2022 American College of Rheumatology Guideline for
Exercise, Rehabilitation, Diet, and Additional Integrative
Interventions for Rheumatoid Arthritis
Bryant R. England,
1
Benjamin J. Smith,
2
Nancy A. Baker,
3
Jennifer L. Barton,
4
Carol A. Oatis,
5
Gordon Guyatt,
6
Allen Anandarajah,
7
Kristine Carandang,
8
Karmela Kim Chan,
9
Deb Constien,
10
Eileen Davidson,
11
Carole V. Dodge,
12
Anita Bemis-Dougherty,
13
Sotiria Everett,
14
Nadine Fisher,
15
Liana Fraenkel,
16
Susan M. Goodman,
9
Janet Lewis,
17
Victoria Menzies,
18
Larry W. Moreland,
19
Iris Navarro-Millan,
20
Sarah Patterson,
21
Lawrence “Rick” Phillips,
22
Neha Shah,
23
Namrata Singh,
24
Daniel White,
25
Rawan AlHeresh,
26
Kamil E. Barbour,
27
Thomas Bye,
25
Dana Guglielmo,
28
Rebecca Haberman,
29
Tate Johnson,
1
Anatole Kleiner,
7
Chris Y. Lane,
30
Linda C. Li,
31
Hiral Master,
32
Daniel Pinto,
33
Janet L. Poole,
34
Kimberly Steinbarger,
35
Daniel Sztubinski,
36
Louise Thoma,
30
Vlad Tsaltskan,
37
Marat Turgunbaev,
38
Courtney Wells,
39
Amy S. Turner,
38
and Jonathan R. Treadwell
36
Objective. To develop initial American College of Rheumatology (ACR) guidelines on the use of exercise,
rehabilitation, diet, and additional interventions in conjunction with disease-modifying antirheumatic drugs (DMARDs)
as part of an integrative management approach for people with rheumatoid arthritis (RA).
Methods. An interprofessional guideline development group constructed clinically relevant Population, Intervention,
Comparator, and Outcome (PICO) questions. A literature review team then completed a systematic literature review and
applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to rate the cer-
tainty of evidence. An interprofessional Voting Panel (n = 20 participants) that included 3 individuals with RA achieved con-
sensus on the direction (for or against) and strength (strong or conditional) of recommendations.
Results. The Voting Panel achieved consensus on 28 recommendations for the use of integrative interventions in
conjunction with DMARDs for the management of RA. Consistent engagement in exercise received a strong recom-
mendation. Of 27 conditional recommendations, 4 pertained to exercise, 13 to rehabilitation, 3 to diet, and 7 to addi-
tional integrative interventions. These recommendations are speci?c to RA management, recognizing that other
medical indications and general health bene?ts may exist for many of these interventions.
Conclusion. This guideline provides initial ACR recommendations on integrative interventions for the management of
RA to accompany DMARD treatments. The broad range of interventions included in these recommendations illustrates the
importanceofaninterprofessional,team-basedapproachtoRAmanagement.Theconditionalnatureofmostrecommenda-
tionsrequiresclinicianstoengagepersonswithRAinshareddecision-makingwhenapplyingtheserecommendations.
Guidelines and recommendations developed and/or endorsed by the American College of Rheumatology (ACR) are
intended to provide guidance for patterns of practice and not to dictate the care of a particular patient. The ACR con-
siders adherence to the recommendations within this guideline to be voluntary, with the ultimate determination regarding
their application to be made by the clinician in light of each patient’s individual circumstances. Guidelines and recom-
mendations are intended to promote bene?cial or desirable outcomes but cannot guarantee any speci?c outcome.
Guidelines and recommendations developed and endorsed by the ACR are subject to periodic revision as warranted
by the evolution of medical knowledge, technology, and practice. ACR recommendations are not intended to dictate
payment or insurance decisions, and drug formularies or other third-party analyses that cite ACR guidelines should state
this. These recommendations cannot adequately convey all uncertainties and nuances of patient care.
The American College of Rheumatology is an independent, professional medical, and scienti?c society that does not
guarantee, warrant, or endorse any commercial product or service.
1
1
Arthritis & Rheumatology
Vol. 0, No. 0, Month 2023, pp 1–13
DOI 10.1002/art.42507
? 2023 American College of Rheumatology
INTRODUCTION
Rheumatoid arthritis (RA) is a chronic, systemic in?ammatory
condition,andimprovedoutcomesoccurwith earlydiagnosis, eval-
uation, and management. The American College of Rheumatology
(ACR) has previously published pharmacologic guidelines to aid cli-
nicians and individuals with RA (1–4). In addition to pharmacologic
interventions, individuals with RA and their clinicians consider
howexercise,rehabilitation,diet,andadditionalintegrativetherapies
canbene?tandbeincludedintheirdiseasemanagement.Usingthe
Grading of Recommendations Assessment, Development and
Evaluation (GRADE) methodology, the ACR developed this
?rst guideline to support decision-making when using speci?cinte-
grative interventions in the management of RA. The interventions
considered in this guideline are de?ned in Table 1; the critical out-
comeswerepainandphysicalfunction,andforselectinterventions,
diseaseactivityorworkoutcomes.AlthoughindividualswithRAmay
have other indications for these interventions (e.g., comorbidities),
this guideline focuses speci?cally on managing RA.
METHODS
This guideline follows the ACR guideline development pro-
cess and ACR policy guiding management of con?icts of interest
and disclosures (https://rheumatology.org/clinical-practice-
guidelines), which includes GRADE methodology (5,6) and
adheres to AGREE criteria (7). Supplementary Appendix 1 (avail-
able on the Arthritis & Rheumatology website at https://
onlinelibrary.wiley.com/doi/10.1002/art.42507) includes a
detailed description of the methods. Brie?y, the Core Leadership
Team (BRE, BJS, NAB, JLB, CAO, and GG) drafted clinical Popu-
lation, Intervention, Comparator, and Outcome (PICO) questions
with input from the rest of the guideline development group, and
thesewerepostedonlineforpublic comment (seeSupplementary
Appendix 2, https://onlinelibrary.wiley.com/doi/10.1002/art.
42507). For most questions, the critical outcomes were physical
function, which refers to the ability to perform both basic and
instrumental activities of daily living, and pain. Disease activity
was an additional critical outcome for questions pertaining to diet
and dietary supplements. Work outcomes were additional critical
outcomes for questions pertaining to vocational rehabilitation
and work site evaluation and modi?cation.
The Literature Review Team performed a systematic litera-
ture review for all PICO questions, extracted relevant study data,
graded the quality of evidence (high, moderate, low, very low),
and produced the evidence report (see Supplementary Appen-
dix 3, https://onlinelibrary.wiley.com/doi/10.1002/art.42507).
A Patient Panel of 12 patients with varying manifestations of RA
and varying experiences with the considered interventions for
RA management met virtually. This panel was moderated by a
member of the Core Team (JLB) and Literature Review Team
(LT). The panel reviewed the evidence report (along with a sum-
mary and interpretation by the moderator) and provided patient
perspectives and preferences for consideration by the Voting
Panel.AtaseparateVotingPanelmeetingheldvirtually,theresult-
ing evidence was reviewed, patient perspectives considered, and
recommendations formulated and voted on. Three members of
the Patient Panel were also members of the Voting Panel, to
ensure the Patient Panel’s perspective was considered when ?nal
decisions on the recommendations were made. Rosters of the
This article is published simultaneously in Arthritis Care & Research.
The ?ndings and conclusions in this report are those of the authors and
do not necessarily represent the of?cial position of the Centers for Disease
Control and Prevention, the National Institutes of Health, or the US Depart-
ment of Veterans Affairs.
Supported by the American College of Rheumatology.
1
Bryant R. England, MD, PhD, Tate Johnson, MD: University of
Nebraska Medical Center and VA Nebraska-Western Iowa Health Care
System, Omaha;
2
Benjamin J. Smith, DMSc, PA-C: Florida State University,
Tallahassee;
3
Nancy A. Baker, ScD, MPH, OTR/L: Tufts University, Boston,
Massachusetts;
4
Jennifer L. Barton, MD, MCR: VA Portland Health Care
System and Oregon Health & Science University, Portland, Oregon;
5
Carol
A. Oatis, PT, PhD: Arcadia University, Glenside, Pennsylvania;
6
Gordon
Guyatt, MD: McMaster University, Hamilton, Ontario, Canada;
7
Allen Ana-
ndarajah, MD, MS, Anatole Kleiner, MD: University of Rochester Medical
Center, Rochester, New York;
8
Kristine Carandang, PhD, OTR/L: San
Diego, California;
9
Karmela Kim Chan, MD, Susan M. Goodman, MD: Hos-
pital for Special Surgery, New York;
10
Deb Constien: Sun Prairie, Wiscon-
sin;
11
Eileen Davidson: Burnaby, British Columbia, Canada;
12
Carole
V. Dodge, OTR, CHT: University of Michigan Hospital and Health System,
Ann Arbor;
13
Anita Bemis-Dougherty, PT, DPT, MAS: American Physical
Therapy Association, Alexandria, Virginia;
14
Sotiria Everett, EdD, RD,
CDN, CSSD: Department of Family, Population, Preventive Medicine,
Stony Brook Renaissance School of Medicine, Stony Brook, New York;
15
Nadine Fisher, EdD: University of Buffalo, Buffalo, New York;
16
Liana
Fraenkel, MD, MPH: Yale School of Medicine, New Haven, Connecticut;
17
Janet Lewis, MD: University of Virginia, Charlottesville, Virginia;
18
Victoria Menzies, PhD, APRN: University of Florida, Gainesville;
19
Larry
W. Moreland, MD: University of Colorado Anschutz Medical Campus,
Aurora;
20
Iris Navarro-Millan, MD, MSPH: Weill Cornell Medicine,
New York;
21
Sarah Patterson, MD: UCSF Osher Center for Integrative
Medicine, San Francisco, California;
22
Lawrence “Rick” Phillips, EdD:
Noblesville, Indiana;
23
Neha Shah, MD: Stanford Health Care, Palo Alto,
California;
24
Namrata Singh, MD, MSCI: University of Washington, Seattle;
25
DanielWhite,PT,ScD,MSc,ThomasBye,PT,DPT,MS:UniversityofDel-
aware, Newark;
26
RawanAlHeresh,MSOT,PhD,OTR/L:MGHInstituteof
Health Professions, Boston, Massachusetts;
27
Kamil E. Barbour, PhD,
MPH: Centers for Disease Control and Prevention, Atlanta, Georgia;
28
Dana Guglielmo, MPH: Research Consultant, Los Angeles, California;
29
Rebecca Haberman, MD: NYU Langone Health, New York;
30
Chris
Y. Lane, PT, DPT, Louise Thoma, PT, PhD: University of North Carolina at
Chapel Hill;
31
Linda C. Li, PT, PhD: University of British Columbia and
Arthritis Research Canada, Vancouver, British Columbia, Canada;
32
Hiral
Master, PT, PhD, MPH: Vanderbilt University Medical Center, VICTR, Nash-
ville, Tennesee;
33
Daniel Pinto, PT, PhD: Marquette University, Milwaukee,
Wisconsin;
34
Janet L. Poole, PhD, OTR/L: University of New Mexico, Albu-
querque;
35
Kimberly Steinbarger, PT, MHS, DHSc: Husson University, Ban-
gor, Maine;
36
Daniel Sztubinski, BS, Jonathan R. Treadwell, PhD: ECRI
Institute, Plymouth Meeting, Pennsylvania;
37
Vlad Tsaltskan, MD: Univer-
sity of California, San Diego;
38
Marat Turgunbaev, MD, MPH, Amy
S. Turner: American College of Rheumatology, Atlanta, Georgia;
39
Court-
ney Wells, PhD, MPH, MSW: University of Wisconsin, River Falls.
Drs. England and Smith were co-?rst authors and contributed equally to
this work.
Author disclosures are available online at https://onlinelibrary.wiley.com/
doi/10.1002/art.42507.
Address correspondence via email to Bryant R. England, MD, PhD, at
Bryant.england@unmc.edu.
Submitted for publication November 23, 2022; accepted in revised form
March 17, 2023.
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Table 1. Descriptions and examples of interventions included in the integrative management of rheumatoid arthritis guideline
Intervention Description and/or examples
Exercise
Physical activity Movement of the body requiring energy expenditure.
Exercise Performance of physical activity in regular and structured manner to improve ?tness and health.
Aerobic exercise Exercise intended to improve cardiorespiratory ?tness and muscular endurance. Examples include walking,
biking or cycling, running, hiking, aerobics, rowing, swimming, using an elliptical machine.
Aquatic exercise Exercise performed in water, containing elements of both aerobic and resistance exercise. Examples include
swimming, water aerobics, water walking or jogging.
Resistance exercise Exercise intended to increase muscular strength. Examples include free weights, weight machines, resistance
bands, Pilates.
Mind–body exercise Exercise that combines movement, mental focus, and controlled breathing. Examples include yoga, Tai Chi,
Qigong.
Rehabilitation
Comprehensive
occupational therapy
Evaluation and treatment by an occupational therapist with the goal of increasing physical function and
participation. Receives patient-centered individualized treatment. Components of occupational therapist
services vary and may include arthritis education, activities of daily living evaluation and training, joint
protection, activity pacing, work simpli?cation and fatigue management, exercise (particularly for the hand
and arm), splinting/orthotics, provision of assistive/adaptive devices, environmental adaptations, work and
leisure counseling/rehabilitation, work site assessment, sexual advice, relaxation, pain and stress
management training.
Comprehensive physical
therapy
Evaluation and treatment by a physical therapist. Components of physical therapist services will vary and
should include exercise. May also include functional training and physical activity, energy conservation,
workplace accommodations, mobility and gait training, manual therapy, self-management education,
electrotherapy, application of orthoses, instruction in assistive devices, pain management (including thermal
therapy).
Hand therapy exercises Exercises of the hand to improve mobility and strength.
Bracing and orthoses Devices to correct and support musculoskeletal function, improve joint alignment, or protect the joint.
Examples include wrist and ?nger splints, foot or knee orthoses, compression gloves, taping.
Joint protection techniques Self-management approach that aims to maintain function by providing people with ways to alter work
methods and movement patterns of affected joints to reduce pain, in?ammation, and joint stress. Examples
include changing the way of performing activities to avoid pain, resting, use of alternative muscle groups.
Activity pacing Balancing activity and rest to accomplish activities. Includes activity pacing, energy conservation, activity
modi?cation, fatigue management techniques.
Assistive devices Devices to assist with mobility. Examples include crutches, canes, walkers, wheelchairs, tricycles, scooters.
Adaptive equipment Devices to assist with activities of daily living. Examples include built-up and/or long-handled equipment, sock
aide, button hook, reachers, pill cutters, cell phone holders.
Environmental adaptations Adapting environment to improve safety. Examples include adaptations for toileting (raised toilet seat,
commode, toilet safety rail), showering (tub seat, handheld shower, walk-in bath), grab bars, ramps, stair lifts,
home modi?cation.
Vocational rehabilitation Training programs to overcome barriers preventing successful employment.
Work site evaluation and
modi?cations
Evaluating and adjusting work site conditions and duties for safety and well-being.
Dietary
Formally de?ned diet Speci?c diets include antiin?ammatory, Mediterranean-style, ketogenic, paleo, gluten-free, vegetarian, vegan,
intermittent fasting, elemental, elimination, raw foods, whole food plant-based.
Mediterranean-style diet Diet pattern that emphasizes intake of vegetables, fruits, whole grains, nuts, seeds, and olive oil; moderate
amounts of low-fat dairy and ?sh; and limits to added sugars, sodium, highly processed foods, re?ned
carbohydrates, and saturated fats.
Dietary supplement Substancesusedtoaddnutrients,botanicals,herbs,ormicrobials(probiotics)tothediet.Speci?csupplements
evaluated include vitamin D, probiotics, ?sh oil and omega fatty acids, antioxidants (selenium, zinc, vitamin A,
vitamin C, vitamin E), turmeric, glucosamine, γ-linolenic acid, borage seed oil, evening primrose oil, black
currant seed oil, selenium, Boswellia, ginger.
Weight loss Intentional loss of body weight. Examples include lifestyle modi?cation through diet and/or exercise, support
groups, health coaching, medically supervised weight loss programs, branded dietary weight loss programs,
weight loss surgery.
Additional integrative therapies
Self-management program Standardized program to guide self-management. Examples include Arthritis Self-Management Program,
Chronic Disease Self-Management Program, Better Choices Better Health, Tomando Control de su Salud,
Rheumatoid Arthritis Self-Management Intervention, OPERAS (an On-demand Program to EmpoweR Active
Self-management).
Cognitive behavioral therapy Psychological therapy to identify and change thought and behavior patterns.
Mind–body approaches Practices engaging both mind and body functions. Examples include biofeedback, goal setting, meditation,
mindfulness, breathing exercises, progressive muscle relaxation, guided imagery.
(Continued)
ACR GUIDELINE FOR INTEGRATIVE INTERVENTIONS IN RA 3
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Core Leadership Team, Literature Review Team, Voting Panel,
and Patient Panel are included in Supplementary Appendix 4
(https://onlinelibrary.wiley.com/doi/10.1002/art.42507). These
teams included individuals with expertise in epidemiology, exer-
cise physiology, GRADE methodology, integrative medicine,
nursing, nutrition, occupational therapy, physical therapy, rheu-
matology, and social work.
Consensus among the Voting Panel members required
≥70% agreement on both directions (for or against) and
strength (strong or conditional) of each recommendation, as
per ACR practice. According to GRADE, a recommendation is
categorized as strong if the panel is very con?dent that the ben-
e?ts ofaninterventionclearlyoutweightheharms(orviceversa);
a conditional recommendation denotes uncertainty regarding
the balance of bene?ts and harms, such as when the evidence
quality is low or very low, or when the decision is particularly
sensitive to individual patient preferences, or when costs are
expected to affect the decision. Thus, conditional recommen-
dations refer to decisions in which incorporation of patient
preferences and values is an essential element of shared
decision-making.
Guiding principles
Nine guiding principles (Table 2) were established by the
Core Leadership Team to aid in the preparation of this guideline.
These guiding principles specify that integrative interventions
considered in this guideline should complement pharmacologic
treatments, an interprofessional approach for the management
of RA should be used, and shared decision-making is needed
when caring for people with RA.
RESULTS/RECOMMENDATIONS
Twenty-eight recommendations were made based on a
set of 28 PICO questions. The systematic literature review initially
identi?ed 8,994 manuscripts (see searchstrategies inSupplemen-
tary Appendix 5, https://onlinelibrary.wiley.com/doi/10.1002/art.
42507).Afterscreening,275manuscriptsweremappedto≥1PICO
question (see ?ow diagram in Supplementary Appendix 6, https://
onlinelibrary.wiley.com/doi/10.1002/art.42507). The literature
reviewdidnotidentifyanyevidencetoindicateful?llmentoftheeli-
gibilitycriteriafor29%(8 of28)ofthePICOquestions.
Exercise recommendations (Table 3)
We strongly recommend consistent engagement in
exercise over no exercise.
We recommend consistent engagement in exercise over no
exercise based on moderate certainty evidence suggesting that
regular exercise results in improved physical function and pain in
Table 1. (Cont’d)
Intervention Description and/or examples
Acupuncture Stimulation of speci?c body points through insertion of thin needles.
Massage therapy Rubbing and kneading of muscles and joints with the hands. Examples include Swedish, Deep Tissue, Trigger
Point.
Thermal modalities Use of heat and cold for medical treatment. Examples include cryotherapy, heat, therapeutic ultrasound,
infrared sauna, paraf?n therapy, laser therapy.
Electrotherapy Use of electrical energy for medical treatment. Examples include transcutaneous electrical nerve stimulation
(TENS), neuro-muscular electrical nerve stimulation (NMES).
Vagal nerve stimulation Implantation of a device to stimulate the vagus nerve with electrical impulses.
Chiropractic Diagnosis and manipulation of malaligned joints, particularly the spine.
Tobacco cessation Counseling on tobacco cessation, tobacco-cessation programs (via telephone, mobile applications), nicotine-
replacement therapies, tobacco cessation. medications without nicotine.
Table 2. Guiding principles for the integrative management of
rheumatoid arthritis
Rheumatoid arthritis is a chronic, systemic in?ammatory condition
that requires early diagnosis, evaluation, and management to
achieve optimal outcomes.
Rheumatoid arthritis should be treated with disease-modifying
antirheumatic drugs and follow a treat-to-target management
strategy, as detailed in the 2021 ACR Rheumatoid Arthritis
Pharmacologic Treatment Guidelines (1).
Individuals with chronic diseases like rheumatoid arthritis seek
many available therapies to maintain physical function, reduce
pain, and improve their quality of life.
Treatment decisions should follow a shared decision-making
process. Individuals with rheumatoid arthritis present with a
variety of manifestations and experiences.
Optimum rheumatoid arthritis treatment outcomes are achieved
through interprofessional teams providing expert patient-
centered care.
Recommendations assume no contraindications to listed
management strategies.
Recommendations pertain to rheumatoid arthritis management.
Recommendations do not pertain to clinical situations in which
patients have alternative indications for listed treatments. Other
general health bene?ts may exist for listed treatments.
Surgical interventions are not included in this guideline because
there are other guideline efforts that address large joint
replacement,andsmalljointsurgeriesarenotfrequentlyapartof
the current management of rheumatoid arthritis.
Disease activity and disease activity levels refer to those calculated
using an ACR-endorsed rheumatoid arthritis disease activity
measure (32).
ACR = American College of Rheumatology.
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individuals with RA. Aerobic, resistance, aquatic, and mind–body
exercisewereconsideredtogetherintheevidencesupporting this
recommendation. The exercise type, frequency, intensity, and
duration were not formally de?ned because the evidence on exer-
cise interventions did not support such precision in the recom-
mendation, and there is considerable variation in patient values,
preferences, and access to different types of exercise. The spe-
ci?c elements of an exercise intervention should be tailored to
each person at the given time in their disease trajectory, consider-
ingtheircapabilities,access,andotherhealthconditions.National
physical activity guidelines can aid such instruction (8).
We conditionally recommend consistent engagement in
aerobic exercise over no exercise.
We recommend consistent engagement in aerobic exercise
based on very low to low certainty evidence suggesting that it
results in improved physical function but moderate certainty evi-
dence suggesting there is no difference in pain. The recommen-
dation is conditional because of the level of certainty of the
evidence and recognizing that patient preferences may vary due
to RA diseaseactivity level,the presence of joint damage or defor-
mities, comorbidities, and the cost of, access to, or burden of
engaging in consistent aerobic exercise.
We conditionally recommend consistent engagement in
aquatic exercise over no exercise.
We recommend consistent engagement in aquatic exercise
based on low certainty evidence to indicate that it results in
improvement in physical function but no difference in pain. The
recommendation is conditional because of the level of certainty
of the evidence, the variability in patient preferences related to
comfort in engaging in water activities, and the variations in the
cost of, access to, and burden of aquatic exercise.
We conditionally recommend consistent engagement in
resistance exercise over no exercise.
We recommend consistent engagement in resistance exer-
cise based on very low to low certainty evidence to indicate that
it results in improvement in physical function (inferred from perfor-
mance measures) and pain. The recommendation is conditional
because of the level of certainty of the evidence, variability in
patient preferences related to joint damage or deformities that
may limit participation, and variations in the access to, cost of,
and burden of resistance exercise. The Voting Panel and Patient
Panel emphasized the importance of appropriate prescription
and supervision of resistance exercise by physical therapists or
other quali?ed exercise professionals to prevent harm.
We conditionally recommend consistent engagement in
mind–body exercise over no exercise.
We recommend consistent engagement in mind–body exer-
cise (e.g., yoga, Tai Chi, Qigong) based on very low to low cer-
tainty evidence suggesting that it results in improved physical
function but no difference in pain. The recommendation is condi-
tional because of the level of certainty of the evidence, variability
in patient preferences, and variations in the cost of, access to,
and burden of this type of activity.
Rehabilitation recommendations (Table 4)
We conditionally recommend participation in compre-
hensive occupational therapy (OT) over no comprehen-
sive OT.
We conditionally recommend participation in compre-
hensive physical therapy (PT) over no comprehensive PT.
We conditionally recommend that individuals with RA
participate in comprehensive OT and PT based on very low
certainty evidence to indicate that it results in improvement
in pain and physical function, expected variability in patient
preferences, and variations in the burden of, access to, and
cost of these approaches. In these recommendations, “com-
prehensive” refers to the numerous different approaches and
interventions that occupational therapists and physical thera-
pists utilize in the assessment and management of individuals
with RA. The comprehensive nature of these interventions
also highlights the importance of identifying occupational
therapists and physical therapists with expertise in tailoring
these interventions to the management of RA through a
Table 3. Exercise recommendations for the management of rheumatoid arthritis
Recommendation
Certainty of
evidence
PICO questions
used for the
Evidence Report
Evidence Summary
page nos. in
Supplementary Appendix 3?
We strongly recommend consistent engagement in
exercise over no exercise.
Moderate 4–7 194–344
Weconditionallyrecommendconsistentengagementin
aerobic exercise over no exercise.
Very low to low 4 194–242
Weconditionallyrecommendconsistentengagementin
aquatic exercise over no exercise.
Low 5 243–260
Weconditionallyrecommendconsistentengagementin
resistance exercise over no exercise.
Very low 6 261–317
Weconditionallyrecommendconsistentengagementin
mind–body exercise over no exercise.
Very low to low 7 318–344
Intervention de?nitions and examples are provided in Table 1. PICO = Population, Intervention, Comparator, and Outcome.
? Available on the Arthritis & Rheumatology website at https://onlinelibrary.wiley.com/doi/10.1002/art.42507.
ACR GUIDELINE FOR INTEGRATIVE INTERVENTIONS IN RA 5
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shared decision-making approach. This recommendation
applies throughout the RA disease course. Clinicians should
discuss the opportunity to refer the patient to OT and/or PT
early in the RA disease course, with the recognition that OT
and/or PT interventions can be tailored to unique patient
needs throughout the patient’s experience with RA. Access
to OT and PT services (e.g., availability, insurance coverage)
may be a barrier to care. Interventions in the subsequent rec-
ommendationstatementsareoftenincludedincomprehen-
sive OT and/or PT services.
For patients with hand involvement, we conditionally
recommend performance of hand therapy over no hand ther-
apy exercises.
We conditionally recommend that RA patients with hand
involvement undergo hand therapy exercises based on low
certainty evidence indicating that hand therapy results in pain
reduction and improvement in physical function. Therapists and
patients on the Voting Panel acknowledged that the evaluation
of the unique needs of the RA patient with hand involvement
may be best performed by an experienced hand therapist
(e.g., a certi?ed hand therapist, who is typically an occupational
or physical therapist with additional training) who can guide the
speci?c design and intensity of the intervention.
For patients with hand and/or wrist involvement and/or
deformity, we conditionally recommend use of splinting,
orthoses, and/or compression over no splinting, orthoses,
and/or compression.
For patients with foot and/or ankle involvement, we con-
ditionally recommend use of bracing, orthoses, and/or tap-
ing over no bracing, orthoses, and/or compression.
Table 4. Rehabilitation interventions for the management of rheumatoid arthritis
Recommendation
Certainty of
evidence
PICO questions
for the Evidence
Report
Evidence Summary page
nos. in Supplementary
Appendix 3?
We conditionally recommend participation in
comprehensive occupational therapy over no
comprehensive occupational therapy.
Very low 17 409–427
We conditionally recommend participation in
comprehensive physical therapy over no comprehensive
physical therapy.
Very low 18 428–443
For patients with hand involvement, we conditionally
recommend performing hand therapy exercises over no
hand therapy exercises.
Low 8 345–368
For patients with hand and/or wrist involvement and/or
deformity, we conditionally recommend use of splinting,
orthoses, and/or compression over no splinting, orthoses,
and/or compression.
Very low 9 369–376
For patients with foot and/or ankle involvement, we
conditionally recommend use of bracing, orthoses, and/or
taping over no bracing, orthoses, and/or compression.
Very low 10 377–398
For patients with knee involvement, we conditionally
recommend use of bracing and/or orthoses over no
bracing and/or orthoses.
No studies met eligibility
criteria
11 399
We conditionally recommend use of joint protection
techniques over no joint protection techniques.
Low 12 400–404
We conditionally recommend use of activity pacing, energy
conservation, activity modi?cation, and/or fatigue.
management over no activity pacing, energy conservation,
activity modi?cation, and/or fatigue management.
No studies met eligibility
criteria
13 405
We conditionally recommend use of assistive devices over
no assistive devices.
No studies met eligibility
criteria
14 406
We conditionally recommend use of adaptive equipment
over no adaptive equipment.
No studies met eligibility
criteria
15 407
We conditionally recommend use of environmental
adaptations over no environmental adaptations.
No studies met eligibility
criteria
16 408
For patients who are currently employed or desire to become
employed, we conditionally recommend use of vocational
rehabilitation over no work interventions.
No studies met eligibility
criteria
21 500
For patients who are currently employed or desire to become
employed, we conditionally recommend work site
evaluations and/or modi?cations over no work site
evaluations and/or modi?cations.
Low 22 501–507
Intervention de?nitions and examples are provided in Table 1. PICO = Population, Intervention, Comparator, and Outcome.
? Available on the Arthritis & Rheumatology website at https://onlinelibrary.wiley.com/doi/10.1002/art.42507.
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For patients with knee involvement, we conditionally
recommend use of bracing and/or orthoses over no bracing
and/or orthoses.
We conditionally recommend use of splinting, orthoses,
and/or compression among individuals with hand/wrist involve-
ment, use of bracing, orthoses, and/or taping among individuals
with foot/ankle involvement, and use of bracing and/or orthoses
among individuals with knee involvement. These recommenda-
tions are based on verylow certainty evidence toindicatethat these
approaches improve pain and physical function at the hand/wrist
andfoot/ankle. No studies pertaining tothe useoftheseapproaches
for patients with knee involvement met the eligibility criteria. Although
the Patient Panel discussed the discomfort and burdenaccompany-
ing the periodic and regular use of these interventions, the Patient
Panel and VotingPanel alsorecognized their potential to reduce pain
and improve physical function. In addition, although these interven-
tions are available without a prescription, the Voting Panel recom-
mends their prescription and use under the guidance of an
experienced occupational therapist or physical therapist to ensure
appropriate item selection and ?t.
We conditionally recommend use of joint protection
techniques over no joint protection techniques.
We conditionally recommend use of joint protection tech-
niques based on low certainty evidence to indicate that it results
in improved pain and function. Experienced healthcare profes-
sional guidance in joint protection techniques at various stages
of a patient’s experience with RA is vital for this intervention, in
order to aid the patient in maintaining physical function. The Vot-
ing Panel also stressed the importance of proper patient educa-
tion in joint protection techniques by occupational or physical
therapists.
We conditionally recommend use of activity pacing,
energy conservation, activity modi?cation, and/or fatigue
management over no activity pacing, energy conservation,
activity modi?cation, and/or fatigue management.
There was no evidence found to support the conditional rec-
ommendation that individuals with RA should use activity pacing,
energy conservation, activity modi?cation, and/or fatigue man-
agement. However, these interventions are generally safe and
may help preserve physical function and manage fatigue. Proper
instruction in these approaches by occupational or physical ther-
apists (e.g., ensuring no prolonged inactivity) as well as periodic
reminders to employ them were suggested by the Patient Panel
and Voting Panel.
We conditionally recommend use of assistive devices
over no assistive devices.
Weconditionallyrecommenduseofadaptiveequipment
over no adaptive equipment.
We conditionally recommend use of environmental
adaptations over no environmental adaptations.
In the absence of evidence addressing recommendations for
the use of assistive devices, adaptive equipment, or environmental
adaptations for RA patients, a conditional recommendation was
made in favor of using assistive devices/equipment because of
the potential for meaningfully improving the function and quality of
life and the lack of known harms. The timing of the use of interven-
tions, guidance on intervention selection, and education on how
tousetheseinterventionsshouldbeconsidered.Involvinganoccu-
pational or physical therapist can aid these processes and ensure
patient safety. The Voting Panel recognized cost and burden as
barriers to the use of these interventions.
For patients who are currently employed or want to
become employed, we conditionally recommend use of
vocational rehabilitation (training programs to support
employment) over no vocational rehabilitation.
For patients who are currently employed or want to
become employed, we conditionally recommend work site
evaluations and/or modi?cations over no work site evalua-
tions and/or modi?cations.
In theabsence of evidenceto support use of vocational reha-
bilitation and low certainty evidence for use of work site evalua-
tions and modi?cations, we conditionally recommend use of
these approaches. The Voting Panel recognized that the following
factors should be considered in implementing work site evalua-
tions and modi?cations: 1) the employee/employer relationship
regarding health-speci?c variables and con?dentiality, 2) the
patient’s comfort with disclosure of RA to the employer, 3) the
requirements of the Americans with Disabilities Act and the Family
and Medical Leave Act, 4) the heterogeneity of employer
resources and employee job responsibilities, and 5) the variable
availability of experienced work and ergonomics specialists.
Diet recommendations (Table 5)
We conditionally recommend adherence to a
Mediterranean-style diet over no formally de?ned diet.
The Mediterranean-style diet pattern emphasizes the intake
of vegetables, fruits, whole grains, nuts, seeds, and olive oil and
the intake of moderate amounts of low-fat dairy and ?sh, and
limits the use of added sugars, sodium, highly processed foods,
re?ned carbohydrates, and saturated fats. We conditionally rec-
ommend adherence to a Mediterranean-style diet based on low
to moderate certainty of evidence of improvement in pain and no
difference in physical function or disease activity. The recommen-
dation is conditional because of the level of certainty of the evi-
dence, patient preferences, and costs of, access to, and burden
associated with this type of diet. The Voting Panel recognized the
potential bene?ts of a Mediterranean-style diet for long-term health
outcomes (e.g., longevity and cardiovascular disease) that are
affected by RA disease activity and the evidence from studies in
the general population (9,10). The expert role of a registered dieti-
cian as a member of the interprofessional team is recognized.
We conditionally recommend against adherence to a
formally de?ned diet, other than a Mediterranean-style diet.
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Weconditionallyrecommend against adherencetoaformally
de?ned diet, other than the Mediterranean-style diet, based on
very low to moderate certainty evidence demonstrating no con-
sistent, clinically meaningful bene?t from following other formally
de?ned diet strategies (other than a Mediterranean-style diet) on
physical function, pain, or disease activity speci?c to RA (see
Table 1). In addition to the level of certainty of the evidence, this
recommendation is conditional because of the burden and costs
that accompany adhering to a formally de?ned diet, and patient
preferences are expected to differ.
We conditionally recommend following established die-
tary recommendations without use of dietary supplements
over adding dietary supplements.
We conditionally recommend following established dietary
recommendations without the use of dietary supplements for RA
management.Thisrecommendationpertainstoalldietarysupple-
mentsconsidered (as listed inTable1)and is basedon verylow to
moderate certainty evidence demonstrating no consistent, clini-
cally meaningful bene?t from adding dietary supplements with
regard to physical function, pain, or disease activity speci?cto
RA. The recommendation is conditional because of the level of
certainty of the evidence, expected variation in patient prefer-
ences, adequacy of nutrient intake through diet, lack of regulation
(e.g.,bytheUSFoodand DrugAdministration),possibilityof harm
(e.g., interactions with medications, side effects), and costs. The
Voting Panel supported a “food ?rst” approach but recognized
the role dietary supplements may serve for bone (e.g., vitamin D)
and cardiovascular health (e.g., ?sh oil), which are particularly
important in individuals with RA (11). In this recommendation,
established dietary recommendations refer to those produced
by the US Department of Agriculture and US Department of
Health and Human Services (12) and the American Heart Associ-
ation (13). Recommendations on folic acid supplementation in the
setting of treatment with methotrexate are included in the ACR’s
pharmacologic treatment guidelines (1).
Body weight and weight loss
Given the broad spectrum of weight loss interventions, includ-
inglifestylemodi?cation,commercialweight lossprograms,pharma-
cologictherapies,andsurgicalinterventions,theVotingPaneldidnot
vote on recommendations regarding weight loss interventions spe-
ci?cally for RA management in overweight or obese people with
RA. However, the Voting Panel was unanimous in its support of clini-
cians engaging in discussion about maintaining a healthy body
weight for individuals with RA, in order to optimize long-term RA
and general health outcomes. In RA, obesity is associated with
higher disease activity, impairments in physical function, and poorer
treatment response, in addition to poor long-term health outcomes
(14). General population recommendations on body weight classi?-
cation and weight loss strategies for those who are overweight or
obese can serve as a guide for these discussions (15,16).
Additional integrative intervention
recommendations (Table 6)
We conditionally recommend use of a standardized
self-management program over no standardized self-
management program.
We conditionally recommend that RA patients use a stan-
dardized self-management program based on low certainty evi-
dence to indicate that it results in improved physical function and
pain. The Patient Panel described how these programs can be
“life changing” and can provide motivation related to several fac-
tors that contribute to quality of life, including mental wellness
and psychological adaptation to disease experience. The avail-
ability of and access to theseprograms as wellas their costs were
noted as potential barriers.
We conditionally recommend use of cognitive behav-
ioral therapy and/or mind–body approaches over no cogni-
tive behavioral therapy and/or mind-body approaches.
We conditionally recommend use of cognitive behavioral
therapy and/or mind–body approaches based on very low to
low certainty evidence indicating no consistent improvement in
pain and physical function (critical outcomes) but low to moder-
ate certainty evidence of improvement in depression, anxiety,
fatigue, and sleep (important outcomes) when individuals with
RA use these approaches. Although these interventions are
bene?cial for chronic disease management, access to
Table 5. Diet recommendations for the management of rheumatoid arthritis
Recommendation Certainty of evidence
PICO questions
for the
Evidence Report
Evidence Summary
page nos. in
Supplementary Appendix 3?
We conditionally recommend adherence to a
Mediterranean-style diet over no formally de?ned diet.
Low to moderate 1 8–78
We conditionally recommend against adherence to a
formally de?ned diet, other than Mediterranean-style.
Very low to moderate 1 8–78
We conditionally recommend following established dietary
recommendations without dietary supplements over
adding dietary supplements.
Very low to moderate 2 79–190
Intervention de?nitions and examples are provided in Table 1. PICO = Population, Intervention, Comparator, and Outcome.
? Available on the Arthritis & Rheumatology website at https://onlinelibrary.wiley.com/doi/10.1002/art.42507.
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experienced healthcare professionals, cost, and the burden of
using these interventions were recognized barriers.
We conditionally recommend use of acupuncture over
no acupuncture.
We conditionally recommend use of acupuncture based on
low certainty evidence indicating inconsistent improvements in
pain and function. The Patient Panel generally found acupuncture
to be of lower value than other considered interventions for RA
management based on their disease experiences. For individuals
with RA, the burden, cost, access, and invasiveness of acupunc-
ture may impact the choice to use this intervention.
We conditionally recommend use of massage therapy
over no massage therapy.
We conditionally recommend use of massage therapy based
on very low certainty evidence that it results in improvement of
pain. Massage therapy intensity and technique may affect a
patient’s experience; therefore, it is best delivered by a provider
(e.g., massage therapist, physical therapist) with knowledge of
and experience in treating people with RA. Burden, cost, access,
and short-term duration of bene?t should be considered.
We conditionally recommend use of thermal modalities
over no thermal modalities.
We conditionally recommend use of thermal modalities, such
as cryotherapy, heat, and therapeutic ultrasound, based on very
low certainty evidence indicating that it results in improvement in
pain and physical function. Individuals with RA receive varying
levels of bene?t from thermal modalities, and patient preferences
are expected to vary with regard to the choice of a thermal modal-
ity. Individuals with RA can control and administer many of these
modalities at home, though others may bene?t from guidance
from an occupational or physical therapist.
We conditionally recommend against use of
electrotherapy.
We conditionally recommend against use of electrotherapy
modalities, such as transcutaneous electrical nerve stimulation
(TENS) and neuro-muscular electrical nerve stimulation, for RA
management, based on low certainty evidence indicating that
there is no improvement of pain and physical function speci?cto
RA with these modalities. While some individuals with RA may
receive bene?t from these interventions (e.g., in the setting of
comprehensive PT or OT), the Voting Panel recommended
against electrotherapy because the evidence was not felt to out-
weigh the burden and costs.
No recommendation was made by the Voting Panel on the
use of vagus nerve stimulation, because this invasive procedure
is not currently approved by the FDA as an intervention in RA.
Weconditionally recommend against useof chiropractic
therapy.
In the absence of evidence, we conditionally recommend
against use of chiropractic therapy (i.e., chiropractic spinal adjust-
ment) directly for the management of RA because of the potential
cervical spine complications that can occur (17). The Voting Panel
and Patient Panel perceived a lack of bene?t from chiropractic
therapy speci?cally for RA, and indicated that this approach car-
ries a perceived burden and costs.
Tobacco cessation
Due to existing clinical quality measures for tobacco use
screening and cessation (18) and the absence of studies on
tobacco cessation in RA (those meeting the eligibility criteria), the
Voting Panel did not make further recommendations on individual
tobacco cessation interventions for the speci?c management of
RA beyond the clinical quality measures. The Voting Panel
Table 6. Additional integrative interventions for the management of rheumatoid arthritis
Recommendation
Certainty of
evidence
PICO questions
for the
Evidence
Report
Evidence Summary
page nos. in
Supplementary
Appendix 3?
We conditionally recommend use of a standardized
self-management program over no standardized
self-management program.
Low 19 445–456
We conditionally recommend use of cognitive
behavioral therapy and/or mind–body approaches
over no cognitive behavioral therapy and/or mind–
body approaches.
Very low to low 20 457–500
We conditionally recommend use of acupuncture over
no acupuncture.
Low 23 508–528
We conditionally recommend use of massage therapy
over no massage therapy.
Very low 24 529–533
We conditionally recommend use of thermal
modalities over no thermal modalities.
Very low 25 534–553
We conditionally recommend against using
electrotherapy.
Low 26 554–562
We conditionally recommend against using
chiropractic therapy.
No studies met
eligibility criteria
27 563
Intervention de?nitions and examples are provided in Table 1. PICO = Population, Intervention, Comparator, and Outcome.
? Available on the Arthritis & Rheumatology website at https://onlinelibrary.wiley.com/doi/10.1002/art.42507.
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recognized the well-established harms of tobacco, including det-
rimental effects on RA that include higher disease severity, poorer
treatment response, and increased risk of poor long-term disease
outcomes (19). Because of the trust that is frequently developed
between RA patients and their clinicians and the low success rate
of individual tobacco cessation counseling efforts (20), there was
unanimous agreement that clinicians caring for individuals with
RA serve an integral role in counseling on tobacco cessation (21).
DISCUSSION
This is the ?rst ACR guideline on the use of exercise, rehabil-
itation, diet, and additional integrative interventions in conjunction
with DMARDs for RA management. This guideline highlights the
importance of an interprofessional healthcare team to provide
optimal care to individuals with RA. The recommended interven-
tions do not replace DMARD treatments, in accordance with
existing ACR pharmacologic treatment guidelines (1), but are
intended to be integrated into the comprehensive management
of individuals with RA. The recommended interventions in this
new guideline, which are intended to augment DMARD therapy,
were considered speci?cally for their ef?cacy in the management
of RA outcomes, rather than other general health bene?ts or alter-
native medical indications. The guideline is meant to increase
patient and clinician awareness, provide evidence to inform
shared decision-making, improve access to the recommended
interventions, and inspire much-needed future research in this
area to generate higher-certainty evidence for the manage-
ment of RA.
The one strong recommendation was for consistent
engagement in exercise. Recommendations for exercise include
multiple types (aerobic, aquatic, resistance, mind–body), which
is consistent with physical activity guidelines produced by the
US Department of Health and Human Services (8).The speci?c
type, frequency, intensity, and duration of exercise should be tai-
lored to each person with the assistance of their clinicians, con-
sidering the potential burden on and capacity of each person
(22). The US recommendations on exercise and physical activity
can serve as a guide to clinicians counseling patients (8). Because
the symptoms and consequences of RA may impact participation
(23), more personalized exercise prescription and monitoring may
be needed with the assistance of physical therapists and/or clini-
cal exercise physiologists.
Several rehabilitation interventions as well as comprehen-
sive OT and PT were recommended for their bene?ts on pain,
physical function, preserving independence, remaining in work,
and safety, although the certainty of evidence was low or very
low. The Patient Panel consistently emphasized the importance
of receiving interventions from occupational and/or physical
therapists to ensure proper use and their desire for referrals to
occupational and physical therapists earlier in the disease
course. Early referral to these services can educate individuals
with RA as to how to continue interventions independently
(e.g., exercise, joint protection, energy conservation, assistive
and adaptive devices) to self-manage their disease. Ensuring a
suf?cient workforce of occupational and physical therapists
well-versed in the management of RA and access to this care
are high priorities.
Dietary patterns and quality have been associated with RA
risk and severity in many, though not all, epidemiologic studies
(24). Of several diets evaluated in this guideline (e.g., vegan, anti-
in?ammatory, elimination), only a Mediterranean-style diet had
suf?cient evidence to be recommended, given the burden and
costs that accompany adhering to a formally de?ned diet. Dietary
supplements were heavily debated by the Voting Panel. Ulti-
mately, there was not suf?cient evidence to recommend their
use for RA management. The Voting Panel supported a “food
?rst” approach, which emphasizes using high-quality foods to
obtain necessary nutrients. Although no recommendation was
made on weight loss interventions, the Voting Panel was unani-
mous in its support for maintaining a healthy body weight. Rheu-
matology clinicians should consider involving registered
dieticians to assist individuals with RA who seek to modify their
diet as part of their RA management plan.
Additional integrative interventions that we conditionally recom-
mended included standardized self-management programs, cogni-
tive behavioral therapy and mind–body approaches, acupuncture,
massage therapy, and thermal modalities. Although the evidence
supportingtheseinterventions wasofverylow tolow certainty, these
interventions possess few harms and a modest burden for many
individuals with RA. The Patient Panel favored standardized self-
management,cognitivebehavioraltherapy,mind–bodyapproaches,
and thermal modalities because these interventions allowed them to
better cope with the chronic disease aspects of RA and/or they
offered a management option that could be controlled indepen-
dently, often at home.
Individuals with RA who currently use tobacco should be
supported in their tobacco cessation journey. The limited ef?cacy
of counseling on tobacco cessation (20) illustrates why it is critical
for all members of the interprofessional care team to engage in
this practice, which is an existing clinical quality measure (25).
There was not suf?cient evidence to establish more speci?c rec-
ommendations for tobacco use screening and cessation in RA.
A broad range of interventions was considered in this guide-
line. It is unlikely that one clinician will possess the necessary
expertise in all these areas, which illustrates the importance of
assembling an interprofessional healthcare team to best support
individuals with RA. The Patient Panel emphasized that rheuma-
tology clinicians (e.g., physicians, physician assistants, nurse
practitioners) are most often their ?rst contact for therapeutic
decisions. Thus, it was important to patients that their rheumatol-
ogy clinician(s) be knowledgeable about integrative therapies and
help guide patients to other professionals with relevant expertise
(e.g., physical and occupational therapists, dieticians, clinical
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exercise physiologists, psychologists, massage therapists, acu-
puncturists) early in the disease course, so that they can be
involved in shared-decision making throughout the disease
course.
RA is a chronic disease that imposes considerable costs on
those affected as well as increased costs to society (26,27). The
recommended interventions in this guideline are variably covered
by health insurance, and many of the costs become the responsi-
bility of the individual with RA. We encourage health policymakers
to advocate for insurance coverage of these interventions in order
to support an integrative and comprehensive approach to the
management of RA. The availability of and access to these inter-
ventions was a concern of both the Patient Panel and the Voting
Panel, particularly for underserved populations. Improving access
to and ensuring high-quality delivery of these interventions across
diverse settings are important endeavors to support. In addition,
the Voting Panel acknowledged that patients and/or clinicians
may have implicit and/or explicit biases regarding interventions
that may make them reluctant to recommend or use these inter-
ventions (28). While the evidence-based approach used in this
guideline can help overcome such biases, clinicians should con-
sider whether such biases may exist and work to reduce them.
The majority of recommendations were conditional in part
because of low certainty evidence. Several factors contributed to
the low certainty grading, including the following: 1) the limited
number of studies evaluating relevant interventions; 2) lack of
blinding and study attrition; 3) small sample sizes resulting in
imprecision; and 4) heterogeneity of study designs (e.g., various
interventions [comprehensive therapy versus an individual com-
ponent], comparators, and outcomes) that prevented pooling
results through a formal meta-analysis. Many of these issues are
inherent to research evaluating the considered interventions
(e.g., exercise, diet). These conditional recommendations indicate
that clinicians should engage in shared decision-making with
patients when deciding whether to use these interventions. The
low or very low certainty evidence supporting most recommenda-
tions calls for prioritizing research into these interventions and
prompted a proposed research agenda (Table 7). Key items
include determining the ef?cacy, safety, optimal timing, mode of
delivery, and personalization of these interventions.
There are limitations to the development of these guidelines.
Studies that were conducted prior to more recent treatment eras
(characterized by early diagnosis of RA and a treat-to-target
approach) were included in the evidence report and may be less
generalizable than more recently completed studies. Although
broad expertise was recruited and an extensive list of interven-
tions was considered in thisguideline, we couldnot ensure exper-
tise in every area of integrative RA management or consider all
possible integrative interventions. For example, members of the
Patient Panel inquired about use of cannabinoids as an RA treat-
ment, given the rising prevalence of their use in rheumatic dis-
eases (29,30). Cannabinoids were not included in this guideline,
and emerging evidence for cannabidiol, a pharmacologic therapy
that is not FDA-approved for RA, is being synthesized in a living
systematic review through a joint US Department of Veterans
Affairs and Center for Evidence-Based Policy at Oregon Health &
Table 7. Research agenda for the integrative management of rheumatoid arthritis
Evaluate the ef?cacy and safety of integrative therapies for the management of rheumatoid arthritis. Initial evidence is needed in the areas of
activity pacing, energy conservation, activity modi?cation, fatigue management, and vocational rehabilitation. Additional strong evidence from
larger, well-designed studies is needed in all other areas.
Determine the appropriate timing of different integrative interventions in the rheumatoid arthritis disease course.
Examine the delivery, education, and implementation of integrative interventions. For example, evaluating various methods of instruction and
training of joint protection and activity pacing interventions.
Establish the cost-effectiveness of different integrative interventions and develop approaches for cost-effective delivery.
Identify barriers to the adoption and implementation of integrative therapies. These may include variability in access, costs, and implicit and/or
explicit biases.
Describe the assembly of, communication between, and role delineation among the interprofessional care team delivering pharmacologic and
integrative interventions.
Improve access to experienced healthcare professionals who provide integrative interventions.
Determine ef?cacy and safety of integrative interventions based on rheumatoid arthritis disease manifestations and pharmacologic therapies,
e.g., modifying exercise interventions based on disease activity level or diet based on disease-modifying antirheumatic drugs utilized.
Tailor interventions (and their delivery) studied in the general population to individuals with rheumatoid arthritis, e.g., tobacco cessation
programs, exercise programs, and weight loss.
De?ne ef?cacy and safety of therapies not included in this guideline such as cannabidiol, vaping, and occupational exposures and protections as
well as emerging therapies such as vagal nerve stimulation.
Evaluate dietary supplements (especially vitamin D and omega-3 fatty acids such as “?sh oil”) in the context of dietary intake. The assessment and
implementation of diets should focus on being inclusive of different cultures.
Develop vocational rehabilitation programs and work site modi?cations that improve the ability of individuals with rheumatoid arthritis to work
without negative stigma in the workplace.
Establishtheef?cacyandsafetyof integrativetherapieson extraarticularmanifestationsandlong-termrheumatoidarthritis–relatedoutcomes.In
addition to disease activity, physical function, pain, and quality of life outcomes considered in this guideline, other outcomes that should be
considered are longevity, cardiovascular disease, lung disease, cancer, osteoporosis, and infection.
Develop research methodology to study integrative therapies, e.g., de?ning an adequate control intervention. Publication of research standards
for integrative therapies relevant to rheumatoid arthritis to guide research efforts.
Establish dedicated funding from organizations to study integrative rheumatoid arthritis therapies and their implementation.
ACR GUIDELINE FOR INTEGRATIVE INTERVENTIONS IN RA 11
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Sciences University (31). Different modes of delivering interven-
tions (e.g., telehealth versus in-person) were not assessed, as this
was beyond the scope of this project.
In summary, this guideline outlines initial recommendations on
the management of RA with exercise, rehabilitation, diet, and addi-
tional integrative interventions. These recommendations comple-
ment existing pharmacologic treatment guidelines that instruct on
the use of DMARDs and, taken together, can guide a shared
decision-makingapproachbetweentheindividualwithRAandtheir
clinician.Interprofessionaltreatmentteamsarecrucialtoimplement-
ing these recommendations. The generally low-quality evidence
highlightstheneedforwell-designedstudiesintheareaofintegrative
management of RA. Policy efforts are needed to ensure access to
recommended interventions for individuals with RA from diverse
backgroundsandsettings.Together,theseintegrativeandpharma-
cologicguidelinessupportthecomprehensivemanagementofRAin
pursuitofoptimaloutcomesforpeoplelivingwithRA.
ACKNOWLEDGMENTS
We thank the patients who (along with authors Deb Constien,
Eileen Davidson, and Lawrence “Rick” Phillips) participatedinthePatient
Panel meeting: Grace M. Becker, Denise Cedar, Judith Flanagan, Caro-
lyn R. Mason, Eileen Julie O’Rourke, Catherine Simons, Sharon
A. Sharp, and Sumayya Spencer. We thank the ACR staff, including
Regina Parker, for assistance in coordinating the administrative aspects
of the project and Cindy Force for assistance with manuscript prepara-
tion. We thank Janet Waters for her assistance in developing the litera-
ture search strategy and performing the initial literature search and
update searches. We thank Theresa Wampler Muskardin and Karen
Smarr for their thoughtful review and feedback during the project.
REFERENCES
1. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of
Rheumatology guideline for the treatment of rheumatoid arthritis.
Arthritis Care Res (Hoboken) 2021;73:924–39.
2. Saag KG, Teng GG, Patkar NM, et al. American College of Rheuma-
tology 2008 recommendations for the use of nonbiologic and biologic
disease-modifyingantirheumaticdrugsinrheumatoidarthritis.Arthritis
Rheum 2008;59:762–84.
3. SinghJA,FurstDE,BharatA,etal.2012updateofthe2008American
College of Rheumatology recommendations for the use of disease-
modifying antirheumatic drugs and biologic agents in the treatment
of rheumatoid arthritis. Arthritis Care Res (Hoboken) 2012;64:625–39.
4. Singh JA, Saag KG, Bridges SL Jr, et al. 2015 American College of
Rheumatology guideline for the treatment of rheumatoid arthritis.
Arthritis Rheumatol 2016;68:1–26.
5. Andrews JC, Schünemann HJ, Oxman AD, et al. GRADE guidelines:
15. Going from evidence to recommendation-determinants of a rec-
ommendation’s direction and strength. J Clin Epidemiol 2013;66:
726–35.
6. Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consen-
sus on rating quality of evidence and strength of recommendations.
BMJ 2008;336:924–6.
7. Brouwers MC, Kho ME, Browman GP, et al. AGREE II: advancing
guideline development, reporting and evaluation in health care. CMAJ
2010;182:E839–42.
8. Physical Activity Guidelines for Americans. 2nd Edition; 2018. URL:
https://health.gov/sites/default/?les/2019-09/Physical_Activity_
Guidelines_2nd_edition.pdf.
9. Ge L, Sadeghirad B, Ball GD, et al. Comparison of dietary macronutri-
ent patterns of 14 popular named dietary programmes for weight and
cardiovascular risk factor reduction in adults: systematic review and
network meta-analysis of randomised trials. BMJ 2020;369:m696.
10. Rees K, Takeda A, Martin N, et al. Mediterranean-style diet for the pri-
mary and secondary prevention of cardiovascular disease. Cochrane
Database Syst Rev 2019;3:Cd009825.
11. Buckley L, Guyatt G, Fink HA, et al. 2017 American College of Rheu-
matology guideline for the prevention and treatment of
glucocorticoid-induced osteoporosis. Arthritis Care Res (Hoboken)
2017;69:1095–110.
12. US Department of Agriculture and US Department of Health and
Human Services. Dietary Guidelines for Americans, 2020-2025. 9th
Edition. URL: https://www.dietaryguidelines.gov/.
13. Lichtenstein AH, Appel LJ, Vadiveloo M, et al. 2021 dietary guidance
to improve cardiovascular health: a scienti?c statement from the
American Heart Association. Circulation 2021;144:e472–87.
14. Poudel D, George MD, Baker JF. The impact of obesity on disease
activity and treatment response in rheumatoid arthritis. Curr Rheuma-
tol Rep 2020;22:56.
15. Curry SJ, Krist AH, Owens DK, et al. Behavioral weight loss interven-
tions to prevent obesity-related morbidity and mortality in adults: US
Preventive Services Task Force recommendation statement. JAMA
2018;320:1163–71.
16. JensenMD,RyanDH,ApovianCM,etal.2013AHA/ACC/TOSguide-
line for the management of overweight and obesity in adults: a report
of the American College of Cardiology/American Heart Association
Task Force on Practice Guidelines and The Obesity Society. Circula-
tion 2014;129:S102–38.
17. Gillick JL,Wainwright J,Das K.Rheumatoidarthritisand the cervical spine:
a review on the role of surgery. Int J Rheumatol 2015;2015:252456.
18. Explore Measures & Activities. URL: https://qpp.cms.gov/mips/
explore-measures.
19. Vittecoq O, Richard L, Banse C, et al. The impact of smoking on rheu-
matoid arthritis outcomes. Joint Bone Spine 2018;85:135–8.
20. Stead LF, Buitrago D, Preciado N, et al. Physician advice for smoking
cessation. Cochrane Database Syst Rev 2013;2013:Cd000165.
21. Vreede AP, Johnson HM, Piper M, et al. Rheumatologists
modestly more likely to counsel smokers in visits without rheuma-
toid arthritis control: an observational study. J Clin Rheumatol
2017;23:273–7.
22. Spencer-Bonilla G, Qui?ones AR, Montori VM. Assessing the burden
of treatment. J Gen Intern Med 2017;32:1141–5.
23. Sokka T, H?kkinen A, Kautiainen H, et al. Physical inactivity in patients
with rheumatoid arthritis: data from twenty-one countries in a cross-
sectional, international study. Arthritis Rheum 2008;59:42–50.
24. Philippou E, Nikiphorou E. Are we really what we eat? Nutrition and its
role in the onset of rheumatoid arthritis [review]. Autoimmun Rev
2018;17:1074–7.
25. BartelsCM,JohnsonL,RamlyE,etal.Impactofa rheumatologyclinic
protocol on tobacco cessation quit line referrals. Arthritis Care Res
(Hoboken) 2022;74:1421–9.
26. Hresko A, Lin TC, Solomon DH. Medical care costs associated with
rheumatoid arthritis in the US: a systematic literature review and
meta-analysis. Arthritis Care Res (Hoboken) 2018;70:1431–8.
27. Hsieh PH, Wu O, Geue C, et al. Economic burden of rheumatoid
arthritis: a systematic review of literature in biologic era. Ann Rheum
Dis 2020;79:771–7.
28. Green JA, Hohmann C, Lister K, et al. Implicit and explicit attitudes
towards conventional and complementary and alternative medicine
ENGLAND ET AL12
23265205, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/art.42507 by CochraneChina, Wiley Online Library on [25/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
treatments: introduction of an implicit association test. J Health Psy-
chol 2016;21:927–33.
29. Katz-Talmor D, Katz I, Porat-Katz BS, et al. Cannabinoids for the
treatment of rheumatic diseases—where do we stand [review]? Nat
Rev Rheumatol 2018;14:488–98.
30. Wip?er K, Simon TA, Katz P, et al. Increase in cannabis use among
adults with rheumatic diseases: results from a 2014-2019
United States observational study. Arthritis Care Res (Hoboken)
2022;74:2091–9.
31. Evidence-based research about cannabis. URL: https://www.
cannabisevidence.org/.
32. England BR, Tiong BK, Bergman MJ, et al. 2019 update of the Amer-
ican Collegeof Rheumatology recommended rheumatoidarthritis dis-
ease activity measures. Arthritis Care 2019;71:1540–55.
ACR GUIDELINE FOR INTEGRATIVE INTERVENTIONS IN RA 13
23265205, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/art.42507 by CochraneChina, Wiley Online Library on [25/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
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