The highlights from day four of the American College of Rheumatology (ACR) annual meeting included topics related to bone health, managing and treating lupus, new treatment guidelines for juvenile idiopathic arthritis (JIA) and evidence-based research for osteoarthritis.
Targeted Exercise Improves Bone and Joint Health
In two separate sessions, researchers Laura Bilek, PhD, physical therapist, associate professor for women’s health research at the University of Nebraska Medical Center, and physical therapist Yvonne Golightly, PhD, department of epidemiology at the Thurston Arthritis Research Center at the University of North Carolina School of Medicine, gave presentations on therapeutic exercise for bone health and for joint health, respectively.
Exercise for Bone Health: People with rheumatic diseases are likely to have decreased bone density and increased fracture risk. Bilek examined the role of evidence-based exercise interventions for improving bone health and decreasing fracture risk. Bilek said special attention must be paid to modifications.
For example, weight machines that assist with proper form are recommended over free weights for resistance training, which is a key component to improving bone health and reducing the risk of osteoporosis fractures in the spine, but not the hip for premenopausal women. The opposite is true for impact exercises, which had a positive response to the hip but not the spine. How should this be applied to patients?
“We need to do impact exercise as well as resistance training,” said Laura Bilek, PT, PhD.
How should this be applied to patients?
Effective impact exercises include jumping rope, step classes, hiking and climbing stairs. Resistance training should focus on all major muscle groups and strength, not endurance, and can include free weights and weight machines.
The first set is the most important and will provide the greatest benefit, said Bilek. She recommends two sets of eight to 12 reps at the maximum weight a patient can handle, with a focus on good form and no twisting. If time or energy is limited, one set will provide more than a 50% benefit, so some is better than none. The same recommendations apply for postmenopausal women with low bone mass.
For patients with osteoporosis who are at greater risk for fracture, the goal is to focus on exercises for the spine and to reduce fall risk and loss of bone mass.
When arthritis is present, consider modifications. Resistance exercises and impact exercises are recommended as long as good form can be maintained, but free weights are not recommended for those at greatest risk of fracture, and impact exercises that require “landing hard,” such as jumping rope, should be eliminated.
Exercise for Joint Health: Considering the joint structure as well as patient experience are keys to effective therapeutic exercise for improving joint health in rheumatic musculoskeletal diseases (RMDs), said Golightly. For example, “What their joint symptoms are like. Do they have pain, stiffness or swelling? And we also need to learn how their joints function,” she said. “How well can they move their joints through the full range of motion? Are they able to perform their usual activities at home and at work?”
A mix of therapeutic exercises — including aerobic, strength training, neuromuscular and mind-body — may be used as therapy. The benefits are extensive, including:
- Strengthening muscles, ligaments and tendons
- Increasing circulation of synovial fluid (which lubricates joints), blood and nourishing oxygen and nutrients
- Removal of cellular waste during a healthy balance of cell break down and repair. “Sedentary behavior or big changes in intensity can cause an imbalance that alters joint health,” said Golightly.
- Gene activation for the rebuilding of cartilage
Golightly was also keen to dispel the myth that exercise aggravates articular cartilage loss in patients with RMDs. Cartilage responds to physiologic loading similar to muscle and bone, she said. A four-month randomized controlled trial of moderate exercise in a small group of patients with partial medial meniscus resection (a key risk of knee osteoarthritis) showed joint symptoms and function, as well as cartilage quality in MRIs, improved with supervised aerobic and weight-bearing exercise one hour, three times per week. The research is similar for RA.
The best types of exercise are those that can be tailored to the patient, said Golightly, and health care providers must provide guidance. Exercise should provide the following: warm up (10 to 15 minutes) and cool down; strengthening three days per week; endurance 30 minutes each at least three time per week; daily stretching, flexibility and range of motion; and other types such as neuromuscular and mind-body. Considerations for disease-specific exercise focus should include:
- Osteoarthritis (OA) — full range of motion as comfort allows; strengthening with proper form and fewer reps, even with severe disease; low-impact activities; higher activity/intensity levels
- Inflammatory/rheumatoid arthritis (RA) with morning stiffness — gentle stretching/flexibility exercise at night; reduced exercise, not ceasing, during acute flares; no resistance exercise and stretching of inflamed/affected joints
- Ankylosing spondylitis, for posture — neck, back, shoulder and hip range of motion; back and hip extensor muscles strengthening; breathing exercise to improve chest mobility
- Lupus — use pacing and short exercise sessions to address fatigue; monitor breathing during sessions
- Fibromyalgia — endurance and moderate strengthening; avoiding long, vigorous exercise that may worsen symptoms —BRYAN D. VARGO
New ACR Guidelines for JIA
New treatment guidelines have been developed for oligoarthritis, temporomandibular joint (TMJ) and systemic forms of juvenile idiopathic arthritis (JIA). These new recommendations, which are still in the draft phase, serve as complement to existing guidelines used to treat polyarticular, sacroiliitis, enthesitis and uveitis.
Recommendations were developed by reviewing the current literature about treatments and graded by quality of evidence, patient (and parent) preferences and risks versus benefits. If these new guidelines pass the review board, considerations for treatment will include:
- More modest therapy for initial treatment of oligoarthritis, including the use of Intra-articular glucocorticoids (IAGC) and/or a trial of nonsteroidal anti-inflammatory drugs (NSAIDs). If initial therapy doesn’t work, the use of non-biologic DMARDs (methotrexate) and/or biologics is strongly recommended.
- For TMJ, a painful condition affecting the jaw, an initial round of IAGC and NSAIDs is conditionally recommended. If initial therapy doesn‘t work, the use of DMARDs is strongly recommended versus biologics, which are conditionally recommended.
- In SJIA presenting without macrophage activation syndrome (MAS), NSAIDs and interleukin (IL) inhibitors are conditionally recommended for initial monotherapy treatment, whereas oral glucocorticoids and monotherapy using nonbiologic DMARDs, such as methotrexate, are strongly recommended against.
The new guidelines also offer suggestions for lab monitoring, immunizations and nonpharmacologic treatments. For children taking immunosuppressive drugs, non-live vaccines, such as the flu vaccine, are strongly recommended, whereas live vaccines, such as the MMR immunization are conditionally recommended against. Children not on immunosuppressive vaccines should receive all immunizations recommended by the Centers for Disease Control and Prevention.
Recommended nonpharmacological therapies include healthy diet (strongly recommended) and physical therapy (conditionally recommended), whereas supplements and special diets are strongly recommended against.
Researchers acknowledge that these recommendations are only guidelines, and care outcomes and treatment depend heavily on the individual child and shared-decision making between health care providers, patients and their parents. —ROBYN ABREE
The State of Lupus Treatment
The Food and Drug Administration (FDA) approved hydroxychloroquine in 1955, and it is still the standard treatment for systemic lupus erythematosus (SLE). Scientists have learned a great deal about lupus in the past decade, though, which has led to many new therapeutic targets and potential treatments. Anifrolumab, a fully human monoclonal antibody that blocks the interferon pathway, may be available next year, according to Mary Crow, MD, professor of medicine at Weill Cornell Medical College and attending physician at New York Presbyterian Hospital and Hospital for Special Surgery, all in New York City.
Dr. Crow says several new findings are particularly important in understanding SLE:
- Genetic factors. The heritability of SLE is about 44%. There are a few rare gene changes that can lead to very severe disease, but common variants account for most of the genetic risk. These variants differ from person to person. Combinations of different genes from each parent can increase the chance of SLE.
- Effect of race and ethnicity. Black Americans are many times more likely to have SLE than European Americans. They may have unique genetic variations that are passed from generation to generation, including more impaired B-cell function.
- Smoking. People at high genetic risk who smoke have a greatly increased risk of SLE.
- COVID-19 similarities. The immune response in SLE may be the same as in COVID-19. In any immune response, the innate immune system kicks in immediately and the adaptive immune system follows. The adaptive immune system recognizes and remembers specific pathogens and responds to them more strongly each time they’re encountered. Normally, the immune system calms down after this process, but in SLE, the immune response remains activated for years. In COVID-19, it’s a matter of weeks.
- Importance of monocytes. It’s still not clear what drives tissue damage in SLE, but Dr. Crow thinks more attention should be paid to monocytes — white blood cells in the innate immune system. They’re produced in bone marrow and normally fight viruses and bacteria, but they also make inflammatory cytokines that may attack healthy tissue. —LINDA RATH
Self-management for Lupus Patients
Managing a chronic illness can be difficult, especially for those with rheumatic conditions. One session focused on the importance of providing tools and techniques for patients who have lupus or lupus nephritis for self-management. Irene Blanco, MD, Albert Einstein College of Medicine fellowship program director, emphasized that patients need to have a sense of self-management and autonomy, and health care providers play a significant role by helping to “tailor it, based on the needs of a patient, that will help in adoption of the program.”
Dr. Blanco discussed patient barriers to self-management, such as materials that don’t take into consideration health literacy, a patient’s baseline health beliefs, or a challenging relationship with the physician. But providers also experience barriers to self-management, such as lack of time, staff, funding and being unaware of resources to which to refer patients. She stressed that providers could use insurance billing codes for counseling to bill for their time to provide self-management education.
Research shows benefits across the board for self-efficacy and self-management programs. They have minimal risks and can be led by different types of providers. Having multiple weekly sessions can reinforce the education.
Cristina Drenkard, MD, PhD, associate professor in Emory University’s Department of Medicine, discussed development of a specific self-management program for lupus nephritis (www.lupusinitiative.org), which includes training materials for providers and self-management resources for patients.
“It’s imperative that providers start thinking more on self-management and encourage their patients to go these resources,” said Dr. Drenkard.
Dermatologist Victoria Werth, MD, professor of medicine and dermatology at the University of Pennsylvania, rounded out the session with research on fostering connections between rheumatologists and patient engagement for self-management. “By connecting the patients with trusted and tested self-management resources, doctors can support their patients in self-management efforts outside of the clinic,” said Dr. Werth. —REBECCA GILLETT
What to Eat – and More – for Rheumatic Diseases
Many people with rheumatic conditions want to know what they should or shouldn’t eat for their condition, and while diet is not a cure, there is evidence that what they eat – or refrain from eating – may improve or worsen their disease and symptoms.
Three experts addressed these questions and other lifestyle considerations for people with autoimmune diseases in a session called, “What’s Food Got To Do With It? Food, Fasting and Supplements in Rheumatic Disease.”
Valter Longo, PhD, professor of gerontology and director of the Longevity Institution at the University of Southern California, has been investigating the effects of fasting on the aging process as well as on immunity. Research has shown that fasting has benefits for people with autoimmune diseases; however, fasting isn’t feasible for long periods of time. Longo developed the fasting mimicking diet (FMD), five consecutive days of eating a specific calorie-restricted but healthy diet for three months and eating normally the rest of the time. This eating pattern shows the same benefits on a cellular level as fasting and has also shown real benefits in mice and humans with multiple sclerosis (MS), an autoimmune disease.
In humans with MS, FMD measurably improved quality of life both physically and mentally. It also helped those with inflammatory bowel disease, in part by providing a protective effect in the gut by repopulating the healthy microbes, which went from 16% to 58% in his study.
Sara Tedeschi, MD, a rheumatologist at Brigham and Women’s Hospital and assistant professor of medicine at Harvard Medical School, reviewed randomized controlled trials (RCTs) to summarize what is known so far about the effect of diet on rheumatoid arthritis (RA) and on lupus, although these RCTs on lupus are scarce, she said.
Omega-3 fatty acids have anti-inflammatory effects, and the body can’t produce them, so they have to be consumed — typically in fatty fish, like salmon and sardines, nuts, poultry, leafy greens and berries.
One trial found that among people who are at increased risk of developing RA, such as those with a close relative who has it, higher levels of omega-3s was associated with a lower risk of developing it. Studies also show that moderate alcohol — ½ of an alcoholic drink a day — is associated with a lower risk of developing RA or lupus compared to no alcohol consumption. And one large study found that those who drank one sugary soda per day had a 33% higher risk of developing RA than those who drank less than one per month. (Diet drinks had no association.)
Studies also show that pain improved in RA patients who fasted then adopted a vegetarian diet for 13 months as well as in those who followed a Mediterranean diet for 12 weeks. Another study showed improvements in disease activity, but both study groups lost weight, which might have driven those results, she added.
According to one report, almost 40% of patients surveyed seek complementary or alternative treatment options such as mind-body interventions, acupuncture, diet and herbal supplements, said Neha Shah, MD, clinical assistant professor in the rheumatology and immunology division and Adult Rheumatology Fellowship Program director at Stanford University.
Colleagues working in arthritis self-management have found that “a patient’s perceived self-efficacy to cope with their ailment was mediating the outcomes of this program, and this is particularly true with pain and depression,” she said. “Lifestyle approach is a way we can empower our patients and allow them some control back in their lives.”
Key for physicians is to proactively ask about patient’s lifestyle — what do they eat, how much exercise and sleep do they get, have they quit smoking, what stressors to they have and “who’s your cheerleader?” Listen and help boost their self-efficacy, she advised other physicians, and tap into local acupuncture and massage practitioners, physical therapists and psychologists who can work with patients. She also provides videos to help patients learn stress management techniques, and she recently started group visits via Zoom, so she can speak to many patients at the same time about these interventions without taking up time during individual visits.
There isn’t much data on these kinds of therapies in rheumatology, but there is in many other conditions that rheumatology patients also have, like cardiovascular disease, sleep disorders and depression. “For a holistic, whole-person approach, lifestyle medicine is the way to go,” she said.
In addition to basic dietary advice, she recommends turmeric and ginger for certain patients. Both spices come in supplement form and have anti-inflammatory effects, among other benefits. They are not appropriate for certain patients, she added, including those who are on blood thinners, preparing for surgery or are taking medications that may interact in ways that can be harmful. —JILL TYRER
Strong Association Between Inflammatory Bowel Disease, Psoriatic Arthritis and Psoriasis
Daniella Schwartz, MD, assistant clinical investigator at the National Institutes of Health, highlighted the increased risk of developing inflammatory bowel disease (IBD) among patients with psoriatic arthritis (PsA) and psoriasis. She noted that patients with psoriasis have a two- to four-fold increased risk and those with PsA have a six- to 10-fold increased risk. Dr. Schwartz also noted that Crohn’s disease is more likely among these patients than ulcerative colitis.
This data suggests that PsA and psoriasis patients should closely monitor their gastrointestinal symptoms and discuss them with their health care providers.
Dr. Schwartz encouraged clinicians to screen for these diseases as they may affect PsA and psoriasis treatment decisions. —MICHELE ANDWELE