Added value of ultrasound-guided percutaneous needle tenotomy over hydrodissection and physiotherapy in chronic lateral elbow tendinopathy: a pilot randomized controlled trial.

Aim of the study: There is no consensus on the most suitable non-surgical treatment of chronic lateral elbow tendinopathy. The aim of this pilot randomized controlled trial was to evaluate the size of effect of ultrasound-guided percutaneous needle tenotomy. Material and methods: Three intervention arms were formed: 1) percutaneous needle tenotomy, hydrodissection, and physiotherapy; 2) hydrodissection and physiotherapy; and 3) physiotherapy alone. Patients with chronic lateral elbow tendinopathy were randomized. Clinical endpoints included multiple questionnaires after three months: Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), Numeric Rating Scale (NRS) pain at rest and during activity, and EuroQol 5D-5L (EQ-5D-5L). Results: Thirty patients were included of 128 screened. The QuickDASH score improved in the percutaneous needle tenotomy and physiotherapy group, but not in the hydrodissection group. The NRS pain at rest and during activity improved more in the percutaneous needle tenotomy (resp. -2 and -2) and hydrodissection (resp. -3 and -3) groups than in the physiotherapy (resp. +1 and -1) group. The EQ-5D-5L improved similarly in all groups. Conclusions: Patients receiving percutaneous needle tenotomy and/or hydrodissection may show better results in terms of pain but not in their functional outcomes compared to those who received physiotherapy alone. The size of effect, however, is small, so a large sample size is needed for a future randomized controlled trial to further investigate these results.

An International Multidisciplinary Delphi-Based Consensus on Heat Therapy in Musculoskeletal Pain.

INTRODUCTION: Musculoskeletal pain (MP) is prevalent in our society, having a strong negative impact on physical and psychosocial quality of life. Heat therapy (HT) has been frequently described as a treatment strategy for musculoskeletal pain, but scientific evidence is still poor. The aim of the present Delphi method study is to gather a consensus among European experts on the role of HT in MP. METHODS: To address this topic, a list of 54 statements was developed, concerning mechanism of action of heat on muscle, types of MP eligible for heat treatment, efficacy of HT, time and modalities of treatment, maximizing compliance to HT, safety (based on heat wraps), wrong beliefs and common errors in the prescription of HT and the role of HT in preventing muscular damage in athletes. The survey was distributed to 116 European experts, using a 5-point Likert scale to express agreement or disagreement with the statements; 66% concordance with the statements was needed to define a consensus. RESULTS: Consensus was reached on 78% of statements. There was a strong consensus on the mechanism of action of heat on muscle, the indication in chronic MP, its effectiveness as part of a multimodal approach to MP and the safety and tolerability of superficial heat therapy. A low-level of consensus was obtained on the role of heat in preventing muscular damage and in acute MP. CONCLUSION: This Delphi consensus recognizes the role of HT mostly in chronic MP and highlights the need for stronger scientific evidence to regulate the use of this therapy in clinical practice.

[Lactate changes during mobilization of intensive care patients : A retrospective observational study]. / Laktatveränderungen während der Mobilisation internistischer IntensivpatientInnen : Eine retrospektive Beobachtungsstudie.

BACKGROUND: For intensive care patients the return to normal life is usually a long and strenuous journey. In addition to the severity of the underlying disease, possible comorbidities, sedation and pain management as well as the use of various drugs together with the length of stay in the intensive care unit are factors that strongly influence the course of early rehabilitation and thus the functional outcome. Intensive care patients in particular are exposed to extreme stress during mobilization and often reach their cardiopulmonary stress limit. In order to determine such limits, lactate measurement is used in the performance diagnostics of athletes. METHODS: In a retrospective study 20 intensive care patients were mobilized up to their subjective maximum load capacity during physiotherapy (sitting on the edge of the bed n = 6, standing n = 12 and walking n = 2). The lactate value was determined from the routine arterial blood gas analysis and then an attempt was made to establish a correlation between the subjectively perceived change in exercise load (Borg CR10) and the changes in lactate measurements. RESULTS: Changes in the sense of an increase in stress occurred in both in the Borg scale and in the lactate measurements. The subjective maximum load capacity increased on average by 4.85 points (p = 0.13, 95% confidence interval, CI 4.58-5.12). In addition, a significant mean increase in lactate by 10.8 mg/dl (p < 0.001, 95% CI 9.73-11.87) was observed. No positive correlation between the load-induced changes in Borg values and the development of lactate values was shown (Pearson correlation: r = 0.123). CONCLUSION: The subjective load increase in the Borg CR10 observed in all 20 intensive care patients included in the study and the associated significant increase in lactate after mobilization, suggest that an efficient load in the sense of a training-desired supercompensation was achieved through mobilization. The tendency towards a correlation between the changes in Borg CR10 and the lactate values can be interpreted as an indication that the development of lactate values can also be used in intensive care patients to avoid overloading of patients in early rehabilitation.

General and Disease-Specific Health Indicator Changes Associated with Inpatient Rehabilitation.

OBJECTIVES: Rehabilitation plays a vital role in the mitigation and improvement of functional limitations associated with aging and chronic conditions. Moderating factors such as sex, age, the medical diagnosis, and rehabilitation timing for admission status, as well as the expected change related to inpatient rehabilitation, are examined to provide a valid basis for the routine assessment of the quality of medical outcomes. DESIGN: An observational study was carried out, placing a focus on general and disease-specific health measurements, to assess representative results of multidisciplinary inpatient rehabilitation. Aspects that were possibly confounding and introduced bias were controlled based on data from a quasi-experimental (waiting) control group. MEASURES: Existing data or general health indicators were extracted from medical records. The indicators included blood pressure, resting heart rate, self-assessed health, and pain, as well as more disease-specific indicators of physical function and performance (eg, activities of daily living, walking tests, blood lipids). These are used to identify moderating factors related to health outcomes. SETTING AND PARTICIPANTS: A standardized collection of routine data from 16,966 patients [61.5 ± 12.5 years; 7871 (46%) women, 9095 (54%) men] with different medical diagnoses before and after rehabilitation were summarized using a descriptive evaluation in terms of a content and factor analysis. RESULTS: Without rehabilitation, general health indicators did not improve independently and remained stable at best [odds ratio (OR) = 0.74], whereas disease-specific indicators improved noticeably after surgery (OR = 3.20). Inpatient rehabilitation was shown to reduce the risk factors associated with certain lifestyles, optimize organ function, and improve well-being in most patients (>70%; cutoff: z-difference >0.20), with a standardized mean difference (SMD) seen in overall medical quality outcome of -0.48 ± 0.37 [pre- vs post-rehabilitation: ηp2 = 0.622; dCohen = -1.22; 95% confidence interval (95% CI) -1.24 to -1.19]. The baseline medical values obtained at the beginning of rehabilitation were influenced by indication, age, and sex (all P < .001); however, these factors have less significant effects on improvements in general health indicators (ηp2 < 0.01). According to the disease-specific results, the greatest improvements were found in older patients (SMD for patients >60 vs ≤60 years: 95% CI 0.08-0.11) and during the early rehabilitation stage (ηp2 = 0.063). CONCLUSIONS AND IMPLICATIONS: Compared with those who received no inpatient rehabilitation, patients who received rehabilitation showed greater improvements in 2 independent areas, general and disease-specific health measures, regardless of their diagnosis, age, and sex. Due to the study design and the use of a nonrandomized waiting group, causal conclusions must be drawn with caution. However, the comparability and stability of the presented results strongly support the validity of the observed improvements associated with inpatient rehabilitation.

Combined Hyperbaric Oxygen Partial Pressure at 1.4 Bar with Infrared Radiation: A Useful Tool To Improve Tissue Hypoxemia?

Tissue hypoxia contributes to the pathogenesis of several acute and chronic diseases. Hyperbaric oxygen therapy (HBO) and whole-body warming using low-temperature infrared technology (LIT) are techniques that might improve hypoxemia. Combining HBO and LIT as hyperbaric oxygen therapy combined with low-temperature infrared radiation (HBOIR) might be an approach that results in positive synergistic effects on oxygenation. LIT increases blood flow and could reduce HBO-induced vasoconstriction, and hyperoxia could compensate for the increased metabolic oxygen requirements mediated by LIT. Both LIT and HBO increase the oxygen diffusion distance in the tissues. HBOIR at 0.5 bar has been shown to be safe and feasible. However, physiological responses and the safety of HBOIR at an increased oxygen (O2) partial pressure of 1.4 bar or 2.4 atmospheres absolute (ATA) still need to be determined. The hope is that should HBOIR at an increased oxygen partial pressure of 1.4 bar be safe, future studies to examine its efficacy in patients with clinical conditions, which include peripheral arterial disease (PAD) or wound healing disorders, will follow. The results of pilot studies have shown that HBOIR at an overload pressure is safe and well tolerated in healthy participants but can generate moderate cardiovascular changes and an increase in body temperature. From the findings of this pilot study, due to its potential synergistic effects, HBOIR could be a promising tool for the treatment of human diseases associated with hypoxemia.

Methotrexate therapy impacts on red cell distribution width and its predictive value for cardiovascular events in patients with rheumatoid arthritis.

BACKGROUND: Methotrexate (MTX) is well known to affect folic acid metabolism, so MTX treatment can result in alterations of mean corpuscular volume (MCV), which may impact on red cell distribution width (RDW), as MCV levels feed into RDW calculation. We thus questioned whether RDW levels and subsequently its diagnostic utility in RA subjects, as reported before, are influenced by ongoing MTX therapy.We assessed the impact of disease modifying drug (DMARD) treatment, especially MTX, on RDW and evaluated their influence on the predictive value of RDW for cardiovascular (CV) events in patients with rheumatoid arthritis (RA). As far as we know, this is the first study evaluating the influence of MTX on RDW. METHODS: Medical treatment, disease activity, laboratory parameters and history of CV events were retrospectively analysed in 385 RA patients at disease onset and at last follow up at our clinic. Additionally, in patients with CV event, data were recorded at last follow up prior the CV event. RESULTS: Disease parameters and laboratory findings associated with a serious vascular event were older age (p < 0,001), longer disease duration (p = 0,002) and a higher RDW at diagnosis (p = 0,025). No differences in RDW levels became evident with any other treatment regimen beside MTX. MTX treated patients had significantly higher RDW compared to subjects without this drug (p < 0,001). In RA patients without MTX treatment, we found RDW level significantly different between those with versus without a CV event, whereas this difference disappeared in subjects receiving MTX. CONCLUSION: MTX impacts on RDW and might therefor reduce its prognostic value for CV events in patients taking MTX, whereas an increased RDW at diagnosis remains an early risk predictor for myocardial infarction and stroke in RA patients.

Structured Evaluation of Glioma Patients by an Occupational Therapist-Is Our Clinical Examination Enough?

BACKGROUND: Preservation of neurologic function is mandatory when offering a surgical intervention to patients with low-grade gliomas (LGGs), given that the goal of any treatment is the patient's return to their normal everyday life. OBJECTIVE: To determine whether a structured evaluation by an occupational therapist can reveal deficits that might be overseen in routine clinical examination of patients with a surgically treated LGG. METHODS: A total of 20 patients with radiographically suspected LGG were examined in a standardized fashion at 3 stages: preoperatively, postoperatively, and 3 months thereafter. Results were analyzed descriptively. RESULTS: A total of 19 patients (95%) showed no postoperative motor deficit; one suffered from akinesia due to supplementary motor area involvement and demonstrated a transient deficit with manifestation on the first postoperative day. Patients with eloquent LGGs, involving speech (n = 6, 30%), exhibited different transient speech disturbances according to the location of the lesion. Structured testing revealed a postoperative worsening of movement mirroring (upper extremity) and finger discrimination (sensory) in 5 of 20 patients (25%). Force meter evaluation of the upper extremity was decreased significantly postoperatively for the affected hemisphere, even though motor deficits were absent in most patients. The action research arm test detected deterioration in more than one half of the patients postoperatively. Patients recovered from these deficits within the first 3 months. CONCLUSIONS: Routine clinical examination and neuropsychological evaluation fail to detect mild deficits in sensory function, reactivity, and apraxia, which may have a serious impact on patients' ability to return to their normal lives and work.

Interface Management between General Practitioners and Rheumatologists-Results of a Survey Defining a Concept for Future Joint Recommendations.

OBJECTIVE: To measure the views of general practitioners (GPs) and rheumatologists in a nationwide evaluation, so as to optimise their cooperation in managing patients with inflammatory rheumatic diseases. METHODS: A questionnaire covering aspects of collaboration was sent, both by mail and/or by email, to all GPs and rheumatologists in Austria. Topics covered were (i) examinations and interventions to be performed before referral, (ii) the spectrum of diseases to be referred, and (iii) the role of GPs in follow-up and continuous management of patients. RESULTS: 1,229 GPs of the 4,016 GPs (31%) and 110 of the 180 rheumatologists (61%) responded to the questionnaire. In cases of suspected arthritis, 99% of the GPs and 92% of the rheumatologists recommended specific laboratory tests, and 92% and 70%, respectively, recommended X-rays of affected joints before referral. Rheumatoid arthritis and spondyloarthritis, psoriatic arthritis and connective tissue disease were unanimously seen as indications for referral to a rheumatologist. Only 12% of rheumatologists felt responsible for the treatment of hand osteoarthritis and fibromyalgia. 80% of GPs and 85% of rheumatologists were of the opinion that treatment with disease-modifying drugs should be initiated by a specialist. Subsequent drug prescription and administration by GPs was supported by a majority of GPs and rheumatologists, with a concomitant rheumatologist follow-up every three to six months. CONCLUSION: The considerable consensus between the two professional groups constitutes a solid base for future joint recommendations, with the aim to accelerate the diagnostic process and the initiation of adequate therapy.

Sonographic criteria for therapy follow-up in the course of ultrasound-guided intra-articular injections of hyaluronic acid in hand osteoarthritis.

OBJECTIVE: To assess the value of sonographic criteria, based on measurements of joint capsule distension and synovial hyperemia, during the course of repeated ultrasound (US)-guided intra-articular injections of hyaluronic acid (HA) in hand osteoarthritis (OA). MATERIALS AND METHODS: Thirty-three patients (28 females/5 males), with hand OA in 78 joints, were included in this study. Patients underwent sonographic evaluation at baseline and consecutively for 4 weeks at weekly US-guided intra-articular injections of HA (Hyalgan(®)). Measurements of joint thickening and joint inflammation were performed with Grey-scale and semi-quantitative Power-Doppler US (PDUS). Sonographic values were correlated with weekly patients self-assessment of pain for each treated joint. RESULTS: The mean (SD) patients self-assessment of pain statistically significantly (p<0.0001) decreased from the first [68.3(22.3)] to the last week [37.3(30.34)]. A steady pain relief could be noticed in 67 (86%) of all treated joints. Over the whole observation period, the mean (SD) joint thickening of all joints markedly decreased from 15.6mm (5.3) to 13.1mm (6.4) (p<0.0001). The PDUS-score before initiation of HA treatment was statistically significantly higher than at the end of therapy (p<0.0001). The decrease in pain statistically significantly correlated with the decrease of joint thickening and PDUS-score between baseline and the end of therapy (p<0.001). CONCLUSION: In this study, we demonstrate the meaningfulness of sonographic evaluation criteria including measurements of joint capsule distension and PDUS vascularization, both significantly correlating with the decrease of pain, during the therapy follow-up of US-guided intra-articular HA-injections in patients with hand OA.

Body image in patients with ankylosing spondylitis.

OBJECTIVES: Physical disabilities generally cause disturbances in a patient's body image. The aim of the present study is to assess the prevalence of different aspects of body image disturbances (attractiveness /self-confidence, negative body judgement, accentuation of external appearance, worry about possible physical deficits, sexual problems and physical vitality) in patients with ankylosing spondylitis (AS) in the context of the severity of impairment, mood and pain intensity. METHODS: Fifty-six patients with AS and 48 healthy controls were investigated using a questionnaire for assessing one's body (1) and the body image questionnaire (2). Furthermore, in the AS patients' medical parameters including BASMI and BASFI, pain intensity and state of well-being were assessed. RESULTS: In comparison to the controls, the AS patients reported significantly more worries about possible physical deficits. The mildly impaired patients (including significantly more women) were even more insecure than the severely impaired patients. Furthermore the patients considered themselves as being less attractive. The AS patients reported better physical vitality than the controls. This result might be due to patients carrying out regular physical activity and performing exercises with therapeutic value. There were no differences between the groups concerning sexual problems. The total group of AS patients showed normal scores in the state of well-being and did not report pain intensity as being higher than what is expected in chronic pain patients in general. CONCLUSIONS: Rheumatologists should address problems in body image in patients with AS and in severe cases psychological therapy should be initiated.

US guided injections in arthritis.

US guided procedures for diagnosis or treatment of different forms of arthritis are becoming more and more important. This review describes general considerations for fluid aspiration, articular or periarticular injections and biopsies by US guidance according to the recent literature. Guidelines regarding instrumentation, different techniques, pre- and postprocedural care as well as complications are outlined and in the second part a more detailed overview of different interventions in joints, tendons and other periarticular regions (nerves, bursae, etc.) is included. Furthermore, some newer, more sophisticated techniques are briefly discussed.

[Physical Therapy in the early treatment of ankylosing spondylitis]. / Physikalische Therapie in der Frühphase des M. Bechterew.

The primary goals of physiotherapeutic interventions at the early phase of M. Bechterew are alleviation of pain and prevention of functional impairments in patients. In order to achieve these goals, measures that have proved effective at later stages of the disease can also be implemented early in the course of the disease. Movement therapy is of particular importance, and so are thermo- and electrotherapeutic interventions. Combined with adequate pharmacotherapy, established physiotherapeutic procedures can have a positive influence on the course of this disease.

Value of contrast-enhanced ultrasound in rheumatoid arthritis.

The purpose of this review is to describe the spectrum of sonographic findings in rheumatic diseases with respect to the diagnostic potential using US contrast media which prove activity or inactivity in synovial tissue where new treatment regimes target. Synovial activity can be found in non-erosive and erosive forms of primary and secondary osteoarthritis, and in inflammatory forms of joint diseases like rheumatoid arthritis and peripheral manifestations of spondyloarthritis including, ankylosing spondylitis, Reiter's syndrome, psoriatic arthritis and enteropathic arthritis. It can also be present in metabolic and endocrine forms of arthritis, in connective tissue arthropathies like systemic lupus erythematosus or scleroderma and in infectious arthritis. Ultrasound should be used as first-line imaging modality in suspected early cases of RA and other forms of arthritis, whereas contrast-enhanced ultrasound (CEUS) can further enable for sensitive assessment of vascularity which correlates with disease activity.

Sonographic investigation of the temporomandibular joint in patients with juvenile idiopathic arthritis: a pilot study.

OBJECTIVE: To evaluate whether there are any correlations between the clinical parameters of temporomandibular joint (TMJ) arthritis and pathologic ultrasound (US) findings of the TMJ in patients with juvenile idiopathic arthritis (JIA). METHODS: We conducted prospective clinical and US investigations of the TMJs of 48 patients with JIA. The US investigation was performed by a 12-MHz high-resolution transducer, which was positioned parallel to the ramus of the mandible overlying the zygomatic arch in a closed-mouth position and maximum open-mouth position. RESULTS: Patients with > or = 5 peripheral affected joints showed significantly more sonographically diagnosed destructive changes in the TMJ than did patients with <5 affected joints. There was no significance between the number of affected peripheral joints and disc dislocation in the closed-mouth position. In the maximum open-mouth position, there was a significant correlation between the number of affected peripheral joints and disc dislocation. Patients with a JIA duration >23 months had a significantly higher rate of disc dislocation and destructive changes. Patients with a JIA duration >60 months had a significantly higher rate of destructive changes of the TMJ than patients with a disease duration <60 months, but no statistical significance was found concerning disc dislocation. CONCLUSION: The significant correlation between pathologic sonographic findings, duration of JIA, and the number of affected peripheral joints make the technique interesting for use as a diagnostic screening method.

[The medical reason for the prescription of COX-2 selective cyclo oxygenase inhibitor rofecoxib for the treatment of rheumatoid arthritis. A post-marketing surveillance study from Austria]. / Arztliche Beweggründe für die Verordnung des COX-2 selektiven Zyklooxygenasehemmers Rofecoxib bei rheumatoider Arthritis. Eine Anwendungsbeobachtung aus Osterreich.

This study was designed to analyze reasons why rheumatologists prescribed coxibs instead of non-selective NSAIDs in the treatment of rheumatoid arthritis in Austria. A simple questionnaire was distributed among interested doctors of internal or orthopedic medicine in medical practices treating patients with rheumatic diseases. 730 patients with rheumatoid arthritis could be included in this study. The argument most often mentioned was the low incidence of gastrointestinal side-effects followed by analgesic effectiveness compared with non-selective NSAIDs. Easy to use, age of patients and general tolerability were further reasons for the decision to prescribe rofecoxib.

Remitting seronegative symmetrical synovitis with pitting edema of the hands: ultrasound, color doppler ultrasound, and magnetic resonance imaging findings.

OBJECTIVE: To assess the value of gray-scale ultrasound (US), color Doppler ultrasound (CDUS), contrast-enhanced CDUS, and magnetic resonance imaging (MRI) in the diagnostic evaluation of the hands in patients with remitting seronegative symmetrical synovitis with pitting edema (RS3PE). METHODS: Eight patients (5 men, 3 women; mean +/- SD age 69.3 +/- 7.2 years) with clinical diagnosis of RS3PE syndrome underwent US, CDUS, contrast-enhanced CDUS, and MRI. US was performed with a linear array transducer operating at 12 MHz. The US contrast agent (SHU 508; Levovist, Schering, Germany) was intravenously infused in a concentration of 300 mg/ml at a rate of 1 ml/minute. RESULTS: All patients showed symmetric subcutaneous edema and synovitis of tendons and finger joints on both US and MRI. Vascularity was detected subcutaneously in tendon sheaths and in the joint synovia on CDUS and MRI. Detection of increased vascularity was improved after contrast administration compared with unenhanced CDUS (P < 0.01). CONCLUSION: Ultrasound, CDUS, contrast-enhanced CDUS, and MRI are valuable tools in the diagnostic evaluation of involved anatomic structures in patients with RS3PE. Contrast-enhanced CDUS is superior to CDUS in assessment of inflammatory edema, effusion, and synovitis.

Moderate hyperhomocysteinaemia and immune activation in patients with rheumatoid arthritis.

BACKGROUND: Moderate hyperhomocysteinaemia related to folate deficiency has been described in patients with cardiovascular risk and also in patients with autoimmune diseases including rheumatoid arthritis (RA). METHODS: In 33 patients with RA, serum concentrations of homocysteine and cysteine, of B-vitamins folate and vitamin B(12), and of immune activation markers neopterin and soluble 75-kDa TNF-receptor (sTNF-R75) were measured. RESULTS: A significant proportion of patients presented with elevated homocysteine and cysteine concentrations in comparison to reference ranges of healthy control persons. Moderate hyperhomocysteinaemia coincided with decreased serum folate and with higher concentrations of sTNF-R75 and neopterin, but it was rather independent from methotrexate (MTX) therapy. CONCLUSIONS: The coincidence of higher homocysteine and lower folate concentrations with increased concentrations of immune activation markers in patients with RA suggests that immune activation could be involved in the development of hyperhomocysteinaemia.

Increased degradation of tryptophan in blood of patients with rheumatoid arthritis.

OBJECTIVE: Activation of the enzyme indoleamine-(2,3)-dioxygenase (IDO) by interferon (IFN)-g leads to enhanced tryptophan conversion to kynurenine. In consequence of chronic immune activation, tryptophan availability is reduced, leading to inhibition of cell proliferation as protein synthesis is affected. Tryptophan deprivation due to IDO activation could therefore be effective in abrogating processes with high metabolic turnover, thus modulating cellular immune response. METHODS: Concentrations of tryptophan, kynurenine, and neopterin were measured by HPLC in the sera of 38 patients with rheumatoid arthritis (RA). The kynurenine:tryptophan ratios (kyn/trp) were calculated to estimate IDO activity. RESULTS: Tryptophan concentrations were lower in patients with RA (median, interquartile range: 44.95 microM, 40.31-49.95 microM) compared to healthy blood donors (62.62 microM, 57.27-74.61 microM; p < 0.001). Kynurenine in patients (1.86 microM, 1.54-2.31 microM) did not differ from controls (2.06 microM, 1.58-2.65 microM; NS). The kyn/trp ratio was higher in patients (42.39 mM/M, 37.02-48.60 mM/M) than in controls (31.72 mM/M; 27.95-35.03 mM/M; p < 0.001). Kynurenine concentrations (rs = 0.611; p < 0.001) and kyn/trp ratios (rs = 0.621; p < 0.001) correlated with neopterin concentrations, which indicate stimulated cellular immune response in patients with RA. CONCLUSIONS: The data point to a role of immune activation and Th1-type cytokine INF-g to induce elevated tryptophan degradation in patients with RA.

Randomized double blind trial of an extract from the pentacyclic alkaloid-chemotype of uncaria tomentosa for the treatment of rheumatoid arthritis.

OBJECTIVE: To evaluate safety and clinical efficacy of a plant extract from the pentacyclic chemotype of Uncaria tomentosa (UT) in patients with active rheumatoid arthritis (RA). METHODS: Forty patients undergoing sulfasalazine or hydroxychloroquine treatment were enrolled in a randomized 52 week, 2 phase study. During the first phase (24 weeks, double blind, placebo controlled), patients were treated with UT extract or placebo. In the second phase (28 weeks) all patients received the plant extract. RESULTS: Twenty-four weeks of treatment with the UT extract resulted in a reduction of the number of painful joints compared to placebo (by 53.2% vs 24.1%; p = 0.044). Patients receiving the UT extract only during the second phase experienced a reduction in the number of painful (p = 0.003) and swollen joints (p = 0.007) and the Ritchie Index (p = 0.004) compared to the values after 24 weeks of placebo. Only minor side effects were observed. CONCLUSION: This small preliminary study demonstrates relative safety and modest benefit to the tender joint count of a highly purified extract from the pentacyclic chemotype of UT in patients with active RA taking sulfasalazine or hydroxychloroquine.