2022 American College of Rheumatology Guideline for Exercise, Rehabilitation, Diet, and Additional Integrative Interventions for Rheumatoid Arthritis

Efficacy and safety of electrical stimulation for functional impairment and pain in patients with rheumatoid arthritis: a protocol for systematic review and network meta-analysis of RCTs

OBJECTIVE

Several studies have indicated that transcutaneous electrical nerve stimulation, functional electrical stimulation, neuromuscular electrical stimulation and electroacupuncture exhibit certain therapeutic effects in the treatment of rheumatoid arthritis (RA). However, definitive proof of the effectiveness of different types of electrical stimulation in relieving the different symptomatic manifestations of RA is required. This study aims to analyse the efficacy (health assessment questionnaire, visual analogue scale, etc), safety (adverse reactions) of electrical stimulation for functional impairment (morning stiffness and decreased muscle strength) and pain (joint tenderness and swelling) of RA, and to explore their comparative advantages and potential benefits for patients.

METHODS

We will conduct a systematic and comprehensive search of eight databases, and the search will proceed from the beginning to 5 September 2024. Two reviewers will independently screen the retrieved literature to determine the final included studies. Two reviewers will independently assess the risk of bias for all included eligible studies using the Cochrane Risk of Bias tool (V.2.0). Data synthesis will be performed using a random-effects model for network meta-analysis to compare the efficacy and safety of different electrical stimulations. The surface under the cumulative ranking curve will be used to demonstrate the probability of the benefits and harms of interventions. Funnel plots will be used to detect potential publication bias and small sample study effects. The strength of the evidence will be assessed through the Grading of Recommendations, Assessment, Development and Evaluation framework.

ETHICS AND DISSEMINATION

Our study data comes from public databases, and the entire study does not directly involve patients and the public, so ethical approval is not required. The final study results will be peer-reviewed and published in a journal.

PROSPERO REGISTRATION NUMBER

CRD42024586835.

Clinical knowledge, experiences, and perceptions of yoga providers in arthritis treatment: a UK-based qualitative study

This study explored yoga providers' clinical knowledge of arthritis, experiences of delivering yoga to people with arthritis, their perceived role in arthritis treatment, and perceived yoga training needs. Qualitative semi-structured interviews with 20 United Kingdom (UK)-based yoga providers were conducted. The interviews were digitally recorded, transcribed verbatim, and analysed thematically. The analysis generated eight themes. Yoga providers were generally aware of their attendees' health conditions and had clinical knowledge of arthritis through their yoga training. They were reasonably confident in delivering yoga to attendees with arthritis and felt that they had an important role in supporting these attendees. Gentle yoga practices were considered appropriate by the yoga providers, with a perception that a potential interplay between major components of yoga including yogic poses (asana), breathing practices (pranayama), and meditation (dhyana) and relaxation practices could help impart mind-body benefits in arthritis. Creating a safe and supportive environment in yoga sessions, being empathetic towards attendees' needs, and offering tailored modifications were perceived to be important for delivering yoga in arthritis treatment. Major system-level challenges to yoga delivery in arthritis treatment included the inadequate promotion of yoga, the unregulated nature of yoga delivery, and the absence of evidence-based arthritis-specific yoga training. Yoga providers felt they could play a key role in arthritis treatment in the UK, provided yoga is adequately promoted and made accessible to people with arthritis, yoga delivery is regulated, and arthritis-specific yoga training using the best available scientific evidence is made accessible to them.

Real-World-Evidence of Digital Health Applications (DiGAs) in Rheumatology: Insights from the DiGAReal Registry

INTRODUCTION

Prescribable digital health applications (DiGAs) present scalable solutions to improve patient self-management in rheumatology, however real-world evidence is scarce. Therefore, we aimed to assess the effectiveness, usage, and usability of DiGAs prescribed by rheumatologists, as well as patient satisfaction.

METHODS

The DiGAReal registry includes adult patients with rheumatic conditions who received a DiGA prescription. Data at baseline (T0) and the 3-month follow-up (T1) were collected through electronic questionnaires. Study outcomes included DiGA-specific outcome assessments as well as generic outcome assessments, including the Patient Global Impression of Change (PGIC), Patient Activation Measure (PAM®), and the German Telehealth Usability and Utility Short Questionnaire (TUUSQ). Changes between T0 and T1 were analyzed using descriptive statistics and paired tests.

RESULTS

A total of 191 patients were included between June 2022 and April 2023. Of these, 127 completed the 3-month follow-up, and 114 reported using the prescribed DiGA, with 66% reporting weekly use and 15% completing the full DiGA program. The most commonly prescribed DiGAs targeted pain management (53%). Symptom improvement was reported by 51% of patients using a DiGA, with significant reductions in exhaustion levels (p = 0.03). Significant DiGA-specific improvements were observed for DiGAs addressing back pain (p = 0.05) and insomnia (p = 0.006). However, no overall significant changes were detected in patient activation, health literacy, pain, overall health, or disease activity. Back pain and weight management DiGAs were the most effective, frequently used, and best-rated DiGAs, with symptom improvements reported by 50% to 82% of patients.

CONCLUSION

The findings suggest that DiGAs can improve symptom management in rheumatic patients, especially for conditions like back pain and weight control. Further real-world evidence is needed and may support value-based digital health efforts and reimbursement frameworks.

Non-Pharmacological Pain Management of Rheumatoid Arthritis

PURPOSE OF REVIEW

Many individuals with rheumatoid arthritis (RA) continue to suffer from pain despite treatment with disease-modifying antirheumatic drugs. In this review, we aim to summarize the evidence for non-pharmacological approaches for managing pain in RA.

RECENT FINDINGS

Few studies have examined the effect of non-pharmacological therapies on pain in patients with RA. Of these studies, many were not designed to specifically target pain and examined pain as a secondary outcome. While most studies reported within group improvements in pain, the magnitude of improvement varied, and differences between intervention and control groups often were not statistically significant. We recommend non-pharmacologic approaches for management of RA, based primarily on data for improving pain-related outcomes (e.g., physical function, overall health), as opposed to pain itself. The evidence base for non-pharmacologic interventions for pain remains poor, and there is a critical need for large RCTs designed to specifically target pain.

Work in the picture? The reporting of and effects on work outcomes in exercise therapy trials in people with rheumatoid arthritis or axial spondyloarthritis: a systematic review

OBJECTIVE

Many people with rheumatoid arthritis (RA) or axial spondyloarthritis (axSpA) face limitations in societal participation, including work. Supervised exercise therapy improves symptoms and physical functioning, but its impact on work outcomes is unclear. This systematic review aims to examine the reporting of and effects on work outcomes in exercise therapy trials.

METHOD

Eight databases were searched up to February 2024 for randomized controlled trials (RCTs) evaluating the (cost-)effectiveness of supervised exercise therapy interventions in adults with RA/axSpA. The reporting of work and other social participation outcomes, the content of the exercise therapy intervention, and their effects on work outcomes were extracted. Within- and between-group results on work outcomes were summarized.

RESULTS

In total, 41 (22 RA, 19 axSpA) RCTs on supervised exercise therapy were included, none of which was specifically targeted at work. Two RCTs in people with RA included work outcomes (absenteeism and employment hours). None of the RCTs in axSpA reported work outcomes. A work-related item or subscale was reported in 6/22 of the RA and 7/19 of the axSpA trials. Outcomes on societal participation (including work) were reported in 13/22 of the RA and 18/19 of the axSpA trials. Effects on work were reported on different outcomes and results were inconclusive.

CONCLUSION

Work outcomes are rarely reported in exercise therapy trials in people with RA/axSpA. To determine the effects of supervised exercise therapy on work, future studies should include work outcomes. International consensus on which outcome to use could increase the comparability of results.

Long COVID for the Rheumatologist: Current Understanding and Approach to Management

There are estimated tens of millions of individuals throughout the world suffering from a variety of postinfectious sequela following infection with severe acute respiratory syndrome coronavirus 2 also commonly referred to as long coronavirus disease (COVID). Long COVID is providing an opportunity for the field of rheumatology to explore the relationship between similar syndromes including fibromyalgia seen in patients with underlying inflammatory and noninflammatory rheumatic diseases, as well as other postacute infectious sequela and bring our field's traditional skill sets to bear on improving our understanding of these disorders and the care of such patients.

Therapy for the Rheumatoid Hand

Rheumatoid arthritis (RA) of the hand results in the progressive, inflammatory destruction of multiple tissue types resulting in significant functional deficit. Occupational therapy for the hand often plays a synergistic role in the improvement of health-related quality of life outcomes when employed alongside biological, disease-modifying antirheumatic drugs, and surgical regimens. Furthermore, postoperative therapeutic rehabilitation protocols in patients with RA have been shown to optimize surgical outcomes. While significant clinical data exist to support the role of occupational therapy in RA, further investigation is warranted to compare treatment protocols to further improve functional outcomes for the rheumatoid hand.

Advances in the Medical Treatment of Rheumatoid Arthritis

Rheumatoid arthritis is a common, chronic autoimmune disease. Its clinical presentation includes both articular and extra-articular manifestations. The past few decades have seen significant developments in our understanding of RA pathogenesis, leading to the development of effective novel targeted treatment options. This article reviews the clinical presentation, pathogenesis, and treatment of RA, along with specific treatment considerations related to reproductive health, vaccination, and the perioperative period.

Self-Perceptions of Aging and Physical Activity in Older Adults with Arthritis: Impact of General Health

How negative self-perceptions of aging relate to physical activity (PA) in older adults with arthritis is unclear. We examined whether general health mediated the relationship between Awareness of Age-Related change (AARC) losses and PA. We analyzed baseline data from a randomized controlled trial of a PA intervention for adults ≥60 years who self-reported PA, AARC, general health, pain, and social support. We evaluated point-biserial correlations between PA and other factors in participants with self-reported arthritis and developed a mediation model incorporating AARC losses, general health, and PA. We observed significant correlations between PA and general health, social support, and AARC losses in this physically active sample. General health mediated the effect of AARC losses on PA. While negative self-perceptions of aging were associated with less PA in older adults with arthritis, their impact was attenuated by general health. PA interventions for this population may benefit by targeting perceived general health.

Obesity and Chronic Inflammation: Implications for Rheumatoid Arthritis, Spondyloarthritis, and Ulcerative Colitis

BACKGROUND

Immune-mediated inflammatory diseases (IMIDs) are a group of chronic conditions characterized by dysregulated immune responses and persistent inflammation. Rheumatoid arthritis (RA), spondyloarthritis (SpA), and ulcerative colitis (UC) exemplify prominent IMIDs, each presenting unique challenges for their management, that impact patient's quality of life (QoL). Obesity, marked by persistent low-grade inflammation, influences the progression, response to treatment, and clinical management of patients with RA, SpA, and UC. Besides, the emerging role of sarcopenic obesity, a special subtype of obesity with malnutrition, should be considered in the definition of the appropriated therapeutic interventions.

METHODS

This narrative literature review summarizes recent evidence on the interplay between obesity-induced inflammation and IMIDs.

RESULTS

Obesity contributes to elevated levels of proinflammatory cytokines, influencing the inflammatory pathways common to IMIDs. White adipose tissue, acting as an endocrine organ, produces cytokines like TNF-α and IL-6, fueling chronic inflammation. The dysregulation of adipokines, such as leptin and adiponectin, further complicates this interplay, impacting immune responses and metabolic processes.

CONCLUSIONS

Understanding the cross-talk between inflammatory pathways in obesity and IMIDs can provide insight into potential targets for intervention. This includes lifestyle modifications aimed to regulate weight gain, paving the way for comprehensive strategies to manage IMIDs in the context of obesity.

The relationship between low-carbohydrate diet score, dietary macronutrient intake, and rheumatoid arthritis: results from NHANES 2011-2016

BACKGROUND

This study sought to determine if dietary macronutrient consumption and the low-carbohydrate diet (LCD) score were linked to rheumatoid arthritis (RA).

METHODS

Participants ≥ 20 years were analyzed from the National Health and Nutrition Examination Survey (NHANES) 2011-2016. LCD score was calculated by summing the 11 quantiles values of the percentages of energy derived from carbohydrate, protein, and fat. Weighted logistic regression, eXtreme Gradient Boosting (XGBoost), and Light Gradient Boosting Machine (LightGBM) models were used to explore the relationship between LCD score, dietary macronutrient intake, and RA. Propensity score matching (PSM) were applied for sensitivity analysis.

RESULTS

Ultimately, 8118 participants (RA: 499, without RA: 7619) were analyzed. After fully adjusting for confounders, a negative association was found between the LCD score and the presence of RA [OR (95% CI), 0.97 (0.96, 0.99)]. A higher LCD score was also negatively associated with a lower likelihood of RA based on a categorical model. Among macronutrients, participants in the third and fourth quartiles had significantly increased odds of RA compared with the lowest carbohydrate intake. Regarding protein intake, individuals in the highest quartile of percentage of energy from protein had a 46% lower presence of RA compared with the lowest reference group. The relative importance of the LCD score on RA was determined based on XGBoost and LightGBM models. Moreover, the association between the LCD score, dietary macronutrient intake, and RA presence remained substantial after PSM.

CONCLUSIONS

LCD score was negatively associated with odds of RA in US adults. Moreover, a correlation was found between a lower likelihood of RA and high protein, and low carbohydrate consumption. Key Points • A significant negative association was found between LCD score and RA presence. • Machine learning models revealed the LCD score was a significant predictor of the presence of RA. • Low carbohydrate intake and high protein intake were correlated with a lower odds of RA.

Improved vascular health linked to increased physical activity levels and reduced sedentary behavior in rheumatoid arthritis

Rheumatoid arthritis (RA) is characterized by deteriorated vascular health and increased cardiovascular risk. Physical activity (PA) is recommended for cardiovascular management in RA, but evidence on the associations between objectively measured PA and vascular health markers in RA is limited. In this cross-sectional study, 82 postmenopausal women with RA (62 ± 7 yr) undertook ultrasound assessments of vascular function and structure, including brachial and superficial femoral artery (BA and SFA) flow-mediated dilation; baseline and post-hyperemia peak diameters; and carotid intima-media thickness. Participants also performed a 7-day accelerometer-based assessment of PA and sedentary behavior (SB). Fitted regression models controlled for age, body mass index, and disease activity were conducted to examine associations between vascular and PA outcomes. Regression analyses revealed that prolonged SB (bouts >60 min) and total sedentary time were inversely associated with both baseline and peak BA diameters, with each additional hour of SB resulting in decreases of 0.08-0.1 mm in these diameters (P ≤ 0.01). Total sedentary time also showed similar negative associations with peak SFA diameters (β = -0.14 [-0.24 to -0.05], P < 0.01). Conversely, light-intensity PA and stepping time were positively associated with both baseline and peak BA diameters, with each additional hour increasing these diameters by 0.10-0.24 mm (P ≤ 0.02). Finally, standing time was positively associated with SFA peak diameter (β = 0.11 [0.01-0.20], P = 0.02). No associations were found between moderate-to-vigorous PA and vascular outcomes. In conclusion, in patients with RA, SB was negatively, whereas light PA was positively, associated with BA and SFA diameters. These findings suggest that reducing SB and increasing PA, even at light intensities, may improve vascular health in RA.NEW & NOTEWORTHY This was the first study to investigate associations between objectively measured physical activity and markers of vascular health in rheumatoid arthritis (RA). The findings suggest that reducing sedentary behavior and increasing light or total physical activity are associated with improved vascular outcomes in RA. These results support further investigation into interventions aimed at reducing sedentary time and replacing with any type of physical activity as a potential strategy for improving cardiovascular outcomes in individuals with RA.

Rheumatoid arthritis treatment: Is exercise a game changer?

It is known that physical activity and exercise have many effects on patients with rheumatoid arthritis, such as reducing pain, stiffness, and fatigue and having positive effects on the development of complications related to the disease. However, despite all this information, the level of exercise and physical activity in patients with rheumatoid arthritis is lower than in healthy individuals. This may be due to reasons such as thinking that the disease will worsen, not having enough information about exercises, and not being supported enough by healthcare professionals and family in this regard. This review summarized the basic effects of exercises and recommended exercise programs.

"I Prefer High-Intensity Exercise"-A Qualitative Study of Men's Experiences with a Nature-Based Exercise Program for People with Arthritis

Arthritis significantly reduces health-related quality of life, causing pain, fatigue, and decreased physical activity. To address this, exercise is highly recommended. However, men are less likely to participate in rehabilitation compared to women. We detected the same tendency in a nationwide nature-based exercise program in Denmark, with only 8% male participants. Therefore, this qualitative study investigated what engaged and restrained men with arthritis from participating in a nature-based exercise program. We employed interviews as the primary method for data collection. Data were analyzed using Braun and Clarke's thematic analysis, revealing key patterns in participants' experiences. This study finds that the fourteen participants' experiences revealed two themes: (1) meeting with the nature-based exercise program was confusing, motivating, and disappointing, and (2) the social aspect is less important. To better engage men, future programs should include a clear description of the concept of the exercise, high-intensity exercise, a reduced emphasis on social activities, and consistency in the instructors' roles and guidance. Incorporating these findings can better address the needs and preferences of men, helping them feel more like individuals than patients.

Knowledge, attitudes, and practices of dietary management among patients with rheumatoid arthritis in China

Background

This study aims to assess the knowledge, attitudes, and practices (KAP) regarding dietary management among patients with rheumatoid arthritis (RA).

Methods

A cross-sectional survey was conducted at JiuJiang NO.1 People's Hospital from November 2023 to May 2024. Data were gathered using structured questionnaires that solicited demographic information and measured KAP scores related to dietary management in RA patients.

Results

The survey yielded 504 valid questionnaires. Of the respondents, 306 (60.71%) had a Body Mass Index (BMI) within the optimal range of 18.5-23.9 kg/m2. The mean scores for knowledge, attitude, and practice were 10.13 ± 3.58 (possible range: 0-22), 31.38 ± 2.38 (possible range: 9-45), and 4.46 ± 2.30 (possible range: 0-12), respectively. Correlation analysis revealed significant relationships between knowledge and practice (r = 0.294, p < 0.001) as well as between attitude and practice (r = 0.178, p < 0.001). Multivariate logistic regression showed that knowledge score (OR = 1.165, 95% CI: [1.078, 1.259], p < 0.001) was independently associated with proactive practice. The structural equation model (SEM) results showed that knowledge had direct effects on attitude (β = 0.291, p < 0.001) and practice (β = 0.188, p < 0.001). Meanwhile, attitude had a direct impact on practice (β = 0.081, p = 0.045).

Conclusion

This study indicates that patients with RA generally demonstrate inadequate knowledge but hold positive attitudes toward dietary management, despite relatively inactive practices in implementing such dietary changes. Healthcare providers should prioritize educational interventions that not only enhance patient understanding but also actively support the implementation of dietary management strategies in clinical settings.

Gut Dysbiosis and Dietary Interventions in Rheumatoid Arthritis-A Narrative Review

Rheumatoid arthritis (RA) is a chronic and progressive autoimmune disease. The pathogenesis of RA is complex and involves interactions between articular cells, such as fibroblast-like synoviocytes, and immune cells. These cells secrete pro-inflammatory cytokines, chemokines, metalloproteinases and other molecules that together participate in joint degradation. The current evidence suggests the important immunoregulatory role of the gut microbiome, which can affect susceptibility to diseases and infections. An altered microbiome, a phenomenon known as gut dysbiosis, is associated with the development of inflammatory diseases. Importantly, the profile of the gut microbiome depends on dietary habits. Therefore, dietary elements and interventions can indirectly impact the progression of diseases. This review summarises the evidence on the involvement of gut dysbiosis and diet in the pathogenesis of RA.

Attitudes, practices and perceived barriers toward implementing non-pharmacological management for rheumatoid arthritis among rheumatologists: an online cross-sectional survey

Introduction

Our study aimed to evaluate the integration level of non-pharmacological management (NPM) for rheumatoid arthritis (RA), analyze attitudes, practices, and perceived barriers towards NPM implementation, and identify factors contributing to the underutilization of non-pharmacological treatment in RA.

Material and methods

A descriptive and analytical cross-sectional study was conducted among rheumatologists in Morocco. Rheumatologists received an online questionnaire gathering sociodemographic data, NPM integration level for RA, exploring their attitudes, practices and perceived barriers regarding the integration of NPM for RA, using a Likert scale ranging from 1 to 5. Univariate analyses were conducted to identify risk factors for under-integration of NPM for RA.

Results

Out of 440 questionnaires sent, 132 rheumatologists responded to the survey (mean age of 44 ±12 years, 112 (84.8%) females, median professional experience of 15 years [4.7; 26.3]) with a response rate of 30%. All rheumatologists agreed on the importance of NPM integration into their practice with 130 (98.5%) supporting the necessity of tailored recommendations of NPM of RA for the Moroccan context. Sixty-nine (52.3%) reported a lack of NPM integration for RA. Only 36 (27.3%) consistently provided personalized NPM from RA diagnosis and 47 (35.6%) involved patients in decision-making. Comment perceived barriers included difficulties in organizing multidisciplinary care (122; 92.4%), difficulties with time management in consultation (119; 90.2%), and lack of multidisciplinary team members (116; 87.9%). In univariate analysis, lack of suitable training and lack of knowledge on NPM of RA were risk factors of under-integration of NPM of RA with respectively an odds ratio (OR) of 0.09, 95% CI: 0.01-0.86 and OR of 0.34, 95% CI: 0.15-0.76.

Conclusions

Our study revealed significant insufficiencies in the integration of NPM of RA among Moroccan rheumatologists. Perceived barriers, including insufficient training, lack of knowledge, and infrastructural limitations, hinder effective implementation. Addressing these through tailored education and multidisciplinary collaboration is essential for improving RA management.

Holistic Care for People Living With Chronic Musculoskeletal Pain: The Relevance and Importance of Sexual Function

People living with chronic primary or secondary musculoskeletal pain conditions such as low back pain, fibromyalgia, and inflammatory arthritis typically experience wide-ranging impacts on their physical function, activity participation, and psychosocial wellbeing. These can extend to negative impacts on a person's sexual function and their intimate relationships. While sexual function is an important component of wellbeing, it is often not considered within musculoskeletal pain care. Without awareness or targeted training, physical therapists may lack the confidence and skills to screen, assess, and manage the impacts that pain may be having on a person's sexual function and can miss the opportunity to tailor their care and optimize wellbeing. This article seeks to raise awareness among physical therapists of how living with chronic musculoskeletal pain can impact a person's sexual function and intimate relationships, and provide guidance on how to consider these issues within a person-centered approach to care. It describes why considering sexual function and intimate relationship issues as part of a person's lived musculoskeletal pain experience may be relevant, outlines the use of validated patient-reported outcome measures to assess sexual dysfunction, and suggests practical strategies for sensitively raising sexual function in consultations. Management approaches and possible referral pathways are also presented, to assist physical therapists in understanding available care options. This article seeks to support holistic care by improving physical therapists' knowledge and understanding of sexual dysfunction and its management in people living with chronic musculoskeletal pain.

IMPACT

Considering sexual function as a valued functional activity, together with other activities of daily living, will assist physical therapists to provide more holistic and person-centered care. This article covers the main considerations for raising sexual function and intimate relationship issues with people living with chronic musculoskeletal pain, as well as management options and potential referral pathways. Physical therapists are encouraged to seek targeted training to improve their confidence and skills in this area, and to use inclusive, respectful language for discussions around sexual function and intimate relationships.

Anti-inflammatory and anti-rheumatic effects of Phoenix dactylifera L. (date palm) seed by controlling cytokines and inhibiting JAK1/STAT3 pathway on CFA-induced arthritis rat and its phytochemical profiling

ETHNOPHARMACOLOGICAL RELEVANCE

Phoenix dactylifera L. (date palm) seed is widely used in Arabian traditional medicine to alleviate several health problems including inflammatory conditions. The herbal tea of date palm seed has been consumed by rheumatoid patients to relief their symptoms.

AIM OF THE STUDY

The purpose of this study was to investigate the claimed beneficial use of P. dactylifera L. (Sewy variety) seed (PDS) in the treatment of rheumatoid arthritis (RA) and its mechanism of action as well as to study its phytoconstituents.

MATERIALS AND METHODS

The anti-inflammatory and anti-oxidative properties of the non-polar and the polar extracts of PDS were studied using Complete Freund's adjuvant (CFA)-induced arthritis rat model. Paw edema, body weight, total nitrate/nitrite NOX content and cytokine markers were evaluated to monitor the progress of arthritis. Also, histological examination and thermal analysis were conducted. The phytoconstituent profiles of non-polar and polar extracts of PDS were investigated using liquid chromatography-electrospray ionization-tandem mass spectrometry (LC-ESI-MS/MS). The multiple reactions monitoring mode (MRM) of liquid chromatography-electrospray ionization-tandem mass spectrometry (LC-ESI-MS/MS) was used to quantify phenolic phytoconstituents in both extracts.

RESULTS

According to the findings, the polar and non-polar PDS extracts kept body weight comparable to those of healthy individuals while considerably lowering paw swelling, edema, and neutrophil infiltration. It also reduced the levels of Nuclear Factor Kappa B (NF-κB), Tumor Necrosis Factor Alpha (TNF-α), Interleukin 22, Interleukin 23, Interferon (IFN), Interleukin 17, Interleukin 1β, Interleukin 6, Interleukin 36, Janus Kinase 1 (JAK1), and Signal Transducer and Activator of Transcription 3 (STAT3). They also reduced the degenerative alterations caused by RA. Thermal research gave additional support for these findings. 83 phytoconstituents were identified in the non-polar PDS extract and 86 phytoconstituents were identified in the polar PDS extract. 74 of the identified phytoconstituents were common in both extracts. 33 phytoconstituents were identified here from P. dactylifera for the first time as far as we know. In MRM-LC-ESI-MS/MS analysis, the major phenolics in both extracts were chlorogenic acid, naringenin, and vanillin. Catechin was only detected in the non-polar PDS extract. On the other hand, apigenin, kaempferol, and hesperetin were only detected in the polar PDS extract. Generally, the polar PDS extract showed higher concentrations of the identified phenolics than the non-polar extract.

CONCLUSIONS

The PDS extracts especially the non-polar extract showed significant anti-inflammatory and anti-oxidative properties in the CFA-induced arthritis rat model. PDS might be used to produce RA medicines.

Assessment of causal relationships between omega-3 and omega-6 polyunsaturated fatty acids in autoimmune rheumatic diseases: a brief research report from a Mendelian randomization study

Background

Currently, the association between the consumption of polyunsaturated fatty acids (PUFAs) and the susceptibility to autoimmune rheumatic diseases (ARDs) remains conflict and lacks substantial evidence in various clinical studies. To address this issue, we employed Mendelian randomization (MR) to establish causal links between six types of PUFAs and their connection to the risk of ARDs.

Methods

We retrieved summary-level data on six types of PUFAs, and five different types of ARDs from publicly accessible GWAS statistics. Causal relationships were determined using a two-sample MR analysis, with the IVW approach serving as the primary analysis method. To ensure the reliability of our research findings, we used four complementary approaches and conducted multivariable MR analysis (MVMR). Additionally, we investigated reverse causality through a reverse MR analysis.

Results

Our results indicate that a heightened genetic predisposition for elevated levels of EPA (ORIVW: 0.924, 95% CI: 0.666-1.283, P IVW = 0.025) was linked to a decreased susceptibility to psoriatic arthritis (PsA). Importantly, the genetically predicted higher levels of EPA remain significantly associated with an reduced risk of PsA, even after adjusting for multiple testing using the FDR method (P IVW-FDR-corrected = 0.033) and multivariable MR analysis (P MV-IVW < 0.05), indicating that EPA may be considered as the risk-protecting PUFAs for PsA. Additionally, high levels of LA showed a positive causal relationship with a higher risk of PsA (ORIVW: 1.248, 95% CI: 1.013-1.538, P IVW = 0.037). It is interesting to note, however, that the effects of these associations were weakened in our MVMR analyses, which incorporated adjustment for lipid profiles (P MV-IVW > 0.05) and multiple testing using the FDR method (P IVW-FDR-corrected = 0.062). Moreover, effects of total omega-3 PUFAs, DHA, EPA, and LA on PsA, were massively driven by SNP effects in the FADS gene region. Furthermore, no causal association was identified between the concentrations of other circulating PUFAs and the risk of other ARDs. Further analysis revealed no significant horizontal pleiotropy and heterogeneity or reverse causality.

Conclusion

Our comprehensive MR analysis indicated that EPA is a key omega-3 PUFA that may protect against PsA but not other ARDs. The FADS2 gene appears to play a central role in mediating the effects of omega-3 PUFAs on PsA risk. These findings suggest that EPA supplementation may be a promising strategy for preventing PsA onset. Further well-powered epidemiological studies and clinical trials are warranted to explore the potential mechanisms underlying the protective effects of EPA in PsA.

The Impact of Occupational Therapy on the Self-Management of Rheumatoid Arthritis: A Mixed Methods Systematic Review

OBJECTIVE

To determine the impact of occupational therapy (OT) on the self-management of function, pain, fatigue, and lived experience for people living with rheumatoid arthritis (RA).

METHODS

Five databases and gray literature were searched up to June 30, 2022. Three reviewers screened titles and abstracts, with two independently extracting and assessing full texts using the Cochrane risk of bias (quantitative) and Critical Appraisal Skills Programme (qualitative) tools to assess study quality. Studies were categorized into four intervention types. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) (quantitative) and GRADE- Confidence in Evidence from Reviews of Qualitative research (qualitative) were used to assess the quality of evidence for each intervention type.

RESULTS

Of 39 eligible papers, 29 were quantitative (n = 2,029), 4 qualitative (n = 50), and 6 mixed methods (n = 896). Good evidence supports patient education and behavior change programs for improving pain and function, particularly group sessions of joint protection education, but these do not translate to long-term improvements for RA (>24 months). Comprehensive OT had mixed evidence (limited to home OT and an arthritis gloves program), whereas limited evidence was available for qualitative insights, splints and assistive devices, and self-management for fatigue.

CONCLUSION

Although patient education is promising for self-managing RA, no strong evidence was found to support OT programs for self-managing fatigue or patient experience and long-term effectiveness. More research is required on lived experience, and the long-term efficacy of self-management approaches incorporating OT, particularly timing programs to meet the individual's conditional needs (i.e., early or established RA) to build on the few studies to date.

The effectiveness and safety of lifestyle medicine and integrative therapies in inflammatory arthritis: an umbrella review using a hierarchical evidence gathering approach

Objective

An umbrella review was conducted to provide a comprehensive evaluation of the evidence on lifestyle medicine and integrative therapies for inflammatory arthritis.

Methods

Five electronic databases were searched for umbrella reviews, meta-analyses, and systematic reviews of randomised controlled trials on acupuncture, diet, exercise, herbal medicine, nutrient supplements, and mind-body therapies for rheumatoid arthritis, spondyloarthritis, and gout published from January 2012 to December 2022. The primary outcomes were functional status and quality of life. Quality assessment was performed using the A MeaSurement Tool to Assess systematic Reviews (AMSTAR-2) tool, and the certainty of evidence for our primary outcomes was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach where possible.

Results

We included 52 reviews. Exercise was beneficial for functional status in both rheumatoid arthritis and spondyloarthritis, with moderate certainty of evidence. Chinese herbal medicine in combination with disease-modifying anti-rheumatic drugs may improve functional status in rheumatoid arthritis (very low certainty evidence). Acupuncture may improve functional status in rheumatoid arthritis and pain in both rheumatoid arthritis and gout; however, the evidence is of very low certainty. Evidence for other therapies was not clinically significant; however, it suggests possible benefits from quercetin and polyunsaturated fatty acids. Yoga may result in a moderate improvement in functional status when used as an adjunct to medication; however, the certainty of evidence is very low. Diet interventions offered inconsistent improvements to functional status in rheumatoid arthritis, spondyloarthritis, and gout with low to very low certainty.

Conclusion

Exercise should be prescribed for people with rheumatoid arthritis and spondyloarthritis. More research is needed to confirm or refute evidence for Chinese herbal medicine, acupuncture, yoga, and anti-inflammatory diets.

Effectiveness of longstanding exercise therapy compared with usual care for people with rheumatoid arthritis and severe functional limitations: a randomised controlled trial

OBJECTIVES

To compare the effectiveness of longstanding (>52 weeks), supervised exercise therapy with usual care in adults with rheumatoid arthritis (RA) and severe functional limitations.

METHODS

Participants were randomised 1:1 to the intervention (individualised goal-setting, active exercises, education and self-management regarding physical activity) or usual care. Primary endpoint was the change in the Patient-Specific Complaints activity ranked 1 (PSC1, 0-10) at 52 weeks. Secondary endpoints included the PSC activities ranked 2 and 3 (PSC2, PSC3), Health Assessment Questionnaire-Disability Index (HAQ-DI), Rheumatoid Arthritis Quality of Life Questionnaire (RAQoL), 6-minute walk test (6MWT), Patient Reported Outcome Measurement Information System Physical Function-10 (PROMIS PF-10) and the Short Form-36 Physical and Mental Component Summary Scales (SF-36 PCS and MCS). (Serious) Adverse events (AEs) were recorded. Measurements were done by blinded assessors. Analyses at 52 weeks were based on the intention-to-treat principle.

RESULTS

In total, 217 people (90% female, age 58.8 (SD 12.9) years) were randomised (n=104 intervention, n=98 usual care available for analyses). At 52 weeks, the improvement of the PSC1 was significantly larger in the intervention group (mean difference (95% CI) -1.7 (-2.4, -1.0)). Except for the SF-36 MCS, all secondary outcomes showed significantly greater improvements favouring the intervention (PSC2 -1.8 (-2.4, -1.1), PSC3 -1.7 (-2.4, -1.0), PROMIS PF-10 +3.09 (1.80, 4.38), HAQ-DI -0.17 (-0.29, -0.06), RAQoL -2.03 (-3.39, -0.69), SF-36 PCS +3.83 (1.49, 6.17) and 6MWT +56 (38, 75) m). One mild, transient AE occurred in the intervention group.

CONCLUSION

Longstanding, supervised exercise therapy was more effective than usual care in people with RA and severe functional limitations.

TRIAL REGISTRATION NUMBER

Netherlands Trial Register (NL8235), included in the International Clinical Trial Registry Platform (https://trialsearch.who.int/Trial2.aspx?TrialID=NL8235).

Effect of Remotely Supervised Weight Loss and Exercise Training Versus Lifestyle Counseling on Cardiovascular Risk and Clinical Outcomes in Older Adults With Rheumatoid Arthritis: A Randomized Controlled Trial

OBJECTIVE

To compare a remotely supervised weight loss and exercise intervention to lifestyle counseling for effects on cardiovascular disease risk, disease activity, and patient-reported outcomes in older patients with rheumatoid arthritis (RA) and overweight/obesity.

METHODS

Twenty older (60-80 years), previously sedentary participants with seropositive RA and overweight/obesity were randomized to 16 weeks of either Supervised Weight loss and Exercise Training (SWET) or Counseling Health As Treatment (CHAT). The SWET group completed aerobic training (150 minutes/week moderate-to-vigorous intensity), resistance training (two days/week), and a hypocaloric diet (7% weight loss goal). The CHAT control group completed two lifestyle counseling sessions followed by monthly check-ins. The primary outcome was a composite metabolic syndrome z-score (MSSc) derived from fasting glucose, triglycerides, high density lipoprotein-cholesterol, minimal waist circumference, and mean arterial pressure. Secondary outcomes included RA disease activity and patient-reported outcomes.

RESULTS

Both groups improved MSSc (absolute change -1.67 ± 0.64 in SWET; -1.34 ± 1.30 in CHAT; P < 0.01 for both groups) with no between-group difference. Compared with CHAT, SWET significantly improved body weight, fat mass, Disease Activity Score-28 C-reactive protein, and patient-reported physical health, physical function, mental health, and fatigue (P < 0.04 for all between-group comparisons). Based on canonical correlations for fat mass, cardiorespiratory fitness, and leg strength, component-specific effects were strongest for (1) weight loss improving MSSc, physical health, and mental health; (2) aerobic training improving physical function and fatigue; and (3) resistance training improving Disease Activity Score-28 C-reactive protein.

CONCLUSION

In older patients with RA and overweight/obesity, 16 weeks of remotely supervised weight loss, aerobic training, and resistance training improve cardiometabolic health, patient-reported outcomes, and disease activity. Less intensive lifestyle counseling similarly improves cardiovascular disease risk profiles, suggesting an important role for integrative interventions in the routine clinical care of this at-risk RA population.

Exercise therapy for improving cardiovascular health in rheumatoid arthritis

There is increased risk of cardiovascular disease in patients with rheumatoid arthritis. Primary cardiovascular disease prevention in rheumatoid arthritis patients is difficult, especially in those with high disease activity. According to current evidence, people with rheumatoid arthritis can significantly improve clinical indices and patient-reported outcomes by engaging in organized physical activity such as resistance training and aerobic activities. Additionally, participating in an exercise regimen can lower the risk of experiencing cardiovascular problems. Nevertheless, the percentage of patients with sedentary lifestyle habits is high among individuals with rheumatoid arthritis. Patient education regarding the benefits of physical activity/exercise is essential. The cardiovascular effects of exercise depend on several mechanisms such as (i) increased vascular function, (ii) decreased systemic inflammation, (iii) restoration of the autonomic system, (iv) improved lipid profile, and (v) increased muscular function. Maintaining the exercise routine is crucial for continuing benefits. A customized exercise plan helps to improve adherence and compliance. Engaging patients in shared decision-making is important since their personal choices can alter depending on several factors such as the severity of the disease, the cost, and accessibility. The current narrative review aimed to explore the recent evidence related to exercise therapy for cardiovascular health in patients with rheumatoid arthritis.

Quality of reporting and nature of harms in clinical trials on supervised exercise in patients with rheumatoid arthritis or axial spondyloarthritis

To describe the quality of reporting and the nature of reported harms in clinical studies on the effectiveness of supervised exercises in patients with rheumatoid arthritis (RA) or axial spondyloarthritis (axSpA). We performed a systematic review, searching eight databases up to February 2023. Randomized controlled trials (RCTs) evaluating supervised exercises in adults with RA or axSpA were considered eligible. Data on harms were extracted according to the CONSORT Harms 2022 Checklist. Among others, it was recorded if harms were prespecified or non-prespecified. Moreover, the nature of reported harms was listed. Forty RCTs were included for RA and 25 for axSpA, of which 29 (73%) and 13 (52%) reported information on harms. In 13 (33%) RCTs in RA and four (16%) in axSpA, the collection of harms outcomes was described in the methods section. Prespecified outcomes were reported by eight (RA) and two (axSpA) RCTs. Non-specified harms outcomes were reported by six (RA) and four (axSpA) RCTs. Prespecified harms outcomes included measures of pain, disease activity, inflammation, and structural joint changes. The nature of non-prespecified harms outcomes varied largely, with pain being most common. A considerable proportion of trials on supervised exercise in RA or axSpA does not or inadequately report harms outcomes. Pain was the most commonly reported prespecified or non-specified harm. For a considerate interpretation of the balance between benefits and harms of supervised exercise in RA or axSpA, use of the CONSORT Harms 2022 Checklist for the design, conduct and reporting of trials is advocated.

Building the Case for Telehealth Yoga for Minors With Arthritis and Chronic Pain: A Perspective

Childhood arthritis has a prevalence of around 300 000 US children. It has no cure, and is just one of many juvenile conditions associated with pain, fatigue, and a lifetime of medical care. Yoga has demonstrated effectiveness in improving symptoms and quality of life for adults with arthritis. Yoga can be easily adapted according to affected joints, movement limitations, and changes in disease status. It combines movement that is necessary for arthritis management and maintaining physical function, along with mental practices that help to address common psychosocial comorbidities such as depressive symptoms and affect. No research has been published on the effects of yoga in minors with arthritis and chronic pain. In-person yoga may not be feasible for this population because many patients live hours from their specialist healthcare. As telehealth becomes more acceptable, online yoga may offer an additional tool for symptom management and improved quality of life in juvenile chronic pain conditions. Clinical trials are necessary to evaluate the safety, feasibility, acceptability and effectiveness of teleyoga in the whole-person management of juvenile arthritis and chronic pain conditions.

Exercise Training for Chronic Pain: Available Evidence, Current Recommendations, and Potential Mechanisms

Chronic pain conditions pose a significant global burden of disability, with epidemiological data indicating a rising incidence. Exercise training is commonly recommended as a standalone or complementary approach for managing various chronic pain conditions like low back pain, osteoarthritis, rheumatoid arthritis, fibromyalgia syndrome, and neuropathic pain. Regardless of the specific condition or underlying cause (e.g., autoimmune disease, chronic inflammation), exercise training consistently leads to moderate to large reductions in pain. Moreover, exercise yields numerous benefits beyond pain alleviation, including small-to-moderate improvements in disability, quality of life, and physical function. Despite its efficacy, there is a lack of comprehensive research delineating the optimal intensity, duration, and type of exercise for maximal benefits; however, evidence suggests that sustained engagement in regular exercise or physical activity is necessary to achieve and maintain reductions in both clinical pain intensity ratings and the level that pain interferes with activities of daily living. Additionally, the precise mechanisms through which exercise mitigates pain remain poorly understood and likely vary based on the pathophysiological mechanisms underlying each condition.

Tolerability of low to moderate biomechanical stress during leisure sport activity in patients with psoriasis and psoriatic arthritis

OBJECTIVES

To assess the impact of low to moderate biomechanical stress on entheses in patients with psoriasis and psoriatic arthritis (PsA).

METHODS

We conducted a prospective interventional study on a cohort of psoriasis and PsA patients who underwent a 60 min badminton training session. Pain assessment by Visual Analogue Scale (VAS), physical examination of 29 entheses (SPARCC, LEI, MASES) and bilateral ultrasound at the lateral humeral epicondyle, inferior patellar pole and Achilles tendon were performed before and after training. Ultrasound changes were assessed using the OMERACT scoring system. A follow-up assessment of pain and adverse events was performed at 1 week.

RESULTS

Sixteen patients were included (n=7 PsA; n=9 psoriasis) and 196 entheseal ultrasound scans were acquired. At baseline, median VAS pain (IQR) was 0.5 cm (0-2.3) and the total number of tender entheses was 12/464. Mean (min; max) Disease Activity Index for Psoriatic Arthritis was 6.1 (0.8; 19) and 5/7 PsA patients had an Minimal Disease Activity status. After training, no significant change in VAS pain (0.0 cm (0.0-2.0)) nor in tender entheses (13/464) emerged. Four patients (n=2 PsA, n=2 psoriasis) developed a grade-1 power Doppler-signal at six entheses, which, however, remained non-tender. At 1 week, median VAS pain remained stable (0.0 cm (0.0-3.0); p>0.05) and only one participant with active PsA at baseline reported increased arthralgias in three joints.

CONCLUSIONS

Low to moderate physical strain, as in the context of leisure sport activity, seems well tolerated in psoriatic patients without increases in tenderness, pain and ultrasound-proven inflammation. Evidence-based recommendations for physical activity in PsA are direly needed and larger controlled studies should be conducted to define safe exercise thresholds.

Employment of patients with rheumatoid arthritis - a systematic review and meta-analysis

BACKGROUND

Patients with rheumatoid arthritis (RA) have difficulties maintaining employment due to the impact of the disease on their work ability. This review aims to investigate the employment rates at different stages of disease and to identify predictors of employment among individuals with RA.

METHODS

The study was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines focusing on studies reporting employment rate in adults with diagnosed RA. The literature review included cross-sectional and cohort studies published in the English language between January 1966 and January 2023 in the PubMed, Embase and Cochrane Library databases. Data encompassing employment rates, study demographics (age, gender, educational level), disease-related parameters (disease activity, disease duration, treatment), occupational factors, and comorbidities were extracted. Quality assessment was performed employing Newcastle-Ottawa Scale. Meta-analysis was conducted to ascertain predictors for employment with odds ratios and confidence intervals, and test for heterogeneity, using chi-square and I2-statistics were calculated. This review was registered with PROSPERO (CRD42020189057).

RESULTS

Ninety-one studies, comprising of a total of 101,831 participants, were included in the analyses. The mean age of participants was 51 years and 75.9% were women. Disease duration varied between less than one year to more than 18 years on average. Employment rates were 78.8% (weighted mean, range 45.4-100) at disease onset; 47.0% (range 18.5-100) at study entry, and 40.0% (range 4-88.2) at follow-up. Employment rates showed limited variations across continents and over time. Predictors for sustained employment included younger age, male gender, higher education, low disease activity, shorter disease duration, absence of medical treatment, and the absence of comorbidities. Notably, only some of the studies in this review met the requirements for high quality studies. Both older and newer studies had methodological deficiencies in the study design, analysis, and results reporting.

CONCLUSIONS

The findings in this review highlight the prevalence of low employment rates among patients with RA, which increases with prolonged disease duration and higher disease activity. A comprehensive approach combining clinical and social interventions is imperative, particularly in early stages of the disease, to facilitate sustained employment among this patient cohort.