not affect the underlying disease and appear to have no effect on people's long term disease course and thus are no longer first line agents. nsaids should be used with caution in those with gastrointestinal, cardiovascular, or kidney problems. rofecoxib was withdrawn from the global market as its long-term use was associated to an increased risk of heart attacks and strokes. use of methotrexate together with nsaids is safe, if adequate monitoring is done. cox-2 inhibitors, such as celecoxib, and nsaids are equally effective. a 2004 cochrane review found that people preferred nsaids over paracetamol. however, it is yet to be clinically determined whether nsaids are more effective than paracetamol. the neuromodulator agents topical capsaicin may be reasonable to use in an attempt to reduce pain. nefopam by mouth and cannabis are not recommended as of 2012 as the risks of use appear to be greater than the benefits. limited evidence suggests the use of weak oral opioids but the adverse effects may outweigh the benefits. alternatively, physical therapy has been tested and shown as an effective aid in reducing pain in patients with ra. as most ra is detected early and treated aggressively, physical therapy plays more of a preventative and compensatory role, aiding in pain management alongside regular rheumatic therapy. surgery especially for affected fingers, hands, and wrists, synovectomy may be needed to prevent pain or tendon rupture when drug treatment has failed. severely affected joints may require joint replacement surgery, such as knee replacement. postoperatively, physiotherapy is always necessary.: 1080, 1103 there is insufficient evidence to support surgical treatment on arthritic shoulders. physiotherapy for people with ra, physiotherapy may be used together with medical management. this may include cold and heat application, electronic stimulation, and hydrotherapy. although medications improve symptoms of ra, muscle function is not regained when disease activity is controlled. physiotherapy promotes physical activity. in ra, physical activity like exercise in the appropriate dosage (frequency, intensity, time, type, volume, progression) and physical activity promotion is effective in improving cardiovascular fitness, muscle strength, and maintaining a long term active lifestyle. in the short term, resistance exercises, with or without range of motion exercises, improve self-reported hand functions. physical activity promotion according to the public health recommendations should be an integral part of standard care for people with ra and other arthritic diseases. additionally, the combination of physical activities and cryotherapy show its efficacy on the disease activity and pain relief. the combination of aerobic activity and cryotherapy may be an innovative therapeutic strategy to improve the aerobic capacity in arthritis patients and consequently reduce their cardiovascular risk while minimizing pain and disease activity. compression gloves compression gloves are handwear designed to help prevent the occurrence of various medical disorders relating to blood circulation in the wrists and hands. they can be used to treat the symptoms of arthritis, though the medical benefits may be limited. alternative medicine in general, there is not enough evidence to support any complementary health approaches for ra, with safety concerns for some of them. some mind and body practices and dietary supplements may help people with symptoms and therefore may be beneficial additions to conventional treatments, but there is not enough evidence to draw conclusions. a systematic review of cam modalities (excluding fish oil) found that " the available evidence does not support their current use in the management of ra.". studies showing beneficial effects in ra on a wide variety of cam modalities are often affected by publication bias and are generally not high quality evidence such as randomized controlled trials (rcts). a 2005 cochrane review states that low level laser therapy can be tried to improve pain and morning stiffness due to rheumatoid arthritis as there are few side-effects. there is limited evidence that tai chi might improve the range of motion of a joint in persons with rheumatoid arthritis. the evidence for acupuncture is inconclusive with it appearing to be equivalent to sham acupuncture. a cochrane review in 2002 showed some benefits of the electrical stimulation as a rehabilitation intervention to improve the power of the hand grip and help to resist fatigue. d‐penicillamine may provide similar benefits as dmards but it is also highly toxic. low-quality evidence suggests the use of therapeutic ultrasound on arthritic hands. potential benefits include increased grip strength, reduced morning stiffness and number of swollen joints. there is tentative evidence of benefit of transcutaneous electrical nerve stimulation (tens) in ra. acupuncture‐like tens (al-tens) may decrease pain intensity and improve muscle power scores. low-quality evidence suggests people with active ra may benefit from assistive technology. this may include less discomfort and difficulty such as when using an eye drop device. balance training is of unclear benefits. fatty acids there has been a growing interest in the role of long-chain omega-3 polyunsaturated fatty acids to reduce inflammation and alleviate the symptoms of ra. metabolism of omega-3 polyunsaturated fatty acids produces docosahexaenoic acid (dha) and eicosapentaenoic acid (epa), which inhibits pro-inflammatory eicosanoids and cytokines (tnf-a, il-1b and il-6), decreasing both lymphocyte proliferation and reactive oxygen species. these studies showed evidence for significant clinical improvements on ra in inflammatory status and articular index. gamma-linolenic acid, an omega-6 fatty acid, may reduce pain, tender joint count and stiffness, and is generally safe. for omega-3 polyunsaturated fatty acids (found in fish oil, flax oil and hemp oil), a meta-analysis reported a favorable effect on pain, although confidence in the effect was considered moderate. the same review reported less inflammation but no difference in joint function. a review examined the effect of marine oil omega-3 fatty acids on pro-inflammatory eicosanoid concentrations; leukotriene4 (ltb4) was lowered in people with rheumatoid arthritis but not in those with non-autoimmune chronic diseases. (ltb4) increases vascular permeabiltity and stimulates other inflammatory substances. a third meta-analysis looked at fish consumption. the result was a weak, non-statistically significant inverse association between fish consumption and ra. a fourth review limited inclusion to trials in which people eat ≥2.7 g/day for more than three months. use of pain relief medication was decreased, but improvements in tender or swollen joints, morning stiffness and physical function were not changed. collectively, the current evidence is not strong enough to determine that supplementation with omega-3 fatty acids or regular consumption of fish are effective treatments for rheumatoid arthritis. diets patients with ra often claim that their symptoms are alleviated by special diets or by simple elimination of certain foods. in contrast, some foods might provoke hypersensitivity responses, which may increase symptoms of ra. the dong diet has been suggested for a benefit in ra. this diet is rich in oils, seafood, vegetables, and rice which improve symptoms of ra. it eliminates citrus fruits, chocolate, dairy produce, flour products, alcohol, additives, spices, fizzy drinks, and red meat which are implicated in the aggravation of symptoms. the mediterranean diet is a well‐balanced, nutritionally adequate diet that encompasses all the food groups. this diet is rich in fresh fruits and vegetables, whole grains, seafood, nuts and legumes, and olive oil. in contrast, it limits red meat, sugary foods, and dairy, in small portions of yogurt and cheese. the foods in this category parallel the dong diet closely and show evidence of overlap. there is beneficial effect in using a mediterranean diet and dong diet for a reduction in the number of tender joints, stiffness, and pain. vitamins adequate vitamin concentrations may provide an important defence against the increased oxidant stress in patients with ra. here we look at the effects of vitamins e, c and b on the management of ra. in general vitamin e deficiency enhances components of the inflammatory response and suppresses components of the immune response. molecular studies have demonstrated that the formation of the pro-inflammatory prostaglandin e2 is inhibited 95% by aspirin when combined with vitamin e compared to control. this suggests that vitamin e supplementation reduces the need for high dosage of aspirin needed by patients with ra to relieve joint symptoms. this can offer double benefits because lowering the dose of aspirin can also reduce the gastric irritation side effect for patients. even though there is no evidence of only taking vitamin e supplementation alone, i believe patients with ra should be encouraged to increase their consumption of vitamin e rich cereals, fruit, and vegetables. vitamin c is necessary for the growth and development of all body tissues and plays an important role in antioxidant defences. in animal studies biochemical markers of antioxidant defence mechanisms were increased with vitamin c supplementation and infiltration of inflammatory cells into synovial fluid were decreased. from these studies i can conclude that vitamin c supplementation may be more effective for the pain associated with ra however long-term use might aggravate onset of osteoarthritis. vitamin b6 and b9 play a role in ra management as well. studies have shown that low plasma levels of pyridoxal-5-phosphate, the metabolically active form of vitamin b6, have been reported in ra patients, which may be associated with the elevated tnf-a production. folate supplies are also decreased in ra patients who are taking methotrexate, an anti-rheumatic drug. we see that folate supplementation can reduce the mucosal and gastrointestinal side effects of low dose methotrexate in patients with ra. this works in a similar pattern to aspirin and vitamin e supplementation. therefore, ra patients should be advised to consume dietary sources of vitamin b6 and b9 up to the dietary reference value, until further research is undertaken into the toxicity and effectiveness of large dose supplementation. food containing high source of vitamin e to help treat rheumatoid arthritis include almonds, avocados, spinach, sunflower seeds and peanut butter. vitamin c foods include oranges, orange juice, strawberry, broccoli, brussel sprouts and potatoes. brown rice, barley, and fish contain sources of vitamin b6 and b9. lastly, vitamin d can be included in the diet by incorporating tuna, salmon, orange juice and almond milk into diet. minerals minerals including fluoride, iron, calcium, and zinc have been studied in the role of ra management. the effects of fluoride supplementation in preventing ra-induced bone loss were examined in a randomized control trial. results suggest that fluoride therapy may increase vertebral bone mass in ra patients. approximately, one-third of cases of anaemia in ra patients may be caused by depletion of iron stores. a major cause for iron deficiency anaemia is the poor dietary intake. deferioxamine, an iron-chelating agent, which has possible anti-inflammatory properties, causes haemoglobin and serum iron levels to increases. this shows that iron stores are needed within the body and an adequate dietary intake to meet the recommended intakes should be encouraged, even though there is no evidence for additional routine supplementation for patients with ra. studies have examined the effect of calcium supplementation on bone mineral density among subjects taking corticosteroids. a study of calcium combined with vitamin d3 in ra patients taking low-dose corticosteroids demonstrated a reduction in bone mineral density loss in both the spine and trochanter, but not the femoral neck. however, no change was seen in bmd with calcium and vitamin d3 supplementation in ra patients not receiving corticosteroids. therefore, there is little evidence to support calcium and vitamin d supplementation in corticosteroid receiving ra patients. lastly, low levels of serum zinc have been reported in patients with ra which may be caused by elevated il-1b levels. however, zinc supplementations yield contradictory results and at present do not support a therapeutic use of zinc. food containing high source of fluoride to help treat rheumatoid arthritis include tomatoes, oranges, bell peppers and grapefruit, which you should eat in moderation. iron can be incorporated into the diet by eating seafood, spinach, and peas. moderate amounts of calcium should be included into the diet by having milk, cheese, dairy products, curly kale, okra, bread and fortified flour products such as cereals. herbal the american college of rheumatology states that no herbal medicines have health claims supported by high-quality evidence and thus they do not recommend their use. there is no scientific basis to suggest that herbal supplements advertised as "natural" are safer for use than conventional medications as both are chemicals. herbal medications, although labelled "natural", may be toxic or fatal if consumed. due to the false belief that herbal supplements are always safe, there is sometimes a hesitancy to report their use which may increase the risk of adverse reaction.