Medical school, residency, and fellowship taught me pathophysiology, diagnosis, and the most advanced treatments for autoimmune diseases like rheumatoid arthritis. As an attending physician, seeing my own patients, I noticed that targeted therapy is not able to control the disease in all patients with rheumatoid arthritis. The results varied. I could not stop asking myself, why is it so different?
In my previous article, I wrote about one of my patient’s stories as well as my discovery journey of integrative medicine. After taking a nutrition science course at Stanford University, a mindfulness training program at the University of Massachusetts, and doing a lot of research, I started to recognize the vital role of nutrition in managing my rheumatoid arthritis patients. However, to have the most optimal outcomes, we must discuss with patients about essential lifestyle changes. Despite acknowledging the role of lifestyle changes, many physicians will not have time to properly educate patients or are not properly rewarded by the current traditional billing/coding system.
Nutrition: the key to decreasing inflammation
Nutrition influences our gut microbiome, which is now recognized to significantly impact many aspects of our lives, including mood, obesity, and even our immune system. Many studies have demonstrated that switching to the vegetarian diet, Mediterranean diet, and/or intermittent fasting can profoundly impact rheumatoid arthritis. Omega-3 supplementation, like fish oil, increases patients’ likelihood of getting into remission, decreases disease activity, reduces the duration of morning stiffness, and provides symptomatic relief. This is why we, as medical professionals, should encourage our patients to develop and maintain healthy eating habits.
Exercise: Modulating effects on mood and chronic pain
Exercise has long been associated with health, improving mood, reducing the risk of developing diseases, and even helping with chronic pain management. When it comes to exercise, I consulted with Dr. Melissa Koehl, a physical therapist, who explained that “[more] and more evidence is found on the effect of exercise on reducing pain, inflammation, fatigue, and improving joint mobility, strength, flexibility, and mood.” This results from exercise-induced hypoalgesia, a series of biochemical events that result in reduced pain. This pain-dampening response occurs even after one round of exercise and increases when training is done consistently. As such, exercise should be introduced early as an essential part of treating patients with rheumatoid arthritis.
A frequent question is: What is the best type of exercise? Unfortunately, there is no one-size-fits-all answer. The best exercise program is individualized and uses a combination of strength training, aerobic exercise, and even exercise in water. The buoyancy of water significantly decreases the compressive forces on the joints, making exercise far more comfortable. Water also provides resistance to help build muscle strength, and many find they can do light jumping exercises in water. These are very beneficial as they promote the movement of the lymphatic system, which helps move inflammatory substances and edema (swelling) out of the joints.
Sleep for rheumatoid arthritis patients
Unfortunately, about 60 percent of arthritis patients report poor sleep quality, averaging only 5.7 hours per night. Sleep and pain appear to have a bidirectional relationship. Chronic sleep deprivation will lead to severe fatigue, anxiety, depression, insomnia, increased pain, inflammation, and decreased immune system function. In addition, chronic pain, medications, and comorbidities (OSA, restless leg syndrome) can contribute to sleep deprivation.
For example, patients with rheumatoid arthritis that sleep shorter periods or have fragmented sleep will have increased pain sensitivity the following day. In my experience, patients describe their pain levels worsening after a night of poor sleep while sleeping better decreases their pain level. Fatigue will impact the patient’s ability to exercise or make appropriate choices regarding nutrition. I always talk to my patients with rheumatoid arthritis about optimizing sleep up to 8 to 9 hours per night to improve their disease activity.
Mindfulness: the power of the mind to control chronic pain
As rheumatologists, we often try to target molecules of inflammation. In doing so, we often forget that a patient is a whole person, and their mind, body, and behavior are well-connected. Many patients describe that before their symptoms of autoimmune disease surface, they experience significant stress in their life, such as losing their job, someone dear, or going through a dramatic health change like surgery or being diagnosed with a malignancy. Is there a connection between the immune system and our mind? Yes, there is.
In the 1980s, Dr. Jon Kabat Zinn introduced mindfulness to medicine by starting the Mindfulness-Based Stress Reduction (MBSR) programs in the U.S. He proved that eight weeks of mindfulness had great benefits for controlling the pain level in chronic autoimmune conditions like psoriasis. A 2020 meta-analysis of randomized control trials in patients with rheumatoid arthritis of 337 patients showed that mindfulness interventions can significantly improve pain intensity, depression, and symptoms compared with conventional therapy. Mindfulness will also decrease the daily pain in patients with rheumatoid arthritis.
I teach patients how to approach pain and how to incorporate simple breathing techniques, guided imagery, or other relaxation techniques. Less pain translates into better sleep and quality of life.
Rheumatoid arthritis treatment is complex. Patients deserve a personalized and integrative medicine approach. In my clinic, I focus on the patient, not their disease. We, as rheumatologists, have the best tools to help patients from DMARDs to targeted therapies. However, the patient day by day choices will influence their ability to respond and maintain good control of their disease. Educating and empowering my patients to make the right nutrition choices, exercise regularly, sleep longer and better, add certain supplements when appropriate, and use relaxation techniques to manage pain, have tremendously changed my patient’s life for good.
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