Rheumatoid arthritis (RA) is an autoimmune disease where the body's immune system mistakenly attacks the synovium, a thin membrane that lines the joints. It causes chronic inflammation that leads to pain, swelling, and stiffness. Over time, RA can damage bones and joints leading to disability.

RA usually affects joints on both sides of the body equally, meaning if a joint on one side is affected, the same joint on the opposite side is affected. Wrists, fingers, knees, feet, and ankles, and elbows are most often affected. RA can also affect other organs, and people who have RA are at higher risk for other diseases including heart disease, diabetes, and osteoporosis.

RA is a chronic disease, meaning it lasts a long time and can get worse. It is important that people with RA work closely with their doctor to find a treatment plan that lessens symptoms and joint damage.

There is no cure for RA. But taking medication and making lifestyle changes can help you manage the disease. Alternative and complementary therapies can also help relieve symptoms, but only conventional medications halt the progression of the disease and stop further joint damage. In some cases, medications can help put RA into remission and symptoms may go away completely.

Symptoms of RA include:

• Morning stiffness. Waking up with stiff joints, often the wrists and base of the fingers, ankles, balls of the feet, elbows, or knees.
• Joint pain with warmth, swelling, tenderness, and stiffness of the joint after resting.
• Limited range of motion in the affected joints.
• Fatigue
• Low-grade fever, when having a flare.
• Small, round, firm bumps called nodules under the skin; you can feel these, but they are generally painless.

Researchers do not know what causes RA, although both genetics and environment probably play a part. Researchers believe that genetics make some people more likely to get RA. In those people, environmental factors, bacteria, and viruses may then trigger RA. Some evidence suggests that hormones may also play a role.

In RA, the body's immune system, which normally fights off foreign invaders, mistakenly attacks the lining of the joints (called the synovium). That causes inflammation, which makes the synovium thicker and eventually destroys the cartilage and bone in the joints.

RA can occur at any age. It usually occurs in people between 25 to 55 years of age. Women are affected more often than men.

RA usually affects joints on both sides of the body equally. Wrists, fingers, knees, feet, elbows, and ankles are the most often affected.

• Age. RA occurs at all ages, but it generally starts in young adulthood, usually between ages 25 to 55.
• Gender. Women get RA 2.5 more often than men, and are more likely to have severe symptoms.
• Family history. Having relatives with RA increases your risk of getting it yourself.
• Cigarette smoking. Smoking seems to increases your risk of getting RA.
• Obesity. People who are overweight or obese are more likely to have RA.

RA can be hard to diagnose because it looks like many other conditions, and symptoms often develop gradually. Even after RA has been diagnosed, it is important to see how the disease is progressing to treat it effectively.

Your doctor will take your medical history and do a physical exam. Blood tests, x-rays, and aspiration (the removal of fluid from the joint) may also be needed.

Your doctor may order several blood tests. One test checks for an elevated erythrocyte sedimentation rate (ESR, or sed rate), which is a sign of inflammation in the body. Other blood tests that may be done include checking for certain antibodies, including rheumatoid factor, antinuclear antibodies (ANA), and anticyclic citrullinated peptide (anti-CCP) antibodies. Most people with RA, but not all, have these antibodies.

If you have RA, it is important to get diagnosed and start treatment early. Studies show that early, aggressive treatment for RA can stop the destruction of joints. In addition to rest, regular exercise, and taking anti-inflammatory medications, your doctor will start you on disease-modifying antirheumatic drugs (DMARDs). These drugs do more than relieve symptoms, they halt the progression of the disease.

You can use complementary and alternative therapies along with conventional treatment to help relieve pain and stiffness. Studies show that certain dietary supplements, particularly omega-3 fatty acids, may help relieve pain and stiffness. Be sure to tell all your health care providers about any supplements, herbs, or other therapies you are using. Some herbs and supplements can interact with medications and should not be taken together.

RA usually requires lifelong treatment, including medications, physical therapy, education, and possibly surgery. Often, a combination of treatments can control the disease.

Lifestyle

Regular exercise, consisting of aerobic exercise, strengthening exercises, and flexibility or range-of-motion exercises, can help to maintain joint motion and strength. Exercise also helps you relieve pain and maintain a proper weight, which takes pressure off your joints. A physical therapist can help create an exercise program for you.

Doctors often recommend walking, swimming, warm-water exercise, or biking for people with RA. If you are not used to exercising, start slow and work your way up, aiming for 30 minutes of aerobic exercise, 5 or more days a week.

Weight-bearing exercises, such as lifting weights, using a resistance band, or walking, are also recommended to keep bones strong. People with RA often take corticosteroids to reduce inflammation. Taking corticosteroids long term raises the risk of developing osteoporosis.

Joint protection techniques, such as heat and cold treatments and splints or orthotic (straightening) devices to support and align joints, may help as well.

Medications

The following drugs are used to treat RA:

Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDS are used to relieve joint pain and inflammation. They do not stop the progression of RA. Long term use can cause stomach problems, such as ulcers and bleeding, and possible heart problems. In April 2005, the U.S. Food and Drug Administration (FDA) asked drug manufacturers of NSAIDs to include a warning label on their products to alert users of an increased risk for heart problems and stomach bleeding. These drugs include ibuprofen (Motrin, Advil) and naproxen (Aleve), as well as prescription medications.

Celecoxib (Celebrex). Celebrex is a type of drug called a COX-2 inhibitor, which blocks an inflammation-promoting enzyme called COX-2. COX-2 inhibitors were developed to work as well as traditional NSAIDs but with fewer stomach problems. However, many reports of heart attacks and stroke have prompted the FDA to re-evaluate the risks and benefits of the COX-2s. Two drugs in this class were taken off the U.S. market following reports of heart attacks in people who took them. Celebrex is still available, but it is labeled with strong warnings and a recommendation that it be prescribed at the lowest possible dose for the shortest time possible.

Corticosteroids. Also known as steroids, these medications are used to quickly bring down inflammation, often during a flare. Steroids have side effects including weight gain, nausea, and fluid retention. Long-term use raises the risk of osteoporosis and diabetes.

Disease-modifying antirheumatic drugs (DMARDs). These drugs can slow progression of the disease and halt joint damage. Current recommendations are that everyone diagnosed with RA should start taking a DMARD, whether their symptoms are mild or severe. Side effects can include liver damage and being prone to infection. Methotrexate (Rheumatrex) is used most often for RA. Other DMARDs include:

• Leflunomide (Arava)
• Sulfasalazine (Azulfidine)
• Hydroxychloroquine (Plaquenil)
• Minocycline (Minocin)

Immune suppressants. These medicines suppress the immune system, which is overactive in people with RA. Side effects include being prone to infection. These drugs include:

• Azathioprine (Imuran)
• Cyclosporine (Neoral)
• Cyclophosphamide (Cytoxan)

Biologic agents. Biologics are newer drugs that target a specific part of the inflammation process and can slow or halt progression of joint damage. Etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), and certolizumab pegol (Cimzia) block production of TNF-alpha, or tumor necrosis factor-alpha, a chemical produced by your body that is involved in inflammation. Anakinra (Kineret) stops a protein called interleukin-1 (IL-1). Abatacept (Orencia) stops the activation of T cells, a type of white blood cell, in the body. Rituximab (Rituxan) blocks B cells, another type of white blood cell involved in the immune system response.

Biologics are often used after other treatments have failed, and are often combined with a DMARD (usually methotrexate). DMARDs may increase the risk of harmful infections. Discuss the risks and benefits of these drugs with your doctor.

Surgery and Other Procedures

If a joint is severely affected, you may need surgery. The most successful surgeries are those on the knees and hips.

Sometimes people with RA need total joint replacement with an artificial joint. Surgeries may relieve pain, correct deformities, and modestly improve joint function. In some cases, total knee or hip replacement can restore mobility and improve quality of life.

Nutrition and Dietary Supplements

For anyone with a chronic illness, eating a healthy diet high in antioxidant-rich foods, fruits and vegetables, is essential. Eating a poor diet may increase inflammation in the body.

Also, people with RA are at higher risk of developing heart disease and diabetes. A healthy diet and regular exercise can lower that risk.

Although diet cannot cure RA, studies show that people with RA report less pain, stiffness, and fatigue when they switched from a typical Western diet to a Mediterranean diet that is high in fruits, vegetables, beans, nuts, seeds, fish, and olive oil, and low in red meat. Other studies link a vegan diet, with lots of uncooked berries, fruits, vegetables, nuts, roots, seeds, and sprouts with reduced RA symptoms. Vegan diets contain no animal products and get protein from vegetable sources.

Some people think food allergies play a part in the inflammation common in RA, and say their symptoms get worse after they eat certain foods. Although researchers are not sure if food allergies are to blame, you may want to try an elimination diet, which removes certain foods from your diet and then adds them back, one by one. You will need to keep track of your symptoms in a food diary. Usually it's best to try an elimination diet under the supervision of your doctor or a registered dietitian.

These general nutritional tips can help you eat a healthy diet:

• Avoid refined foods, such as white breads, pastas, and sugar.
• Eat fewer red meats and more lean meats, cold-water fish, tofu (soy, if no allergy), or beans for protein.
• Use healthy cooking oils, such as olive oil or coconut oil.
• Reduce or eliminate trans-fatty acids, found in commercially-baked goods such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine.
• Avoid caffeine and other stimulants, alcohol, and tobacco.
• Drink 6 to 8 glasses of filtered water daily.
• Exercise 30 minutes daily, 5 days a week.

Some supplements may help relieve pain and inflammation when you have RA, but none have been shown to stop joint damage. Supplements may also interact with some of the medications used to treat RA. Ask your doctor before taking any supplements.

These supplements may help relieve inflammation and pain:

• Omega-3 fatty acids, such as fish oil. Omega-3 fatty acids may help reduce inflammation. A review of studies where people with RA took omega-3 fatty acids found they had fewer tender joints but no difference in joint damage. In some studies, people who took omega-3s were able to reduce their dose of NSAIDs or corticosteroids they take for RA. Omega-3 fatty acids may also reduce the risk of heart disease, which is higher in people with RA. Omega-3 fatty acid supplements may raise the risk of bleeding, especially if you also take blood thinners such as clopidogrel (Plavix), warfarin (Coumadin), or aspirin.
• Vitamin E. One study suggests that taking vitamin E, along with standard medications for rheumatoid arthritis, may help reduce pain (but not inflammation) better than standard medications alone. Vitamin E may increase the risk of bleeding, especially if you already take blood thinners, such as warfarin (Coumadin), clopidogrel (Plavix), or aspirin. People with heart disease, diabetes, retinitis pigmentosa, or with cancer of the head, neck, or prostate, should avoid high doses of vitamin E without first asking their doctor.
• Bromelain. This enzyme derived from pineapples may help reduce inflammation and pain. Bromelain increases the risk of bleeding, especially if you also take blood thinners, such as clopidogrel (Plavix), warfarin (Coumadin), or aspirin. People with stomach ulcers should avoid bromelain. Turmeric is sometimes combined with bromelain because it makes the effects of bromelain stronger.
• Gamma linolenic acid (GLA). Found in borage oil, evening primrose oil, and black currant seed oil, may help reduce pain, stiffness, and swelling. One study found that people with RA who took 2.8 g of GLA for 6 months reduced pain and swelling and improved their grip strength. People with a history of seizures should not take GLA. GLA may increase the risk of bleeding, especially if you already take blood thinners.
• Folic acid. People who take methotrexate for RA may need additional folic acid because methotrexate makes it hard for the body to absorb folic acid. In addition, one study found that folic acid supplements helped reduce side effects (including liver problems) from methotrexate. However, folic acid may interfere with some medications, including methotrexate, so your physician should decide whether supplementation with folic acid in combination with methotrexate is appropriate. High doses of folic acid can hide a vitamin B-12 deficiency, and may interact with other medications. Ask your doctor if you need folic acid supplements, DO NOT just start taking them on your own.

Herbs

You can use herbs in the form of dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, make teas with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups per day.

Herbs may be a helpful addition to conventional treatment for RA, but you should never use them alone to treat RA. Herbs do not halt joint damage and progression of the disease, as some conventional medications can. Herbs can potentially interact with other medications and therapies. Speak to your doctor before adding herbal supplements to your regimen.

• Boswellia (Boswellia serrata). Boswellia has been used traditionally to treat arthritis in Ayurvedic medicine. Studies using it to treat RA have been mixed. Some found that it relieved pain and swelling, but others found it was no better than placebo.
• Ginger (Zingiber officinale), may reduce joint inflammation and pain. One study found that ginger extract blocked COX-2, a chemical in the body that causes pain. Ginger may increase the risk of bleeding, especially if you also take blood thinners, such as clopidogrel (Plavix), warfarin (Coumadin), or aspirin.
• Green tea (Camelia sinensis) standardized extract. Green tea is loaded with antioxidants, and test tube studies show that it may block inflammatory chemicals that are involved in RA. Use caffeine-free products. You may also prepare teas from the leaf of this herb.
• Cat's claw (Uncaria tomentosa) standardized extract. May help reduce inflammation. One study found that people with RA who took cat's claw experienced a modest reduction in pain and swelling. Cat's claw may stimulate the immune system, which could cause problems in a disease like RA where the immune system is already overactive. For that reason, do not take cat's claw except under the supervision of your doctor. People who have low blood pressure, leukemia, or other autoimmune diseases should also speak with their physician before taking cat's claw.
• Turmeric (Curcuma longa) standardized extract. May help reduce pain and inflammation. It is sometimes combined with bromelain, because it makes the effects of bromelain stronger. Turmeric can increase the risk of bleeding, especially if you also take blood thinners or NSAIDs.
• Devil's claw (Harpagophytum procumbens) standardized extract. May reduce inflammation. One study found that people with RA who took devil's claw reduced pain and improved their mobility, however not all studies have found that devil's claw was effective for RA. People with heart disease, diabetes, gallstones, or stomach ulcers should not take devil's claw without talking to their doctor. Devil's claw may interact with several medications processed by the liver and may increase the risk of bleeding in people who take blood-thinning medications, such as warfarin (Coumadin), aspirin, and others.
• Capsaicin (Capsicum frutescens) cream, applied to the skin (topically). Capsaicin is the main component in hot chili peppers (also known as cayenne). Applied to the skin, it may temporarily reduce amounts of "substance P," a chemical that contributes to inflammation and pain in arthritis. Pain reduction generally starts 3 to 7 days after applying the capsaicin cream to the skin. Wash hands well with vinegar after use and avoid touching the eyes. For topical use only.

Acupuncture

There is little scientific evidence supporting the use of acupuncture for RA, however, some people with RA say that acupuncture helps relieve pain and improves their quality of life. Acupuncturists treat people with RA based on an individualized assessment of the excesses and deficiencies of qi, or energy, located in various meridians. A qi deficiency is usually detected in the spleen and kidney meridians.

Acupuncturists may use moxibustion (a technique in which the herb mugwort is burned over specific acupuncture points) to strengthen the entire energy system. Qualified acupuncturists may also provide lifestyle, dietary, and herbal advice to people with RA. Practitioners may apply local treatment to the painful areas and related sore points, either with a needle or moxibustion. You should not rely on acupuncture alone to treat RA, as it does not halt progression of the disease. It may help along with conventional medical therapy.

Exercise

Regular exercise is important for people with RA. It boosts overall health, helps you maintain a proper weight (which takes pressure off joints), and helps prevent heart disease, diabetes, and osteoporosis. It also reduces pain and can boost your mood.

While you may choose to rest during an active flare, it's important to stay in good shape and maintain range of motion in your joints. Ask your doctor or physical therapist to design an exercise program for you. Many people with RA find that walking, swimming, or warm-water exercise are helpful.

Doctors used to advise people with RA to do only gentle exercises, fearing more joint damage. But recent research suggests that more intense exercise may produce greater muscle strength and overall functioning. To know how long or hard you should exercise, ask your doctor and pay attention to your bodies signals.

If you feel sharp pains while exercising, stop immediately.

Some soreness after exercising is normal. If aches and pains continue for more than 2 hours afterward, try a lighter exercise program for awhile.

Be sure to warm up and cool down.

Using large joints instead of small ones for ordinary tasks can help relieve pain. For example, use your hip to close doors or the palm of your hand to push buttons.

Balneotherapy (Hydrotherapy or spa therapy)

Balneotherapy is one of the oldest forms of therapy for pain relief for people with arthritis. The term "balneo" comes from the Latin word for bath (balneum), and refers to bathing in thermal or mineral waters. For example, sulfur-containing mud baths have been shown to relieve symptoms of arthritis. Sulfur-containing mud baths, for example, have been shown to relieve symptoms of arthritis. However, hydrotherapy, which can be done under the guidance of certain physical therapists, is sometimes referred to with the word balneotherapy. The goals of balneotherapy for RA include:

• Improving range of joint motion
• Increasing muscle strength
• Stopping muscle spasm
• Enhancing functional mobility
• Easing pain

Exercising and swimming in a heated pool may also help.

Mechanical Aids

Many devices, called orthoses, are available for people with RA to help support and protect joints. Made from lightweight metal leather, elastic, foam, and plastic, they allow the affected joint to move a little while not restricting nearby joints. For example, splints or braces help align joints and properly distribute weight.

Shock-absorbing soles in shoes can help in daily activities and during exercise. Physical therapists use these mechanical aids most frequently to treat hands, wrists, knees, ankles, and feet. Orthoses should be custom fit by a physical or occupational therapist.

Compression gloves may help some people. Two studies on the overnight use of compression gloves, close-fitting, nylon-spandex gloves, concluded that the gloves reduced pain and stiffness in people with RA in the fingers.

Other possibilities for symptom relief include:

• Transcutaneous nerve stimulation (TENS). Small clinical studies show that TENS, a technique used by many physical therapists, may provide short-term pain relief for people with RA.
• Heat and cold applications, may reduce pain

Homeopathy

Recent trials evaluating homeopathy to treat RA found that the remedies were no better than placebo in reducing symptoms. These studies contradict an older trial that showed positive effects with homeopathic treatment. Despite the lack of definitive evidence, professional homeopaths might recommend one of the following treatments for RA based on their knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account an individual's constitutional type, includes your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.

Potential remedies include:

• A topical homeopathic gel containing comfrey (Symphytum officinale), poison ivy (Rhus toxicodendron), and marsh tea (Ledum palustre).
• A combination homeopathic preparation containing R. toxicodendron, Arnica montana (arnica), Solanum dulcamara (climbing nightshade), Sanguinaria canadensis (bloodroot), and Sulphur.
• A liquid homeopathic preparation containing R. toxicodendron, Causticum (potassium hydrate), and Lac vaccinum (cow's milk).

Mind-Body Medicine

Chronic pain and disability can make daily life difficult, and stress can make an RA flare worse. Many people report that relaxation techniques, such as guided imagery and meditation, help improve quality of life and reduce pain and other symptoms of RA.

Yoga

This ancient Indian practice is well known for its physical, psychological, emotional, and spiritual benefits. In the West, it is often recommended to relieve musculoskeletal symptoms and some studies have found it can help relieve RA pain.

Some yoga "asanas" (postures) strengthen the quadriceps and emphasize stretching, both of which help people with RA of the knee. People with arthritis should begin asanas slowly and they should be performed only after a warm up. Look for a reputable instructor who knows how to modify postures for people with RA.

People with RA should avoid "hot yoga."

Tai Chi

This gentle exercise program practiced in China for centuries has been shown to produce a number of benefits, including the following:

• Better fitness
• Increased muscular strength
• Better flexibility
• Reduced percentage of body fat
• Reduced risk of falls in the elderly

Tai chi is generally safe for people with RA, and a review of scientific studies suggests it may help improve flexibility and range of motion, especially for people with RA in their ankles.

Prognosis and Complications

RA can have many complications, including:

• Joint deformities
• Cervical spine problems (can be life threatening)
• Painless, hard, round or oval masses called nodules that appear under the skin
• Pleuritis, inflammation of the lungs
• Anemia
• Rheumatoid vasculitis, inflammation of the blood vessels
• Pericarditis, inflammation of the outer lining of the heart
• Myocarditis, inflammation of the heart muscle
• Heart failure
• Eye inflammation
• Osteoporosis
• Heart disease
• Diabetes

RA is different for everyone. People with a certain antibody in the blood (anti-CCP) or nodules may be at risk for faster progression of the disease. People who develop RA at younger ages also tend to have faster disease progression.

Although complications may shorten the life expectancy of people with RA, treatment is constantly improving and newer medications offer better chances for remission.

Al-Okbi SY. Nutraceuticals of anti-inflammatory activity as complementary therapy for rheumatoid arthritis. Toxicol Ind Health. 2014;30(8):738-49.

Ang-Lee M, Moss J, Yuan C. Herbal medicines and perioperative care. JAMA. 2001;286(2):208-16.

Belch JJ, Hill A. Evening primrose oil and borage oil in rheumatologic conditions. Am J Clin Nutr. 2000;71(1 Suppl):352S-6S.

Berman BM, Swyers JP, Ezzo J. The evidence for acupuncture as a treatment for rheumatologic conditions. Rheum Dis Clin N Amer. 2000;26(1):103-15.

Calder PC, Albers R, Antoine JM, et al. Inflammatory disease processes and interactions with nutrition. Br J Nutr. 2009 May;101 Suppl 1:S1-45. Review.

Cameron M, Gagnier JJ, Little CV, Parsons TJ, Blümle A, Chrubasik S. Evidence of effectiveness of herbal medicinal products in the treatment of arthritis. Part 2: Rheumatoid arthritis. Phytother Res. 2009 Dec;23(12):1647-62.

Choi HK. Dietary risk factors for rheumatic diseases. Curr Opin Rheumatol. 2005;17(2):141-6.

Dash M, Telles S. Improvement in hand grip strength in normal volunteers and rheumatoid arthritis patients following yoga training. Indian J Physiol Pharmacol. 2001;45(3):355-60.

De Pablo P, Dietrich T, Karlson EW. Antioxidants and other novel cardiovascular risk factors in subjects with rheumatoid arthritis in a large population sample. Arthritis Rheum. 2007;57(6):953-62.

Elkayam O, Ophir J, Brener S, et al. Immediate and delayed effects of treatment at the Dead Sea in patients with psoriatic arthritis. Rheumatol Int. 2000;19(3):77-82.

Elkan AC, Engvall IL, Tengstrand B, Cederholm T, Hafstrom I. Malnutrition in women with rheumatoid arthritis is not revealed by clinical anthropometrical measurements or nutritional evaluation tools. Eur J Clin Nutr. 2007 Jul 18; [Epub ahead of print]

Ernst E. Complementary and alternative medicine in rheumatology. Baillieres Clin Rheumatol. 2000;14(4):731-49.

Ernst E, Chrubasik S. Phyto -- anti-inflammatories. A systematic review of randomized, placebo-controlled, double-blind trials. Rheum Dis Clin North Am. 2000;26(1):13-27.

Ferri: Ferri's Clinical Advisor 2016. 1st ed. Philadelphia, PA: Elsevier; 2016.

Forestier R, André-Vert J, Guillez P, Coudeyre E, Lefevre-Colau MM, Combe B, Mayoux-Benhamou MA. Non-drug treatment (excluding surgery) in rheumatoid arthritis: Clinical practice guidelines. Joint Bone Spine. 2009 Nov 27. [Epub ahead of print]

Friso S, Jacques PF, Wilson PW, Rosenberg IH, Selhub J. Low circulating vitamin B(6) is associated with elevation of the inflammation marker C-reactive protein independently of plasma homocysteine levels. Circulation. 2001;103(23):2788-91.

Funk JL, Frye JB, Oyarzo JN, Kuscuoglu N, Wilson J, McCaffrey G, Stafford G, Chen G, Lantz RC, Jolad SD, Sólyom AM, Kiela PR, Timmermann BN. Efficacy and mechanism of action of turmeric supplements in the treatment of experimental arthritis. Arthritis Rheum. 2006 Nov;54(11):3452-64.

Galarraga B, Ho M, Youssef HM, Hill A, McMahon H, Hall C, Ogston S, Nuki G, Belch JJ. Cod liver oil (n-3 fatty acids) as an non-steroidal anti-inflammatory drug sparing agent in rheumatoid arthritis. Rheumatology (Oxford). 2008 May;47(5):665-9.

Garfinkel M, Schumacher HR, Jr. Yoga. Rheum Dis Clin North Am. 2000;26(1):125-32.

Goldberg RJ, Katz J. A meta-analysis of the analgesic effects of omega-3 polyunsaturated fatty acid supplementation for inflammatory joint pain. Pain. 2007 May;129(1-2):210-23.

Guardia T, Rotelli AE, Juarez AO, Pelzer LE. Anti-inflammatory properties of plant flavonoids. Effects of rutin, quercetin, and hesperidin on adjuvant arthritis in rat. Farmaco. 2001;56(9):683-7.

Hafstrom I, Ringertz B, Spangberg A, et al. A vegan diet free of gluten improves the signs and symptoms of rheumatoid arthritis: the effects on arthritis correlate with a reduction in antibodies to food antigens. Rheumatology (Oxford). 2001;40(10):1175-9.

Halpern GM. Anti-inflammatory effects of a stabilized lipid extract of Perna canaliculus (Lyprinol). Allerg Immunol (Paris). 2000;32(7):272-8.

Han A, Robinson V, Judd M, Taixiang W, Wells G, Tugwell P. Tai chi for treating rheumatoid arthritis. Cochrane Database Syst Rev. 2004;(3):CD004849.

Han C, Smolen J, Kavanaugh A, et al. The impact of infliximab treatment on quality of life in patients with inflammatory rheumatic diseases. Arthritis Res Ther. 2007;9(5):R103 [Epub ahead of print].

Hanninen, Kaartinen K, Rauma AL, et al. Antioxidants in vegan diet and rheumatic disorders. Toxicology. 2000;155(1-3):45-53.

Hutchinson D, Shepstone L, Moots R, Lear JT, Lynch MP. Heavy cigarette smoking is strongly associated with rheumatoid arthritis (RA), particularly in patients without a family history of RA. Ann Rheum Dis. 2001;60(3):223-7.

Karlson EW, Mandl LA, Aweh GN, Grodstein F. Coffee consumption and risk of rheumatoid arthritis. Arhtritis Rheum. 2003 Nov;48(11):3055-60.

Kast RE. Borage oil reduction of rheumatoid arthritis activity may be mediated by increased cAMP that suppresses tumor necrosis factor-alpha. Int Immunopharmacol. 2001;1(12):2197-9.

Karatay S, Erdem T, Kiziltunc A, et al. General or personal diet: the individualized model for diet challenges in patients with rheumatoid arthritis. Rheumatol Int. 2006;26(6):556-60.

Klein G, Kullich W. Short-term treatment of painful osteoarthritis of the knee with oral enzymes. A randomized, double-blind study versus diclofenec. Clin Drug Invest. 2000;19(1):15-23.

Kinjo M, Setoguchi S, Solomon DH. Bone mineral density in older adult patients with rheumatoid arthritis: an analysis of NHANES III. J Rheumatol. 2007;34(10):1971-5.

Kneckt P. Serum selenium, serum alpha-tocopherol, and the risk of rheumatoid arthritis. Epidemiology. 2000;11(4):402-5.

Kremer JM. N-3 fatty acid supplements in rheumatoid arthritis. Am J Clin Nutr. 2000;(suppl 1):349S-51S.

Kumazawa Y, Kawaguchi K, Takimoto H. Immunomodulating effects of flavonoids on acute and chronic inflammatory responses caused by tumor necrosis factor alpha. Curr Pharm Des. 2006;12(32):4271-9.

Li S, Micheletti R. Role of Diet in Rheumatic Disease. Rheumatic Diseases Clinics of North America. 2011;37(1).

Lineker SC, Bell MJ, Wilkins AL, Badley EM. Improvements following short term home based physical therapy are maintained at one year in people with moderate to severe rheumatoid arthritis. J Rheumatol. 2001;28(1):165-8.

Little C, Parsons T. Herbal therapy for treating rheumatoid arthritis. Cochrane Database Syst Rev. 2001;(1):CD002948.

Loppenthin K, Esbensen BA, Jennum P, et al. BMC Musculoskelet Disord. 2014;15:49.

Loppenthin K, Esbensen B, Ostergaard M, Jennum P, Thomsen T, Midtgaard J. Physical activity maintenance in patients with rheumatoid arthritis: a qualitative study. Clin Rehabil. 2014;28(3):289-99.

Macfarlane GJ, El-Metwally A, De Silva V, Ernst E, Dowds GL, Moots RJ; Arthritis Research UK Working Group on Complementary and Alternative Medicines. Evidence for the efficacy of complementary and alternative medicines in the management of rheumatoid arthritis: a systematic review. Rheumatology (Oxford). 2011 Sep;50(9):1672-83. Epub 2011 Jun 6. Review.

McDougall J, Bruce B, Spiller G, Westerdahl J, McDougall M. Effects of a very low-fat, vegan diet in subjects with rheumatoid arthritis. J Altern Complement Med. 2002;8(1):71-75.

Mesa Garcia MD, Aguilera Garcia CM, Gil Hernandez A. Importance of lipids in the nutritional treatment of inflammatory diseases. Nutr Hosp. 2006;21 Suppl 2:28-41, 30-43.

Milanino R, Marrella M, Crivellente F, Benoni G, Cuzzolin L. Nutritional supplementation with copper in the rat. Effects on adjuvant arthritis development and on some in vivo- and ex vivo-markers of blood neutrophils. Inflamm Res. 2000;49(5):214-23.

Mur E, Hartig F, Eibl G, Schirmer M. Randomized double blind trial of an extract from the pentacyclic alkaloid-chemotype of uncaria tomentosa for the treatment of rheumatoid arthritis. J Rheumatol. 2002;29(4):678-81.

Pedersen M, Stripp C, Klarlund M, Olsen SF, Tjonneland AM, Frisch M. Diet and risk of rheumatoid arthritis in a prospective cohort. J Rheumatol. 2005;32(7):1249-52.

Rothman D, DeLuca P, Zurier RB. Botanical lipids: effects on inflammation, immune responses, and rheumatoid arthritis. Semin Arthritis Rheum. 1995;25(2):87-96.

Segal NA, Toda Y, Huston J, et al. Two configurations of static magnetic fields for treating rheumatoid arthritis of the knee: a double-blind clinical trial. Arch Phys Med Rehabil. 2001;82(10):1453-60.

Simard JF, Mittleman MA. Prevalent rheumatoid arthritis and diabetes among NHANES III participants aged 60 and older. J Rheumatol. 2007;34(3):469-73.

Singh JA, Cameron C, Noorbaloochi S, et al. Risk of serious infection in biological treatment of patients with rheumatoid arthritis: a systematic review and meta-analysis. Lancet. 2015;386(9990):258-65.

Smith HS, Smith AR, Seidner P. Painful rheumatoid arthritis. Pain Physician. 2011;14(5):E427-58.

Stamp LK, James MJ, Cleland LG. Diet and rheumatoid arthritis: a review of the literature. Semin Arthritis Rheum. 2005;35(2):77-94.

Stark LJ, Janicke DM, McGrath AM, Mackner LM, Hommel KA, Lovell D. Prevention of osteoporosis: a randomized clinical trial to increase calcium intake in children with juvenile rheumatoid arthritis. J Pediatr Psychol. 2005 Jul-Aug;30(5):377-86.

Tam LS, Leung PC, Li TK, Zhang L, Li EK. Acupuncture in the treatment of rheumatoid arthritis: a double-blind controlled pilot study. BMC Complement Altern Med. 2007;7(1):35 [Epub ahead of print].

Tengstrand B, Larsson E, Klareskog L, Hafstrom I. Randomized withdrawal of long-term prednisolone treatment in rheumatoid arthritis: effects on inflammation and bone mineral density. Scand J Rheumatol. 2007;36(5):351-8.

Wasserman AM. Diagnosis and management of rheumatoid arthritis. Am Fam Physician. 2011;84(11):1245-52.

Willer B, Stucki G, Hoppeler H, Bruhlmann P, Krahenbuhl S. Effects of creatine supplementation on muscle weakness in patients with rheumatoid arthritis. Rheumatology. 2000;39(3):293-8.