‘A good start’: ACR guideline heralds increased use, recognition of integrative therapies
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Integrative medicine approaches such as tai chi and yoga, which have long been used in rheumatology in a secondary or supplementary role, are increasingly being viewed as essential care.
The recent publication of a guideline for integrative strategies in rheumatoid arthritis by the American College of Rheumatology represents one big step forward in that regard.
“It is important to recognize that integrative medicine has elevated in recognition by both patients and providers in recent years,” Benjamin J. Smith, DMSc, PA-C, DFAAPA, program director and associate dean at the Florida State University College of Medicine, told Healio.
Smith served as co-principal investigator on the ACR document, which offers recommendations on diet, exercise and mindfulness behaviors, among others. It is the first of its kind for ACR.
This guideline is “a good start,” according to George Muñoz, MD, program director for Larkin Rheumatology, in Miami, team physician and associate professor medicine for the Herbert Wertheim School of Medicine at Florida International University, and chief of integrative medicine at American Arthritis and Rheumatology Associates.
“It is important that integrative rheumatologists be part of the understanding and architectural configuration of how conventional rheumatology, with its advanced pharmacotherapies, will best interface with whole-person integrative approaches to enhance the value proposition,” Muñoz said. “For that reason, this document is a good first step for the ACR.”
Meanwhile, on the patient side, many Americans feel that health is about far more than just not being sick, according to Wayne Jonas, MD, president of Healing Works Foundation and clinical professor of family medicine at Georgetown University.
“It includes factors essential to well-being such as being happy, being calm and relaxed, sleeping well and being able to live independently,” he said.
However, providers may be failing patients when it comes to achieving these outcomes.
“Unfortunately, a majority of those who have a primary care physician say they do not talk about much more than their physical medical needs with their doctor,” Jonas said. “Increasingly, these patients are looking for options that fit their lifestyle and personal needs.”
The good news is that because both patients and providers are recognizing that medicine should be more than just pills and injections, organizations like the ACR have taken it upon themselves to act.
That said, there is more work to be done in terms of putting integrative medicine front and center in rheumatology, according to Leonard Calabrese, DO, RJ Fasenmyer chair of clinical immunology at the Cleveland Clinic.
“Every single disease that we care for stands to benefit from care that incorporates such practices,” he said.
A close look at the guidelines specifically, and integrative medicine as a whole, could shed light on how rheumatology patients may optimize these potential benefits.
‘Essential’ recommendations
The ACR guideline covers topics ranging from exercise and rehabilitation to diet. All strategies are framed as working in conjunction with disease-modifying anti-rheumatic drugs to provide patients with RA a broad approach and multiple tools for disease management.
Like most other ACR documents in recent years, the researchers formulated Population, Intervention, Comparison and Outcome (PICO) questions and used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to rate the quality of evidence. “Strong” recommendations were those backed by the most robust evidence, while “conditional” recommendations had fewer data supporting them. Expert opinion was complemented by patient input.
The single strong recommendation is for consistent engagement in exercise.
“Consistent engagement in exercise is advised over no exercise,” reads the ACR recommendation.
Conditional recommendations, meanwhile, are additionally offered in favor or aerobic, aquatic, resistance and mind-body exercise routines, as well as following the Mediterranean diet, and against dietary supplements.
However, that last item — the ACR’s conditional recommendation against dietary supplements — may be taken with a grain of salt, according to Muñoz, who argued that supplements could potentially be just as essential as any other form of integrative care.
“Food and soil no longer have the same amounts of vitamins and micronutrients that they had decades ago,” he said. “Every year, there is a consistent degradation of the nutritional value of our food due to population increase, over farming and the vast commercialization of agriculture.”
It is for this reason that Muñoz suggested that dietary supplementation has transitioned from “a nice thing to do” to “essential and part of the overall prescriptive plan for many patients.”
Meanwhile, mind-body interventions covered by the ACR recommendations include cognitive behavioral therapy, along with acupuncture, massage and thermal modalities — all conditionally.
“I agree with the ethos of virtually all of the recommendations,” Calabrese said.
Smith stressed that the document was the product of collaboration between patients and providers, which included not only doctors, but also nurses and other practitioners who care for patients with RA.
“Patients wanted to know about the availability of integrative approaches right at the time of initial diagnosis,” Smith said. “They want to know what their options are at the outset, which is one of the strongest highlights of the document for me.”
Understanding that RA can progress differently in each patient was another critical component of the document for Smith.
“This can help providers decide which intervention is preferable for a patient with more pain or physical limitations, or both,” he said.
Additionally, patients expressed a desire for guidance from their health care team regarding when to use integrative approaches like mindfulness and physical activity approaches, according to Smith.
Historically, many patients have been told to exercise or meditate but were then left to their own devices. However, an increasing number of rheumatologists have learned that prescribing specific interventions tailored to each individual patient, along with behavior support, can produce better and more lasting outcomes. This is just one way that attitudes surrounding integrative medicine have shifted in recent years.
Attitude improvement
“Attitudes about integrative medicine in general have improved significantly over the last few years,” Muñoz said. “There is more understanding, open-mindedness and appreciation of the value of whole-person care in medicine in general, and rheumatology specifically.”
It is difficult to pinpoint why this evolution has occurred, but two factors may be at play.
One is a general reduction in the stigma surrounding mental health outcomes like depression and anxiety, and an acceptance that caring for these outcomes requires the integrative approaches used in rheumatology, according to Muñoz .
“The other is more physician-centric and pertains to burnout,” he said.
Muñoz suggested that a “silver lining” of the COVID-19 pandemic was an acknowledgement that burnout was a real concern in all corners of health care, including rheumatology. “Stress reduction became much more important,” he said. “All of these things have really become more top-line items to focus on in addition to the great pharmaceutical therapeutics we have developed.”
Indeed, understanding how integrative approaches fit in with biologics and other pharmacotherapies has become essential knowledge for any rheumatologist.
‘Not one or the other’
“In the early stage of this guideline development, one of the guiding principles was that pharmacotherapy is needed in conjunction with, or parallel to, integrative interventions,” Smith said. “It is not one or the other. The two together really do make a difference.”
However, the idea of integrative interventions, and their goals, can sometimes run counter to some of the larger, structural aspects of the U.S. health care system, according to Jonas.
“The U.S. health care system is designed to treat acute or late-stage disease,” he said. “It does an excellent job if that.
“However, it is not well-designed to treat or prevent chronic disease,” he added. “Poor management of chronic disease has led to a relentless rise in health care costs, declining life expectancy and quality of life, increasing patient dissatisfaction and growing provider burnout.”
These deficiencies in the system are particularly evident in rheumatology, where many of the conditions last a lifetime.
“Most chronic diseases can be delayed, managed or improved by addressing the underlying behavioral and lifestyle choices, as well as the social and economic determinants of health, that contribute to them,” Jonas said. “Yet these things — which account for about 80% of the healing of an individual or a population — are rarely addressed in the health care system.”
As a guiding principle, conventional approaches may be used for the intense and acute phases of illness, but with integrative approaches added for long-term management of the chronic condition, “supplementing those with new drugs and biologics,” he said.
Meanwhile, according to Calabrese, integrative interventions can also potentially address the frequent disconnect reported between the physician’s goals of controlling disease activity and the patient’s goals of simply feeling better.
“We are starting to wake up and recognize that much of the difficulty we have been encountering in putting people into remission long-term is not a failure of medications, but a gap in wellness,” he said.
Although many experts view this disconnect as a “problem,” Calabrese sees it as an “opportunity.”
“Patients have an interest in seriously pursuing integrative interventions like diet, exercise and mindfulness to improve their pain, function and sleep,” he said. “The more these interventions are used, the more we are going to get validation of them.”
However, if the effort to validate integrative strategies is to succeed, it will be necessary to think bigger than the rheumatology clinic, according to Calabrese.
“Ultimately, we are fighting a larger battle, which is that Americans have been taught that there is a pill to cure everything,” he said, noting the debacle of opioid use and the subsequent epidemic. “There is no easy fix for this, but we are at a turning point for integrative approaches. We are embracing them more than ever before.”
References:
ACR guideline document:
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