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      <span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Recent advances have improved drug treatment of rheumatoid arthritis &#40;RA&#41;&#46; Despite this fact&#44; most RA patients need lifelong pharmacological therapy&#46; An increasing number of RA patients are resorting to various complementary and alternative medicine &#40;CAM&#41; approaches for relief of symptoms and general well-being&#46; CAM is the term for medical products and practices that are not part of standard care and are not generally taught in conventional medical schools&#46; Alternative medicine is used instead of conventional medicine&#44; whereas complementary medicine is used together with it&#46; CAM has been mainly used to treat back pain or other back problems&#44; neck pain&#44; joint pain or stiffness and anxiety or depression in RA patients&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">1</span></a> For this reason&#44; rheumatologists should be aware of CAM when treating RA patients&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The American College of Rheumatology &#40;ACR&#41; recognizes the interest in CAM approaches in the Position Statement Document&#46; &#8220;The ACR supports rigorous scientific evaluation of all modalities that improve the treatment or rheumatic diseases&#46; The ACR understands that certain characteristics of some CAMs and some conventional medical interventions make it difficult or impossible to conduct standard randomized controlled trials&#46; For these modalities&#44; innovative methods of evaluation are needed&#44; as are measures and standards for the generation and interpretation of evidence&#46; The ACR supports the integration of those modalities proven to be safe and effective by scientifically rigorous clinical trials published in the biomedical peer review literature&#46; In the absence of such rigorous clinical trials&#44; the ACR recommends advising patients that potential harm can occur from unproven or alternative therapies and thus advises caution in the use of unproven treatments&#46; The ACR believes healthcare providers should be informed about the more common CAM modalities&#44; based upon appropriate scientific evaluation as described above&#44; and should be able to discuss them knowledgeably with patients&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">This article provides an overview of the current body of knowledge about the role of CAM in the treatment of RA&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">In order to explore available evidence about CAM used in RA patients&#44; we performed a systematic search including Medline and Cochrane library databases&#46; Medline search was performed including the following appropriate combination of MeSH &#40;Medical Subject Heading&#41; terms including&#58; &#8220;complementary therapies&#8221;&#44; &#8220;diet&#8221;&#44; &#8220;dietary supplements&#8221;&#44; &#8220;phytotherapy&#8221;&#44; &#8220;medicinal plants&#8221;&#44; &#8220;exercise&#8221;&#44; &#8220;mind-body therapies&#8221;&#44; &#8220;acupuncture&#8221;&#44; &#8220;homeopathy&#8221;&#44; &#8220;hydrotherapy&#8221; AND &#8220;rheumatoid arthritis&#8221;&#46; The references cited in the obtained papers were also examined to identify additional studies not indexed by MEDLINE&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Nutrition</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Nutritional intervention</span><p id="par0025" class="elsevierStylePara elsevierViewall">Nutritional intervention has been used in patients with chronic inflammatory diseases&#46; Specifically&#44; nutritional intervention used in RA patients included&#58; supervised fasting &#40;200&#8211;300<span class="elsevierStyleHsp" style=""></span>kcal&#47;day&#41; during 7&#8211;10 days&#44; Mediterranean diet &#40;small amount of meat&#44; fish&#44; more fruits and vegetables and olive oil&#41;&#44; vegetarian diet&#44; vegan diet&#44; elemental diet &#40;liquid diets that contain nutrients that are broken down to make digestion easier&#41; and elimination diet &#40;foods that are thought to be the cause of symptoms are eliminated&#44; and then added one at a time to find which ones cause symptoms&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">There is evidence that fasting produces a decrease in pain and inflammation in RA patients&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">3</span></a> However&#44; the inflammation reappears when the patient starts his&#47;her normal diet&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">4</span></a> It has been shown that fasting followed by a vegetarian diet may help patients with RA&#46; The effect of fasting followed by a year of a vegetarian diet was assessed in a randomized&#44; single-blind controlled trial&#46;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">5</span></a> The diet group showed a significant improvement in the number of tender joints&#44; Ritchie&#39;s articular index&#44; number of swollen joints&#44; pain score&#44; duration of morning stiffness&#44; grip strength&#44; erythrocyte sedimentation rate&#44; C-reactive protein&#44; white blood cell count&#44; and a health assessment questionnaire score &#40;HAQ&#41;&#46; These benefits in the diet group were still present after one year<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">5</span></a> and this improvement can be sustained through an additional follow-up two-year diet period&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">A Mediterranean diet has been proved to reduce blood pressure&#59; improve glucose metabolism&#44; the lipid profile&#44; and lipoprotein particle characteristics and decrease inflammation and oxidative stress&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">7</span></a> In RA patients&#44; a Mediterranean diet decreases pain&#44; morning stiffness&#44; the number of swollen joints and also improves HAQ&#44; Disease Activity Score 28 &#40;DAS28&#41; and disease patient perception&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">7</span></a> Three systematic reviews stated that a Mediterranean diet decreased pain in RA patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">8&#8211;10</span></a> Moreover&#44; the Mediterranean diet has been recommended for cardiovascular diseases and osteoporosis &#40;frequent RA comorbidities&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">A Cochrane review<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">8</span></a> assessed the effectiveness and safety of dietary interventions in the treatment of RA&#46; The authors concluded that fasting&#44; followed by 13 months on a vegetarian diet&#44; may reduce pain&#46; The effects of vegan and elimination diets are uncertain due to inadequate data reporting&#46; Trials that studied elemental diets reported no significant differences in pain&#44; function or stiffness&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Nutritional supplements</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Fish oil</span><p id="par0045" class="elsevierStylePara elsevierViewall">Fish oil is rich in &#937;-3 polyunsaturated fatty acids &#40;PUFAs&#41;&#44; eicosapentaenoic acid &#40;EPA&#41; and docosahexaenoic acid &#40;DHA&#41;&#44; which have been associated with reduced expression of TNF-&#945; and interleukin-1&#946;&#46;<a class="elsevierStyleCrossRefs" href="#bib0530"><span class="elsevierStyleSup">11&#44;12</span></a> These properties are similar to synthetic drugs used in RA patients such as nonsteroidal anti-inflammatory drugs &#40;NSAIDs&#41; and TNF blockers&#46; Furthermore&#44; EPA and DHA can be metabolized in E-series and D-series of resolvins that reduce inflammation&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">13</span></a> The American Heart Association recommends consuming fish oil to reduce the occurrence of cardiovascular disease events in patients with coronary artery disease&#46;<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">14</span></a> RA patients present high cardiovascular morbid-mortality rate and fish oil consumption could represent an additional benefit in this population&#46; A meta-analysis suggested that including omega-3 PUFAs at dosages &#62;2&#46;7<span class="elsevierStyleHsp" style=""></span>g&#47;day in the diet for &#62;3 months reduces NSAID consumption in RA patients&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">15</span></a> A systematic review including 23 randomized controlled trials testing marine &#937;-3 PUFAs has been performed in patients with RA&#46; This review has showed a modest benefit on joint swelling and pain&#44; duration of morning stiffness&#44; global assessment of pain and disease activity&#44; and a reduction in the use of NSAIDs&#46;<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">16</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Proudman et al&#46; studied in a randomized&#44; double-blind controlled trial the effects of fish oil consumption in early RA&#44; employing a &#8216;treat-to-target&#8217; protocol in combination with disease-modifying anti-rheumatic drugs &#40;DMARDs&#41;&#46; Fish oil intake was associated with a higher rate of ACR remissions&#44; and a reduction in DMARDs dosage&#46;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">17</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Although not necessarily clinically significant&#44; when prescribing &#937;-3 PUFAs&#44; rheumatologist should be aware that high dose &#937;-3 PUFAs are not recommended in patients who may be susceptible to increased bleeding &#40;e&#46;g<span class="elsevierStyleItalic">&#46;</span>&#44; patients taking warfarin&#41;&#44; because they may increase coagulation times&#46;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">18</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Virgin olive oil</span><p id="par0060" class="elsevierStylePara elsevierViewall">Virgin olive oil contains numerous compounds that exert potent anti-inflammatory and antioxidant actions&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">19</span></a> The main active components of olive oil include oleic acid&#44; linolenic acid&#44; alpha-linoleic acid and phenolic constituents&#46;<a class="elsevierStyleCrossRefs" href="#bib0575"><span class="elsevierStyleSup">20&#44;21</span></a> Oleic acid is metabolized to eicosatrienoic acid &#40;omega-9 fatty acid&#41; with similar anti-inflammatory properties than fish oil omega-3 fatty acids&#46;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">21</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Berbert et al&#46; evaluated whether supplementation with olive oil could improve clinical and laboratory parameters of disease activity in RA patients who were already taking fish oil supplements&#46; RA patient groups that received fish oil omega-3 fatty acids and olive oil showed a more precocious and accentuated improvement&#46;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Vitamin D</span><p id="par0070" class="elsevierStylePara elsevierViewall">Vitamin D plays a role in the maintenance of the homeostasis of the calcium and phosphorus metabolism&#46; Vitamin D deficiency is linked to osteopenia&#44; which is frequently associated to RA&#46; Nevertheless vitamin D functions go much further since it is considered an immune system regulator&#46; It intervenes in the innate and acquired immune systems&#46;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">23</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">In vitro</span>&#44; vitamin D inhibits the activation of IL-2&#44; IL-12&#44; IL-6&#44; interferon gamma &#40;IF-&#947;&#41;&#44; and TNF&#46; Instead&#44; vitamin D promotes monocyte differentiation into macrophages&#46; Moreover&#44; vitamin D has anti-inflammatory qualities through its capacity to regulate the production of prostaglandins&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">24</span></a> In fact&#44; in murine models of human arthritis&#44; vitamin D inhibits the progression of arthritis&#46;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">25</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">A meta-analysis summarizes published results on the association between vitamin D intake and the development of RA&#46; The authors conclude that an insufficient vitamin D intake is associated with an elevated risk of RA development&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">26</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Vitamin D supplements could have an effect on RA treatment&#46; Brohult et al&#46; studied the effects of large doses of calciferol on patients with RA in a double-blind clinical trial&#46; After 1 year&#44; high dose oral calciferol therapy showed a positive effect on disease activity in RA patients&#46;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">27</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Furthermore&#44; in a 3-month open-label trial&#44; vitamin D administration as an adjunct therapy with DMARDs was correlated with a decrease in pain and PCR in RA patients&#46; No adverse reactions related to vitamin D were reported&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">28</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Probiotics</span><p id="par0095" class="elsevierStylePara elsevierViewall">Probiotics are live microorganisms that&#44; when administered in adequate amounts&#44; confer health benefits on the host&#46;<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">29</span></a> Current evidence suggests that probiotics may play a therapeutic role in chronic inflammatory diseases such as RA&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">30</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In murine models of RA&#44; oral administration of <span class="elsevierStyleItalic">Lactobacillus casei</span> decreased the pro-inflammatory cytokines and improved RA index disease activity in comparison with a control group or even compare with a control group treated with indomethacin&#46;<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">31</span></a> Furthermore&#44; So et al&#46; demonstrated that the administration of <span class="elsevierStyleItalic">Lactobacillus casei</span> improved histopathological changes&#44; and the lymphocytic infiltrates in the joints&#44; similarly to the administration of methotrexate &#40;MTX&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">32</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Several studies showed an improvement in HAQ or disease patient perception related to probiotics intake&#46;<a class="elsevierStyleCrossRefs" href="#bib0640"><span class="elsevierStyleSup">33&#8211;36</span></a> However&#44; the evidence of the use of probiotics in humans is scarce&#46; A recently reported randomized&#44; double-blind&#44; clinical trial study showed beneficial effects of <span class="elsevierStyleItalic">Lactobacillus casei</span> in pain&#44; tender and swollen joint counts and DAS28&#44; in RA women patients&#46; It also showed amelioration in PCR&#44; TNF&#945;&#44; IL-12 e IL-10 levels&#46;<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">36</span></a> No side effects were described&#46;</p></span></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Herbal medicine</span><p id="par0110" class="elsevierStylePara elsevierViewall">Some herbal medicinal products have been shown to interact with the mediators of inflammation and&#44; therefore&#44; may be used in the treatment of RA&#46;<a class="elsevierStyleCrossRefs" href="#bib0660"><span class="elsevierStyleSup">37&#44;38</span></a> These products can also act as free radical scavengers&#44; and through other mechanisms&#46; For example&#44; topical capsaicin is a highly selective agonist of TRPV1 receptors&#44; which are expressed in afferent neuronal C fibers and some A&#948; fibers&#46; Capsaicin induces local depletion of substance P which is thought to be part of its mechanism for pain relief&#46;<a class="elsevierStyleCrossRef" href="#bib0670"><span class="elsevierStyleSup">39</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">However&#44; few high quality clinical trials have yet been carried out to substantiate the safety and efficacy of herbal medicines&#44; which are not free of potentially serious side effects&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Eleven randomized controlled trials including 940 patients have reported the effects of <span class="elsevierStyleItalic">Tripterygium wilfordii</span> extracts &#40;TWE&#41; in the treatment of RA&#59; the methodological quality of these studies was generally low and the results have been inconsistent&#46;<a class="elsevierStyleCrossRef" href="#bib0675"><span class="elsevierStyleSup">40</span></a> A randomized controlled trial by Goldbach-Mansky et al&#46;&#44; was conducted to compare the benefits and side effects of TWE with those of sulfasalazine for the treatment of active RA&#46; The results showed that the attainment of the ACR 20 response criteria was significantly higher with TWE extract than with sulfasalazine&#46;<a class="elsevierStyleCrossRef" href="#bib0680"><span class="elsevierStyleSup">41</span></a> A multicenter&#44; open-label&#44; randomized controlled trial compared the efficacy and safety of TWE with MTX in the treatment of active RA&#46; After 6 months&#44; the proportion of patients reaching the ACR50 response criteria was 46&#46;4&#37;&#44; 55&#46;1&#37; and 76&#46;8&#37;&#44; respectively&#44; in the MTX&#44; TWE and MTX<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>TWE groups&#46; The authors concluded that TWE monotherapy was not worse than MTX&#44; and that MTX<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>TWE was better than MTX alone in controlling disease activity in patients with active RA&#46;<a class="elsevierStyleCrossRef" href="#bib0685"><span class="elsevierStyleSup">42</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">It has also been suggested that plants such as <span class="elsevierStyleItalic">Borago officinalis</span>&#44; <span class="elsevierStyleItalic">Oenothera blennis</span> and <span class="elsevierStyleItalic">Ribes migrum</span> with a high grade of acid gamma linolenic &#40;AGL&#41; may improve pain and disease activity in RA patients&#46;<a class="elsevierStyleCrossRef" href="#bib0670"><span class="elsevierStyleSup">39</span></a> AGL is an essential fatty acid precursor of prostaglandin E1&#44; an eicosanoid with anti-inflammatory and immunomodulatory properties&#46;<a class="elsevierStyleCrossRef" href="#bib0690"><span class="elsevierStyleSup">43</span></a> In clinical trials&#44; the AGL group&#44; developed more frequently adverse reactions than the placebo group&#44; although no significant differences were reported&#46; Cases of convulsions due to <span class="elsevierStyleItalic">Oenothera blennis</span> have been reported in epileptic patients or patients being treated with central nervous system medications&#46;<a class="elsevierStyleCrossRef" href="#bib0670"><span class="elsevierStyleSup">39</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">The quality of herbal medicines can directly affect their safety and efficacy&#46; Good manufacturing practices &#40;GMP&#41; are one of the most important tools to avoid contamination of herbal products&#46;<a class="elsevierStyleCrossRef" href="#bib0695"><span class="elsevierStyleSup">44</span></a> If the manufacturer keeps GMP&#44; this issue is rare&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Physical activity</span><p id="par0135" class="elsevierStylePara elsevierViewall">Physical inactivity is the fourth leading risk factor for mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0700"><span class="elsevierStyleSup">45</span></a> People who exercise more have lower rates of coronary heart disease&#44; hypertension&#44; stroke&#44; type 2 diabetes&#44; metabolic syndrome&#44; colon cancer&#44; breast cancer&#44; depression and mortality from all causes&#46;<a class="elsevierStyleCrossRef" href="#bib0705"><span class="elsevierStyleSup">46</span></a> Physical activity decreases the risk of fracture and loss of bone mineral density and increases muscle mass&#44; strength&#44; power and intrinsic neuromuscular activity&#46;<a class="elsevierStyleCrossRefs" href="#bib0705"><span class="elsevierStyleSup">46&#44;47</span></a> However&#44; in RA patients physical activity has been considered to increase joint stress&#44; pain&#44; disease activity and joint damage&#46; Then&#44; is it appropriate to recommend exercise to RA patients&#63;</p><p id="par0140" class="elsevierStylePara elsevierViewall">According to the latest evidence&#44; exercise has not been associated with harmful effects on disease activity&#44; pain or radiological damage&#46;<a class="elsevierStyleCrossRefs" href="#bib0715"><span class="elsevierStyleSup">48&#44;49</span></a> Therefore&#44; physical activity does not worsen RA&#44; and probably provides additional benefits&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Hurkmans et al&#46; reviewed the effectiveness and safety of short-term &#40;\n
      &lt;three months)="" and="" long-term="" (=""&gt;\n
       three months&#41; dynamic exercise programs for RA patients&#46; The authors concluded that aerobic capacity training combined with muscle strength training is recommended as routine practice in RA patients&#46;\n
      &lt;/three&gt;<a class="elsevierStyleCrossRef" href="#bib0715"><span class="elsevierStyleSup">48</span></a> A randomized controlled trial showed for the first time that after a 24 week progressive training program&#44; RA patients gained muscle mass&#44; also functional improvement was observed&#46;<a class="elsevierStyleCrossRef" href="#bib0725"><span class="elsevierStyleSup">50</span></a> Therefore exercise must be recommended in RA patients&#46; However&#44; physical activity should be of low joint impact in order to avoid pain and musculoskeletal injuries&#46;<a class="elsevierStyleCrossRef" href="#bib0705"><span class="elsevierStyleSup">46</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Yoga</span><p id="par0150" class="elsevierStylePara elsevierViewall">In western countries&#44; mind-body interventions&#44; such as yoga&#44; which combines stress management with physical activity&#44; are growing&#46; Yoga modulates sweating response to dynamic exercise and improves respiratory muscle strength&#44; handgrip strength&#44; handgrip endurance and flexibility&#46;<a class="elsevierStyleCrossRefs" href="#bib0730"><span class="elsevierStyleSup">51&#8211;53</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">There is very low evidence of the role yoga plays in RA patients&#46; The methodological quality of the studies is poor because of a lack of patient blindness&#46; Two trials showed a significant improvement of DAS28 associated with yoga&#46;<a class="elsevierStyleCrossRefs" href="#bib0745"><span class="elsevierStyleSup">54&#44;55</span></a> In other studies&#44; yoga improved pain&#44; HAQ&#44; balance and handgrip strength&#46;<a class="elsevierStyleCrossRefs" href="#bib0745"><span class="elsevierStyleSup">54&#44;56&#44;57</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Evans et al&#46; aimed to assess the effects of a yoga program on health-related quality of life &#40;HRQoL&#41; for young adults with RA compared with a usual-care waitlist control group&#46; The results of the study suggested that yoga is a feasible and safe complementary treatment for young people with RA&#44; leading to HRQoL&#44; pain&#44; disability&#44; fatigue&#44; and mood benefits&#46;<a class="elsevierStyleCrossRef" href="#bib0765"><span class="elsevierStyleSup">58</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">No side effects were reported for yoga in RA patients&#46;<a class="elsevierStyleCrossRef" href="#bib0770"><span class="elsevierStyleSup">59</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Taichi</span><p id="par0170" class="elsevierStylePara elsevierViewall">Tai Chi is a Chinese martial art that combines meditation with slow&#44; gentle&#44; graceful movements&#44; as well as&#44; deep breathing and relaxation&#46;<a class="elsevierStyleCrossRef" href="#bib0775"><span class="elsevierStyleSup">60</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Wang et al&#46; conducted a systematic review of reports on the effects of Tai Chi over various chronic medical conditions&#46; Nine randomized controlled trials&#44; 23 non-randomized controlled studies&#44; and 15 observational studies were included&#46; Tai Chi appeared to have benefits and also appeared to be safe and effective in promoting balance control&#44; flexibility&#44; and cardiovascular fitness in older patients with chronic conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0780"><span class="elsevierStyleSup">61</span></a> Thus Tai Chi may benefit RA patients who have limited strength&#44; mobility and comorbidities &#40;cardiovascular risk&#44; osteoporosis and depression&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0775"><span class="elsevierStyleSup">60</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Several reviews about the effect of Tai Chi in RA patients have been published&#44; including a Cochrane Review&#46;<a class="elsevierStyleCrossRefs" href="#bib0770"><span class="elsevierStyleSup">59&#44;60&#44;62&#8211;64</span></a> Tai Chi was associated with improvement in terms of RA disease activity&#46; Although existing evidence remains limited and inconclusive&#46; No adverse events were observed and Tai Chi does not exacerbate RA symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0795"><span class="elsevierStyleSup">64</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Meditation</span><p id="par0185" class="elsevierStylePara elsevierViewall">Meditation incorporates a diverse range of techniques that helps to focus attention and bring a state of self-awareness and inner calm&#46; Meditation may alleviate patients&#8217; suffering associated with physical&#44; psychosomatic and psychiatric disorders&#44; it can even reduce cardiovascular risk factors&#46;<a class="elsevierStyleCrossRef" href="#bib0800"><span class="elsevierStyleSup">65</span></a> Meditation may improve pain&#44;<a class="elsevierStyleCrossRef" href="#bib0805"><span class="elsevierStyleSup">66</span></a> anxiety&#44;<a class="elsevierStyleCrossRef" href="#bib0810"><span class="elsevierStyleSup">67</span></a> depression in RA patients&#44;<a class="elsevierStyleCrossRefs" href="#bib0815"><span class="elsevierStyleSup">68&#44;69</span></a> and fibromyalgia&#46;<a class="elsevierStyleCrossRef" href="#bib0825"><span class="elsevierStyleSup">70</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">In a randomized&#44; waitlist-controlled pilot study Pradhan et al&#46; evaluated the effect of mindfulness meditation on depressive symptoms&#44; psychological status&#44; and disease activity in 63 RA patients&#46; After 2 months&#44; there were no statistically significant differences between groups in any outcomes&#46; After 6 months&#44; there was significant improvement in psychological distress &#40;35&#37; reduction&#41; and well-being&#46; However&#44; the intervention had no impact on RA disease activity&#46;<a class="elsevierStyleCrossRef" href="#bib0830"><span class="elsevierStyleSup">71</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Acupuncture</span><p id="par0195" class="elsevierStylePara elsevierViewall">Acupuncture is a traditional Chinese medicine where thin needles are inserted in specific points of the body to facilitate the recovery of health and to enhance well-being&#46; The effectiveness or efficacy of acupuncture has been tested in randomized controlled trials with poor methodological standards&#46;<a class="elsevierStyleCrossRef" href="#bib0835"><span class="elsevierStyleSup">72</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">The mechanism of action in acupuncture is associated with an analgesic effect by interaction with endogen opioids and serotonin mediators&#46; Mayer et al&#46; reported that acupuncture analgesia was blocked after naloxone administration&#46; These findings support the effect of acupuncture over endogenous opioids&#46;<a class="elsevierStyleCrossRef" href="#bib0840"><span class="elsevierStyleSup">73</span></a> A positron emission tomography study showed that acupuncture therapy evoked short-term increases in &#956;-opioid cerebral receptors binding potential&#46;<a class="elsevierStyleCrossRef" href="#bib0845"><span class="elsevierStyleSup">74</span></a> Despite these studies&#44; the current evidence about decreased pain due to acupuncture in RA patients is scarce and non conclusive&#46;<a class="elsevierStyleCrossRef" href="#bib0850"><span class="elsevierStyleSup">75</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">Two studies involving a total of 84 people were included in a Cochrane review&#46; One study used acupuncture and no significant differences between groups were observed&#46;<a class="elsevierStyleCrossRef" href="#bib0855"><span class="elsevierStyleSup">76</span></a> In the second study&#44; using electroacupuncture&#44; a significant decrease in knee pain was reported in the experimental group when compared to the placebo group&#46; However&#44; the authors concluded that the poor quality of the trial&#44; including the small sample size preclude any recommendation&#46;<a class="elsevierStyleCrossRef" href="#bib0860"><span class="elsevierStyleSup">77</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">More recently&#44; two systematic reviews reported that despite some favorable results in active-controlled trials&#44; conflicting evidence exists in placebo-controlled trials concerning the efficacy of acupuncture for RA&#46; Rigorous and well-controlled randomized trials are warranted&#46; Minor adverse events in the acupuncture groups were observed&#46;<a class="elsevierStyleCrossRefs" href="#bib0865"><span class="elsevierStyleSup">78&#8211;81</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">Another systematic review assessed the effect of bee venom acupuncture &#40;BVA&#41; used as an RA therapy&#46; The authors concluded that the evidence is insufficient to suggest that BVA is an effective treatment for RA&#46;<a class="elsevierStyleCrossRef" href="#bib0885"><span class="elsevierStyleSup">82</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Homeopathy</span><p id="par0220" class="elsevierStylePara elsevierViewall">In 1978&#44; the first study of homeopathy in RA patients was published&#46; Ninety-five RA patients were randomized to receive acetylsalicylic acid or homeopathy&#46; After 1 year of treatment&#44; 42&#46;6&#37; patients of the homeopathy group and only 14&#46;6&#37; of the salicylate group continued&#46; During the first year of the study&#44; 33&#46;4&#37; patients of the homeopathy group and 85&#46;4&#37; in the salicylate group withdrew the study&#46;<a class="elsevierStyleCrossRef" href="#bib0890"><span class="elsevierStyleSup">83</span></a> Gibson et al&#46; compared orthodox first-line anti-inflammatory treatment plus homeopathy with anti-inflammatory treatment plus an inert preparation&#46; In the treatment group improvement in subjective pain&#44; articular index&#44; stiffness and grip strength were observed&#46;<a class="elsevierStyleCrossRef" href="#bib0895"><span class="elsevierStyleSup">84</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">In a 6-month double-blind trial&#44; 44 RA patients were entered comparing homeopathy with a placebo&#46; There was no statistically significant difference between groups&#46;<a class="elsevierStyleCrossRef" href="#bib0900"><span class="elsevierStyleSup">85</span></a> A randomized controlled trial by Fisher and Scott was conducted to study if homeopathy was effective in reducing the symptoms of joint inflammation in RA&#46; The results of the trial showed no evidence that active homeopathy improves the symptoms of RA&#46;<a class="elsevierStyleCrossRef" href="#bib0905"><span class="elsevierStyleSup">86</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">Brien et al&#46; sought to assess whether any benefits from complementary homeopathic treatment in patients with RA are due to the homeopathic consultation&#44; homeopathic remedies or both&#46; The authors concluded that homeopathic consultations but not homeopathic remedies are associated with clinically relevant benefits in RA&#46;<a class="elsevierStyleCrossRef" href="#bib0910"><span class="elsevierStyleSup">87</span></a> This publication has received several criticisms&#44;<a class="elsevierStyleCrossRefs" href="#bib0915"><span class="elsevierStyleSup">88&#8211;90</span></a> mainly because the insufficient statistical power to detect differences between groups&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">In conclusion&#44; we have limited clinical trials with adequate methodology to assess the effectiveness of homeopathy in patients with RA&#46; None of the published studies have reported side effects associated with homeopathic drugs&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Balneotherapy&#47;Hydrotherapy</span><p id="par0240" class="elsevierStylePara elsevierViewall">Hydrotherapy&#47;Balneotherapy involves the use of water in treatments and in the case of RA is considered the oldest therapy&#46; The recuperative and healing properties of these therapies are based on their mechanic and thermal effects&#46;<a class="elsevierStyleCrossRef" href="#bib0930"><span class="elsevierStyleSup">91</span></a> The protracted application of heat&#44; and the pressure exerted by the water carries impulses felt at the skin deeper into the body&#44; where they are instrumental in stimulating the immune system&#44; reducing stress&#44; invigorating circulation and digestion&#44; encouraging blood flow&#44; lessening pain sensitivity and blocking the sympathetic nervous system&#46;<a class="elsevierStyleCrossRef" href="#bib0935"><span class="elsevierStyleSup">92</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">A Cochrane review assessed the effectiveness of balneotherapy for RA patients&#46; Nine trials&#44; representing 579 people were included&#46; Most trials reported positive findings&#44; but were methodologically flawed to some extent&#44; and withdrawals due to adverse events were not reported&#46;<a class="elsevierStyleCrossRef" href="#bib0940"><span class="elsevierStyleSup">93</span></a> Another systematic review found evidence that aquatic exercise had small but statistically significant effects on pain relief and related outcomes in RA&#46; However&#44; due to the poor methodological quality of balneotherapy studies&#44; we are unable to make any conclusion on the effects of this intervention&#46;<a class="elsevierStyleCrossRef" href="#bib0945"><span class="elsevierStyleSup">94</span></a></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conclusion</span><p id="par0250" class="elsevierStylePara elsevierViewall">The use of CAM in rheumatology is common&#46;<a class="elsevierStyleCrossRef" href="#bib0950"><span class="elsevierStyleSup">95</span></a> The increased interest of RA patients in CAM approaches is a reality&#44; thus rheumatologists should advice their patients with scientific rigor and the best evidence available&#46; In this sense the ACR sets its position which supports rigorous scientific evaluation on all approaches that improve the treatment of rheumatic diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">2</span></a><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> presents the CAM approaches that may be beneficial for RA patients&#44; although there is still a long way ahead in terms of research in order to draw firm conclusions&#46; There are no long-term studies&#44; nor studies to assess joint damage progression&#44; however some complementary therapies may represent an opportunity to improve the quality of life of our patients&#44; and in the future may be integrated in the management of RA patients&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflicts of interest</span><p id="par0255" class="elsevierStylePara elsevierViewall">The authors have no affiliations with or financial interest in any company or organization that could conflict with the views expressed in this manuscript&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Ethical responsibilities</span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Protection of people and animals</span><p id="par0260" class="elsevierStylePara elsevierViewall">The authors declare that this research has not been conducted experiments on humans or animals&#46;</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Confidentiality of data</span><p id="par0265" class="elsevierStylePara elsevierViewall">The authors declare that this article does not appear patient data&#46;</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Right to privacy and informed consent</span><p id="par0270" class="elsevierStylePara elsevierViewall">The authors declare that this article does not appear patient data&#46;</p></span></span></span>
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          "titulo" => "Palabras clave"
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          "titulo" => "Introduction"
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          "identificador" => "sec0010"
          "titulo" => "Methods"
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        6 => array:3 [
          "identificador" => "sec0015"
          "titulo" => "Nutrition"
          "secciones" => array:2 [
            0 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Nutritional intervention"
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              "titulo" => "Nutritional supplements"
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                  "identificador" => "sec0030"
                  "titulo" => "Fish oil"
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                  "titulo" => "Virgin olive oil"
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                  "identificador" => "sec0040"
                  "titulo" => "Vitamin D"
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                  "identificador" => "sec0045"
                  "titulo" => "Probiotics"
                ]
              ]
            ]
          ]
        ]
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          "identificador" => "sec0050"
          "titulo" => "Herbal medicine"
        ]
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          "identificador" => "sec0055"
          "titulo" => "Physical activity"
        ]
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          "identificador" => "sec0060"
          "titulo" => "Yoga"
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          "identificador" => "sec0065"
          "titulo" => "Taichi"
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          "identificador" => "sec0070"
          "titulo" => "Meditation"
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          "identificador" => "sec0075"
          "titulo" => "Acupuncture"
        ]
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          "identificador" => "sec0080"
          "titulo" => "Homeopathy"
        ]
        14 => array:2 [
          "identificador" => "sec0085"
          "titulo" => "Balneotherapy&#47;Hydrotherapy"
        ]
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          "identificador" => "sec0090"
          "titulo" => "Conclusion"
        ]
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          "identificador" => "sec0095"
          "titulo" => "Conflicts of interest"
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          "identificador" => "sec0100"
          "titulo" => "Ethical responsibilities"
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            0 => array:2 [
              "identificador" => "sec0105"
              "titulo" => "Protection of people and animals"
            ]
            1 => array:2 [
              "identificador" => "sec0110"
              "titulo" => "Confidentiality of data"
            ]
            2 => array:2 [
              "identificador" => "sec0115"
              "titulo" => "Right to privacy and informed consent"
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          "titulo" => "References"
        ]
      ]
    ]
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    "fechaRecibido" => "2015-07-25"
    "fechaAceptado" => "2015-10-30"
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          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec819336"
          "palabras" => array:11 [
            0 => "Rheumatoid arthritis"
            1 => "Complementary therapy"
            2 => "Diet"
            3 => "Nutritional supplements"
            4 => "Phytotherapy"
            5 => "Medicinal plants"
            6 => "Exercise"
            7 => "Body&#8211;mind therapies"
            8 => "Acupuncture"
            9 => "Homeopathy"
            10 => "Hydrotherapy"
          ]
        ]
      ]
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          "titulo" => "Palabras clave"
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          "palabras" => array:11 [
            0 => "Artritis reumatoide"
            1 => "Terapia complementaria"
            2 => "Dieta"
            3 => "Suplementos nutricionales"
            4 => "Fitoterapia"
            5 => "Plantas medicinales"
            6 => "Ejercicio"
            7 => "Terapias cuerpo-mente"
            8 => "Acupuntura"
            9 => "Homeopat&#237;a"
            10 => "Hidroterapia"
          ]
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">In recent decades the treatment of rheumatoid arthritis &#40;RA&#41; has improved thanks to the use of highly effective drugs&#46; However&#44; patients usually require long term therapy&#44; which is not free of side effects&#46; Therefore RA patients often demand complementary medicine&#44; they seek additional sources of relief and&#47;or less side effects&#46; In fact 30&#8211;60&#37; of rheumatic patients use some form of complementary medicine&#46; Therefore&#44; from conventional medicine&#44; if we want to optimally treat our patients facilitating communication with them we must know the most commonly used complementary medicines&#46; The aim of this review is to assess&#44; based on published scientific research&#44; what complementary therapies commonly used by patients with RA are effective and safe&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">En las &#250;ltimas d&#233;cadas el tratamiento de la Artritis Reumatoide &#40;AR&#41; ha mejorado mucho gracias a la utilizaci&#243;n de f&#225;rmacos altamente eficaces&#46; Sin embargo&#44; los enfermos suelen requerir tratamiento farmacol&#243;gico de por vida&#44; no exento de efectos adversos&#46; Por esta raz&#243;n los pacientes con AR a menudo acuden a la medicina complementaria&#44; buscan fuentes adicionales de alivio y&#47;o menores efectos secundarios&#46; Un 30&#8211;60&#37; de los pacientes reum&#225;ticos utilizan alg&#250;n tipo de medicina complementaria&#46; Por lo tanto&#44; desde la medicina convencional&#44; si queremos optimizar el tratamiento de nuestros pacientes y facilitar la comunicaci&#243;n con ellos debemos conocer las medicinas complementarias m&#225;s utilizadas&#46; El objetivo de esta revisi&#243;n es valorar&#44; en base a la investigaci&#243;n cient&#237;fica publicada&#44; qu&#233; tratamientos complementarios habitualmente utilizados por los pacientes con AR son efectivos y seguros&#46;</p></span>"
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        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fasting followed by vegetarian diet&#59; Mediterranean diet&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">May benefit patients with RA&#46;<br>Mediterranean diet is safe and decreases cardiovascular risk &#40;frequent RA comorbidity&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fish oil&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Evidence of benefits in the use as complementary therapy in RA&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Virgin olive oil&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Evidence of benefits <span class="elsevierStyleItalic">in vitro</span> and <span class="elsevierStyleItalic">in vivo</span> in inflammatory diseases such as RA&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vitamin D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Evidence <span class="elsevierStyleItalic">In vitro</span> and in animal experimentation of its anti-inflammatory and immunomodulatory effects&#46; Epidemiological studies suggest that vitamin D supplementation could have a protective effect on the susceptibility to develop RA&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Probiotics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Several studies showed an improvement in HAQ or disease patient perception related to probiotics intake&#46;<a class="elsevierStyleCrossRefs" href="#bib0640"><span class="elsevierStyleSup">33&#8211;36</span></a> However&#44; the evidence of the use of probiotics in humans is scarce&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Herbal medicinal products&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Some herbal medicinal products&#44; like Tripterygium wilfordii&#44; have demonstrated beneficial effects for RA patients&#46; However&#44; there is a very limited evidence base available&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Physical Activity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exercise is recommended in RA patients&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yoga and Taichi&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Adapt the exercise to patients&#8217; joint restrictions and may reduce patient stress&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Meditation&#47;Mindfulness&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Possible improvement in psychological distress and well-being&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Acupuncture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Conflicting evidence concerning the efficacy of acupuncture for RA patients&#46; There is positive evidence in the treatment of pain&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Homeopathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">There is a very limited evidence base available&#46; No adverse reactions were observed&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Balneotherapy&#47;Hydrotherapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Most trials reported positive findings&#44; but methodological quality of balneotherapy studies is poor&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">CAM modalities that may be beneficial for RA patients&#46;</p>"
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      "titulo" => "References"
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              "identificador" => "bib0480"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Complementary and alternative medicine use among adults&#58; United States&#44; 2002"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
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                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Adv Data"
                        "fecha" => "2004"
                        "volumen" => "343"
                        "paginaInicial" => "1"
                        "paginaFinal" => "19"
                      ]
                    ]
                  ]
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              "identificador" => "bib0485"
              "etiqueta" => "2"
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                0 => array:1 [
                  "referenciaCompleta" => "American Collage of Rheumatology&#46; American Collage of Rheumatology position statement&#58; complementary and alternative medicine for rheumatic diseases&#46; <a href="http://www.rheumatology.org/Practice-Quality/Administrative-Support/Position-Statements.09/2012">http&#58;&#47;&#47;www&#46;rheumatology&#46;org&#47;Practice-Quality&#47;Administrative-Support&#47;Position-Statements&#46;09&#47;2012</a>"
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0490"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Fasting&#58; molecular mechanisms and clinical applications"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.cmet.2013.12.008"
                      "Revista" => array:6 [
                        "tituloSerie" => "Cell Metab"
                        "fecha" => "2014"
                        "volumen" => "19"
                        "paginaInicial" => "181"
                        "paginaFinal" => "192"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0495"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Fasting followed by vegetarian diet in patients with rheumatoid arthritis&#58; a systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Scand J Rheumatol"
                        "fecha" => "2001"
                        "volumen" => "30"
                        "paginaInicial" => "1"
                        "paginaFinal" => "10"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0500"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Controlled trial of fasting and one-year vegetarian diet in rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "1991"
                        "volumen" => "338"
                        "paginaInicial" => "899"
                        "paginaFinal" => "902"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0505"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Vegetarian diet for patients with rheumatoid arthritis &#8211; status&#58; two years after introduction of the diet"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Rheumatol"
                        "fecha" => "1994"
                        "volumen" => "13"
                        "paginaInicial" => "475"
                        "paginaFinal" => "482"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0510"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Importance of nutritional treatment in the inflammatory process of rheumatoid arthritis patients&#59; a review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3305/nh.2014.29.2.7067"
                      "Revista" => array:6 [
                        "tituloSerie" => "Nutr Hosp"
                        "fecha" => "2014"
                        "volumen" => "29"
                        "paginaInicial" => "237"
                        "paginaFinal" => "245"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0515"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Dietary interventions for rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Cochrane Database Syst Rev"
                        "fecha" => "2009"
                        "paginaInicial" => "CD006400"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0520"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Scientific evidence of interventions using the Mediterranean diet&#58; a systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Nutr Rev"
                        "fecha" => "2006"
                        "volumen" => "64"
                        "paginaInicial" => "S27"
                        "paginaFinal" => "S47"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0525"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effectiveness and safety of dietary interventions for rheumatoid arthritis&#58; a systematic review of randomized controlled trials"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jada.2010.02.010"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Diet Assoc"
                        "fecha" => "2010"
                        "volumen" => "110"
                        "paginaInicial" => "727"
                        "paginaFinal" => "735"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0530"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Session 3&#58; Joint Nutrition Society and Irish Nutrition and Dietetic Institute Symposium on Nutrition and autoimmune disease PUFA&#44; inflammatory processes and rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [ …1]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1017/S0029665108008690"
                      "Revista" => array:6 [
                        "tituloSerie" => "Proc Nutr Soc"
                        "fecha" => "2008"
                        "volumen" => "67"
                        "paginaInicial" => "409"
                        "paginaFinal" => "418"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0535"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Dietary omega-3 fats for treatment of inflammatory joint disease&#58; efficacy and utility"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.rdc.2008.03.003"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rheum Dis Clin North Am"
                        "fecha" => "2008"
                        "volumen" => "34"
                        "paginaInicial" => "469"
                        "paginaFinal" => "479"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0540"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Resolving inflammation&#58; dual anti-inflammatory and pro-resolution lipid mediators"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1038/nri2294"
                      "Revista" => array:6 [
                        "tituloSerie" => "Nat Rev Immunol"
                        "fecha" => "2008"
                        "volumen" => "8"
                        "paginaInicial" => "349"
                        "paginaFinal" => "361"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0545"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Fish consumption&#44; fish oil&#44; omega-3 fatty acids&#44; and cardiovascular disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Circulation"
                        "fecha" => "2002"
                        "volumen" => "106"
                        "paginaInicial" => "2747"
                        "paginaFinal" => "2757"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0550"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Omega-3 polyunsaturated fatty acids and the treatment of rheumatoid arthritis&#58; a meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.arcmed.2012.06.011"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Med Res"
                        "fecha" => "2012"
                        "volumen" => "43"
                        "paginaInicial" => "356"
                        "paginaFinal" => "362"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0555"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Influence of marine n-3 polyunsaturated fatty acids on immune function and a systematic review of their effects on clinical outcomes in rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1017/S0007114512001560"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Nutr"
                        "fecha" => "2012"
                        "volumen" => "107"
                        "paginaInicial" => "S171"
                        "paginaFinal" => "S184"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0560"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Fish oil in recent onset rheumatoid arthritis&#58; a randomised&#44; double-blind controlled trial within algorithm-based drug use"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/annrheumdis-2013-204145"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Rheum Dis"
                        "fecha" => "2015"
                        "volumen" => "74"
                        "paginaInicial" => "89"
                        "paginaFinal" => "95"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0565"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Therapeutic potential of n-3 polyunsaturated fatty acids in disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.2146/ajhp080411"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Health Syst Pharm"
                        "fecha" => "2009"
                        "volumen" => "66"
                        "paginaInicial" => "1169"
                        "paginaFinal" => "1179"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0570"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Molecular mechanisms of inflammation&#46; Anti-inflammatory benefits of virgin olive oil and the phenolic compound oleocanthal"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Curr Pharm Des"
                        "fecha" => "2011"
                        "volumen" => "17"
                        "paginaInicial" => "754"
                        "paginaFinal" => "768"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S073510970801838X"
                          "estado" => "S300"
                          "issn" => "07351097"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0575"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Active components and clinical applications of olive oil"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Altern Med Rev"
                        "fecha" => "2007"
                        "volumen" => "12"
                        "paginaInicial" => "331"
                        "paginaFinal" => "342"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib0580"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The role of omega-3 fatty acids contained in olive oil on chronic inflammation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Acta Med Indones"
                        "fecha" => "2011"
                        "volumen" => "43"
                        "paginaInicial" => "138"
                        "paginaFinal" => "143"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib0585"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Supplementation of fish oil and olive oil in patients with rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.nut.2004.03.023"
                      "Revista" => array:6 [
                        "tituloSerie" => "Nutrition"
                        "fecha" => "2005"
                        "volumen" => "21"
                        "paginaInicial" => "131"
                        "paginaFinal" => "136"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib0590"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Vitamin D&#44; immunoregulation&#44; and rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/RHU.0b013e31820edd18"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Clin Rheumatol"
                        "fecha" => "2011"
                        "volumen" => "17"
                        "paginaInicial" => "102"
                        "paginaFinal" => "107"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib0595"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Does vitamin D affect risk of developing autoimmune disease&#63; A systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.semarthrit.2010.07.009"
                      "Revista" => array:6 [
                        "tituloSerie" => "Semin Arthritis Rheum"
                        "fecha" => "2011"
                        "volumen" => "40"
                        "paginaInicial" => "512"
                        "paginaFinal" => "531"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib0600"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "1&#44;25-Dihydroxycholecalciferol inhibits the progression of arthritis in murine models of human arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "J Nutr"
                        "fecha" => "1998"
                        "volumen" => "128"
                        "paginaInicial" => "68"
                        "paginaFinal" => "72"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S014067361260110X"
                          "estado" => "S300"
                          "issn" => "01406736"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib0605"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Association between vitamin D intake and the risk of rheumatoid arthritis&#58; a meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s10067-012-2080-7"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Rheumatol"
                        "fecha" => "2012"
                        "volumen" => "31"
                        "paginaInicial" => "1733"
                        "paginaFinal" => "1739"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib0610"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effects of large doses of calciferol on patients with rheumatoid arthritis&#46; A double-blind clinical trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Scand J Rheumatol"
                        "fecha" => "1973"
                        "volumen" => "2"
                        "paginaInicial" => "173"
                        "paginaFinal" => "176"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib0615"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Disease modifying and immunomodulatory effects of high dose 1 alpha &#40;OH&#41; D3 in rheumatoid arthritis patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Exp Rheumatol"
                        "fecha" => "1999"
                        "volumen" => "17"
                        "paginaInicial" => "453"
                        "paginaFinal" => "456"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            28 => array:3 [
              "identificador" => "bib0620"
              "etiqueta" => "29"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Probiotics in food&#58; health and nutritional properties and guidelines for evaluation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "colaboracion" => "FAO&#47;WHO"
                          "etal" => false
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:2 [
                        "tituloSerie" => "FAO Food Nutr Pap"
                        "fecha" => "2006"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            29 => array:3 [
              "identificador" => "bib0625"
              "etiqueta" => "30"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The role of the microbiome in rheumatic diseases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s11926-012-0314-y"
                      "Revista" => array:5 [
                        "tituloSerie" => "Curr Rheumatol Rep"
                        "fecha" => "2013"
                        "volumen" => "15"
                        "paginaInicial" => "314"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            30 => array:3 [
              "identificador" => "bib0630"
              "etiqueta" => "31"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "<span class="elsevierStyleItalic">Lactobacillus casei</span> reduces the inflammatory joint damage associated with collagen-induced arthritis &#40;CIA&#41; by reducing the pro-inflammatory cytokines&#58; <span class="elsevierStyleItalic">Lactobacillus casei</span>&#58; COX-2 inhibitor"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s10875-010-9457-7"
                      "Revista" => array:7 [
                        "tituloSerie" => "J Clin Immunol"
                        "fecha" => "2011"
                        "volumen" => "31"
                        "paginaInicial" => "147"
                        "paginaFinal" => "154"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0378512212001223"
                          "estado" => "S300"
                          "issn" => "03785122"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            31 => array:3 [
              "identificador" => "bib0635"
              "etiqueta" => "32"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "<span class="elsevierStyleItalic">Lactobacillus casei</span> suppresses experimental arthritis by down-regulating T helper 1 effector functions"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.molimm.2007.12.010"
                      "Revista" => array:6 [
                        "tituloSerie" => "Mol Immunol"
                        "fecha" => "2008"
                        "volumen" => "45"
                        "paginaInicial" => "2690"
                        "paginaFinal" => "2699"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            32 => array:3 [
              "identificador" => "bib0640"
              "etiqueta" => "33"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effects of probiotic therapy on the activity and activation of mild rheumatoid arthritis &#8211; a pilot study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Scand J Rheumatol"
                        "fecha" => "2003"
                        "volumen" => "32"
                        "paginaInicial" => "211"
                        "paginaFinal" => "215"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            33 => array:3 [
              "identificador" => "bib0645"
              "etiqueta" => "34"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "<span class="elsevierStyleItalic">Bacillus coagulans</span>&#58; a viable adjunct therapy for relieving symptoms of rheumatoid arthritis according to a randomized&#44; controlled trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/1472-6882-10-1"
                      "Revista" => array:5 [
                        "tituloSerie" => "BMC Complement Altern Med"
                        "fecha" => "2010"
                        "volumen" => "10"
                        "paginaInicial" => "1"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            34 => array:3 [
              "identificador" => "bib0650"
              "etiqueta" => "35"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A randomized&#44; double-blinded&#44; placebo-controlled pilot study of probiotics in active rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Med Sci Monit"
                        "fecha" => "2011"
                        "volumen" => "17"
                        "paginaInicial" => "CR347"
                        "paginaFinal" => "CR354"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            35 => array:3 [
              "identificador" => "bib0655"
              "etiqueta" => "36"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effects of <span class="elsevierStyleItalic">Lactobacillus casei</span> supplementation on disease activity and inflammatory cytokines in rheumatoid arthritis patients&#58; a randomized double-blind clinical trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/1756-185X.12333"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Rheum Dis"
                        "fecha" => "2014"
                        "volumen" => "17"
                        "paginaInicial" => "519"
                        "paginaFinal" => "527"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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              "etiqueta" => "37"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Scientific basis of botanical medicine as alternative remedies for rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s12016-012-8329-8"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Rev Allergy Immunol"
                        "fecha" => "2013"
                        "volumen" => "44"
                        "paginaInicial" => "284"
                        "paginaFinal" => "300"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            37 => array:3 [
              "identificador" => "bib0665"
              "etiqueta" => "38"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Evidence of effectiveness of herbal medicinal products in the treatment of arthritis&#46; Part 2&#58; Rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/ptr.3006"
                      "Revista" => array:6 [
                        "tituloSerie" => "Phytother Res"
                        "fecha" => "2009"
                        "volumen" => "23"
                        "paginaInicial" => "1647"
                        "paginaFinal" => "1662"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            38 => array:3 [
              "identificador" => "bib0670"
              "etiqueta" => "39"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Herbal therapy for treating rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Cochrane Database Syst Rev"
                        "fecha" => "2011"
                        "volumen" => "16"
                        "paginaInicial" => "CD002948"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            39 => array:3 [
              "identificador" => "bib0675"
              "etiqueta" => "40"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Extracts of <span class="elsevierStyleItalic">Tripterygium wilfordii</span> Hook F in the treatment of rheumatoid arthritis&#58; a systemic review and meta-analysis of randomised controlled trials"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1155/2013/410793"
                      "Revista" => array:5 [
                        "tituloSerie" => "Evid Based Complement Alternat Med"
                        "fecha" => "2013"
                        "volumen" => "2013"
                        "paginaInicial" => "410793"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            40 => array:3 [
              "identificador" => "bib0680"
              "etiqueta" => "41"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Comparison of <span class="elsevierStyleItalic">Tripterygium wilfordii</span> Hook F versus sulfasalazine in the treatment of rheumatoid arthritis&#58; a randomized trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Intern Med"
                        "fecha" => "2009"
                        "volumen" => "151"
                        "paginaInicial" => "229"
                        "paginaFinal" => "240"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            41 => array:3 [
              "identificador" => "bib0685"
              "etiqueta" => "42"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Comparison of <span class="elsevierStyleItalic">Tripterygium wilfordii</span> Hook F with methotrexate in the treatment of active rheumatoid arthritis &#40;TRIFRA&#41;&#58; a randomised&#44; controlled clinical trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/annrheumdis-2013-204807"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Rheum Dis"
                        "fecha" => "2015"
                        "volumen" => "74"
                        "paginaInicial" => "1078"
                        "paginaFinal" => "1086"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            42 => array:3 [
              "identificador" => "bib0690"
              "etiqueta" => "43"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Gamma linolenic acid&#58; an antiinflammatory omega-6 fatty acid"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Curr Pharm Biotechnol"
                        "fecha" => "2006"
                        "volumen" => "7"
                        "paginaInicial" => "531"
                        "paginaFinal" => "534"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            43 => array:3 [
              "identificador" => "bib0695"
              "etiqueta" => "44"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "EFPIA&#46; European Federation of Pharmaceutical Industries&#46; Good manufacturing practices for active ingredient manufacturers&#46; 1996&#46;"
                ]
              ]
            ]
            44 => array:3 [
              "identificador" => "bib0700"
              "etiqueta" => "45"
              "referencia" => array:1 [
                0 => array:3 [
                  "comentario" => "ISBN&#58; 9789241563871"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Global health risks&#58; mortality and burden of disease attributable to selected major risks"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [ …1]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:2 [
                        "fecha" => "2009"
                        "editorial" => "World Health Organization"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            45 => array:3 [
              "identificador" => "bib0705"
              "etiqueta" => "46"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "2008 Physical Activity Guidelines for Americans"
                      "autores" => array:1 [
                        0 => array:2 [
                          "colaboracion" => "US Department of Health and Human Services"
                          "etal" => false
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1753-4887.2008.00136.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Nutr Rev"
                        "fecha" => "2009"
                        "volumen" => "67"
                        "paginaInicial" => "114"
                        "paginaFinal" => "120"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            46 => array:3 [
              "identificador" => "bib0710"
              "etiqueta" => "47"
              "referencia" => array:1 [
                0 => array:3 [
                  "comentario" => "47&#8211;58"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "New Canadian physical activity guidelines"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1139/H11-009"
                      "Revista" => array:6 [
                        "tituloSerie" => "Appl Physiol Nutr Metab"
                        "fecha" => "2011"
                        "volumen" => "36"
                        "paginaInicial" => "36"
                        "paginaFinal" => "46"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            47 => array:3 [
              "identificador" => "bib0715"
              "etiqueta" => "48"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Dynamic exercise programs &#40;aerobic capacity and&#47;or muscle strength training&#41; in patients with rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Cochrane Database Syst Rev"
                        "fecha" => "2009"
                        "volumen" => "7"
                        "paginaInicial" => "CD006853"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            48 => array:3 [
              "identificador" => "bib0720"
              "etiqueta" => "49"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Is dynamic exercise beneficial in patients with rheumatoid arthritis&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jbspin.2007.04.015"
                      "Revista" => array:6 [
                        "tituloSerie" => "Joint Bone Spine"
                        "fecha" => "2008"
                        "volumen" => "75"
                        "paginaInicial" => "11"
                        "paginaFinal" => "17"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            49 => array:3 [
              "identificador" => "bib0725"
              "etiqueta" => "50"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effects of high-intensity resistance training in patients with rheumatoid arthritis&#58; a randomized controlled trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/art.24891"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arthritis Rheum"
                        "fecha" => "2009"
                        "volumen" => "61"
                        "paginaInicial" => "1726"
                        "paginaFinal" => "1734"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            50 => array:3 [
              "identificador" => "bib0730"
              "etiqueta" => "51"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of six weeks yoga training on weight loss following step test&#44; respiratory pressures&#44; handgrip strength and handgrip endurance in young healthy subjects"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Indian J Physiol Pharmacol"
                        "fecha" => "2008"
                        "volumen" => "52"
                        "paginaInicial" => "164"
                        "paginaFinal" => "170"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            51 => array:3 [
              "identificador" => "bib0735"
              "etiqueta" => "52"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Randomized controlled trial of yoga and exercise in multiple sclerosis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Neurology"
                        "fecha" => "2004"
                        "volumen" => "62"
                        "paginaInicial" => "2058"
                        "paginaFinal" => "2064"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            52 => array:3 [
              "identificador" => "bib0740"
              "etiqueta" => "53"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Yoga as steadiness training&#58; effects on motor variability in young adults"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1519/JSC.0b013e31818200dd"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Strength Cond Res"
                        "fecha" => "2008"
                        "volumen" => "22"
                        "paginaInicial" => "1659"
                        "paginaFinal" => "1669"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            53 => array:3 [
              "identificador" => "bib0745"
              "etiqueta" => "54"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The benefits of yoga for rheumatoid arthritis&#58; results of a preliminary&#44; structured 8-week program"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00296-009-0871-1"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rheumatol Int"
                        "fecha" => "2009"
                        "volumen" => "29"
                        "paginaInicial" => "1417"
                        "paginaFinal" => "1421"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            54 => array:3 [
              "identificador" => "bib0750"
              "etiqueta" => "55"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Yoga for arthritis&#58; a scoping review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.rdc.2010.11.001"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rheum Dis Clin North Am"
                        "fecha" => "2011"
                        "volumen" => "37"
                        "paginaInicial" => "33"
                        "paginaFinal" => "46"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            55 => array:3 [
              "identificador" => "bib0755"
              "etiqueta" => "56"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Measuring the effects of yoga in rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Rheumatol"
                        "fecha" => "1994"
                        "volumen" => "33"
                        "paginaInicial" => "787"
                        "paginaFinal" => "788"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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            56 => array:3 [
              "identificador" => "bib0760"
              "etiqueta" => "57"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Functional and physiological effects of yoga in women with rheumatoid arthritis&#58; a pilot study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Altern Ther Health Med"
                        "fecha" => "2009"
                        "volumen" => "15"
                        "paginaInicial" => "24"
                        "paginaFinal" => "31"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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            57 => array:3 [
              "identificador" => "bib0765"
              "etiqueta" => "58"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Impact of iyengar yoga on quality of life in young women with rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
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                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/AJP.0b013e31827da381"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin J Pain"
                        "fecha" => "2013"
                        "volumen" => "29"
                        "paginaInicial" => "988"
                        "paginaFinal" => "997"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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            58 => array:3 [
              "identificador" => "bib0770"
              "etiqueta" => "59"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Tai Chi and yoga as complementary therapies in rheumatologic conditions"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [ …1]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.berh.2012.05.006"
                      "Revista" => array:6 [
                        "tituloSerie" => "Best Pract Res Clin Rheumatol"
                        "fecha" => "2012"
                        "volumen" => "26"
                        "paginaInicial" => "387"
                        "paginaFinal" => "398"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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            59 => array:3 [
              "identificador" => "bib0775"
              "etiqueta" => "60"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Tai chi and rheumatic diseases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [ …1]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.rdc.2010.11.002"
                      "Revista" => array:7 [
                        "tituloSerie" => "Rheum Dis Clin North Am"
                        "fecha" => "2011"
                        "volumen" => "37"
                        "paginaInicial" => "19"
                        "paginaFinal" => "32"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0735109711014033"
                          "estado" => "S300"
                          "issn" => "07351097"
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                  ]
                ]
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            60 => array:3 [
              "identificador" => "bib0780"
              "etiqueta" => "61"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The effect of Tai Chi on health outcomes in patients with chronic conditions&#58; a systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/archinte.164.5.493"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Intern Med"
                        "fecha" => "2004"
                        "volumen" => "164"
                        "paginaInicial" => "493"
                        "paginaFinal" => "501"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            61 => array:3 [
              "identificador" => "bib0785"
              "etiqueta" => "62"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Tai chi for treating rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Cochrane database Syst Rev"
                        "fecha" => "2004"
                        "paginaInicial" => "CD004849"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            62 => array:3 [
              "identificador" => "bib0790"
              "etiqueta" => "63"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Tai chi for rheumatoid arthritis&#58; systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/rheumatology/kem151"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rheumatology"
                        "fecha" => "2007"
                        "volumen" => "46"
                        "paginaInicial" => "1648"
                        "paginaFinal" => "1651"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            63 => array:3 [
              "identificador" => "bib0795"
              "etiqueta" => "64"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Role of Tai Chi in the treatment of rheumatologic diseases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [ …1]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s11926-012-0294-y"
                      "Revista" => array:6 [
                        "tituloSerie" => "Curr Rheumatol Rep"
                        "fecha" => "2012"
                        "volumen" => "14"
                        "paginaInicial" => "598"
                        "paginaFinal" => "603"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            64 => array:3 [
              "identificador" => "bib0800"
              "etiqueta" => "65"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mindfulness-based stress reduction and health benefits&#46; A meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S0022-3999(03)00573-7"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Psychosom Res"
                        "fecha" => "2004"
                        "volumen" => "57"
                        "paginaInicial" => "35"
                        "paginaFinal" => "43"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            65 => array:3 [
              "identificador" => "bib0805"
              "etiqueta" => "66"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The clinical use of mindfulness meditation for the self-regulation of chronic pain"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Behav Med"
                        "fecha" => "1985"
                        "volumen" => "8"
                        "paginaInicial" => "163"
                        "paginaFinal" => "190"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            66 => array:3 [
              "identificador" => "bib0810"
              "etiqueta" => "67"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Three-year follow-up and clinical implications of a mindfulness meditation-based stress reduction intervention in the treatment of anxiety disorders"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Gen Hosp Psychiatry"
                        "fecha" => "1995"
                        "volumen" => "17"
                        "paginaInicial" => "192"
                        "paginaFinal" => "200"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            67 => array:3 [
              "identificador" => "bib0815"
              "etiqueta" => "68"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Association of depression and rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Psychosomatics"
                        "fecha" => "2003"
                        "volumen" => "44"
                        "paginaInicial" => "209"
                        "paginaFinal" => "215"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            68 => array:3 [
              "identificador" => "bib0820"
              "etiqueta" => "69"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mindfulness-based cognitive therapy for depression&#58; replication and exploration of differential relapse prevention effects"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1037/0022-006X.72.1.31"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Consult Clin Psychol"
                        "fecha" => "2004"
                        "volumen" => "72"
                        "paginaInicial" => "31"
                        "paginaFinal" => "40"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            69 => array:3 [
              "identificador" => "bib0825"
              "etiqueta" => "70"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mindfulness meditation alleviates depressive symptoms in women with fibromyalgia&#58; results of a randomized clinical trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/art.22478"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arthritis Rheum"
                        "fecha" => "2007"
                        "volumen" => "57"
                        "paginaInicial" => "77"
                        "paginaFinal" => "85"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            70 => array:3 [
              "identificador" => "bib0830"
              "etiqueta" => "71"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of mindfulness-based stress reduction in rheumatoid arthritis patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/art.23010"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arthritis Rheum"
                        "fecha" => "2007"
                        "volumen" => "57"
                        "paginaInicial" => "1134"
                        "paginaFinal" => "1142"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            71 => array:3 [
              "identificador" => "bib0835"
              "etiqueta" => "72"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Controversies in acupuncture research&#58; selection of controls and outcome measures in acupuncture clinical trials"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1089/acm.2006.12.943"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Altern Complement Med"
                        "fecha" => "2006"
                        "volumen" => "12"
                        "paginaInicial" => "943"
                        "paginaFinal" => "953"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            72 => array:3 [
              "identificador" => "bib0840"
              "etiqueta" => "73"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Antagonism of acupuncture analgesia in man by the narcotic antagonist naloxone"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Brain Res"
                        "fecha" => "1977"
                        "volumen" => "121"
                        "paginaInicial" => "368"
                        "paginaFinal" => "372"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            73 => array:3 [
              "identificador" => "bib0845"
              "etiqueta" => "74"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Traditional Chinese acupuncture and placebo &#40;sham&#41; acupuncture are differentiated by their effects on mu-opioid receptors &#40;MORs&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.neuroimage.2009.05.083"
                      "Revista" => array:6 [
                        "tituloSerie" => "Neuroimage"
                        "fecha" => "2009"
                        "volumen" => "47"
                        "paginaInicial" => "1077"
                        "paginaFinal" => "1085"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            74 => array:3 [
              "identificador" => "bib0850"
              "etiqueta" => "75"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Acupuncture for rheumatic conditions&#58; an overview of systematic reviews"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/rheumatology/keq180"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rheumatology"
                        "fecha" => "2010"
                        "volumen" => "49"
                        "paginaInicial" => "1957"
                        "paginaFinal" => "1961"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            75 => array:3 [
              "identificador" => "bib0855"
              "etiqueta" => "76"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Acupuncture and electroacupuncture for the treatment of rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Cochrane Database Syst Rev"
                        "fecha" => "2005"
                        "volumen" => "19"
                        "paginaInicial" => "CD003788"
                        "itemHostRev" => array:3 [
                          "pii" => "S0140673611619314"
                          "estado" => "S300"
                          "issn" => "01406736"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            76 => array:3 [
              "identificador" => "bib0860"
              "etiqueta" => "77"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The effect of acupuncture on patients with rheumatoid arthritis&#58; a randomized&#44; placebo-controlled cross-over study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Rheumatology"
                        "fecha" => "1999"
                        "volumen" => "38"
                        "paginaInicial" => "864"
                        "paginaFinal" => "869"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            77 => array:3 [
              "identificador" => "bib0865"
              "etiqueta" => "78"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A systematic review of evidence for the effectiveness of practitioner-based complementary and alternative therapies in the management of rheumatic diseases&#58; rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                           …1
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/rheumatology/kes133"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rheumatology"
                        "fecha" => "2012"
                        "volumen" => "51"
                        "paginaInicial" => "1707"
                        "paginaFinal" => "1713"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            78 => array:3 [
              "identificador" => "bib0870"
              "etiqueta" => "79"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Acupuncture for pain relief in patients with rheumatoid arthritis&#58; a systematic review"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/art.24009"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arthritis Rheum"
                        "fecha" => "2008"
                        "volumen" => "59"
                        "paginaInicial" => "1249"
                        "paginaFinal" => "1256"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            79 => array:3 [
              "identificador" => "bib0875"
              "etiqueta" => "80"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Acupuncture for rheumatoid arthritis&#58; a systematic review"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/rheumatology/ken330"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rheumatology"
                        "fecha" => "2008"
                        "volumen" => "47"
                        "paginaInicial" => "1747"
                        "paginaFinal" => "1753"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            80 => array:3 [
              "identificador" => "bib0880"
              "etiqueta" => "81"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The evidence for acupuncture as a treatment for rheumatologic conditions"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Rheum Dis Clin North Am"
                        "fecha" => "2000"
                        "volumen" => "26"
                        "paginaInicial" => "103"
                        "paginaFinal" => "115"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            81 => array:3 [
              "identificador" => "bib0885"
              "etiqueta" => "82"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Bee venom acupuncture for rheumatoid arthritis&#58; a systematic review of randomised clinical trials"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/bmjopen-2014-006140"
                      "Revista" => array:5 [
                        "tituloSerie" => "BMJ Open"
                        "fecha" => "2014"
                        "volumen" => "4"
                        "paginaInicial" => "e006140"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            82 => array:3 [
              "identificador" => "bib0890"
              "etiqueta" => "83"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Salicylates and homoeopathy in rheumatoid arthritis&#58; preliminary observations"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Clin Pharmacol"
                        "fecha" => "1978"
                        "volumen" => "6"
                        "paginaInicial" => "391"
                        "paginaFinal" => "395"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            83 => array:3 [
              "identificador" => "bib0895"
              "etiqueta" => "84"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Homoeopathic therapy in rheumatoid arthritis&#58; evaluation by double-blind clinical therapeutic trial"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Clin Pharmacol"
                        "fecha" => "1980"
                        "volumen" => "9"
                        "paginaInicial" => "453"
                        "paginaFinal" => "459"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            84 => array:3 [
              "identificador" => "bib0900"
              "etiqueta" => "85"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A randomized controlled trial to evaluate the effectiveness of homeopathy in rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Scand J Rheumatol"
                        "fecha" => "1991"
                        "volumen" => "20"
                        "paginaInicial" => "204"
                        "paginaFinal" => "208"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            85 => array:3 [
              "identificador" => "bib0905"
              "etiqueta" => "86"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A randomized controlled trial of homeopathy in rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Rheumatology"
                        "fecha" => "2001"
                        "volumen" => "40"
                        "paginaInicial" => "1052"
                        "paginaFinal" => "1055"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            86 => array:3 [
              "identificador" => "bib0910"
              "etiqueta" => "87"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Homeopathy has clinical benefits in rheumatoid arthritis patients that are attributable to the consultation process but not the homeopathic remedy&#58; a randomized controlled clinical trial"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/rheumatology/keq234"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rheumatology"
                        "fecha" => "2011"
                        "volumen" => "50"
                        "paginaInicial" => "1070"
                        "paginaFinal" => "1082"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            87 => array:3 [
              "identificador" => "bib0915"
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Review article
Have complementary therapies demonstrated effectiveness in rheumatoid arthritis?
¿Han demostrado eficacia las terapias complementarias en la artritis reumatoide?
Nagore Fernández-Llanio Comella
Autor para correspondencia
, Meritxell Fernández Matilla, Juan Antonio Castellano Cuesta
Sección de Reumatología, Hospital Arnau de Vilanova, Valencia, Spain
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      <span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Recent advances have improved drug treatment of rheumatoid arthritis &#40;RA&#41;&#46; Despite this fact&#44; most RA patients need lifelong pharmacological therapy&#46; An increasing number of RA patients are resorting to various complementary and alternative medicine &#40;CAM&#41; approaches for relief of symptoms and general well-being&#46; CAM is the term for medical products and practices that are not part of standard care and are not generally taught in conventional medical schools&#46; Alternative medicine is used instead of conventional medicine&#44; whereas complementary medicine is used together with it&#46; CAM has been mainly used to treat back pain or other back problems&#44; neck pain&#44; joint pain or stiffness and anxiety or depression in RA patients&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">1</span></a> For this reason&#44; rheumatologists should be aware of CAM when treating RA patients&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The American College of Rheumatology &#40;ACR&#41; recognizes the interest in CAM approaches in the Position Statement Document&#46; &#8220;The ACR supports rigorous scientific evaluation of all modalities that improve the treatment or rheumatic diseases&#46; The ACR understands that certain characteristics of some CAMs and some conventional medical interventions make it difficult or impossible to conduct standard randomized controlled trials&#46; For these modalities&#44; innovative methods of evaluation are needed&#44; as are measures and standards for the generation and interpretation of evidence&#46; The ACR supports the integration of those modalities proven to be safe and effective by scientifically rigorous clinical trials published in the biomedical peer review literature&#46; In the absence of such rigorous clinical trials&#44; the ACR recommends advising patients that potential harm can occur from unproven or alternative therapies and thus advises caution in the use of unproven treatments&#46; The ACR believes healthcare providers should be informed about the more common CAM modalities&#44; based upon appropriate scientific evaluation as described above&#44; and should be able to discuss them knowledgeably with patients&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">This article provides an overview of the current body of knowledge about the role of CAM in the treatment of RA&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">In order to explore available evidence about CAM used in RA patients&#44; we performed a systematic search including Medline and Cochrane library databases&#46; Medline search was performed including the following appropriate combination of MeSH &#40;Medical Subject Heading&#41; terms including&#58; &#8220;complementary therapies&#8221;&#44; &#8220;diet&#8221;&#44; &#8220;dietary supplements&#8221;&#44; &#8220;phytotherapy&#8221;&#44; &#8220;medicinal plants&#8221;&#44; &#8220;exercise&#8221;&#44; &#8220;mind-body therapies&#8221;&#44; &#8220;acupuncture&#8221;&#44; &#8220;homeopathy&#8221;&#44; &#8220;hydrotherapy&#8221; AND &#8220;rheumatoid arthritis&#8221;&#46; The references cited in the obtained papers were also examined to identify additional studies not indexed by MEDLINE&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Nutrition</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Nutritional intervention</span><p id="par0025" class="elsevierStylePara elsevierViewall">Nutritional intervention has been used in patients with chronic inflammatory diseases&#46; Specifically&#44; nutritional intervention used in RA patients included&#58; supervised fasting &#40;200&#8211;300<span class="elsevierStyleHsp" style=""></span>kcal&#47;day&#41; during 7&#8211;10 days&#44; Mediterranean diet &#40;small amount of meat&#44; fish&#44; more fruits and vegetables and olive oil&#41;&#44; vegetarian diet&#44; vegan diet&#44; elemental diet &#40;liquid diets that contain nutrients that are broken down to make digestion easier&#41; and elimination diet &#40;foods that are thought to be the cause of symptoms are eliminated&#44; and then added one at a time to find which ones cause symptoms&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">There is evidence that fasting produces a decrease in pain and inflammation in RA patients&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">3</span></a> However&#44; the inflammation reappears when the patient starts his&#47;her normal diet&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">4</span></a> It has been shown that fasting followed by a vegetarian diet may help patients with RA&#46; The effect of fasting followed by a year of a vegetarian diet was assessed in a randomized&#44; single-blind controlled trial&#46;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">5</span></a> The diet group showed a significant improvement in the number of tender joints&#44; Ritchie&#39;s articular index&#44; number of swollen joints&#44; pain score&#44; duration of morning stiffness&#44; grip strength&#44; erythrocyte sedimentation rate&#44; C-reactive protein&#44; white blood cell count&#44; and a health assessment questionnaire score &#40;HAQ&#41;&#46; These benefits in the diet group were still present after one year<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">5</span></a> and this improvement can be sustained through an additional follow-up two-year diet period&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">A Mediterranean diet has been proved to reduce blood pressure&#59; improve glucose metabolism&#44; the lipid profile&#44; and lipoprotein particle characteristics and decrease inflammation and oxidative stress&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">7</span></a> In RA patients&#44; a Mediterranean diet decreases pain&#44; morning stiffness&#44; the number of swollen joints and also improves HAQ&#44; Disease Activity Score 28 &#40;DAS28&#41; and disease patient perception&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">7</span></a> Three systematic reviews stated that a Mediterranean diet decreased pain in RA patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">8&#8211;10</span></a> Moreover&#44; the Mediterranean diet has been recommended for cardiovascular diseases and osteoporosis &#40;frequent RA comorbidities&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">A Cochrane review<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">8</span></a> assessed the effectiveness and safety of dietary interventions in the treatment of RA&#46; The authors concluded that fasting&#44; followed by 13 months on a vegetarian diet&#44; may reduce pain&#46; The effects of vegan and elimination diets are uncertain due to inadequate data reporting&#46; Trials that studied elemental diets reported no significant differences in pain&#44; function or stiffness&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Nutritional supplements</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Fish oil</span><p id="par0045" class="elsevierStylePara elsevierViewall">Fish oil is rich in &#937;-3 polyunsaturated fatty acids &#40;PUFAs&#41;&#44; eicosapentaenoic acid &#40;EPA&#41; and docosahexaenoic acid &#40;DHA&#41;&#44; which have been associated with reduced expression of TNF-&#945; and interleukin-1&#946;&#46;<a class="elsevierStyleCrossRefs" href="#bib0530"><span class="elsevierStyleSup">11&#44;12</span></a> These properties are similar to synthetic drugs used in RA patients such as nonsteroidal anti-inflammatory drugs &#40;NSAIDs&#41; and TNF blockers&#46; Furthermore&#44; EPA and DHA can be metabolized in E-series and D-series of resolvins that reduce inflammation&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">13</span></a> The American Heart Association recommends consuming fish oil to reduce the occurrence of cardiovascular disease events in patients with coronary artery disease&#46;<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">14</span></a> RA patients present high cardiovascular morbid-mortality rate and fish oil consumption could represent an additional benefit in this population&#46; A meta-analysis suggested that including omega-3 PUFAs at dosages &#62;2&#46;7<span class="elsevierStyleHsp" style=""></span>g&#47;day in the diet for &#62;3 months reduces NSAID consumption in RA patients&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">15</span></a> A systematic review including 23 randomized controlled trials testing marine &#937;-3 PUFAs has been performed in patients with RA&#46; This review has showed a modest benefit on joint swelling and pain&#44; duration of morning stiffness&#44; global assessment of pain and disease activity&#44; and a reduction in the use of NSAIDs&#46;<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">16</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Proudman et al&#46; studied in a randomized&#44; double-blind controlled trial the effects of fish oil consumption in early RA&#44; employing a &#8216;treat-to-target&#8217; protocol in combination with disease-modifying anti-rheumatic drugs &#40;DMARDs&#41;&#46; Fish oil intake was associated with a higher rate of ACR remissions&#44; and a reduction in DMARDs dosage&#46;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">17</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Although not necessarily clinically significant&#44; when prescribing &#937;-3 PUFAs&#44; rheumatologist should be aware that high dose &#937;-3 PUFAs are not recommended in patients who may be susceptible to increased bleeding &#40;e&#46;g<span class="elsevierStyleItalic">&#46;</span>&#44; patients taking warfarin&#41;&#44; because they may increase coagulation times&#46;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">18</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Virgin olive oil</span><p id="par0060" class="elsevierStylePara elsevierViewall">Virgin olive oil contains numerous compounds that exert potent anti-inflammatory and antioxidant actions&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">19</span></a> The main active components of olive oil include oleic acid&#44; linolenic acid&#44; alpha-linoleic acid and phenolic constituents&#46;<a class="elsevierStyleCrossRefs" href="#bib0575"><span class="elsevierStyleSup">20&#44;21</span></a> Oleic acid is metabolized to eicosatrienoic acid &#40;omega-9 fatty acid&#41; with similar anti-inflammatory properties than fish oil omega-3 fatty acids&#46;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">21</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Berbert et al&#46; evaluated whether supplementation with olive oil could improve clinical and laboratory parameters of disease activity in RA patients who were already taking fish oil supplements&#46; RA patient groups that received fish oil omega-3 fatty acids and olive oil showed a more precocious and accentuated improvement&#46;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Vitamin D</span><p id="par0070" class="elsevierStylePara elsevierViewall">Vitamin D plays a role in the maintenance of the homeostasis of the calcium and phosphorus metabolism&#46; Vitamin D deficiency is linked to osteopenia&#44; which is frequently associated to RA&#46; Nevertheless vitamin D functions go much further since it is considered an immune system regulator&#46; It intervenes in the innate and acquired immune systems&#46;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">23</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">In vitro</span>&#44; vitamin D inhibits the activation of IL-2&#44; IL-12&#44; IL-6&#44; interferon gamma &#40;IF-&#947;&#41;&#44; and TNF&#46; Instead&#44; vitamin D promotes monocyte differentiation into macrophages&#46; Moreover&#44; vitamin D has anti-inflammatory qualities through its capacity to regulate the production of prostaglandins&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">24</span></a> In fact&#44; in murine models of human arthritis&#44; vitamin D inhibits the progression of arthritis&#46;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">25</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">A meta-analysis summarizes published results on the association between vitamin D intake and the development of RA&#46; The authors conclude that an insufficient vitamin D intake is associated with an elevated risk of RA development&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">26</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Vitamin D supplements could have an effect on RA treatment&#46; Brohult et al&#46; studied the effects of large doses of calciferol on patients with RA in a double-blind clinical trial&#46; After 1 year&#44; high dose oral calciferol therapy showed a positive effect on disease activity in RA patients&#46;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">27</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Furthermore&#44; in a 3-month open-label trial&#44; vitamin D administration as an adjunct therapy with DMARDs was correlated with a decrease in pain and PCR in RA patients&#46; No adverse reactions related to vitamin D were reported&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">28</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Probiotics</span><p id="par0095" class="elsevierStylePara elsevierViewall">Probiotics are live microorganisms that&#44; when administered in adequate amounts&#44; confer health benefits on the host&#46;<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">29</span></a> Current evidence suggests that probiotics may play a therapeutic role in chronic inflammatory diseases such as RA&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">30</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In murine models of RA&#44; oral administration of <span class="elsevierStyleItalic">Lactobacillus casei</span> decreased the pro-inflammatory cytokines and improved RA index disease activity in comparison with a control group or even compare with a control group treated with indomethacin&#46;<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">31</span></a> Furthermore&#44; So et al&#46; demonstrated that the administration of <span class="elsevierStyleItalic">Lactobacillus casei</span> improved histopathological changes&#44; and the lymphocytic infiltrates in the joints&#44; similarly to the administration of methotrexate &#40;MTX&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">32</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Several studies showed an improvement in HAQ or disease patient perception related to probiotics intake&#46;<a class="elsevierStyleCrossRefs" href="#bib0640"><span class="elsevierStyleSup">33&#8211;36</span></a> However&#44; the evidence of the use of probiotics in humans is scarce&#46; A recently reported randomized&#44; double-blind&#44; clinical trial study showed beneficial effects of <span class="elsevierStyleItalic">Lactobacillus casei</span> in pain&#44; tender and swollen joint counts and DAS28&#44; in RA women patients&#46; It also showed amelioration in PCR&#44; TNF&#945;&#44; IL-12 e IL-10 levels&#46;<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">36</span></a> No side effects were described&#46;</p></span></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Herbal medicine</span><p id="par0110" class="elsevierStylePara elsevierViewall">Some herbal medicinal products have been shown to interact with the mediators of inflammation and&#44; therefore&#44; may be used in the treatment of RA&#46;<a class="elsevierStyleCrossRefs" href="#bib0660"><span class="elsevierStyleSup">37&#44;38</span></a> These products can also act as free radical scavengers&#44; and through other mechanisms&#46; For example&#44; topical capsaicin is a highly selective agonist of TRPV1 receptors&#44; which are expressed in afferent neuronal C fibers and some A&#948; fibers&#46; Capsaicin induces local depletion of substance P which is thought to be part of its mechanism for pain relief&#46;<a class="elsevierStyleCrossRef" href="#bib0670"><span class="elsevierStyleSup">39</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">However&#44; few high quality clinical trials have yet been carried out to substantiate the safety and efficacy of herbal medicines&#44; which are not free of potentially serious side effects&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Eleven randomized controlled trials including 940 patients have reported the effects of <span class="elsevierStyleItalic">Tripterygium wilfordii</span> extracts &#40;TWE&#41; in the treatment of RA&#59; the methodological quality of these studies was generally low and the results have been inconsistent&#46;<a class="elsevierStyleCrossRef" href="#bib0675"><span class="elsevierStyleSup">40</span></a> A randomized controlled trial by Goldbach-Mansky et al&#46;&#44; was conducted to compare the benefits and side effects of TWE with those of sulfasalazine for the treatment of active RA&#46; The results showed that the attainment of the ACR 20 response criteria was significantly higher with TWE extract than with sulfasalazine&#46;<a class="elsevierStyleCrossRef" href="#bib0680"><span class="elsevierStyleSup">41</span></a> A multicenter&#44; open-label&#44; randomized controlled trial compared the efficacy and safety of TWE with MTX in the treatment of active RA&#46; After 6 months&#44; the proportion of patients reaching the ACR50 response criteria was 46&#46;4&#37;&#44; 55&#46;1&#37; and 76&#46;8&#37;&#44; respectively&#44; in the MTX&#44; TWE and MTX<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>TWE groups&#46; The authors concluded that TWE monotherapy was not worse than MTX&#44; and that MTX<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>TWE was better than MTX alone in controlling disease activity in patients with active RA&#46;<a class="elsevierStyleCrossRef" href="#bib0685"><span class="elsevierStyleSup">42</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">It has also been suggested that plants such as <span class="elsevierStyleItalic">Borago officinalis</span>&#44; <span class="elsevierStyleItalic">Oenothera blennis</span> and <span class="elsevierStyleItalic">Ribes migrum</span> with a high grade of acid gamma linolenic &#40;AGL&#41; may improve pain and disease activity in RA patients&#46;<a class="elsevierStyleCrossRef" href="#bib0670"><span class="elsevierStyleSup">39</span></a> AGL is an essential fatty acid precursor of prostaglandin E1&#44; an eicosanoid with anti-inflammatory and immunomodulatory properties&#46;<a class="elsevierStyleCrossRef" href="#bib0690"><span class="elsevierStyleSup">43</span></a> In clinical trials&#44; the AGL group&#44; developed more frequently adverse reactions than the placebo group&#44; although no significant differences were reported&#46; Cases of convulsions due to <span class="elsevierStyleItalic">Oenothera blennis</span> have been reported in epileptic patients or patients being treated with central nervous system medications&#46;<a class="elsevierStyleCrossRef" href="#bib0670"><span class="elsevierStyleSup">39</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">The quality of herbal medicines can directly affect their safety and efficacy&#46; Good manufacturing practices &#40;GMP&#41; are one of the most important tools to avoid contamination of herbal products&#46;<a class="elsevierStyleCrossRef" href="#bib0695"><span class="elsevierStyleSup">44</span></a> If the manufacturer keeps GMP&#44; this issue is rare&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Physical activity</span><p id="par0135" class="elsevierStylePara elsevierViewall">Physical inactivity is the fourth leading risk factor for mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0700"><span class="elsevierStyleSup">45</span></a> People who exercise more have lower rates of coronary heart disease&#44; hypertension&#44; stroke&#44; type 2 diabetes&#44; metabolic syndrome&#44; colon cancer&#44; breast cancer&#44; depression and mortality from all causes&#46;<a class="elsevierStyleCrossRef" href="#bib0705"><span class="elsevierStyleSup">46</span></a> Physical activity decreases the risk of fracture and loss of bone mineral density and increases muscle mass&#44; strength&#44; power and intrinsic neuromuscular activity&#46;<a class="elsevierStyleCrossRefs" href="#bib0705"><span class="elsevierStyleSup">46&#44;47</span></a> However&#44; in RA patients physical activity has been considered to increase joint stress&#44; pain&#44; disease activity and joint damage&#46; Then&#44; is it appropriate to recommend exercise to RA patients&#63;</p><p id="par0140" class="elsevierStylePara elsevierViewall">According to the latest evidence&#44; exercise has not been associated with harmful effects on disease activity&#44; pain or radiological damage&#46;<a class="elsevierStyleCrossRefs" href="#bib0715"><span class="elsevierStyleSup">48&#44;49</span></a> Therefore&#44; physical activity does not worsen RA&#44; and probably provides additional benefits&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Hurkmans et al&#46; reviewed the effectiveness and safety of short-term &#40;\n
      &lt;three months)="" and="" long-term="" (=""&gt;\n
       three months&#41; dynamic exercise programs for RA patients&#46; The authors concluded that aerobic capacity training combined with muscle strength training is recommended as routine practice in RA patients&#46;\n
      &lt;/three&gt;<a class="elsevierStyleCrossRef" href="#bib0715"><span class="elsevierStyleSup">48</span></a> A randomized controlled trial showed for the first time that after a 24 week progressive training program&#44; RA patients gained muscle mass&#44; also functional improvement was observed&#46;<a class="elsevierStyleCrossRef" href="#bib0725"><span class="elsevierStyleSup">50</span></a> Therefore exercise must be recommended in RA patients&#46; However&#44; physical activity should be of low joint impact in order to avoid pain and musculoskeletal injuries&#46;<a class="elsevierStyleCrossRef" href="#bib0705"><span class="elsevierStyleSup">46</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Yoga</span><p id="par0150" class="elsevierStylePara elsevierViewall">In western countries&#44; mind-body interventions&#44; such as yoga&#44; which combines stress management with physical activity&#44; are growing&#46; Yoga modulates sweating response to dynamic exercise and improves respiratory muscle strength&#44; handgrip strength&#44; handgrip endurance and flexibility&#46;<a class="elsevierStyleCrossRefs" href="#bib0730"><span class="elsevierStyleSup">51&#8211;53</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">There is very low evidence of the role yoga plays in RA patients&#46; The methodological quality of the studies is poor because of a lack of patient blindness&#46; Two trials showed a significant improvement of DAS28 associated with yoga&#46;<a class="elsevierStyleCrossRefs" href="#bib0745"><span class="elsevierStyleSup">54&#44;55</span></a> In other studies&#44; yoga improved pain&#44; HAQ&#44; balance and handgrip strength&#46;<a class="elsevierStyleCrossRefs" href="#bib0745"><span class="elsevierStyleSup">54&#44;56&#44;57</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Evans et al&#46; aimed to assess the effects of a yoga program on health-related quality of life &#40;HRQoL&#41; for young adults with RA compared with a usual-care waitlist control group&#46; The results of the study suggested that yoga is a feasible and safe complementary treatment for young people with RA&#44; leading to HRQoL&#44; pain&#44; disability&#44; fatigue&#44; and mood benefits&#46;<a class="elsevierStyleCrossRef" href="#bib0765"><span class="elsevierStyleSup">58</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">No side effects were reported for yoga in RA patients&#46;<a class="elsevierStyleCrossRef" href="#bib0770"><span class="elsevierStyleSup">59</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Taichi</span><p id="par0170" class="elsevierStylePara elsevierViewall">Tai Chi is a Chinese martial art that combines meditation with slow&#44; gentle&#44; graceful movements&#44; as well as&#44; deep breathing and relaxation&#46;<a class="elsevierStyleCrossRef" href="#bib0775"><span class="elsevierStyleSup">60</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Wang et al&#46; conducted a systematic review of reports on the effects of Tai Chi over various chronic medical conditions&#46; Nine randomized controlled trials&#44; 23 non-randomized controlled studies&#44; and 15 observational studies were included&#46; Tai Chi appeared to have benefits and also appeared to be safe and effective in promoting balance control&#44; flexibility&#44; and cardiovascular fitness in older patients with chronic conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0780"><span class="elsevierStyleSup">61</span></a> Thus Tai Chi may benefit RA patients who have limited strength&#44; mobility and comorbidities &#40;cardiovascular risk&#44; osteoporosis and depression&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0775"><span class="elsevierStyleSup">60</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Several reviews about the effect of Tai Chi in RA patients have been published&#44; including a Cochrane Review&#46;<a class="elsevierStyleCrossRefs" href="#bib0770"><span class="elsevierStyleSup">59&#44;60&#44;62&#8211;64</span></a> Tai Chi was associated with improvement in terms of RA disease activity&#46; Although existing evidence remains limited and inconclusive&#46; No adverse events were observed and Tai Chi does not exacerbate RA symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0795"><span class="elsevierStyleSup">64</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Meditation</span><p id="par0185" class="elsevierStylePara elsevierViewall">Meditation incorporates a diverse range of techniques that helps to focus attention and bring a state of self-awareness and inner calm&#46; Meditation may alleviate patients&#8217; suffering associated with physical&#44; psychosomatic and psychiatric disorders&#44; it can even reduce cardiovascular risk factors&#46;<a class="elsevierStyleCrossRef" href="#bib0800"><span class="elsevierStyleSup">65</span></a> Meditation may improve pain&#44;<a class="elsevierStyleCrossRef" href="#bib0805"><span class="elsevierStyleSup">66</span></a> anxiety&#44;<a class="elsevierStyleCrossRef" href="#bib0810"><span class="elsevierStyleSup">67</span></a> depression in RA patients&#44;<a class="elsevierStyleCrossRefs" href="#bib0815"><span class="elsevierStyleSup">68&#44;69</span></a> and fibromyalgia&#46;<a class="elsevierStyleCrossRef" href="#bib0825"><span class="elsevierStyleSup">70</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">In a randomized&#44; waitlist-controlled pilot study Pradhan et al&#46; evaluated the effect of mindfulness meditation on depressive symptoms&#44; psychological status&#44; and disease activity in 63 RA patients&#46; After 2 months&#44; there were no statistically significant differences between groups in any outcomes&#46; After 6 months&#44; there was significant improvement in psychological distress &#40;35&#37; reduction&#41; and well-being&#46; However&#44; the intervention had no impact on RA disease activity&#46;<a class="elsevierStyleCrossRef" href="#bib0830"><span class="elsevierStyleSup">71</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Acupuncture</span><p id="par0195" class="elsevierStylePara elsevierViewall">Acupuncture is a traditional Chinese medicine where thin needles are inserted in specific points of the body to facilitate the recovery of health and to enhance well-being&#46; The effectiveness or efficacy of acupuncture has been tested in randomized controlled trials with poor methodological standards&#46;<a class="elsevierStyleCrossRef" href="#bib0835"><span class="elsevierStyleSup">72</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">The mechanism of action in acupuncture is associated with an analgesic effect by interaction with endogen opioids and serotonin mediators&#46; Mayer et al&#46; reported that acupuncture analgesia was blocked after naloxone administration&#46; These findings support the effect of acupuncture over endogenous opioids&#46;<a class="elsevierStyleCrossRef" href="#bib0840"><span class="elsevierStyleSup">73</span></a> A positron emission tomography study showed that acupuncture therapy evoked short-term increases in &#956;-opioid cerebral receptors binding potential&#46;<a class="elsevierStyleCrossRef" href="#bib0845"><span class="elsevierStyleSup">74</span></a> Despite these studies&#44; the current evidence about decreased pain due to acupuncture in RA patients is scarce and non conclusive&#46;<a class="elsevierStyleCrossRef" href="#bib0850"><span class="elsevierStyleSup">75</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">Two studies involving a total of 84 people were included in a Cochrane review&#46; One study used acupuncture and no significant differences between groups were observed&#46;<a class="elsevierStyleCrossRef" href="#bib0855"><span class="elsevierStyleSup">76</span></a> In the second study&#44; using electroacupuncture&#44; a significant decrease in knee pain was reported in the experimental group when compared to the placebo group&#46; However&#44; the authors concluded that the poor quality of the trial&#44; including the small sample size preclude any recommendation&#46;<a class="elsevierStyleCrossRef" href="#bib0860"><span class="elsevierStyleSup">77</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">More recently&#44; two systematic reviews reported that despite some favorable results in active-controlled trials&#44; conflicting evidence exists in placebo-controlled trials concerning the efficacy of acupuncture for RA&#46; Rigorous and well-controlled randomized trials are warranted&#46; Minor adverse events in the acupuncture groups were observed&#46;<a class="elsevierStyleCrossRefs" href="#bib0865"><span class="elsevierStyleSup">78&#8211;81</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">Another systematic review assessed the effect of bee venom acupuncture &#40;BVA&#41; used as an RA therapy&#46; The authors concluded that the evidence is insufficient to suggest that BVA is an effective treatment for RA&#46;<a class="elsevierStyleCrossRef" href="#bib0885"><span class="elsevierStyleSup">82</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Homeopathy</span><p id="par0220" class="elsevierStylePara elsevierViewall">In 1978&#44; the first study of homeopathy in RA patients was published&#46; Ninety-five RA patients were randomized to receive acetylsalicylic acid or homeopathy&#46; After 1 year of treatment&#44; 42&#46;6&#37; patients of the homeopathy group and only 14&#46;6&#37; of the salicylate group continued&#46; During the first year of the study&#44; 33&#46;4&#37; patients of the homeopathy group and 85&#46;4&#37; in the salicylate group withdrew the study&#46;<a class="elsevierStyleCrossRef" href="#bib0890"><span class="elsevierStyleSup">83</span></a> Gibson et al&#46; compared orthodox first-line anti-inflammatory treatment plus homeopathy with anti-inflammatory treatment plus an inert preparation&#46; In the treatment group improvement in subjective pain&#44; articular index&#44; stiffness and grip strength were observed&#46;<a class="elsevierStyleCrossRef" href="#bib0895"><span class="elsevierStyleSup">84</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">In a 6-month double-blind trial&#44; 44 RA patients were entered comparing homeopathy with a placebo&#46; There was no statistically significant difference between groups&#46;<a class="elsevierStyleCrossRef" href="#bib0900"><span class="elsevierStyleSup">85</span></a> A randomized controlled trial by Fisher and Scott was conducted to study if homeopathy was effective in reducing the symptoms of joint inflammation in RA&#46; The results of the trial showed no evidence that active homeopathy improves the symptoms of RA&#46;<a class="elsevierStyleCrossRef" href="#bib0905"><span class="elsevierStyleSup">86</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">Brien et al&#46; sought to assess whether any benefits from complementary homeopathic treatment in patients with RA are due to the homeopathic consultation&#44; homeopathic remedies or both&#46; The authors concluded that homeopathic consultations but not homeopathic remedies are associated with clinically relevant benefits in RA&#46;<a class="elsevierStyleCrossRef" href="#bib0910"><span class="elsevierStyleSup">87</span></a> This publication has received several criticisms&#44;<a class="elsevierStyleCrossRefs" href="#bib0915"><span class="elsevierStyleSup">88&#8211;90</span></a> mainly because the insufficient statistical power to detect differences between groups&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">In conclusion&#44; we have limited clinical trials with adequate methodology to assess the effectiveness of homeopathy in patients with RA&#46; None of the published studies have reported side effects associated with homeopathic drugs&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Balneotherapy&#47;Hydrotherapy</span><p id="par0240" class="elsevierStylePara elsevierViewall">Hydrotherapy&#47;Balneotherapy involves the use of water in treatments and in the case of RA is considered the oldest therapy&#46; The recuperative and healing properties of these therapies are based on their mechanic and thermal effects&#46;<a class="elsevierStyleCrossRef" href="#bib0930"><span class="elsevierStyleSup">91</span></a> The protracted application of heat&#44; and the pressure exerted by the water carries impulses felt at the skin deeper into the body&#44; where they are instrumental in stimulating the immune system&#44; reducing stress&#44; invigorating circulation and digestion&#44; encouraging blood flow&#44; lessening pain sensitivity and blocking the sympathetic nervous system&#46;<a class="elsevierStyleCrossRef" href="#bib0935"><span class="elsevierStyleSup">92</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">A Cochrane review assessed the effectiveness of balneotherapy for RA patients&#46; Nine trials&#44; representing 579 people were included&#46; Most trials reported positive findings&#44; but were methodologically flawed to some extent&#44; and withdrawals due to adverse events were not reported&#46;<a class="elsevierStyleCrossRef" href="#bib0940"><span class="elsevierStyleSup">93</span></a> Another systematic review found evidence that aquatic exercise had small but statistically significant effects on pain relief and related outcomes in RA&#46; However&#44; due to the poor methodological quality of balneotherapy studies&#44; we are unable to make any conclusion on the effects of this intervention&#46;<a class="elsevierStyleCrossRef" href="#bib0945"><span class="elsevierStyleSup">94</span></a></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conclusion</span><p id="par0250" class="elsevierStylePara elsevierViewall">The use of CAM in rheumatology is common&#46;<a class="elsevierStyleCrossRef" href="#bib0950"><span class="elsevierStyleSup">95</span></a> The increased interest of RA patients in CAM approaches is a reality&#44; thus rheumatologists should advice their patients with scientific rigor and the best evidence available&#46; In this sense the ACR sets its position which supports rigorous scientific evaluation on all approaches that improve the treatment of rheumatic diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">2</span></a><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> presents the CAM approaches that may be beneficial for RA patients&#44; although there is still a long way ahead in terms of research in order to draw firm conclusions&#46; There are no long-term studies&#44; nor studies to assess joint damage progression&#44; however some complementary therapies may represent an opportunity to improve the quality of life of our patients&#44; and in the future may be integrated in the management of RA patients&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflicts of interest</span><p id="par0255" class="elsevierStylePara elsevierViewall">The authors have no affiliations with or financial interest in any company or organization that could conflict with the views expressed in this manuscript&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Ethical responsibilities</span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Protection of people and animals</span><p id="par0260" class="elsevierStylePara elsevierViewall">The authors declare that this research has not been conducted experiments on humans or animals&#46;</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Confidentiality of data</span><p id="par0265" class="elsevierStylePara elsevierViewall">The authors declare that this article does not appear patient data&#46;</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Right to privacy and informed consent</span><p id="par0270" class="elsevierStylePara elsevierViewall">The authors declare that this article does not appear patient data&#46;</p></span></span></span>
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          "titulo" => "Keywords"
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          "titulo" => "Palabras clave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Methods"
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        6 => array:3 [
          "identificador" => "sec0015"
          "titulo" => "Nutrition"
          "secciones" => array:2 [
            0 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Nutritional intervention"
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            1 => array:3 [
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              "titulo" => "Nutritional supplements"
              "secciones" => array:4 [
                0 => array:2 [
                  "identificador" => "sec0030"
                  "titulo" => "Fish oil"
                ]
                1 => array:2 [
                  "identificador" => "sec0035"
                  "titulo" => "Virgin olive oil"
                ]
                2 => array:2 [
                  "identificador" => "sec0040"
                  "titulo" => "Vitamin D"
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                3 => array:2 [
                  "identificador" => "sec0045"
                  "titulo" => "Probiotics"
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          ]
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        7 => array:2 [
          "identificador" => "sec0050"
          "titulo" => "Herbal medicine"
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          "identificador" => "sec0055"
          "titulo" => "Physical activity"
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          "identificador" => "sec0060"
          "titulo" => "Yoga"
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          "identificador" => "sec0065"
          "titulo" => "Taichi"
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          "identificador" => "sec0070"
          "titulo" => "Meditation"
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          "titulo" => "Acupuncture"
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          "identificador" => "sec0080"
          "titulo" => "Homeopathy"
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          "identificador" => "sec0085"
          "titulo" => "Balneotherapy&#47;Hydrotherapy"
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          "identificador" => "sec0090"
          "titulo" => "Conclusion"
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          "identificador" => "sec0095"
          "titulo" => "Conflicts of interest"
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          "identificador" => "sec0100"
          "titulo" => "Ethical responsibilities"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0105"
              "titulo" => "Protection of people and animals"
            ]
            1 => array:2 [
              "identificador" => "sec0110"
              "titulo" => "Confidentiality of data"
            ]
            2 => array:2 [
              "identificador" => "sec0115"
              "titulo" => "Right to privacy and informed consent"
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        ]
        18 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
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    "fechaRecibido" => "2015-07-25"
    "fechaAceptado" => "2015-10-30"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec819336"
          "palabras" => array:11 [
            0 => "Rheumatoid arthritis"
            1 => "Complementary therapy"
            2 => "Diet"
            3 => "Nutritional supplements"
            4 => "Phytotherapy"
            5 => "Medicinal plants"
            6 => "Exercise"
            7 => "Body&#8211;mind therapies"
            8 => "Acupuncture"
            9 => "Homeopathy"
            10 => "Hydrotherapy"
          ]
        ]
      ]
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          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec819337"
          "palabras" => array:11 [
            0 => "Artritis reumatoide"
            1 => "Terapia complementaria"
            2 => "Dieta"
            3 => "Suplementos nutricionales"
            4 => "Fitoterapia"
            5 => "Plantas medicinales"
            6 => "Ejercicio"
            7 => "Terapias cuerpo-mente"
            8 => "Acupuntura"
            9 => "Homeopat&#237;a"
            10 => "Hidroterapia"
          ]
        ]
      ]
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">In recent decades the treatment of rheumatoid arthritis &#40;RA&#41; has improved thanks to the use of highly effective drugs&#46; However&#44; patients usually require long term therapy&#44; which is not free of side effects&#46; Therefore RA patients often demand complementary medicine&#44; they seek additional sources of relief and&#47;or less side effects&#46; In fact 30&#8211;60&#37; of rheumatic patients use some form of complementary medicine&#46; Therefore&#44; from conventional medicine&#44; if we want to optimally treat our patients facilitating communication with them we must know the most commonly used complementary medicines&#46; The aim of this review is to assess&#44; based on published scientific research&#44; what complementary therapies commonly used by patients with RA are effective and safe&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">En las &#250;ltimas d&#233;cadas el tratamiento de la Artritis Reumatoide &#40;AR&#41; ha mejorado mucho gracias a la utilizaci&#243;n de f&#225;rmacos altamente eficaces&#46; Sin embargo&#44; los enfermos suelen requerir tratamiento farmacol&#243;gico de por vida&#44; no exento de efectos adversos&#46; Por esta raz&#243;n los pacientes con AR a menudo acuden a la medicina complementaria&#44; buscan fuentes adicionales de alivio y&#47;o menores efectos secundarios&#46; Un 30&#8211;60&#37; de los pacientes reum&#225;ticos utilizan alg&#250;n tipo de medicina complementaria&#46; Por lo tanto&#44; desde la medicina convencional&#44; si queremos optimizar el tratamiento de nuestros pacientes y facilitar la comunicaci&#243;n con ellos debemos conocer las medicinas complementarias m&#225;s utilizadas&#46; El objetivo de esta revisi&#243;n es valorar&#44; en base a la investigaci&#243;n cient&#237;fica publicada&#44; qu&#233; tratamientos complementarios habitualmente utilizados por los pacientes con AR son efectivos y seguros&#46;</p></span>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fasting followed by vegetarian diet&#59; Mediterranean diet&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">May benefit patients with RA&#46;<br>Mediterranean diet is safe and decreases cardiovascular risk &#40;frequent RA comorbidity&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fish oil&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Evidence of benefits in the use as complementary therapy in RA&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Virgin olive oil&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Evidence of benefits <span class="elsevierStyleItalic">in vitro</span> and <span class="elsevierStyleItalic">in vivo</span> in inflammatory diseases such as RA&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vitamin D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Evidence <span class="elsevierStyleItalic">In vitro</span> and in animal experimentation of its anti-inflammatory and immunomodulatory effects&#46; Epidemiological studies suggest that vitamin D supplementation could have a protective effect on the susceptibility to develop RA&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Probiotics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Several studies showed an improvement in HAQ or disease patient perception related to probiotics intake&#46;<a class="elsevierStyleCrossRefs" href="#bib0640"><span class="elsevierStyleSup">33&#8211;36</span></a> However&#44; the evidence of the use of probiotics in humans is scarce&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Herbal medicinal products&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Some herbal medicinal products&#44; like Tripterygium wilfordii&#44; have demonstrated beneficial effects for RA patients&#46; However&#44; there is a very limited evidence base available&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Physical Activity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exercise is recommended in RA patients&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yoga and Taichi&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Adapt the exercise to patients&#8217; joint restrictions and may reduce patient stress&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Meditation&#47;Mindfulness&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Possible improvement in psychological distress and well-being&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Acupuncture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Conflicting evidence concerning the efficacy of acupuncture for RA patients&#46; There is positive evidence in the treatment of pain&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Homeopathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">There is a very limited evidence base available&#46; No adverse reactions were observed&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Balneotherapy&#47;Hydrotherapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Most trials reported positive findings&#44; but methodological quality of balneotherapy studies is poor&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">CAM modalities that may be beneficial for RA patients&#46;</p>"
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      "seccion" => array:1 [
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Complementary and alternative medicine use among adults&#58; United States&#44; 2002"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
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                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Adv Data"
                        "fecha" => "2004"
                        "volumen" => "343"
                        "paginaInicial" => "1"
                        "paginaFinal" => "19"
                      ]
                    ]
                  ]
                ]
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                0 => array:1 [
                  "referenciaCompleta" => "American Collage of Rheumatology&#46; American Collage of Rheumatology position statement&#58; complementary and alternative medicine for rheumatic diseases&#46; <a href="http://www.rheumatology.org/Practice-Quality/Administrative-Support/Position-Statements.09/2012">http&#58;&#47;&#47;www&#46;rheumatology&#46;org&#47;Practice-Quality&#47;Administrative-Support&#47;Position-Statements&#46;09&#47;2012</a>"
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0490"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Fasting&#58; molecular mechanisms and clinical applications"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.cmet.2013.12.008"
                      "Revista" => array:6 [
                        "tituloSerie" => "Cell Metab"
                        "fecha" => "2014"
                        "volumen" => "19"
                        "paginaInicial" => "181"
                        "paginaFinal" => "192"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0495"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Fasting followed by vegetarian diet in patients with rheumatoid arthritis&#58; a systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Scand J Rheumatol"
                        "fecha" => "2001"
                        "volumen" => "30"
                        "paginaInicial" => "1"
                        "paginaFinal" => "10"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0500"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Controlled trial of fasting and one-year vegetarian diet in rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "1991"
                        "volumen" => "338"
                        "paginaInicial" => "899"
                        "paginaFinal" => "902"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0505"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Vegetarian diet for patients with rheumatoid arthritis &#8211; status&#58; two years after introduction of the diet"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Rheumatol"
                        "fecha" => "1994"
                        "volumen" => "13"
                        "paginaInicial" => "475"
                        "paginaFinal" => "482"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0510"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Importance of nutritional treatment in the inflammatory process of rheumatoid arthritis patients&#59; a review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3305/nh.2014.29.2.7067"
                      "Revista" => array:6 [
                        "tituloSerie" => "Nutr Hosp"
                        "fecha" => "2014"
                        "volumen" => "29"
                        "paginaInicial" => "237"
                        "paginaFinal" => "245"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0515"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Dietary interventions for rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Cochrane Database Syst Rev"
                        "fecha" => "2009"
                        "paginaInicial" => "CD006400"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0520"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Scientific evidence of interventions using the Mediterranean diet&#58; a systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Nutr Rev"
                        "fecha" => "2006"
                        "volumen" => "64"
                        "paginaInicial" => "S27"
                        "paginaFinal" => "S47"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0525"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effectiveness and safety of dietary interventions for rheumatoid arthritis&#58; a systematic review of randomized controlled trials"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jada.2010.02.010"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Diet Assoc"
                        "fecha" => "2010"
                        "volumen" => "110"
                        "paginaInicial" => "727"
                        "paginaFinal" => "735"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0530"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Session 3&#58; Joint Nutrition Society and Irish Nutrition and Dietetic Institute Symposium on Nutrition and autoimmune disease PUFA&#44; inflammatory processes and rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [ …1]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1017/S0029665108008690"
                      "Revista" => array:6 [
                        "tituloSerie" => "Proc Nutr Soc"
                        "fecha" => "2008"
                        "volumen" => "67"
                        "paginaInicial" => "409"
                        "paginaFinal" => "418"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0535"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Dietary omega-3 fats for treatment of inflammatory joint disease&#58; efficacy and utility"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.rdc.2008.03.003"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rheum Dis Clin North Am"
                        "fecha" => "2008"
                        "volumen" => "34"
                        "paginaInicial" => "469"
                        "paginaFinal" => "479"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0540"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Resolving inflammation&#58; dual anti-inflammatory and pro-resolution lipid mediators"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1038/nri2294"
                      "Revista" => array:6 [
                        "tituloSerie" => "Nat Rev Immunol"
                        "fecha" => "2008"
                        "volumen" => "8"
                        "paginaInicial" => "349"
                        "paginaFinal" => "361"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0545"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Fish consumption&#44; fish oil&#44; omega-3 fatty acids&#44; and cardiovascular disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Circulation"
                        "fecha" => "2002"
                        "volumen" => "106"
                        "paginaInicial" => "2747"
                        "paginaFinal" => "2757"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0550"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Omega-3 polyunsaturated fatty acids and the treatment of rheumatoid arthritis&#58; a meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.arcmed.2012.06.011"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Med Res"
                        "fecha" => "2012"
                        "volumen" => "43"
                        "paginaInicial" => "356"
                        "paginaFinal" => "362"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0555"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Influence of marine n-3 polyunsaturated fatty acids on immune function and a systematic review of their effects on clinical outcomes in rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1017/S0007114512001560"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Nutr"
                        "fecha" => "2012"
                        "volumen" => "107"
                        "paginaInicial" => "S171"
                        "paginaFinal" => "S184"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0560"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Fish oil in recent onset rheumatoid arthritis&#58; a randomised&#44; double-blind controlled trial within algorithm-based drug use"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/annrheumdis-2013-204145"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Rheum Dis"
                        "fecha" => "2015"
                        "volumen" => "74"
                        "paginaInicial" => "89"
                        "paginaFinal" => "95"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0565"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Therapeutic potential of n-3 polyunsaturated fatty acids in disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.2146/ajhp080411"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Health Syst Pharm"
                        "fecha" => "2009"
                        "volumen" => "66"
                        "paginaInicial" => "1169"
                        "paginaFinal" => "1179"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0570"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Molecular mechanisms of inflammation&#46; Anti-inflammatory benefits of virgin olive oil and the phenolic compound oleocanthal"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Curr Pharm Des"
                        "fecha" => "2011"
                        "volumen" => "17"
                        "paginaInicial" => "754"
                        "paginaFinal" => "768"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S073510970801838X"
                          "estado" => "S300"
                          "issn" => "07351097"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0575"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Active components and clinical applications of olive oil"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Altern Med Rev"
                        "fecha" => "2007"
                        "volumen" => "12"
                        "paginaInicial" => "331"
                        "paginaFinal" => "342"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib0580"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The role of omega-3 fatty acids contained in olive oil on chronic inflammation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Acta Med Indones"
                        "fecha" => "2011"
                        "volumen" => "43"
                        "paginaInicial" => "138"
                        "paginaFinal" => "143"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib0585"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Supplementation of fish oil and olive oil in patients with rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.nut.2004.03.023"
                      "Revista" => array:6 [
                        "tituloSerie" => "Nutrition"
                        "fecha" => "2005"
                        "volumen" => "21"
                        "paginaInicial" => "131"
                        "paginaFinal" => "136"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib0590"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Vitamin D&#44; immunoregulation&#44; and rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/RHU.0b013e31820edd18"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Clin Rheumatol"
                        "fecha" => "2011"
                        "volumen" => "17"
                        "paginaInicial" => "102"
                        "paginaFinal" => "107"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib0595"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Does vitamin D affect risk of developing autoimmune disease&#63; A systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.semarthrit.2010.07.009"
                      "Revista" => array:6 [
                        "tituloSerie" => "Semin Arthritis Rheum"
                        "fecha" => "2011"
                        "volumen" => "40"
                        "paginaInicial" => "512"
                        "paginaFinal" => "531"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib0600"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "1&#44;25-Dihydroxycholecalciferol inhibits the progression of arthritis in murine models of human arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "J Nutr"
                        "fecha" => "1998"
                        "volumen" => "128"
                        "paginaInicial" => "68"
                        "paginaFinal" => "72"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S014067361260110X"
                          "estado" => "S300"
                          "issn" => "01406736"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib0605"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Association between vitamin D intake and the risk of rheumatoid arthritis&#58; a meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s10067-012-2080-7"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Rheumatol"
                        "fecha" => "2012"
                        "volumen" => "31"
                        "paginaInicial" => "1733"
                        "paginaFinal" => "1739"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib0610"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effects of large doses of calciferol on patients with rheumatoid arthritis&#46; A double-blind clinical trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Scand J Rheumatol"
                        "fecha" => "1973"
                        "volumen" => "2"
                        "paginaInicial" => "173"
                        "paginaFinal" => "176"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib0615"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Disease modifying and immunomodulatory effects of high dose 1 alpha &#40;OH&#41; D3 in rheumatoid arthritis patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Exp Rheumatol"
                        "fecha" => "1999"
                        "volumen" => "17"
                        "paginaInicial" => "453"
                        "paginaFinal" => "456"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            28 => array:3 [
              "identificador" => "bib0620"
              "etiqueta" => "29"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Probiotics in food&#58; health and nutritional properties and guidelines for evaluation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "colaboracion" => "FAO&#47;WHO"
                          "etal" => false
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:2 [
                        "tituloSerie" => "FAO Food Nutr Pap"
                        "fecha" => "2006"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            29 => array:3 [
              "identificador" => "bib0625"
              "etiqueta" => "30"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The role of the microbiome in rheumatic diseases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s11926-012-0314-y"
                      "Revista" => array:5 [
                        "tituloSerie" => "Curr Rheumatol Rep"
                        "fecha" => "2013"
                        "volumen" => "15"
                        "paginaInicial" => "314"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            30 => array:3 [
              "identificador" => "bib0630"
              "etiqueta" => "31"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "<span class="elsevierStyleItalic">Lactobacillus casei</span> reduces the inflammatory joint damage associated with collagen-induced arthritis &#40;CIA&#41; by reducing the pro-inflammatory cytokines&#58; <span class="elsevierStyleItalic">Lactobacillus casei</span>&#58; COX-2 inhibitor"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s10875-010-9457-7"
                      "Revista" => array:7 [
                        "tituloSerie" => "J Clin Immunol"
                        "fecha" => "2011"
                        "volumen" => "31"
                        "paginaInicial" => "147"
                        "paginaFinal" => "154"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0378512212001223"
                          "estado" => "S300"
                          "issn" => "03785122"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            31 => array:3 [
              "identificador" => "bib0635"
              "etiqueta" => "32"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "<span class="elsevierStyleItalic">Lactobacillus casei</span> suppresses experimental arthritis by down-regulating T helper 1 effector functions"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.molimm.2007.12.010"
                      "Revista" => array:6 [
                        "tituloSerie" => "Mol Immunol"
                        "fecha" => "2008"
                        "volumen" => "45"
                        "paginaInicial" => "2690"
                        "paginaFinal" => "2699"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            32 => array:3 [
              "identificador" => "bib0640"
              "etiqueta" => "33"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effects of probiotic therapy on the activity and activation of mild rheumatoid arthritis &#8211; a pilot study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Scand J Rheumatol"
                        "fecha" => "2003"
                        "volumen" => "32"
                        "paginaInicial" => "211"
                        "paginaFinal" => "215"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            33 => array:3 [
              "identificador" => "bib0645"
              "etiqueta" => "34"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "<span class="elsevierStyleItalic">Bacillus coagulans</span>&#58; a viable adjunct therapy for relieving symptoms of rheumatoid arthritis according to a randomized&#44; controlled trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/1472-6882-10-1"
                      "Revista" => array:5 [
                        "tituloSerie" => "BMC Complement Altern Med"
                        "fecha" => "2010"
                        "volumen" => "10"
                        "paginaInicial" => "1"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            34 => array:3 [
              "identificador" => "bib0650"
              "etiqueta" => "35"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A randomized&#44; double-blinded&#44; placebo-controlled pilot study of probiotics in active rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Med Sci Monit"
                        "fecha" => "2011"
                        "volumen" => "17"
                        "paginaInicial" => "CR347"
                        "paginaFinal" => "CR354"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            35 => array:3 [
              "identificador" => "bib0655"
              "etiqueta" => "36"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effects of <span class="elsevierStyleItalic">Lactobacillus casei</span> supplementation on disease activity and inflammatory cytokines in rheumatoid arthritis patients&#58; a randomized double-blind clinical trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/1756-185X.12333"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Rheum Dis"
                        "fecha" => "2014"
                        "volumen" => "17"
                        "paginaInicial" => "519"
                        "paginaFinal" => "527"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            36 => array:3 [
              "identificador" => "bib0660"
              "etiqueta" => "37"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Scientific basis of botanical medicine as alternative remedies for rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s12016-012-8329-8"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Rev Allergy Immunol"
                        "fecha" => "2013"
                        "volumen" => "44"
                        "paginaInicial" => "284"
                        "paginaFinal" => "300"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            37 => array:3 [
              "identificador" => "bib0665"
              "etiqueta" => "38"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Evidence of effectiveness of herbal medicinal products in the treatment of arthritis&#46; Part 2&#58; Rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/ptr.3006"
                      "Revista" => array:6 [
                        "tituloSerie" => "Phytother Res"
                        "fecha" => "2009"
                        "volumen" => "23"
                        "paginaInicial" => "1647"
                        "paginaFinal" => "1662"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            38 => array:3 [
              "identificador" => "bib0670"
              "etiqueta" => "39"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Herbal therapy for treating rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Cochrane Database Syst Rev"
                        "fecha" => "2011"
                        "volumen" => "16"
                        "paginaInicial" => "CD002948"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            39 => array:3 [
              "identificador" => "bib0675"
              "etiqueta" => "40"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Extracts of <span class="elsevierStyleItalic">Tripterygium wilfordii</span> Hook F in the treatment of rheumatoid arthritis&#58; a systemic review and meta-analysis of randomised controlled trials"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1155/2013/410793"
                      "Revista" => array:5 [
                        "tituloSerie" => "Evid Based Complement Alternat Med"
                        "fecha" => "2013"
                        "volumen" => "2013"
                        "paginaInicial" => "410793"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            40 => array:3 [
              "identificador" => "bib0680"
              "etiqueta" => "41"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Comparison of <span class="elsevierStyleItalic">Tripterygium wilfordii</span> Hook F versus sulfasalazine in the treatment of rheumatoid arthritis&#58; a randomized trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Intern Med"
                        "fecha" => "2009"
                        "volumen" => "151"
                        "paginaInicial" => "229"
                        "paginaFinal" => "240"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            41 => array:3 [
              "identificador" => "bib0685"
              "etiqueta" => "42"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Comparison of <span class="elsevierStyleItalic">Tripterygium wilfordii</span> Hook F with methotrexate in the treatment of active rheumatoid arthritis &#40;TRIFRA&#41;&#58; a randomised&#44; controlled clinical trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/annrheumdis-2013-204807"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Rheum Dis"
                        "fecha" => "2015"
                        "volumen" => "74"
                        "paginaInicial" => "1078"
                        "paginaFinal" => "1086"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            42 => array:3 [
              "identificador" => "bib0690"
              "etiqueta" => "43"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Gamma linolenic acid&#58; an antiinflammatory omega-6 fatty acid"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Curr Pharm Biotechnol"
                        "fecha" => "2006"
                        "volumen" => "7"
                        "paginaInicial" => "531"
                        "paginaFinal" => "534"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            43 => array:3 [
              "identificador" => "bib0695"
              "etiqueta" => "44"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "EFPIA&#46; European Federation of Pharmaceutical Industries&#46; Good manufacturing practices for active ingredient manufacturers&#46; 1996&#46;"
                ]
              ]
            ]
            44 => array:3 [
              "identificador" => "bib0700"
              "etiqueta" => "45"
              "referencia" => array:1 [
                0 => array:3 [
                  "comentario" => "ISBN&#58; 9789241563871"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Global health risks&#58; mortality and burden of disease attributable to selected major risks"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [ …1]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:2 [
                        "fecha" => "2009"
                        "editorial" => "World Health Organization"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            45 => array:3 [
              "identificador" => "bib0705"
              "etiqueta" => "46"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "2008 Physical Activity Guidelines for Americans"
                      "autores" => array:1 [
                        0 => array:2 [
                          "colaboracion" => "US Department of Health and Human Services"
                          "etal" => false
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1753-4887.2008.00136.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Nutr Rev"
                        "fecha" => "2009"
                        "volumen" => "67"
                        "paginaInicial" => "114"
                        "paginaFinal" => "120"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            46 => array:3 [
              "identificador" => "bib0710"
              "etiqueta" => "47"
              "referencia" => array:1 [
                0 => array:3 [
                  "comentario" => "47&#8211;58"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "New Canadian physical activity guidelines"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1139/H11-009"
                      "Revista" => array:6 [
                        "tituloSerie" => "Appl Physiol Nutr Metab"
                        "fecha" => "2011"
                        "volumen" => "36"
                        "paginaInicial" => "36"
                        "paginaFinal" => "46"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            47 => array:3 [
              "identificador" => "bib0715"
              "etiqueta" => "48"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Dynamic exercise programs &#40;aerobic capacity and&#47;or muscle strength training&#41; in patients with rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Cochrane Database Syst Rev"
                        "fecha" => "2009"
                        "volumen" => "7"
                        "paginaInicial" => "CD006853"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            48 => array:3 [
              "identificador" => "bib0720"
              "etiqueta" => "49"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Is dynamic exercise beneficial in patients with rheumatoid arthritis&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jbspin.2007.04.015"
                      "Revista" => array:6 [
                        "tituloSerie" => "Joint Bone Spine"
                        "fecha" => "2008"
                        "volumen" => "75"
                        "paginaInicial" => "11"
                        "paginaFinal" => "17"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            49 => array:3 [
              "identificador" => "bib0725"
              "etiqueta" => "50"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effects of high-intensity resistance training in patients with rheumatoid arthritis&#58; a randomized controlled trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/art.24891"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arthritis Rheum"
                        "fecha" => "2009"
                        "volumen" => "61"
                        "paginaInicial" => "1726"
                        "paginaFinal" => "1734"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            50 => array:3 [
              "identificador" => "bib0730"
              "etiqueta" => "51"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of six weeks yoga training on weight loss following step test&#44; respiratory pressures&#44; handgrip strength and handgrip endurance in young healthy subjects"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Indian J Physiol Pharmacol"
                        "fecha" => "2008"
                        "volumen" => "52"
                        "paginaInicial" => "164"
                        "paginaFinal" => "170"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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            51 => array:3 [
              "identificador" => "bib0735"
              "etiqueta" => "52"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Randomized controlled trial of yoga and exercise in multiple sclerosis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Neurology"
                        "fecha" => "2004"
                        "volumen" => "62"
                        "paginaInicial" => "2058"
                        "paginaFinal" => "2064"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            52 => array:3 [
              "identificador" => "bib0740"
              "etiqueta" => "53"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Yoga as steadiness training&#58; effects on motor variability in young adults"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1519/JSC.0b013e31818200dd"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Strength Cond Res"
                        "fecha" => "2008"
                        "volumen" => "22"
                        "paginaInicial" => "1659"
                        "paginaFinal" => "1669"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            53 => array:3 [
              "identificador" => "bib0745"
              "etiqueta" => "54"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The benefits of yoga for rheumatoid arthritis&#58; results of a preliminary&#44; structured 8-week program"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00296-009-0871-1"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rheumatol Int"
                        "fecha" => "2009"
                        "volumen" => "29"
                        "paginaInicial" => "1417"
                        "paginaFinal" => "1421"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            54 => array:3 [
              "identificador" => "bib0750"
              "etiqueta" => "55"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Yoga for arthritis&#58; a scoping review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.rdc.2010.11.001"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rheum Dis Clin North Am"
                        "fecha" => "2011"
                        "volumen" => "37"
                        "paginaInicial" => "33"
                        "paginaFinal" => "46"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            55 => array:3 [
              "identificador" => "bib0755"
              "etiqueta" => "56"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Measuring the effects of yoga in rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Rheumatol"
                        "fecha" => "1994"
                        "volumen" => "33"
                        "paginaInicial" => "787"
                        "paginaFinal" => "788"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            56 => array:3 [
              "identificador" => "bib0760"
              "etiqueta" => "57"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Functional and physiological effects of yoga in women with rheumatoid arthritis&#58; a pilot study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Altern Ther Health Med"
                        "fecha" => "2009"
                        "volumen" => "15"
                        "paginaInicial" => "24"
                        "paginaFinal" => "31"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            57 => array:3 [
              "identificador" => "bib0765"
              "etiqueta" => "58"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Impact of iyengar yoga on quality of life in young women with rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/AJP.0b013e31827da381"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin J Pain"
                        "fecha" => "2013"
                        "volumen" => "29"
                        "paginaInicial" => "988"
                        "paginaFinal" => "997"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            58 => array:3 [
              "identificador" => "bib0770"
              "etiqueta" => "59"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Tai Chi and yoga as complementary therapies in rheumatologic conditions"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [ …1]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.berh.2012.05.006"
                      "Revista" => array:6 [
                        "tituloSerie" => "Best Pract Res Clin Rheumatol"
                        "fecha" => "2012"
                        "volumen" => "26"
                        "paginaInicial" => "387"
                        "paginaFinal" => "398"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            59 => array:3 [
              "identificador" => "bib0775"
              "etiqueta" => "60"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Tai chi and rheumatic diseases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [ …1]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.rdc.2010.11.002"
                      "Revista" => array:7 [
                        "tituloSerie" => "Rheum Dis Clin North Am"
                        "fecha" => "2011"
                        "volumen" => "37"
                        "paginaInicial" => "19"
                        "paginaFinal" => "32"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0735109711014033"
                          "estado" => "S300"
                          "issn" => "07351097"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            60 => array:3 [
              "identificador" => "bib0780"
              "etiqueta" => "61"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The effect of Tai Chi on health outcomes in patients with chronic conditions&#58; a systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/archinte.164.5.493"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Intern Med"
                        "fecha" => "2004"
                        "volumen" => "164"
                        "paginaInicial" => "493"
                        "paginaFinal" => "501"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            61 => array:3 [
              "identificador" => "bib0785"
              "etiqueta" => "62"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Tai chi for treating rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Cochrane database Syst Rev"
                        "fecha" => "2004"
                        "paginaInicial" => "CD004849"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            62 => array:3 [
              "identificador" => "bib0790"
              "etiqueta" => "63"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Tai chi for rheumatoid arthritis&#58; systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/rheumatology/kem151"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rheumatology"
                        "fecha" => "2007"
                        "volumen" => "46"
                        "paginaInicial" => "1648"
                        "paginaFinal" => "1651"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            63 => array:3 [
              "identificador" => "bib0795"
              "etiqueta" => "64"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Role of Tai Chi in the treatment of rheumatologic diseases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [ …1]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s11926-012-0294-y"
                      "Revista" => array:6 [
                        "tituloSerie" => "Curr Rheumatol Rep"
                        "fecha" => "2012"
                        "volumen" => "14"
                        "paginaInicial" => "598"
                        "paginaFinal" => "603"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            64 => array:3 [
              "identificador" => "bib0800"
              "etiqueta" => "65"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mindfulness-based stress reduction and health benefits&#46; A meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S0022-3999(03)00573-7"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Psychosom Res"
                        "fecha" => "2004"
                        "volumen" => "57"
                        "paginaInicial" => "35"
                        "paginaFinal" => "43"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            65 => array:3 [
              "identificador" => "bib0805"
              "etiqueta" => "66"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The clinical use of mindfulness meditation for the self-regulation of chronic pain"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Behav Med"
                        "fecha" => "1985"
                        "volumen" => "8"
                        "paginaInicial" => "163"
                        "paginaFinal" => "190"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            66 => array:3 [
              "identificador" => "bib0810"
              "etiqueta" => "67"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Three-year follow-up and clinical implications of a mindfulness meditation-based stress reduction intervention in the treatment of anxiety disorders"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Gen Hosp Psychiatry"
                        "fecha" => "1995"
                        "volumen" => "17"
                        "paginaInicial" => "192"
                        "paginaFinal" => "200"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            67 => array:3 [
              "identificador" => "bib0815"
              "etiqueta" => "68"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Association of depression and rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Psychosomatics"
                        "fecha" => "2003"
                        "volumen" => "44"
                        "paginaInicial" => "209"
                        "paginaFinal" => "215"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            68 => array:3 [
              "identificador" => "bib0820"
              "etiqueta" => "69"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mindfulness-based cognitive therapy for depression&#58; replication and exploration of differential relapse prevention effects"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1037/0022-006X.72.1.31"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Consult Clin Psychol"
                        "fecha" => "2004"
                        "volumen" => "72"
                        "paginaInicial" => "31"
                        "paginaFinal" => "40"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            69 => array:3 [
              "identificador" => "bib0825"
              "etiqueta" => "70"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mindfulness meditation alleviates depressive symptoms in women with fibromyalgia&#58; results of a randomized clinical trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/art.22478"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arthritis Rheum"
                        "fecha" => "2007"
                        "volumen" => "57"
                        "paginaInicial" => "77"
                        "paginaFinal" => "85"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            70 => array:3 [
              "identificador" => "bib0830"
              "etiqueta" => "71"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of mindfulness-based stress reduction in rheumatoid arthritis patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/art.23010"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arthritis Rheum"
                        "fecha" => "2007"
                        "volumen" => "57"
                        "paginaInicial" => "1134"
                        "paginaFinal" => "1142"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            71 => array:3 [
              "identificador" => "bib0835"
              "etiqueta" => "72"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Controversies in acupuncture research&#58; selection of controls and outcome measures in acupuncture clinical trials"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1089/acm.2006.12.943"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Altern Complement Med"
                        "fecha" => "2006"
                        "volumen" => "12"
                        "paginaInicial" => "943"
                        "paginaFinal" => "953"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            72 => array:3 [
              "identificador" => "bib0840"
              "etiqueta" => "73"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Antagonism of acupuncture analgesia in man by the narcotic antagonist naloxone"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Brain Res"
                        "fecha" => "1977"
                        "volumen" => "121"
                        "paginaInicial" => "368"
                        "paginaFinal" => "372"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            73 => array:3 [
              "identificador" => "bib0845"
              "etiqueta" => "74"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Traditional Chinese acupuncture and placebo &#40;sham&#41; acupuncture are differentiated by their effects on mu-opioid receptors &#40;MORs&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.neuroimage.2009.05.083"
                      "Revista" => array:6 [
                        "tituloSerie" => "Neuroimage"
                        "fecha" => "2009"
                        "volumen" => "47"
                        "paginaInicial" => "1077"
                        "paginaFinal" => "1085"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            74 => array:3 [
              "identificador" => "bib0850"
              "etiqueta" => "75"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Acupuncture for rheumatic conditions&#58; an overview of systematic reviews"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/rheumatology/keq180"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rheumatology"
                        "fecha" => "2010"
                        "volumen" => "49"
                        "paginaInicial" => "1957"
                        "paginaFinal" => "1961"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            75 => array:3 [
              "identificador" => "bib0855"
              "etiqueta" => "76"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Acupuncture and electroacupuncture for the treatment of rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Cochrane Database Syst Rev"
                        "fecha" => "2005"
                        "volumen" => "19"
                        "paginaInicial" => "CD003788"
                        "itemHostRev" => array:3 [
                          "pii" => "S0140673611619314"
                          "estado" => "S300"
                          "issn" => "01406736"
                        ]
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              ]
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            76 => array:3 [
              "identificador" => "bib0860"
              "etiqueta" => "77"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The effect of acupuncture on patients with rheumatoid arthritis&#58; a randomized&#44; placebo-controlled cross-over study"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
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                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Rheumatology"
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                        "paginaInicial" => "864"
                        "paginaFinal" => "869"
                        "link" => array:1 [
                          0 => array:2 [ …2]
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                    ]
                  ]
                ]
              ]
            ]
            77 => array:3 [
              "identificador" => "bib0865"
              "etiqueta" => "78"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A systematic review of evidence for the effectiveness of practitioner-based complementary and alternative therapies in the management of rheumatic diseases&#58; rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                           …1
                        ]
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                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/rheumatology/kes133"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rheumatology"
                        "fecha" => "2012"
                        "volumen" => "51"
                        "paginaInicial" => "1707"
                        "paginaFinal" => "1713"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            78 => array:3 [
              "identificador" => "bib0870"
              "etiqueta" => "79"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Acupuncture for pain relief in patients with rheumatoid arthritis&#58; a systematic review"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/art.24009"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arthritis Rheum"
                        "fecha" => "2008"
                        "volumen" => "59"
                        "paginaInicial" => "1249"
                        "paginaFinal" => "1256"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            79 => array:3 [
              "identificador" => "bib0875"
              "etiqueta" => "80"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Acupuncture for rheumatoid arthritis&#58; a systematic review"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/rheumatology/ken330"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rheumatology"
                        "fecha" => "2008"
                        "volumen" => "47"
                        "paginaInicial" => "1747"
                        "paginaFinal" => "1753"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            80 => array:3 [
              "identificador" => "bib0880"
              "etiqueta" => "81"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The evidence for acupuncture as a treatment for rheumatologic conditions"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Rheum Dis Clin North Am"
                        "fecha" => "2000"
                        "volumen" => "26"
                        "paginaInicial" => "103"
                        "paginaFinal" => "115"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            81 => array:3 [
              "identificador" => "bib0885"
              "etiqueta" => "82"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Bee venom acupuncture for rheumatoid arthritis&#58; a systematic review of randomised clinical trials"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/bmjopen-2014-006140"
                      "Revista" => array:5 [
                        "tituloSerie" => "BMJ Open"
                        "fecha" => "2014"
                        "volumen" => "4"
                        "paginaInicial" => "e006140"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            82 => array:3 [
              "identificador" => "bib0890"
              "etiqueta" => "83"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Salicylates and homoeopathy in rheumatoid arthritis&#58; preliminary observations"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Clin Pharmacol"
                        "fecha" => "1978"
                        "volumen" => "6"
                        "paginaInicial" => "391"
                        "paginaFinal" => "395"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            83 => array:3 [
              "identificador" => "bib0895"
              "etiqueta" => "84"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Homoeopathic therapy in rheumatoid arthritis&#58; evaluation by double-blind clinical therapeutic trial"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Clin Pharmacol"
                        "fecha" => "1980"
                        "volumen" => "9"
                        "paginaInicial" => "453"
                        "paginaFinal" => "459"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            84 => array:3 [
              "identificador" => "bib0900"
              "etiqueta" => "85"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A randomized controlled trial to evaluate the effectiveness of homeopathy in rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Scand J Rheumatol"
                        "fecha" => "1991"
                        "volumen" => "20"
                        "paginaInicial" => "204"
                        "paginaFinal" => "208"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            85 => array:3 [
              "identificador" => "bib0905"
              "etiqueta" => "86"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A randomized controlled trial of homeopathy in rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Rheumatology"
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                        "paginaInicial" => "1052"
                        "paginaFinal" => "1055"
                        "link" => array:1 [ …1]
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Homeopathy has clinical benefits in rheumatoid arthritis patients that are attributable to the consultation process but not the homeopathic remedy&#58; a randomized controlled clinical trial"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/rheumatology/keq234"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rheumatology"
                        "fecha" => "2011"
                        "volumen" => "50"
                        "paginaInicial" => "1070"
                        "paginaFinal" => "1082"
                        "link" => array:1 [ …1]
                      ]
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                  ]
                ]
              ]
            ]
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                0 => array:3 [
                  "comentario" => "author reply 1531&#8211;2"
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                    0 => array:2 [
                      "titulo" => "Comment 1 on&#58; Homeopathy has clinical benefits in rheumatoid arthritis patients that are attributable to the consultation process but not the homeopathic remedy&#58; a randomized controlled trial"
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                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1093/rheumatology/ker109"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rheumatology"
                        "fecha" => "2011"
                        "volumen" => "50"
                        "paginaInicial" => "1529"
                        "link" => array:1 [ …1]
                        "itemHostRev" => array:3 [ …3]
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                        "paginaFinal" => "1531"
                        "link" => array:1 [ …1]
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                ]
              ]
            ]
            89 => array:3 [
              "identificador" => "bib0925"
              "etiqueta" => "90"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical trial of homeopathy in rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Homeopathy&#46; The Faculty of Homeopathy"
                        "fecha" => "2011"
                        "volumen" => "100"
                        "paginaInicial" => "300"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            90 => array:3 [
              "identificador" => "bib0930"
              "etiqueta" => "91"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Hydrotherapy&#44; balneotherapy&#44; and spa treatment in pain management"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00296-004-0487-4"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rheumatol Int"
                        "fecha" => "2005"
                        "volumen" => "25"
                        "paginaInicial" => "220"
                        "paginaFinal" => "224"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            91 => array:3 [
              "identificador" => "bib0935"
              "etiqueta" => "92"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Forearm vascular and neuroendocrine responses to graded water immersion in humans"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1046/j.1365-201x.2000.00680.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Acta Physiol Scand"
                        "fecha" => "2000"
                        "volumen" => "169"
                        "paginaInicial" => "87"
                        "paginaFinal" => "94"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0940"
              "etiqueta" => "93"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Balneotherapy &#40;or spa therapy&#41; for rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Cochrane Database Syst Rev"
                        "fecha" => "2015"
                        "volumen" => "11"
                        "paginaInicial" => "CD000518"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            93 => array:3 [
              "identificador" => "bib0945"
              "etiqueta" => "94"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effectiveness of aquatic exercise and Balneotherapy&#58; a summary of systematic reviews based on randomized controlled trials of water immersion therapies"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Epidemiol"
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                        "paginaInicial" => "2"
                        "paginaFinal" => "12"
                        "link" => array:1 [ …1]
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              "etiqueta" => "95"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Perspectives about complementary and alternative medicine in rheumatology"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.rdc.2010.11.008"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rheum Dis Clin North Am"
                        "fecha" => "2011"
                        "volumen" => "37"
                        "paginaInicial" => "1"
                        "paginaFinal" => "8"
                        "link" => array:1 [ …1]
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