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Date: Wednesday, July 5, 2023
In this review: American College of Rheumatology Guideline for Exercise, Rehabilitation, Diet, and Additional Integrative Interventions for Rheumatoid Arthritis (Arthritis & Rheumatology)
The Message
In its first-ever set of guidelines for the use of interventions beyond antirheumatic drugs in the treatment of rheumatoid arthritis, the American College of Rheumatology strongly recommends consistent engagement in exercise and emphasizes the role of physical therapists and occupational therapists in what it believes should be a multidisciplinary treatment team.
Authors say that while more research is needed to identify which types of exercise and rehabilitation approaches are most effective, that only underscores the importance of knowledgeable therapists working with patients to identify the kinds of exercises and treatments that are best suited to the patient’s own needs and goals. Additional recommendations offer guidance related to diet, cognitive behavioral therapy, acupuncture, thermal modalities, and more.
The Study
Development of the guideline began with the establishment of a set of clinical population, intervention, comparator, and outcome questions, which were the basis for a systematic review of the research literature. That team gathered relevant research, evaluated the quality of evidence, and presented an initial report that was reviewed by additional guideline team members as well as a panel of 12 patients with RA. The patient panel added its perspectives and preferences to the review, which was presented to a voting panel. That panel had to reach agreement of 70% or more of panel members in order to arrive at a recommendation as well as establish a level of evidence to support the recommendation. Three members of the patient panel served on the voting panel.
The initial review identified nearly 9,000 potentially eligible manuscripts, which were winnowed to 275 that met criteria for use in guideline development.
APTA members Anita Bemis-Dougherty, PT, DPT, MAS; Thomas Bye, PT, DPT, MS; Chris Lane PT, DPT; Hiral Master, PT, MPT, PhD, MPH; Carol Oatis, PT, PhD; Daniel Pinto, PT, PhD; Kimberly Steinbarger, PT, MSPT, DHSc, MHS; Louise Thoma, PT, PhD; and Daniel White, PT, ScD, MSc, participated in the development of the guideline. Oatis, Thoma, and White were among the authors of an accompanying editorial.
Recommendations and Evidence Strength
The recommendations are presented in four broad areas: exercise, rehabilitation, diet, and “additional integrative intervention recommendations.” Recommendations are identified as either “strong” or “conditional” and include guidance both for and against various interventions. Only engagement in exercise was supported by moderate evidence strength, the single highest strength rating given in this resource. The remaining recommendations were supported by low- to very low-certainty evidence, or were not supported by evidence but were identified by the voting panel as important to include in the guideline.
Findings
The full guideline, the accompanying editorial, and appendices are available for free. Here’s a rundown of the recommendations with passages from the report.
Exercise Recommendations
Consistent Engagement in Exercise Over no Exercise
Evidence Certainty: Moderate
Recommendation Strength: Strong
“The exercise type, frequency, intensity, and duration were not formally defined because the evidence … did not support such precision … and there is considerable variation in patient values, preference, and access to different types of exercise. The specific elements of an exercise intervention should be tailored to each person.”
The panel also developed conditional recommendations in favor of aerobic, aquatic, resistance, and mind-body exercise (for example, Tai Chi or yoga) over no exercise, with the aerobic, resistance, and mind-body recommendations supported by low- to very low-certainty evidence. The aquatic exercise recommendation was supported by low-certainty evidence.
Rehabilitation Recommendations
Participation in Comprehensive Physical Therapy and/or Occupational Therapy
Evidence Certainty: Very low
Recommendation Strength: Conditional
“This recommendation applies throughout the RA disease course. Clinicians should discuss the opportunity to refer the patient to [occupational therapy] and/or [physical therapy] early in the RA disease course, with the recognition that [these] interventions can be tailored to unique patient needs.”
Additional Rehabilitation-Related Recommendations
The guideline includes several more-specific types of rehab and related equipment use. These recommendations include:
Hand therapy over no hand therapy for patients with hand involvement (conditional; low certainty).
Splinting, orthoses, and/or compression over non-use of these approaches for patients with hand/wrist involvement and/or deformity (conditional; very low certainty).
Bracing, orthoses, and/or taping over non-use of these approaches for patients with foot/ankle involvement (conditional; very low certainty).
Bracing and/orthoses over no bracing/orthoses for patients with knee involvement (conditional, no evidence).
Joint protection techniques over no joint protection techniques (conditional; low certainty).
Activity pacing, energy conservation, activity modification, and/or fatigue management over their absence (conditional; no evidence but found to be “generally safe and may help preserve physical function”).
Use of assistive devices, adaptive equipment, and environmental adaptations over non-use (conditional; no evidence).
Vocational rehab and work site evaluations and modifications (conditional; no evidence).
Diet Recommendations
Based on low- to moderate-certainty evidence, the panel conditionally recommends a Mediterranean-style diet but acknowledges that “patient preferences, and costs of, access to, and burden associated with this diet” may make it hard to maintain. Other recommendations in the diet category:
A conditional recommendation against “adherence to a formally defined diet other than Mediterranean-style,” based on very low to moderate certainty of evidence.
A conditional recommendation in favor of following established dietary recommendations without use of dietary supplements, based on very low- to moderate-certainty evidence.
The panel didn’t issue recommendation on weight but voiced “unanimous support of clinicians engaging in discussion about maintaining healthy body weight.”
Additional Recommendations
In addition to the exercise, rehab, and diet recommendations, the guidance also includes recommendations for and against other interventions. These include:
For the use of standardized self-management programs (conditional; low certainty).
For cognitive behavioral therapy and/or mind-body approaches (conditional; very low to low certainty).
For acupuncture (conditional; low certainty).
For massage therapy (conditional; very low certainty).
For thermal modalities (conditional; very low certainty).
Against the use of electrotherapy (conditional; low certainty).
Against use of chiropractic therapy (conditional; no evidence).
‘An Important Step in Actualizing the Role of Physical Therapy’
In an editorial that accompanied the publication of the guidelines, panel member authors characterize the guideline as “a critical step toward meaningful progress in integrating physical therapy into routine care for RA.”
Editorial authors acknowledge that when it comes to the physical therapy-related recommendations, all but the general exercise recommendations were framed as conditional, but they point to the range of intervention approaches included in the review as the primary cause. Viewed in that context, they argue, the additional recommendations underscore the need for an informed, patient-centered approach.
“To integrate this new guideline into physical therapy practice, it is essential to appreciate the implications of the conditional recommendations,” they write. “In this care, the choice to use or not use a treatment is preference-sensitive, meaning current evidence suggests no superior option and the choice depends on what matters most to the patient. The final decision should be made jointly between the patient and the provider.”
While the editorial describes the guideline as an “important step in actualizing physical therapy,” authors also map out several barriers to full implementation. These include gaps in knowledge about the importance of exercise among rheumatology providers, low levels of awareness of the role of physical therapy among persons with RA, varying levels of expertise with RA among physical therapists, barriers in current payment policies, and a lack of sufficient research. Each of these barriers, once recognized, can be addressed so that the recommendations can be employed “to advance the role of physical therapy toward meeting the health needs of adults with RA,” they write.
Reference: American Physical Therapy Association 2023 (https://www.apta.org/article/2023/07/05/ra-exercise-guidelines)
