Acupuncture For Rheumatoid Arthritis In Glasgow

Acupuncture For Rheumatoid Arthritis | Glasgow

About rheumatoid arthritis

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 microorganism 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 factoralpha (TNFα) such as ▼etanercept, ▼infliximab or ▼adalimumab.(NICE 2008)
None-drug treatments such as physiotherapy may also be used.(NICE 2008)

References

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.
November 2014 page 2
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 neuropeptide (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 ofpain in the brain and spinal cord (Pomeranz 1987; Han 2004; Zhao 2008; Cheng2009);
  • increasing local microcirculation (Komori 2009), which aids dispersal of swelling.

About traditional acupuncture

Acupuncture is a tried and tested system of traditional medicine, which has been used in China and other eastern cultures for thousands of years to restore, promote
and maintain good health. Its benefits are now widely acknowledged all over the world and in the past decade traditional acupuncture has begun to feature more
prominently in mainstream healthcare in the UK. In conjunction with needling, the practitioner may use techniques such as moxibustion, cupping, massage or electroacupuncture. They may also suggest dietary or lifestyle changes.

Traditional acupuncture takes a holistic approach to health and regards illness as a sign that the body is out of balance. The exact pattern and degree of imbalance is
unique to each individual. The traditional acupuncturist’s skill lies in identifying the precise nature of the underlying disharmony and selecting the most effective
treatment. The choice of acupuncture points will be specific to each patient’s needs. Traditional acupuncture can also be used as a preventive measure to strengthen
the constitution and promote general well-being.

An increasing weight of evidence from Western scientific research (see overleaf) is demonstrating the effectiveness of acupuncture for treating a wide variety of
conditions. From a biomedical viewpoint, acupuncture is believed to stimulate the nervous system, influencing the production of the body’s communication substances
- hormones and neurotransmitters. The resulting biochemical changes activate the body's self-regulating homeostatic systems, stimulating its natural healing abilities
and promoting physical and emotional well-being.

About the British Acupuncture Council

With over 3000 members, the British Acupuncture Council (BAcC) is the UK’s largest professional body for traditional acupuncturists. Membership of the BAcC guarantees
excellence in training, safe practice and professional conduct. To find a qualified traditional acupuncturist, contact the BAcC on 020 8735 0400 or visit
www.acupuncture.org.uk

Acupuncture For Rheumatoid Arthritis

The evidence
Research Conclusion
Systematic Reviews
Choi TY et al. Moxibustion for
rheumatic conditions: a systematic
review and meta-analysis. Clin
Rheumatol. 2011 Feb 18. [Epub
ahead of print]
A systematic review that pooled data from 14 randomised
controlled trials testing effectiveness of moxibustion for major
rheumatic conditions. Trials were included if moxibustion was
used alone (8 trials) or as a part of a combination therapy with
conventional drugs (6 trials) for rheumatic conditions. All were of
low methodological quality. The data suggested favourable
effects of moxibustion alone on response rate compared with
conventional drug therapy (p<0.02). The results also suggested
favourable effects of moxibustion plus drug therapy on the
response rate compared with conventional drug therapy alone
(p<0.02). The reviewers concluded that the trials included in this
review were of low methodological quality, making it difficult to
draw firm conclusions.
Wang C et al. Acupuncture for pain
relief in patients with rheumatoid
arthritis: a systematic review. Arthritis
Rheum 2008; 59: 1249-56.
A systematic review that assessed the efficacy of acupuncture
on pain relief in patients with rheumatoid arthritis (RA). In all, 8
randomised controlled trials, involving a total of 536 patients,
were included. The outcome measures were pain, measured by
tender joint count (TJC) or a pain scale, morning stiffness,
erythrocyte sedimentation rate (ESR), and C-reactive protein
(CRP) level. There were 4 placebo-controlled trials and 4 activecontrolled trials. Average study duration was 11 weeks. Six
studies reported a decrease in pain for acupuncture versus
controls. In addition, 4 studies reported a significant reduction in
morning stiffness, but the difference was nonsignificant versus
controls. With regard to inflammatory markers, 5 studies
observed a reduction in ESR and 3 observed a CRP level
reduction; only 1 study showed a significant difference for both
ESR and CRP. The reviewers concluded that there were some
favourable results in active-controlled trials, but conflicting
evidence in placebo-controlled trials concerning the efficacy of
acupuncture for RA.
Lee MS et al. Acupuncture for
rheumatoid arthritis: a systematic
review. Rheumatology 2008; 47:
1747-53.
A systematic review that evaluated the evidence on acupuncture
for treating patients with rheumatoid arthritis (RA). It included 8
randomised clinical trials of acupuncture, with or without
electrical stimulation or moxibustion. Four trials compared the
effects of manual or electro-acupuncture with penetrating or
non-penetrating sham acupuncture and failed to show specific
effects of acupuncture on pain or other outcome measures. One
trial compared manual acupuncture with indomethacin and
suggested favourable effects with acupuncture in terms of total
response rate. Three trials tested acupuncture plus moxibustion
versus conventional drugs and failed to show that it was
superior to conventional drugs in terms of response rate, pain
reduction or joint swelling. The reviewers concluded that
penetrating or non-penetrating sham-controlled trials have failed
to show specific effects of acupuncture for pain control in
patients with RA.
Clinical studies
Lao WN et al. Effects of acupuncture
on rheumatoid arthritis. International
Journal of Rheumatic Diseases.
Conference: 14th Congress of Asia
Pacific League of Associations for
Rheumatology, APLAR 2010 Hong
Kong Hong Kong. Conference
Publication 2010; 13: 231.
An uncontrolled pilot study that explored the effects of
acupuncture on disease activity, pain scores, functional ability
and quality of life in 8 patients with RA (6 were positive for
rheumatoid factor). No change in disease modifying antirheumatic drugs (DMARDs) was allowed 3 months before the
study. Tender joint count improved by 33.3% to 100% in six
patients. The visual analogue scale for pain score improved by
12.5% to 87.5% in four patients. Disease activity score using 28-
joint counts dropped by 3.4% to 29.1% in 6 patients. Health
assessment questionnaire score remained unchanged in five
patients and improved by 37% to 60% in two patients. Physical
well- being improved by 28.6% to 71.4% and social well-being
improved by 4.4% to 75% in half of the patients, emotional wellbeing improved by 25% to 57.2% in three patients, functional
well-being improved by 16.7% to 35.3% in two patients, fatigue
sub-scale improved by 10% to 56.5% in three patients. No
patients required adjustment of DMARDs, anti-inflammatory
drugs or steroid during the therapy. The researchers concluded
that their observations suggest acupuncture may be helpful in
alleviating pain, improving disease activity, quality of life and
functional ability in some patients with RA.
Bernateck M et al. Adjuvant auricular
electroacupuncture and autogenic
training in rheumatoid arthritis: A
randomized controlled trial - Auricular
acupuncture and autogenic training in
rheumatoid arthritis. Forschende
Komplementarmedizin 2008; 15: 187-
93.
A randomised controlled trial to compare the efficacy of auricular
electroacupuncture (EA) with autogenic training (AT) in 44
patients with RA. At the end of the treatment and at 3-month
follow-up a clinically meaningful and statistically significant
improvement (p<0.05) could be observed in all outcome
parameters in both groups. In contrast to the AT group, the
onset of these effects in the EA group could already be
observed after the 2nd treatment week. In the 4th treatment
week the EA group reported significantly less pain than the AT
group (p=0.040). After the end of treatment (7th week) the EA
group assessed their outcome as significantly more improved
than the AT group (p=0.035). The erythrocyte sedimentation
rate in the EA group was significantly reduced (p=0.010), and
the serum concentration of tumour necrosis factor-alpha was
significantly increased compared to the AT group (p=0.020). The
researchers concluded that the adjuvant use of both EA and AT
in the treatment of RA resulted in significant short- and longterm treatment effects. The treatment effects of auricular EA
were more pronounced.
Zanette S de A et al. A pilot study of
acupuncture as adjunctive treatment
of rheumatoid arthritis. Clinical
Rheumatology 2008; 27: 627-35.
A double-blind randomised controlled pilot study that looked at
the efficacy of acupuncture as an adjuvant treatment in the
management of 40 patients with active rheumatoid arthritis (RA).
They were allocated to receive a standard protocol of
acupuncture (AC) or superficial acupuncture at non-acupuncture
points (control AC) for 9 weeks. The primary outcome was
achievement of 20% improvement according to the American
College of Rheumatology (ACR) 20 criteria but this showed no
significant difference between the groups , either at the end of
treatment (p=0.479) or after 1 month of follow-up (p=0.068).
Only the AC group showed significant improvement over
baseline for a range of secondary clinical measures.
Nevertheless, it was only statistically superior to the control for
the patient and physician global assessment of treatment and
physician global assessment of disease activity, not for other
clinical and laboratory measures... The researchers concluded
that there was no significant difference in the proportion of
patients that reached ACR20 between the AC and control AC
groups, but that this negative result could be related to the small
sample size, selection of patients, type of acupuncture protocol
applied, and difficulties in establishing an innocuous and
trustworthy placebo group to studies involving acupuncture.
Tam LS et al. Acupuncture in the
treatment of rheumatoid arthritis: A
double-blind controlled pilot study.
BMC Complementary and Alternative
Medicine 2007; 7: 35.
A randomised double-blind placebo-controlled pilot study of
acupuncture to obtain preliminary data on efficacy and
tolerability of 3 different forms of acupuncture treatment as an
adjunct for the treatment of chronic pain in patients with
rheumatoid arthritis (RA). A total of 36 patients were allocated to
electroacupuncture (EA), traditional Chinese acupuncture (TCA)
or sham acupuncture (Sham). The primary outcome measure
was change in the pain score. At week 10, the pain score
remained unchanged in all 3 groups. However, the number of
tender joints was significantly reduced for the EA and TCA
groups. Physician's global score was significantly reduced for
the EA group and patient's global score was significantly
reduced for the TCA group. All the outcomes except patient's
global score remained unchanged in the Sham group. The
researchers concluded that the pilot study allowed a number of
recommendations to be made to facilitate the design of a largescale trial, which in turn would help to clarify the existing
evidence base on acupuncture for RA.
Research on mechanisms for acupuncture
He TF et al. Electroacupuncture
inhibits inflammation reaction by
upregulating vasoactive intestinal
Peptide in rats with adjuvant-induced
arthritis. Evid Based Complement
Alternat Med 2011; 2011.
A study in rats that assessed the effects of electroacupuncture
with adjuvant-induced arthritis. It was found to markedly
decreased paw swelling and the histologic scores of
inflammation in the synovial tissue, and reduced body weight
loss in an adjuvant-induced arthritis rat model.
Electroacupuncture also resulted in an enhanced
immunostaining for vasoactive intestinal peptide (VIP), a potent
anti-inflammatory neuropeptide, in the synovial tissue.
Moreover, the VIP-immunostaining intensity was negatively
correlated with the scores of inflammation in the synovial tissue
(p=0.0026). The researchers concluded that their findings
suggest that electroacupuncture may offer therapeutic benefits
for the treatment of rheumatoid arthritis, at least partially through
the induction of VIP expression.
Ouyang BS et al. Effects of
electroacupuncture and simple
acupuncture on changes of IL-1, IL-4,
IL-6 and IL-10 in peripheral blood and
joint fluid in patients with rheumatoid
arthritis. [Article in Chinese]
Zhongguo Zhen Jiu 2010; 300: 840-4.
A randomised controlled trial that explored the mechanism of
acupuncture and electroacupuncture on rheumatoid arthritis
(RA) in 63 patients. After 3 courses, changes of interleukins in
peripheral blood and joint fluid of patients were observed. Both
acupuncture and electroacupuncture had significant effects on
interleukin (IL)-1, IL-4, IL-6 and IL-10 in the peripheral blood and
joint fluid of patients with RA (p<0.05 and p<0.01, respectively).
The researchers concluded that acupuncture and
electroacupuncture can decrease the pro-inflammatory
cytokines IL-1 and IL-6 and increase anti-inflammatory IL-4 and
IL-10.
Gao J et al. Involvement of the
hypothalamus-pituitary-adrenal axis in
moxibustion-induced changes of NFkappaB signaling in the synovial
tissue in rheumatic arthritic rats
[Article in Chinese]. Zhen Ci Yan Jiu
2010; 35: 198-203.
A study to observe the effect of moxibustion on the acupuncture
points BL 23 and ST 36 on synovial nuclear factor (NF)-kappaB
p65 expression, and plasma adrenocorticotropic hormone
(ACTH) and serum cortisol (CS) contents in rats with rheumatoid
arthritis (RA) with adrenalectomy (ADX). In comparison with the
control group, the degree of swelling in the rats’ paws
decreased significantly after moxibustion (p<0.01). Compared
with the model group, serum CS contents and synovial NFkappaB p 65 immunoactivity in reduced with moxibustion
(p<0.01, p<0.05). The researchers concluded that moxibustion
treatment can reduce inflammation reactions in rats with RA,
which is closely associated with its effects in upregulating
plasma ACTH, downregulating serum CS level and synovial NFkappaB p 65 immunoactivity, and the intact hypothalamuspituitary-adrenal axis (HPAA).
He TF et al. Effects of acupuncture on
the number and degranulation ratio of
mast cells and expression of tryptase
in synovium of rats with adjuvant
arthritis [Article in Chinese]. Zhong Xi
Yi Jie He Xue Bao 2010; 8: 670-7.
A study that observed the effects of acupuncture on synovial
pathology, synovial mast cell degranulation and tryptase
expression and investigated the relationship between the
functions of mast cells and effects of acupuncture on early
adjuvant arthritis in rats. Compared with untreated rats, the body
weight in the acupuncture group increased (p<0.05), while the
paw volume decreased (p<0.01). Acupuncture inhibited
inflammatory cell infiltration, synovial cell hyperplasia, and
synovial fibroplasia compared with no treatment (p<0.05). Also
it diminished the numbers of total and degranulated mast cells
and the expression of tryptase in the synovium (p<0.01). The
number of mast cells and degranulation ratio of mast cells were
positively correlated with the pathological scores. The
researchers concluded that acupuncture can improve
pathological conditions of inflammatory synovium in rats with
early adjuvant arthritis by inhibiting the function of synovial mast
cells.
Hui KK et al. Acupuncture, the limbic
system, and the anticorrelated
networks of the brain. Auton Neurosci
2010; 157: 81-90.
A paper that discusses research showing that acupuncture
mobilises the functionally anti-correlated networks of the brain to
mediate its actions, and that the effect is dependent on the
psychophysical response. The research used functional
magnetic resonance imaging studies of healthy subjects to show
that acupuncture stimulation evokes deactivation of a limbicparalimbic-neocortical network, which encompasses the limbic
system, as well as activation of somatosensory brain regions. It
has also been shown that the effect of acupuncture on the brain
is integrated at multiple levels, down to the brainstem and
cerebellum.
Cheng KJ. Neuroanatomical basis of
acupuncture treatment for some
common illnesses. Acupunct Med
2009;27: 61-4.
A review that looked at acupuncture treatment for some
common conditions. It is found that, in many cases, the
acupuncture points traditionally used have a neuroanatomical
significance from the viewpoint of biomedicine. From this, the
reviewers hypothesize that plausible mechanisms of action
include intramuscular stimulation for treating muscular pain and
nerve stimulation for treating neuropathies.
Komori M et al. Microcirculatory
responses to acupuncture stimulation
Experimental study on rabbits in which acupuncture stimulation
was directly observed to increase diameter and blood flow
and phototherapy. Anesth Analg
2009; 108: 635-40.
velocity of peripheral arterioles, enhancing local
microcirculation.
Zhao ZQ. Neural mechanism
underlying acupuncture analgesia.
Prog Neurobiol 2008; 85: 355-75.
Review article that discusses the various peripheral and central
nervous system components of acupuncture anaesthesia in
detail.
Kavoussi B, Ross BE. The
neuroimmune basis of antiinflammatory acupuncture. Integr
Cancer Ther 2007; 6: 251-7.
Review article that suggests the anti-inflammatory actions of
traditional and electro-acupuncture are mediated by efferent
vagus nerve activation and inflammatory macrophage
deactivation.
Han JS. Acupuncture and endorphins.
Neurosci Lett 2004; 361: 258-61.

A literature review of studies relating to the release of
endorphins by acupuncture.
Zijlstra FJ et al. Anti-inflammatory
actions of acupuncture. Mediators
Inflamm 2003; 12: 59-69.
An article that suggests a hypothesis for anti-inflammatory
action of acupuncture: Insertion of acupuncture needles initially
stimulates production of beta-endorphins, CGRP and
substance P, leading to further stimulation of cytokines and NO.
While high levels of CGRP have been shown to be proinflammatory, CGRP in low concentrations exerts potent antiinflammatory actions. Therefore, a frequently applied 'low-dose'
treatment of acupuncture could provoke a sustained release of
CGRP with anti-inflammatory activity, without stimulation of proinflammatory cells.
Pomeranz B. Scientific basis of
acupuncture. In: Stux G, Pomeranz
B, eds. Acupuncture Textbook and
Atlas. Heidelberg: Springer-Verlag;
1987: 1-18.
Needle activation of A delta and C afferent nerve fibres in
muscle sends signals to the spinal cord, where dynorphin and
enkephalins are released. Afferent pathways continue to the
midbrain, triggering excitatory and inhibitory mediators in spinal
cord. Ensuing release of serotonin and norepinephrine onto the
spinal cord leads to pain transmission being inhibited both preand postsynaptically in the spinothalamic tract. Finally, these
signals reach the hypothalamus and pituitary, triggering release
of adrenocorticotropic hormones and beta-endorphin.



Terms and conditions
The use of this fact sheet is for the use of British Acupuncture Council members and is subject to the strict conditions imposed by the British Acupuncture Council details of which can be found in the members area of its’ website www.acupuncture.org.uk.

For more information on acupuncture and how it can help with chronic conditions that cause pain or stiffness, contact Elaine Collins at 0141 585 7904 or fill in our Contact form, and we will get back to you.