Integration of Complementary & Conventional Care for Patients with Musculoskeletal Disorders

Editor’s note: ACR on Air, the official podcast of the ACR, dives into topics important to the rheumatology community, such as the latest research, solutions for practice management issues, legislative policies, patient care and more. Twice a month, host Jonathan Hausmann, MD, a pediatric and adult rheumatologist in Boston, interviews healthcare professionals and clinicians on the rheumatology front lines. In a series for The Rheumatologist, we provide highlights from these relevant conversations. Listen to the podcast online at acronair.org, or download and subscribe to ACR on Air wherever you get your podcasts. Here we highlight episode 21, “Use of Complementary Alternative Therapies in Rheumatic Care,” which aired on April 20, 2021.

When used along with traditional therapy for rheumatic diseases, complementary and integrative therapies, such as acupuncture and tai chi mind-body practice, can benefit patients, according to Chenchen Wang, MD, MSc, a professor at Tufts University School of Medicine, Boston, and director of the Center for Complementary and Integrative Medicine in the Division of Rheumatology at Tufts Medical Center, Boston.

Dr. Wang, who has led several studies related to tai chi and other integrative approaches for musculoskeletal pain conditions, discussed her findings and perspectives with Dr. Hausmann, ACR on Air podcast host and a pediatric and adult rheumatologist in Boston.

The Terminology

Drs. Hausmann and Wang drilled down to identify the preferred terminology for therapies, such as acupuncture and tai chi. Until recently, these were often called alternative therapies. Nowadays, complementary or integrative are the preferred terms used to describe them.

“Integrated health brings a conventional and complementary approach together in a coordinated way,” Dr. Wang says. She noted that the National Center for Complementary and Integrative Health defines integrative health as well-coordinated care among different providers that uses conventional and complementary approaches to care for the whole person rather than just one organ system.¹

Dr. Hausmann applauded the concept of integrative health, while acknowledging current limitations. “We may be prescribing all the right medicines, but we’re leaving the patient behind. I like the concept that this is not something to do instead of [prescribing tumor necrosis factor] inhibitors or methotrexate. This is something that you should integrate in the care of rheumatic disease,” he says.

Acupuncture

Acupuncture is one treatment becoming more mainstream. Acupuncture, which began with traditional Chinese medicine thousands of years ago, involves inserting and manipulating fine needles to stimulate specific anatomic points in the body, Dr. Wang explained. This method can help facilitate better health.

In 2020, the U.S. Centers for Medicare and Medicaid Services agreed to cover acupuncture for Medicare patients with chronic lower back pain. This is the first time that acupuncture will be covered by insurance in the U.S. Some European countries have covered it before.

Dr. Wang discussed the results from a 2020 Current Rheumatology Reports review article focusing on acupuncture and chronic musculoskeletal pain that she co-authored.² With an analysis of 16 updated review articles and 11 recent randomized controlled trials over the previous five years, researchers found that acupuncture provided short-term pain relief for symptomatic knee osteoarthritis (OA) and chronic low back pain. It also may have a beneficial role for fibromyalgia. The studies they examined did not show evidence to support acupuncture for hip OA or rheumatoid arthritis.²

Dr. Wang emphasized that acupuncture should not replace conventional care or be used to postpone seeking medical advice. When discussing acupuncture with patients, rheumatologists should emphasize the importance of finding an experienced practitioner who has previously treated the condition the patient has. An inexperienced practitioner may cause serious side effects, such as an infection, punctured organ or nervous system injuries. Most states require licenses to practice acupuncture, which is something else patients can check.

Patients should also ask acupuncture practitioners about the estimated number of treatments needed and the cost of each treatment. As a point of reference, under Medicare’s coverage for chronic low back pain, 12 visits within a 90-day period are covered, as well as eight additional visits if the treatment is working.³

Researchers found that acupuncture provided short-term pain relief for symptomatic knee osteoarthritis & chronic low back pain.

Tai Chi & Musculoskeletal Disorders

Another area researched by Dr. Wang is tai chi. She described tai chi as a multicomponent traditional Chinese mind-body practice that combines meditation with gentle graceful movement along with breathing and relaxation. In a broader sense, tai chi combines breathing techniques, awareness, mindfulness, balance, relaxation, social support and more, she said. Like acupuncture, tai chi has been part of Chinese culture and medicine for thousands of years.

By targeting physical, psychological and psychosocial symptoms, tai chi can reduce pain and lead to better patient results, according to those who practice it. Tai chi may be especially suited to tackle both the psychological and somatic symptoms associated with chronic pain.

Dr. Wang has led a series of studies on tai chi for chronic rheumatic conditions and found that the practice has short-term therapeutic benefits for pain relief and well-being.^4-6 A trial published in 2016 included 204 participants and compared tai chi twice a week for 12 weeks with standard physical therapy twice weekly for six weeks for knee OA, followed by six weeks of home exercise.⁵

In the study, both groups had significantly reduced Western Ontario and McMaster Universities Osteoarthritis Index scores at 12 weeks. Both groups also had similar, significant improvement in clinical outcomes, such as depression and quality of life. The benefits in both groups were maintained up to 52 weeks, although the tai chi group had significantly greater improvements in depression and the physical component of quality of life.⁵

A randomized controlled trial published in 2018 that focused on tai chi vs. aerobic exercise for fibromyalgia found similar or greater improvements with tai chi than aerobic exercise. The trial included 226 adults with fibromyalgia and had a primary outcome of change in revised fibromyalgia impact questionnaire scores at 24 weeks compared with baseline.⁶

The study showed that tai chi is as or more effective than aerobic exercise and that longer duration of treatment provides a greater effect. The study also found these therapeutic benefits were consistent across a diverse group of patients regardless of the instructor. This finding suggests the intervention can be delivered in a standardized way by appropriately trained instructors. Tai chi may be applied in a variety of settings for a range of patients.⁶

The gentler approach of tai chi may benefit fibromyalgia patients who say aerobic exercise causes too much pain. “The key is how can we use this exercise in combination with different pharmacological treatments and have long-term benefits,” Dr. Wang says.

Dr. Wang’s patients who use tai chi report that it helps pain, lowers stress and depression and improves life satisfaction because of the social interaction involved.

“I think it’s interesting that it affects not just the pain, but a patient’s experience of their quality of life, depression, anxiety, stress, confidence and social aspects,” Dr. Hausmann says.

As with acupuncture, rheumatologists should emphasize the importance of finding instructors with experience helping those with musculoskeletal disorders. Dr. Wang noted she is fortunate to have instructors in her area who have decades of experience.

The Role of Mindfulness

Mindfulness is one of the crucial components of tai chi from recent publications, according to both Drs Wang and Hausmann. Dr. Hausmann described it as not just doing the movements but being aware of the movements you’re doing during tai chi.

Dr. Hausmann asked if mindfulness is something that can be learned. Dr. Wang said yes and added that it may help fibromyalgia symptoms. Dr. Wang previously gave a talk on mindful training and how it may improve fibromyalgia symptoms.

Dr. Wang’s team regularly recommends meditation/mindfulness to patients, especially in the late afternoon after they are tired from the day. “Just put your mind there for 20 minutes so you will see how much changes,” she says.

References

1. NIH: National Center for Complementary and Integrative Health. Complementary, alternative, or integrative health: What’s in a name? 2022 Oct.
2. Zhang YG, Wang C. Acupuncture and chronic musculoskeletal pain. Curr Rheumatol Rep. 2020 Sept 25; 22(11):80.
3. U.S. Centers for Medicare and Medicaid Services. Acupuncture for chronic lower back pain (cLBP). 2020 Jan 21.
4. Wang C, Schmid C, Rones, R, et al. A randomized trial of Tai Chi for fibromyalgia. New Eng J Med. 2010 Aug 19;363:743–754.
5. Wang C, Schmid CH, Iversen MD, et al. Comparative effectiveness of tai chi versus physical therapy for knee osteoarthritis: A randomized trial. Ann Intern Med. 2016 Jul 19;165(2):77–86.
6. Wang C, Schmid CH, Fielding RA, et al. Effect of tai chi versus aerobic exercise for fibromyalgia: Comparative effectiveness randomized controlled trial. BMJ. 2018; 360:k851.