**3.1 Tai Chi mind-body therapeutics**

In the past two decades, the literature has consistently recognized the potential therapeutic benefits of Tai Chi mind-body exercise. Significant improvements have been reported in balance, strength, flexibility, cardiovascular and respiratory function, mood, depression and anxiety, self-efficacy, pain reduction and health-related quality of life in diverse eastern and western populations for a variety of chronic conditions (Wang et al., 2004). Several recent reviews have further suggested that Tai Chi appears to improve a variety of medical conditions (Adler & Roberts, 2006; Jahnke et al., 2010; Rogers et al., 2009; Wang et al., 2010a; Yeh et al., 2009).

Tai Chi, a traditional Chinese mind-body exercise, has grown in popularity in the United States. According to the 2007 National Health Interview Survey, around 2.5 million

Complementary and Alternative Medicine in the Treatment of Rheumatoid Arthritis 359

The author's group systematically reviewed the evidence of the effects of Tai Chi on stress, anxiety, depression and mood disturbance in various eastern and western populations (Wang et al., 2010a). Specifically, the results of 33 randomized and nonrandomized trials suggest that regular Tai Chi practice is significantly associated with improvements in psychological well-being including reduced stress (effect size, 0.66; 95% confidence interval [CI], 0.23 to 1.09), anxiety (effect size, 0.66; 95% CI, 0.29 to 1.03), depression (effect size, 0.56; 95% CI, 0.31 to 0.80), and mood disturbance (effect size, 0.45; 95% CI, 0.20 to 0.69) in healthy participants and patients with chronic conditions. Seven observational studies with relatively large sample sizes reinforced the beneficial association between Tai Chi practice and psychological health. Notably, the review found that Tai Chi tended to reduce depression compared to various controls among individuals with osteoarthritis (Fransen et al., 2007; Wang et al., 2009), rheumatoid arthritis (Wang, 2008b) fibromyalgia (Taggart et al., 2003; Wang et al., 2010b), depression disorders (Chou et al., 2004), sedentary obese women (Dechamps et al., 2009), and elderly participants with cardiovascular disease risk factors (Taylor-Piliae et al., 2006). This positive result was associated with improvement in symptoms and physical function in patients with rheumatoid arthritis and other chronic conditions. Interestingly, the benefits were also associated with an improvement in the immune respons. A 50% improvement in varicella zoster virus-specific cell-mediated immunity (T cell-dependent response) after 15 and 25 weeks of Tai Chi in healthy elderly Americans (Irwin et al., 2003;

However, the vast majority of the studies suffer from less rigorous designs with only two studies reporting results on participants diagnosed with clinical depression. Nevertheless, the potential mental health benefits of Tai Chi mind-body therapy support its inclusion as a key component of a multidisciplinary medical approach to promote psychological health, treat chronic pain, and better inform clinical decision-making for rheumatoid arthritis. As a chronic disorder characterized by inflammation leading to joint destruction, rheumatoid arthritis has increased clinically important comorbidities including cardiovascular complications and osteoporosis. Numerous studies have evaluated the effects of Tai Chi on cardiovascular and respiratory function (Lai et al., 1993; Lai et al., 1995; Lan et al., 1996; Lan et al., 1998; Lan et al., 1999). Since 1979, results related to the effect of Tai Chi on cardiovascular and pulmonary function have been reported in 43 eastern and western publications (Wang et al., 2004; Yeh et al., 2008; Yeh et al., 2009). Among them, one study (Zhuo et al., 1984) reported that the metabolic intensity of the activity seems insufficient to generate improvements of cardiorespiratory fitness in healthy young adults. Yet, all other studies suggested that regular Tai Chi practice may preserve cardiorespiratory function in older individuals and may be prescribed as a suitable exercise for older adults. Our systematic reviews of literature have shown that Tai Chi can reduce blood pressure and increase cardiovascular exercise capacity (Yeh et al., 2008; Yeh et al., 2009). A very recent large single-blind, multisite, randomized controlled trial evaluated a 12 week Tai Chi exercise in patients with heart failure (Yeh et al., 2011). At completion of the study, patients in the Tai Chi group had greater improvements in quality of life (P=0.02), exercise selfefficacy (P<0.001) and mood (P=0.01). The authors concluded that Tai Chi exercise, a multicomponent mind-body training modality that is safe and has good rates of adherence, may provide value in improving daily exercise, quality of life, mood, and exercise self-efficacy in patients with chronic heart failure. Thus, encouraging evidence suggests that Tai Chi may be a safe and beneficial adjunctive therapy to conventional care for patients with rheumatoid

arthritis-associated cardiovascular disease and related complications.

Irwin et al., 2007) was observed.

Americans have practiced Tai Chi for health reasons and that number is increasing (Barnes et al., 2009). Furthermore, individuals with musculoskeletal conditions are more likely to practice Tai Chi (Birdee et al., 2009). It is clear that our patients with rheumatic disease are interested in seeking this type of complementary and alternative treatment. Thus, it is important to examine the evidence base for mind-body medicine to provide the clinician with an overview of these new sources of knowledge for the best care for our rheumatic patients.

### **3.2 Scientific evaluation of Tai Chi for rheumatoid arthritis**

One early publication by Kirsteins and colleagues reported on two non-randomized controlled trials of 47 and 28 rheumatoid arthritis patients with 10 weeks Tai Chi training. Disease activity (joint tenderness, number of swollen joints), 50 foot walks, handgrip strength, a written functional assessment, and exacerbation of joint symptoms were measured. The studies showed that Tai Chi appears to be safe for rheumatoid arthritis patients and may serve as a suitable weight-bearing exercise with the additional potential advantages of stimulating bone growth and strengthening connective tissue (Kirsteins et al., 1991).

Two randomized controlled trials were recently published in Korea. A study of 31 patients reported by Lee showed that compared with a usual care group, 6 weeks of Tai Chi training significantly improved mood and sleep disturbance (Lee, 2005). Another trial of 61 patients showed that 50 minutes per week of Tai Chi training for 12 weeks significantly decreased pain and fatigue compared to usual care controls (Lee & Jeong, 2006).

To obtain preliminary data on the effects of Tai Chi on rheumatoid arthritis, the author's research group conducted a pilot randomized controlled trial (Wang, 2008b). Twenty patients with functional Class I or II rheumatoid arthritis were randomly assigned to Tai Chi or attention control in twice-weekly sessions for 12 weeks. The American College Rheumatology 20 response criteria, functional capacity, health-related quality of life and the depression index were assessed. At 12 weeks, 5/10 patients (50%) randomized to Tai Chi achieved an American College Rheumatology 20% response compared with 0/10 (0%) in the control (p= 0.03). Tai Chi had greater improvement in the Disability Index (p = 0.01), Vitality subscale of the SF-36 (p = 0.01) and the Depression Index (p = 0.003). Similar trends to improvement were also observed for disease activity, functional capacity and health related quality of life. No adverse events were observed and no patients withdrew from the study, suggesting that Tai Chi is safe and may be beneficial for Functional Class I or II rheumatoid arthritis.

A subsequent study of Tai Chi in rheumatoid arthritis patients by Uhlig and colleagues, however, has produced inconsistent results. A with-in group comparison study involving 15 female patients with rheumatoid arthritis aged 40-70 years, participating in 8-week Tai Chi training showed no improvements in disease activity, muscle strength, flexibility, balance and health status (Uhlig et al., 2005). The second study from the same group of investigators overcame the previous limitations, using a 12-week Tai Chi program for another 15 patients. They found that Tai Chi improved lower-limb muscle function and endurance at 12 weeks follow-up (Uhlig et al., 2010). A Cochrane review, examining the evidence from 4 clinical trials, suggested that Tai Chi does not exacerbate symptoms of rheumatoid arthritis and has some benefits on lower extremity range of motion for people with rheumatoid arthritis, in particular ankle range of motion (Han et al., 2004).

Chronic pain in rheumatoid arthritis is commonly accompanied by psychosocial stress, anxiety and depression. Therapeutic approaches with psychological and behavioral impact, such as Tai Chi mind-body therapy, could better patients' emotional health outcomes (Bradley & Alberts, 1999).

Americans have practiced Tai Chi for health reasons and that number is increasing (Barnes et al., 2009). Furthermore, individuals with musculoskeletal conditions are more likely to practice Tai Chi (Birdee et al., 2009). It is clear that our patients with rheumatic disease are interested in seeking this type of complementary and alternative treatment. Thus, it is important to examine the evidence base for mind-body medicine to provide the clinician with an overview of these

One early publication by Kirsteins and colleagues reported on two non-randomized controlled trials of 47 and 28 rheumatoid arthritis patients with 10 weeks Tai Chi training. Disease activity (joint tenderness, number of swollen joints), 50 foot walks, handgrip strength, a written functional assessment, and exacerbation of joint symptoms were measured. The studies showed that Tai Chi appears to be safe for rheumatoid arthritis patients and may serve as a suitable weight-bearing exercise with the additional potential advantages of

Two randomized controlled trials were recently published in Korea. A study of 31 patients reported by Lee showed that compared with a usual care group, 6 weeks of Tai Chi training significantly improved mood and sleep disturbance (Lee, 2005). Another trial of 61 patients showed that 50 minutes per week of Tai Chi training for 12 weeks significantly decreased

To obtain preliminary data on the effects of Tai Chi on rheumatoid arthritis, the author's research group conducted a pilot randomized controlled trial (Wang, 2008b). Twenty patients with functional Class I or II rheumatoid arthritis were randomly assigned to Tai Chi or attention control in twice-weekly sessions for 12 weeks. The American College Rheumatology 20 response criteria, functional capacity, health-related quality of life and the depression index were assessed. At 12 weeks, 5/10 patients (50%) randomized to Tai Chi achieved an American College Rheumatology 20% response compared with 0/10 (0%) in the control (p= 0.03). Tai Chi had greater improvement in the Disability Index (p = 0.01), Vitality subscale of the SF-36 (p = 0.01) and the Depression Index (p = 0.003). Similar trends to improvement were also observed for disease activity, functional capacity and health related quality of life. No adverse events were observed and no patients withdrew from the study, suggesting that Tai Chi is safe

A subsequent study of Tai Chi in rheumatoid arthritis patients by Uhlig and colleagues, however, has produced inconsistent results. A with-in group comparison study involving 15 female patients with rheumatoid arthritis aged 40-70 years, participating in 8-week Tai Chi training showed no improvements in disease activity, muscle strength, flexibility, balance and health status (Uhlig et al., 2005). The second study from the same group of investigators overcame the previous limitations, using a 12-week Tai Chi program for another 15 patients. They found that Tai Chi improved lower-limb muscle function and endurance at 12 weeks follow-up (Uhlig et al., 2010). A Cochrane review, examining the evidence from 4 clinical trials, suggested that Tai Chi does not exacerbate symptoms of rheumatoid arthritis and has some benefits on lower extremity range of motion for people

Chronic pain in rheumatoid arthritis is commonly accompanied by psychosocial stress, anxiety and depression. Therapeutic approaches with psychological and behavioral impact, such as Tai Chi mind-body therapy, could better patients' emotional health outcomes

stimulating bone growth and strengthening connective tissue (Kirsteins et al., 1991).

new sources of knowledge for the best care for our rheumatic patients.

pain and fatigue compared to usual care controls (Lee & Jeong, 2006).

and may be beneficial for Functional Class I or II rheumatoid arthritis.

with rheumatoid arthritis, in particular ankle range of motion (Han et al., 2004).

(Bradley & Alberts, 1999).

**3.2 Scientific evaluation of Tai Chi for rheumatoid arthritis** 

The author's group systematically reviewed the evidence of the effects of Tai Chi on stress, anxiety, depression and mood disturbance in various eastern and western populations (Wang et al., 2010a). Specifically, the results of 33 randomized and nonrandomized trials suggest that regular Tai Chi practice is significantly associated with improvements in psychological well-being including reduced stress (effect size, 0.66; 95% confidence interval [CI], 0.23 to 1.09), anxiety (effect size, 0.66; 95% CI, 0.29 to 1.03), depression (effect size, 0.56; 95% CI, 0.31 to 0.80), and mood disturbance (effect size, 0.45; 95% CI, 0.20 to 0.69) in healthy participants and patients with chronic conditions. Seven observational studies with relatively large sample sizes reinforced the beneficial association between Tai Chi practice and psychological health. Notably, the review found that Tai Chi tended to reduce depression compared to various controls among individuals with osteoarthritis (Fransen et al., 2007; Wang et al., 2009), rheumatoid arthritis (Wang, 2008b) fibromyalgia (Taggart et al., 2003; Wang et al., 2010b), depression disorders (Chou et al., 2004), sedentary obese women (Dechamps et al., 2009), and elderly participants with cardiovascular disease risk factors (Taylor-Piliae et al., 2006). This positive result was associated with improvement in symptoms and physical function in patients with rheumatoid arthritis and other chronic conditions. Interestingly, the benefits were also associated with an improvement in the immune respons. A 50% improvement in varicella zoster virus-specific cell-mediated immunity (T cell-dependent response) after 15 and 25 weeks of Tai Chi in healthy elderly Americans (Irwin et al., 2003; Irwin et al., 2007) was observed.

However, the vast majority of the studies suffer from less rigorous designs with only two studies reporting results on participants diagnosed with clinical depression. Nevertheless, the potential mental health benefits of Tai Chi mind-body therapy support its inclusion as a key component of a multidisciplinary medical approach to promote psychological health, treat chronic pain, and better inform clinical decision-making for rheumatoid arthritis.

As a chronic disorder characterized by inflammation leading to joint destruction, rheumatoid arthritis has increased clinically important comorbidities including cardiovascular complications and osteoporosis. Numerous studies have evaluated the effects of Tai Chi on cardiovascular and respiratory function (Lai et al., 1993; Lai et al., 1995; Lan et al., 1996; Lan et al., 1998; Lan et al., 1999). Since 1979, results related to the effect of Tai Chi on cardiovascular and pulmonary function have been reported in 43 eastern and western publications (Wang et al., 2004; Yeh et al., 2008; Yeh et al., 2009). Among them, one study (Zhuo et al., 1984) reported that the metabolic intensity of the activity seems insufficient to generate improvements of cardiorespiratory fitness in healthy young adults. Yet, all other studies suggested that regular Tai Chi practice may preserve cardiorespiratory function in older individuals and may be prescribed as a suitable exercise for older adults. Our systematic reviews of literature have shown that Tai Chi can reduce blood pressure and increase cardiovascular exercise capacity (Yeh et al., 2008; Yeh et al., 2009). A very recent large single-blind, multisite, randomized controlled trial evaluated a 12 week Tai Chi exercise in patients with heart failure (Yeh et al., 2011). At completion of the study, patients in the Tai Chi group had greater improvements in quality of life (P=0.02), exercise selfefficacy (P<0.001) and mood (P=0.01). The authors concluded that Tai Chi exercise, a multicomponent mind-body training modality that is safe and has good rates of adherence, may provide value in improving daily exercise, quality of life, mood, and exercise self-efficacy in patients with chronic heart failure. Thus, encouraging evidence suggests that Tai Chi may be a safe and beneficial adjunctive therapy to conventional care for patients with rheumatoid arthritis-associated cardiovascular disease and related complications.

Complementary and Alternative Medicine in the Treatment of Rheumatoid Arthritis 361

Chinese herbal remedy TwHF administered from four weeks to over 24 weeks may be both

Tibetan Five Nectar Formula is derived from five types of plants and has been considered to have anti-inflammatory and immunomodulating effects for rheumatoid arthritis when used as bath therapy. To understand the beneficial effect of Tibetan Five Nectar Formula Medicated-Bath Therapy on patients with rheumatoid arthritis, the author's research group has recently conducted a comprehensive review of the literature of Tibetan Five Nectar Formula Medicated-Bath Therapy on patients with rheumatoid arthritis (Jacobson

Eighty-seven potentially relevant studies were identified. Nine non-randomized controlled trials of 757 subjects met eligibility criteria (Jacobson et al., 2010). All the trials were conducted in the Tibetan area of China and used the Five Nectar formula in the Tibetan Medicated-Bath. Bath temperatures were of 35-46 0C for 10-15 min, once or twice a day. Mean treatment duration ranged from 7-30 days per course, for 1-3 courses. Two studies stopped some or all western medications during treatment. The 9 studies also used supplemental oral Tibetan herbal therapy. The effect of the Tibetan Five Nectar Formula Medicated-Bath Therapy on clinical symptoms was measured with Physician-assessed composite outcomes. All studies reported a positive association between the Tibetan Five Nectar Formula Medicated-Bath Therapy and improved clinical pain symptoms within group comparisons. In addition, three studies reported an improvement in immune function. There are discordant trial designs and lack of reported qualitative outcomes measure were among other methodological limitations. The overall study quality was poor with no controls or randomization, blinding or reports of dropout rates. However, these studies suggest that Tibetan Five Nectar Formula Medicated-Bath Therapy may be helpful in the treatment of pain symptoms due to rheumatoid arthritis. However, they are of only weak evidentiary value due to uniformly poor methodological quality. Future studies with

In summary, as a complex immunologically mediated disorder, rheumatoid arthritis is still a therapeutically challenging chronic condition to control. Emerging evidence from clinical trials reviewed here support that evidence-based complementary and alternative medicine or integrative medicine therapies may offer effective treatments for patients with Rheumatoid Arthritis. Integrative approaches combine the best of conventional medicine and the wisdom of complementary and alternative medical approaches. These modalities may lead to the development of better lifestyle modifying strategies, while mind-body medicine such as Tai Chi exercise could affect progression of disease and decrease morbidity and mortality among individuals with rheumatoid arthritis. While existing evidence regarding complementary and alternative medicine on rheumatoid arthritis remains limited and inconclusive, the promising results suggest that these complementary and alternative medicine treatments may be a safe adjunctive therapy for rheumatoid

**5. Tibetan Five Nectar Formula medicated bath therapy for pain relief in** 

effective and safe in treating patients with active rheumatoid arthritis.

more rigorous design and adequate statistical analysis are warranted.

**patients with RA** 

et al., 2010).

**6. Conclusion** 

arthritis and warrant further exploration.

Taken together, these trials show that Tai Chi may provide some important components in the treatment of Rheumatoid Arthritis. Further research should focus on ideal dose and duration of intervention to provide valuable information about how Tai Chi may be best used in clinical practice.
