How to deal with autoimmune disease flares- A Rheumatologist POV

Flares happen. We do everything we can to prevent them and understand why they occur, but sometimes, they just happen. This is true regardless of the inflammatory or autoimmune disease: lupus, arthritis, fibromyalgia, vasculitis, and all the others. As frustrating as they can be, there are things you can do to manage them with care and grace.

Most people with arthritis and disabling chronic pain are in excellent mental health – is this true for you?

More than three quarters of Canadians living with arthritis and debilitating chronic pain are free of all psychiatric disorders, including depression, and more than half are happy and in excellent mental health
More than three quarters of Canadians living with arthritis and debilitating chronic pain are free of all psychiatric disorders, including depression, and more than half are happy and in excellent mental health

A new study published by researchers at the University of Toronto indicates a very high level of resilience among Canadians with arthritis whose activities were restricted due to pain.

The vast majority (76%) of these individuals were free of any mental illness in the past year, including depression.  The paper was published online this week in PLOS ONE.

More than half (56%) of the respondents went beyond just being free of psychiatric disorders to achieving excellent mental health.  The definition of excellent mental health sets a very high bar. To be defined in excellent mental health, respondents had to achieve three things: 1) almost daily happiness or life satisfaction in the past month, 2) high levels of social and psychological well-being in the past month, and 3) freedom from generalized anxiety disorder and depressive disorders, suicidal thoughts and substance dependence for at least the preceding full year.

“We were so encouraged to learn that the majority of older Canadians with arthritis who were in debilitating chronic pain had excellent mental health. These findings bring a hopeful message to those living with disabling pain and their families as well as to clinicians addressing their physical and mental health care needs,” says the study’s senior author, Esme Fuller-Thomson.  Fuller-Thomson is Director of the U of T Institute for Life Course and Aging and Professor at the Factor-Inwentash Faculty of Social Work (FIFSW) and the Department of Family & Community Medicine.

Consistent with earlier studies, this study found insomnia to be negatively associated with mental health.  

“These findings underscore the importance of health professionals asking about sleep problems, particularly as chronic pain can undermine the quality of sleep,” says co-author Denise Marshall, a recent graduate of U of T’s FIFSW. “Among individuals with chronic pain, cognitive behavioral therapy or CBT has been shown to significantly reduce insomnia. CBT is an already established effective and relatively rapid treatment for depression and anxiety in the general population, and among those with chronic pain.”

Those with a confidant were much more likely to be in complete mental health than those without a confidant (60% vs 8%, respectively).

“Confidants are an important source of emotional and instrumental support,” says co-author Matthew Moses, also a recent graduate of the U of T’s FIFSW. “Although the exact mechanisms by which a confidant supports mental health are not fully understood, we hypothesize that the provision of emotional support can help enhance self-esteem and help the individual buffer general stress associated with the chronic pain.”  

Other factors associated with excellent mental health in the year preceding the survey included having no previous history of major depressive disorder and/or generalized anxiety disorder.

“The current research shifts away from a deficit-focused approach to mental health among individuals with arthritis, and instead uses a strengths-based perspective to explore factors associated with resilience in individuals with arthritis who are experiencing chronic and disabling pain.” says co-author Sally Abudiab, who also recently graduated from U of T’s FIFSW.

The study investigated factors associated with mental flourishing in a nationally representative sample of 620 Canadian adults drawn from the Canadian Community Health Survey-Mental Health who had been diagnosed with arthritis who are living with disabling chronic pain.

These bones were made for walking

Perhaps the most profound advance in primate evolution occurred about 6 million years ago when our ancestors started walking on two legs. The gradual shift to bipedal locomotion is thought to have made primates more adaptable to diverse environments and freed their hands to make use of tools, which in turn accelerated cognitive development. With those changes, the stage was set for modern humans.

The genetic changes that made possible the transition from knuckle-based scampering in great apes to upright walking in humans have now been uncovered in a new study by researchers at Columbia University and the University of Texas.

Using a combination of deep learning (a form of artificial intelligence) and genome-wide association studies, the researchers have created the first map of the genomic regions responsible for skeletal changes in primates that led to upright walking. The map reveals that genes that underlie the anatomical transitions observed in the fossil record were strongly acted on by natural selection and gave early humans an evolutionary advantage.

“On a more practical level, we’ve also identified genetic variants and skeletal features that are associated with hip, knee, and back arthritis, the leading causes of adult disability in the United States,” says Tarjinder Singh, PhD, assistant professor of computational and statistical genomics (in psychiatry) at the Columbia University Vagelos College of Physicians and Surgeons and a co-leader of the study. 

For example, slight deviations from the average hip width-to-height ratio were associated with an increased risk of hip osteoarthritis, while slight deviations in the tibia-femur angle were associated with an increased risk of knee osteoarthritis. These insights could help researchers devise new ways to prevent and treat these debilitating conditions.

The findings were published July 21 in Science. The study was co-led by Vagheesh M. Narasimhan, PhD, assistant professor of integrative biology and of statistics and data sciences at the University of Texas at Austin.

New techniques deployed

The researchers applied deep learning to analyze more than 30,000 full-body X-rays from the UK Biobank. Deep learning, a technology modeled after the brain’s neural networks, trains computers to do what comes naturally to humans, such as driving a car or translating languages. In this case, the technique was used to standardize the X-rays, remove any images with quality issues, and then precisely measure dozens of skeletal features, tasks that would have taken the researchers months, if not years, to complete. 

Next, the researchers scanned the human genome to identify chromosomal regions associated with variations in 23 key skeletal measures, such as shoulder width, torso length, and tibia-to-femur angle. (These scans, called genome-wide association studies, involve surveying the genomes of large groups of people, looking for genomic variants that occur more frequently in those with a specific disease or trait compared to those without the disease or trait.) This process revealed 145 regions associated with genes that regulate skeletal development. Only a handful of these loci were known from previous studies.

Many of the 145 regions overlapped with “accelerated” regions of the human genome, which have rapidly evolved over eons compared with the same regions in great apes. In contrast, few genes associated with the heart, immune system, metabolism, and other traits were found in accelerated regions. 

“What we’re seeing is the first genomic evidence that there was selective pressure on genetic variants that affect skeletal proportions, enabling a transition from knuckle-based walking to bipedalism,” says Narasimhan.  

The study also shows the power of combining large-scale biobank data, machine learning, and genomics to help us understand human health and disease. Singh, who joined Columbia in 2022, is now applying these techniques to understand the causes of mental illness.

Managing anxiety and depression in arthritis

Anxiety and depression are the mental health issues most commonly associated with inflammatory arthritis, and it is well-established that there is a link between mental health issues and poor health outcomes.2 The EULAR recommendations emphasize the need to assess mental health regularly;1 however, little is known about the association between self-management and mental health in people with inflammatory arthritis.

At the 2023 EULAR congress, Vestergaard and colleagues report on their cross-sectional study in Denmark. This included 42,407 adult patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), or spondylarthritis (axSpA). The aim was to find out more about the association between low self-management behavior and people’s mental health status.

A total of 12,713 people responded to the questionnaire. The results showed the prevalence of anxiety was highest for patients with axSpA and lowest for RA: 34.5% compared to 22.1%. When looking at depression, the prevalence was highest for patients with PsA and lowest for RA: 27.2% compared to 18.6%. For both anxiety and depression, the prevalence was higher in women, younger patients under the age of 55, those with more newly diagnosed diseases (less than 3 years), and patients with basic education.

Patients with clinical anxiety and depression were more likely to have low self-management behaviour for all included self-management measures, such as adherence to treatment, physical activity, and taking an active role in their healthcare.

These findings call for a systematic approach to identifying mental health issues in patients with inflammatory arthritis.

Osteoarthritis sufferers swing their way to better health.

Golf is acknowledged as a sport allowing players to blow off steam and enjoy the outdoors, but a new study led by the University of South Australia shows it may also have significant benefits for people with chronic disease osteoarthritis.

UniSA researcher Dr Brad Stenner from the Alliance for Research in Exercise, Nutrition and Activity (ARENA) and a team of academics from Australia and the UK found that golfers with the degenerative condition experience lower psychological distress and better general health compared to the general population.

The same was found with golfers without osteoarthritis.

The findings are reported in the Journal of Science and Medicine in Sport.

Osteoarthritis affects more than two million Australians who suffer joint pain and stiffness most commonly in their hands, neck, lower back, knees, or hips, contributing to a lower likelihood of meeting physical exercise guidelines.

Osteoarthritis is the most common form of arthritis, the leading cause of chronic pain and the second most common cause of disability.

In a survey of 459 golfers with osteoarthritis more than 90% of participants rated their health as good, very good or excellent, compared to just 64% of the general population with the condition.

Almost three times as many non-golfers (22%) reported high to very high levels of psychological distress compared to golfers with osteoarthritis (8%).

Dr Stenner, a lecturer and occupational therapist, says regular golfers are kept active due to the amount of walking required and they can also experience a range of social benefits.

“People who play golf are often walking 8-10km per round and, as such, are regularly meeting or exceeding recommended physical activity guidelines, which is known to reduce the risk of cardiovascular disease, diabetes, obesity and improve metabolic and respiratory health,” he says.

“There are also significant benefits to mental health and wellbeing.

“Our research has highlighted the important role that golf has in building friendships, contributing to community, and bringing a sense of belonging, all of which are known to contribute to mental health and wellbeing.”

Staying active and exercising regularly is one of the most important aspects of managing osteoarthritis.

“Lower impact activity such as golf can assist in maintaining activity whereas higher impact activities such as running, jogging and gym may place significant stress on the joints, contributing to increased symptoms and pain,” Dr Stenner says.

“There is a growing body of evidence that golf reduces the risk of many chronic conditions such as obesity, diabetes, and cardiovascular disease, and may contribute to the management of these illnesses, which in turn may lower the longer term health and medical costs.

“From a mental health point of view, playing golf is associated with improved wellbeing and lower levels of psychological distress, and this is an important consideration for older adults.”

Dr Stenner says there is a gap in the known literature on the topic despite it being one of the most popular sporting activities for older adults.

“Very little is known about the relationship between golf and health and there is so much more we need to find out,” he says.