Prevalence of complementary therapy use for inflammatory arthritis patients: A cross-sectional study

doi:10.21203/rs.3.rs-5283366/v1

Objective

To investigate the characteristics of patients with inflammatory arthritis (IA) who use complementary and alternative medicine (CAM) and to examine the relationship between pain, fatigue, anxiety, depression, and sleep status in patients with IA and the use of CAM.

Method

A cross-sectional study was conducted at the Department of Rheumatology and Immunology, First Affiliated Hospital of Anhui Medical University in Anhui, China between October 2021 and February 2022. Unpaired Student's t-tests, Chi-square tests, and Pearson correlation tests were employed to compare users versus non-users. Finally, logistic regression analysis was used to explore the independent influences on the use of CAM in inflammatory joint disease.

Result

Significant associations were found between Multidimensional Fatigue Inventory (MFI) scores, the Depression-Anxiety-Stress Self-Assessment Scale (DASS-21), and the Pittsburgh Sleep Quality Index (PSQI), and CAM use. The results showed that the logistic regression model was statistically significant (χ2 = 64.891, P = 0.000), and the model diagnostic compliance rate was 65.2%. The Hosmer Leeshawn test showed P = 0.787 > 0.05 and the model was well fitted.

Conclusion

Overall, older age, longer disease duration, higher disease activity, and more severe anxiety levels were associated with higher rates of CAM utilization.

Inflammatory arthritis

complementary and alternative medicine

influencing factor

Inflammatory arthritis (IA) is a heterogeneous group of diseases characterized by autoimmune-mediated joint inflammation, which results in joint pain, damage, and disability^[1]. About 80–100 adults in 100000 develop inflammatory arthritis every year. Inflammatory arthritis can be divided into many types, such as rheumatoid arthritis, spondyloarthropathies, etc. Rheumatoid arthritis, the most common form of inflammatory arthritis, and spondyloarthropathies, which include peripheral spondyloarthritis, psoriatic arthritis and ankylosing spondylitis, are less common^[2]. IA, which frequently causes chronic pain, can also lead to fatigue and sleep disorders, both of which can seriously affect the patient's daily life. Based on research, it is estimated that about 50% of all patients with IA suffer from chronic pain, 40–80% report chronic fatigue, and more than two-thirds report sleep disturbances^[3–6].

In recent years, Complementary and Alternative Medicine (CAM) has become steadily more recognized and accepted by ordinary people and people with chronic illnesses around the world^[7–8]. CAM is defined by the National Center for Complementary and Alternative Medicine (NCCAM) as a group of medical and health care systems that are different from traditional medicine^[9]. Its treatment methods mainly include the following categories: (1) natural product therapy, which uses natural products such as natural foods, nutritional supplements, and herbs to have a beneficial effect on the treatment of diseases; (2) mind-body therapy, which uses acupuncture, tai chi, meditation, yoga, etc.; (3) body adjustment therapy, mainly including massage and acupressure; (4) exercise and energy therapy, including light therapy, magnet therapy, qigong, etc.; (5) independent alternative medicine systems such as traditional Chinese medicine, Indian herbal medicine, and traditional European homeopathy^[10–12]. In a large number of countries, more than half of people with chronic conditions use CAM or use CAM in conjunction with prescription medications as a way to treat chronic conditions, such as chronic pain and arthritis, or more serious, life-threatening conditions.

Inflammatory arthritis patients, like those with all other chronic conditions, use CAM more frequently than those with no such condition^[13]. However, there is not enough information to assess whether frequent use of CAM in patients with inflammatory arthritis is associated with their fatigue, depression, anxiety, or sleep quality. Therefore, the aim of this study was to investigate how patients with inflammatory arthritis differ in their general condition, fatigue, anxiety, depression, or quality of sleep, and other aspects, with or without the use of CAM.

Subjects

This cross-sectional study was conducted at the Department of Rheumatology and Immunology, First Affiliated Hospital, Anhui Medical University, after approval by the Ethics Committee of Anhui Medical University. All research procedures are in accordance with the 1964 Helsinki Declaration. Informed consent for the study was obtained from all participants and they were informed of study protocol. This study started in October 2021 and completed by June 2022 with all baseline data collected. The criteria for inclusion were verified diagnosis of IA in patients who were at least 18 years old. Patients with IA in this study were mainly rheumatoid arthritis patients and spondyloarthritis patients. The diagnostic criteria for IA were based on the confirmation by rheumatologist assessment. Patients with significant cardiovascular illness, liver, renal, or blood system disease, as well as those with cognitive impairment or mental disorder who were unable to appropriately explain their state, were eliminated. According to the NCCAM definition of CAM and the definition of CAM use in previous studies, this study used as criteria for CAM use whether respondents had used herbs and their products, acupuncture therapy, massage therapy, and other nontraditional therapies that are part of the CAM treatment modality to treat inflammatory joint disease in the past 12 months.

Data collection

The information of demographic and clinical characteristics of IA patients were collected via a unified questionnaire. Patients completed self-administered questionnaires to collect information about their current use of complementary and alternative medications, pain intensity, and pain intensity as assessed by the Numerical rating scale (NRS), Multidimensional Fatigue Inventory (MFI-20), Depression anxiety stress scale-21 (DASS-21), and Pittsburgh Sleep Quality Index (PSQI), respectively. stress scale-21 (DASS-21) and Pittsburgh Sleep Quality Index (PSQI) to assess the severity and different dimensions of pain, fatigue, anxiety, depression or sleep quality^[14–15].

Numerical rating scale (NRS)

The patient's pain status was scored using the NRS, the most widely used unidimensional pain assessment scale. The patient's pain status is scored. The scale consists of a straight line divided equally into 10 The scale consists of a straight line divided equally into 10 parts, representing a score of 0 to 10: 0 is no pain, 1 to 3 is mild pain that does not interfere with sleep, 4 to 6 is moderate pain, and 7 to 10 is severe pain that interferes with sleep or forces the patient to awaken from sleep^[16–17].

Multidimensional Fatigue Inventory (MFI-20)

MFI-20 was used for assessment of fatigue. It is a self-reported questionnaire consists of 20 items, evaluating 5 dimensions of fatigue: general fatigue, physical fatigue, reduced activity, reduced motivation, and mental fatigue. Each dimension contains four items with scores ranging from 1 to 5 for each item. Scores of items in each dimension and scores of all items are summed, with higher scores indicating more severe fatigue in that dimension or overall [12]. The MFI-20 has been used in several clinical and healthcare populations and could be considered as a universal tool. Previous studies have used MFI-20 to measure fatigue in an IA population^[18].

Depression anxiety stress scale-21(DASS-21)

The DASS-21 has three dimensions: depression, anxiety, and stress, each with 7 entries, for a total of 21 entries. Each entry is scored on a 4-point scale from 0 to 3. The scores of the 7 entries in each dimension are summed and multiplied by 2, which is the total score corresponding to each dimension. The total scores for each dimension were summed to obtain the final score for the scale (total score ranges from 0 to 63), and the higher the individual's total score, the more severe his or her overall negative affect^[19].

Pittsburgh Sleep Quality Index (PSQI)

All subjects completed the PSQI questionnaire, which evaluates sleep quality during the last month. In PSQI, all measurement questions can be divided into 7 components including subjective sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbances, use of sleep medication and daytime dysfunction. Calculations were based on 7 component scores, and poor sleep quality was defined if the total calculated the PSQI score was greater than 5. The PSQI has been a recently popular tool for the evaluation of sleep quality in the IA populations^[20].

Statistical analysis

Data analysis was performed in SPSS 23.0 (SPSS, Chicago, IL, USA). Quantitative data of normal distribution were expressed as mean ± standard deviation (SD), while proportions were computed for categorical variables. An unpaired student t-test was used for comparing the means of continuous variables. Qualitative data intergroup analysis was performed by the Chi-square test. Quantitative data of skewed distribution were analyzed by Mann–Whitney U test between two groups. Finally, logistic regression analysis was used to explore the independent influences on the use of CAM in inflammatory joint disease. All statistical tests were two sided, and P < 0.05 was considered to be statistically significant^[21].

Baseline characteristics

The total number of IA patients actually included in this study was 503, of which 371 were diagnosed with rheumatoid arthritis, accounting for 73.8% of the total population, and the rest of the patients had spondyloarthropathies. The majority of the total surveyed population was female, with 354 (70.4%) females. In addition, the mean age of all patients surveyed was (50.92 ± 15.07), with 279 patients (55.5%) aged between 41 and 65 years. Among them, 322 patients (64%) were investigated in the outpatient clinic. There were 253 study subjects (50.3%) who had used CAM within the past year (Table 1).

Table 1. Basic Information of Patients with Inflammatory Arthropathy
variable	categorization		Frequency Composition ratio（%）
Diagnosis		RA		371		73.8
		SpA		132		26.2
Forms of medical treatment		outpatient		322		64.0
		inpatient		181		36.0
Gender		male		149		29.6
		female		354		70.4
Age		≤40		133		26.4
		41～65		279		55.5
		≥66		91		18.1
BMI		underweight		61		12.1
		normal weight		298		59.2
		overweight		102		20.3
		obese		42		8.4
Marital status		without spouse		83		16.5
		with spouse		420		83.5
Educational attainment		illiterate		101		20.1
		elementary school		125		24.9
junior high school				128		25.4
high school/secondary school			58		11.5
Bachelor's degree/college and above			91		18.1
Working condition	physical labor		148		29.4
	mental labor		100		19.9
unemployed/retired			255		50.7
Place of residence	urban		150		29.8
	rural		353		70.2
Table 1 (Continue). Basic Information of Patients with Inflammatory Arthropathy
variable		categorization		Frequency Composition ratio（%）
Monthly income		≤1000		97		19.3
		( 1000, 2000 ]		165		32.8
		( 2000, 5000 ]		169		33.6
		( 5000, 10000 ]		52		10.3
		>10000		20		4.0
Monthly expenditure of the disease		≤500		89		17.7
		( 500, 1000 ]		148		29.4
		( 1000, 2000 ]		149		29.6
		( 2000, 5000 ]		93		18.5
		>5000		24		4.8
CAM utilization		Yes		253		50.3
		No		250		49.7

RA: Rheumatoid arthritis; SpA: spondyloarthropathy

CAM utilization

Of the 253 patients with inflammatory joint disease who used CAM, 199 were patients with rheumatoid arthritis (78.6%), accounting for 53.6% of all patients with rheumatoid arthritis in this survey, and 54 were patients with spondyloarthropathies (21.4%), accounting for 40.9% of all patients with spondyloarthropathies. The main types of CAM they used were Chinese herbs and their products (188, 74.3% of all CAM users), acupuncture (98, 38.7%), and massage/tui na (66, 26.0%). Of these patients, 155 used only one CAM treatment modality (61.3%), and 98 used two or more CAM treatment modalities (38.7%) (Table 2).

Table 2

CAM use in Patients with Inflammatory Arthropathy
variable	categorization	Frequency Composition ratio(%)
Diseases	RA	199	78.6
Diseases	SpA	54	21.4
Type of CAM	herbs and their products	188	74.3
	acupuncture and moxibustion	98	38.7
	massage/Tui Na	66	26.0
	other	42	16.6
Type of CAM used	one type	155	61.3
Type of CAM used	two or more	98	38.7
CAM: complementary and alternative medicine; RA: Rheumatoid arthritis;
SpA: spondyloarthropathy

Analysis of scales affecting the use of CAM in patients with IA

An overall comparison of the total scores of fatigue, mood and sleep condition was made between the use group and the non-use group. The results showed that the total scores of fatigue, mood, and sleep condition indicators in the use group were higher than those in the no-use group, and the difference was statistically significant (P < 0.05). Patients in the use group showed more severe fatigue, more pronounced negative mood, and poorer sleep quality. A box plot visualizing the specific scores of each group is shown in Fig. 1 below.

Further stratified analysis of the collected data based on the five dimensions within the MFI-20 showed that the patients in the use group scored higher than the use group in the five dimensions of comprehensive fatigue, physical fatigue, reduced activity, decreased motivation, and cerebral fatigue, and the difference was statistically significant (Table 3). Further stratification of the different dimensions of the Self-Assessment Scale of Mood (DASS-21) showed that patients in the use group scored higher in all three categories than those in the non-use group, and the difference was statistically significant (Table 3). The results of the PSQI, which can comprehensively reflect the quality of sleep, were further analyzed by stratifying the results into different classification levels, and the results showed that in the category of very good quality of sleep, the percentage of the number of people in the use group (25.7%) was significantly lower than that of the non-use group (44.8%), and in the category of very poor quality of sleep, the percentage of the number of people in the use group (6.3%) was significantly higher than that of the non-use group (3.6%), with a statistically significant difference in distribution, and the difference in distribution between the two groups was statistically significant (Table 3).

Table 3

Stratified Comparison of Fatigue Between Inflammatory Arthropathy patients with CAM use and No CAM use Groups
		Group [ n ( % ) ]		statistic
project	categorization	no use CAM ( n = 250 )	use CAM ( n = 253 )	Z值	P-value
MFI-20	general fatigue	11 ( 9, 14 )	12 ( 10, 15 )	-3.385	0.001
	physical fatigue	13 ( 10, 15 )	14 ( 11, 16 )	-3.904	< 0.001
	reduced activity	11 ( 8, 15 )	12 ( 9, 15.5 )	-2.388	0.017
	reduced motivation	12 ( 9, 14 )	13 ( 10, 16 )	-3.266	0.001
	mental fatigue	11 ( 9, 12 )	11 ( 9, 13 )	-3.450	0.001
	total score	58 ( 47, 66.5 )	63 ( 52, 71.5 )	-3.953	< 0.001
DASS-21	depression	2 ( 0, 6 )	4 ( 0, 10 )	-3.403	0.001
	anxiety	4 ( 2, 8 )	6 ( 2, 10 )	-4.277	< 0.001
	stress	6 ( 2, 14 )	10 ( 4, 14 )	-2.76	0.006
PSQI	Very good.	112 ( 44.8 )	65 ( 25.7 )	-4.573	< 0.001
	Good	83 ( 33.2 )	99 ( 39.1 )
	Fair	46 ( 18.4 )	73 ( 28.9 )
	Very poor	9 ( 3.6 )	16 ( 6.3 )
CAM: complementary and alternative medicine; MFI-20: Multidimensional Fatigue Inventory-20; DASS-21: Depression anxiety stress scale-21; PSQI, Pittsburgh Sleep Quality Index.

Multifactorial analysis of factors influencing CAM use in IA patients

In the univariate analysis, the indicators with statistically significant data results were co-included as independent variables in a logistic regression model for stepwise screening, and the specific assignments are shown in Table S1. The results showed that the logistic regression model was statistically significant (χ2 = 64.891, P = 0.000), and the model diagnostic compliance rate was 65.2%. The Hosmer Leeshawn test showed P = 0.787 > 0.05 and the model was well fitted. Eventually age, work status, disease duration, family history related to inflammatory joint disease, disease activity, and anxiety could be simultaneously included in one regression equation (Table 4).

Table 4

Binary Logistic Regression Analysis of Influencing Factors on the use of CAM in Patients with Inflammatory Arthropathy
factor	β	S.E	Wald	df	OR	95%CI	P 值
Age	0.014	0.007	4.013	1	1.014	1.000ཞ1.029	0.045
Working condition	0.511	0.204	6.295	1	1.667	1.118ཞ2.485	0.012
Duration of disease	0.025	0.012	4.617	1	1.026	1.002ཞ1.049	0.032
IA family history	-0.681	0.250	7.435	1	0.506	0.310ཞ0.826	0.006
Disease Activity	0.334	0.102	10.616	1	1.396	1.142ཞ1.707	0.001
Anxiety	0.037	0.019	3.968	1	1.038	1.001ཞ1.076	0.046

CAM is defined as a group of health care interventions, practices, products or disciplines that are distinct from conventional medicine, including herbs, acupuncture, massage and other therapies. Pain is usually the primary reason IA patients seek treatment^[22]. Taking rheumatoid arthritis as an example, the factors that cause pain in RA are multifaceted, and pain caused by inflammation can only account for a portion of the patient's complaints; more of the patient's pain is related to non-inflammatory factors, including sleep disorders, anxiety, depression, stress, fatigue and other negative physical and mental states^[23–24]. Pain caused by inflammatory factors can often be relieved with anti-inflammatory medications, while pain caused by non-inflammatory factors requires patients to consider other therapeutic measures as a complementary treatment to traditional therapies^[25–26].

Fatigue, mood and sleep status are important indicators of an individual's physical and mental health and are influenced by a variety of factors. In individuals with inflammatory joint disease, chronic pain and an incurable condition may lead to a gradual deterioration in physical and mental health. Frequent use of medication fails to significantly improve symptoms, and individuals with inflammatory joint disease often experience a range of problems including fatigue, depression, anxiety, stress, and decreased sleep quality. Traditional anti-rheumatic medications often fail to meet their needs for symptomatic relief and improved quality of life ^[27–28]. Therefore, in the face of these emerging dilemmas, patients with inflammatory joint disease tend to seek CAM as a therapeutic option in an effort to achieve physical and psychological comfort and symptom relief, as well as improved quality of life and mental well-being. Sharpe, in his study, found that patients who used CAM typically had greater perceptions of fatigue, which is consistent with the findings of the present study. Meanwhile, a Korean observational study found that depression was also a factor highly associated with CAM use. Patients with inflammatory joint disease were more likely to be diagnosed with depressive symptoms compared to the general population^[29–30]. The association between CAM use and depression in this paper supports the findings of other studies that depression is also one of the main reasons for patients to receive CAM^[31–33].Prof. Alexander Bystritsky, in his study, found that 43% of patients with anxiety disorders use CAM treatments, which presents a similar trend to the findings of this study[34]. The presence of stress can also have an impact on patients' choice of CAM use, especially when patients perceive stress as having a negative impact on their condition, patients who feel stressed tend to choose CAM treatment.

Since this study adopts a cross-sectional survey research approach, it can only provide correlations between different variables and cannot determine causal sequential relationships. Secondly, most of the information collected by the questionnaire in this study came from the respondents' self-dictation and answers to the questions, and since some of the questions required recall of experiences or behaviors over a period of time in the past, recall bias was difficult to avoid^[35–36]. Meanwhile, since the onset of inflammatory joint disease is affected by temperature, climate and other factors, the same respondent may have different feelings of illness in different time periods, which will have some impact on the research results^[37]. In addition, most of the study subjects in this paper were from Anhui and neighboring areas, and there may be some limitations in promoting the study to other provinces and regions. Finally, there are many factors affecting the use of CAM in IA patients, and it may be difficult to fully consider all factors in the current study. More in-depth studies need to be conducted to further explore this issue in the future.

In summary, CAM utilization is higher in our patients with inflammatory joint disease. Overall, older age, longer disease duration, higher disease activity, and greater anxiety levels were associated with higher rates of CAM utilization.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Funding

This study was supported by grants from the National Natural Science Foundation of China (82073655) and the funds for Scientific Research of Anhui Medical University(2021lcxk004).

Author Contribution

J.N. and X.W. wrote the main manuscript. J.F. obtained, analyzed, and interpreted the data.T.Z.、M.N.、Y.D. and X.S. accessed the data. P.F. designed and critical revision of the manuscript.All authors reviewed the manuscript.

Acknowledgments

The authors thank the participants who made this study possible and gratefully acknowledge the role of the staff and volunteers in collecting the data.

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No competing interests reported.

SupplementaryMaterial.docx

Prevalence of complementary therapy use for inflammatory arthritis patients: A cross-sectional study

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Abstract

Objective

Method

Result

Conclusion

Figures

Introduction

Materials and methods

Statistical analysis

Results

Discussion

Conclusion

Declarations

Declaration of competing interest

Funding

Author Contribution

Acknowledgments

References

Additional Declarations

Supplementary Files

Status:

Version 1