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

Dynamic exercise programs (aerobic capacity and/or muscle strength training) in patients with rheumatoid arthritis

BACKGROUND

An up-to-date overview of the effectiveness and safety of dynamic exercise therapy (exercise therapy with a sufficient intensity, duration, and frequency to establish improvement in aerobic capacity and/or muscle strength) is lacking.

OBJECTIVES

To assess the effectiveness and safety of short-term (< three months) and long-term (> three months) dynamic exercise therapy programs (aerobic capacity and/or muscle strength training), either land or water-based, for people with RA. To do this we updated a previous Cochrane review (van den Ende 1998) and made categories for the different forms of dynamic exercise programs.

SEARCH STRATEGY

A literature search (to December 2008) within various databases was performed in order to identify randomised controlled trials (RCTs).

SELECTION CRITERIA

RCTs that included an exercise program fulfilling the following criteria were selected: a) frequency at least twice weekly for > 20 minutes; b) duration > 6 weeks; c) aerobic exercise intensity > 55% of the maximum heart rate and/or muscle strengthening exercises starting at 30% to 50% of one repetition maximum; and d) performed under supervision. Moreover, the RCT included one or more of the following outcome measures: functional ability, aerobic capacity, muscle strength, pain, disease activity or radiological damage.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected eligible studies, rated the methodological quality, and extracted data. A qualitative analysis (best-evidence synthesis) was performed and, where appropriate, a quantitative data analysis (pooled effect sizes).

MAIN RESULTS

In total, eight studies were included in this updated review (two additional studies). Four of the eight studies fulfilled at least 8/10 methodological criteria. In this updated review four different dynamic exercise programs were found: (1) short-term, land-based aerobic capacity training, which results show moderate evidence for a positive effect on aerobic capacity (pooled effect size 0.99 (95% CI 0.29 to 1.68). (2) short-term, land-based aerobic capacity and muscle strength training, which results show moderate evidence for a positive effect on aerobic capacity and muscle strength (pooled effect size 0.47 (95% CI 0.01 to 0.93). (3) short-term, water-based aerobic capacity training, which results show limited evidence for a positive effect on functional ability and aerobic capacity. (4) long-term, land-based aerobic capacity and muscle strength training, which results show moderate evidence for a positive effect on aerobic capacity and muscle strength. With respect to safety, no deleterious effects were found in any of the included studies.

AUTHORS' CONCLUSIONS

Based on the evidence, aerobic capacity training combined with muscle strength training is recommended as routine practice in patients with RA.

How do middle-aged patients conceive exercise as a form of treatment for knee osteoarthritis?

PURPOSE

To describe conceptions, as registered by a semi-structured interview, of exercise as treatment among sixteen middle-aged patients with moderate to severe knee osteoarthritis.

METHOD

Sixteen patients (aged 39-64) with symptomatic, radiographic knee osteoarthritis and previous participants in an exercise intervention, were interviewed. The qualitative data obtained were analysed using phenomenographic approach.

RESULTS

Four descriptive categories containing 13 conceptions emerged: Category 1) To gain health included five conceptions; to experience coherence, to experience well-being, to be in control, to experience improved physical functioning, to experience symptom relief; 2) To become motivated included three conceptions; to experience inspiration, to be prepared to persevere, to experience the need to exercise; 3) To experience the need for support included three conceptions; to have structure, to receive guidance, to devote time; 4) To experience resistance included two conceptions; to hesitate, to deprecate.

CONCLUSION

Patients with knee osteoarthritis and knee pain, previously participating in exercise intervention, are aware of the health benefits of exercise, but have many doubts and concerns about exercise as treatment. These aspects should be considered when designing patient information and treatment programmes. Furthermore, a hesitative and resistive perception of exercise as a concept could have major influences on the implementation of health programmes.

Non-drug therapies in early rheumatoid arthritis

Non-pharmacological treatment modalities are often used as an adjunct to drug therapy in patients with rheumatoid arthritis (RA). The aim of this overview is to summarize the available evidence on the effectiveness of these modalities in early RA. The few available randomized controlled trials that have specifically investigated patients with early RA support the effectiveness of dynamic exercise and cognitive behavioural interventions, and to a lesser extent of joint protection programmes and foot orthoses. The effectiveness of multidisciplinary team-care programmes, specialist nurse care, electro-physical modalities (including passive hydrotherapy), wrist orthoses, and dietary interventions have not been studied in patients with early RA. Current recommendations on the usage of non-pharmacological treatment modalities in sets of guidelines on the management of early RA vary with respect to their scope, strength and level of detail. The results of this review indicate a need for further investigation into the most clinically effective and cost-effective strategies to deliver non-pharmacological treatment modalities as well as comprehensive arthritis care models in early RA.

[Physical activity for prevention and therapy of internal diseases in the elderly]

There is a growing number of elderly people in Western societies. Therefore, the prevalence of age-associated diseases increases. For most of these conditions, exercise and physical activity play a major role in the prevention and therapy. However, it is well established that the level of physical activity is lowest in elderly people. Physical fitness continues to be the most important protective health factor and should be improved in the elderly population. Many exercise recommendations include only endurance programs, but strength and coordination also deliver positive therapeutic effects in cardiovascular and metabolic diseases, lung diseases, neoplasms, and many other pathologic conditions including dementia. Age-specific recommendations should be included in exercise programs for health.

Physical activity and quality of life in subjects with chronic disease: chronic obstructive pulmonary disease compared with rheumatoid arthritis and diabetes mellitus

OBJECTIVE

Chronic diseases interfere with the life situation of the affected person in different ways. The aim was to compare the burden of disease in three chronic diseases - chronic obstructive pulmonary disease (COPD), rheumatoid arthritis (RA), diabetes mellitus (DM) - and in healthy subjects, with a particular interest in physical activity, quality of life, and psychological health.

DESIGN

Cross-sectional, observational study.

SETTING AND SUBJECTS

Postal survey questionnaire to a stratified, random population of 68 460 subjects aged 18-84 years in Sweden. The subjects included were 40-84 years old (n = 43 589) and data were analysed for COPD (n = 526), RA (n = 1120), DM (n = 2149) and healthy subjects (n = 6960).

RESULT

Some 84% of subjects with COPD, 74% (RA), 72% (DM), and 60% in healthy subjects (p < 0.001, COPD versus RA, DM, and healthy subjects) had a physical activity level considered too low to maintain good health according to guidelines. Quality of life (EuroQol five-dimension questionnaire, EQ-5D) was lower in COPD and RA than in DM. Anxiety/depression was more common in subjects with COPD (53%) than in those with RA (48%) and DM (35%) (p < 0.001, COPD versus RA and DM), whereas mobility problems were more common in RA (55%) than COPD (48%) and DM (36%) (p < 0.001, RA versus COPD and DM). All differences between groups remained significant after adjusting for age, sex, and socioeconomic background factors.

CONCLUSION

Subjects with chronic diseases had a low level of physical activity, most evident in subjects with COPD. COPD and RA had a higher negative impact on quality of life than DM. Our results indicate that increased attention regarding physical inactivity in subjects with chronic diseases is needed to minimize the burden of disease.

Views on exercise maintenance: variations among patients with rheumatoid arthritis

BACKGROUND AND PURPOSE

Individuals with rheumatoid arthritis (RA) often have to make changes in exercise behavior in order to gain and sustain health benefits. The purpose of this study was to explore and describe ways of understanding exercise maintenance among individuals with RA who had already started to exercise.

PARTICIPANTS

Fourteen women and 4 men with RA of at least 2 years' duration, selected from 4 hospitals or primary health care physical therapy clinics, participated. They had exercised regularly at least twice weekly during the previous 2 months with various levels of support from a physical therapist, and they had attempted to exercise without support outside of the health care environment during the previous year.

METHOD

A phenomenographic approach was used to analyze semistructured interviews. A pattern of categories of descriptions was constructed based on the participants' conceptions and ways of understanding the phenomenon of exercise maintenance.

RESULTS

Five categories were identified: "external control," "sticks and carrots," "a joint venture," "the easy way," and "on one's own terms." The categories became clear by elucidating 2 aspects related to exercise maintenance: (1) the way the participants talked about and experienced the type of support needed and (2) personal factors.

DISCUSSION AND CONCLUSION

The results highlight the importance of finding the proper context and support for each patient's needs. Furthermore, preparing for exercise maintenance by strengthening the patient's beliefs in his or her ability to exercise in different settings, by discussing pros and cons of exercise, and by exploiting the patient's ability to adapt and continue exercise outside of the health care environment might be valuable.

Factors associated with exercise participation in adults with arthritis

Most people with arthritis are not regularly active. Understanding what factors influence exercise is essential for designing programs to increase participation. The objective of this study was to examine the correlates of exercise in people with arthritis. Using a cross-sectional design, sociodemographic, health-related, and psychosocial variables were collected from community-dwelling individuals with arthritis (N = 141). Associations with exercise level were examined with bivariate statistics (ANOVAs, chi-squares) and logistic-regression analyses. Exercisers were less likely than nonexercisers and insufficiently active people to report that arthritis negatively affected their physical and social functioning, and they reported more positive affect and greater self-efficacy (p < .05). Exercisers also reported less pain than nonexercisers (p < .05). In multiple logistic-regression analyses, self-efficacy and physical limitations remained independent predictors of exercise. The results suggest the need to target exercise self-efficacy when designing exercise interventions. Results also suggest the need to tailor exercise programs to individuals' physical limitations.

Rheumatoid cachexia: a clinical perspective

Rheumatoid cachexia is under-recognized in clinical practice. The loss of lean body tissue, which characterizes cachexia, is often compensated for by gain in body fat-so called 'cachectic obesity'-so that 85% or more RA patients have a normal BMI. Severe cachexia with loss of weight leads to increased morbidity and premature mortality but loss of muscle bulk with a normal BMI also associates with poor clinical outcomes. Increasing BMI, even into the obese range, is associated with less joint damage and reduced mortality. Measurement of body composition using DXA and other techniques is feasible but the results must be interpreted with care. Newer techniques such as whole-body MRI will help define with more confidence the mass and distribution of fat and muscle and help elucidate the relationships between body composition and outcomes. Cachexia shows little response to diet alone but progressive resistance training and anti-TNF therapies show promise in tackling this potentially disabling extra-articular feature of RA.

The role of physical activity in rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory auto-immune disease, causing progressive damage to the musculoskeletal system. Many patients with RA also suffer from accelerated muscle loss or cachexia, which contributes to the loss of physical function and quality of life. Physical activity plays a central role in the management of the disease as it is essential to maintain muscle strength and endurance, range of motion and the ability to perform activities of daily life. On the other hand, given the nature of the disease, there is always an increased risk for injury. There is a large amount of literature investigating the effect of exercise interventions on muscle function and disease activity. These studies show that exercise clearly improves muscle function without affecting disease activity. Studies including radiographic evaluation of joint damage as an endpoint also show that there is no evidence that exercise, even high-intensity exercise, increases inflammation or joint damage, although care should be taken with patients with severe baseline damage. Regarding daily physical activity (exercise is only one component of physical activity) there is hardly any research done showing either that physical activity is indeed decreased in patients or whether or not there is a relation between daily physical activity and disease activity. The results from studies looking at the effect of exercise on muscle mass or the ability to prevent or reverse cachexia are somewhat contradictory, but it seems that when the training dose is sufficiently large, gains in muscle mass can be achieved.

Predictors of exercise and effects of exercise on symptoms, function, aerobic fitness, and disease outcomes of rheumatoid arthritis

OBJECTIVE

To determine the effects of participation in a low-impact aerobic exercise program on fatigue, pain, and depression; to examine whether intervention groups compared with a control group differed on functional (grip strength and walk time) and disease activity (total joint count, erythrocyte sedimentation rate, and C-reactive protein) measures and aerobic fitness at the end of the intervention; and to test which factors predicted exercise participation.

METHODS

A convenience sample of 220 adults with rheumatoid arthritis (RA), ages 40-70, was randomized to 1 of 3 groups: class exercise, home exercise using a videotape, and control group. Measures were obtained at baseline (T1), after 6 weeks of exercise (T2), and after 12 weeks of exercise (T3).

RESULTS

Using structural equation modeling, overall symptoms (latent variable for pain, fatigue, and depression) decreased significantly at T3 (P < 0.04) for the class exercise group compared with the control group. There were significant interaction effects of time and group for the functional measures of walk time and grip strength: the treatment groups improved more than the control group (P <or= 0.005). There were no significant increases in measures of disease activity. Fatigue and perceptions of benefits and barriers to exercise affected participants' amount of exercise, supporting previous research.

CONCLUSION

This study supported the positive effects of exercise on walk time and grip strength, and demonstrated that fatigue and perceived benefits/barriers to exercise influenced exercise participation. Furthermore, overall symptoms of fatigue, pain, and depression were positively influenced in this selective group of patients with RA ages 40-70 years.

Is dynamic exercise beneficial in patients with rheumatoid arthritis?

INTRODUCTION

Dynamic exercise therapy as defined by the American College of Sports Medicine for healthy individuals is of unclear relevance to patients with rheumatoid arthritis (RA). No recommendations on this issue are available. Few studies have evaluated the optimal program, frequency, or target population; furthermore, there is no consensus about the best assessment tools for monitoring clinical, functional, and structural parameters during dynamic exercise therapy in patients with RA.

METHODS

We conducted an extensive review of the literature published between 1964 and 2005. We identified nine randomized controlled studies that provided a high level of proof regarding the effects of dynamic exercise therapy in RA patients older than 18 years of age.

RESULTS

Dynamic exercise programs improve aerobic capacity and muscle strength in patients with RA. Their effects on functional capacity are unclear, and many sources of bias influenced the study results. The clinical and laboratory safety profiles were good. The structural impact of dynamic exercise remains to be determined.

Are Patients With Rheumatoid Arthritis Less Physically Active Than the General Population?

BACKGROUND

Although promoting physical activity (PA) and exercise among patients with rheumatoid arthritis (RA) is highly advocated nowadays, little is known about actual PA levels of these patients. In particular, the literature investigating how these PA levels are in proportion to the levels among the general population is scarce.

OBJECTIVE

To compare the self-reported PA levels of patients with RA with those of the general Dutch population.

METHODS

A sample of 400 RA patients were sent the Short QUestionnaire to ASsess Health-Enhancing PA comprising 10 questions about PA. From these data the proportions meeting the Dutch public health recommendation for PA (i.e., moderate PA for 30 minutes on > or = 5 days/wk) and the total number of minutes of PA per week were calculated. These data were compared with similar data from a representative sample of the general Dutch population.

RESULTS

Two hundred fifty-two patients returned the questionnaire (response 63%). The proportions of RA patients meeting the PA recommendation were similar to those of the general population (57% in categories 45-64 years; 59% in categories > or = 65 years, and 58% in the total groups). The average number of minutes of PA per week was significantly lower in the RA population compared with the general population in the category 45 to 64 years (1836 vs. 2199, respectively, P = 0.001), whereas the difference in the category > or = 65 years was not significant (1115 vs. 1218 minutes, respectively, P = 0.33).

CONCLUSIONS

The proportion of RA patients meeting the Dutch PA recommendation was similar to the general Dutch population. However, with respect to the average number of minutes of PA per week, the RA patients were less physically active. Because patients with RA have an increased risk of chronic conditions such as osteoporosis or cardiovascular diseases along with their arthritis, it remains a matter of utmost importance for health care professionals such as rheumatologists, physical therapists, and clinical nurse specialists to promote PA in daily clinical practice and guide patients in achieving and maintaining a healthy lifestyle.

Reconditioning in patients with rheumatoid arthritis

Rheumatologists traditionally have recommended to rheumatoid arthritis (RA) patients that they avoid dynamic and weight-bearing exercises because of concerns about aggravating joint inflammation and accelerating joint damage in such patients. These restrictions may lead to inadequate levels of physical activity and deconditioning.

OBJECTIVE

To review the literature on tolerance and benefits of conditioning training, including dynamic and weight-bearing activities in RA patients.

MATERIALS AND METHODS

Medline and Cochrane databases were searched with the keywords RA, rehabilitation, physical therapy, exercise, reconditioning, and rest.

RESULTS

Rest therapy is more deleterious than beneficial in most patients with RA and may lead to deconditioning. Dynamic and aerobic exercises do not aggravate joint inflammation and do not accelerate joint damage in such patients. The important goal of reconditioning patients with RA is the prevention of functional decline. Conditioning programs designed to prevent widespread morbidities in healthy subjects are attainable by most RA patients, but an individualized approach to exercise is required.

CONCLUSION

RA patients need to be persuaded about the effectiveness and safety of moderate and even high-intensity exercise.

Rehabilitation in rheumatoid arthritis: a critical review

This article considers the evidence for effectiveness and timing of rehabilitation for people with rheumatoid arthritis (RA). The Cochrane Library, DARE, Medline, Embase, CINAHL and AMED were searched to identify systematic reviews and randomized controlled trials evaluating rehabilitation interventions for people with rheumatoid arthritis. Many trials identified had methodological limitations (e.g. short follow-up periods, small sample sizes). Evidence to date is that symptomatic relief results from thermotherapy, laser therapy, acupuncture and assistive devices. In the short-term, comprehensive occupational therapy (in established rheumatoid arthritis), orthoses, and mind-body approaches can help maintain function. Over at least a one-year period, the following are effective in reducing pain and maintaining function: patient education and joint protection training using behavioural approaches; dynamic exercise therapy, hand exercises and hydrotherapy; and cognitive-behavioural therapy (in people with poorer psychological status). Many trials have recruited people with moderate to severe, established RA and relatively little is known about the long-term effectiveness of early rehabilitation, although this is becoming much more common in practice. Despite the increased availability of guidelines and systematic reviews, most conclude there is insufficient evidence for many areas of rheumatology rehabilitation. Further well-designed clinical trials are needed recruiting people with early disease using patient-centred outcomes.

Cross cultural aspects of rehabilitation in rheumatic diseases

PURPOSE OF REVIEW

The aim of this article is to describe progress in the understanding of the relationship between culture, race, ethnicity and similar factors as they pertain to rehabilitation and the rheumatic diseases. This review highlights important current issues and indicates areas for future study.

RECENT FINDINGS

There is very little published research in this area of rehabilitation medicine. Recent findings and observations indicate that there are many important cultural aspects of rehabilitation in the rheumatic diseases with several societal as well as individual implications. This is a rapidly growing area of work as it is being increasingly recognized that an understanding of these cross cultural issues is essential in order to be able to ensure the delivery of clinically and cost effective rehabilitation services which are client centred and consequently culturally appropriate. Although the interrelationship of culture, race, genetics, ethnicity, language, religion, history, geography, socioeconomic status and educational level is complex, studies are beginning to reveal the contributions of these factors to ensuring minimization of disability and high quality rehabilitation strategies.

SUMMARY

Although much neglected, the importance of cultural aspects of rehabilitation in rheumatic diseases is being increasingly recognized and understood. Issues that have been identified include the rehabilitation needs assessment of different ethnic groups, the development of culturally valid outcome measures and the implementation and evaluation of culturally competent multidisciplinary rehabilitation programs.

The role of exercise in the rehabilitation of patients with systemic lupus erythematosus and patients with primary Sjögren's syndrome

PURPOSE OF REVIEW

The purpose of this review is to present an update on the evidence-based effects of exercise in systemic lupus erythematosus and in primary Sjögren's syndrome.

RECENT FINDINGS

Physical capacity is reduced in both systemic lupus erythematosus and primary Sjögren's syndrome and fatigue is a dominating and disabling symptom in both conditions. The documentation on the effect of exercise on the rehabilitation of patients with systemic lupus erythematosus and primary Sjögren's syndrome is sparse; the studies are few and the sample sizes often small. The available studies indicate that patients with systemic lupus erythematosus of mild to moderate disease activity as well as patients with primary Sjögren's syndrome benefit from exercise of moderate to high intensity. Positive effects can be expected with regard to aerobic capacity, fatigue, physical function and depression.

SUMMARY

There is reason to believe that exercise should be included in the rehabilitation of patients with mild to moderate systemic lupus erythematosus and patients with primary Sjögren's syndrome. Further research is needed and should aim to evaluate the effect of exercise on groups with varying degree of disease severity and to document the long-term impact on the disease.

Effects of dynamic exercise on circulating IGF-1 and IGFBP-3 levels in patients with rheumatoid arthritis or ankylosing spondylitis

This study was performed to determine the effects of short-term dynamic exercise on serum insulin-like growth factor-1 (IGF-1) and insulin-like growth factor binding protein-3 (IGFBP-3) levels in the patients with rheumatoid arthritis (RA) and ankylosing spondylitis (AS). Patients with RA or AS and healthy controls were recruited. Dynamic treadmill exercise therapy was accomplished for 20 min/session with all of the participants. There were five sessions per week for 2 weeks. Morning stiffness duration, body pain, Stanford health assessment questionnaire, Ritchie articular index, Bath ankylosing spondylitis disease activity index (BASDAI), and Bath ankylosing spondylitis functional index (BASFI) were evaluated in the RA and AS patients. Laboratory assessments included: erythrocyte sedimentation rate, serum C-reactive protein, IGF-1, and IGFBP-3. Clinical and laboratory assessments were recorded at baseline and during exercise treatment on days 7 and 15. Twenty patients with RA, 15 with AS, and 14 healthy controls were included in this study. The pain evaluation, Ritchie, BASDAI, and BASFI scores were significantly improved by the exercise treatment in both patient groups. The important increases were found in circulating IGF-1 in RA (p < 0.001) and AS (p = 0.001) at the end of 2 weeks. In control individuals, serum IGF-1 levels showed a significant decline in the first week (p < 0.05). No significant changes were observed on serum IGFBP-3 levels. Our data suggest that serum IGF-1 levels are increased by the dynamic exercise program in RA and AS patients. The increased IGF-1 may play an important role in the beneficial effects of dynamic exercise therapy in these patients.

Using internet technology to deliver a home-based physical activity intervention for patients with rheumatoid arthritis: A randomized controlled trial

OBJECTIVE

To compare the effectiveness of 2 Internet-based physical activity interventions for patients with rheumatoid arthritis (RA).

METHODS

A total of 160 physically inactive patients with RA who had a computer with Internet access were randomly assigned to an Internet-based physical activity program with individual guidance, a bicycle ergometer, and group contacts (individualized training [IT] group; n = 82) or to an Internet-based program providing only general information on exercises and physical activity (general training [GT] group; n = 78). Outcome measures included quantity of physical activity (questionnaire and activity monitor), functional ability, quality of life, and disease activity (baseline, 3, 6, 9, and 12 months).

RESULTS

The proportion of physically active patients was significantly greater in the IT than in the GT group at 6 (38% versus 22%) and 9 months (35% versus 11%; both P < 0.05) regarding a moderate intensity level for 30 minutes in succession on at least 5 days a week, and at 6 (35% versus 13%), 9 (40% versus 14%), and 12 months (34% versus 10%; all P < 0.005) regarding a vigorous intensity level for 20 minutes in succession on at least 3 days a week. In general, there were no statistically significant differences regarding changes in physical activity as measured with an activity monitor, functional ability, quality of life, or disease activity.

CONCLUSION

An Internet-based physical activity intervention with individually tailored supervision, exercise equipment, and group contacts is more effective with respect to the proportion of patients who report meeting physical activity recommendations than an Internet-based program without these additional elements in patients with RA. No differences were found regarding the total amount of physical activity measured with an activity monitor.

The effects of vigorous exercise training on physical function in children with arthritis: A randomized, controlled, SINGLE-BLINDED trial

OBJECTIVE

To examine the effectiveness of high-intensity aerobic training compared with low-intensity training in terms of energy cost of locomotion, peak oxygen uptake, peak power, and self-reported physical function in children with juvenile idiopathic arthritis (JIA).

METHODS

Eighty children with JIA, ages 8-16 years, were enrolled in a randomized, single-blind controlled trial. Both groups participated in a 12-week, 3-times-weekly training program consisting of high-intensity aerobics in the experimental group and qigong in the control group. Subjects underwent exercise testing measuring submaximal oxygen uptake at 3 km/hour (VO(2submax)) as the primary outcome, maximal oxygen uptake, and peak power at the beginning and end of the program. Physical function was measured using the Child Health Assessment Questionnaire (C-HAQ).

RESULTS

The exercise program was well tolerated in both groups. There was no difference in VO(2submax) or any other exercise testing measures between the groups through the study period and no indication of improvement. Both groups showed significant improvements in C-HAQ with no difference between the groups. Adherence was higher in the control group than the experimental group.

CONCLUSION

Our findings suggest that activity programs with or without an aerobic training component are safe and may result in an important improvement in physical function. The intensity of aerobic training did not seem to provide any additional benefits, but higher adherence in the qigong program may suggest that less intensive regimens are easier for children with JIA to comply with, and provide a degree of benefit equivalent to more intensive programs.

Comparison of energy expenditure from lifestyle physical activities between patients with rheumatoid arthritis and healthy controls

OBJECTIVE

Low energy expenditure is a risk for cardiovascular morbidity. The goals of this study were to compare energy expenditure between patients with rheumatoid arthritis (RA) and healthy controls.

METHODS

A total of 121 RA patients and 120 healthy controls in New York City completed the Paffenbarger Physical Activity and Exercise Index at time of enrollment (1999-2000) and 1 year later to measure energy expenditure from walking, climbing stairs, and exercise/sports. Analyses were adjusted for age, sex, education, pain, social support, and depressive symptoms and were compared with recommended thresholds of energy expenditure.

RESULTS

Participants' mean age was 49 years, and 87% were women. Patients with RA expended fewer kilocalories per week than controls (mean +/- SD 1,474 +/- 1,198 versus 1,958 +/- 1,940, P = 0.003), with most of this difference from less walking as opposed to high-intensity activities. Although similar percents of RA patients and controls met national recommendations for total weekly energy expenditure (56% versus 64% for the lower [> or =1,000 kilocalories per week] threshold; P = 0.14, and 41% versus 48% for the higher [> or =1,400 kilocalories per week] threshold; P = 0.17), fewer RA patients met the recommendations (> or =700 kilocalories per week) for walking (32% versus 48%; P = 0.01). The strongest predictor of more energy expenditure at 1 year for both groups was more energy expenditure at enrollment.

CONCLUSION

Most of the difference in energy expenditure between RA patients and healthy controls was due to less walking. Given that walking is an effective and relatively safe lifestyle activity, increasing walking should be a priority to improve cardiovascular risk in RA.

Partial Examination of the Public Health Impact of the People with Arthritis Can Exercise (PACE�) Program: Reach, Adoption, and Maintenance

OBJECTIVE

To partially evaluate the public health impact (i.e., reach, adoption, maintenance) of People with Arthritis Can Exercise (PACE) programs, which were initiated as a result of two PACE instructor-training workshops.

DESIGN

The study design involved a one-time only, cross-sectional assessment of reach, adoption, and maintenance, conducted 6 months after the workshops.

SAMPLE

Participants were 11 adults (n(females)=10) trained to be PACE instructors at one of the workshops.

MEASUREMENTS

One-on-one phone interviews, developed using the RE-AIM framework, assessed reach, adoption, and maintenance.

RESULTS

Eight of the 11 individuals trained as instructors subsequently began PACE in one of 10 organizations across various communities, indicating high program adoption. However, on average, only 7 individuals with arthritis participated in each PACE program, indicating a low program reach. Within 6 months of beginning PACE, only 3 organizations continued to offer PACE, indicating low program maintenance. Two primary challenges to initiating PACE included recruiting a sufficient number of people to participate in the program and in finding a convenient time to offer it so more individuals could join.

CONCLUSION

The public health impact, as assessed by reach, adoption, and maintenance, of PACE programs initiated as a result of 2 instructor-training workshops was low.

Aerobic fitness in women with chronic discogenic nonradicular low back pain

OBJECTIVE

The purpose of this study was to determine if aerobic fitness varies between women with and without chronic discogenic non-radicular low back pain.

DESIGN

Prospective cross-sectional descriptive study.

RESULTS

: Analysis of variance revealed that maximal oxygen consumption was lower (P = 0.05) in women with low back pain compared with the control group. In addition, there was a significant reduction (P = 0.05) in reported exercise training duration and frequency but no change in exercise intensity (P = 0.1) in the study group after the onset of low back pain. The low back pain group had minimal disability (19%) based on the Oswestry Disability Questionnaire.

CONCLUSIONS

Women with chronic discogenic non-radicular low back pain have lower maximal oxygen consumption than age-matched controls. However, this study group continued to exercise safely at the same exercise training intensity as before their low back pain and had minimal disability and above-average aerobic fitness.

Prevention of cardiovascular disease in patients with rheumatic diseases

Cardiovascular disease (CVD), the leading cause of death in the USA, has emerged as an important comorbidity in the rheumatic diseases. As disease-modifying therapies have resulted in better disease control and decreases in disease-associated mortality, it is now apparent that the prevalence of CVD and cardiovascular (CV) events is significantly increased in a number of rheumatic disorders when compared with age and gender-matched subjects from the general population. Investigations into the mechanisms of CVD in the general population have provided insights into potential mechanisms in rheumatic disease patients and possible aetiologies for their increased risk. Although there are no evidence-based guidelines for CV risk factor screening and interventions specific to patients with rheumatic disease, the best current approach utilizes evidence-based recommendations for the general population (and higher-risk subgroups) modified by what is known of CV risk factor and event prevalence in these patients.

Pilot study of fitness training and exercise testing in polyarticular childhood arthritis

OBJECTIVE

To 1) assess the safety and feasibility of laboratory-based exercise testing in juvenile idiopathic arthritis (JIA), 2) test the safety and feasibility of a 3-month exercise program in JIA, 3) assess pain during exercise in JIA, 4) compare ratings of perceived effort (RPE) with heart rate (HR) achieved, and 5) estimate the training effect on metabolic efficiency of gait as measured by submaximal exercise testing.

METHODS

Nine children with JIA were enrolled in a 12-week circuit training program involving pool, stationary bicycle, treadmill, and Fitball. They underwent formal exercise testing before and after the program, underwent a full joint assessment, were administered the Childhood Health Assessment Questionnaire and Juvenile Arthritis Functional Status Index, and were assessed for overall quality of life and health-related quality of life. A visual analog scale was used to assess pain during testing and training, and the Borg scale was used to measure RPE.

RESULTS

Children with JIA were able to participate in exercise testing without any significant problems. Children with severe hip disease dropped out of the exercise program due to pain during the exercise sessions and worsened arthritis symptoms. Target HR was achieved and correlated with RPE in the bicycle and treadmill sessions. Submaximal exercise testing showed an improvement with a small to moderate effect size.

CONCLUSION

This study suggests that it is safe, feasible, and acceptable for children with arthritis, in the absence of severe hip involvement, to participate in formal exercise testing and structured fitness programs.

Successfully living with chronic arthritis

The treatment and care of patients with rheumatoid arthritis (RA) is complex and various health professionals with different areas of expertise may be involved. The objective of this article is to review the treatments and their efficacy as provided by health care professionals in RA care. The requirements for further research in this area are formulated. To achieve better effects of treatment it is necessary to improve the coordination of services as provided by the different specialists. The important roles of the patients themselves in the care and management of the disease are emphasized, as well as the roles of the informal caregivers such as a spouse or other family members and friends and the role of patient societies. The possible role of the International Classification of Functioning, Disability and Health (ICF) to improve the communication and facilitate the coordination among health professionals and between patients and health professionals is mentioned. The topics presented in this article may encourage further discussion and research, particularly concerning the effects of the treatments as provided by allied health professionals. Health professionals play an important role in the life of patients with rheumatic disorders, in all the domains of the ICF: body functions and structure, activities (action by an individual) and participation (involvement in a life situation). Health professionals in rheumatology can make the difference in the lives of RA patients and their families.

Perceived exercise barriers, enablers, and benefits among exercising and nonexercising adults with arthritis: Results from a qualitative study

OBJECTIVE

Rates of participation in regular exercise are lower among individuals with arthritis than those without arthritis. This study examined perceived exercise barriers, benefits, and enablers in exercising and nonexercising adults with arthritis.

METHODS

Twelve focus groups were conducted with 68 adults with arthritis. Groups were segmented by exercise status, socioeconomic status, and race. Focus group discussions were transcribed verbatim and coded. NVivo software was used to extract themes for exercisers and nonexercisers.

RESULTS

A wide range of physical, psychological, social, and environmental factors were perceived to influence exercise. Some of these factors were similar to those in general adult samples, whereas others were unique to individuals with chronic disease. Symptoms of arthritis were barriers to exercise, yet improvements in these outcomes were also seen as potential benefits of and motivations for exercise. Exercisers had experienced these benefits and were more likely to have adapted their exercise to accommodate the disease, whereas nonexercisers desired these benefits and were more likely to have stopped exercising since developing arthritis. Health care providers' advice to exercise and the availability of arthritis-specific programs were identified as needs.

CONCLUSION

This study has implications for how to market exercise to individuals with arthritis and how communities and health care professionals can facilitate the uptake of exercise. These implications are discussed.

Safety of exercise in patients with rheumatoid arthritis

PURPOSE OF REVIEW

Patients with rheumatoid arthritis benefit from long-term moderate or high-intensity exercises. Moderate or high-intensity exercises were found to improve aerobic capacity, muscle strength, functional ability, and psychological well-being, and slow the age-related and sex-related decrease in bone mineral density of the hip. Despite these positive findings, there is also concern about its risks. Studies on the effects of exercise on disease activity and joint damage are reviewed.

RECENT FINDINGS

Studies on the effects of moderate or high-intensity exercise in rheumatoid arthritis demonstrate either decreased or stable disease activity. From the few available studies that address exercise and radiologic progression of the small joints, results indicate that exercises are safe for the joints of hands and feet. However, a recent study suggests caution in prescribing long-term high-intensity weight-bearing exercises to patients who have significant radiologic damage of large joints, as some patients might develop additional damage.

SUMMARY

Moderate or high-intensity weight-bearing exercises are safe with respect to disease activity and radiologic damage of the hands and feet. In the absence of sufficient data on exercise and radiologic progression of the large joints, patients with significant radiologic damage of the large joints should not be encouraged to participate in moderate to high-intensity weight-bearing exercise unless individualized to protect affected joints. A broader dissemination of the effectiveness and safety of moderate and high-intensity exercise for patients with rheumatoid arthritis is needed among rheumatologists, physical therapists, and patients.

Exercise: An important component of treatment in the idiopathic inflammatory myopathies

Resistive exercise is controversial for patients with idiopathic inflammatory myopathies. This paper provides an update on exercise and clinical assessment in these patients. The few published studies on this topic report unchanged disease activity from a variety of exercise regimens in patients in all stages of disease. Reduced disability was achieved in patients with polymyositis and dermatomyositis. In one study a slightly reduced impairment was reported in patients with inclusion body myositis, while in another study no objective reduction of disability could be detected. An increasing number of valid and reliable outcome measures are available for patients with polymyositis and dermatomyositis, but for patients with inclusion body myositis reliable and sensitive outcome measures are still needed.

Cost-utility and cost-effectiveness analyses of a long-term, high-intensity exercise program compared with conventional physical therapy in patients with rheumatoid arthritis

OBJECTIVE

To estimate the cost utility and cost effectiveness of long-term, high-intensity exercise classes compared with usual care in rheumatoid arthritis (RA) patients.

METHODS

RA patients (n = 300) were randomly assigned to either exercise classes or UC; followup lasted for 2 years. Outcome measures were quality-adjusted life years (QALYs) according to the EuroQol (EQ-5D), Short Form 6D (SF-6D), and a transformed visual analog scale (VAS) rating personal health; functional ability according to the Health Assessment Questionnaire (HAQ) and McMaster Toronto Arthritis Patient Preference Interview (MACTAR); and societal costs.

RESULTS

QALYs in both randomization groups were similar according to the EQ-5D and SF-6D, but were in favor of usual care according to the VAS (annual difference 0.037 QALY; 95% confidence interval [95% CI] 0.002, 0.069). Functional ability was similar according to the HAQ, but in favor of the exercise classes according to the MACTAR (annual difference 2.9 QALY; 95% CI 0.9, 4.9). Annual medical costs of the exercise program were estimated at 780 per participating patient (1 approximately $1.05). The increase per patient in total medical costs of physical therapy was estimated at 430 (95% CI 318, 577), and the increase in total societal costs at 602 (95% CI -490, 1,664). For societal willingness-to-pay equal to 50,000 per QALY, usual care had better cost utility than exercise classes, and significantly so according to the VAS.

CONCLUSION

From a societal perspective and without taking possible preventive health effects into account, long-term, high-intensity exercise classes provide insufficient improvement in the valuation of health to justify the additional costs.

The role of exercise in the rehabilitation of idiopathic inflammatory myopathies

PURPOSE OF REVIEW

The objective of this review is to provide an update on exercise and clinical assessment in the idiopathic inflammatory myopathies.

RECENT FINDINGS

Polymyositis, dermatomyositis and inclusion body myositis are rare conditions with muscle weakness as a common prominent feature. Earlier, these patients were discouraged from active exercise due to a fear of increased muscle inflammation with recommendations to rest, perform range of motion exercises and in some cases, isometric exercises. However, beginning in the 1990s, studies reported reduced disability in patients with chronic polymyositis/dermatomyositis following resistive mild/moderate to intensive muscular training and aerobic endurance training, without signs of increased muscle inflammation. Patients with active, recent onset disease seem to benefit from mild/moderate muscular exercise without signs of increased muscle inflammation. There is no evidence of increased muscle inflammation following exercise in inclusion body myositis. However the beneficial effects are unclear as one study report increased muscle strength, while the other could not achieve impairment reduction.

SUMMARY

Studies evaluating active exercise in IIM support the notion of safety and benefits. However, large multi-center studies are needed to fully establish the safety and benefits of different types of exercise. Data indicate that active exercise, adapted to disease activity and disability should be included in the rehabilitation of patients in all stages of IIM. The newly developed and validated outcome measures for patients with polymyositis and dermatomyositis help assess the effects of interventions on disease activity and disability in clinical trials and in clinical practice. However, there are no sensitive and valid outcome measure for patients with inclusion body myositis.

Pain and joint mobility explain individual subdimensions of the health assessment questionnaire (HAQ) disability index in patients with rheumatoid arthritis

OBJECTIVE

To explore the associations between individual subdimensions of the health assessment questionnaire (HAQ) and clinical variables in patients with rheumatoid arthritis.

METHODS

304 patients with rheumatoid arthritis (73% female, mean (SD) age, 58 (13) years; disease duration 6 (9) years, 69% rheumatoid factor positive) completed the HAQ for functional capacity (0-3) and a 100 mm visual analogue scale for pain. Grip strength, range of motion of the large joints, Larsen score for radiographic damage of hand and foot joints, and the number of tender and swollen joints were recorded. A logit regression model was used to study associations between subdimensions of the HAQ and other variables.

RESULTS

Mean (range) total HAQ score was 0.92 (0 to 2.88) and varied from 0.73 to 1.04 in the subdimensions. Disability was lowest in the "walking" and highest in the "reach" subdimension. Pain was an explanatory variable in all individual subdimensions. Decreased grip strength, limitation of shoulder and wrist motion, and a larger number of swollen and tender joints in the upper extremities were related to several subdimensions. A higher pain score and swollen joint count in the upper extremities, decreased grip strength, and limited motion of wrist, shoulder, and knee joints explained increased disability (higher total HAQ scores).

CONCLUSIONS

In patients with rheumatoid arthritis, pain and range of movements of joints have the greatest impact on individual subdimensions of the HAQ. Extent of radiographic damage in peripheral joints and the number of swollen and tender joints are of lesser importance for function.

Effect of a high-intensity weight-bearing exercise program on radiologic damage progression of the large joints in subgroups of patients with rheumatoid arthritis

OBJECTIVE

To investigate whether a high-intensity exercise program accelerates the rate of radiologic damage of the large joints in predefined subgroups of patients with rheumatoid arthritis.

METHODS

The data of 277 participants in a 2-year randomized controlled trial, comparing the effects of high-intensity exercises with usual care, were used. Linear regression analysis was used to test which predefined variables at baseline (age, disease duration, disease activity, physical capacity, functional ability, joint damage) modified the effect of high-intensity exercise on the progression of radiologic damage of the large joints over 24 months.

RESULTS

Baseline radiologic joint damage was the only variable associated with the effect of high-intensity exercise on joint damage progression in large joints. In a subgroup of 218 patients with no or little joint damage (defined as Larsen score < or = 5; 80% of our study population) the proportions of patients with an increase in joint damage were similar for the exercise and usual-care group (35% versus 36%, risk ratio [RR] 1.0 [0.7-1.4]; P = not significant), whereas, in a subgroup of 59 patients who already had extensive damage of large joints (defined as Larsen score >5) the proportion was significantly higher in the exercise group (85% versus 48%, RR 1.8 [1.2-2.6]; P < 0.05).

CONCLUSION

High-intensity weight-bearing exercises appear to accelerate joint damage progression in patients with preexisting extensive damage. Patients with extensive large joint damage should, therefore, be advised to refrain from activities excessively loading the damaged joints.

The effectiveness of hand exercises for persons with rheumatoid arthritis: a systematic review

A systematic review was conducted to evaluate the efficacy of hand exercises for persons with rheumatoid arthritis. The databases Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, PEDro, and Cochrane were used to search for articles on exercise and hand and rheumatoid arthritis (and their synonyms). Any articles that evaluated the effects of exercise on the hand were included in the review and evaluated for quality on a form specifically developed for the reviews in this issue. Only nine studies evaluated the effect of hand exercise or a program that included hand exercise. Quality scores ranged from 21 to 39 out of a possible 48. Few studies used psychometrically sound measures or reported on changes to everyday function. Although some significant results were obtained, they may have been due to multiple outcome measures, lack of blinding, and within-group rather than between-group comparisons. Impairment and dexterity were frequent outcomes, but measurement of self-report function was lacking. Long-term exercise may increase strength, but results on range of motion are inconsistent across studies, subjects, and joints. There is a need for randomized controlled trials with goal-specific exercise, measurement of outcomes appropriate to the goals, adequate sample size, and comparison with an appropriate control condition.

Are US adults with arthritis meeting public health recommendations for physical activity?

OBJECTIVE

To estimate the prevalence of US adults with self-reported, doctor-diagnosed arthritis (without specifying the type of rheumatic disease) who are meeting the US Surgeon General's recommendations for physical activity.

METHODS

Using population-based survey data from the 2001 Behavioral Risk Factor Surveillance Survey, we classified respondents according to their arthritis status and their level of physical activity (i.e., physically inactive, insufficiently active, or meeting recommendations). Prevalence data were weighted to take account of the complex sampling design, and were broken down by a variety of demographic characteristics such as race, education, and body weight.

RESULTS

Nearly one-quarter (23%) of US adults reported having doctor-diagnosed arthritis. Among adults with arthritis, 23.8% were physically inactive, 38% reported insufficient levels of physical activity, and 38.3% reported meeting the recommendations for physical activity. The highest prevalence of inactivity in adults with arthritis was found among those subjects with fewer than 8 years of formal education (47.6%), those with 9-11 years of education (35.5%), those who were African American (35.4%), those whose age was > or =65 years (31.1%), and those who were Hispanic (30.4%).

CONCLUSION

Despite the benefits of physical activity, more than 60% of adults with arthritis do not meet the physical activity recommendations. Efforts should be made to ensure that adults with arthritis are made aware of the benefits of physical activity, and that interventions are prescribed to assist these individuals in becoming more physically active.

Physiological and psychological effects of exercise interventions in HIV disease

The use of both aerobic and resistance exercise has been shown to improve physiologic parameters such as strength, endurance, time to fatigue, and body composition in the HIV-infected population. Exercise has also been used successfully to treat psychologic conditions such as depression and anxiety that are common in HIV-infected individuals. However, the effects of exercise on immune function in these individuals are uncertain because of conflicting results found among studies. Additionally, many ventures into this area have been attempted with poor research design, resulting in inconclusive evidence or poor generalizability. The focus of this paper is to review the research that has been performed using exercise as an intervention for HIV-infected persons and to determine what needs to be done next to further our understanding of how the HIV-infected body and mind respond to exercise training.