Saundra Jain, MA, PsyD, LPC, and Andrew Laster, MD, on Wellness for Patients With RMDs: Part 2

In part 2 of their podcast on wellness, Drs Jain and Laster discuss 5 specific wellness practices recommended for patients with rheumatic diseases.

Saundra Jain, MA, PsyD, LPC, is an adjunct clinical affiliate at the University of Texas at Austin with the School of Nursing a psychotherapist in private practice in Austin, Texas. Andrew Laster, MD, is a rheumatologist in private practice in Charlotte, North Carolina.

TRANSCRIPT:

Thank you for joining us today for the continuation of this conversation between Drs Saundra Jain and Andrew Laster on wellness among patients with rheumatic disease. Today, they're going to be discussing certain wellness-enhancing practices that they have found helpful for their patients and for themselves.

RALN: In the article, you touch on several wellness enhancing practices, such as exercise, mindfulness, sleep, social connectedness, and nutrition. I'd like to explore these 5 practices by asking both of you to offer us a couple of important pearls of wisdom on each. So Dr. Jain, to begin with you, what about sleep and social connectedness? Can you tell us how they contribute to wellness for patients with rheumatoid arthritis?

Dr. Jain:
Yeah. I bet you, Rebecca, that Andy would agree with me that this question is really the fun part of the conversation we're going to have today because this is the practical part. This is the part where we hope to offer you and our listeners, really, ways they can take these complimentary practices like Andy referenced earlier, put them into practice and really begin to integrate wellness into our patients' treatment plans. So I have to say, sleep and social connectedness, absolutely 2 of my favorites. So let's get started.

Sleep, without a doubt, I have to tell you in my practice, it's one of the most commonly reported difficulties that my patients are reporting. Now, I'll refer everybody back to the article that we just mentioned for additional references, supporting information that we already know about sleep. And quite simply, I mean, I would say this. The takeaway is disrupted sleep is bad for a person's overall physical and mental wellbeing. And the data is there to support that.

I want to share with everyone, I heard a colleague not too long ago describe it this way. That while sleeping, the brain's cleaning crew gets busy clearing out cellular waste and debris from the day. So things like oxidative stress and tau accumulation, and we all know that increases the progression of tauopathies including Alzheimer's disease. And sadly, I mean, honest truth is we know too well that cell death can eventually lead to affective disorders, memory learning deficits, as well as cognitive dysfunction. And there are studies, I want everyone to know, that show that disrupted sleep in patients, specifically with RA, will increase not only mood difficulties, but also levels of pain.

Now, I know this doesn't come as a surprise to any of us. But I think the real question is this: Okay, so what do we do? This is what I think. Quite simply, offer lots of education about basic sleep hygiene practices. So things like this: Setting a regular bedtime and a wake up schedule. Decreasing consumption of caffeine, alcohol, and nicotine as we're nearing bedtime. Keep the bedroom quiet, keep it dark, and keep it cool. And we can review these practices. And I would strongly encourage all of us to do this routinely as we're seeing our patients. Just review these practices with them regularly. Kind of reinforce that messaging.

Now, social connectedness. Well, I really believe, I have to say that our brains are hard-wired for social connection. In all of our clinical and research work, we have never rank-ordered any of the wellness practices in terms of importance. And the reason is this—we wanted to encourage patients to try all of them so we avoided saying exercise is the most important or social connect. We just encourage people to engage and try them all. But I want you to know, over the years, based on the data, it is quite clear. The need for us as humans to connect with others is critically, I would say vitally, important to our overall wellbeing. And the data tells us that loneliness and social isolation promotes immune dysfunction, including proinflammatory cytokine production and it increases inflammatory markers.

So I think it's fair to say it benefits us all to encourage our patients to just get out there, connect with others. Volunteer, join a book club, stay connected with your friends and your family. Whatever works for that patient. And again, just to make this point, as clinicians, we have to be flexible in terms of what we're recommending based on that particular patient's needs and situation.

RALN: Dr. Laster, why don't you take on nutrition, exercise and mindfulness in this discussion? Can you tell us how they contribute?

Dr Laster:  Thanks, Rebecca. So let's go ahead and begin with diet and nutrition, since I think that's probably the thing that patients bring up on their own the most frequently to me. And so just to highlight a few things: We think that a Mediterranean diet is the way to go. Even if the effect on rheumatoid arthritis is felt to be fairly modest, the diet has other clearly proven benefits in terms of reducing cardiovascular risk. And we know that's a significant issue for patients with rheumatoid arthritis and other systemic inflammatory disorders. The other important point is that moderate or high alcohol consumption is clearly associated with a higher risk of rheumatoid flares. And that was recently documented in the updated 2021 ULAR guidelines.

If we turn to exercise, we want to encourage all of our patients to exercise on a regular basis, no matter how severe their disease. And certainly, patients who have advanced disease may require meeting with a physical therapist and having something fairly structured. But we need to let patients know that the benefits from exercise are really significant. Improved strength, improved mobility, and increased range of motion, decreased pain, can help with fatigue, can improve sleep. And again, also, its impact on cardiovascular health.

So what we typically recommend are 2 elements and 2 others, I think, that are also important. So number 1, aerobic exercise. So moderate exercise for 30 minutes a day, 3 days a week. And you don't have to do it all in 30 minutes. We have busy lives. You could break it up into 5- or 10-minute increments. And by moderate, people say you're exerting enough that you're a little bit short of breath, but you can still carry on a normal conversation. So aerobic exercise is important.

Resistance training, also called progressive resistance training, or PRT—that's using the stretchy TheraBands or free weights—is important. And then I think range of motion and stretching. So things like tai chi, yoga, and Pilates are definitely helpful for our patients with arthritis. And then for our older patients, balance training is really important. We're more likely to fall as we get older. That increases the risk for osteoporosis. So every patient that I talk to, I go over the importance of balance training. Just simply standing on one leg for more than 6 seconds when you brush your teeth every day is a good way to do that. And as we're interested in the immune aspects, there are clearly changes that have been documented. Increased levels of IL-6 from skeletal muscle, which actually has an anti-inflammatory effect. We see changes in adhesion molecules on the endothelial cell surface, increased angiogenesis. So there are a number of processes going on where exercise clearly can be beneficial.

And then finally, let's go ahead and talk a bit about mindfulness and meditation. And this is really, I think for me, fascinating. And it goes beyond forest bathing, but certainly, there's an element there as well. And if you would, this is a way that you can actually hack your vagal nerve. And it's clear that increasing vagal nerve tone, which you can measure by increased heart rate variability, really plays a key role in immune health. I mentioned earlier that the brain and the immune system are hard-wired, and the vagal nerve is really part of that. Stimulating the vagal nerve increases anti-inflammatory cytokines. And in fact, there are animal models of inflammatory arthritis and inflammatory bowel disease. And if you stimulate the vagal nerve, you can decrease the amount of inflammation in the gut and in the joints. And conversely, if you do a vagotomy, sever the vagal nerve, you see increased disease activity.

So there are lots of apps that are out there. I often recommend several to my patients. I'll show them on my phone, they'll take a picture of them. And so I think that mindfulness meditation, definitely is really key here and really essential.

Please join us again for part 3 of this podcast on wellness among patients with rheumatic diseases, as Drs Jain and Laster discuss ways busy clinicians can incorporate wellness practices into their visits with their patients.