Nonpharmacologic therapies and preventive measures for patients with rheumatoid arthritis

Nonpharmacologic therapies and preventive measures for patients with rheumatoid arthritis

Authors
Peter H Schur, MD
Ravinder N Maini, BA, MB BChir, FRCP, FMedSci, FRS
Allan Gibofsky, MD, JD, FACP, FCLM

Section Editor
James R O'Dell, MD

Deputy Editor
Paul L Romain, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: May 2016. &#124 This topic last updated: Dec 23, 2014.

INTRODUCTION — Despite advances in pharmacologic therapy for rheumatoid arthritis (RA), many patients continue to experience some measure of ongoing disease activity with the risk of developing resultant disability. Although measures aimed at identifying early active disease and controlling inflammation are essential, the disease itself and the drugs used for treatment may contribute to increased risks of cardiovascular disease, bone loss, and serious infection. Many of these risks can be substantially reduced by a range of preventive interventions. (See "Disease outcome and functional capacity in rheumatoid arthritis".)
A comprehensive management program for RA includes patient education; psychosocial interventions; appropriate use of rest, exercise, physical and occupational therapy; and nutritional and dietary counseling. The management program also includes interventions to reduce the risks of cardiovascular disease and osteoporosis, and immunizations to decrease the risk of infectious complications of immunosuppressive therapies.
The nonpharmacologic and preventive therapies used in the management of RA are presented here. An overview of the management of RA, including the stages of the disease, assessment of disease activity and severity, and pharmacologic management, is presented separately. (See "General principles of management of rheumatoid arthritis in adults".)
NONPHARMACOLOGIC AND PREVENTIVE THERAPIES
Patient education and counseling — Education and counseling are important in the management of rheumatoid arthritis (RA), a disorder in which therapy is continuous, using a mixture of modalities to maximize efficacy and reduce the risk of side effects [1]. Many patients have misconceptions about the nature of arthritis and its cause. Correcting these may help establish a good long-term relationship between the clinician and patient. The clinician can provide information concerning the therapeutic roles of physical therapy, medications, and surgery. A longitudinal plan should be developed with each patient that addresses prognosis and options for treatment [2,3]. Informed and sympathetic discussions concerning alternative, controversial, and unproven therapies are also important elements of patient education. (See "Complementary and alternative remedies for rheumatic disorders".)
Various psychosocial interventions can benefit patients with RA. A systematic review and metaanalysis of 13 trials, involving 1579 patients, has documented that psychosocial interventions can modestly reduce symptoms of fatigue [4]. Cognitive behavioral therapies may also significantly reduce the patient's self-reported pain, functional disabilities, joint involvement, disease activity, and feelings of low self-esteem [5]. One trial has shown that an online cognitive-behavioral, self-management program with weekly telephone support can improve self-efficacy and quality of life [6].
Patients may need to be convinced that modern therapeutic regimens for the disease are effective for most patients in diminishing pain and swelling and in retarding (sometimes preventing) joint destruction. There is evidence that the course of disease activity in RA patients has become milder since the mid-1980s [7] and much of the improvement, particularly in the rate of progression of joint damage, may be attributable to earlier and more widespread use of effective medications [8].
Patients should be encouraged to seek information and care from health care professionals other than their clinicians. As an example, formal patient education programs, mostly delivered by voluntary agencies such as the Arthritis Foundations, may include:
●General information
●Teaching skills for management of chronic illness
●Strategies for preserving joint function
●Training in biofeedback and the use of cognitive-behavioral and other psychotherapeutic techniques
●Enhanced social support
Such programs have been shown to reduce pain, depression, and disability. They also allow patients to share in management decisions, thereby gaining some control over their illness [9]. A year 2003 meta-analysis of 17 trials of arthritis self-management educational interventions for patients with RA or osteoarthritis found a clinically small, but statistically significant, beneficial effect on both pain and disability (effect size 0.12, 95% CI 0-0.24, and 0.07, CI 0-0.15) [10].
A year 2004 systematic review of patient education in RA concluded that there is evidence for these benefits, at least in the short-term; however, evidence of long-term effects on outcomes is lacking [11].
Rest — Since RA produces fatigue, the performance of many normal tasks may be difficult. Resting an inflamed joint as well as the entire body by taking a nap may, therefore, be beneficial; these rest periods can alternate with exercise. Fatigue can also be reduced by psychosocial interventions and by participation in physical activity. (See 'Patient education and counseling' above and 'Exercise' below.).
Exercise — Pain and stiffness often lead patients to avoid using affected joints. This lack of use can result in loss of joint motion, contractures, and muscle atrophy, thereby decreasing joint stability and producing a further increase in fatigue. As a result, it is important that patients exercise regularly to prevent and reverse these potentially disabling problems.
Range of motion exercises help preserve or restore joint motion. Exercises to increase muscle strength (such as isometric, isotonic, isokinetic), performed as infrequently as once or twice a week, improve function and do not worsen disease activity [12].
Regular aerobic exercise (such as walking, swimming, cycling, and supervised cardiorespiratory aerobic conditioning) improves muscle function, joint stability, aerobic capacity, and physical performance over the short-term and can result in improved overall pain control and quality of life, without an increase in disease activity [13-16]. Whether these benefits are maintained in the long term is unclear. Physical activity has also been shown, in a systematic review and meta-analysis, to decrease the level of fatigue in patients with RA [4]. Preliminary evidence suggests aerobic weightbearing exercise may help prevent glucocorticoid-associated osteoporosis in RA [17], a benefit which strength training alone probably does not produce [12].
Exercise programs should be prescribed by a physical therapist and tailored for each patient's disease severity, body build, and previous activity level. High-intensity weightbearing exercises may not be appropriate for patients with preexisting structural damage of lower extremity joints [18]. Less intense or non-weightbearing exercises are alternatives for such patients.
Physical therapy — The goals of physical therapy are pain relief, reduction of inflammation, and preservation of joint integrity and function. Physical therapy principally involves specific modalities targeted to problem areas, including:
●The application of heat [19] or cold to relieve pain or stiffness
●Ultrasound to assuage tenosynovitis [20]
●Passive and active exercises to improve and maintain range of motion of joints
●Dynamic exercise to improve aerobic capacity and strength [21]
●Rest and splinting during rest to reduce pain and improve function
●Finger splinting to prevent deformity or improve hand function
●Relaxation techniques to relieve secondary muscle spasm
Referral to a podiatrist for provision of semirigid orthoses and supportive footwear is also helpful for those with involvement of the feet, especially for those with metatarsalgia [22].
Occupational therapy — Goals of occupational therapy (OT) are similar to those of physical therapy, but occupational therapists focus on upper extremity activities and offer services to patients with RA that most often include:
●Education regarding joint protection and self-care
●Provision of assistive devices and splints
●Instruction in use of assistive devices
An individualized hand exercise program involving stretching and strengthening can also be beneficial in selected patients, even in patients on a stable regimen of disease-modifying antirheumatic drugs (DMARDs). In a randomized trial involving 490 patients, the addition of a tailored strengthening and stretching hand exercise program (including six face-to-face sessions and support for a daily home exercise program) to usual care (advice regarding joint protection and general exercise, and functional splinting and assistive devices, as indicated) resulted in significantly greater improvement in overall hand function at one year of follow-up compared with usual care alone (improvement in Michigan Hand Questionnaire overall hand function score of 7.9 points, 95% CI 6.0-9.9, versus 3.6 points, 95% CI 1.5-5.7) [23-25].
A systematic review of OT interventions provided for patients with RA, published in 2002, found limited evidence of efficacy that comprehensive OT and/or patient education by a therapist had a beneficial effect on patient functional ability, whilehand/wrist splinting decreased pain [26]. However, a subsequent randomized trial in employed RA patients at risk of work disability found significant benefit at six months in both functional and work outcomes from combining usual medical care with targeted, comprehensive OT, compared with usual care alone (without OT) [27].
Nutrition and dietary therapy — Active RA may be associated with anorexia and poor dietary intake. Attempts to overcome these difficulties should, therefore, be a part of the management of the disease [28]. Many different dietary manipulations have been proposed as therapy in RA, but the majority are unproven. An exception to this may be that diets rich in fish oil or a diet to which eicosapentaenoic acid or docosahexaenoic acid is added may result in decreased arachidonic acid metabolites and cytokines, with a concurrent decrease in symptoms [29]. In one randomized trial, involving 139 patients with recent-onset RA, the addition of high-dose fish oil (5.5 g daily) to triple therapy with traditional DMARDs (methotrexate plus sulfasalazine plus hydroxychloroquine) significantly reduced the proportion of patients failing to achieve remission or low disease activity on the initial treatment regimen, compared with the addition of low-dose fish oil (0.4 g daily) (11 versus 32 percent, hazard ratio 0.28, 95% CI 0.12-0.63) [30].
The obese patient should be encouraged to lose weight, as even mild excess weight increases the stress upon joints involved with synovitis, potentially hastening joint destruction. Referral to a registered dietitian can provide patients with assistance in weight and nutritional management.
Bone protection — RA alone appears to cause a gradual loss of bone mineral density, even without the administration of glucocorticoids (table 1). (See "Overview of the systemic and nonarticular manifestations of rheumatoid arthritis", section on 'Osteopenia' and "Osteoporotic fracture risk assessment".)
The prolonged use of large doses of glucocorticoids promotes osteopenia, while improved mobility associated with chronic use of lower doses (eg, less than 7.5 mg/day of prednisolone) may at least partially offset the adverse effects on bone mineral content. (See "Pathogenesis, clinical features, and evaluation of glucocorticoid-induced osteoporosis", section on 'Effect of low-dose glucocorticoid therapy'.)
Given the risks associated with glucocorticoid-induced bone loss, preventive measures are warranted. (See "Prevention and treatment of glucocorticoid-induced osteoporosis".)
Cardiovascular risk reduction — Because of an increased risk of coronary atherosclerosis and associated morbidity and mortality in patients with RA, efforts to modify risk factors such as cigarette smoking, hyperlipidemia, hypertension, and sedentary lifestyle should accompany treatment directed at RA. Control of the inflammatory process also may contribute to cardiovascular protection, while there is some evidence that statin therapy improves inflammation in patients with RA. These issues are discussed separately. (See "Coronary artery disease in rheumatoid arthritis: Implications for prevention and management" and "Overview of primary prevention of coronary heart disease and stroke".)
Vaccinations — Patients receiving immunosuppressive drugs should NOT receive live vaccines. Use of killed virus or polysaccharide vaccines (eg, influenza and pneumococcal vaccines) is appropriate for RA patients, whose disease and antirheumatic drug treatment put them at higher risk for serious infection.
The following vaccination recommendations were included in the 2008 American College of Rheumatology (ACR) guidelines [3] and are consistent with Centers for Disease Control and Prevention (CDC) recommendations for influenza and pneumococcal vaccination:
●Influenza vaccine should be given to all RA patients who are going to be or are already treated with immunosuppressive drugs, regardless of when the drugs are initiated, unless the patient was vaccinated during the previous influenza season or has a contraindication to the use of such vaccines. (See "Seasonal influenza vaccination in adults", section on 'Schedule' and "Seasonal influenza vaccination in adults".)
●Pneumococcal vaccine should be given to all RA patients who are going to be or are already treated with immunosuppressive drugs, and a single revaccination is warranted if ≥5 years have elapsed since the first vaccination (table 2). (See "Pneumococcal vaccination in adults".)
●Hepatitis B vaccine should be given before methotrexate, leflunomide, and biologic DMARDs if risk factors for hepatitis B are present, such as a history of multiple sexual partners in past six months, household contacts with hepatitis B, intravenous drug abuse, or work in healthcare. (See "Hepatitis B virus vaccination".)
●Live vaccines should generally not be given to patients receiving significant doses of glucocorticoids or other immunosuppressive agents. However, the US CDC has suggested that the zoster vaccine can be given to patients on low doses of certain agents, including low- to moderate-dose glucocorticoids (prednisone less than 20 mg daily); methotrexate (≤0.4 mg/kg weekly); azathioprine (≤0.3 mg/kg daily); or 6-mercaptopurine (≤1.5 mg/kg daily) [31].
Low doses of glucocorticoids, DMARDs, and tumor necrosis factor inhibitors may blunt, but do not appear to abolish, the response to such vaccines [32-34].
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)
●Basics topics (see "Patient information: Arthritis and exercise (The Basics)")
●Beyond the Basics topics (see "Patient information: Rheumatoid arthritis symptoms and diagnosis (Beyond the Basics)" and "Patient information: Rheumatoid arthritis treatment (Beyond the Basics)" and "Patient information: Disease-modifying antirheumatic drugs (DMARDs) (Beyond the Basics)" and "Patient information: Complementary and alternative therapies for rheumatoid arthritis (Beyond the Basics)" and "Patient information: Arthritis and exercise (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS — A comprehensive management program for rheumatoid arthritis (RA) includes measures to prevent and treat disability resulting from the disease and to reduce other disease risks and the complications of immunosuppressive therapies. (See 'Introduction' above.)
●Education and counseling are important in the management of RA. The clinician can provide information concerning the therapeutic roles of physical therapy, medications, surgery, and complementary and alternative therapies. An individualized longitudinal plan should be developed with each patient that addresses prognosis and options for treatment. (See 'Patient education and counseling' above.)
●Since RA produces fatigue, the performance of many normal tasks may be difficult. Temporarily resting an inflamed joint as well as the entire body by taking a nap may, therefore, be beneficial; these rest periods can alternate with exercise. (See 'Rest' above.)
●Pain and stiffness often lead patients to avoid using affected joints, which can result in loss of joint motion, contractures, and muscle atrophy, thereby decreasing joint stability and producing a further increase in fatigue. It is thus important that patients exercise regularly to prevent and reverse these potentially disabling problems. Such exercise may include a combination of range of motion exercises, muscle strengthening, and aerobic exercise. Exercise programs should be prescribed by a physical therapist and tailored for each patient. (See 'Exercise' above.)
●The goals of physical therapy are pain relief, reduction of inflammation, and preservation of joint integrity and function. Physical therapy involves specific modalities targeted to problem areas. Goals of occupational therapy (OT) are similar to those of physical therapy, but occupational therapists focus on upper extremity activities and offer services to patients with RA that most often include education regarding joint protection and self-care, provision of assistive devices and splints, and instruction in their use. (See 'Physical therapy' above and 'Occupational therapy' above.)
●Active RA may be associated with anorexia and poor dietary intake. Attempts to overcome these difficulties should, therefore, be a part of the management of the disease. The obese patient should be encouraged to lose weight, as even mild excess weight increases the stress upon joints involved with synovitis, potentially hastening joint destruction. (See 'Nutrition and dietary therapy' above.)
●RA itself, in addition to glucocorticoid use, can contribute to reductions in bone density and increase risk of osteoporosis. Appropriate preventive measures should be utilized. (See 'Bone protection' above.)
●Because of an increased risk of coronary atherosclerosis and associated morbidity and mortality in patients with RA, efforts to modify risk factors such as cigarette smoking, hyperlipidemia, hypertension, and sedentary lifestyle should accompany treatment directed at RA. (See 'Cardiovascular risk reduction' above.)
●Patients receiving immunosuppressive drugs should NOT receive live vaccines. Use of killed virus or polysaccharide vaccines (eg, influenza and pneumococcal vaccines) is appropriate for RA patients whose disease and antirheumatic drug treatment put them at higher risk for serious infection. Vaccination recommendations are consistent with Centers for Disease Control and Prevention (CDC) recommendations for influenza and pneumococcal vaccination. Other vaccinations may also be indicated in specific patients at risk, including immunization for Hepatitis B. Low doses of glucocorticoids, disease-modifying antirheumatic drugs, and tumor necrosis factor inhibitors may blunt, but do not appear to abolish, the response to such vaccines. (See 'Vaccinations' above.)