Guideline for Integrative RA Interventions Released

A new ACR guideline on integrative interventions for rheumatoid arthritis (RA) emphasizes the importance of patient preferences and shared decision making.¹ Clinicians can use the guideline to open important conversations with patients about complementary aspects of their care.

Assessing Integrative Choices

Dr. Bryant England

“We have many potential modalities we can utilize to help manage rheumatoid arthritis that aren’t medications,” says Bryant R. England, MD, PhD, associate professor, Division of Rheumatology, University of Nebraska Medical Center, Omaha, and lead author of the new guideline. “These don’t replace medications, but can be used alongside them. Previously, the data had not been put together in an evidence-based fashion to systematically recommend or use those potential integrative interventions.”

Many patients bring up questions related to integrative approaches, such as diet, exercise and supplements, in their initial discussions on disease management, shares Dr. England.

“I think we all carry our own personal preferences, our own biases,” notes Dr. England. “That’s why it’s so critical to [approach this guideline] following a standardized methodology, so we can evaluate the evidence critically.”

The guideline repeatedly emphasizes the importance of shared decision making in integrative approaches. This partly reflects the fact that due to the evidence base, all but one of the recommendations are conditional. “You have to spend the time talking with the patient and understanding their values and preferences because that is going to meaningfully influence your therapy decisions,” he says.

It’s also important to consider these recommendations in the context of the patient’s comorbidities, which may also influence integrative therapy choices. Dr. England stresses the importance of providing patients with an overview of all their treatment options, including integrative ones, while not pressuring them to pursue too many at once.

Exercise Recommendations

Dr. England has been bringing up the guideline with patients to begin conversations about the importance of exercise (see sidebar, below). “They may have thought their rheumatologist only cared about whether or not they’re taking their methotrexate,” he says.

The guideline provides a strong recommendation for consistent exercise due to clear evidence of its role in improving patients’ function and reducing their pain. Additionally, the guideline provides separate conditional recommendations for aerobic exercise, aquatic-based exercise, resistance exercise and mind body exercises such as yoga and tai chi, with no specific recommendations ranking one approach above the others.

“An old belief that sometimes still circulates around the medical community is that people with rheumatoid arthritis shouldn’t exercise because it would damage their joints. But that’s not the case. We’ve seen through this systematic appraisal of the evidence that exercise benefits [rheumatoid arthritis] management,” says Dr. England.

For guidance on exercise duration, intensity, etc., the guideline suggests following recommendations from the U.S. Department of Health and Human Services for the general population.² However, Dr. England emphasizes that the recommendations should be adapted to patients’ individual needs, abilities and preferences, as well as their specific capacities on a given day.

Occupational & Physical Therapy

The guideline also contains a conditional recommendation for a course of occupational therapy for patients with RA. Such therapy can help individuals adapt daily activities to meet their needs and goals, provide education on managing fatigue and assist them in maintaining their desired work and leisure activities.³

Dr. Nancy A. Baker

Nancy A. Baker, ScD, MPH, OTR/L, is a professor in the Department of Occupational Therapy, Tufts University, Boston, who also worked on the integrative rheumatoid arthritis guideline. She points out that occupational therapists have a long history of helping patients with rheumatoid arthritis improve their overall function. However, many rheumatologists and other doctors stopped referring patients to occupational therapy after the development of methotrexate and later biologic disease-modifying anti-rheumatic drugs.

“We’ve discovered that [the medication-only] approach is incomplete,” says Dr. Baker. RA is a chronic disease. Although medications are certainly preventing the disease from damaging patients’ joints in many cases, people with RA still have a lot of problems to navigate. “In occupational therapy, we can provide people with tips and help them figure out how they can modify their lives so they can control the impact of the chronic disease on their everyday lives,” she continues.

Dr. Baker points out that people often develop RA in the middle of their working lives. Roughly a third of employed people with RA are not working within three years of their diagnosis, and that number reaches 50% within 10 years.⁴ Occupational therapy can be very helpful in finding strategies to help patients manage their pain and fatigue and adapt their working environment so they can continue their employment, she says.

The guideline also conditionally recommends a course of physical therapy for patients with RA. Physical therapy is focused more on building patients’ physical capacity, strength and overall muscle tone than occupational therapy, which is focused more on helping patients optimally use their existing capacity. Dr. Baker points out that physical therapists are ideally suited to help people with RA find ways to exercise safely.

The guideline conditionally recommends the use of assistive devices, adaptive equipment, environmental adaptations, activity pacing strategies, joint protection techniques and splinting or orthoses for selected patients. Both occupational and physical therapists can apply such tools and strategies in an individualized way. They may also employ other methods conditionally recommended in the guideline, such as thermal modalities or massage.

Dr. England notes that clinicians should consider referring patients to occupational therapy and/or physical therapy, even if they have already completed a group of sessions. As patients’ needs, disease limitations and preferences change over time, going back to one or both is often helpful.

Other Integrative Approaches

The guideline also discusses a variety of other integrative approaches and whether they improve RA-specific outcomes, including a conditional recommendation for a Mediterranean diet and a conditional recommendation against a variety of supplements, including vitamin D, fish oil and glucosamine.

The guideline also conditionally recommends cognitive behavioral therapy or other mind-body therapies, as well as acupuncture, while conditionally recommending against electrotherapy and chiropractic spinal adjustment. For full discussion of these and other recommendations, please see the complete guideline.¹

Building a Collaborative Team

Unfortunately, some patients will face barriers accessing some of these interventions, partly because some may require significant out-of-pocket costs. Dr. England points out one goal of the guideline is to encourage policy makers to advocate for coverage of these interventions by payers. Another explicit goal is to outline knowledge gaps and inspire future research in these areas, some of which are very challenging to study.

Another barrier to implementation is physician time constraints. Still, it’s worth taking the time to engage with patients and collaborate with other types of health professionals to get the best outcomes for patients. “We need people from different directions and with different knowledge bases coming together to work with the client,” says Dr. Baker.

“It’s critical to build up that team of individuals with complementary expertise,” adds Dr. England. “Through this guideline development process, I’ve seen that my role is not only for diagnosing, choosing therapies and monitoring patients, but also being that facilitator to other people in the healthcare system, like an occupational therapist, physical therapist or a nutritionist.”

Recommendations for Exercise & Diet

Ruth Jessen Hickman, MD, is a graduate of the Indiana University School of Medicine. She is a freelance medical and science writer living in Bloomington, Ind.

References

1. England BR, Smith BJ, Baker NA, et al. 2022 American College of Rheumatology guideline for exercise, rehabilitation, diet, and additional integrative interventions for rheumatoid arthritis. Arthritis Rheumatol. 2023;10.1002/art.42507. 
2. Physical activity guidelines for Americans. U.S. Department of Health and Human Services (2nd edition). 2018.
3. Baker NA, Carandang K, Dodge C, Poole JL. Occupational therapy is a vital member of the interprofessional team-based approach for the management of rheumatoid arthritis: Applying the 2022 American College of Rheumatology guideline for exercise, rehabilitation, diet, and additional integrative interventions for rheumatoid arthritis. Arthritis Care Res (Hoboken). 2023;10.1002/acr.25122.
4. Hammond A, O’Brien R, Woodbridge S, et al. Job retention vocational rehabilitation for employed people with inflammatory arthritis (WORK-IA): A feasibility randomized controlled trial. BMC Musculoskelet Disord. 2017 Jul 21;18(1):315.