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
The 2022 ACR Guideline for Exercise, Rehabilitation, Diet, and Additional Integrative Interventions for Rheumatoid Arthritis includes the following. Refer to the full guideline for all recommendations: https://tinyurl.com/yhfksszj| FOR |
| A strong recommendation for consistent exercise; |
| 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; |
| A conditional recommendation for a course of occupational therapy for patients with RA; |
| A conditional recommendation for a course of physical therapy for patients with RA; |
| Conditional recommendations for the use of assistive devices, adaptive equipment, environmental adaptations, activity pacing strategies, joint protection techniques and splinting or orthoses for selected patients; |
| A conditional recommendation for a Mediterranean diet; |
| Conditional recommendations for cognitive behavioral therapy or other mind-body therapies, as well as acupuncture; but |
| AGAINST |
| Conditional recommendations against a variety of supplements, including vitamin D, fish oil and glucosamine; and |
| Conditional recommendations against electrotherapy and chiropractic spinal adjustment. |
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
- 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.
- Physical activity guidelines for Americans. U.S. Department of Health and Human Services (2nd edition). 2018.
- 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.
- 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.
