Rheumatoid arthritis is a chronic condition that can cause pain, stiffness, progressive joint destruction and deformity, and reduce physical function, quality of life and life expectancy.(Östör 2009; DTB 2008) Estimates indicate that around 0.5-1.0% of the UK population have rheumatoid arthritis.(NICE 2008) The condition involves synovial joint inflammation.(Smolen 2003); both T- and B-cells are implicated in the underlying immune pathology, as is the over-production of pro-inflammatory cytokines, including tumour necrosis factor alpha (TNF-α), interleukin-1 (IL-1) and IL-6.(NICE 2008; Panayi 2005; Smolen 2003)
The course of rheumatoid arthritis is variable, following a pattern of relapses and remissions.(Masi 1983) However, within about 2 years of diagnosis, patients usually have moderate disability and, after 10 years, around 30% are severely disabled.(NICE 2008) People with rheumatoid arthritis have a reduced life expectancy compared with healthy controls, and have excess cardiovascular disease mortality.(Goodson 2005)
The cause of rheumatoid arthritis is, as yet, unknown. Infection with a micro-organism in those genetically susceptible, hormonal influences, obesity, diet, and cigarette smoking have all been implicated as risk factors.(Silman 2004)
The aim of treatment is to control pain and inflammation, reduce joint damage, disability and loss of function, achieve low disease activity or remission, and improve quality of life.(NICE 2008; Smolen 2007) A variety of drugs are used, including NSAIDs, analgesics, corticosteroids, disease-modifying anti-rheumatic drugs (DMARDs) like methotrexate, and 'biologic' drugs that block tumour necrosis factor-alpha (TNFα) such as etanercept, infliximab or adalimumab.(NICE 2008) None-drug treatments such as physiotherapy may also be used.(NICE 2008)
Goodson N et al. Cardiovascular admissions and mortality in an inception cohort of patients with rheumatoid arthritis with onset in the 1980s and 1990s. Ann Rheum Dis 2005; 64: 1595-601.
Masi AT. Articular patterns in the early course of rheumatoid arthritis. Am J Med 1983; 75(suppl6A): 16-26.
National Institute for Health and Clinical Excellence, 2007. Adalimumab, etanercept and infliximab for the treatment of rheumatoid arthritis [online]. Available: http://www.nice.org.uk/nicemedia/pdf/TA130guidance.pdf
Panayi GS. B cells: a fundamental role in the pathogenesis of rheumatoid arthritis? Rheumatology 2005; 44 (suppl 2): ii3-ii7.
Östör AJ, Conaghan PG. Tight control in rheumatoid arthritis improves outcomes. Practitioner 2009; 253: 29-32.
Rituximab and abatacept for rheumatoid arthritis. DTB 2008; 46: 57-61.
Silman AJ. Rheumatoid arthritis. In: Silman AJ, Hochberg MC, eds. Epidemiology of the rheumatic diseases, 2nd ed. Oxford, Oxford Press, 2004: chapter 2, 31-71.
Smolen JS, Steiner G. Therapeutic strategies for rheumatoid arthritis. Nat Rev Drug Discov 2003; 2: 473-88.
Smolen JS, et al. Consensus statement on the use of rituximab in patients with rheumatoid arthritis. Ann Rheum Dis 2007; 66: 143-50.
How acupuncture can help
Systematic reviews have come up with conflicting conclusions regarding the effects of acupuncture treatment for rheumatoid arthritis. One found that the data suggest favourable effects of moxibustion (alone or combined with conventional drugs) on response rate compared with conventional drug therapy.(Choi 2011) The other two reviews found acupuncture to be as good as or better than drugs, but with no consistent advantage over sham acupuncture controls.(Wang 2008; Lee 2008)
More recent trials have been small and do not present a compelling case for upgrading the reviews' conclusions. It appears likely that some people may benefit from acupuncture treatment,(Lao 2010) but it is not known what proportion this may be, and to what degree and how acupuncture would compare to other possible interventions. More research is needed.
In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules. The resulting biochemical changes influence the body's homeostatic mechanisms, thus promoting physical and emotional well-being. Stimulation of certain acupuncture points has been shown to affect areas of the brain that are known to reduce sensitivity to pain and stress (Hui 2010) It has also be shown to reduce inflammation, by promoting release of vascular and immunomodulatory factors.(Zijlstra 2003; Kavoussi 2007)
Acupuncture treatment may help to relieve pain and improve function in patients with rheumatoid arthritis by:
- decreasing the proinflammatory cytokines IL-1 and IL-6 and increasing the inhibitory cytokines IL-4 and IL-10 (Ouyang 2010);
- inducing vasoactive intestinal peptide expression, an anti-inflammatory neuro-peptide (He 2011);
- inhibiting the function of synovial mast cells (which are substantially involved in the initiation of inflammatory arthritis) (He 2010);
- upregulating plasma adrenocorticotropic hormone, downregulating serum cortisol levels and synovial nuclear factor-kappa B p 65 immunoactivity, and restoring the hypothalamus-pituitary-adrenal axis (HPAA).(Gao 2010);
- stimulating nerves located in muscles and other tissues, which leads to release of endorphins and other neurohumoral factors, and changes the processing of pain in the brain and spinal cord (Pomeranz 1987; Han 2004; Zhao 2008; Cheng 2009);
- increasing local microcirculation (Komori 2009), which aids dispersal of swelling.