Exercise tops the list of 28 recommendations in a guideline for integrative interventions in patients with rheumatoid arthritis (RA) developed by the American College of Rheumatology.

The guideline is specific to RA and presents integrative interventions to accompany treatment with disease-modifying antirheumatic drugs (DMARDs), according to a summary statement issued by the ACR. The summary was approved by the ACR Board of Directors in October 31, and the recommendations are part of a manuscript that will be submitted for publication in both Arthritis & Rheumatology and Arthritis Care & Research.

Consistent engagement in exercise earned the only strong recommendation; the other 27 were conditional. In the exercise category, the authors offered conditional recommendations for aerobic exercise, aquatic exercise, resistance exercise, and mind-body exercise.

Dr Bryant England

Three recommendations focused on diet. Notably, the recommended diet is Mediterranean style. Two other recommendations were specifically against any other formal diet and against the use of dietary supplements. “The conditional recommendation for adhering to a Mediterranean-style diet but not other formally defined diets, to improve RA-specific outcomes, may be surprising to some clinicians,” said Bryant R. England, MD, PhD, of the University of Nebraska Medical Center, Omaha, and one of the guideline’s co-principal investigators, in a press release. “The Voting Panel acknowledged, however, that other health indications may exist for alternative diet and dietary supplements, which makes it crucial for clinicians and patients to engage in shared decision-making,” England said.

Nearly half of the 28 recommendations (13) focused on rehabilitation, but all were conditional. These included comprehensive occupational and physical therapy and hand therapy, as well as the use of splinting, orthoses, compression, bracing, and taping of affected areas. Other conditional recommendations supported the use of joint protection techniques, assistive devices, adaptive equipment, and/or environmental adaptations. The authors also included a conditional recommendation for vocational rehabilitation and work site evaluations and/or modifications.

A category of additional integrative interventions included recommendations against both electrotherapy and chiropractic care. However, conditional recommendations were positive for acupuncture, massage therapy, and thermal modalities. Conditional recommendations also supported cognitive behavioral therapy and/or mind-body strategies, and a standardized self-management program.

The guideline was developed by an interprofessional voting panel of 20 individuals with expertise in epidemiology, exercise physiology, GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology, integrative medicine, nursing, nutrition, occupational therapy, physical therapy, rheumatology, and social work, as well as three individuals who have RA. The panel developed questions, conducted a literature review, and used the GRADE approach to rate the certainty of evidence.

“These recommendations are specific to RA management, understanding that other medical indications and general health benefits may exist for many of these interventions,” the authors write in the summary statement.

The range of interventions shows both the importance of an interprofessional team-based approach to RA management and the need to engage patients in shared decision-making, they said.

American College of Rheumatology. 2022 American College of Rheumatology (ACR) Guideline for Exercise, Rehabilitation, Diet, and Additional Integrative Interventions for Rheumatoid Arthritis: Summary

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