What are the recommended lifestyle changes and alternative treatments with scientific proof for managing psoriatic arthritis?

Lifestyle Changes and Alternative Treatments for Psoriatic Arthritis

Smoking cessation is the single most important lifestyle change you should make, supported by moderate-quality evidence as a strong recommendation, while exercise and weight loss (if overweight/obese) provide additional benefits for disease control and quality of life. 1

Strongly Recommended Lifestyle Modifications

Smoking Cessation

• Stop smoking immediately—this is a strong recommendation with the highest level of evidence (moderate quality) among all lifestyle interventions for psoriatic arthritis. 1
• Smoking cessation improves disease outcomes and reduces systemic inflammation beyond just general health benefits. 1

Weight Loss (If Overweight/Obese)

• Achieve weight loss if your BMI is elevated—this improves disease activity independently of other interventions. 1
• Weight loss is conditionally recommended based on low-quality evidence, but the clinical benefits are substantial for disease control. 1
• Mediterranean diet adherence shows inverse correlation with ESR, PASI scores, and body surface area involvement (p=0.009-0.056). 2
• Even after adjusting for BMI, exercise retains positive correlation with disease activity, while Mediterranean diet shows significant correlation with enthesitis (p=0.015). 2

Exercise Recommendations

General Exercise Principles

• Engage in regular exercise rather than remaining sedentary—this is conditionally recommended despite low-quality evidence. 1
• Exercise reduces disease activity (DAPSA scores, p=0.004), tender joint counts (p=0.003), swollen joint counts (p=0.015), ESR (p=0.001), and PASI scores (p=0.015). 2
• Exercise reduces systemic inflammation, pain, fatigue, and helps control comorbidities like dysmetabolism and obesity. 3

Specific Exercise Types

Low-Impact Exercise (Preferred)

• Choose low-impact activities such as tai chi, yoga, or swimming over high-impact exercises like running. 1
• This is a conditional recommendation based on very-low-quality evidence, but the safety profile favors low-impact options. 1
• High-impact exercise may be considered only due to patient preference. 1

Cardiorespiratory Training

• High-intensity interval training (11 weeks) in patients with low disease activity produces long-term increases in peak oxygen uptake and short-term decreases in truncal fat percentage. 4
• This represents the highest quality evidence (low risk of bias) among physical therapy interventions. 4

Resistance Training

• Resistance exercises improve functional capacity, disease activity, pain, and general health even in patients with active disease, though muscle strength gains may not be significant. 4
• Combine supervised aerobic, strength, endurance, and stretching exercises at progressively increasing intensity. 3

Important Exercise Caveats

• Avoid exercise if you have existing muscle/tendon injury or multiple inflamed symptomatic joints with worsening pain during exercise. 1
• Regular practice of motor activity should be personalized according to disease activity, phenotype, comorbidities, and individual tolerability. 3

Rehabilitation Therapies

Physical Therapy

• Consider physical therapy to improve function and reduce pain—this is conditionally recommended based on very-low-quality evidence. 1
• Physical therapy may be declined due to patient preference, out-of-pocket costs, distance to facility, or lack of transportation. 1
• Physical therapy provides additional benefits by reducing disease activity and improving function beyond pharmacological treatment. 5

Occupational Therapy

• Consider occupational therapy for functional improvement—conditionally recommended based on low-quality evidence. 1
• Similar barriers apply as with physical therapy (cost, access, patient preference). 1

Alternative/Complementary Therapies

Massage Therapy

• Massage therapy may be considered over no massage therapy, though evidence is very low quality. 1
• May be declined due to associated costs. 1

Acupuncture

• Acupuncture may be considered as an adjunctive treatment, though evidence is very low quality. 1
• May be declined due to associated costs. 1

Dietary Interventions

Mediterranean Diet

• Adopt a Mediterranean diet pattern—this shows correlation with reduced disease activity markers. 2
• Higher Mediterranean diet adherence associates with reduced ESR (p=0.056), PASI (p=0.011), and BSA indices (p=0.009). 2
• Approximately 44% of psoriatic arthritis patients do not follow a Mediterranean diet, representing a significant opportunity for intervention. 2
• Mediterranean diet effects on disease activity are independent of BMI reduction. 2

Clinical Context and Pitfalls

Common Pitfall: Most patients show low exercise patterns (72.4% of PsA patients) and poor dietary adherence (43.4% don't follow Mediterranean diet), yet these interventions have measurable effects on disease outcomes. 2

Important Consideration: While the quality of evidence for most non-pharmacological interventions is low to very low, the 2018 ACR/NPF guidelines still conditionally recommend them because they improve quality of life, reduce symptoms, and have minimal risks compared to pharmacological options. 1

Multidisciplinary Approach: The polyhedral clinical expression of psoriatic arthritis necessitates combining pharmacological treatments with these lifestyle modifications for optimal outcomes. 3

Comorbidity Management: PsA patients have significantly more comorbidities than psoriasis-only patients (42.7% vs 26.3%, p=0.038), making lifestyle interventions particularly important for overall health management. 2