Nonpharmacologic therapies for patients with rheumatoid arthritis

INTRODUCTION — A comprehensive management program for rheumatoid arthritis (RA) involves not only drug therapy but also nonpharmacologic interventions, which include patient education; psychosocial interventions; appropriate use of rest, physical activity, and exercise; physical and occupational therapy; and nutritional and dietary counseling.

Nonpharmacologic therapies for patients with RA, other than surgery, are presented here. An overview of the management of RA, including strategies for the prevention of adverse effects of disease and drugs, immunization practices, and discussions of surgical interventions are reviewed separately. (See "General principles and overview of management of rheumatoid arthritis in adults" and "Immunizations in autoimmune inflammatory rheumatic disease in adults" and "Evaluation and medical management of end-stage rheumatoid arthritis", section on 'Surgical management' and "Cervical subluxation in rheumatoid arthritis", section on 'Surgery' and "Surgical management of end-stage rheumatoid arthritis".)

FEATURES AND GOALS OF NONPHARMACOLOGIC THERAPY — Nonpharmacologic measures, provided through a multidisciplinary team approach, are important in the treatment of patients with rheumatoid arthritis (RA) [1]. Despite advances in pharmacologic therapy for RA, many patients continue to experience some measure of ongoing disease activity with the risk of developing resultant disability.

Measures aimed at identifying early active disease and controlling inflammation are essential but may be insufficient to optimize functional capacity and quality of life, and patients may continue to experience problems with physical function, as well as emotional and social function, that are not adequately addressed by providing drug therapy alone. (See "Disease outcome and functional capacity in rheumatoid arthritis".)

The major elements of such nonpharmacologic therapy include:

●Patient education

●Psychosocial interventions

●Physical activity and exercise

●Physical and occupational therapy

●Proper nutrition and diet

PATIENT EDUCATION AND PSYCHOSOCIAL INTERVENTIONS

Patient education and counseling — All patients with rheumatoid arthritis (RA) should receive education from their clinicians and supplemental sources. Consistent with the recommendations of the European Alliance of Associations for Rheumatology (EULAR; formerly known as European League Against Rheumatism) for patients with inflammatory arthritis, features of patient education for RA should include [2]:

●Patient education for all patients throughout their disease and integrated into their care. This is most critical at diagnosis, when there is any change in therapy, and when it is necessitated by the patient's physical or psychological status.

●Education should be individualized with respect to the content and mode of delivery, and it may involve both individual and group sessions and both direct interaction with a clinician and use of other technologies, such as online materials and interactions.

●Programs used to provide patient education and counseling should be evidence based. Multidisciplinary programs are helpful.

Education and counseling are important in the management of RA, a disorder in which therapy is continuous, using a mixture of modalities to maximize efficacy and reduce the risk of disability [3].

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 [4,5]. Informed and sympathetic discussions concerning alternative, controversial, and unproven therapies are also important elements of patient education. (See "Complementary and alternative therapies for rheumatic disorders".)

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 [6] 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 [7].

Patients should be encouraged to seek information and care from health care professionals other than their clinicians. Multidisciplinary pain and disease management programs, where available, can be beneficial [8]. As an example, formal patient education programs, mostly delivered by voluntary agencies such as the Arthritis Foundations (in the United States), may include:

●General information

●Teaching skills for management of chronic illness

●Strategies for preserving joint function

●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 shared decision-making model for disease management that involves the patient and their clinician is a feature of guidelines from major organizations [10,11]. 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 sizes 0.12, 95% CI 0-0.24, and 0.07, 95% CI 0-0.15) [12].

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 [13].

Psycho-behavioral interventions — Various psychosocial interventions can benefit patients with RA. A systematic review and meta-analysis of 13 trials, involving 1579 patients, has documented that psychosocial interventions can modestly reduce symptoms of fatigue [14]. 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 [15]. One trial has shown that an online cognitive-behavioral, self-management program with weekly telephone support can improve self-efficacy and quality of life [16]. Stress-reduction techniques and mindfulness interventions may also be beneficial.

PHYSICAL ACTIVITY

Physical activity and exercise — Physical activity, including aerobic and resistance exercise, should be part of the treatment program for patients with rheumatoid arthritis (RA) because it reduces disease activity, fatigue, and pain and improves psychological well-being, while risk of harm is very low [17-20]. Patients should receive guidance and encouragement regarding self-directed physical activity, in addition to and in coordination with formal programs and instruction with physical and occupational therapy. (See 'Physical therapy' below and 'Occupational therapy' below.)

A comprehensive set of recommendations for increased physical activity and exercise that is applicable to patients with RA and consistent with international guidelines for physical activity, as well as recommendations of the European Alliance of Associations for Rheumatology (EULAR) and the American College of Sports Medicine (ACSM) includes guidance regarding physical activity levels, aerobic and muscle-strengthening exercise, and individual modifications depending upon level of fitness, prior activity levels, and disease activity (table 1) [17-19]. To facilitate physical activity uptake and maintenance, patients should be provided with specific guidance and goals. A summary instruction sheet for patients with RA has also been developed by the ACSM Exercise is Medicine program [21].

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 and weaker muscles. However, physical activity and exercise reduce overall fatigue and pain and can improve sleep [14,22]. 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 [23].

Regular aerobic exercise (such as walking, swimming, cycling, and supervised cardiorespiratory aerobic conditioning) improves muscle and joint function, joint structure and stability, range of motion of joints, 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 [24-27]. 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 [14]. Preliminary evidence suggests aerobic weightbearing exercise may help prevent glucocorticoid-associated osteoporosis in RA [28], a benefit that strength training alone probably does not produce [23]. Benefits of exercise and exercise programs are further described in analyses of trials of aerobic exercise and strengthening programs. (See 'Physical therapy' below.)

High-intensity weightbearing exercises and repetitive, high-impact activities may not be appropriate for patients with preexisting structural damage of lower extremity joints [29]. Less intense or non-weightbearing exercises are alternatives for such patients. (See 'Physical therapy' below.)

Rest — General rest as a strategy to decrease fatigue or other symptoms is no longer considered appropriate. RA patients tend to be sedentary, so recommendations for rest are likely to exacerbate sedentary time with its attendant negative outcomes.

Resting an inflamed joint may be beneficial. Resting a particular joint by splinting can help reduce joint pain and function and prevent deformities. (See 'Patient education and counseling' above and 'Physical activity and exercise' above.)

PHYSICAL AND OCCUPATIONAL THERAPY

Physical therapy — The goals of physical therapy are pain relief, reduction of inflammation, and preservation of joint integrity, strength, and physical function. Patients should be evaluated and receive education and instruction by an expert in physical therapy to optimize strength and joint function without worsening pain and inflammation. The general approach depends upon the severity of inflammation that is present:

●Arthritis under good control – Patients with good control of their arthritis can participate in variable-resistance exercise programs or progressive high-intensity strength training, which can improve strength, fatigue, and pain. Graded aerobic training is also of benefit.

●Moderate levels of joint inflammation – Patients with moderate disease activity should be instructed in isometric exercises in which muscles are contracted in a fixed position. Such exercise can help to maintain a functional level of muscle strength without worsening joint inflammation and pain.

●Severe and acute joint inflammation – Patients with markedly inflamed joints may initially require resting splints, rather than resistance or aerobic exercise, for joint immobilization until antiinflammatory agents and disease-modifying antirheumatic drugs (DMARDs) effectively control disease activity. However, passive full range of motion exercises for all joints should be performed daily to prevent flexion contractures, even in patients with marked inflammation.

Evidence from various types of trials supports the benefits of aerobic exercise and strengthening programs, including a 2009 systematic review of eight clinical trials that suggested that aerobic capacity training combined with muscle strength training is beneficial and can be used as routine practice in patients with rheumatoid arthritis (RA) [30]. As an example of the available data, a study involving 24 individuals (8 with RA) found that a 12-week supervised high-intensity progressive resistance training program was effective and safe in improving strength (by 75 percent in major exercised muscle groups) in patients with RA, with similar benefits to those seen in healthy younger and older adults [31]; RA patients experienced improvements in pain and fatigue without worsening of disease activity or joint pain. Similarly, another study documented the value of a 12-week graded aerobic exercise training program, done 3 times weekly, in women with RA; the participants demonstrated improved aerobic capacity, exercise time, and joint counts, together with subjective reports of improvement in activities of daily living and reduced joint pain and fatigue [32]. Additional evidence regarding the benefits of aerobic, strengthening, and other exercise is described in this review separately. (See 'Physical activity and exercise' above.)

In addition to passive and active exercises to improve and maintain range of motion of joints, and dynamic exercise to improve aerobic capacity and strength, physical therapy also utilizes specific modalities targeted to problem areas, including:

●The application of heat or cold to relieve pain or stiffness [33]. Heat can come from moist hot packs, electric mittens, a hot shower, spas, diathermy, paraffin.

●Ultrasound, which is used by some therapists to assuage tenosynovitis [34].

●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.

For patients with involvement of the feet, particular those with metatarsalgia, referral to a podiatrist for provision of semirigid orthoses and supportive footwear is also helpful [35].

Occupational therapy — Goals of occupational therapy are similar to those of physical therapy (see 'Physical therapy' above), but occupational therapists focus on upper extremity activities, especially of the hands. Most patients with RA should be referred for one or more sessions with an expert in occupational therapy to assist in the maintenance of joint function and proper anatomic alignment, together with preservation of the capacity to perform activities of daily living, as well as desired work and avocational pursuits.

Occupational therapy services to patients with RA often include:

●Education regarding joint protection and self-care

●Provision of assistive devices and splints

●Instruction in optimal use of assistive devices and splinting

Patients should be instructed in how to avoid the application of excessive force across non-weightbearing joints and to minimize impact-loading on weightbearing joints.

Occupational therapy can be provided in a hospital or outpatient clinic setting, and home therapy can also effectively provide meaningful functional improvement [36].

An individualized hand exercise program involving stretching and strengthening can also be beneficial in selected patients, even in patients on a stable regimen of DMARDs [37-39]. 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) [37].

A systematic review of occupational therapy interventions provided for patients with RA, published in 2002, found limited evidence of efficacy that comprehensive occupational therapy and/or patient education by a therapist had a beneficial effect on patient functional ability, while hand/wrist splinting did decrease pain [40]. 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 occupational therapy, compared with usual care alone (without occupational therapy) [41].

NUTRITION AND DIETARY THERAPY

●Anorexia and poor dietary intake – Active rheumatoid arthritis (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 [42,43].

●Obesity – Patients with obesity 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. Patients can also benefit from referral to a weight loss program.

Obesity predicts a poor treatment response, which can be improved with weight loss. In a study of 5428 patients with RA, patients with obesity were less likely to achieve remission when compared with patients with a normal body mass index (BMI), regardless of the therapy used (adjusted hazard ratio [HR] 0.77) [44]. In another study of RA patients with obesity on stable immunosuppression, subjects were randomized to receive a high protein, hypocaloric diet (1000 to 1500 kcal/day) versus education. The diet intervention group lost an average of 9.5 kg/patient, and also had modest improvement in several disease activity indices, including the Routine Assessment of Patient Index Data (RAPID) 3 (7 versus 10.5) and the Health Assessment Questionnaire (HAQ) Disability Index (0.6 versus 1) [45]. However, ultrasound measures did not differ between the two groups.

An overview of the management of obesity in adults is presented separately. (See "Obesity in adults: Overview of management".)

●Dietary interventions for inflammatory arthritis – 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 [46]. 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 disease-modifying antirheumatic drugs (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, HR 0.28, 95% CI 0.12-0.63) [47].

Patients should be encouraged to eat a healthy diet, such as the "Mediterranean diet," which is high in vegetables and fruits and associated with a reduced risk of cardiovascular disease in observational studies (see "Overview of primary prevention of cardiovascular disease"). Standard measures for the prevention of cardiovascular disease, including a healthy diet, are part of the strategy for reducing the increased risk of cardiovascular disease seen in patients with RA. (See "Coronary artery disease in rheumatoid arthritis: Implications for prevention and management", section on 'General prevention measures'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Rheumatoid arthritis".)

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 education: Rheumatoid arthritis (The Basics)" and "Patient education: Physical activity for people with arthritis (The Basics)" and "Patient education: Disease-modifying antirheumatic drugs (DMARDs) (The Basics)" and "Patient education: Oral steroid medicines (The Basics)" and "Patient education: Rheumatoid arthritis and pregnancy (The Basics)")

●Beyond the Basics topics (see "Patient education: Rheumatoid arthritis symptoms and diagnosis (Beyond the Basics)" and "Patient education: Rheumatoid arthritis treatment (Beyond the Basics)" and "Patient education: Disease-modifying antirheumatic drugs (DMARDs) in rheumatoid arthritis (Beyond the Basics)" and "Patient education: Arthritis and exercise (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Nonpharmacologic measures, provided through a multidisciplinary team approach, are important in the treatment of patients with rheumatoid arthritis (RA) to optimize functional capacity, including physical, emotional, and social function, and quality of life, which may not be adequately addressed by providing drug therapy alone. (See 'Features and goals of nonpharmacologic therapy' above.)

●Patients with RA should receive education from their clinicians and supplemental sources. This should include individualized education throughout the disease course, integrated into their care, and may involve both individual and group sessions and both direct interaction with a clinician and use of other technologies. (See 'Patient education and counseling' above.)

●Physical activity, including aerobic and resistance exercise, should be part of the treatment program for patients with RA because it reduces disease activity, fatigue, and pain, and improves psychological well-being, while risk of harm is very low. Exercise may include a combination of range of motion exercises, muscle strengthening, and aerobic exercise. (See 'Physical activity and exercise' above.)

●Patients should be evaluated and receive education and instruction by an expert in physical therapy to optimize strength and joint function without worsening pain and inflammation. The general approach depends upon the severity of inflammation that is present. The goals of physical therapy are pain relief, reduction of inflammation, and preservation of joint integrity and function. Goals of occupational therapy 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. Patients with obesity should be encouraged to lose weight, as even mild excess weight increases the stress upon joints involved with synovitis, potentially hastening joint destruction. Patients should be encouraged to eat a healthy diet, such as the "Mediterranean diet," which is high in vegetables and fruits and associated with a reduced risk of cardiovascular disease. (See 'Nutrition and dietary therapy' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Ravinder N Maini, BA, MB BChir, FRCP, FMedSci, FRS, who contributed to an earlier version of this topic review.