Wellness in Rheumatic Diseases: A Conversation with Saundra Jain, MS, PsyD, and Andrew Laster, MD

Dr. Saundra Jain, who is an adjunct clinical affiliate at the University of Texas at Austin School of Nursing and a psychotherapist in private practice, and Dr. Andrew Laster, who is a rheumatologist in private practice in Charlotte, North Carolina, took some time to talk with the Rheumatology and Arthritis Learning Network about the concept and the importance of wellness across disease states in rheumatology.

Dr. Jain, I know your research over the years has focused strongly on wellness. So would you share your definition of wellness with us?

Dr Saundra Jain: Of course, Rebecca, I'd be happy to. But before we start, I'd love to begin by saying how excited we are to be having this really important conversation, bringing together two specialties like rheumatology and psychiatry, it really is... I mean, honestly, it's a unique opportunity to come together so we can talk about our shared learnings in hopes of what I know we all want to do, which is to take better care of our patients. So back to your question, Rebecca, and that is how do we go about defining wellness? And I have to be honest, it's a little bit of a challenge. It's an overused term. It has a lot of varieties of meaning, lots of definitions. It kind of depends upon your set and setting as to how you define the word wellness. So I'm going to do this for our conversation today. I'm just going to offer a definition that comes straight from World Health Organization.

And I want you to know this, the definition dates back to the mid-'40s. So it's tried and true and has been around for a very long time. And WHO defines health this way: as a state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity. And I just love this. Andy, you and I have talked about this many times, that we as patients, we all have kind of our own things, whether we're clinicians or actual patients, we are more than just our disease.

And again, as clinicians, we're always interested in the reduction of symptoms and improvement in functionality, regardless of disease state. But what we don't want to do is overlook how our patients are doing in terms of their overall wellbeing. So if you leave our conversation today with that in your back pocket, I think we've been hugely successful in achieving our goals.

Andy, if I could, I'd love to turn to you. I'm so curious, from your perspective as a rheumatologist, how important do you think wellness is in the lives of patients who are suffering and dealing with RA?

Dr Andrew Laster: I'll use the word huge again. That really is hugely important. I think patients really want to retain some control over their arthritis and how it's managed. And this concept of wellness, I think, really helps to empower the patient. If you've been diagnosed with an autoimmune disease, I'm sure it's incredibly intimidating that your immune system has gone awry, and you're going to need to take drugs to go ahead and modify it. But wellness acknowledges that the patient really has some control.

I mean, we know that the brain is hardwired to the immune system and that the behaviors that we're going to be talking about in a few minutes really are complimentary. It's not an alternative to traditional drug therapy. So I think that when we sit down and talk to patients and we acknowledge the importance of wellness, their eyes often light up. Finally, I found somebody who I can talk to, not just about allopathic medicine and the drugs, but also, this concept of wellness, which more and more individuals are coming to understand.

RALN: Dr. Laster, you and Dr. Jain were coauthors, with others, on an article recently published in Rheumatic and Musculoskeletal Diseases, titled “Call for action: incorporating wellness practices into a holistic management plan for rheumatoid arthritis - going beyond treat to target.” Can you explain what is meant by going beyond treat to target?

Dr Laster: Sure. Rebecca, so treat to target is really an essential aspect of caring for patients with inflammatory arthritis. And I think understood by rheumatologists, but just to kind of give you a definition. So basically you determine the metrics that you're going to use to measure disease activity over time, and then you adjust the treatment accordingly if the metrics—it's usually low disease activity or remission—if the metrics are not met at that fixed time point. But the challenge here is that all the metrics we use, whether it's a RAPID3 or a CDAI or a DAS28, all of them include a patient global. And the patient global can be driven by more than just the number of tender and swollen joints.

So the dilemma is that if you simply follow the metrics, and you have a patient with moderate and high disease activity, but they don't have corresponding tender and swollen joints, then you'd be led to go ahead and make a change in their conventional DMARD therapy or biologic. When really what you need to do is to focus on other aspects, such as the patient's sense of wellbeing. This is what we'll be talking about and really how we can improve the patient overall. If we can incorporate that, I think the patient global will improve and will be further along in terms of caring for our patients.

RALN: In the article, you touch on several wellness enhancing practices, such as exercise, mindfulness, sleep, social connectedness, and nutrition. I'd like to explore these 5 practices by asking both of you to offer us a couple of important pearls of wisdom on each. So Dr. Jain, to begin with you, what about sleep and social connectedness? Can you tell us how they contribute to wellness for patients with rheumatic diseases?

Dr. Jain: Yeah. I bet you, Rebecca, that Andy would agree with me that this question is really the fun part of the conversation we're going to have today because this is the practical part. This is the part where we hope to offer you and our listeners, really, ways they can take these complimentary practices like Andy referenced earlier, put them into practice and really begin to integrate wellness into our patients' treatment plans. So I have to say, sleep and social connectedness, absolutely 2 of my favorites. So let's get started.

Sleep, without a doubt, I have to tell you in my practice, it's one of the most commonly reported difficulties that my patients are reporting. Now, I'll refer everybody back to the article that we just mentioned for additional references, supporting information that we already know about sleep. And quite simply, I mean, I would say this. The takeaway is disrupted sleep is bad for a person's overall physical and mental wellbeing. And the data is there to support that.

I want to share with everyone, I heard a colleague not too long ago describe it this way. That while sleeping, the brain's cleaning crew gets busy clearing out cellular waste and debris from the day. So things like oxidative stress and tau accumulation, and we all know that increases the progression of tauopathies including Alzheimer's disease. And sadly, I mean, honest truth is we know too well that cell death can eventually lead to affective disorders, memory learning deficits, as well as cognitive dysfunction. And there are studies, I want everyone to know, that show that disrupted sleep in patients, specifically with RA, will increase not only mood difficulties, but also levels of pain.

Now, I know this doesn't come as a surprise to any of us. But I think the real question is this: Okay, so what do we do? This is what I think. Quite simply, offer lots of education about basic sleep hygiene practices. So things like this: Setting a regular bedtime and a wake up schedule. Decreasing consumption of caffeine, alcohol, and nicotine as we're nearing bedtime. Keep the bedroom quiet, keep it dark, and keep it cool. And we can review these practices. And I would strongly encourage all of us to do this routinely as we're seeing our patients. Just review these practices with them regularly. Kind of reinforce that messaging.

Now, social connectedness. Well, I really believe, I have to say that our brains are hard-wired for social connection. In all of our clinical and research work, we have never rank-ordered any of the wellness practices in terms of importance. And the reason is this—we wanted to encourage patients to try all of them so we avoided saying exercise is the most important or social connect. We just encourage people to engage and try them all. But I want you to know, over the years, based on the data, it is quite clear. The need for us as humans to connect with others is critically, I would say vitally, important to our overall wellbeing. And the data tells us that loneliness and social isolation promotes immune dysfunction, including proinflammatory cytokine production and it increases inflammatory markers.

So I think it's fair to say it benefits us all to encourage our patients to just get out there, connect with others. Volunteer, join a book club, stay connected with your friends and your family. Whatever works for that patient. And again, just to make this point, as clinicians, we have to be flexible in terms of what we're recommending based on that particular patient's needs and situation.

RALN: Dr. Laster, why don't you take on nutrition, exercise and mindfulness in this discussion? Can you tell us how they contribute?

Dr Laster:  Thanks, Rebecca. So let's go ahead and begin with diet and nutrition, since I think that's probably the thing that patients bring up on their own the most frequently to me. And so just to highlight a few things: We think that a Mediterranean diet is the way to go. Even if the effect on rheumatic disease is felt to be fairly modest, the diet has other clearly proven benefits in terms of reducing cardiovascular risk. And we know that's a significant issue for patients with systemic inflammatory disorders. The other important point is that moderate or high alcohol consumption is clearly associated with a higher risk of rheumatic flares. And that was recently documented in the updated 2021 ULAR guidelines.

If we turn to exercise, we want to encourage all of our patients to exercise on a regular basis, no matter how severe their disease. And certainly, patients who have advanced disease may require meeting with a physical therapist and having something fairly structured. But we need to let patients know that the benefits from exercise are really significant. Improved strength, improved mobility, and increased range of motion, decreased pain, can help with fatigue, can improve sleep. And again, also, its impact on cardiovascular health.

So what we typically recommend are 2 elements and 2 others, I think, that are also important. So number 1, aerobic exercise. So moderate exercise for 30 minutes a day, 3 days a week. And you don't have to do it all in 30 minutes. We have busy lives. You could break it up into 5- or 10-minute increments. And by moderate, people say you're exerting enough that you're a little bit short of breath, but you can still carry on a normal conversation. So aerobic exercise is important.

Resistance training, also called progressive resistance training, or PRT—that's using the stretchy TheraBands or free weights—is important. And then I think range of motion and stretching. So things like tai chi, yoga, and Pilates are definitely helpful for our patients with arthritis. And then for our older patients, balance training is really important. We're more likely to fall as we get older. That increases the risk for osteoporosis. So every patient that I talk to, I go over the importance of balance training. Just simply standing on one leg for more than 6 seconds when you brush your teeth every day is a good way to do that. And as we're interested in the immune aspects, there are clearly changes that have been documented. Increased levels of IL-6 from skeletal muscle, which actually has an anti-inflammatory effect. We see changes in adhesion molecules on the endothelial cell surface, increased angiogenesis. So there are a number of processes going on where exercise clearly can be beneficial.

And then finally, let's go ahead and talk a bit about mindfulness and meditation. And this is really, I think for me, fascinating. And it goes beyond forest bathing, but certainly, there's an element there as well. And if you would, this is a way that you can actually hack your vagal nerve. And it's clear that increasing vagal nerve tone, which you can measure by increased heart rate variability, really plays a key role in immune health. I mentioned earlier that the brain and the immune system are hard-wired, and the vagal nerve is really part of that. Stimulating the vagal nerve increases anti-inflammatory cytokines. And in fact, there are animal models of inflammatory arthritis and inflammatory bowel disease. And if you stimulate the vagal nerve, you can decrease the amount of inflammation in the gut and in the joints. And conversely, if you do a vagotomy, sever the vagal nerve, you see increased disease activity.

So there are lots of apps that are out there. I often recommend several to my patients. I'll show them on my phone, they'll take a picture of them. And so I think that mindfulness meditation, definitely is really key here and really essential.

Look for part 2 of this conversation on how to incorporate wellness into the treatment regimen for patients with rheumatic diseases.