OBJECTIVES: This pilot study aimed to determine if an elemental diet could be used to treat patients with active rheumatoid arthritis and to compare its effect to that of oral prednisolone.

METHODS: Thirty patients with active rheumatoid arthritis were randomly allocated to 2 weeks of treatment with an elemental diet (n = 21) or oral prednisolone 15 mg/day (n = 9). Assessments of duration of early morning stiffness (EMS), pain on a 10 cm visual analog scale (VAS), the Ritchie articular index (RAI), swollen joint score, the Stanford Health Assessment Questionnaire, global patient and physician assessment, body weight, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and haemoglobin, were made at 0, 2, 4 and 6 weeks.

RESULTS: All clinical parameters improved in both groups (p<0.05) except the swollen joint score in the elemental diet group. An improvement of greater than 20% in EMS, VAS and RAI occurred in 72% of the elemental diet group and 78% of the prednisolone group. ESR, CRP and haemoglobin improved in the steroid group only (p<0.05).

CONCLUSIONS: An elemental diet for 2 weeks resulted in a clinical improvement in patients with active rheumatoid arthritis, and was as effective as a course of oral prednisolone 15 mg daily in improving subjective clinical parameters. This study supports the concept that rheumatoid arthritis may be a reaction to a food antigen(s) and that the disease process starts within the intestine.

The goals in the management of established rheumatoid arthritis (RA) are to control pain and disease activity, prevent further joint damage, and enhance functioning and quality of life. Despite the fact that aggressive and the early use of biological and nonbiological disease-modifying antirheumatic drugs have been associated with substantial gains in clinical, radiological, and disability outcomes, a considerable proportion of patients still report significant problems of physical, emotional and social functioning, and unmet needs in established RA. Therefore, nonpharmacological treatments are also administered for patients with RA. The aim of this article is to overview the nonpharmacological, therapeutical, and rehabilitative interventions, to minimize the consequences of the disease in patients with established RA. First, the principles of functional assessment in RA will be addressed. Then nonpharmacological interventions including therapeutic patient education, exercise therapy, physical modalities, orthoses, assistive devices, dietary interventions, and balneotherapy will be reviewed in the light of evidence-based literature data.

Rheumatoid arthritis denotes hyperplasia and intense inflammatory process. Treatment involves exercise protocols and use of resources such as low-level laser therapy (LLLT) to modulate the inflammatory process and maintain physical capacity. The objective was to investigate whether treatment with LLLT and exercise modulates the inflammatory process and peripheral functionality. Sample is composed of 128 male rats, separated into three groups, control, treated and untreated, in the acute and chronic period of the disease with 64 animals in each group, divided into 8 subgroups with n = 8. The animals were immunized with injection at the base of the tail and 7 days after intra-articular injection with complete Freund adjuvant (CFA) for lesion groups, and saline solution for the controls. Joint disability was evaluated by PET (paw elevation time) and joint edema and treated with LLLT and/or resisted stair climbing exercise. Normality Shapiro-Wilk test, ANOVA mixed for the functional analyses, and ANOVA one-way for the variables of cellular differentiation, with Bonferroni post hoc, p = 5% were used. For the evaluations of joint disability and nociception, there was a significant difference between the evaluations, the groups, and the interaction groups-evaluations. The treated groups showed recovery of functionality; it is still verified that laser therapy increased the nociceptive threshold of the chronic inflammatory period, and the exercise reflected in significant functional improvement and modulation of the inflammatory process both in the acute and chronic periods. LLLT, resistance exercise, or a combination of treatments had a positive effect on the modulation of the inflammatory process, reducing the migration of leukocytes, in addition to helping the return of peripheral functionality by reducing joint disability in a model of rheumatoid arthritis induced by CFA in rats.

Reactive oxygen species (ROS) and reactive nitrogen species (RNS) have distinct contribution to the destructive, proliferative synovitis of rheumatoid arthritis (RA) and play a prominent role in cell-signaling events. However, few studies had clarified the role of individual ROS and RNS in the etiopathogenesis of RA. To date, most of the studies were concerned with the measurement of the total oxidative and nitrative stress levels in RA. The aim of this study was to monitor the levels of individual ROS and RNS to emphasize the role that each plays in the pathogenesis of RA and their usefulness as possible biomarkers for the disease activity. In addition, the effect of an antioxidant (ascorbic acid), added to the treatment regimen, on the levels of ROS, RNS and disease activity has been evaluated. Forty-two Saudi RA patients and 40 healthy controls of both genders were included in this study. Serum levels of six different ROS and three different RNS were measured using specific fluorescent probes. The ROS included the hydroxyl radical ((•)OH), the superoxide anion (O2(•-)), hydrogen peroxide (H2O2), the singlet oxygen ((1)O2), the hypochlorite radical (OHCl(•)), and the peroxyl radical (ROO(•)). The RNS included nitric oxide (NO(•)), nitrogen dioxide (ONO-) and peroxynitrite (ONOO-). The main clinical and biochemical markers for disease activity were assessed and correlated with ROS and RNS levels. The clinical markers included the 28 swollen joint count (SJC-28), the 28-tender joint count (TJC-28), morning stiffness and symmetric arthritis, in addition to the disease activity score assessing 28 joints with erythrocyte sedimentation rate (DAS28-ESR). The biochemical markers included undercarboxylated osteocalcin (ucOC), matrix metalloproteinase (MMP-3), ESR, C-reactive protein (CRP), rheumatoid factor (RF) and anticyclic citrullinated polypeptide (Anti-CCP). Ascorbic acid (1mg/day) was added as an antioxidantto the regular treatment regimen of RA patients for two months, and the levels of ROS and RNS, as well as disease activity were re-evaluated. The results have shown significant higher serum levels of individual ROS and RNS in RA patients compared with healthy subjects. Moreover, this study might bethe first to report strong positive correlations between most of the reactive species and the clinical and biochemical markers of RA. Interestingly, the addition of ascorbic acid had significantly reduced the levels of all ROS and RNS in RA patients. In conclusion, the role of oxidative and nitrative stress in the pathogenesis of RA has been confirmed by this study. Serum levels of ROS and RNS may effectively serve as biomarkers for monitoring disease progression. Finally, the addition of an antioxidant, such as ascorbic acid, in the management of RA may be of a great value.

The notion that dietary factors may influence rheumatoid arthritis (RA) has been a part of the folklore of the disease, but scientific support for this has been sparse. In a controlled, single-blind trial we tested the effect of fasting for 7-10 d, then consuming an individually adjusted, gluten-free, vegan diet for 3.5 mo, and then consuming an individually adjusted lactovegetarian diet for 9 mo on patients with RA. For all clinical variables and most laboratory variables measured, the 27 patients in the fasting and vegetarian diet groups improved significantly compared with the 26 patients in the control group who followed their usual omnivorous diet throughout the study period. One year after the patients completed the trial, they were reexamined. Compared with baseline, the improvements measured were significantly greater in the vegetarians who previously benefited from the diet (diet responders) than in diet nonresponders and omnivores. The beneficial effect could not be explained by patients' psychologic characteristics, antibody activity against food antigens, or changes in concentrations of prostaglandin and leukotriene precursors. However, the fecal flora differed significantly between samples collected at time points at which there was substantial clinical improvement and time points at which there were no or only minor improvements. In summary, the results show that some patients with RA can benefit from a fasting period followed by a vegetarian diet. Thus, dietary treatment may be a valuable adjunct to the ordinary therapeutic armamentarium for RA.

BACKGROUND: Rheumatoid arthritis (RA) is a chronic, systemic inflammatory autoimmune disease that results in the destruction of the musculoskeletal system. The major goals of treatment are to relieve pain, reduce inflammation, slow down or stop joint damage, prevent disability, and preserve or improve the person's sense of well-being and ability to function. Tai Chi, interchangeably known as Tai Chi Chuan, is an ancient Chinese health-promoting martial art form that has been recognized in China as an effective arthritis therapy for centuries. OBJECTIVES: To assess the effectiveness and safety of Tai Chi as a treatment for people with RA. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register (CCTR), MEDLINE, Pedro and CINAHL databases up to September 2002, using the Cochrane Collaboration search strategy for randomised controlled trials. We also searched the Chinese Biomedical Database up to December 2003 and the Beijing Chinese Academy of Traditional Medicine up to December 2003. SELECTION CRITERIA: Randomized controlled trials and controlled clinical trials examining the benefits and harms of exercise programs with Tai Chi instruction or incorporating principles of Tai Chi philosophy were selected. We included control groups who received no therapy, sham therapy or another type of therapy. DATA COLLECTION AND ANALYSIS: Two reviewers determined the studies to be included in this review, rated the methodological quality and extracted data using standardized forms. MAIN RESULTS: Four trials including 206 participants, were included in this review. Tai Chi-based exercise programs had no clinically important or statistically significant effect on most outcomes of disease activity, which included activities of daily living, tender and swollen joints and patient global overall rating. For range of motion, Tai Chi participants had statistically significant and clinically important improvements in ankle plantar flexion. No detrimental effects were found. One study found that compared to people who participated in traditional ROM exercise/rest programs those in a Tai Chi dance program reported a significantly higher level of participation in and enjoyment of exercise both immediately and four months after completion of the Tai Chi program. REVIEWERS' CONCLUSIONS: The results suggest Tai Chi does not exacerbate symptoms of rheumatoid arthritis. In addition, Tai Chi has statistically significant benefits on lower extremity range of motion, in particular ankle range of motion, for people with RA. The included studies did not assess the effects on patient-reported pain.

OBJECTIVE:Hepatitis B vaccination has been associated with reactive arthritis and rarely rheumatoid arthritis (RA). We defined the clinical, serologic, and immunogenetic background of patients developing RA, soon after recombinant hepatitis B vaccination.

METHODS:The clinical, serologic, and HLA antigens of a cluster of firefighters who developed arthritis after prophylactic recombinant hepatitis B vaccination (5 subjects), as well as a second group of sporadic cases of arthritis (6 patients) after hepatitis B vaccination are described.

RESULTS:Ten of 11 patients fulfilled revised American College of Rheumatology criteria for RA. All cases had persistent arthritis for more than 6 months; at 48 months followup 2 cases no longer had inflammatory arthritis. Nine patients required disease modifying antirheumatic drugs. Five subjects were HLA-DR4 positive. HLA class II genes expressing the RA shared motif were identified in 9/11 patients genotyped for HLA-DRbeta1 and DQbeta1 alleles (0401, 0101, or 0404). All the firefighters shared the HLA-DRbeta1 allele 0301 and the DQbeta1 allele 0201, with which it is in linkage disequilibrium.

CONCLUSION:These polymorphic residues in the binding site of the MHC class II molecules of the affected patients appear capable of binding some peptide sequences of the recombinant vaccine peptides they received and may be responsible for hepatitis B vaccine triggering development of RA in these cases. Recombinant hepatitis B vaccine may trigger the development of RA in MHC class II genetically susceptible individuals.

Nonpharmacologic interventions for symptom management in patients with rheumatoid arthritis are underinvestigated. Limited data suggest that aromatherapy massage and reflexology may help to reduce pain and fatigue in patients with rheumatoid arthritis. The aim of this study was to examine and compare the effects of aromatherapy massage and reflexology on pain and fatigue in patients with rheumatoid arthritis. The study sample was randomly assigned to either an aromatherapy massage (n = 17), reflexology (n = 17) or the control group (n = 17). Aromatherapy massage was applied to both knees of subjects in the first intervention group for 30 minutes. Reflexology was administered to both feet of subjects in the second intervention group for 40 minutes during weekly home visits. Control group subjects received no intervention. Fifty-one subjects with rheumatoid arthritis were recruited from a university hospital rheumatology clinic in Turkey between July 2014 and January 2015 for this randomized controlled trial. Data were collected by personal information form, DAS28 index, Visual Analog Scale and Fatigue Severity Scale. Pain and fatigue scores were measured at baseline and within an hour after each intervention for 6 weeks. Pain and fatigue scores significantly decreased in the aromatherapy massage and reflexology groups compared with the control group (p < .05). The reflexology intervention started to decrease mean pain and fatigue scores earlier than aromatherapy massage (week 1 vs week 2 for pain, week 1 vs week 4 for fatigue) (p < .05). Aromatherapy massage and reflexology are simple and effective nonpharmacologic nursing interventions that can be used to help manage pain and fatigue in patients with rheumatoid arthritis.

PURPOSE:The purpose of this study was to investigate the effect of aromatherapy on pain, depression, and feelings of satisfaction in life of arthritis patients.

METHOD:This study used a quasi-experimental design with a non-equivalent control group, pre-and post-test. The sample consisted of 40 patients, enrolled in the Rheumatics Center, Kangnam St. Mary's Hospital, South Korea. The essential oils used were lavender, marjoram, eucalyptus, rosemary, and peppermint blended in proportions of 2:1:2:1:1. They were mixed with a carrier oil composed of almond (45%), apricot(45%), and jojoba oil(10%) and they were diluted to 1.5% after blending. The data were analyzed using an 2-test, Fisher's exact test, t-test and paired t-test.

RESULT:Aromatherapy significantly decreased both the pain score and the depression score of the experimental group compared with the control group. However, aromatherapy didn't increase the feeling of satisfaction in life of the experimental group compared with the control group.

CONCLUSION:The result of this study clearly shows that aromatherapy has major effects on decreasing pain and depression levels. Based on our experiment's findings, we suggest that aromatherapy can be a useful nursing intervention for arthritis patients.

OBJECTIVE:To study the clinical efficacy and safety of bee-venom acupuncture therapy for rheumatoid arthritis (RA).

METHODS:A total of 120 cases of RA patients were randomized into bee-sting acupuncture group (treatment) and western medicine group (control) in accordance with the random number table. The patients of the control group were treated by oral administration of Methotrexate (10 mg, once a week) and Celecoxlb (0.2 g, once a day), and those of the treatment group treated by 5 to 15 bee stings of-points or acupoints according to different conditions and corporeity, and with the bee-sting retained for about 5 min every time, once every other day. The treatment lasted for 8 weeks. The therapeutic effect was assessed by examining symptoms and signs of the affected joints as morning stiffness duration, swollen/tender joint counts (indexes), handgrip strength, 15 m-walking time, visual analogue scale (VAS), Disease Activity Score including a 28-joint count (DAS 28), rheumatoid factor (RF), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), anti-cyclic citrullinated peptide antibody (ACCPA); and for assessing the safety of bee-venom acupuncture, the patients' responses of fever, enlargement of lymph nodes, regional red and swollen, itching, blood and urine tests for routine were examined.

RESULTS:Findings of DAS 28 responses displayed that of the two 60 cases in the control and bee-venom acupuncture groups, 15 and 18 experienced marked improvement, 33 and 32 were effective, 12 and 10 ineffective, with the effective rates being 80% and 83. 33%, respectively. No significant difference was found between the two groups in the effective rate (>0.05). After the treatment, both groups have witnessed a marked decrease in the levels of morning stiffness duration, arthralgia index, swollen joint count index, joint tenderness index, 15 m walking time, VAS, RF, ESR, CRP and ACCPA, and an obvious increase of handgrip strength relevant to their own levels of pre-treatment in each group (<0.05). There were no significant differences between the two groups in the abovementioned indexes (>0.05). The routine blood test, routine urine test, routine stool test, electrocardiogram result, the function of liver and kidney and other security index were within the normal range, without any significant adverse effects found after bee-stinging treatment.

CONCLUSION:Bee-venom acupuncture therapy for RA patients is safe and effective, worthy of popularization and application in clinical practice.

OBJECTIVE:to evaluate changes in the expression of tumor necrosis factor-α in patients with rheumatoid arthritis submitted to phototherapy.

MATERIALS AND METHODS:This was an open label study, enrolling ten patients. The phototherapy scheme within a range of 425 to 650 nm, 11.33 Joules/cm2, 30 cm above the chest was as follows: a) 45-min daily sessions from Monday to Friday for 2 to 3 months; b) three, 45- min weekly sessions for 1 to 2 months; c) twice weekly 45-min sessions for 1 to 2 months, and d) one weekly session for 1 to 2 months until completion. Erythrocyte sedimentation rate, C-reactive protein and rheumatoid factor were measured in peripheral blood and tumor necrosis factor-α, interleukin-1β, and interleukin-10 in leukocytes by quantitative real-time Reverse transcriptase-Polymerase chain reaction. In all the patients the next indexes: Karnofsky scale, Rheumatoid Arthritis-specific quality of life instrument, Steinbrocker Functional Capacity Rating and the Visual Analog Scale were evaluated.

RESULTS:Erythrocyte sedimentation rate, C-reactive protein, and rheumatoid factor declined notoriously after the indicated sessions. In gene expression, there was a tendency in tumor necrosis factor-α to decrease after 1 month, from 24.5±11.4 to 18±9.2 relative units, without reaching a significant statistical difference. The four tested indexes showed improvement.

CONCLUSION:Phototherapy appears to be a plausible complementary option to reduce the inflammatory component in rheumatoid arthritis.

Infectious agents contribute to the environmental factors involved in the development of autoimmune diseases possibly through molecular mimicry mechanisms. Hence, it is feasible that vaccinations may also contribute to the mosaic of autoimmunity. Evidence for the association of vaccinations and the development of these diseases is presented in this review. Infrequently reported post-vaccination autoimmune diseases include systemic lupus erythematosus, rheumatoid arthritis, inflammatory myopathies, multiple sclerosis, Guillain-Barré syndrome, and vasculitis. In addition, we will discuss macrophagic myofasciitis, aluminum containing vaccines, and the recent evidence for autoimmunity following the use of human papillomavirus vaccine.

OBJECTIVE:The aim of the present study was to determine the feasibility of a relaxation-based yoga intervention for rheumatoid arthritis, designed and reported in accordance with Delphi recommendations for yoga interventions for musculoskeletal conditions.

METHODS:Participants were recruited from a hospital database, and randomized to either eight weekly 75-min yoga classes or a usual care control. Feasibility was determined by recruitment rates, retention, protocol adherence, participant satisfaction and adverse events. Secondary physical and psychosocial outcomes were assessed using self-reported questionnaires at baseline (week 0), week 9 (primary time point) and week 12 (follow-up).

RESULTS:Over a 3-month period, 26 participants with mild pain, mild to moderate functional disability and moderate disease activity were recruited into the study (25% recruitment rate). Retention rates were 100% for yoga participants and 92% for usual care participants at both weeks 9 and 12. Protocol adherence and participant satisfaction were high. Yoga participants attended a median of seven classes; additionally, seven of the yoga participants (54%) reported continuing yoga at home during the follow-up period. No serious adverse events were related to the study. Secondary outcomes showed no group effects of yoga compared with usual care.

CONCLUSIONS:A relaxation-based yoga programme was found to be feasible and safe for participants with rheumatoid arthritis-related pain and functional disability. Adverse events were minor, and not unexpected from an intervention including physical components. This pilot provides a framework for larger intervention studies, and supports further exploration of yoga as a complex intervention to assist with the management of rheumatoid arthritis.