Treatments for Inflammatory Arthritis: Potential But Unproven Role of Topical Copaiba.

Traditional medicines for inflammatory arthritis (IA) include nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase-2 inhibitors (COXIBs), which have variable clinical benefits and serious side effects. In large-scale randomized, controlled trials (RCTs) in IA, they have demonstrated significant decreases in pain and inflammation but also significant increases in gastrointestinal symptoms, serious bleeding, and cardiovascular events. Copaiba, an essential oil used topically, has potential but unproven benefits, with few to no side effects. Basic research supports its mechanisms of benefit, but human data are sparse and include 1 case series and 1 small RCT examining its benefits for another inflammatory condition, not IA. Providing effective and safe pain relief for patients with IA presents clinical, public health, and research challenges. The clinical challenge is to maximize the benefits of treatment and minimize its risks. Sales of copaiba are increasing and may continue to do so even in the absence of reliable evidence from RCTs, providing a public health challenge. Thus, the research challenge is to test topical copaiba versus a placebo for IA patients against a background of usual care in RCTs of sufficient size, dose, and duration. If such trials show positive results, a logical next step might be head-to-head comparisons against NSAIDs and COXIBs. Evidence from RCTs may support more widespread use or, to paraphrase Huxley, conclude that copaiba is yet another beautiful hypothesis slain by ugly facts.

Modest dietary reductions in blood cholesterol have important public health benefits.

Large reductions in blood cholesterol produce major clinical and public health benefits. Based on extrapolations from randomized evidence, assuming no threshold, a 3% to 4% reduction in blood cholesterol would decrease risk of coronary heart disease (CHD) by 12%. If so, treating larger numbers of people at lower risk would yield greater reductions in CHD than treating smaller numbers at higher risk. High- and moderate-risk patients require evidence-based doses of high-potency statins, as adjuncts to dietary management and benefits to individuals are large and easily quantifiable in randomized trials. In low-risk patients, however, dietary modifications contribute to a public health benefit while that benefit to any individual is small. Thus, the hypothesis that modest dietary reductions in blood cholesterol have important public health benefits is easily quantifiable by extrapolation from existing data but impossible to test among randomized individuals, as the sample sizes and costs are prohibitively large.

Lumbar spinal stenosis: can positional therapy alleviate pain?

METHODS: We analyzed a retrospective case series of 52 patients with spinal stenosis confirmed by spinal imaging and walking limitations treated with a wheeled walker set to induce lumbosacral flexion. RESULTS: Of the 52 patients, improvement in ambulation was classified as excellent for 30 (58%), good for 7 (13%), moderate for 8 (16%), and poor for 7 (13%). Among 48 patients with neurogenic pain, pain relief was classified as excellent for 22 (46%), good for 11 (23%), moderate for 7 (14.5%), and poor for 8 (16.5%). CONCLUSIONS: These retrospective data from a case series support the hypothesis that positional therapy with a wheeled walker set to induce lumbosacral flexion relieves lower extremity symptoms of spinal stenosis. However, an adequate test of this hypothesis will require randomized trials of sufficient size and duration that include objective clinical endpoints such as quality-of-life measures, immobility complications and need for drugs, physical therapy, procedures including epidural injections, and spinal surgery. In the meantime, this conservative strategy is an option for patients following the recommendations of the North American Spine Society, or for those who have contraindications (or aversions) to surgery or epidural injections, or who have found these options ineffective. Positional therapy with a wheeled walker offers the possibility of short-term benefits for ambulation and pain, with minimal risks and costs.