Arthritis
Complementary and Alternative Therapies for Managing Arthritis Pain
By Gail C. Davis, RN, EdD
Abstract
Objective: To compare the use of complementary and alternative medicine (CAM) for arthritis between two ethnically distinct metropolitan Chicago community areas.
Methods: A telephone interview survey of adults age 45 years or older living in North (88.9% white) or South (79.7% African American) areas. Of 763 respondents, 405 reported arthritis or chronic joint symptoms and were asked about use and satisfaction with seven CAM therapies. Differences between areas were compared with population-weighted tests; multiple logistic regression was used to analyze the likelihood of CAM use controlled for demographics, behavioral risk factors, and arthritis severity.
Results: South Chicago respondents had a higher prevalence and more severe arthritis symptoms such as mean joint pain and more functional limitations. Use of CAM therapy by South Chicago respondents, most commonly massage and relaxation techniques, was 10% greater than North Chicago respondents (61.5% to 51%), but this was not significantly different. Among CAM users, South Chicago respondents reported higher satisfaction with six of the seven CAM therapies and greater future interest in CAM therapies. Poor overall health status (p=0.03), arthritis pain (p=0.005), and concomitant use of prescription medications (p=0.03) were the only significant predictors of CAM use.
Discussion: Although there were only small differences in overall CAM use by area, older residents of largely African American communities were enthusiastic users of relaxation, massage, and nutritional and dietary techniques. CAM modalities could be important adjuncts to traditional medical treatment of arthritis pain for minority communities.
Commentary
The authors note that treatment approaches for the pain and disability associated with arthritis can be very expensive. CAM therapies are often adopted by individuals as approaches to dealing with pain and joint symptoms. Personal characteristics associated with those most likely to turn to CAM use are not well understood. This study specifically addressed the variables of demographics (e.g., income level, educational level, and ethnicity), health-related risk factors (e.g., obesity or uninsured), and arthritis severity (e.g., perceived health status, prescription medicines, and pain severity) as possible predictors of CAM use.
Study data were based on telephone interviews using selected arthritis questions from the Centers for Disease Control (CDC) Behavioral Risk Factor Surveillance System (BRFSS) (www.cdc.gov/brfss). The sample (n=763) was selected to represent two culturally diverse Chicago-area communities referred to as South Chicago (n=414) and North Chicago (n=349). The variables of ethnicity, income, education, insurance, body mass index (BMI), and arthritis or chronic joint symptoms (CJS) were significantly different between the two groups. The South Chicago group was primarily African American (79.9%); had lower income, educational level, and insurance coverage rates; were less frequently married; and had greater BMIs and frequency of arthritis or CJS. The mean age of both groups was 60.
The CAM category used the most by those in both areas was “nutritional supplements, vitamins, or herbal therapies.” The South Chicago group reported a greater use of CAM strategies, specifically relaxation techniques and massage, though the difference in use was not significant. Their overall satisfaction with use of CAM therapies was also higher. The use of professional CAM services (i.e., chiropractic service, naprapathy or manual therapy, and acupuncture) was low for the total sample, but use was significantly greater for those with at least a high school education. The findings from logistic regression analysis showed the factors that significantly predicted any CAM use: severity of joint pain (>6 on a 10-point scale), use of prescription medicine for joint pain, and fair to poor health status. The investigators designated these three predictors as proxies for arthritis severity.
The authors note that their findings are similar to those in clinic-based samples.1 While arthritis severity as measured by health status, joint pain, and use of prescribed medicine was a stronger predictor of CAM use than any of the study’s sociodemographic or cultural variables, it does not completely rule out the importance of understanding how these other variables affect CAM use. Self-management is important in any chronic condition such as arthritis.2 Learning appropriate self-management strategies that assist in dealing with the pain and function over time is especially important for those who have not sought treatment previously for a variety of reasons that may include mistrust of the medical system, lack of insurance, or limited financial resources.
Teaching about how to use CAM strategies is needed to assist individuals in self-managing their condition, and assessing the need for teaching is important. Careful attention should be given to those who have not been exposed to learning a variety of methods. For example, those who are older may not be familiar with using a variety of nonpharmacological strategies.3 As the population ages, it is likely that the burden of arthritis will grow, making age an important demographic variable to address.
References
- Rao JK, Kroenke K, et al. Rheumatology patients’ use of complementary therapies: results from a one-year longitudinal study. Arthritis Rheum. 2003;49:619-625.
- Lorig K, Ritter PL, Plant K. A disease-specific self-help program compared with a generalized chronic disease self-help program for arthritis patients. Arthritis Rheum. 2005;53:950-957.
- Davis GC, Cortez C, Rubin BR. Pain management in the older adult with rheumatoid arthritis or osteoarthritis. Arthritis Care Res. 1990;3:127-131.
Vasculitis
PR3-ACNA Little Help in Guiding Wegener Granulomatosis Treatment
By Michael M. Ward, MD
Abstract
Background: The utility of antineutrophil cytoplasmic antibody (ANCA) levels to guide the management of patients with Wegener granulomatosis remains controversial.
Objective: To determine whether pro–pro-teinase 3 (PR3)-ANCA levels are a better measure of disease activity than mature–PR3-ANCA levels, whether decreases in either level are associated with shorter time to remission, and whether increases are followed by relapse.
Design: Prospective, observational cohort study.
Setting: Eight U.S. medical centers that participated in a treatment trial for Wegener granulomatosis.
Patients: 156 patients with Wegener granulomatosis enrolled during periods of active disease.
Measurements: PR3-ANCA levels (by capture enzyme-linked immunosorbent assay) and disease activity (by the Birmingham Vasculitis Activity Score for Wegener granulomatosis).
Results: The ANCA levels were only weakly associated with disease activity across patients. The longitudinal association within patients was stronger, but changes in ANCA levels explained less than 10% of the variation in disease activity. Decreases in mature– and pro–PR3-ANCA levels were not statistically significantly associated with shorter time to remission, and increases in mature–PR3-ANCA levels (adjusted hazard ratio, 0.8 [95% confidence interval (CI), 0.4–1.9]; p=0.67) and pro–PR3-ANCA levels (adjusted hazard ratio, 1.0 [CI, 0.5–2.1]; p=0.99) were not associated with relapse. The proportion of patients who had relapse within one year of an increase in PR3-ANCA levels was 40% for mature-PR3 (CI, 18% to 56%) and 43% for pro-PR3 (CI, 22% to 58%).
Limitations: Samples were collected approximately every three months. Sensitivity and specificity of ANCA levels for detecting remission and relapse could not be calculated because each patient had different follow-up times.
Conclusion: Pro–PR3-ANCA is no better than mature–PR3-ANCA as a measure of Wegener granulomatosis activity. Decreases in PR3-ANCA levels are not associated with shorter time to remission, and increases are not associated with relapse. These findings suggest that ANCA levels cannot be used to guide immunosuppressive therapy.
Commentary
While the value of ANCA, and specifically antibodies to PR3-ANCA, as a diagnostic test for Wegener granulomatosis is undisputed, there have been conflicting data and ongoing debate about whether serum concentrations of these antibodies correlate with clinical disease activity, and whether increases in antibody concentration among patients with quiescent disease predict imminent relapse.
This prospective observational study, the largest to examine this question to date, found little relationship between within-patient changes in PR3-ANCA levels and clinical disease activity, assessed on a median of 11 visits over 34 months, among patients with active disease undergoing immunosuppressive treatment.
In the subset of patients who entered sustained remission during the study, increases in serum PR3-ANCA levels were also not associated with subsequent clinical relapses. Forty percent of patients in clinical remission who had an increase in serum PR3-ANCA levels relapsed within one year, but 60% did not.
This study is important because the sample was large, the follow-up was long, and clinical assessments were standardized and used a validated measure of vasculitis activity. The antibody tests had large inter-assay variation, but sera from all time points of each patient were tested together in the same assay. The data were carefully analyzed and considered not only correlations over time, but whether antibody concentrations decreased with clinical remission or increased with relapse.
But does this study close the book completely on this topic? Likely not. While the definition of sustained remission was credible (a score of zero on the Birmingham Vasculitis Activity Score for Wegener granulomatosis for six months), relapse was defined as any score above zero on this scale. We do not know if minor symptoms such as arthralgias or fever constituted the majority of relapses, or if glomerulonephritis or pulmonary involvement represented the majority of relapses. Maybe the lack of association between antibody levels and relapse was a consequence of many “relapses” being due to mild symptoms alone. The study did not grade the severity of relapse, leaving one to wonder if PR3-ANCA levels might be associated with severe relapses.
The study also does not address whether serum PR3-ANCA levels correlated with clinical disease activity in subsets of patients with particular disease manifestations. For example, at study entry, patients with renal involvement were more likely to have PR3-ANCA antibodies than those without renal involvement. It would be interesting to know if antibody levels correlated with the activity of glomerulonephritis or risk of relapse among these patients. PR3-ANCA levels were found to be decreased among patients in sustained remission, and the time to achieve remission was shorter among those with a decrease in antibody levels. Although the latter association was not statistically significant, the power of the study to detect a 60% difference in time to remission as significant might have been limited. These findings suggest the possibility that the lack of association in the overall cohort may be hiding associations in a clinically relevant subset.1
Diagnostic tests are used to separate diseased from nondiseased persons. Good diagnostic tests are able to detect affected individuals regardless of whether the disease is active or not. In contrast, good evaluative tests accurately reflect disease activity. Therefore, it should not be surprising that good diagnostic tests are rarely good evaluative tests. This study suggests that serum PR3-ANCA in patients with Wegener granulomatosis follow this rule. The authors conclude that ANCA levels should not be used to guide treatment. Whether this apples to all subsets of patients and different levels of disease severity is still uncertain. While I would not use PR3-ANCA levels to guide treatment, I might monitor patients more closely if I knew their antibody levels were rising.