‘Hug a tree, take a walk’: Sleep, exercise key for patients with autoimmune disease

ORLANDO — Adequate sleep, exercise and stress management are critical for patients with autoimmune diseases, according to a presenter at the 2022 Rheumatology Nurses Society Conference.

“On average, an individual needs 7 to 8 hours of uninterrupted sleep,” George E. Munoz, MD, medical director of American Arthritis and Rheumatology Associates, and chief medical officer of the Oasis Institute, in Miami told attendees. He added that four REM cycles per night optimal.

If these levels of sleep are not routinely met, immune pathways and cytokines can be altered, according to Munoz.

“If you have an immune mediated inflammatory disease, pain, inflammation, HAQ scores and patient-reported outcomes are adversely effected,” he said. “It actually affects the disease state.”

Importantly, interleukin-6 and TNF are the proinflammatory markers that are most easily impacted by poor sleep, according to Munoz.

He urged attendees to conduct ongoing evaluations of fatigue in patients, noting that the cycle of fatigue and poor sleep can impact pain, and vice versa.

In addition, Munoz said it is necessary to understand that acute stress is not as significant a problem as chronic stress. He used the example of COVID-19.

“We are 30 months into the pandemic, and all of the associated stress,” he said. “After 3 to 6 months, depending on how you measure it, it went from acute to chronic stress.”

Anything that health care personnel can do to help patients reduce stress is going to be beneficial, according to Munoz.

For example, simple breathing techniques can have a positive impact on patients. He suggested the 4-7-8 technique, which involves breathing in through the nose for a four-count, holding it for a seven-count and exhaling for an eight-count.

“This has amazing results in terms of reducing stress and anxiety,” Munoz said. “If you have that anxious individual, you can teach this to them.”

Transcendental meditation, yoga, tai chi and qi gong are other stress-reducing interventions that are “easy, accessible and affordable,” according to Munoz.

“They have all been noted in peer-reviewed and scientific literature of improving stress and balance,” he said. “They may also improve mortality.”

Simply getting out into nature can also yield improvements in stress.

“Hug a tree, water the garden, take a walk,” Munoz said.

Although these approaches may seem simple, access to nature is not always guaranteed.

“This is a problem in burgeoning cosmopolitan areas,” Munoz said.

Turning to exercise, most physicians would recommend 3 to 5 days a week for a total of 150 minutes.

“The association with that type of exercise volume is a reduction in all-cause mortality that is significant,” Munoz said, adding that reductions in cardiovascular events, cancer and mortality have also been observed. “There is no pill that does that.”

He added that it is important to codify the recommendation for exercise.

“When I say recommend, I mean prescribe,” Munoz said.

He urged RNS attendees to actually write a prescription for walking, biking or yoga, with the number of days per week and number of minutes clearly delineated. If patients are unable to work out to the recommended threshold, Munoz is willing to compromise.

“If a patient tells me they don’t exercise at all, I start with 2 days a week for 10 minutes,” he said. “I work with them.”