EFFICACY OF CAM INTERVENTION IN RHEUMATOID ARTHRITIS

本子项目是利用由NIH/NCRR资助的中心赠款提供的资源的众多研究子项目之一。子项目和研究者（PI）可能已经从另一个NIH来源获得了主要资金，因此可以在其他CRISP条目中表示。列出的机构是中心的，不一定是研究者的机构。传统的医学治疗方法对类风湿关节炎（RA）的治疗是有效的，但迄今为止，还没有提供“治愈”。许多患者寻求补充或替代治疗来应对疾病的影响。补充治疗包括标准（通常是医学或精神病学）治疗，在针对特定医疗状况的通常处方之外，是在患者规定的医疗方案之外提供的。替代疗法是指非标准疗法，如维生素或营养补充剂、按摩、磁铁、其他疗法，这些疗法的有效性尚未得到证实。尽管患者发现这些补充和替代疗法有益，但人们对这些疗法如何影响健康结果，或它们是否能减少疾病并提高患者在日常生活中的能力知之甚少。太极拳是一种流行的另类行为技巧。据报道，太极拳利用缓慢的重复动作，放松和冥想的焦点来改善健康和福祉。太极拳与改善身体机能有关，如机动性和平衡性，心肺功能，血压，以及主观疼痛的减少。据报道，太极拳还可以通过减少消极情绪和增加积极情绪和自信来改善情绪功能。尽管对太极的精心设计的研究很少，但有证据表明，情绪反应的改善、身体功能和免疫功能的增强（即身体对抗疾病或从伤害中恢复的能力）可能是增强健康功能的重要预测因素。我们已经初步表明，太极拳（TCC；太极的西化版本）的做法有助于改善病人所说的健康功能和他们的福祉。我们还表明，TCC与健康老年人体力活动的增加有关，独立于TCC实践，对免疫系统功能有额外的影响。我们还表明，积极情绪和积极的自我感知与RA疾病活动的重要标志物有关，因此可能影响疾病结局。总之，这些发现可能与患者应对类风湿性关节炎的方式以及他们的身体对类风湿性关节炎的反应方式特别相关。在这项研究中，我们询问TCC是否可以用于改变RA患者的免疫和健康功能，以及这些假设变化的相关生理或心理途径是什么。重要的是，我们询问TCC是否通过促炎细胞因子的减少、神经内分泌激素的改变或情绪或自我感知的改变来改变疾病活动。在这项对照试验中，我们的目标是：1)确定一种补充行为治疗——太极（TCC）是否可以改善RA患者群体的心理适应（即情绪和自我感知）、生理适应（即身体对抗疾病或从损伤中恢复的能力，身体在一段时间的压力或损伤后恢复正常功能的能力）和疾病严重程度；2)评估免疫的变化(即TCC干预后的免疫系统产物（如促炎细胞因子）或神经内分泌功能（即神经内分泌系统产物，如皮质醇和β -内啡肽水平）导致疾病严重程度的变化。3)评估干预后心理适应的变化是否与免疫、神经内分泌功能的变化、疾病严重程度的改善和健康结果有关。我们假设TCC的健康益处是由于多种因素的结合，包括减少自主神经觉醒（神经系统功能），自我感知的积极改变和身体状况的改善。通过使用标准化的治疗方案和积极的治疗控制条件来关注这些因素，在一组精心挑选的初诊TCC的医疗患者中，这种干预措施比以前的补充和替代医学（CAM）干预措施有了重要的改进。此外，评估疾病相关的免疫指标、疾病活动和健康功能的客观指标，以及与疾病进展相关的心理社会因素，可以更清楚地了解行为因素和补充干预对RA疾病进展和健康结局的影响。目的1)本项目的主要目的是比较太极拳（TCC）与放松疗法（渐进式肌肉放松、膈呼吸和其他放松技术；RT）对成人类风湿关节炎（RA）患者疾病活动性和疾病相关残疾的影响。一个次要目标将是探索患者因素如何改变治疗和健康结果。假设1)与rt相比，TCC会产生更大的疾病活动性和疾病相关残疾的降低。这种关系将被患者因素直接或间接地调节。目的2)第二个目标是比较TCC和RC对生物行为因子（即促炎细胞因子：IL-1、IL-6、TNF的产生；神经内分泌因子：皮质醇、β -内啡肽；主动反应）变化的影响，这些因素被认为是RA疾病活动的重要因素。假设2)与RC相比，TCC会产生更大的促炎细胞因子减少和β -内啡肽增加。第三个更具探索性的目标是确定TCC有效性的机制，收集初步数据以评估对RA重要的认知、影响和生理变化的临床贡献。我们将研究两种可能解释TCC对健康功能影响的机制或途径：一种是通过负面疾病评估和负面影响的变化；第二种探索途径是自我效能感和积极情绪的改变。通过评估这两种途径，我们将开始探索认知、情感和对RA疾病进展重要的生理因素之间的相互作用。假设3)我们预计TCC将通过这两种途径产生疾病感知、情感反应、神经内分泌和免疫因素的变化，但TCC将独特地促进积极影响的持续改变，增加β -内啡肽释放，减少疼痛和增加幸福感。

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.