The highlights from day four of theAmerican College of Rheumatology(ACR)annual meetingincluded topics related to bone health,managingandtreatinglupus,newtreatmentguidelines for juvenile idiopathic arthritis (JIA) andevidence-based research for osteoarthritis.
Targeted Exercise Improves Bone and Joint Health
In two separate sessions, researchers Laura Bilek, PhD,physical therapist,associateprofessor forwomen’shealthresearch at the University of Nebraska Medical Center,andphysical therapistYvonne Golightly, PhD,department ofepidemiology at the ThurstonArthritisResearch Center at the University of North CarolinaSchool of Medicine,gavepresentationson therapeutic exercise for bone health andfor关节健康,分别。
Exercise for Bone Health:People with rheumatic diseases are likely to have decreased bone density and increased fracture risk.Bilek examined therole of evidence-based exercise interventions for improving bonehealthand decreasing fracture risk.Bilek said special attentionmust be paidto modifications.
For example, weight machines thatassist with proper form arerecommended over free weights for resistance training, which is a key component toimprovingbone health and reducing the risk of osteoporosis fracturesin the spine, but not the hipfor premenopausal women.The opposite is true forimpact exercises,which had a positive responseto thehipbut not the spine.这应该如何应用到病人身上?
“We need to do impact exercise as well as resistance training,” saidLauraBilek, PT, PhD.
这应该如何应用到病人身上?
Effective impact exercises includejumping rope, step classes, hikingand climbing stairs. Resistance training shouldfocus onallmajormuscle groupsand strength, not endurance,and can includefree weightsandweight machines.
The first set is the most important and will provide the greatest benefit, said Bilek. She recommends two setsof eight to 12 repsatthe maximum weighta patientcan handle,with a focus on good formand no twisting.If time or energyis limited, one set will provide more than a 50% benefit, so some is better than none.The same recommendations apply for postmenopausal women with low bone mass.
Forpatients with osteoporosiswhoare at greater risk for fracture, the goal is to focus on exercises forthe spineand to reducefall riskand loss of bone mass.
Whenarthritis is present,considermodifications.Resistance exercisesand impact exercises arerecommendedas long as good form can be maintained, butfree weights are not recommended for those at greatest risk of fracture,and impactexercisesthat require “landing hard,” such as jumping rope, should be eliminated.
Exercise for Joint Health:Considering the joint structure as well as patient experience are keys toeffective therapeutic exercise for improvingjoint health in rheumaticmusculoskeletaldiseases (RMDs), said Golightly.For example,“Whattheir joint symptomsarelike.Dothey havepain, stiffnessorswelling?And wealso need to learn how their joints function,”shesaid. “How wellcan they move their joints through the full range of motion? Are they able to perform their usual activities at home and at work?”
A mix oftherapeutic exercises — includingaerobic,strength training,neuromuscularandmind-body —may be usedas therapy. The benefits are extensive, including:
- Strengthening muscles, ligaments and tendons
- Increasingcirculation ofsynovial fluid(which lubricates joints),bloodandnourishing oxygen andnutrients
- Removal of cellular waste during a healthy balance ofcellbreak down and repair.“Sedentary behavior or big changes in intensity can cause an imbalance that alters joint health,” said Golightly.
- Gene activationfor the rebuilding of cartilage
Golightly was also keento dispelthe myth that exerciseaggravatesarticular cartilage loss inpatients with RMDs.Cartilagerespondsto physiologic loading similar to muscle and bone, she said. A four-month randomized controlledtrial of moderate exercise in a small group of patients with partialmedial meniscus resection(a key risk of knee osteoarthritis)showedjointsymptoms andfunction, as wellascartilagequalityin MRIs,improvedwith supervised aerobic and weight-bearing exercise one hour, three timesper week.The research is similar for RA.
The best types of exerciseare those that can be tailored to the patient, said Golightly, and health care providers must provide guidance.Exercise should provide the following: warm up (10to15 minutes) and cool down; strengthening three days per week; endurance 30 minutes each at least threetime per week;dailystretching, flexibility and range of motion; and other types such as neuromuscular and mind-body.Considerations for disease-specific exercisefocus shouldinclude:
- Osteoarthritis(OA)—full range of motion as comfort allows; strengtheningwith proper form and fewer reps, evenwith severe disease; low-impact activities; higher activity/intensity levels
- Inflammatory/rheumatoid arthritis(RA)withmorning stiffness—gentle stretching/flexibility exercise at night;reducedexercise, not ceasing,during acute flares;noresistance exerciseand stretchingof inflamed/affected joints
- Ankylosing spondylitis,forposture—neck, back, shoulder and hip range of motion;back and hip extensor muscles strengthening; breathing exercise to improvechest mobility
- Lupus —usepacing and short exercise sessions to address fatigue; monitor breathing during sessions
- Fibromyalgia —endurance and moderate strengthening; avoiding long, vigorous exercise that may worsen symptoms—BRYAN D. VARGO
New ACR Guidelines for JIA
New treatment guidelines have been developed for oligoarthritis, temporomandibular joint (TMJ) and systemic forms of juvenile idiopathic arthritis (JIA). These new recommendations, which are still in the draft phase, serve as complement to existing guidelines used to treat polyarticular, sacroiliitis, enthesitis and uveitis.
Recommendations were developed by reviewing the current literature about treatments and graded by quality of evidence, patient (and parent) preferences and risks versus benefits. If these new guidelines pass the review board, considerations for treatment will include:
- More modest therapy for initial treatment of oligoarthritis, including the use of Intra-articular glucocorticoids (IAGC) and/or a trial of nonsteroidal anti-inflammatory drugs (NSAIDs). If initial therapy doesn’t work, the use of non-biologic DMARDs (methotrexate) and/or biologics is strongly recommended.
- For TMJ, a painful condition affecting the jaw, an initial round of IAGC and NSAIDs is conditionally recommended. If initial therapy doesn‘t work, the use of DMARDs is strongly recommended versus biologics, which are conditionally recommended.
- In SJIA presenting without macrophage activation syndrome (MAS), NSAIDs and interleukin (IL) inhibitors are conditionally recommended for initial monotherapy treatment, whereas oral glucocorticoids and monotherapy using nonbiologic DMARDs, such as methotrexate, are strongly recommended against.
The new guidelines also offer suggestions for lab monitoring, immunizations and nonpharmacologic treatments. For children taking immunosuppressive drugs, non-live vaccines, such as the flu vaccine, are strongly recommended, whereas live vaccines, such as the MMR immunization are conditionally recommended against. Children not on immunosuppressive vaccines should receive all immunizations recommended by the Centers for Disease Control and Prevention.
Recommended nonpharmacological therapies include healthy diet (strongly recommended) and physical therapy (conditionally recommended), whereas supplements and special diets are strongly recommended against.
Researchers acknowledge that these recommendations are only guidelines, and care outcomes and treatment depend heavily on the individual child and shared-decision making between health care providers, patients and their parents. —ROBYN ABREE
The State ofLupusTreatment
The Food and Drug Administration (FDA) approved hydroxychloroquine in 1955, and it is still the standard treatment for systemic lupus erythematosus (SLE). Scientists have learned a greatdealabout lupus in thepast decade, though,whichhas led to many new therapeutic targets and potential treatments. Anifrolumab, a fully human monoclonal antibody that blocks the interferon pathway,may beavailablenext year, according to Mary Crow, MD,威尔康奈尔医学院的医学教授，纽约长老会医院和特殊外科医院的主治医生，都在纽约市。
Dr. Crow says several new findings are particularly important in understanding SLE:
- Genetic factors. The heritabilityof SLE is about 44%. There are a few rare gene changes that can lead to very severe disease, but common variants account for most of the genetic risk. These variants differ from person to person. Combinations of different genes from each parent can increase the chance of SLE.
- Effect of race and ethnicity. Black Americans are many times more likely to have SLE than European Americans. They may have unique genetic variations that are passed from generation to generation, including more impaired B-cell function.
- Smoking. People at high genetic risk who smoke have a greatly increased risk of SLE.
- COVID-19similarities. The immune response in SLE may be the same as in COVID-19. In any immune response, the innate immune system kicks in immediately and the adaptive immune system follows. The adaptive immune system recognizes and remembers specific pathogens and responds to them more strongly each time they’re encountered. Normally, the immune system calms down after this process, but in SLE, the immune response remains activated for years. In COVID-19, it’s a matter of weeks.
- Importance of monocytes. It’s still not clear what drives tissue damage in SLE, but Dr. Crow thinks more attention should be paid to monocytes—white blood cells in the innate immune system. They’re produced in bone marrow and normally fight viruses and bacteria,but they also make inflammatory cytokines that may attack healthy tissue.—LINDA RATH
Self-managementforLupusPatients
Managinga chronic illness can be difficult, especially for those with rheumatic conditions.Onesession focused on the importance of providing tools and techniques for patientswho havelupusorlupus nephritis自我管理。Irene Blanco, MD, Albert Einstein College of Medicinefellowshipprogramdirector,emphasized that patients need to have a sense of self-management and autonomy,and health care providers play a significant roleby helping to“tailorit,basedonthe needs of apatient,that will helpinadoption of the program.”
Dr.Blancodiscussed patient barriers to self-management,such asmaterialsthat don’ttakeinto consideration health literacy,a patient’sbaseline health beliefs,or a challenging relationship with the physician. But providersalso experience barriersto self-management, such as lack of time, staff, funding and being unaware ofresources to which to referpatients.She stressed that providers could useinsurancebilling codesfor counselingto bill for their time to provide self-management education.
Research shows benefits across the boardfor self-efficacy and self-management programs.They haveminimal risksandcanbe led bydifferenttypes of providers.Having multiple weekly sessions can reinforce the education.
Cristina Drenkard, MD, PhD,associateprofessorinEmory University’s Department of Medicine, discussed development ofa specific self-management program for lupus nephritis(www.lupusinitiative.org),whichincludestraining materials forproviders andself-management resources forpatients.
“It’s imperativethat providers start thinking more on self-management and encourage their patients to go these resources,” saidDr.Drenkard.
DermatologistVictoria Werth, MD,professor ofmedicine and dermatology at the University of Pennsylvania,rounded out the sessionwithresearchonfosteringconnectionsbetween rheumatologists and patient engagement for self-management.“By connecting the patients with trusted and tested self-managementresources, doctors can support their patients inself-management efforts outside of the clinic,”saidDr.Werth.—REBECCA GILLETT
What to Eat – and More – for Rheumatic Diseases
Many people with rheumatic conditions want to know what they should or shouldn’t eat for their condition, and while diet is not a cure, there is evidence that what they eat – or refrain from eating – may improve or worsen their disease and symptoms.
Three experts addressedthese questions and other lifestyle considerations for people with autoimmune diseases in a session called,“What’s Food Got To Do With It?Food, Fasting and Supplements in Rheumatic Disease.”
Valter Longo, PhD, professor of gerontology and director of the Longevity Institution at the University of Southern California, has been investigating the effects of fasting on the aging process as well as on immunity. Research has shown that fasting has benefits for people with autoimmune diseases;however, fasting isn’t feasible for long periods of time. Longo developed the fasting mimicking diet (FMD), five consecutive days of eating a specific calorie-restricted but healthy diet for three months and eating normally the rest of the time. This eating pattern shows the same benefits on a cellular level as fasting and has also shown real benefits in mice and humans with multiple sclerosis (MS), an autoimmune disease.
In humans with MS, FMD measurably improved quality of life both physically and mentally. It also helped those with inflammatory bowel disease,in part byproviding a protective effect in the gut by repopulating the healthy microbes, which went from 16% to 58% in his study.
Sara Tedeschi, MD, a rheumatologist at Brigham and Women’s Hospital and assistant professor of medicine at Harvard Medical School, reviewed randomized controlled trials (RCTs) to summarize what is known so far about the effect of diet on rheumatoid arthritis (RA) and on lupus, although these RCTs on lupus are scarce, she said.
Omega-3 fatty acids have anti-inflammatory effects, and the body can’t produce them, so they have to beconsumed—typically in fatty fish, like salmon and sardines, nuts, poultry, leafy greens and berries.
One trial found that among people who are at increased risk of developing RA, such as those with a close relative who has it, higher levels of omega-3s was associated with a lower risk of developing it. Studies also show that moderate alcohol—½ of an alcoholic drink a day—is associated with a lower risk of developing RA or lupus compared to no alcohol consumption. And one large study found that those who drank one sugary soda per day had a 33% higher risk of developing RA than those who drank less than one per month. (Diet drinks had no association.)
Studies also show that pain improved in RA patients who fasted then adopted a vegetarian diet for 13 months as well as in those who followed a Mediterranean diet for 12 weeks. Another study showed improvements in disease activity, but both study groups lost weight, which might have driven those results, she added.
According to one report, almost 40% of patients surveyed seek complementary or alternative treatment options such as mind-body interventions, acupuncture, diet and herbal supplements, said Neha Shah, MD, clinical assistant professor in the rheumatology and immunology division and Adult Rheumatology Fellowship Program director at Stanford University.
Colleagues working in arthritis self-management have found that “a patient’s perceived self-efficacy to cope with their ailment was mediating the outcomes of this program, and this is particularly true with pain and depression,” she said. “Lifestyle approach is a way we can empower our patients and allow them some control back in their lives.”
Key for physicians is to proactively ask about patient’s lifestyle—what do they eat, how much exercise and sleep do they get, have they quit smoking, what stressors to they have and “who’s your cheerleader?” Listen and help boost their self-efficacy, she advised other physicians, and tap into local acupuncture and massage practitioners, physical therapistsandpsychologistswho can work with patients. She also provides videos to help patients learn stress management techniques, and she recently started group visits via Zoom, so she can speak to many patients at the same time about these interventions without taking up time during individual visits.
Thereisn’tmuch data on these kinds of therapies in rheumatology, but thereisin many other conditions that rheumatology patients also have, like cardiovascular disease, sleep disorders and depression. “For a holistic, whole-person approach, lifestyle medicine is the way to go,” she said.
In addition to basic dietary advice, she recommends turmeric and ginger for certain patients. Both spices come in supplement form and have anti-inflammatory effects, among other benefits. They are not appropriate for certain patients, she added, including those who are on blood thinners, preparing for surgery or are taking medications that may interact in ways that can be harmful. —JILL TYRER
Strong Association Between Inflammatory Bowel Disease, Psoriatic Arthritis and Psoriasis
Daniella Schwartz, MD,assistantclinicalinvestigatorat theNational Institutes of Health,highlighted the increased risk of developing inflammatory bowel disease(IBD)在银屑病关节炎(PsA)和银屑病患者中。She noted that patients with psoriasis have atwo- to four-fold increased risk and those with PsA have asix- to10-fold increasedrisk. Dr. Schwartz also noted that Croh与溃疡性结肠炎相比，N氏病在这些患者中更容易发生。
This data suggests that PsA and psoriasis patients should closely monitor their gastrointestinal symptoms and discuss them with their health care providers.
Dr. Schwartz encouraged clinicians to screen for these diseases as they may affect PsA and psoriasis treatment decisions.—MICHELE ANDWELE