Treatments and outcomes for rheumatoid arthritis (RA) have made major advances in the last decade. Earlier diagnoses, better treatment strategies, and improvements in disease modifying anti-rheumatic drugs (DMARDs) have “changed the game,” allowing many people with RA to live with less pain and fatigue and greater function.
“At the same time, both patients and providers are having more discussions about interventions to improve their outcomes that work alongside the medications they are taking,” says Bryant R. England, MD, PhD, associate professor in the division of rheumatology and immunology at the University of Nebraska Medical Center in Omaha. Dr. England is also the co-principal investigator of the American College of Rheumatology's (ACR) new guidelines for integrative approaches for treating RA.
The summary of the ACR panel recommendations (PDF) was released in November 2022, and the full report is expected later in 2023. The guidelines for exercise, rehabilitation, diet, and additional integrative and complementary interventions are intended as an adjunct to the ACR’s 2021 Guidelines for the Treatment of RA (PDF), which covers pharmacologic therapies.
“Rather than examine a few interventions as part of the prior RA treatment guideline, the ACR recognized the importance of focusing a guideline specifically on integrative interventions,” says England.
The ACR’s recognition and focus on integrative interventions for RA is great for both rheumatologists and their patients, says Brian Andonian, MD, a rheumatologist at Duke Health in Durham, North Carolina.
“For people with arthritis, particularly rheumatoid arthritis, I think integrative interventions should be part of care. Everyone should be discussing these things with their provider,” says Dr. Andonian. Your current diet and exercise habits, and the state of the disease — these specific challenges may all factor into the decision-making, he says.
The guidelines include 28 recommendations, with “moving regularly” being the only strong recommendation. Out of the 27 conditional recommendations, four were about exercise, 13 about rehabilitation, three about diet, and seven about additional integrative interventions.
A conditional recommendation is one for which the benefits probably outweigh any downsides, but it’s not completely clear given the current evidence. In many cases, there haven’t been enough well-designed studies to show the impact of the intervention on RA.
“The endpoints or outcomes for RA that the committee focused on were disease activity, patient function, pain, and fatigue,” says Neha Shah, MD, a rheumatologist at Stanford Medicine in Palo Alto, California. Dr. Shah was the content expert for integrative rheumatology for the new ACR guidelines on integrative interventions. That means if a study was designed to investigate whether or not a certain therapy improved quality of life, it wouldn’t have been included in the review of the literature, she says.
If you’re ready to incorporate lifestyle interventions into your care plan, keep reading for expert advice on the best — and worst — integrative therapies for rheumatoid arthritis.
But remember: Integrative approaches don't take the place of medication, and it's important to take your RA meds as directed. Even though there’s a growing recognition that integrative therapies are an important component in managing RA, the guiding principle is that the disease needs to be treated with DMARDs according to pharmacologic treatment guidelines, says England.
“We’ve made huge strides in RA outcome because of this, so we need to continue to treat-to-target with DMARDs,” he says.
Moving regularly was the only strong recommendation put forward by the ACR committee.
“That’s something I talk about with all my patients — any little bit of extra movement throughout their day is going to be beneficial for them,” says Andonian.
Physical activity is important for anyone with RA — it doesn’t matter how active their arthritis is or how sick they are — movement is going to be helpful, Andonian says. “It’s just a matter of gauging the amount of exercise or movement for each individual."
The data clearly shows that a sedentary lifestyle is associated with poor outcomes, both in RA and many other health conditions, says Shah. “Movement of any kind is good, even if it’s just getting up and walking, gardening, or vacuuming your house. More traditional or formal exercise, such as aerobics, stretching, tai chi, yoga, and strengthening and toning programs, are also appropriate,” she says.
The research shows that different types of exercise — strengthening, stretching, cardiovascular exercise — can have a positive effect on several parameters of RA pain, disease activity, and fatigue, says Shah.
“Twenty years ago, the prevailing thought was that exercise might worsen arthritis and cause more damage to the joints, but we’ve learned through the years that it’s really the opposite. if anything, it can improve the disease. That’s why there’s that strong recommendation,” says Andonian.
A physical therapist (PT) can play a crucial role in co-management of disease along with your rheumatologist. The inclusion of a PT on the care team is very important, says Shah. “Physical therapists can provide significant support to patients at any stage of RA,” she says.
A study published in October 2020 in Rheumatology International found that physical therapy improved the quality of life and reduced pain in people with RA who had moderate to severe disease activity.
Physical therapists can customize programs according to a person’s needs, says Andonian.
“I think physical therapy is especially valuable when a person has bad arthritis that’s affecting one area, say the knee or the shoulder. In those situations, it can really help a person with pain and symptoms.”
At any given point in a patient’s RA journey they may have variable needs for occupational therapy (OT) — that’s where the shared decision making comes in, says Andonian.
As with physical therapy, OT can be most impactful when utilized in specific situations, he says.
“For example, we really use occupational therapy to help our patients with hand arthritis — when the arthritis is in the hand and wrist is really affecting day to day activity. OT is really the expert in managing this, for both exercises that might help as well as ways to activities to improve day to day life,” he says.
In certain cases, braces and splints may be used to treat joint pain and swelling and improve functioning in RA. Once a treatment goal is identified, your rheumatologist may recommend an occupational therapist or a physical therapist to work with you on getting a splint with the right fit.
Both PTs and OTs can provide instruction on what movements to avoid while wearing the splints, along with tips on retaining as much strength and flexibility as possible, according to Johns Hopkins Arthritis Center.
It’s always tricky to make dietary recommendations to a large population because diet is a very individualized intervention, says Andonian. “At least from my standpoint, there’s not necessarily one ‘best’ diet for everybody. There are so many factors that go into what we eat based on our culture and our history and everyone has specific needs and preferences in their diet,” he says.
“The Mediterranean diet has a conditional recommendation, and that’s probably because it’s been the most studied diet,” Andonian adds. That doesn’t mean that other diets besides a Mediterranean-type diet are bad, and some may even be helpful in some cases, but there just aren’t many studies out there at this point, he says.
Shah agrees, saying, “The process of putting these guidelines together highlighted the need for more research on the potential impact of diet for people with RA.”
The data that we do have suggests that a Mediterranean-type diet can be useful in many comorbidities that are associated with RA, including early cardiovascular disease and diabetes, she says.
No matter what a person’s culture or background is, they could adopt some of the principles of the Med-type diet — that is, focusing on eating lots of fruits, vegetables, whole grains and high fiber, healthy fats, and limited processed foods, she says.
For some patients, massage can help them relax and help them sleep better, but there’s not a lot of data on how it specifically improves the areas of RA that the committee considered, says Shah.
In a study published in February 2022 in the journal Complementary Therapies in Clinical Practice, researchers randomized 60 people with RA to either Swedish massage or routine care. The group who received eight weeks of regular (two or three times a week) 30-minute massages reported significantly less pain and took less pain medication compared with the group who didn’t get massaged.
“Based on the research we have and the experience of my patients, massage therapy can be really helpful for pain and overall well-being, what we call ‘patient reported outcomes,’” says Andonian.
Access can be a problem. Insurance often doesn't cover alternative therapies, so the out-of-pocket costs can add up. But for patients who can access those therapies, there is very little downside, Andonian says.
Like massage, acupuncture has the potential to manage widespread pain and fatigue, which are common issues for many people with RA, says Andonian.
“Both massage therapy and acupuncture work in different ways, but both can be very beneficial in addressing these issues and treating the whole person,” he says.
A meta-analysis published in April 2022 in Evidence-Based Complementary and Alternative Medicine that included 11 randomized controlled studies found that acupuncture is beneficial for relieving pain and improving quality of life and overall health in people with RA. The study authors concluded that “it should be available as an adjunctive nonpharmacological treatment in rehabilitation programs.”
The ACR committee gave conditional recommendations against using four commonly used RA interventions:
Electrotherapy involves the use of electrical impulses to stimulate the muscle or nerve. In RA, this is often delivered via transcutaneous electrical nerve stimulation (TENS). A TENS unit is commonly used in rehab settings. It can be a noninvasive pain management tool, says Andonian.
Right now, only the summary guidelines are for the ACR integrative recommendations have been released, and so it’s not totally clear why electrotherapy was recommended against, he says.
According to Cleveland Clinic, electrotherapy can have benefits for pain, and there are few reported side effects.
Diet supplements is a very broad category, and there are many different ones, says Andonian. “I would agree, there’s not a lot of potential benefit for just taking a multivitamin or taking supplements in general, but based on individual needs there could be some benefit for certain individuals,” he says.
One negative is that dietary supplements can be costly, says Andonian. “If you look online for dietary supplements for arthritis, a person could potentially be taking 50 different ones — and that can really add up,” he says.
Supplements such as turmeric or ginger root (both are thought to reduce inflammation) are going to be fairly low risk for most people, says Andonian. If you’re really interested in trying something like that and access isn’t an issue for you, talk with your rheumatologist about any potential benefits or risks, he says.
There can be concerns about the safety of chiropractic care for people with RA, particularly in individuals with longstanding disease who have a lot of damage related to their arthritis, says Andonian. “They can get arthritis or damage to their neck or cervical spine, and so if they are getting a chiropractic manipulation in that area, that could be potentially dangerous,” he says.
However, chiropractor therapy is not just manipulation of the spine, says Andonian. “This is a general recommendation, and so for some individuals with RA there may be certain situations where chiropractic care could be beneficial. But it’s certainly something you’d want to discuss with your rheumatologist before doing,” he says.
“I am an advocate for the importance of adding integrative therapies to care, but trying to manage RA completely with these therapies and not taking your RA medicine is a bad idea. It can cause increased damage and poor outcomes,” says Andonian.
Integrative therapies often have a synergistic effect and should be used in conjunction with medications, he says. “It’s not an either-or — both integrative and pharmaceutical therapies should be part of a treatment plan. I have had a few patients try to completely go off medications and just try integrative therapies, and I’ve seen bad outcomes from this,” says Andonian.