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SIR - RA is a complex disease which requires the broad skills of a multidisciplinary team for effective management. Increasing attention is now given to the patient's role with the team. With emphasis on self-help and a greater degree of control by the patients of their disease and its treatment. A logical extension of this process is the use of less conventional methods of management in conjunction with a conventional medical treatment regime. In this context the physical and psychological control and relaxation induced by yoga appeared attractive but reservation has been expressed regarding the applicability of yoga to patients with physical handicap. We therefore set up a pilot study to explore the ability of patients with severe RA to participate in a yoga programme and to make observations regarding any benefit obtained. We believe this is the first controlled trial of yoga for RA [1] . Twenty volunteers with RA of sufficient severity to require disease-modifying therapy were selected for the study. Ten entered a yoga programme and 10 acted as controls. Table 1 gives biodata for the two groups.
 The control group continued with normal medical treatment only(without modification). The yoga group in addition to normal treatment (without modification) took part in a programme of daily 2-h sessions 5 days a week for 3 weeks, followed by weekly 2-h sessions for a further 3 months. The yoga sessions took place in the outpatients department. On days without sessions, patients practiced for 10-30 min at home. The practise, described elsewhere[2], comprised gentle physical movements and postures(asanas) tailored to the individuals, based on the yoga principles of performing them with ease. Slowness and deep awareness; breathing techniques (pranayama) aimed at control and slowing of the breathing rate, meditation, lectures and discussions on yoga philosophy, and sessions aimed at softening the emotions. The movements and postures were modified or omitted to avoid strain when joints were inflamed.
Assessments were carried out 'blind' by qualified nurses at the beginning of the study and after 3 months. They comprised (a) standard rheumatological measurements: ring size, duration of morning stiffness, grip strength and the Stanford Health Assessment Questionnaire Disability Index (HAQ) and (b) psychological assessment: the General Health Questionnaire (GHQ). There was no significant difference in levels of depression between the yoga and control groups, as indicated by GHQ scores at the start of the study. Eleven patients in the yoga group completed the first 3 weeks but four dropped out subsequently based of difficulty with transport. All patients completed the assessments at the end of the trial, except for one of the yoga dropouts.
Table II shows that lefthand grip strength increased by 63 in the yoga group and by 8 in the control group; the difference (55) between the two groups was significant (P<0.02: 98% confidence limits 2-108). Right hand grip strength also increased in the yoga group, relative to the controls. But the difference was not significant. Table III shows that similar confidence limits for the changes were obtained using the final values for grip strength adjusted by covariate analysis for age, duration of RA and initial grip strength. The yoga group also improved relative to the controls in HAQ scores and left hand ring sizes, through not to significant levels. The other indicators remained constant or improved slightly in the yoga group, relative to the control. All six patients who completed the yoga course derived sufficient subjective benefit to want to continue. Although this study was too small and too short for definitive conclusion, it does show that patients with RA even when this is of considerable severity are capable of participating in a yoga programme and of deriving both subjective and objective benefit from it and that this can be measured using conventional clinical trial techniques. The major problem was the logistic one of transport to the yoga sessions. We believe there is a need for a larger trial to evaluate yoga in R.A. and that an appropriate control group would be patients treated by more conventional relaxation techniques. Meryl Bye and Hilde Pawas took the yoga classes: B. Darve and K. Adams carried out the assessments: Dr A.L. Johnson advised on statistical analysis: Marks and Spencer contributed to the costs of data processing. Table II Grip Strength
 Table III : Mean changes in grip strength (after minus before 3 months of yoga). Adjusted by convariate analysis for age duration of RA. and initial grip strength. Grip Strength (mm Hg) (S.D)
 I. Haslock*, R. Monro+, R. Nagarathna#, H.R. Nagandra, N.V. Raghuram.
* South Cleveland Hospital + Yoga Biomedical Trust, P Box 140, Cambridge and Vivekananda Yoga Research Foundation.
Accepted 21 March, 1994.
Correspondence to R. Monro.
1. Monro R.E., Ghosh A.K., Kalish D: Yoga Research Bibiliography, Cambridge: Yoga Biomedical Trust, 1989.
2. Nagarathna R, Nagendra H R, Monro R E: Yoga for Common Ailments, London, GAIA Books, 1991.
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