PHILADELPHIA—It is often the case that a holistic approach to the management of autoimmune disease is what patients are looking for and may indeed provide optimal care for these patients. At ACR Convergence 2022, the session titled ACR Guideline for Physical, Psychosocial, Mind-Body and Nutritional Interventions for Rheumatoid Arthritis: An Integrative Approach to Treatment sought to describe the evidence-based recommendations on this subject and the ways in which clinicians can use these guidelines consistently to help patients.
The first speaker was Bryant England, MD, PhD, associate professor of medicine, Division of Rheumatology & Immunology, University of Nebraska Medical Center, Omaha, and VA Nebraska-Western Iowa Health Care System, Omaha. He opened his talk by discussing the 2021 ACR Guideline for the Treatment of Rheumatoid Arthritis and the ways in which topics that patients often hope to receive guidance for, such as exercise, rehabilitation and diet modification, were not addressed in any great detail in this guideline.1
Dr. England
Guidelines for Exercise, Rehab & Diet
Thus, a team was created to tackle these subjects for a separate guideline, and this team included not only rheumatologists but also experts in the areas of exercise physiology, integrative medicine, physical and occupational therapy, social work and other disciplines. Dr. England outlined several guiding principles that the guideline team used in their work, including: 1) rheumatoid arthritis should be treated with disease-modifying anti-rheumatic drugs (DMARDs) as detailed in pharmacologic treatment guidelines, 2) recommendations pertain to rheumatoid arthritis-specific management and outcomes and not to other medical indications or general health benefits, and 3) optimal treatment outcomes are achieved through interprofessional teams providing expert patient-centered care.
Dr. England noted that consistent engagement in exercise is strongly recommended over no exercise, but which type of exercise is up to the clinician and patient to decide through shared decision making—with aerobic and aquatic exercise, resistance exercise and/or mind-body exercises like yoga or tai chi all conditionally recommended. For rehabilitation, the guideline conditionally recommends engagement in comprehensive physical and occupational therapy; many other forms of rehabilitation, which include hand therapy, environmental adaptations and vocational rehabilitation, are also conditionally recommended.
For diet, Dr. England explained that adherence to a Mediterranean-style diet and following established dietary guidelines without dietary supplements are conditionally recommended. Cognitive behavioral therapy, acupuncture and massage therapy were also conditionally recommended, but a conditional recommendation against electrotherapy and chiropractic therapy was given.
A Hypothetical Case
In the next section of the talk, several speakers worked together to apply the guideline to a hypothetical patient’s case. The patient case was about a 35-year-old parent and small business owner with seropositive rheumatoid arthritis who has been started on treatment with methotrexate.
Dr. Barton
The team responsible for discussing this patient’s case included Jennifer Barton, MD, associate professor of medicine, Division of Arthritis and Rheumatic Diseases, Oregon Health Sciences University, Portland; Nancy Baker, OT, MPH, ScD, associate professor, Occupational Therapy, Tufts University, Medford, Mass.; Carol Oatis, PhD, PT, professor emerita, Arcadia University, Glenside, Pa.; and Kaleb Michaud, PhD, professor, Division of Rheumatology, and director of the Rheumatology Fellowship Research Program, University of Nebraska Medical Center, Omaha.
Patient Goals & Preferences
The panelists began by discussing how patient goals and preferences should be central in supplementing pharmacologic therapy with integrative treatments. For this patient, goals may include minimizing pain and maximizing function, especially concerning the ability to be productive at work and be able to engage in meaningful time spent with family and friends.
Dr. Barton noted that, based on the new ACR guideline, recommendations to follow a Mediterranean diet would be reasonable. This would, of course, have to take into account the patient’s access to healthy foods and budget for such dietary changes.
Dr. Oatis
Dr. Oatis went on to note that, for this patient and all other patients with rheumatoid arthritis, it is not only safe to exercise, but it is also strongly recommended to do so. On the theme of exercise, patients may ask, what if my joints hurt while engaging in exercise? Dr. Oatis preempted this consideration by explaining that guidance from a physical therapist and occupational therapist may be necessary to teach patients how to exercise safely without causing undue pain. Dr. Baker expanded on the subject of safe and effective exercise by describing such concepts as activity pacing, joint protection and ergonomic assessments.
In the Workplace
Dr. Baker
Dr. Baker went on to make specific note of the fact that many patients encounter difficulty managing their rheumatoid arthritis when they are at their place of work. This may relate to several factors, including the challenge of being able to modify work activities and/or the physical work environment in a way that would allow for decreased pain and increased function for patients.
She pointed out that the Americans with Disabilities Act provides a legal support for U.S. patients who are entitled to fair and reasonable accommodations from their employers and that it may be worth pursuing these accommodations, when possible. She further noted that many patients with rheumatoid arthritis desire not to disclose their disease to their employers, but doing so may be necessary to receive the support that they need. She also explained that splints, such as for the hands, may often be instrumental in helping patients to be comfortable and to more easily perform their work duties.
Key Points
Dr. Smith
Benjamin Smith, DMSc, PA-C, DFAAPA, program director and associate dean, School of Physician Assistant Practice, Florida State University College of Medicine, Tallahassee, who served as the moderator for this session, used the panel discussion to highlight several key points.
First, he noted that it is important to educate patients on the variety of integrative interventions that may be available across the spectrum of rheumatoid arthritis manifestations, severity and course. Second, he explained that providers must consider each person’s individual abilities and challenges and provide people with help on how to access appropriate interventions. Third, he stated that integrative interventions for rheumatoid arthritis are not one-size-fits-all. Finally, he advocated for constructing an interprofessional team for patients early in the course of their treatment.
In Sum
Hopefully, guidelines like these will support the pursuit of integrative care, with the result being that more patients have their questions answered and can engage fully in their lives.
Jason Liebowitz, MD, completed his fellowship in rheumatology at Johns Hopkins University, Baltimore, where he also earned his medical degree. He is currently in practice with Skylands Medical Group, N.J.
References
- Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res (Hoboken). 2021 Jul;73(7):924–939.
