan Five Nectar formula. For acupuncture, Dr. Wang reports her personal updated but unpublished review, concluding benefits are uncertain. For Tai Chi, she contrasts her positive pilot trial of 20 patients with a Cochrane review that only suggests it may confer some benefit for a decidedly noncore outcome, i.e., lower extremity range of motion, particularly the ankle joint. For Hook F, she reports a published trial in 35 patients that concluded the treatment was safe (no mention of efficacy) and again an unpublished trial that reports efficacy. For Tibetan nectar, the studies were of such poor quality that even Dr. Wang chose not to provide details. The reference list includes some familiar titles, but also periodicals of import such as BMC Complement Altern Med, Chin Acupunct Moxibustion, and Hunan Guiding J TCM.
The article concludes that, while evidence on complementary therapies on RA remains limited, some of these treatments warrant future exploration.
Even on the basis of this highly selective and unsystematic review, I beg to differ. Let’s spend our money on developments that have more potential than those that have had 3,000 years or more to prove their worth (and still haven’t). Although I realize that The Rheumatologist is not a scientific journal, I think its message should be in keeping with evidence-based medicine. An article on complementary medicine should appropriately weigh the overwhelming amount of evidence against meaningful efficacy of such therapies, and protect us from biased reports of promising, uncontrolled, and unpublished results.
Maarten Boers, MSc, MD, PhD
Professor of Clinical Epidemiology
Department of Epidemiology and Biostatistics
VU University Medical Center
Amsterdam, Netherlands
Criticism for CAM: Dr. Wang Responds
I appreciate the comments and welcome the opportunity to clarify the substance of my overview, titled: “CAM & RA: Acupuncture, mind–body therapy, and Chinese herb and Tibetan medicine may benefit patients with RA” (September 2013, p. 1).
All physicians understand the limits of current treatments for chronic pain and the potential value that nonpharmacological interventions may have.1 In addition to conventional medications, patients suffering from arthritis also seek other effective treatments for pain relief by means of complementary and alternative medicines (CAM) including mind–body practice, herbal remedies, acupuncture, and supplements. In fact, it is estimated that arthritis is among the top six conditions for CAM use.2 Therefore, the availability of complementary, alternative, and integrative health interventions is becoming a vital component of healthcare systems domestically and globally, and the need for such treatment options for chronic conditions such as RA is growing exponentially. To better inform clinicians of possible alternative medical treatments for our patients with RA, the objectives of this article were to: 1) Offer a conceptual overview of the current body of knowledge on CAM; and 2) Explore multidimensional approaches beyond pharmacological therapies to treat RA.
Concerning the question about whether “Wang’s personal updated but unpublished review” is truly evidence-based medicine and … “should appropriately weigh the overwhelming amount of evidence and protect us from biased reports of promising, uncontrolled, and unpublished results,” I acknowledge that several important published trials were omitted in this overview. They are now listed in the references below.3-8
Concerning skepticism about whether or not NIH efforts in CAM are vital and wisely invested, my response is the following. After a mere two decades of NCCAM efforts on CAM research, it remains a challenge for scientists to continue to evaluate over 3,000 years of clinical or research questions to prove the efficacy of CAM. These challenges include, but are not limited to: 1) current models of biomedicine that restrict CAM research; 2) the complex, confounding, and multivariable factors in CAM systems that require innovation to formulate rigorous, well-designed studies; 3) the compulsion to address critical unmet needs for novel yet effective CAM treatments for patients who struggle with the toxicity and increasing costs of medications; 4) the generation of critical insights into comparative clinical effectiveness research for providing optimal treatments for patients, especially over the long term.
Despite these challenges, we are poised for the start of a major paradigm shift in healthcare. This shift will inevitably tilt towards personalized medicine to optimize health and develop individualized therapy and self-management to combat disease, including RA.
My overview was, therefore, intended to push for and incite further exploration of the mysteries and complexities of the human body and mind in conjunction with CAM use for patients with chronic disabling conditions.
Chenchen Wang, MD, MSc
Center For Complementary and Integrative Medicine
Division of Rheumatology
Tufts University School of Medicine
Boston
References
- Briggs JP, Killen J. Perspectives on complementary and research. JAMA. 2013;310:691-692.
- Barnes P, Powell-Griner E, McFann K, Nahin R. Complementary and alternative medicine use among adults: United States, 2002. Adv Data. 2004;343:1-19.
- Wang C, Collet J, Lau J. The effect of Tai Chi on health outcomes in patients with chronic conditions: A systematic review. Archive Intern Med. 2004;164:493-501.
- Goldbach-Mansky R., Wilson M., Fleischmann R., et al. Comparison of Tripterygium wilfordii Hook F versus sulfasalazine in the treatment of rheumatoid arthritis: A randomized trial. Ann Intern Med. 2009;151:229-240.
- Wang C, Schmid C, Kalish R, Yinh J, Rones R, Goldenberg D, McAlindon T. Tai Chi is effective in treating fibromyalgia: A randomized controlled trial. New Eng J Med. 2010;363:743-754.
- Wang C, DePablo P, Chen XY, et al. Acupuncture for pain relief in patients with rheumatoid arthritis: A systematic review. Arthritis Rheum. 2008;59:1249-1256.
- Wang C. Tai Chi and rheumatic diseases. Rheum Dis Clin North Am. 2011;37:19-32.
- Wang C. Role of Tai Chi in the treatment of rheumatologic diseases. Curr Rheumatol Rep. 2012;14:598-603.