Drs Bryant England and Ben Smith on Integrative Care for Rheumatoid Arthritis

Drs England and Smith served on the interprofessional guideline development group that recently produced updated guidelines for the American College of Rheumatology on exercise, rehabilitation, diet, and additional interventions as part of an integrative management approach for people with rheumatoid arthritis (RA). In this podcast, they discuss the key recommendations and how to implement them in practice.

Bryant England, MD, is associate professor of medicine in the Division of Rheumatology at the University of Nebraska Medical Center and director of its Autoimmune Lung Disease Clinic. Benjamin Smith, PA-C, DMSc, is program director and associate dean of the School of Physician Assistant Practice at Florida State University College of Medicine in Tallahassee, Florida.

Reference:

England BR, Smith BJ, Baker NA, et al. 2022 American College of Rheumatology guideline for exercise, rehabilitation, diet, and additional integrative interventions for rheumatoid arthritis. Arthritis Care Res. 2023;75(8):1603-1615   https://doi.org/10.1002/acr.25117

TRANSCRIPT:

Welcome to this podcast from the Rheumatology and Arthritis Learning Network. I'm your moderator, Rebecca Mashaw. With me today are Dr. Bryant England, associate professor of Medicine in the Division of Rheumatology at the University of Nebraska Medical Center and director of its Autoimmune Lung Disease Clinic in Omaha, Nebraska. And Dr. Benjamin Smith, who's the program director and associate dean of the School of Physician Assistant Practice at Florida State University's College of Medicine in Tallahassee, Florida.

Both served in the interprofessional guideline development group that recently produced updated guidelines for the American College of Rheumatology on exercise, rehabilitation, diet, and additional interventions as part of an integrated management approach for people with rheumatoid arthritis. Thank you both for joining us today.

This is the first guideline that ACR has produced on how exercise, diet, and other interventions can be integrated along with the use of DMARDs in managing RA. What caused the ACR to look at producing this sort of guideline right now? Dr. England?

Dr. Bryant England:

So, thanks for having us on to talk about this guideline. This guideline really came out of the pharmacologic treatment guideline. The ACR has produced several iterations of the pharmacologic treatment of rheumatoid arthritis. And we've understood from other disease states and other guideline efforts that there are interventions in addition to medicines that can be very impactful for patients. So as the last iteration of the pharmacologic guideline was being produced, there were discussions of how we could integrate some of these additional interventions besides medicines. And what we realized was that effort really required its own focused project. It required its own separate team with more expertise. And so from that pharmacologic treatment was born, this additional guideline on integrative interventions.

Dr. Benjamin Smith:

Bryant really summed things up very nicely, of course, of how this came to be. I think the timing is really very good with RA being a systemic inflammatory condition, a chronic condition. Both patients and providers are looking for the pharmacologic interventions to make a difference, but also the nonpharmacologic as well. And really seeking guidance of how to manage or navigate with these integrative treatment approaches. And I think that lends itself to the timeliness of what this is.

Rebecca Mashaw:

You developed 28 recommendations for the use of integrative interventions in conjunction with DMARDs for the management of RA. Could you give us an overview of which of these recommendations were the strongest and why?

Dr. Benjamin Smith:

So, that's a wonderful question, Rebecca. I think the title really helps to understand the organization, the real group, the core group that brought this guideline together and helped to lay things out and develop a plan. This idea of exercise, rehabilitation, diet, and additional integrative interventions really serve as a guide for us as we thought about this, began to look at the literature, and develop and ask questions.

I think the last element of that, this additional integrative interventions really also describes well the many, many things that were considered by this group, as we developed these 28 questions that we went to the literature to find answers to. So, that's a general structure for this, that we wanted to approach this in an orderly and intentional way to provide a very valuable resource for colleagues and for patients as well.

Dr. Bryant England:

I agree with Ben. The structure was really helpful for us, as we thought through the evidence. And hopefully it's really helpful for patients and providers as they use this document.

Now, Ben really nicely outlined all these different domains that we looked at. There was only one specific area, though, where we were able to make a strong recommendation. And that one strong recommendation was that we should encourage our patients and help them to consistently engage in exercise. And the reason that was a strong recommendation is, we found moderate level evidence that by doing that, we can improve pain and we can improve function. And these are really important outcomes for patients with rheumatoid arthritis.

Now, while we could make a strong recommendation about exercise in general, we didn't have the evidence that we could make a strong recommendation about specific types of exercise. So the types of exercise, when we looked at them individually—aerobic, resistance, mind-body, aquatic—those were all conditionally recommended. But we didn't have the evidence for them individually to make that a strong recommendation. But that doesn't mean they shouldn't do those, right? Those were all parts of a comprehensive exercise program. So if you look at other national health guidelines like those by the Department of Health and Human Services, all of those different components of exercise would be part of a recommended exercise program for adults.

Rebecca Mashaw:

Doesn't it always come down to whatever exercise you will do and that you enjoy doing, and that keeps you consistent, is the one you should probably be focusing on?

Dr. Benjamin Smith:

Yeah, that's a good point. And that's something I think the group really recognized, and we did have some data, some literature about various forms of exercise. And that's where the discussion with the patient and the health care provider really comes into play and in consideration.

Dr. Bryant England:

The other piece is that rheumatoid arthritis affects people differently. As we think about taking recommendations on exercise from the general population, people with rheumatoid arthritis, we have to be able to modify them a little bit. For example, if someone has a flare of their rheumatoid arthritis in their feet, it's going to be very difficult for them to maybe continue a walking program while they have that flare. They might be able to modify that where they could get into the pool and do more aquatic based exercise at that time. They may be able to do resistance training, particularly if it's more upper extremity predominant. So little adaptations like that is part of why in rheumatoid arthritis, it's hard for a one-size-fits-all exercise program.

Rebecca Mashaw:

That makes a lot of sense. You also had a number of conditional recommendations. Can you tell us a little about those?

Dr. Benjamin Smith:

I think the conditional recommendations are really important to look at, and it really, Bryant... I'll segue to what he just said. Everyone's manifestations of RA, of those who have RA, are different. And we've got lots of modalities, lots of interventions that can be considered based on the patient choice. I think this is a great opportunity to describe briefly, the great approach to review of the evidence. And it really is asking the questions, gathering the evidence, seeing what's available to us, having that team—the core team, the voting panel team—come together and review that, but together with the patients who will talk about for sure, and get their feedback on things to therefore move forward with these guidelines.

And so based on the evidence that we have available, you see just a number of conditional recommendations spanning each of the domains. But each of them were valuable and recognized conditionally in the right patient, could be very helpful in treating their RA. Bryant certainly has things to add in this way as well.

Dr. Bryant England:

Yeah, I think Ben has nailed it here. One of the things that was really fruitful, and I suspect Ben would agree with this guideline effort, was the teamwork that really goes into caring for a patient with rheumatoid arthritis. They may look at a rheumatology professional as sort of their point of contact or quarterback of the team, but that's not how you have a winning team with one person. And so I think what we've realized, and one of the things I take to my clinic now is, I see my role a little bit different. I see my role as also a bit of a coordinator, someone who has to see, what does my patient need right now that maybe is the expertise I don't have?

So as we look at this conditional recommendations, we have several conditional recommendations for rehabilitation interventions. And I realize I'm not an expert in all of those, but I do have physical therapists and occupational therapists who are experts in those. And I can get them connected with them, and they can help them assess, "Well, which one of these modalities might they benefit the most from. How can we get this fit the correct way so that the patient will use it? Is the patient using it the appropriate way? And after using this device, are we getting the results that we want?" So, I think that's just one example of how we can build these interprofessional teams that can really get the expertise to the patients that they need.

Rebecca Mashaw:

One interesting fact that I noticed in reading your study about this group, is that you included 3 patients with RA in your guideline committee. So, how did that come about? Why were they included and what perspective did they provide that you think was really important in developing this guideline?

Dr. Benjamin Smith:

Yeah, what's interesting, Rebecca, there was a larger group of patients who provided feedback. There were some very instructive questions that they were asked. And we took that feedback as represented by a facilitator who attended that session, and 3 patients who participated on the voting panel. And without fail, when the patient spoke, we all listened very intently to what they were saying. And it was helpful for me to accomplish the objective of developing the guideline to hear what was being said and how it was being said. But as I go back to clinic now, I think about that, it often echoes in my ears as I'm helping others with rheumatoid arthritis.

It's certainly part of the process. It's an invaluable element and variable, a needed necessity in this guideline development. As we work towards evidence-based medicine, it is just an important element to have, the patient voice in what we do.

Dr. Bryant England:

I agree. The patients have really insightful comments about living with rheumatoid arthritis and how they may use some of these interventions. And I still think back to the messages they shared with us and how valuable it was. So for example, a couple of things I thought were really powerful was, as we discussed, some of these interventions that maybe didn't have as much evidence—as a clinician and researcher, I'm always looking for evidence. And as we were discussing one of those interventions, one of the patients said, "I understand there's not as much evidence here, but this is one of the few interventions that I can control at my house. Doesn't require specialized equipment, doesn't require expensive visits to someone. This is something that, yeah, there isn't a double-blind randomized controlled trial, but I can do this in my house for low cost. It's really simple." And I thought that was a really enlightening point.

Rebecca Mashaw:

That is very interesting. How do you think or hope this guideline will affect the practice of rheumatoid arthritis management in the clinic?

Dr. Benjamin Smith:

One of our guiding principles, which are included in the manuscript, was the fact that this guideline should be coupled with the pharmacologic guideline, and we can't forget that. I think that's tremendously important to remember. And again, Bryant described early on that historical element of how this guideline came to be. But I think the coupling of these together is so valid. And I think when we couple the two guidelines together in the treatment of RA, which this is specific to RA, I think patient satisfaction, quality of life, I think all of those things can increase, when we think about these 2 guidelines together.

Dr. Bryant England:

I completely agree. When this guideline comes out, one of the things we want front and center is, we've made strides and strides of progress in rheumatoid arthritis because of disease-modifying therapies. And we want to continue the optimal use of disease-modifying therapies. Treating to target, early diagnosis, all of those principles, those haven't gone away. What we're doing is we're trying to provide more holistic care. So in addition to now that we have good medicines, we have treat-to-target, we have good disease activity measures, that's great. But let's build on that. Let's also now discuss with our patients, "What do we do in activity level wise? Are we meeting our physical activity goals? What are those goals? Can we help you achieve those goals despite having rheumatoid arthritis?" Taking those additional steps to really optimize long-term outcomes is really what I hope to see coming from this. Building these interdisciplinary teams, setting these long-term goals, and helping people live full, long lives.

Rebecca Mashaw:

And you've already addressed some of the points in my next question, which is, how do you apply this guidance to your own practice? You mentioned you have occupational therapists, physical therapists, and other professionals…So is that part of the whole thing, is understanding the roles of all the different people in the multidisciplinary team?

Dr. Bryant England:

Understanding our role, engaging these different team members when the right situation comes up. One of the other things that was part of our discussion that came out was this idea of a menu. And one of the things that's helpful for us is giving patients an idea of what might be out there, because oftentimes, they aren't aware. And even if they are aware... So the first visit, we diagnose them with rheumatoid arthritis. We talk about what is rheumatoid arthritis. We talk about what life looks like with rheumatoid arthritis. We talk about disease-modifying therapies, and then now we may talk with them about some of these integrative interventions. That's a lot to throw at a patient at a first visit or first couple of visits.

So one of the things I think I've realized is, we may have to revisit that. A couple encounters down the road, go back to, "Hey, let's just briefly discuss again what's out there." Because what their capacity to handle may have changed, what they're looking for may have changed. So I think just that over time, kind of revisiting this conversation periodically.

Rebecca Mashaw:

Implementing changes in diet and exercise—this is always a challenge, whatever the disease state, whether it's autoimmune or just ordinary osteoarthritis or any other condition—it's hard to do. And patients struggle with it. I think physicians also struggle with how to help them. So, what advice would you give your colleagues on how you think they can best help patients begin and then sustain these kinds of additional interventions in working on creating a healthier diet that they can and will follow and enjoy, and finding a way to move that doesn't exacerbate their pain, but in fact may help relieve it? How do you go about doing that?

Dr. Benjamin Smith:

So this was a very notable discussion, as the guideline was being developed. And we've hinted about this a few minutes ago in one of the responses and points that we made. And I think it's all about recognizing the desires and interests the patient has, and their situation as it relates to disease manifestations, but also as it relates to perhaps socioeconomic things that the patient encounters, and their experience in those ways as well. And so I think when we think about, in this case specifically diet and exercise, it gives us an opportunity to recognize that individual patient's needs and desires, and this concept of shared decision making, which we often talk about. But this is a true opportunity with this one strong recommendation for and multiple conditional recommendations where we can balance those things out, and still do very good for the patient and make a real difference. I think it is discussions, it's conversations, that lead us to providing encouragement. Change if needed, but certainly supporting a patient in their rheumatoid arthritis journey.

Dr. Bryant England:

Completely agree. I think Ben nailed it. One last simple thing I think for people is just simply bring up this discussion with patients. I think that sometimes when patients come to see their rheumatology professional, they think all that we care about is, "Are my joints swollen and am I taking my medicines?" And I think what this guideline may help is help facilitate this conversation so that patients feel comfortable coming in and talking about, "I'm not able to exercise like I was. I understand that my knuckle may not be swollen four times the size that it normally is, but I can't do the exercise that I want to do. I'm not feeling as good just overall, because I'm not able to exercise."

And I think maybe there was a little disconnect between the patient and provider realizing what we were interested in. And we certainly are interested in their physical activity levels. And we as rheumatologists, probably have to bring that question up to kind of create that habit and that space where they feel comfortable letting us know.

Rebecca Mashaw:

And would that also give you some clues about the disease activity? So let's say that they don't have particularly swollen joints, but they don't feel really well. That is going to give you a hint, is it not, about whether their medical therapy is working or whether there are other aspects of their care that may not be actually achieving the goals that you want to achieve, when it comes to treatment?

Dr. Bryant England:

Absolutely.

Rebecca Mashaw:

So any final thoughts about your experiences in creating a new guideline and implementing its recommendations in practice?

Dr. Benjamin Smith:

I'm going to repeat something that Bryant shared because for me, this was the most impactful thing that I took away. And hopefully I'm doing a wonderful job applying it in clinic. And that is, we've got lots of integrative interventions that we can utilize. And what I heard from our wonderful patient experts who participated was, "Let us know what these things are and help us along the journey. Know when to consider or to utilize these interventions." And we can direct that. Even though, as Bryant said, we may not be experts in this intervention or that intervention, we know that it exists. But we as providers, and then as other health care professionals in rheumatology or providing care for patients with rheumatic disease, we can help guide them to make decisions of know when to employ or when to utilize those interventions.

Early on, and certainly we're careful how we do that and how we share these interventions. As a new diagnosis comes, sometimes our ears go off. But we want to share those things that are available and help the patient with rheumatic disease, with RA know when to employ them or when a potentially opportunity to employ these interventions exist. That was such a wonderful take home message for me.

Rebecca Mashaw:

Dr. England. Anything to add?

Dr. Bryant England:

No, I think... When you finish a guideline effort like this, you have a lot of appreciation for all of the people who are part of the guideline effort. You'll look at the author list, and it's a huge author list for additional people in the acknowledgements. And it's really a massive undertaking to go out and search for all these studies to find all that evidence and pull all that together. So, I appreciate what everybody contributed to this so we can help our patients live long, happy lives.

Rebecca Mashaw:

And that's the ultimate goal, right?

Dr. Bryant England:

Absolutely.

Rebecca Mashaw:

Well, thank you both very much for spending this time with us. It's been an interesting conversation, and I'm sure that we'll be hearing more about the application of these recommendations to the practice. Thank you so much.

Dr. Bryant England:

Thank you.

Dr. Benjamin Smith:

Thank you.