Has the Time Come for Wellness Promotion in Rheumatology?

Dr. Tesser

“Patients ask me specifically what to eat. I tend to dissuade them from supplements in general,” says John R.P. Tesser, MD, a rheumatologist with Arizona Arthritis and Rheumatology Associates, Phoenix, and adjunct professor at the Arizona College of Osteopathic Medicine. “I try to keep it simple. I say there’s good research showing the Mediterranean diet, with its focus on fish, poultry, vegetables, fruit, nuts and olive oil, can be anti-inflammatory.”

Movement & exercise

Any kind of physical movement, as tolerated, will help patients with rheumatic conditions, and the benefits of simple exercise can’t be overstated, Dr. Tesser says. “I say exercise is a key to life. If you move, you’ll live longer and better. When we think of exercise, the first thing that often comes to mind is running. But walking is excellent, easy and free.”

Stress reduction, including sleep hygiene

Stress is an important contributor to inflammatory conditions—and moderating it can help patients manage pain and other symptoms. A related issue is sleep hygiene (i.e., sticking to a sleep schedule, creating a restful environment, including physical activity in your daily schedule and limiting naps), which is critical to overall health. 

Focusing on these three areas—diet, movement and stress—will give the most bang for the buck, and should not be controversial for rheumatologists, Dr. Cotter says. Mindfulness meditation and mindfulness-based stress reduction (MBSR) are also emerging as important strategies in disease and wellness management. Mindfulness, described as non-judgmental, present moment awareness, is a learned skill that can be taught and practiced.¹ 

The rheumatology clinic at Johns Hopkins Medicine, Baltimore, has launched a mindfulness initiative in collaboration with psychiatry and behavioral sciences. The clinic is offering classes by a certified MBSR psychologist and a smartphone app-based program to enhance rheumatology patients’ quality of life. 

Dr. DiRenzo

“We have found both to be very beneficial, especially for the increased prevalence of anxiety and depression found with RA [rheumatoid arthritis], as well as for fatigue and other aspects of quality of life,” principal investigator and rheumatologist Dana DiRenzo, MD, MHS, explains in an email. 

Her team’s review of mindfulness-based interventions in RA, focusing on five published trials and one post-hoc analysis of mindfulness interventions involving 399 patients, found that although few studies have been conducted to evaluate the effects of MBSR in patients with RA, improvements in rates of emotional distress were noted for those who completed the MBSR course.² 

The research at Johns Hopkins on the mental health benefits from MBSR in people who have RA plus anxiety and/or depression have not yet been published, but preliminary findings suggest it may be a useful strategy to improve psychological distress in these patients.

“We have generally found that through promoting this study in our clinic, patients seem more comfortable asking not only about mental health and stress reduction, but about other aspects of wellness. That includes diet and exercise,” Dr. DiRenzo says. 

How To …

With a topic as broad as wellness, and with so much information of greater or lesser validity accessible on the internet, it’s important to break the topic down for patients, says Dr. Venuturupalli. “If I have direct knowledge about a particular treatment from other patients, I use that in my decision making regarding whether to share with other patients.” But he also tries to affirm when patients take charge of their own lives, while sharing what science has to offer.

“There is no secret sauce; the information is out there,” Dr. Calabrese says. “We know what moderate exercise can do for our patients. You’ve got to work at it and get passionate about it.” 

Dr. Calabrese recommends rheumatologists develop a working relationship with a practitioner of integrative medicine or a wellness coach. There’s also a role for advanced practitioners, occupational or physical therapists and others on the rheumatology team to get additional training in wellness strategies and spend more time on these issues with patients. 

Dr. Venuturupalli’s practice engages a nutritionist to explore dietary issues with its patients.

“Rheumatologists want to present an evidence-based approach, but I feel strongly that we can’t just wait for all the evidence to arrive. We can use a common sense approach and try to direct [patients] to resources that are validated,” says Dr. Venuturupalli. “When a patient brings studies to me, it fuels my own curiosity and sparks my academic interest.”

Larry Beresford is a medical journalist in Oakland, Calif.