efficacy of the tibetan treatment for arthritis

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Soc. Sci. Med. Vol. 44, No. 4, pp. 535-539, 1997 Copyright © 1997 Elsevier Science Ltd

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SHORT REPORT

EFFICACY OF THE TIBETAN TREATMENT FOR AR'rHRITIS*

MARY RYAN

Institute of Biological Anthropology, Oxford University, 58 Banbury Road, Oxford OX2 6QS, U.K.

Abstract--Tibetans in the refugee communities in Northern India are exposed to both traditional Tibe- tan and Western medicine. For Tibetans suffering from arthritis (or trung-bo), the Tibetan treatment was compared with the Western treatment in an open randomized controlled trial. On a significance level of 0.0005, this trial demonstrated that for these Tibetans, their indigenous treatment worked better than the Western treatment for improved limb mobility. Copyright © 1997 Elsevier Science Ltd

Key words--arthritis, Tibetan medicine, limb rr obility, efficacy

INTRODUCTION

Tibetan refugees in McLeod Ganj in Northern India have available to them both traditional Tibetan and Western medicine. In this setting, a randomized controlled trial was undertaken between the Tibetan and Western treatments for arthritis. Rheumatoid and osteoarthritis correspond to a salient category of dis- ease in Tibetan medicine called trung-bo. Out of ]03 Tibetans suffering from trung-bo, 14 matched pairs were selected, and for each pair, it was randoraly decided who would receive the Tibetan treatment and who the Western. The patients were then followed over a three-month period. The Tibetan treatment was given at a local clinic by Dr Lady Dhadon. It consisted of herbal pills, dietary restrictions, and behavioural advice. The Western treatment was supervised by Dr N. Das at a local Western medical clinic. It was based on the most common Western drugs, ibuprofen and indomethecine (Arthritis Research Council, 1994). Neither the Tibetan nor the Western treatment made any essential distinction between rheumatoid and osteoarthritis, (i.e. patients in either category of rheumatoid and osteoarthritis could receive the same treatment within each medical system). In this study, the distinction is used only in the matching of pairs. To measure efficacy, the study focused on limb mobility, which was quantified using methods from physiotherapy. The null hypothesis that the treatments worked equally well for lirab

*Fieldwork was supported by the Emslie Homiman Fund, the Royal Anthropological Institute, and the Parkes Foundation, Cambridge, as part of a Ph.D. at Oxford University. This short paper reports only the most scientific part of a larger anthropological study, which covers both biological and cultural aspects of Tibetan medicine. The author is supported by DANIDA.

movements was rejected in a non-parametric test with P < 0.0005. Thus, this study demonstrates that for the Tibetans, their own traditional medicine worked better for improving limb mobility than the available Western medicine.

It is hoped that this study will be of more general methodological interest. As pointed out by Anderson (1991), previous efficacy studies in the field have failed to meet the necessary criteria of a biomedical case control study, thus demonstrating the difficulty of using biomedical measurements of efficacy in traditional settings. For concrete studies illustrating the difficulties, the reader is referred to Anderson (1987, 1991, 1993), Finkler (1985), Morse et al. (1987) and Ryan (1994), and to some extent Jilek (1982) and Kleinman (1980). The definitive finding that the Tibetan treatment resulted in improved limb mobility was possible because the design of the clinical trial was carried out in a culturally sensitive way based on a simple, quantifiable measure understood and respected by Western medicine, as well as by Tibetan medicine and the Tibetan patients.

METHODS

The severity of arthritis was measured in terms of limb movements. Thus, as opposed to various chemical measures, this measure can be directly cor- related with the patient's degree of physical disability as experienced in daily life. An advantage to this is that the measurement is fully understood and respected by the Tibetan medical system, as well as by Tibetan patients. In order to quantify the patients' limb movements, we used a manual of simple tests devised by rheumatologist Dr Med. Pekke Helin (1994). The manual offers a simple-to- use praxis-based scale for measuring active limb

535

536 Mary Ryan

T a b l e 1. D e v e l o p m e n t o f l imb m o b i l i t y be fo r e a n d a f t e r t r e a t m e n t for T i b e t a n / W e s t e r n g r oups

P a i r A r t h . type L i m b T i b e t a n L / R W e s t e r n L / R Resu l t o v e r a l l L / R

1 Os teo K n e e 0 ~ 0 / 4 - ~ 1 3 ~ 2 /4 ---* 3 - / T = T 2 Os teo K n e e 4 ~ 1/0 ---* 0 4 ~ 3 /0 ~ 0 T / D = T 3 Os teo K n e e 3 ~ 1/3 --~ 1 3 --* 2/3 ~ 2 T / T = T 4 O s t e o K n e e I ---* 0 /3 ---, 0 2 ~ 2/3 ---* 2 / T = T 5 O s t e o K n e e 2 ---, 2 /2 --~ 1 2 ---, 2 /2 ~ 1 D / D = D 6 Os teo K n e e 3 ~ 1/2 ~ 0 3 ~ 2 /2 ~ 1 T / T = T 7 O s t e o K n e e 3 ---, 1/2 ---, 1 3 ---, 2 /2 ~ 2 T / T = T 8 O s t e o K n e e 2 ---* 1/2 - - , 0 2 ~ 2 /2 ~ 1 T / T = T 9 O s t e o K n e e 2 --~ 0 /2 -- , 0 2 ---, 1/2 ---, I T / T = T 10 Os teo K n e e 3 ---, 2 /4 --~ 2 3 ~ 3 /4 --* 3 T / T = T 11 R h e u m . H a n d 2 ---* 1/3 ---* 2 2 ~ I /3 --~ 3 D / T = T 12 O s t e o K n e e 2 ~ 1/2 ---* 1 2 ~ 2 /2 ~ 2 T / T = T 13 Os teo K n e e 2 ~ 2/1 - - , 1 2 ---, 2/1 ---, I D / D = D 14 R h e u m . H a n d 2 ~ 1/2 ~ 0 2 ~ 1/2 ~ 2 D / T = T

Note s : L = left , R = r igh t , ~ = be fo re to a f t e r , T = T i b e t a n win , W = W e s t e r n win , D = d r a w , - = u n e q u a l s t a r t i ng poin ts .

mobility. Only paper, pen, ruler, and angle measure are needed. The paper and pen are used to measure different types and degrees of grip strength, while the angle measure is used to measure the degree a patient is able to bend or stretch a limb. The manual was developed over 12 experimental editions in collabor- ation with physiotherapists, correlating the scoring system with degree of functional disability in daily life. For each limb, the scale goes from 0 to 5, where 0 means no problems in movement and higher scores mean greater degrees of limitation. For example, a score of 2 in the hands (rheumatoid) implies that a patient is beginning to lose the ability to write clearly, and with a score of 3, writing is almost impossible. For knees (osteo), a score of 3 implies that the patient is unable to squat. An exact description of the scoring system is given in the. The manual was earlier used medically to determine the incidence of arthritis in the Faroe Islands (Recht et al., 1994), and it is pre- sently used at hospitals in Denmark. Here the scoring is used to record changes in limb mobility during the course of treatment. The validity of this usage was approved by the author of the manual, Dr Pekke Helin.

As the general method of the trial between the Tibetan and Western treatments, patients were divided into pairs with each individual in a pair having the same starting score. For each pair, one was randomly chosen to receive the Tibetan treatment, leaving the other to receive the Western treatment. Patients were followed over a three-month period. For each pair the "winner" was chosen as the one who ended on the lowest score (since they started on the same score, ending on the lowest score is obviously better). If both patients got the same score, it was recorded as a draw. The scoring was done by the author with help from an Indian assistant. Everybody involved knew the assignments of treatments to patients, thus classifying the study as a phase 2 trial (see e.g. Brooks, 1994).

*The patients were all settled in McLeod Ganj for at least 15 years, so socio-economic status and household composition were stabilized.

Participants were allocated via local advertise- ment in McLeod Ganj offering free arthritis treatment. A total of 103 Tibetan arthritis participants were diagnosed identically by a Tibetan doctor (Dr Dhadon) and by a Western doctor (Dr Das). At the time of diagnosis, the doctors did not know which mode of treatment the patient would receive. Out of the 103 participants, 15 matched pairs (30 patients) were found. In a matched pair, each individual suf- fered from the same type of arthritis (rheumatoid or osteo). Since it was impossible to obtain identical starting scores for all limbs for paired patients, for each pair, we focused on the most relevant limb for their type of arthritis. For rheumatoid arthritis pairs, we focused on the movements of the hands and for osteoarthritis pairs, we focused on the knees. Besides matching the relevant starting scores, the patients in each pair were matched as well as possible for general duration, age, parity, socio- economic status and household composition,* thus minimizing environmental effects on the difference in the outcome within each pair.

It was only after the patients had been divided into pairs that for each pair one was randomly chosen to receive Tibetan or Western treatment. The null hypothesis is that the two treatments work equally well. Note that in case of a badly matched pair, the random assignment of treatments ensures that each of the two treatments has the same chance of getting the "good" patient in the pair. Thus the null hypothesis implies that the matches not ending in a draw should follow a binomial distribution, no matter how badly the matches were made.

R E S U L T S

Out of the initial 15 pairs, one dropped out. For the remaining 14 pairs (28 patients), the exact scores are given in Table 1. We have 12 Tibetan wins, two draws, and zero Western wins. With a two-sided test, the probability of this is less than 2 x 2 -t2 = 0.0005. Thus, we reject the null hypothesis that the two treatments worked equally well.

Short Report 537

The above non-parametric test is complemented by studying the average improvement for each patient. For example, for the first Tibetan patient, the average improvement over the left and right knee is ( ( 0 - 0 ) + ( 4 - 1 ) ) / 2 = 1.5. Thus, on the Tibetan side, the average improvements are 1.5, 1.5, 2, 2, 0.5, 2, 1.5, 1.5, 2, 1.5, 1, 1, 0, and 1.5. This gives a mean of 1.39 and a standard deviation of 0.59. On the Western side, the average improvements are 1, 0.5, 1, 0.5, 0.5, 1, 0.5, 0.5, 1, 0.5, 0.5, 0, 0, and 0.5, giving a mean of 0.57 and a standard deviation of 033. Assuming normal distribution and equal varian,:es, an unpaired t-test or one-way ANOVA test rejecl:s a null hypothesis of equal means on a significance level of 0.0001. Without the assumption of equal var- iances, the significance level becomes 0.0002. Seme points of criticism, however, may be raised against the normal distribution assumption. First of all, the starting score may strongly affect the possibilities for improvement. In the extreme case of a starting score of 0, there is certainly no room for improvement. Also, from a non-zero starting score, no improvement may be a special case. For example, the 0 improvement for Tibetan patient 13 does not fit well into a normal distribution for the Tibetans. For the above reasons, in the following we will be conserva- tive, and only refer to significance level of 0.0005 from the non-parametric test.

DISCUSSION

As an open randomized controlled trial, our study classifies as a phase 2 trial (see e.g. Brooks, 1994). It should be noted that part of the openness is inherent in the aim of the study, which is to com- pare Tibetan's sensitivity to Tibetan versus Western treatment. The patients' awareness of whether they received their own traditional treatment or the e~:it- ing new Western treatment is a factor that should be included. Also, the fieldwork situation in a small town makes blind studies impractical.

Because of the randomization, any uncertainty in the matching of the pairs only makes the outcome more definitive--in cases of uneven pairs, lhe Tibetan treatment is expected to be unlucky with its patients about half the time, and yet the treatment never lost. Helin's scoring system is of an objective nature, though there is a question of what exactly is meant by, say, a strong grip [see Hand Index 0(a) in ]. The author had to train on several patients in order to develop a consistent interpretation. Thereafter, the identification of scores appeared unambiguous in practice. The author knew which treatment was received by the different patients. However, even tak- ing into account the possibility of a small unintended bias (Kleinman, 1995), on the basis of strong statistical significance of the results in Table 1, it is cen- eluded that the Tibetan treatment worked better than the Western treatment for the improvement of lirab mobility for the Tibetan group in consideration. It

should be noted that a key to the strong statistical significance despite the small sample size (28) is the simple design focusing only on the most relevant limbs. As mentioned earlier, we have not distin- guished between rheumatoid and osteoarthritis except in the matching of the pairs. This is in accord- ance with the Tibetan viewpoint that there is no essential difference between rheumatoid and osteoarthritis. Also, the two types are treated in the same general way both by the Tibetan and by the Western doctor; as mentioned in the introduction, the Western doctor used the non-steroidal anti-inflam- matory drugs ibuprofen and indomethecine for both rheumatoid and osteoarthritis. Nevertheless, note in Table 1 that our sample is dominated by osteoarthritis pairs and that this may have affected the outcome. In fact, restricting ourselves to the case of osteoarthritis, for the Tibetan treatment there are still 10 wins and two draws, giving a significance level of 0.002, which is conclusive. On the other hand, there are only two rheumatoid pairs, which tells very little about the efficacy of the Tibetan treatment for the rheumatoid arthritis pairs.

It should be mentioned that as part of the method- ology, the patients were queried about pain using the Visual Analog Scale (VAS) of pain measurement adapted to Tibetan culture. The VAS is suggested for arthritic diseases in Brooks 1994. However, the data on pain are less revealing because the Tibetans had different concepts of pain that could not be documen- ted within the confines of the adapted VAS. In general, it seems that the Western treatment relieved pain better than the Tibetan treatment did, mainly for sleep during the night. This follows well with a report from the Arthritis Research Council (1994), which says that ibuprofen and indomethecine are effi- cient pain relievers, but do not change the course of the rheumatic diseases. Note that pain and range of motion are not directly related. The range of motion is limited by the degeneration of joints and synovial tissue caused by rheumatoid and osteoarthritis, so the Western treatment working better than the Tibetan for pain does not contradict our finding that the Tibetan treatment worked better than the Western for limb mobility. It coincides with the Tibetan treatment, typically getting down to a score of 1 (see Table 1), meaning that full range of motion has been recovered, but that pain remains upon motion and in excessive use of limbs during the day. This suggests a possible advantage of using the two treatments together.

Many research questions are left unanswered, such as the parts of the therapy that led to improved limb mobil i ty-- the herbal pills, dietary restrictions, or behavioural advice. These shall be considered in later field seasons. However, the results do indicate the importance of continuing research into the efficacy of indigenous treatments.

538 Mary Ryan

Acknowledgements--I would like to thank Professor G. A. Harrison, Robert Anderson, Pekke Helin, Arthur Kleinman, Mikkel Thorup, and the referees from Social Science & Medicine for constructive comments on presen- tation. Also, I would like to thank Dr Lady Dhadon and Dr N. Das for letting me follow their treatments, and the Tibetan Medical Center for blessing the project.

REFERENCES

Anderson, R. (1987) The treatment of musculoskeletal dis- orders by a Mexican bonesetter (sobador). Social Science & Medicine 24(1), 4346.

Anderson, R. (1991) The efficacy of ethnomedicine: research methods in trouble. Medical Anthropology 13, 1-17.

Anderson, R. (1993) Personal communication, 14 March. Arthritis Research Council (1994) Reports on Rheumatic

Diseases. Arthritis Research Council, London. Brooks, P. M. (1994) Protocol for evaluation of nonsteroi-

dal drugs. Journal of Rheumatology 21(41), 82-85. Finkler, K. (1985) Spiritualist Healers in Mexico. Praeger,

Bergin and Garvey, South Hadley, MA. Helin, P. (1994) Funktionsbevarende Kontrolsystem ved

Rheumatoid Arthritis. Manual for the measurement of limb mobility in rheumatoid arthritis. Glostrup Hospital, Copenhagen.

Jilek, W. G. (1982) Cultures in Review Series. Hancock House, Surrey, BC.

Kleinman, A. (1980) Patients and Healers in the Context of Culture. University of California Press, Berkeley.

Kleinman, A. (1995) An anthropological perspective on objectivity: observation, categorization, and the assess- ment of suffering. In Health and Social Change in International Perspective, ed. A. Kleinman, pp. 129-138. Harvard University Press, Cambridge.

Morse, J. M., McConnell, R. and Young, D. E. (1987) Documenting the practice of a traditional healer: methodological problems and issues. In Health Care Issues in the Canadian North, pp. 89-94. Occasional, University of Alberta Press, Alberta.

Recht, L., Helin, P., Rasmussen, J. O., Jacobsen, J., Lithman, T. and Schersten, R. (1994) Hand handicap and rheumatoid arthritis in a fish-eating society (the Faroe Islands). Journal oflnternal Medicine 227, 49-55.

Ryan, M. (1994) Measuring the efficacy of the Tibetan treatment for acute hepatitis, pp. 37-44. Proceedings of the Russian Academy of Sciences, Tenth Annual Conference on Ethnic Culture and Folk Knowledge Moscow University Press, Moscow.

(c) the three fingers holding the pencil hold with enough strength that pencil cannot be pulled away;

(d) with the forefinger and thumb a piece of paper can be held in a pinch grip so that the paper cannot be removed; and

(e) the above exercises can be done without pain.

For Index 1, the following conditions must be satisfied:

(a) the handshake is distinguishable, but not as strong;

(b) all three fingers can grip the pencil in a light touch, but not as strong as before;

(c) all three fingers can still hold pencil with enough strength that pencil cannot be pulled away;

(d) the forefinger and thumb can still grip the piece of paper, but there is not the distinguishable circular shape created by the two digits. Instead, there is an awkward angle which shows some loss of coordination. The paper still cannot be removed; and

(e) these tests cause some pain.


(a) the handshake can still be felt in each area where the two hands meet, below and above, but there is very little strength in the grip;

(b) the patient can grip with the whole hand, all fingers touching, around the wrist of the other hand; and

(c) the patient can hold a normal pencil with a pinch grip including the thumb, forefinger and one other digit, firmly enough that pencil does not fall out or cannot be easily removed.


(a) the handshake can barely be felt; and

(b) the pencil can still be held in a pinch grip between the thumb and three fingers, but cannot write.

For Index 4, one of the following conditions must be satisfied:

APPENDIX A

This appendix describes the hand and knee scoring system from Helin's Danish manual(Helin, 1994). This manual is praxis-based on functional disability of limb movements and requires only paper, a pencil and an angle measure; it is thus easy to use in field situations. Helin's manual further contains descriptive figures as well as suggested treatments.

Hands


(a) the handshake can barely be felt; or

(b) the pencil can still be held in a pinch grip between the thumb and three fingers, but cannot write.

For Index 5, the following condition must be satisfied:

(a) all functional ability has been lost in the hand.

Knees


(a) a handshake with a strong grip, including all the fingers;

(a) 0-10 degrees hyperextension of the knee from stretched out, and up, when sitting;

(b) all three fingers can be held in a line surrounding a (b) rotation to both sides of the knee when bent at 90 pencil; degrees;

Short Report 539

(c) 135 degrees inflexion of knee; and For Index 3, the following conditions must be satisfied:

(d) the above tests cause no pain. (a) at least 80 degrees flexion;

For Index 1, the following conditions must be satisfied: (b) maximum of 15 degrees stretch defect when lying down; and

(a) 0-5 degrees defect in stretching out the knee when sit- (c) above exercises cause pain, and the atrophy has moved ting; further down the leg.

(b) 110 degrees inflexion of the knee; and

(c) the above tests cause some pain.


(a) maximum of 15 degrees defect in stretching out of the knee when sitting;

(b) at least 90 degrees flexion;


(a) at least 60 degrees flexion;

(b) maximum of 25 degrees stretch defect when lying down; and

(c) the above exercises cause pain, and there is extensive atrophy of the leg from lack of use, and a "looseness" in coordination.

(c) maximum of 10 degrees stretch defect when lying down; and For Index 5, the following condition must be satisfied:

(d) the above exercises cause pain, and there are the begin- (a) complete loss of active movement of the limb and ning signs of atrophy around the joint area. joint.

efficacy of the tibetan treatment for arthritis

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