Evidence for the benefit of aerobic and strengthening exercise in rheumatoid arthritis

Physiotherapy and occupational therapy in rheumatoid arthritis: Bridging functional and comorbidity gaps

Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disease affecting a significant portion of the global population. Despite advancements in pharmacological treatments, the management of RA remains complex, particularly in regard to comorbidities such as cardiovascular disease and osteoporosis. Physiotherapy (PT) and occupational therapy (OT) are non-pharmacological approaches that play a critical role in the management of RA. This review explores the impact of PT and OT in improving joint function, reducing pain and fatigue, and enhancing the overall quality of life in RA patients. It also addresses the role of these therapies in managing RA-related comorbidities, with an emphasis on exercise therapy, manual techniques, patient education and emerging digital interventions. Evidence supports the inclusion of tailored exercise regimens, such as cardiorespiratory training, resistance exercises and neuromotor activities, as vital components of RA management. By incorporating PT and OT, healthcare providers can better address the multifaceted needs of RA patients, complementing pharmacological treatments and improving long-term outcomes.

Online physical activity resources for individuals with rheumatoid arthritis: an environmental scan and quality appraisal

OBJECTIVES

To review publicly available physical activity (PA) resources for individuals with rheumatoid arthritis (RA). Aims were to find online print and audiovisual resources, review their characteristics and critically examine their quality from medical, exercise and behavioural science perspectives.

DESIGN

An environmental scan was completed using the Google search engine, following a pragmatic approach to reviewing patient-facing self-care resources.

DATA SOURCES

We used combinations of common search terms for RA and PA. The first five pages of results were reviewed for patient-facing resources.

ELIGIBILITY CRITERIA

Resources were included if they were (1) included RA-specific content, (2) provided specific PA recommendations, (3) written in English and (4) freely available.

DATA EXTRACTION AND SYNTHESIS

Two independent experts completed a medical review of resources to ensure appropriateness for RA. Data were then extracted by two reviewers using a standardised template to record resource characteristics. Two research team members and two patient partners independently evaluated resources for readability, understandability and actionability. Finally, the quality of exercise recommendations and behaviour change technique use was evaluated by an expert reviewer.

RESULTS

The search yielded 23 RA-specific PA resources, 17 of which passed the medical review. All 10 print resources and 7 audiovisual resources were created in English-speaking countries. The mean reading grade was 9.0±1.5. Print resources had mean understandability of 80.0±9.8% and actionability of 60.0±27.7%. Audiovisual materials had mean understandability of 86.0±9.2% and actionability of 86.9±22.9%. The quality of exercise recommendations was low. Only one resource provided comprehensive cardiovascular exercise advice, and two resources provided comprehensive strength exercise advice. 3-14 behaviour change technique groups were featured in each resource. The most common groups were 'shaping knowledge' and 'natural consequences'.

CONCLUSIONS

The quality of RA-specific PA resources is variable. Some high-quality resources exist that provide actionable PA behaviour change advice. Healthcare teams may refer patients to these resources. However, more work is needed to improve the overall quality of resources. Codevelopment with patients, providers and exercise behaviour change experts is recommended, ensuring resources are actionable, contain clear exercise recommendations and promote behaviour change.

Skeletal Muscle Pathology in Pulmonary Arterial Hypertension and Its Contribution to Exercise Intolerance

Pulmonary arterial hypertension is a disease of the pulmonary vasculature, resulting in elevated pressure in the pulmonary arteries and disrupting the physiological coordination between the right heart and the pulmonary circulation. Exercise intolerance is one of the primary symptons of pulmonary arterial hypertension, significantly impacting the quality of life. The pathophysiology of exercise intolerance in pulmonary arterial hypertension is complex and likely multifactorial. Although the significance of right ventricle impairment and perfusion/ventilation mismatch is widely acknowledged, recent studies suggest pathophysiology of the skeletal muscle contributes to reduced exercise capacity in pulmonary arterial hypertension, a concept explored herein.

Therapy for the Rheumatoid Hand

Rheumatoid arthritis (RA) of the hand results in the progressive, inflammatory destruction of multiple tissue types resulting in significant functional deficit. Occupational therapy for the hand often plays a synergistic role in the improvement of health-related quality of life outcomes when employed alongside biological, disease-modifying antirheumatic drugs, and surgical regimens. Furthermore, postoperative therapeutic rehabilitation protocols in patients with RA have been shown to optimize surgical outcomes. While significant clinical data exist to support the role of occupational therapy in RA, further investigation is warranted to compare treatment protocols to further improve functional outcomes for the rheumatoid hand.

Tailoring Strength Training Prescriptions for People with Rheumatoid Arthritis: A Scoping Review

Introduction: Prescribing strength training (ST) for people with rheumatoid arthritis (RA) is complicated by factors (barriers and facilitators) that affect participation. It is unclear whether guidelines include recommendations beyond prescription parameters (frequency, intensity, time, type, volume, and progression) and adequately incorporate participation factors tailored to people with RA. Objective: To summarize available recommendations to aid in the tailoring of ST prescriptions for people with RA. Methods: Medline, Embase, and CINAHL databases and gray literature were searched for guidelines, recommendations, and review articles containing ST prescription recommendations for RA. Article screening and data extraction were performed in duplicate by two reviewers. Results: Twenty-seven articles met the inclusion criteria. The recommendations address RA-specific ST participation factors including: knowledge gaps (of equipment, ST benefits, disease), memory problems, the management of joint deformity, comorbidity, the fluctuating nature of the disease and symptoms (pain, stiffness, flares), fear avoidance, motivation, need for referral to other professionals, and provision of RA-specific resources. Conclusion: This review summarizes recommendations for tailoring ST prescriptions for people with RA. Future research is required to understand how pain, symptom assessment, and unaddressed ST participation factors like sleep and medication side effects can be addressed to support ST participation amongst people with RA.

Follow-up of health-related quality of life and pain in a cohort of patients with rheumatoid arthritis before and after COVID-19

BACKGROUND

The foot is one of the anatomical structures of the body most affected in rheumatoid arthritis (RA), associated with the disability of patients, even more during COVID-19. The aim of this study was to analyse whether the period of physical inactivity during COVID-19 is an influential factor on health-related quality of life and foot pain in patients with RA.

METHODS

162 patients with foot pain and RA, recruited from the Hospital Virgen de las Nieves, Granada (Spain) were included. Data was collected during two different periods: January - December 2018 in person and June - September 2021 by phone. Patients were asked to complete the Spanish adapted version of the 12-Item Short Form Survey (SF-12) and the Visual Analogue Scale (VAS).

RESULTS

The results from the SF-12 questionnaires were divided between its two subscales (i.e., mental, and physical component). The physical component shows an improvement between 2018 and 2021, from 32.05 in 2018-35.18 in 2021 (p < 0.05). The opposite happened with the mental component, showing a deterioration, from 39.69 in 2018-34.48 in 2021 (p < 0.05). Regarding pain, VAS shows higher levels of pain with statistically significant differences, both in general pain (from 6 in 2018-7 in 2012) and in foot pain (from 5 to 7), (p < 0.05).

CONCLUSION

Mental quality of life and pain, both general and foot pain, are influenced by the period of physical inactivity during COVID-19.

LEVEL OF EVIDENCE

Level II.

Novel aspects of muscle involvement in immune-mediated inflammatory arthropathies and connective tissue diseases

Myalgia, myopathy and myositis are the most important types of muscle impairment in immune-mediated inflammatory arthropathies and connective tissue diseases. Multiple pathogenetic and histological changes occur in the striated muscles of these patients. Clinically, the most important muscle involvement is the one that causes complaints to the patients. In everyday practice, insidious symptoms present a serious problem for the clinician; in many cases, it is difficult to decide when and how to treat the muscle symptoms that are often present only subclinically. In this work, authors review the international literature on the types of muscle problems in autoimmune diseases. In scleroderma histopathological picture of muscle shows a very heterogeneous picture, necrosis and atrophy are common. In rheumatoid arthritis and systemic lupus erythematosus, myopathy is a much less defined concept, further studies are needed to describe it. According to our view, overlap myositis should be recognized as a separate entity, preferably with distinct histological and serological characteristics. More studies are needed to describe muscle impairment in autoimmune diseases which may help to explore this topic more in depth and be of clinical use.

The Preventive Role of Physical Activity in Systemic Sclerosis: A Cross-Sectional Study on the Correlation with Clinical Parameters and Disease Progression

Although exercise is associated with improved health in many medical conditions, little is known about the possible influences of physical activity (PA) habits pre- and post- a diagnosis of systemic sclerosis (SSc) on disease activity and progression. This cross-sectional study assessed, for the first time, self-reported pre- and post-diagnostic PA levels with the aim to verify if changes in these levels were correlated with demographic/anthropometric data (e.g., weight, height, gender, age, BMI), disease duration, diagnostic/clinical parameters (e.g., skin involvement, pulmonary hemodynamic/echocardiographic data, disease activity) related to disease activity and progression, and quality of life in a population-based sample of patients with SSc. Adult participants (n = 34, age 56.6 ± 13.3 years) with SSc (limited cutaneous SSc, lcSSc, n = 20; diffuse cutaneous SSc, dcSSc, n = 9; sine scleroderma SSc, n = 5) were enrolled at the Division of Rheumatology and Clinical Immunology of the Humanitas Research Hospital. All medical data were recorded during periodic clinical visits by a rheumatologist. Moreover, all subjects included in this study completed extensive questionnaires to evaluate their health-related quality of life (HRQOL), and others related to health-related physical activity performed before (PRE) and after (POST) the diagnosis of disease. The linear regression analysis has shown that either a high Sport_index or Leisure_index in the PRE-diagnostic period was correlated with lower disease duration in dcSSc patients. Physical load during sport activity and leisure time accounted for ~61.1% and ~52.6% of the individual variation in disease duration, respectively. In lcSSc patients, a high PRE value related to physical load during sporting activities was correlated with a low pulmonary artery systolic pressure (sPAP) and the POST value of the Work_index was positively correlated with the left ventricular ejection fraction (LVEF), and negatively with creatine kinase levels (CK). Interestingly, the univariate analysis showed that Work_index accounts for ~29.4% of the variance in LVEF. Our analysis clearly reinforces the concept that high levels of physical load may play a role in primary prevention-delaying the onset of the disease in those subjects with a family history of SSc-as well as in secondary prevention, improving SSc management through a positive impact on different clinical parameters of the disease. However, it remains a priority to identify a customized physical load in order to minimize the possible negative effects of PA.

Functional exercise capacity in rheumatoid arthritis unrelated to lung injury: A comparison of women with and without rheumatoid disease

BACKGROUND

Rheumatoid arthritis (RA) mainly affects the joints of the upper and lower limbs, so evaluating functional exercise capacity in individuals with RA via dynamic tests of the locomotor system is essential.

OBJECTIVES

To compare functional exercise capacity using the Glittre-activities of daily living (ADL) test (G-AT) in women with and without RA in the absence of RA pulmonary disease (RA-PD) and to correlate the findings with hand functioning, physical functioning, handgrip strength (HGS), and quadriceps strength (QS).

METHODS

This cross-sectional pilot study evaluated 35 women with RA and 25 healthy controls by assessing hand functioning using the Cochin Hand Functional Scale (CHFS), physical functioning with the Health Assessment Questionnaire Disability Index (HAQ-DI), muscle functioning using HGS and QS, and G-AT results.

RESULTS

Compared to the women in the control group, the women with RA presented higher scores for the CHFS (p< 0.0001) and HAQ-DI (p< 0.0001) and lower HGS (p< 0.0001) and QS (p= 0.013) values. The median G-AT time was higher in the RA patients than in the healthy controls [300 (295-420) vs. 180 (155-203) s], p< 0.0001), and the greatest difficulty reported by patients after the G-AT was squatting to perform the shelving tasks. G-AT time was positively correlated with the HAQ-DI (rs= 0.668, p< 0.0001) and CHFS (rs= 0.586, p= 0.0007) and negatively correlated with QS (rs=-0.429, p= 0.037). There was no significant correlation between the G-AT time and HGS.

CONCLUSIONS

Women with RA take longer to perform G-AT tasks. Moreover, G-AT time was associated with hand functioning, physical functioning and QS, but not with HGS.

Assessment of Rheumatoid Hand Function as a Characteristic Feature of Rheumatoid Arthritis in Patients Treated with Methotrexate or Methotrexate with Biological Agents with and without Deformation of Hands

BACKGROUND

The hand is an excellent work tool that provides the functional ability to mechanical work. The hand is affected in rheumatoid arthritis (RA) patients, it is a significant problem in the functional sphere as a result of deformities, the grasping function limitation and muscle strength.

OBJECTIVES

The aim of the study was the assessment of grip strength, endurance and manipulation abilities of rheumatoid hands with or without deformities treated with methotrexate (MTX) or MTX plus biologics (MTX+BIO).

MATERIAL AND METHODS

The study involved 80 RA women, (40 received MTX+BIO, 40 MTX), treated at the Rheumatology Department of the Central Clinical Hospital of Interior Affairs in Warsaw. VAS-pain, DAS28, SDAI, HAQ, HAQ hands, estimation of hand grip strength, endurance, manipulation ability were analyzed.

RESULTS

In group MTX+BIO values of DAS28 (3.7±1.3 vs 4.3±1.2, p=0.019), HAQ (0.72 ± 0.57 vs 1.08± 0.87, p=0.011) and HAQ-hand (0.85±0.65 vs. 1.19±0.68, p=0.024) were statistically lower than in MTX group. Hand deformations recorded in 35 (43.7%) cases, 16 (40%) in MTX group, 19 (47.5%) in MTX+BIO. Comparison of grip strength, endurance, manipulation ability showed better results in MTX+BIO group with deformities (significance level from 0.013 to 0.046) than in MTX group. Relative differences in hand function in MTX + BIO group ranged from 10.8% (maximal power grip strength) to 127.6% (minimal hand endurance), after disease duration adjustment - from 28.2% (maximal power grip strength) to 148.4% (minimal hand endurance).

CONCLUSION

Measuring grip strength, hand endurance, manipulation abilities are useful in RA patients with hand deformities.

Effects of Locomotion Training on the Physical Functions and Quality of Life in Patients with Rheumatoid Arthritis: A Pilot Clinical Trial

Objectives:

Methods:

Results:

Conclusions:

Predictors of response to TNF inhibitors in rheumatoid arthritis: an individual patient data pooled analysis of randomised controlled trials

Objective

To identify patient characteristics associated with responsiveness to tumour necrosis factor inhibitors (TNFi) in rheumatoid arthritis (RA).

Materials and methods

Individual patient data from 29 randomised controlled trials (RCTs) evaluating the efficacy of a TNFi versus placebo or conventional therapy were obtained. Response to treatment was assessed in subgroups according to the following baseline characteristics: smoking status, physical activity, sex, age, body mass index, autoantibody profile, disease duration, high initial disease activity defined by Disease Activity Score on 28 joints (DAS28)(C reactive protein (CRP)) >5.1. The primary outcome was the between-treatment group difference in DAS28(CRP) change from baseline to 6 months. The secondary endpoints were the between-treatment group difference in final DAS28(CRP) measured until 6 months and EULAR response criteria until 6 months. Data from each RCT were then pooled by the Mantel-Haenszel method using a random effects model. A linear metaregression was also carried out on two data-sharing platforms separately to support the results.

Results

Individual data of 11 617 patients from 29 RCTs were analysed. Until 6 months, a significantly higher EULAR non-response rate was observed in obese patients (OR 0.52 vs 0.36 for non-obese, p=0.01). A multivariable regression model performed on 7457 patients indicated that patients treated by TNFi had a final DAS28(CRP) decreased by 0.02 for each year of disease duration (p<0.001), and a 0.21 decreased for patients with a baseline DAS28(CRP) >5.1 (p<0.001).

Conclusions

In RA, patients who are more responsive to TNFi are those who are non-obese, have a long disease duration and have a high initial disease activity.

Relationship between disease activity level and physical activity in rheumatoid arthritis using a triaxial accelerometer and self-reported questionnaire

Objective

This study evaluated the relationship between rheumatoid arthritis (RA) disease activity level and physical activity (PA) by using an accelerometer and self-reported questionnaire.

Results

The cross-sectional study was part of a cohort study designed to determine disease activity is associated with PA in RA patients. We classified patients with a Disease Activity Score 28-erythrocyte sedimentation rate (DAS28-ESR) of less than and higher than 3.2 into the low-disease-activity (LDA) group and moderate/high-disease-activity (MHDA) group, respectively. We measured the wear time, time of vigorous-intensity PA, moderate-intensity PA, light-intensity PA, and sedentary behavior per day using a triaxial accelerometer. 34 patients were included in the study. The accelerometer-measured moderate-to-vigorous PA (MVPA) was 17.2 min/day and 10.6 min/day in the LDA group and MHDA group (p < 0.05), respectively. There was no significant association between RA disease activity level and accelerometer-measured PA with adjustment for age and Functional Assessment of Chronic Illness Therapy-Fatigue score. There was no correlation between accelerometer-measured MVPA and self-reported MVPA in the MHDA group, but these factors were correlated in the LDA group (rs = 0.57, p < 0.05). In conclusion, no significant association was noted between RA disease activity level and accelerometer-measured PA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-021-05666-w.

Evidence for the efficacy of Tai Chi for treating rheumatoid arthritis: an overview of systematic reviews

BACKGROUND

Rheumatoid arthritis (RA) is a chronic disease with higher prevalence among women aged between 30 and 50 years and general prevalence of 1% worldwide. Interventions promoting improvement of quality of life for individuals with RA are required. Tai Chi appears to be a low-cost alternative, with studies showing positive results from this technique. However, regarding aspects of RA such as pain and sensitivity, studies remain inconclusive.

OBJECTIVES

To compare the effectiveness of the Tai Chi method for treating patients diagnosed with rheumatoid arthritis, among systematic reviews.

DESIGN AND SETTING

Overview of systematic reviews with Cochrane and non-Cochrane methodology.

METHODS

Systematic reviews involving quasi-randomized and randomized clinical trials (RCTs) on use of Tai Chi, with no restrictions regarding the date and language of publication, were included.

RESULTS

Three systematic reviews were included. The effects of Tai Chi associated with education and stretching exercises versus education and stretching were evaluated in these reviews. They showed that improvements in the variables of mood, depression and functional index were associated with use of Tai Chi.

CONCLUSIONS

The findings suggest that clinical improvement was achieved, although not statistically significant with regard to pain and disease pattern, as assessed using the ACR20 measurement. Improvements relating to disability and quality of life were also seen. There was a low level of evidence and therefore caution in data analysis is recommended. The three studies included showed poor reliability for providing an accurate and complete summary of use of Tai Chi among people diagnosed with rheumatoid arthritis.

PROSPERO

CRD42019125501.

Identification of differentially expressed genes, signaling pathways and immune infiltration in rheumatoid arthritis by integrated bioinformatics analysis

Background

The disability rate associated with rheumatoid arthritis (RA) ranks high among inflammatory joint diseases. However, the cause and potential molecular events are as yet not clear. Here, we aimed to identify differentially expressed genes (DEGs), pathways and immune infiltration involved in RA utilizing integrated bioinformatics analysis and investigating potential molecular mechanisms.

Materials and methods

The expression profiles of GSE55235, GSE55457, GSE55584 and GSE77298 were downloaded from the Gene Expression Omnibus database, which contained 76 synovial membrane samples, including 49 RA samples and 27 normal controls. The microarray datasets were consolidated and DEGs were acquired and further analyzed by bioinformatics techniques. Gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses of DEGs were performed using R (version 3.6.1) software, respectively. The protein-protein interaction (PPI) network of DEGs were developed utilizing the STRING database. Finally, the CIBERSORT was used to evaluate the infiltration of immune cells in RA.

Results

A total of 828 DEGs were recognized, with 758 up-regulated and 70 down-regulated. GO and KEGG pathway analyses demonstrated that these DEGs focused primarily on cytokine receptor activity and relevant signaling pathways. The 30 most firmly related genes among DEGs were identified from the PPI network. The principal component analysis showed that there was a significant difference between the two tissues in infiltration immune.

Conclusion

This study shows that screening for DEGs, pathways and immune infiltration utilizing integrated bioinformatics analyses could aid in the comprehension of the molecular mechanisms involved in RA development. Besides, our study provides valuable data related to DEGs, pathways and immune infiltration of RA and may provide new insight into the understanding of molecular mechanisms.

The feasibility of an exercise intervention to improve sleep (time, quality and disturbance) in people with rheumatoid arthritis: a pilot RCT

Current rheumatology guidelines recommend exercise as a key component in the management of people with RA, however, what is lacking is evidence on its impact on sleep. Objective is to assess the feasibility of a walking-based intervention on TST, sleep quality, and sleep disturbance and to generate potential effect size estimates for a main trial. Participants were recruited at weekly rheumatology clinics and through social media. Patients with RA were randomized to a walking-based intervention consisting of 28 sessions, spread over 8 weeks (2-5 times/week), with 1 per week being supervised by a physiotherapist, or to a control group who received verbal and written advice on the benefits of exercise. Primary outcomes were recruitment, retention, protocol adherence and participant experience. The study protocol was published and registered in ClinicalTrials.gov NCT03140995. One hundred and one (101) people were identified through clinics, 36 through social media. Of these, 24 met the eligibility criteria, with 20 randomized (18% recruitment; 100% female; mean age 57 (SD 7.3 years). Ten intervention participants (100%) and eight control participants (80%) completed final assessments, with both groups equivalent for all variables at baseline. Participants in the intervention group completed 87.5% of supervised sessions and 93% of unsupervised sessions. No serious adverse events were related to the intervention. Pittsburgh Sleep Quality Index global score showed a significant mean improvement between the exercise group-6.6 (SD 3.3) compared to the control group-0.25 (SD 1.1) (p = 0.012); Intervention was feasible, safe and highly acceptable to study participants, with those participants in the exercise group reporting improvements in sleep duration and sleep quality compared to the control group. Based on these findings, a fully powered randomized trial is recommended. Trial registration number: ClinicalTrials.gov Identifier: NCT03140995 (April 25th, 2017).

Efficacy of physical activities on children with juvenile idiopathic arthritis: a randomized controlled trial

Background

Juvenile idiopathic arthritis (JIA) is one of the serious chronic rheumatic disorders in children and adolescents which results in less physical activities and restlessness hours than their peer. The study aims to assess the efficacy of physical fitness training exercises on aerobic capacity and muscular strength of children with JIA. Sixty-five children with JIA were included in the study, out of a total of 70 children who were screened for eligibility. Children were randomized to a control group (n = 32) who received hot packs, transcutaneous electrical nerve stimulation (TENS), and strengthening exercises, or a study group (n = 33) who received a physical fitness training program (hydrotherapy pool exercises, bicycle ergometer, and treadmill apparatus) in addition to what had been given to the control group. Both groups were engaged in a training program for 12 consecutive weeks for three times per week. Evaluation was done pre- and post-interventions included: peak oxygen uptake (Vo2 peak) during an incremental treadmill test and muscle strength assessed by isokinetic dynamometer.

Results

The current study showed that there were significant differences between pre- and post-interventions in both groups (P < 0.05). Comparing the two groups, there were statistically significant differences between children in both groups in favor of the study group (P < 0.05).

Conclusions

Physical fitness exercise training resulted in improved aerobic capacity and muscle strength of children with JIA. The obtained results suggested that children with arthritis could participate in formal exercise testing and structural physical fitness program.

Trial registration

PACTR, PACTR201907504136763. Registered on May 21, 2019. Retrospectively registered, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID = 8150.

Knowledge of cardiovascular disease risk in rheumatoid arthritis patients before and after educational intervention from a Southeast Asia country: Malaysia

Objectives

This study aims to improve knowledge on cardiovascular disease (CVD) risk among rheumatoid arthritis (RA) patients using a multi- language leaflet tailored to our multi-ethnic patient population.

Patients and methods

This was a prospective study conducted in Hospital Pulau Pinang, Malaysia, between March 2015 and June 2015. Educational intervention was provided to 96 patients (11 males, 85 females; mean age 52.4±12.9 years; range, 20 to 83 years) who fulfilled the inclusion/exclusion criteria. Questionnaires to assess knowledge of CVD risk were given to patients to be answered before reading the informative leaflet, after one hour of intervention, and during their next follow-up three months from the intervention. Both the informative leaflet and questionnaires were prepared in English and then translated into Malay and Chinese languages to suit the need of local patients.

Results

Our results showed that RA patients had good knowledge at baseline regarding risk of smoking, hypertension, and hyperlipidemia on increasing CVD risk and that exercise would not damage their joints. However, they had low knowledge at baseline regarding the amount of exercise needed for lower CVD risks and risk of CVD with use of anti-inflammatory drugs in RA. Total knowledge score increased significantly from baseline immediately after educational intervention. However, total knowledge score decreased after three months compared to immediate post- intervention phase while it was still significantly higher compared to baseline. The improvement was most obvious for knowledge regarding anti- inflammatory drugs and CVD risk and knowledge regarding the number of flares and CVD risk. Our study did not find any significant association between demographic characteristics and traditional cardiovascular risk factors with knowledge of CVD risk.

Conclusion

Rheumatoid arthritis patients have low knowledge regarding their CVD risk related to their disease. The intervention of providing an informative leaflet effectively improved the knowledge of this group of patients on CVD risk particularly in the field related to RA-specific risk.

Low-Load Resistance Training With Blood-Flow Restriction in Relation to Muscle Function, Mass, and Functionality in Women With Rheumatoid Arthritis

OBJECTIVE

To evaluate the effects of a low-load resistance training program associated with partial blood-flow restriction in patients with rheumatoid arthritis (RA).

METHODS

Forty-eight women with RA were randomized into 1 of 3 groups: high-load resistance training (HL-RT; 70% 1 repetition maximum [1RM]), low-load resistance training (30% 1RM) with partial blood-flow restriction training (BFRT), and a control group. Patients completed a 12-week supervised training program and were assessed for lower-extremity 1RM, quadriceps cross-sectional area (CSA), physical function (timed-stands test [TST], timed-up-and-go test [TUG], and Health Assessment Questionnaire [HAQ]), and quality of life (Short Form 36 health survey [SF-36]) at baseline and after the intervention.

RESULTS

BFRT and HL-RT were similarly effective in increasing maximum dynamic strength in both leg press (22.8% and 24.2%, respectively; P < 0.0001 for all) and knee extension (19.7% and 23.8%, respectively; P < 0.0001 for all). Quadriceps CSA was also significantly increased in both BFRT and HL-RT (9.5% and 10.8%, respectively; P < 0.0001 for all). Comparable improvements in TST (11.2% and 14.7%; P < 0.0001 for all) and TUG (-6.8% [P < 0.0053] and -8.7% [P < 0.0001]) were also observed in BFRT and HL-RT, respectively. Improvements in both groups were significantly greater than those of the control group (P < 0.05 for all). SF-36 role physical and bodily pain and HAQ scores were improved only in BFRT (45.7%, 22.5%, and -55.9%, respectively; P < 0.05 for all). HL-RT resulted in 1 case of withdrawal and several cases of exercise-induced pain, which did not occur in BFRT.

CONCLUSION

BFRT was effective in improving muscle strength, mass, function, and health-related quality of life in patients with RA, emerging as a viable therapeutic modality in RA management.

The Association Between Yoga Use, Physical Function, and Employment in Adults With Rheumatoid Arthritis

Mind-body exercises such as yoga offer patients with rheumatoid arthritis (RA) a symptom management strategy for improving physical and mental health. Studies have evaluated yoga to manage symptoms of RA and improve physical function; however, none has examined the relationship between yoga and work status in adults with RA. The objective was to describe differences in RA symptomatology, physical function scores, and work status between adults with RA who participate in yoga and those who do not. This cross-sectional study surveyed adults with rheumatologist-diagnosed RA regarding yoga use in the past year, symptoms, physical function, and work status. Differences between yoga and non-yoga participation groups were assessed with 2-sided t tests or Pearson χ tests. Multivariate linear regression analyses were conducted to identify significant associations between yoga participation and primary outcomes. The sample included 398 adults with RA; 88% were females, 66% were white, mean age 61.8 years, mean disease duration 24.8 years; 10.6% participated in yoga. Vinyasa, Bikram, Hatha, Iyengar, and restorative yoga styles were practiced, mostly in a group setting. Yoga participants were significantly more likely to work full-time, less likely to be unable to work due to disability, and had better physical function. These findings characterize yoga practice and practitioners among adults with RA. In adults with RA, yoga participation is associated with full-time work status and better physical function than nonparticipation. This study adds additional information to the growing body of literature about adults with RA who practice yoga.

The impact of cardiorespiratory fitness on classical cardiovascular disease risk factors in rheumatoid arthritis: a cross-sectional and longitudinal study

Rheumatoid arthritis (RA) is associated with an increased risk of cardiovascular disease (CVD). Advanced measures of cardiorespiratory fitness (CRF) are associated with CVD risk factors. The present study aimed to examine whether CVD risk factors can predict clinic-based measures of CRF, using the Siconolfi step test and to determine if exercise can improve RA patients' cardiovascular health. Sixty-five RA patients (46 females, age 58 ± 11 years) completed assessments of CRF, CVD risk factors, body composition and RA characteristics. Ten patients participated in a follow-up 8-week exercise intervention. CRF was low (22 ml kg^-1 min^-1) and associated with higher diastolic blood pressure (r = - 0.37, p = 0.002), higher global CVD risk (r = - 0.267,  p = 0.031) and worse body composition profile (body fat, r = - 0.48, p < 0.001; waist, r = - 0.65, p < 0.001; hip, r = - 0.58, p < 0.001). Regular exercise significantly improved CRF (p = 0.021), lower body strength (p < 0.001), agility (p < 0.001), systolic blood pressure (p = 0.021), body fat (p = 0.018), waist circumference (p = 0.035), hip circumference (p = 0.016), disease activity (p = 0.002), disability (p = 0.007) and QoL (p = 0.004). Elevated diastolic blood pressure and worse body composition profile are strong predictors of clinic-based measures of CRF. CRF is an important determinant of CVD risk and warrants inclusion in the routine assessment of RA patients. Regular exercise can improve CRF and CVD risk factors without any exacerbation of disease activity and should be offered as part of routine care.

Eccentric training enhances the αB-crystallin binding to the myofibrils and prevents skeletal muscle weakness in adjuvant-induced arthritis rat

Patients with rheumatoid arthritis (RA) frequently suffer from muscle weakness. We examined whether eccentric training prevents skeletal muscle weakness in adjuvant-induced arthritis (AIA) rat, a widely used animal model for RA. AIA was induced in the knees of Wistar rats by injection of complete Freund’s adjuvant. To induce eccentric contractions (ECCs), neuromuscular electrical stimulation (45 V) was applied to the plantar flexor muscles simultaneously with forced dorsiflexion of the ankle joint (0–40°) and was given every 6 s. ECC exercise was applied every other day for a total of 11 sessions and consisted of 4 sets of 5 contractions. There was a significant reduction in in vitro maximum Ca2+-activated force in skinned fibers in gastrocnemius muscle from AIA rats. These changes were associated with reduced expression levels of contractile proteins (i.e., myosin and actin), increased levels of inflammation redox stress-related biomarkers (i.e., TNF-α, malondialdehyde-protein adducts, NADPH oxidase 2, and neuronal nitric oxide synthase), and autolyzed active calpain-1 in AIA muscles. ECC training markedly enhanced the steady-state levels of αB-crystallin, a small heat shock protein, and its binding to the myofibrils and prevented the AIA-induced myofibrillar dysfunction, reduction in contractile proteins, and inflammation-oxidative stress insults. Our findings demonstrate that ECC training preserves myofibrillar function without muscle damage in AIA rats, which is at least partially attributable to the protective effect of αB-crystallin on the myofibrils against oxidative stress-mediated protein degeneration. Thus ECC training can be a safe and effective intervention, counteracting the loss of muscle strength in RA patients.

NEW & NOTEWORTHY Eccentric contractions (ECCs) are regarded as an effective way to increase muscle strength. No studies, however, assess safety and effectiveness of ECC training on muscle weakness associated with rheumatoid arthritis. Here, we used adjuvant-induced arthritis (AIA) rats to demonstrate that ECC training prevents intrinsic contractile dysfunction without muscle damage in AIA rats, which may be attributed to the protective effect of αB-crystallin on the myofibrils against inflammation-oxidative stress insults.

Factors associated with physical activity engagement among adults with rheumatoid arthritis: A cross-sectional study

OBJECTIVES

Physical activity (PA) has a number of benefits for rheumatoid arthritis (RA) patients. However, these patients are more physically inactive than the general population. The primary aim of this study was to investigate factors associated with PA engagement among RA patients. The secondary aim was to identify their preference for PA support.

METHODS

There were 96 participants, 76 of whom were female, with a mean age of 56.9 years (range = 34-72 years) and a median RA disease duration of 5 years (interquartile range = 2-12). All patients completed questionnaires assessing demographic status, health status (including cardiovascular disease [CVD] risk and RA disease profile), PA levels and preferences, alongside the perceived benefits of-and barriers to-PA. Hierarchical regressions were carried out to assess the relationship between reported PA levels and both engagement determinants and disease features.

RESULTS

Forty-five per cent (n = 44) had low levels (<600 metabolic equivalent-min/week) of PA. Low level of PA was significantly associated with: CVD risk profile (η_p ²  = 0.118, p < 0.002); functional disability (η_p ²  = 0.206, p < 0.032); pain (η_p ²  = 0.154, p < 0.028); general personal (η_p ²  = 0.190, p < 0.001) and arthritis-specific personal (η_p ²  = 0.170, p < 0.001) barriers to PA; age (η_p ²  = 0.076, p < 0.026); and sedentary behaviour (η_p ²  = 0.275, p < 0.001). Participants displayed a preference for unsupervised (n = 37, 38.5%), low-intensity (n = 45, 46.9%), indoor home (n = 50, 52.1%) exercises, with no preferences for the diversity of the exercise prescribed (n = 39, 40.6%) or for who provided the exercise counselling (n = 34, 35.4%).

CONCLUSIONS

These results suggest that CVD profile, disability, pain, and general and arthritis-specific personal barriers are associated with PA levels among RA patients. Intervention development should address these factors to facilitate an increase in PA uptake.

Perceived Versus Performance Fatigability in Patients With Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic, inflammatory disease that affects 1% of the general population. Fatigue is a common complaint of patients with RA, however their perceived fatigue may be more exacerbated than objective measures of fatigue may indicate. The assessment of fatigue is made complex due to inconsistent and vague terms used to define fatigue, and the task dependence of fatigability. Fatigue is defined as a state of exhaustion and decreased strength, while fatigability indicates an individual's susceptibility to fatigue. In order to offer some clarity to the manifestation of fatigue in clinical populations, in this review we outline that fatigue should be described with subsections that are related to the symptom, such as: perceived fatigability and performance fatigability. Where perceived fatigability indicates the subjective state of the individual and thus involves the individual's subjective measure of fatigue, performance fatigability would be measured through clinical and laboratory-based assessments that quantify the functional decline in performance. This review describes RA and the various neuromuscular changes associated with the disease that can lead to alterations in both perceived and performance fatigue. From there, we discuss fatigue and RA, how fatigue can be assessed, effects of exercise interventions on RA symptoms and fatigue, and recommendations for future studies investigating subjective and objective measures of fatigability.

[Physical therapy options in rheumatic diseases: what is evidence-based?]

Rheumatic diseases usually progress towards morphological and functional deficits and thus cause impairment of physical health and function. Based on this fact, physiotherapeutic options are elementary and indispensable. This article focuses on the significance and importance of physiotherapy in inflammatory and degenerative rheumatic diseases. Furthermore, an overview is presented on the consequences of rheumatic diseases, the reality of supply of physiotherapy, the principles and therapeutic options, and the evidence.

Exercise for Athletes With Inflammatory Arthritis

Advances in pharmacologic management of inflammatory conditions have allowed those living with these conditions to pursue fitness activities previously difficult due to functional limitations. With that said, many patients with inflammatory arthritis are still not active enough. In this article, we review specific exercise recommendations for a number of inflammatory conditions with a focus on overall health promotion and cardiovascular disease risk reduction, discuss exercise as an adjunct to pharmacologic disease management, and review potential risks of sport participation for athletes with inflammatory arthritis conditions.

Ten weeks of high-intensity interval walk training is associated with reduced disease activity and improved innate immune function in older adults with rheumatoid arthritis: a pilot study

Background

Rheumatoid arthritis (RA) is a chronic inflammatory disease in which adults have significant joint issues leading to poor health. Poor health is compounded by many factors, including exercise avoidance and increased risk of opportunistic infection. Exercise training can improve the health of patients with RA and potentially improve immune function; however, information on the effects of high-intensity interval training (HIIT) in RA is limited. We sought to determine whether 10 weeks of a walking-based HIIT program would be associated with health improvements as measured by disease activity and aerobic fitness. Further, we assessed whether HIIT was associated with improved immune function, specifically antimicrobial/bacterial functions of neutrophils and monocytes.

Methods

Twelve physically inactive adults aged 64 ± 7 years with either seropositive or radiographically proven (bone erosions) RA completed 10 weeks of high-intensity interval walking. Training consisted of 3 × 30-minute sessions/week of ten ≥ 60-second intervals of high intensity (80–90% VO_2reserve) separated by similar bouts of lower-intensity intervals (50–60% VO_2reserve). Pre- and postintervention assessments included aerobic and physical function; disease activity as measured by Disease Activity score in 28 joints (DAS28), self-perceived health, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR); plasma interleukin (IL)-1β, IL-6, chemokine (C-X-C motif) ligand (CXCL)-8, IL-10, and tumor necrosis factor (TNF)-α concentrations; and neutrophil and monocyte phenotypes and functions.

Results

Despite minimal body composition change, cardiorespiratory fitness increased by 9% (change in both relative and absolute aerobic capacity; p < 0.001), and resting blood pressure and heart rate were both reduced (both p < 0.05). Postintervention disease activity was reduced by 38% (DAS28; p = 0.001) with significant reductions in ESR and swollen joints as well as improved self-perceived health. Neutrophil migration toward CXCL-8 (p = 0.003), phagocytosis of Escherichia coli (p = 0.03), and ROS production (p < 0.001) all increased following training. The frequency of cluster of differentiation 14-positive (CD14⁺)/CD16⁺ monocytes was reduced (p = 0.002), with both nonclassical (CD14^dim/CD16^bright) and intermediate (CD14^bright/CD16^positive) monocytes being reduced (both p < 0.05). Following training, the cell surface expression of intermediate monocyte Toll-like receptor 2 (TLR2), TLR4, and HLA-DR was reduced (all p < 0.05), and monocyte phagocytosis of E. coli increased (p = 0.02). No changes were observed for inflammatory markers IL-1β, IL-6, CXCL-8, IL-10, CRP, or TNF-α.

Conclusions

We report for the first time, to our knowledge, that a high-intensity interval walking protocol in older adults with stable RA is associated with reduced disease activity, improved cardiovascular fitness, and improved innate immune functions, indicative of reduced infection risk and inflammatory potential. Importantly, the exercise program was well tolerated by these patients.

Trial registration

ClinicalTrials.gov, NCT02528344. Registered on 19 August 2015.

Pain sensitivity at rest and during muscle contraction in persons with rheumatoid arthritis: a substudy within the Physical Activity in Rheumatoid Arthritis 2010 study

Background

We aimed to explore pressure pain sensitivity and the function of segmental and plurisegmental exercise-induced hypoalgesia (EIH) in persons with rheumatoid arthritis (RA) compared with healthy control subjects (HC).

Methods

Forty-six participants with RA (43 female, 3 male) and 20 HC (16 female, 4 male) participated in the study. Pressure pain thresholds, suprathreshold pressure pain at rest, and segmental and plurisegmental EIH during standardised submaximal contractions were assessed by algometry. Assessments of EIH were made by performing algometry alternately at the contracting (30% of the individual maximum) right m. quadriceps and the resting left m. deltoideus.

Results

Participants with RA had higher sensitivity to pressure pain (RA, 318 kPa; HC, 487 kPa; p < 0.001), suprathreshold pressure pain 4/10 (RA, 433 kPa; HC, 638 kPa; p = 0.001) and suprathreshold pressure pain 7/10 (RA, 620 kPa; HC, 851 kPa; p = 0.002) than HC. Segmental EIH (RA, 0.99 vs 1.27; p < 0.001; HC, 0.89 vs 1.10; p = 0.016) and plurisegmental EIH (RA, 0.95 vs 1.36; p < 0.001; HC, 0.87 vs 1.31; p < 0.001) increased significantly during static muscle contraction in both groups alike (p > 0.05).

Conclusions

Our results indicate a generally increased pain sensitivity but normal function of EIH among persons with RA and offer one possible explanation for pain reduction observed in this group of patients following clinical exercise programmes.

Trial registration

ISRCTN registry, ISRCTN25539102. Retrospectively registered on 4 March 2011.

Effects of a 12-week cardiovascular rehabilitation programme on systemic inflammation and traditional coronary artery disease risk factors in patients with rheumatoid arthritis (CARDIA trial): a randomised controlled trial

INTRODUCTION

Patients with systemic inflammatory diseases such as rheumatoid arthritis (RA) have an increased risk of cardiovascular disease (CVD) above the baseline risk attributable to traditional CVD risk factors seen in the general population. Exercise in cardiac rehabilitation (CR) is designed specifically for high-risk primary prevention and those with established CVD. Even though the European League Against Rheumatism guidelines state that exercise is safe for individuals with RA and exercise can reduce CVD risk, patients with RA rarely participate in CR. Thus, little is known about CR's impact on inflammatory and CVD risk in the RA population. The purpose of this trial is to determine the feasibility of a 12-week CR programme for patients with RA and whether it decreases CVD risk without exacerbating RA.

METHODS AND ANALYSIS

This is a randomised controlled trial whereby 60 participants with RA will be recruited and randomly assigned to either standard of care (SOC) treatment or SOC plus a 12-week CR programme (60 min of education plus two 60 min aerobic exercise sessions/week). Exercise will be performed at 60%-80% of heart rate reserve. Outcome measures (Framingham Risk Score, resting heart rate, blood pressure, blood lipids, markers of systemic inflammation (ie, interleukin (IL) 6 and tumour necrosis factor-α (TNF-α), Clinical Disease Assessment Index, Disease Activity Score-28, physical activity levels and peak cardiorespiratory fitness) will be assessed preintervention (week-0), postintervention (week-13) and 6 months postintervention.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Nova Scotia Health Authority Research Ethics Board. Results will be submitted for publication in an appropriate peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT01534871; Pre-results.

Exercise and Inflammatory Bowel Disease: Insights into Etiopathogenesis and Modification of Clinical Course

There is sparse information regarding exercise and inflammatory bowel disease (IBD). Furthermore, the importance of regular exercise in the optimal management of IBD has not received attention in guidelines and is often overlooked by practitioners. This article summarizes evidence regarding health benefits of exercise, guidelines regarding exercise in the general population and chronic inflammatory disorder populations, limitations regarding exercise capacity in patients with IBD, the association of lack of exercise with IBD pathogenesis, the role of exercise in beneficially modulating IBD clinical course, and extraintestinal benefits of exercise in patients with IBD.

Enjoyment of exercise among people with arthritis: An inductive thematic analysis

Past research into exercise among people with long-term health conditions has paid surprisingly little attention to the concept of enjoyment. This study explored enjoyment of exercise among people with arthritis. Semi-structured interviews were held with 12 participants aged 20-85 years. The transcripts were analysed using inductive thematic analysis. Four themes were identified: enjoyment of exercise in relation to other people, benefits of exercise in relation to enjoyment, working around barriers to enjoy exercise and finding an enjoyable balance to exercise. These themes highlight the relevance of enjoyment and how it could feature in advice about exercise for people with arthritis.

Muscle Weakness in Rheumatoid Arthritis: The Role of Ca2+ and Free Radical Signaling

In addition to the primary symptoms arising from inflammatory processes in the joints, muscle weakness is commonly reported by patients with rheumatoid arthritis (RA). Muscle weakness not only reduces the quality of life for the affected patients, but also dramatically increases the burden on society since patients' work ability decreases. A 25–70% reduction in muscular strength has been observed in pateints with RA when compared with age-matched healthy controls. The reduction in muscle strength is often larger than what could be explained by the reduction in muscle size in patients with RA, which indicates that intracellular (intrinsic) muscle dysfunction plays an important role in the underlying mechanism of muscle weakness associated with RA. In this review, we highlight the present understanding of RA-associated muscle weakness with special focus on how enhanced Ca^2 + release from the ryanodine receptor and free radicals (reactive oxygen/nitrogen species) contributes to muscle weakness, and recent developments of novel therapeutic interventions.

•

Muscle weakness is commonly reported by patients with rheumatoid arthritis (RA).

•

Intrinsic muscle weakness is important in the underlying mechanisms of muscle weakness associated with rheumatoid arthritis.

•

Enhanced Ca^2 + release and peroxynitrite-induced stress contributes to RA-induced muscle weakness.

A Qualitative Study Exploring Community Yoga Practice in Adults with Rheumatoid Arthritis

OBJECTIVE

Yoga may improve physical function and reduce disease symptoms in adults with rheumatoid arthritis (RA). However, little is known about how patients with RA are practicing yoga in the community. The objective of this qualitative study was to explore community yoga practice characteristics and thoughts about yoga practice for adults with RA.

DESIGN

Participants completed a semi-structured telephone interview with open-ended questions. Thematic analysis was used to analyze interview transcripts.

PARTICIPANTS

A convenience sample of 17 adults with rheumatologist-diagnosed RA who had participated in yoga within the past year were asked about the decision to start, continue, and stop yoga; the perceived benefits of yoga; components of yoga sessions; and general thoughts about yoga as it relates to RA.

RESULTS

Although eight different styles of yoga were practiced, commonalities in yoga class components (such as stretching, strengthening, deep breathing, meditation, and positive messaging from the instructor) reveal examples of preferred types of yoga for patients with RA. Three main themes emerged, each with multiple subthemes: (1) motivators (physical fitness, influence of others, reduced price), (2) barriers (cost, symptom burden, class difficulty), and (3) benefits of yoga practice (mind-body, a tool for coping, pride/achievement, social, and "yoga meets you where you are").

CONCLUSION

In this study, patients with RA described how yoga practice helped improve physical and psychosocial symptoms related to their disease. Yoga practice, a dynamic exercise, encompassing many different styles, can provide many benefits for adults with RA; however, yoga may not be beneficial for every adult with RA.

Resistance Training as a Tool for Preventing and Treating Musculoskeletal Disorders

The aging process is characterized by several physiological, morphological, and psychological alterations that result in a decreased functional and health status throughout the life span. Among these alterations, the loss of muscle mass and strength (sarcopenia) is receiving increased attention because of its association with innumerous age-related disorders, including (but not limited to) osteoporosis, osteoarthritis, low back pain, risk of fall, and disability. Regular participation in resistance training programs can minimize the musculoskeletal alterations that occur during aging, and may contribute to the health and well-being of the older population. Compelling evidence suggest that regular practice of resistance exercise may prevent and control the development of several musculoskeletal chronic diseases. Moreover, resistance training may also improve physical fitness, function, and independence in older people with musculoskeletal disorders, which may result in improved quality of the years lived. In summary, regular participation in resistance training programs plays an important role in aging and may be a preventive and therapeutic tool for several musculoskeletal disorders.

Does exercise impact on sleep for people who have rheumatoid arthritis? A systematic review

To systematically search for the availability of evidence for exercise impacting on sleep for people who have rheumatoid arthritis. Two reviewers independently searched seven electronic databases, identified and extracted relevant studies by applying eligibility criteria. Sources of bias were assessed independently by two reviewers using the Cochrane bias assessment tool for randomized controlled trials (RCTs) and Newcastle-Ottawa Quality Assessment Scale for non-RCTs. Data were synthesized using a level of evidence approach. Meta-analyses were deemed to be inappropriate due to the heterogeneity of study designs, measurement tools and interventions. Five studies were included: one RCT; two pilot RCTs and two samples of convenience. A total of 262 people with RA were included. Interventions used were difficult to assess due to the heterogeneity of study designs and the inclusion of two using different types of yoga as an intervention. Different sleep outcome measures were used thus, it was not feasible to pool results. Studies had a high risk of bias. This review could find no consistent or conclusive evidence on whether exercise impacts on sleep in people who have rheumatoid arthritis, therefore no firm conclusions can be made. However, there is some indication that exercise may have positive benefits on sleep in people who have rheumatoid arthritis. Further studies with improved study designs, using subjective and objective measures, are needed.

Medical Yoga Therapy

Medical yoga is defined as the use of yoga practices for the prevention and treatment of medical conditions. Beyond the physical elements of yoga, which are important and effective for strengthening the body, medical yoga also incorporates appropriate breathing techniques, mindfulness, and meditation in order to achieve the maximum benefits. Multiple studies have shown that yoga can positively impact the body in many ways, including helping to regulate blood glucose levels, improve musculoskeletal ailments and keeping the cardiovascular system in tune. It also has been shown to have important psychological benefits, as the practice of yoga can help to increase mental energy and positive feelings, and decrease negative feelings of aggressiveness, depression and anxiety.

Exercise for haemophilia

BACKGROUND

Haemophilia is a bleeding disorder associated with haemorrhaging into joints and muscles. Exercise is often used to aid recovery after bleeds, and to improve joint function in the presence of arthropathy.

OBJECTIVES

Our objective was to systematically review the available evidence on the safety and effectiveness of exercise for people with haemophilia.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register and electronic databases PubMed, OVID-Embase, and CINAHL. We hand searched abstracts from congresses of the World Federation of Hemophilia and the European Hematology Association, trial registries and the reference lists of relevant articles.Date of the last search of the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register: 14 December 2016.

SELECTION CRITERIA

Randomized or quasi-randomized controlled studies comparing any exercise intervention considered relevant in haemophilia management including supervised, unsupervised, aquatic, strengthening, aerobic or cardiovascular, stretching, proprioceptive and balance training exercise programs in males of any age with haemophilia A or B of any severity (those with co-morbidities were not excluded).

DATA COLLECTION AND ANALYSIS

Two authors reviewed the identified abstracts to determine their eligibility. For studies meeting the inclusion criteria, full articles were obtained. The two authors extracted data and assessed the risk of bias. Any disagreements were resolved by discussion. The authors contacted study investigators to obtain any missing data.

MAIN RESULTS

Eight studies were included, which represented 233 males with all severities of haemophilia A and B, ranging in age from eight years to 49 years. Study duration ranged from four to 12 weeks. Exercise interventions varied greatly and included resistance exercises, isometric exercises, bicycle ergometry, treadmill walking and hydrotherapy; therefore, comparison between studies was difficult.None of the studies measured or reported adverse effects from the interventions. None of the studies reported outcomes regarding bleed frequency, quality of life or aerobic activity. Overall risk of bias across all studies was assessed as unclear.Very few studies provided sufficient information for comparison. None of the studies reported data that favoured the control group. One study reported that six weeks of resistance training improved joint health status (Colorado score) compared to controls. The addition of pulsed electromagnetic fields also improved ankle scores compared to exercises alone, but this was not seen in the elbows or knees.Two studies reported statistically significant improvements in pain intensity after exercise interventions compared to controls. Hydrotherapy exercises produced significant decreases in pain compared to controls and land-based exercise groups.Two studies found improvement in joint motion in the exercise group compared to controls. One study compared land- and water-based exercises; there was no difference in the range of motion between the two groups; however, the water-based exercise group did show improvement over the control group.One study, comparing joint traction and proprioceptive neuromuscular facilitation for the elbow to a control group, showed no differences in biceps girth or strength after 12 weeks of intervention.Some studies reported comparisons between interventions. In one study, treadmill training significantly improved balance in children compared to bicycle ergometry. Another study added partial weight bearing exercises to quadriceps exercises and showed improved walking tolerance.Four studies evaluated quadriceps or hamstring strength (or both). The addition of bicycle ergometry and exercises with weights was more effective than static exercises and treadmill walking for strengthening knee flexors and extensors. Partial weight-bearing exercises through range were more effective than static and short arc exercises for improving knee extensor strength. The addition of treadmill walking to ultrasound, stretching and strengthening exercises showed increased peak torque of knee flexors and extensors and decrease in knee effusion.The results should be interpreted with caution due to the quality of evidence (GRADE) as outlined in the summary of findings tables, which demonstrates that all but one of the outcomes assessed were rated as low or very low due to the small sample sizes and potential bias.

AUTHORS' CONCLUSIONS

These results must be considered with caution. There is a lack of confidence in the results due to the small number of included studies and the inability to pool the results due to the heterogeneity of outcome measures. Most exercise interventions produced improvement in one or more of the measured outcomes including pain, range of motion, strength and walking tolerance. Hydrotherapy may be more effective than land exercises for pain relief in adults. Functional exercises such as treadmill walking and partial weight bearing exercises seem to be more effective than static or short arc exercises for improving muscle strength. These findings are consistent with the many non-controlled intervention reports in the haemophilia literature. No adverse effects were reported as a result of any of the interventions. However, some groups used prophylactic factor prior to exercise and other groups studied only subjects with moderate haemophilia. Therefore, the safety of these techniques for persons with severe haemophilia remains unclear.

Green tea and exercise interventions as nondrug remedies in geriatric patients with rheumatoid arthritis

This study aimed to evaluate the effects of green tea and supervised exercise training interventions on improvement of disease activity and bone metabolism markers in rheumatoid arthritis patients. [Subjects and Methods] One-hundred and twenty subjects who had a mean age of (60.7 ± 2.53 years) and had been diagnosed with rheumatoid arthritis at least ten years previously were randomly included in this study. Patients were treated with infliximab, green tea, or a supervised exercise program for six months. Disease activity markers as well as antioxidant activity of green tea extracts were estimated before supplementation using in vitro assays. [Results] Rheumatoid arthritis patients treated with green tea for 6 months alone or in combination with infliximab or an exercise program showed significant improvement in disease activity parameters, including C-reactive protein, and erythrocyte sedimentation rate, swollen and tender joints counts, and modified Stanford Health Assessment Questionnaire score, along with an increase in serum levels of bone resorption markers, i.e., deoxypyridinoline, amino-terminal telopeptide of type 1 collagen, and bone alkaline phosphatase, at 6 months of after initial treatment. The European League Against Rheumatism and American College of Rheumatology scores revealed more clinical improvement in the disease activity of rheumatoid arthritis patients treated with green tea along with exercise compared with rheumatoid arthritis patients treated with infliximab or exercise combinations. This may have been due to the higher potential antioxidant activity of green tea (89.6% to 96.5%). [Conclusion] Both exercise and green tea interventions appeared to be beneficial as nondrug modulates for rheumatoid arthritis disorders.

A prospective pilot study to evaluate an animated home-based physical exercise program as a treatment option for patients with rheumatoid arthritis

Background

Physical exercises and physiotherapy are of great importance for maintenance of joint function in patients with rheumatoid arthritis (RA). However, many RA patients complain about problems to receive prescriptions or have a lack of access to physiotherapy. Recent reports have shown positive effects of the Wii game console on physical and psychosocial conditions of patients with other underlying diseases. The primary objectives of this prospective controlled pilot study were to investigate feasibility and patients’ assessment using an animated home-based exercise program.

Method

This pilot study was conducted as a single-center, cross-over trial with two treatment arms over 24 weeks. Eligibility criteria included patients with RA reaching low disease activity under therapy with a biological disease modifying anti-rheumatic drug (bDMARD). After detailed instruction, 15 patients started with a conventional home-based physical exercise program and 15 patients began with a predefined animated exercise program by using the Wii game console for 12 weeks. Afterwards, patients were crossed-over to the other treatment arm for another period of 12 weeks.

Multi-methodical assessments were performed by qualitative analysis of the interview-data as well as statistical analysis of functional tests and patient reported outcomes (PRO’s).

Results

Evaluation of the interviews indicated feasibility and usefulness of the chosen animated home-based exercise program. Forefoot disabilities were identified as a main limiting factor for performing some of the animated exercises. After 12 weeks, both treatment arms showed improvement of functional tests without significant differences between groups: Overall muscle strength improved for a mean value of 10 Newton (+12 %) and the mean 6-min walk test (6-MWT) distance increased for 28 meters (+5 %).

Conclusion

This study showed that an animated home-based exercise program by using a Wii game console was feasible and beneficial for RA patients. Compared to standard physical home exercises, similar effects were observed indicating that such an animated program might be an alternative supportive option for RA patients.

Trial registration

ClinicalTrials.gov ID: NCT02658370 (19-Jan-2016).

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-016-1208-3) contains supplementary material, which is available to authorized users.

Role of physical activity in the management and assessment of rheumatoid arthritis patients

OBJECTIVES

Rheumatoid arthritis (RA) is a chronic inflammatory disease affecting diarthrodial joints, in which patients tend to perform less physical activity (PA) than recommended. This review focuses on the existing evidence about the relationship of PA and RA, specifically how the former influences joint inflammation, disability, quality of life and pain in RA patients, and also how disease activity potentially impacts PA in these patients.

METHODS

A literature search of EMBASE and MEDLINE databases from January 2000 to January 2015.

RESULTS

The evidence indicating that PA in RA patients is safe and the benefits from regularly performing, both aerobic and resistance exercises, in these patients include improvement in: quality of life, functionality, pain and number of swollen joints. Interestingly, recent studies suggest that changes in disease activity in RA patients inversely correlate with variations in PA, as assessed by accelerometry.

CONCLUSIONS

The regular monitoring of PA in RA patients might facilitate a more objective evaluation of variations in disease activity, helping physicians to make general and therapeutic recommendations that will improve both the health status and the joint functionality of these patients.

Classifying Back Pain and Peripheral Joint Complaints in Inflammatory Bowel Disease Patients: A Prospective Longitudinal Follow-up Study

BACKGROUND AND AIMS

Peripheral joint complaints [pJTC] and chronic back pain [CBP] are the most common extra-intestinal manifestations in patients with inflammatory bowel disease [IBD]. This prospective study evaluates variables associated with joint/back pain, including IBD disease activity.

METHODS

IBD patients with back pain ≥ 3 months and/or peripheral joint pain/swelling [n = 155], and IBD patients without joint complaints [n = 100; controls], were followed for a period of 1 year. Patients were classified as having SpondyloArthritis [SpA] according to several sets of criteria. Statistical analysis included logistic regression models and linear mixed model analysis.

RESULTS

Of the 155 patients with joint/back pain, 13 had chronic back pain, 80 peripheral joint complaints, and 62 axial and peripheral joint complaints. Smoking, female gender, and IBD disease activity were independently associated with IBD joint/back pain. The Assessment in Spondyloarthritis International Society criteria for axial and peripheral SpA were fulfilled in 12.3% of patients, with 9.7% [n = 15] receiving a rheumatological diagnosis of arthritis. During the 12-month follow-up, the majority of the patients reporting joint/back pain remained stable.

CONCLUSIONS

In our cohort, the majority of IBD patients reported joint/back pain and SpA was relatively common. To facilitate effective care, gastroenterologists should be aware of the various features of SpA to classify joint complaints and, by making use of an efficient referral algorithm, to refer CBP patients to the rheumatologist.

Rheumatoid arthritis patients' experience of climate care

The purpose of this qualitative study was to understand and examine how patients with rheumatoid arthritis (RA) experience climate care and its effects. A qualitative approach was chosen for the study. Two men and six women were interviewed according to a semistructured interview guide. The text was analyzed using a manifest content analysis. The analysis resulted in four categories and 10 subcategories. The interviewees experienced climate care positively. The training was perceived increasing gradually. The patients felt that they performed to a maximum capacity during training and were impressed by the staff’s enthusiasm and encouragement. The patients felt that they were involved in the goal setting and the choice of treatment, and the staff noticed individual needs. There was a feeling among the patients of being acknowledged by the staff. Information about the disease was perceived as individualized. The climate and beautiful surroundings were viewed as encouraging physical activity and a feeling of well-being. Patients made new friends, had fun together and also shared experiences about their disease. Furthermore, the patients described a sense of belonging to a group as well as a feeling of not being the only one that was sick among the healthy. Not having to do everyday tasks and having time to themselves were perceived positively. Several factors contributed to the positive experiences of climate care; climate, environment, physical activity, social context, staff involvement, and information about the disease were described as interacting together and resulting in a sense of well-being. A proposal for future research would be to examine if/how the various factors might interact and affect the RA patients’ illness and quality of life.

The beneficial effects of Tai Chi exercise on endothelial function and arterial stiffness in elderly women with rheumatoid arthritis

Background

Rheumatoid arthritis (RA) has been known to be associated with increased risk of cardiovascular disease (CVD). The aim of this study was to investigate the effects of Tai Chi exercise on CVD risk in elderly women with RA.

Method

In total, 56 female patients with RA were assigned to either a Tai Chi exercise group (29 patients) receiving a 3-month exercise intervention once a week or a control group (27 patients) receiving general information about the benefits of exercise. All participants were assessed at baseline and at 3 months for RA disease activity (Disease Activity Score 28 and Routine Assessment of Patient Index Data 3), functional disability (Health Assessment Questionnaire), CVD risk factors (blood pressure, lipids profile, body composition, and smoking), and three atherosclerotic measurements: carotid intima-media thickness, flow-mediated dilatation (FMD), and brachial-ankle pulse wave velocity (baPWV).

Results

FMD, representative of endothelial function, significantly increased in the Tai Chi exercise group (initial 5.85 ± 2.05 versus 3 months 7.75 ± 2.53 %) compared with the control group (initial 6.31 ± 2.12 versus 3 months 5.78 ± 2.13 %) (P = 1.76 × 10⁻³). Moreover, baPWV, representative of arterial stiffness, significantly decreased in the Tai Chi exercise group (initial 1693.7 ± 348.3 versus 3 months 1600.1 ± 291.0 cm/s) compared with the control group (initial 1740.3 ± 185.3 versus 3 months 1792.8 ± 326.1 cm/s) (P = 1.57 × 10⁻²). In addition, total cholesterol decreased significantly in the Tai Chi exercise group compared with the control group (−7.8 ± 15.5 versus 2.9 ± 12.2 mg/dl, P = 2.72 × 10⁻²); other changes in RA-related characteristics were not significantly different between the two groups. Tai Chi exercise remained significantly associated with improved endothelial function (FMD; P = 4.32 × 10⁻³) and arterial stiffness (baPWV; P = 2.22 × 10⁻²) after adjustment for improvement in total cholesterol level.

Conclusion

Tai Chi exercise improved endothelial dysfunction and arterial stiffness in elderly women with RA, suggesting that it can be a useful behavioral strategy for CVD prevention in patients with RA.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-015-0893-x) contains supplementary material, which is available to authorized users.

Assessment of the Quality of Delivered Care for Iranian patients with Rheumatoid Arthritis by Using Comprehensive Quality Measurement Model in Health Care (CQMH)

Introduction: Quality of care has become increasingly critical in the evaluation of healthcare and healthcare services. The aim of this study was to assess quality of delivered care among patients with rheumatoid arthritis using a model of Comprehensive Quality Measurement in Health Care (CQMH).

Methods: This cross-sectional study was conducted on 172 patients with rheumatoid arthritis (RA) who were received care from private clinics of Isfahan University of medical sciences in 2013. CQMH questionnaires were used for assessing the quality of care. Data were analyzed using SPSS for Windows.

Results: The mean scores of Quality Index, Service Quality (SQ), Technical Quality (TQ), and Costumer Quality (CQ) were 72.70, 79.09, 68.54 and 70.25 out of 100, respectively. For CQ only 19.8% of participations staying the course of action even under stress and financial constraints, there is a significant gap between what RA care they received with what was recommended in the guideline for TQ. Scores of service quality was low in majority of aspects especially in "availability of support group" section.

Conclusion: Study shows paradoxical findings and expresses that quality scores of service delivery for patients with arthritis rheumatoid from patient's perspective is relatively low. Therefore, for fixing this paradoxical problem, improving the participation of patients and their family and empowering them for self-management and decision should be regarded by health systems.

Physical activity of elderly patients with rheumatoid arthritis and healthy individuals: an actigraphy study

BACKGROUND

Most people with rheumatoid arthritis (RA) are physically inactive. An accelerometer worn on the waist has been used to evaluate physical activity in people with chronic conditions. It is useful for evaluating moderate to vigorous activity, although it tends to underestimate light or mild activities such as housework or family duties. An accelerometer worn on the wrist (i.e., actigraph) has recently been used to capture daily physical activity in inactive individuals. The purposes of this study were to investigate physical activity measured by an actigraph in patients with RA and in healthy individuals and to investigate the association between actigraphic data and self-reported physical function.

METHODS

The subjects were 20 RA patients and 20 healthy individuals. All participants wore an actigraph on their wrist for 6-7 consecutive days. They also completed the Health Assessment Questionnaire disability index (HAQ-DI) and the Medical Outcomes Study (MOS) 36-item short form health survey (SF-36). We extracted three parameters from the actigraphic data: mean activity count (MAC), peak activity count (PAC), and low activity ratio (LAR). These three parameters were compared between the RA patients and healthy individuals and with the self-reported questionnaires.

RESULTS

The MAC was significantly lower and the LAR was significantly higher in RA patients than in healthy individuals. The PAC was not different between the two groups. The LAR was negatively correlated with the MAC for the RA patients and for the healthy individuals. The decrease ratio of the LAR with the increase of the MAC for the RA patients was twice that of the healthy participants. In the RA patients, the LAR was significantly and moderately correlated with the HAQ-DI score and two dimensions of the SF-36 (i.e., "physical functioning" and "bodily pain").

CONCLUSION

Investigation of the proportion of low activity count using an actigraph may be useful to identify characteristics of the physical function in RA patients.

Preserved skeletal muscle protein anabolic response to acute exercise and protein intake in well-treated rheumatoid arthritis patients

Introduction

Rheumatoid arthritis (RA) is often associated with diminished muscle mass, reflecting an imbalance between protein synthesis and protein breakdown. To investigate the anabolic potential of both exercise and nutritional protein intake we investigated the muscle protein synthesis rate and anabolic signaling response in patients with RA compared to healthy controls.

Methods

Thirteen RA patients (age range 34–84 years; diagnosed for 1–32 years, median 8 years) were individually matched with 13 healthy controls for gender, age, BMI and activity level (CON). Plasma levels of C-reactive protein (CRP), interleukin (IL)-6 and tumor necrosis factor (TNF)-α were measured using enzyme-linked immunosorbent assay (ELISA) in resting blood samples obtained on two separate days. Skeletal muscle myofibrillar and connective tissue protein fractional synthesis rate (FSR) was measured by incorporation of the amino acid ¹³C₆-phenylalanine tracer in the overnight fasted state for 3 hours (BASAL) and 3 hours after intake of whey protein (0.5 g/kg lean body mass) alone (PROT, 3 hrs) and in combination with knee-extensor exercise (EX) with one leg (8 × 10 reps at 70 % of 1RM; PROT + EX, 3 hrs). Expression of genes related to inflammatory signaling, myogenesis and muscle growth/atrophy were analyzed by real-time reverse transcriptase-polymerase chain reaction (RT-PCR).

Results

CRP was significantly higher in the RA patients (2.25 (0.50) mg/l) than in controls (1.07 (0.25) mg/l; p = 0.038) and so was TNF-α (RA 1.18 (0.30) pg/ml vs. CON 0.64 (0.07) pg/ml; p = 0.008). Muscle myofibrillar protein synthesis in both RA patients and CON increased in response to PROT and PROT + EX, and even more with PROT + EX (p < 0.001), with no difference between groups (p > 0.05). The gene expression response was largely similar in RA vs. CON, however, expression of the genes coding for TNF-α, myogenin and HGF1 were more responsive to exercise in RA patients than in CON.

Conclusions

The study demonstrates that muscle protein synthesis rate and muscle gene expression can be stimulated by protein intake alone and in combination with physical exercise in patients with well-treated RA to a similar extent as in healthy individuals. This indicates that moderately inflamed RA patients have maintained their muscle anabolic responsiveness to physical activity and protein intake.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-015-0758-3) contains supplementary material, which is available to authorized users.