EFFICACY OF CAM INTERVENTION IN RHEUMATOID ARTHRITIS

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This subproject is one of many research subprojects utilizing the resources provided by a Center grant funded by NIH/NCRR. The subproject and investigator (PI) may have received primary funding from another NIH source, and thus could be represented in other CRISP entries. The institution listed is for the Center, which is not necessarily the institution for the investigator. Traditional medical treatments have been effective in the management of Rheumatoid Arthritis (RA) but, as yet, provide no "cure." Many patients seek complementary or alternative treatments to cope with the effects of their disease. Complementary treatments encompass standard (usually medical or psychiatric) treatments, outide those commonly prescribed for a given medical condition, and are given in addition to the patients' prescribed medical regimen. Alternative treatments are non-standard therapies, such as vitamins or nutritional supplements, massage, magnets, other therapies, for which the effectiveness of the given treatment has not been established. Although patients find these complementary and alternative therapies beneficial, little is known about how these treatments affect health outcomes or whether they reduce disease and improve patients' ability to function in their day-to-day lives. Tai Chi is a popular alternative behavioral technique. Tai Chi utilizes slow repetitive movements, relaxation and meditative focus, to reportedly improve health and well being. Tai Chi has been linked to improvements in physical functioning such as mobility and balance, cardio respiratory function blood pressure, and declines in subjective pain. Tai Chi has also been reported to improve emotional functioning by decreasing negative emotions and increasing positive emotions and self-confidence. Although well-designed research on Tai Chi is sparse, evidence indicates that improved emotional response, and gains in physical function and the immune function (i.e., the body's ability to fight disease or recover from injury) may be important predictors of enhanced health functioning. We have preliminarily shown that the practice of Tai Chi Chih (TCC; a westernized version of Tai Chi) contributes to improvements in what patients say about health functioning and their well-being. We have also shown that TCC is associated with increased physical activity in healthy older adults, independent of their TCC practice, with additional effects on immune system functioning. We have also shown that positive mood and positive self-perception are related to important markers of disease activity in RA, and therefore may affect disease outcomes. Together, these findings may be particularly relevant to the way patients cope with having RA and the way their bodies respond to having RA. In this study we ask whether TCC can be used to alter immunity and health functioning in persons with RA, and what the relevant physiologiclal or psychological pathways for these hypothesized changes might be. Importantly we ask whether TCC alters disease activity through: reductions in pro-inflammatory cytokines, changes in neuroendocrine hormones, or alterations in emotions or self-perception. In this controlled trial, we aim to 1)determine whether a complimentary behavioral treatment, Tai Chi Chih (TCC), can improve psychological adaptation (i.e. mood and self-perception), physiological adaptation (i.e., the body's ability to fight disease or recover from injury, the body's ability to return to normal function after a period of stress or injury), and disease severity in a group from RA patients, 2)assess whether changes in immunity (i.e., products of the immune system such as pro-inflammatory cytokines) or neuroendocrine function (i.e., products of the neuroendocrine system such as cortisol and beta-endorphin levels) following a TCC intervention lead to changes in disease severity, 3)assess whether changes in psychological adaptation, following this intervention, are related to changes in immunity, neuroendocrine function, improvements in disease severity and health outcomes. We hypothesize that the health benefits of TCC are due to a combination of factors including reduced autonomic arousal (nervous system functioning), positive alterations in self-perception, and improved physical condition. By focusing on these factors using a standardized treatment regimen, and an active treatment control condition, in a carefully selected group of medical patients naive to TCC, this intervention offers an important improvement over previous complementary and alternative medicine (CAM) interventions. Further, evaluation of disease-relevant measures of immunity, objective measures of disease activity and health functioning, and psychosocial factors relevant to disease progression allows for a clearer understanding of the impact of behavioral factors and complementary interventions on disease progression and health outcomes in RA. Aim 1) The primary goal of this project is to compare the effects of Tai Chi Chih (TCC) vs. Relaxation Therapy (progressive muscle relaxation, diaphragmatic breathing, and other relaxation techniques; RT) on disease activity and disease related disability in adults suffering from rheumatoid arthritis (RA). A sub-aim will be to explore how patient factors alter treatment and health outcomes. Hypothesis 1) TCC will produce greater decreases in disease activity and disease related disability, as compared to RT. This relationship will be moderated by patient factors, either directly or indirectly. Aim 2) A second goal is to compare the effects of TCC and RC on changes in biobehavioral factors (i.e., the production of pro-inflammatory cytokines: IL-1, IL-6, TNF; neuroendocrine factors: cortisol, beta-endorphin; active response) hypothesized to be important to disease activity in RA. Hypothesis 2) TCC will produce greater reductions in pro-inflammatory cytokines, and greater increases in beta-endorphin as compared to RC. Aim 3) A third, more exploratory, goal is to identify the mechanisms that underlie the effectiveness of TCC gathering preliminary data to evaluate the clinical contribution of changes in cognition, affect and physiology important to RA. We will examine two mechanisms, or pathways, that may explain the effects of TCC on health functioning: one through negative illness appraisals and changes in negative affect; and a second exploratory pathway through alterations in self-efficacy and positive emotions. By evaluating both pathways we will begin to explore the interaction between cognition, affect, and physiological factors important to disease progression in RA. Hypothesis 3) We anticipate that TCC will produce changes in illness perception, affective response, neuroendocrine and immune factors through both pathways, but that TCC will uniquely contribute to sustained alterations in positive affect, increased beta-endorphin release, decreased pain and increased well being.