While there have been many advances in the treatment for rheumatoid arthritis (RA), drug therapy is not the only factor that influences the disease. There are several behavioral choices that patients with RA can make that may decrease symptoms of pain and stiffness or signs of joint swelling, and improve their quality of life. Educating patients about these choices and their potential benefits may empower them to make changes that can improve their health and well-being.

While there have been many advances in the treatment for rheumatoid arthritis (RA), drug therapy is not the only factor that influences the disease. There are several behavioral choices that patients with RA can make that may decrease symptoms of pain and stiffness or signs of joint swelling, and improve their quality of life. Educating patients about these choices and their potential benefits may empower them to make changes that can improve their health and well-being.

There have been several studies exploring the impact of diet among patients with RA. In recent years, many RA patients have gained weight while losing muscle. This muscle loss is due to the disease process as well as the reduced physical activity associated with RA.1 In cases of sarcopenic obesity, people gain body fat while losing muscle tissue. Patients with reduced activity levels should reduce calories in order to maintain a stable weight.

Weight maintenance is beneficial because increased weight adds pressure to joints and can further limit mobility. Excess fat itself may contribute to inflammation.2 Some studies suggest that particular foods may even affect the inflammatory process. Some individuals with RA may find that certain foods can trigger symptoms. In this regard, foods or supplements rich in omega-3 fatty acids (e.g., fish, flaxseed, walnuts) might be helpful.3 There is also some research that suggests moving toward a vegetarian/vegan diet and/or eliminating problematic foods could be beneficial.4-6

Patients can learn more about nutrition through reputable books, classes or Web sites. They can become more aware of their own dietary choices by reading food labels. Having information about food and nutrition available in your waiting area or clinic can also be helpful. Clinicians may encourage these patients to consume more whole grains, fruits and vegetables, and fewer refined and processed foods that are typically high in saturated fat and calories.

Patients interested in changing their diets may benefit from a consultation with a dietician. You can refer them to someone or suggest a local class or program. There is also evidence that when healthcare practitioners mention weight loss to overweight patients, it increases the likelihood that they will make an effort to lose weight.7,8 Remember that a healthful diet can be beneficial for everyone, even those who are not overweight.

Reviewing The Benefits Of Exercise
Exercise is beneficial for virtually all individuals and both The American College of Rheumatology and the Arthritis Foundation recommend exercise for those with rheumatoid arthritis.9,10 Exercise helps patients maintain range of motion, stabilizes joints, postpones or prevents muscle wasting and can slow the onset of disability.11-18 It can also reduce swollen and tender joints, pain and morning stiffness while improving cardiovascular health, thereby reducing the risk of heart attack or stroke.11,12,15,19-23

When beginning a new exercise program, patients with RA should first consult with their general practitioner and rheumatologist. It may be helpful to work with a personal trainer or exercise specialist who has experience working with arthritis patients and can tailor an activity program to specific needs and limitations. There are also exercise classes designed for arthritis patients. These include classes in water aerobics, walking, gentle yoga or t’ai chi. The Arthritis Foundation Web site (www.arthritis.org/) is a good resource for finding these classes.

For those who prefer to exercise independently, taking walks, using a treadmill or stationary bicycle, and spending time doing more active hobbies can be good ways to increase physical activity. Even small things like taking the steps instead of the elevator or parking further from the mall entrance can be beneficial. Wearing a pedometer to track steps during the day is a good way to keep track of one’s activity.
Explaining the recommendations and benefits of physical activity is an important contribution physician assistants and nurse practitioners can make for the health of patients with RA. You may want to have information available about local classes and/or provide pedometers to encourage more walking. You can also refer patients to an exercise specialist who can give them more specific guidance about beginning an exercise program.

Stress Management Techniques: Can It Be Beneficial In Reducing RA Symptoms?
Patients with RA experience the usual stresses of life as well as the additional stress of living with a chronic, painful disease and coping with its consequences.24,25 Stress can also impair immune function, directly affecting the disease process and possibly exacerbating the frequency or severity of flares.26-28

Learning to better manage stress can improve a patient's quality of life so the disease is less burdensome. Many individuals with chronic disease meditate or use guided relaxation techniques to help manage their disease symptoms. There is even evidence of a connection between stress and inflammation, making stress management particularly beneficial for those with inflammatory diseases such as RA.29-31 Getting adequate sleep is also important for managing stress and minimizing RA symptoms.32

Meditation, deep breathing and relaxation techniques are methods that can help to relieve stress. Patients may want to practice these methods on their own and there are many books and audiotapes that can provide information about how to get started. They may also seek the support of a group or community, or a trained facilitator.

Helping Patients Assess Their Pain

- Certainly, when treating patients suffering from pain, it is worthwhile to have a tool that quantitatively measures treatment effectiveness. This tool can give patients and treating clinicians a means of reviewing even minimal improvements over time. However, keep in mind your patient's ability to read when determining which measurement method you utilize in your practice. Simply ask a patient, “Can you read well?” Producing a visual analog scale (VAS) can surmount a patient's embarrassment. The VAS can show a happy face to represent “no pain” at the low end of the scale and gradually progress to a tearful, unhappy face to represent overwhelming pain at the high end of the scale. For a more high-level patient, clinicians may employ the disease activity score, including a 28-joint count (DAS28), to assess patient response and appreciate this over the continuum of treatment.10

Stress management can also mean making time for cultivating enjoyable and relaxing hobbies, being with friends and accepting social support. It can include taking time out from obligations to enjoy a nice meal or a warm bath, reading books, watching movies or being outdoors. It can be a challenge to take time for these activities when life is full of obligations but patients may find they are able to be more productive after engaging in such activities in addition to having a greater sense of well being. Trying to get a full night’s rest is also important and doing something relaxing before going to sleep can help patients fall asleep easier. When seeing patients with RA, ask them how they are managing stress and if they take the time to relax and do things they enjoy. You might suggest the importance of such activities in helping cope with the added stress of disease. For some patients, hearing this from a health professional can help legitimize taking some much needed time away from obligations. You can also suggest community classes or resources, and relaxation or meditation tapes for patients seeking extra guidance.

A Closer Look At Complementary And Alternative Medicine
Many patients rely on complementary and alternative medicine (CAM) for help with their arthritis symptoms and claim benefits from such therapies.33,34 Even if this benefit is psychological (also known as a placebo effect), it can still offer peace of mind and a feeling of empowerment regarding disease management. Some supplements may have pain or inflammation-reducing properties and some mind/body therapies (acupuncture, massage) may alleviate stress, leading to reduced pain or inflammation.35,36

If patients are interested in learning more about CAM, they should see a professional (massage therapist, acupuncturist, etc) who is trained, certified/licensed and experienced in these areas. Ideally, these professionals should have experience working with arthritis patients. Most mind/body therapies are safe if they are administered correctly by a trained professional.

When considering herbal supplements, it is important to do the research.
Currently, supplements are not regulated in the United States and may not be accurately labeled or consistently packaged. Patients should be aware of the risks involved and should be as cautious with any supplement as they would with other medications. While these medications can be purchased without a prescription, this does not mean they are always safe, especially for people taking multiple medications or dealing with chronic conditions.

Find out about the side effects, risks and contraindications so you are aware of potential interactions with other medications patients may be taking. Whenever possible, consult with a professional who understands herbal medicines and how they may react with other medications or impact disease symptoms.

Clinicians may want to counsel patients about possible benefits but should also strongly encourage them to proceed with caution and seek out qualified professionals.

Also be aware that patients may already be using CAM and might be less likely to reveal this if they fear being judged by healthcare professionals. Be sure to emphasize to patients that communicating about other treatments is crucial to safe and effective care by their rheumatology practitioner(s).

In Conclusion
Taking medications as prescribed is very important for the treatment of RA. However, patients can do other things to improve their quality of life and practitioners can help patients help themselves. Changing lifestyle and behavior is difficult, and not everyone will be interested or willing to make the changes that might improve their health and help them to better manage their disease. For those who are interested, helping them to realize their options and implement them may be an invaluable part of their medical care.