Effect of Aerobic Exercise Training on Fatigue in Rheumatoid Arthritis: A Meta-Analysis

Exercise Training for Chronic Pain: Available Evidence, Current Recommendations, and Potential Mechanisms

Chronic pain conditions pose a significant global burden of disability, with epidemiological data indicating a rising incidence. Exercise training is commonly recommended as a standalone or complementary approach for managing various chronic pain conditions like low back pain, osteoarthritis, rheumatoid arthritis, fibromyalgia syndrome, and neuropathic pain. Regardless of the specific condition or underlying cause (e.g., autoimmune disease, chronic inflammation), exercise training consistently leads to moderate to large reductions in pain. Moreover, exercise yields numerous benefits beyond pain alleviation, including small-to-moderate improvements in disability, quality of life, and physical function. Despite its efficacy, there is a lack of comprehensive research delineating the optimal intensity, duration, and type of exercise for maximal benefits; however, evidence suggests that sustained engagement in regular exercise or physical activity is necessary to achieve and maintain reductions in both clinical pain intensity ratings and the level that pain interferes with activities of daily living. Additionally, the precise mechanisms through which exercise mitigates pain remain poorly understood and likely vary based on the pathophysiological mechanisms underlying each condition.

Nature-Based Group Exercises for People With Arthritis: A Qualitative Along-Side Interview Study of Lived Experiences

Arthritis affects many individuals and can cause pain and limit physical functioning. Exercise is an important treatment option for individuals with arthritis; however, adherence to exercise programs can be challenging. A new initiative in Denmark has introduced nature-based exercises for patients with arthritis. This qualitative study aimed to explore the experiences of the individuals who participated in those exercises. The study used a hermeneutic-phenomenological approach and conducted along-side interviews with 12 women and three men who participated in nature-based exercise programs for arthritis. Analysis of the data revealed two main themes. The first theme highlighted the positive effects of being in nature, such as increased vitality, reduced pain, and a sense of well-being. The second theme emphasized the social benefits of participating in these exercises, including a sense of connection and community with others. Overall, this study suggests that incorporating nature-based exercises in treatment programs for arthritis could have significant benefits for individuals with this condition.

Physical Activity and Fatigue Symptoms: Neurotypical Adults and People with Chronic Multisymptom Illnesses

For neurotypical adults, a single bout of low-to-moderate intensity physical activity usually transiently improves feelings of energy. Similar bouts of exercise have the opposite effect of increased feelings of fatigue when performed by samples with chronic multisymptom illnesses (CMIs) such as Long-COVID, Gulf War Illness (GWI), or Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). The short-term adoption of regular moderate intensity physical activity (typical experiments are 1 to 6 months) among neurotypical adults results in small-to-moderate improvements in self-reported feelings of fatigue, energy, and vitality. Small improvements in these feelings, or no change at all, occur for CMIs, but limited data precludes strong conclusions. The mechanisms of exercise effects on fatigue, whether acute or chronic, are poorly understood but likely involve multiple neural circuits and associated transmitters. For CMIs, the mechanisms of acute worsening of fatigue with exercise may be driven by the yet unknown pathophysiological mechanisms of the disease (perhaps involving brain, immune and autonomic system dysfunction, and their interactions). Likewise, fatigue improvements may depend on whether chronic physical activity is a disease-modifying treatment.

Investigation of the psychometric properties of "exercise Benefits/Barriers scale" in Turkish patients with rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis (RA) is a chronic systemic disease accompanied by several symptoms and functional disabilities. Physical activity (PA) is crucial for disease management and patients' perception of exercise is essential for a rehabilitation plan.

PURPOSE

This study aims to examine the psychometric properties of the Exercise Benefits/Barriers Scale (EBBS) that is frequently used in previous studies in the RA population.

METHODS

We included a total of 104 patients in our study. Test-retest reliability was assessed using intraclass correlation coefficient (ICC 2,k). The International Physical Activity Questionnaire (IPAQ) and the Bristol Rheumatoid Arthritis Fatigue Scale (BRAFS) were used for the convergent validity of the scale. For discriminant validity analysis, the total barriers and benefits scores were examined according to exercise status (yes/no), PA level (high/low), and fatigue severity (high/low). Additionally, standard error of measurement (SEM) and minimal detectable change with 95% confidence (MDC95) are calculated.

RESULTS

EBBS subscores showed moderate to excellent reliability (ICC: 0.71 to 0.98) and correlated PA (r = 0.453 and 0.515, EBBS-barriers and benefits subscores, respectively) and fatigue (r=-0.261 and -0.393, EBBS-barriers and benefits subscores, respectively). The SEM and MDC95 values were calculated as 2.03 and 7.96 for EBBS-benefits subscores and 0.93 and 3.65 for EBBS-barriers subscores. The EBBS-Benefits and Barriers subscores differed according to exercise status (p = .08), PA level (p < .01), and fatigue (p = .08).

CONCLUSION

The results highlighted that the EBBS is a reliable and valid instrument to assess exercise benefits and barriers in patients with RA.

Effects of lifestyle physical activity and sedentary behaviour interventions on disease activity and patient- and clinician- important health outcomes in rheumatoid arthritis: a systematic review with meta-analysis

BACKGROUND

Lifestyle physical activity (PA) is defined as any type of PA undertaken as part of daily life. It can include engagement in activities of daily living (i.e., household chores, gardening, walking to work), incidental PA, walking and/or reducing sedentary or sitting behaviours (SB). Regular PA is recommended for people with Rheumatoid Arthritis (RA) to reduce disease activity and systemic inflammation, as well as to improve patient- and clinician-important health outcomes. However, there is no summarised evidence of the effectiveness of interventions specifically targeting lifestyle PA and SB in this population. The aims of this systematic review with meta-analysis were to evaluate interventions targeting lifestyle PA and/or SB on 1) disease activity; 2) PA, SB and 3) patient- and clinician-important outcomes in people with RA.

METHODS

Eight databases [Medline, Cochrane Library CENTRAL, Web of Science, PsychINFO, Cumulative Index to Nursing & Allied Health Literature, Scopus, Excerpta Medica database and Physiotherapy Evidence Database] were searched from inception-August 2022. Inclusion criteria required interventions to target lifestyle PA and/or SB, conducted in adults with RA, assessing patient- and/or clinician-important outcomes.

RESULTS

Of 880 relevant articles, 16 interventions met the inclusion criteria. Meta-analyses showed statistically significant effects of interventions on disease activity (standardised mean difference = -0.12 (95% confidence interval = -0.23 to -0.01, I2 = 6%, z = 2.19, p = .03), moderate-to-vigorous PA, light/leisure PA, steps, functional ability, and fatigue. Whereas, no intervention effects were visualised for total PA, pain, anxiety or quality of life.

CONCLUSIONS

Lifestyle PA interventions led to increased PA, reductions in SB and improvements in disease activity and other patient- and/or clinician-important health outcomes in people with RA. Future interventions should be less heterogenous in content, structure, focus and outcome measures used to aid understanding of the most effective intervention components for improving health. More SB interventions are needed to determine their effectiveness at producing clinical benefits.

Barriers and facilitators for physical activity in rheumatic and musculoskeletal disease: a European-based survey

Physical activity (PA) is a key strategy for improving symptoms in people with rheumatic and musculoskeletal diseases (RMDs). The aim of this study was to investigate and rank the importance of known barriers and facilitators for engaging in PA, from the perspective of people living with RMD. Five hundred thirty-three people with RMD responded to a survey (nine questions) disseminated by the People with Arthritis and Rheumatism (PARE) network of the European Alliance of Associations for Rheumatology (EULAR). The survey required participants to rank - based on their perceived importance - known PA barriers and facilitators from the literature, and specifically RMD symptoms as well as healthcare and community factors that may affect PA participation. Of the participants, 58% reported rheumatoid arthritis as their primary diagnosis, 89% were female, and 59% were between 51 and 70 years of age. Overall, participants reported fatigue (61.4%), pain (53.6%) and painful/swollen joints (50.6%) as the highest ranked barriers for engaging in PA. Conversely, less fatigue (66.8%) and pain (63.6%), and being able to do daily activities more easy (56.3%) were identified as the most important facilitators to PA. Three literature identified PA barriers, i.e., general health (78.8%), fitness (75.3%) and mental health (68.1%), were also ranked as being the most important for PA engagement. Symptoms of RMDs, such as pain and fatigue, seem to be considered the predominant barriers to PA by people with RMD; the same barriers are also the ones that they want to improve through increasing PA, suggesting a bi-directional relationship between these factors. Key Points • Symptoms of rheumatic and musculoskeletal disease (RMD) are the predominant barriers for lack of physical activity engagement. • RMD symptoms are the factors that people with RMDs want to improve when engaging in PA. • The barriers that stop people living with RMDs to do more PA are the ones that can be significantly improved through PA engagement.

Clinical effect and biological mechanism of exercise for rheumatoid arthritis: A mini review

Rheumatoid arthritis (RA) is a common systematic, chronic inflammatory, autoimmune, and polyarticular disease, causing a range of clinical manifestations, including joint swelling, redness, pain, stiffness, fatigue, decreased quality of life, progressive disability, cardiovascular problems, and other comorbidities. Strong evidence has shown that exercise is effective for RA treatment in various clinical domains. Exercise training for relatively longer periods (e.g., ≥ 12 weeks) can decrease disease activity of RA. However, the mechanism underlying the effectiveness of exercise in reducing RA disease activity remains unclear. This review first summarizes and highlights the effectiveness of exercise in RA treatment. Then, we integrate current evidence and propose biological mechanisms responsible for the potential effects of exercise on immune cells and immunity, inflammatory response, matrix metalloproteinases, oxidative stress, and epigenetic regulation. However, a large body of evidence was obtained from the non-RA populations. Future studies are needed to further examine the proposed biological mechanisms responsible for the effectiveness of exercise in decreasing disease activity in RA populations. Such knowledge will contribute to the basic science and strengthen the scientific basis of the prescription of exercise therapy for RA in the clinical routine.

Regulatory Qualification of a Cross-Disease Digital Measure: Benefits and Challenges from the Perspective of IMI Consortium IDEA-FAST

Background

Innovative Medicines Initiative (IMI) consortium IDEA-FAST is developing novel digital measures of fatigue, sleep quality, and impact of sleep disturbances for neurodegenerative diseases and immune-mediated inflammatory diseases. In 2022, the consortium met with the European Medicines Agency (EMA) to receive advice on its plans for regulatory qualification of the measures. This viewpoint reviews the IDEA-FAST perspective on developing digital measures for multiple diseases and the advice provided by the EMA.

Summary

The EMA considered a cross-disease measure an interesting and arguably feasible concept. Developers should account for the need for a strong rationale that the clinical features to be measured are similar across diseases. In addition, they may expect increased complexity of study design, challenges when managing differences within and between disease populations, and the need for validation in both heterogeneous and homogeneous populations.

Key Messages

EMA highlighted the challenges teams may encounter when developing a cross-disease measure, though benefits potentially include reduced resources for the technology developer and health authority, faster access to innovation across different therapeutic fields, and feasibility of cross-disease comparisons. The insights included here can be used by project teams to guide them in the development of cross-disease digital measures intended for regulatory qualification.

2021 EULAR recommendations regarding lifestyle behaviours and work participation to prevent progression of rheumatic and musculoskeletal diseases

OBJECTIVES

A European League Against Rheumatism taskforce was convened to review the literature and develop recommendations on lifestyle behaviours for rheumatic and musculoskeletal diseases (RMDs).

METHODS

Six lifestyle exposures (exercise, diet, weight, alcohol, smoking, work participation) and seven RMDs (osteoarthritis, rheumatoid arthritis, axial spondyloarthritis, psoriatic arthritis, systemic lupus erythematosus, systemic sclerosis, gout) were considered. The taskforce included health professionals in rheumatology, geriatricians, epidemiologists, public health experts, people with RMDs and exposure domain experts. Systematic reviews were conducted to gather available evidence, from which recommendations were developed.

RESULTS

Five overarching principles and 18 specific recommendations were defined based on available evidence. The overarching principles define the importance of a healthy lifestyle, how lifestyle modifications should be implemented, and their role in relation to medical treatments. Exercise recommendations highlight the safety and benefits of exercise on pain and disability, particularly among people with osteoarthritis and axial spondyloarthritis. The diet recommendations emphasise the importance of a healthy, balanced diet for people with RMDs. People with RMDs and health professionals should work together to achieve and maintain a healthy weight. Small amounts of alcohol are unlikely to negatively affect the outcomes of people with RMDs, although people with rheumatoid arthritis and gout may be at risk of flares after moderate alcohol consumption. Smokers should be supported to quit. Work participation may have benefits on RMD outcomes and should be discussed in consultations.

CONCLUSIONS

These recommendations cover a range of lifestyle behaviours and can guide shared decision making between people with RMDs and health professionals when developing and monitoring treatment plans.

Tablet-based cognitive behavioral intervention to improve arthritis associated fatigue: A pilot study

This pilot study evaluated the effect of the tablet-based cognitive behavioral intervention ("Tab-CBI") on daily steps, fatigue, and self-efficacy. Tab-CBI combined simple walking and a cognitive behavioral approach. An experimental pretest-posttest repeated measures design was used with 24 older adults. RM-ANOVA results showed a significant group difference (Tab-CBI vs. Comparison), F (1, 22) = 2.25, p =0.048 and time difference (baseline vs. week 4 vs. week 6), F (2, 44) =5.04, p =0.01 in daily steps. There was no significant group difference, F (1, 22) = 2.99, p =0.09, but significant time difference existed, F (2, 44) =2.65, p =0.04 in the PROMIS Fatigue scores. In the PROMIS Self-efficacy scores, no significant group difference, F (1, 22) = 0.02, p =0.90) was found, but significant time difference existed, F (2, 44) =3.27, p = 0.04. The findings provide preliminary evidence for the positive impact of Tab-CBI, but should be interpreted cautiously.

EXPERIENCES OF PATIENTS WITH RHEUMATOID ARTHRITIS DURING AND AFTER COVID-19 INDUCED QUARANTINE IN TERMS OF PHYSICAL ACTIVITY AND HEALTH STATUS: A QUALITATIVE STUDY

Aim

The aim of this study was to explore experiences of people with rheumatoid arthritis during and after COVID‐19‐induced quarantine in terms of physical activity and health status.

Background

Rheumatoid arthritis affects multiple facets of the person, both physically and psychologically. Physical activity is considered a safe and effective intervention to improve symptoms and systemic manifestations of rheumatoid arthritis. In the context of the COVID‐19, countries like Spain were forced to impose restrictions on mobility, prohibiting outings even to perform physical activity.

Methods

Structured interviews were conducted and developed using the Tampa Scale for Kinesiophobia‐11 questionnaire. Data were analysed using a six‐step thematic analysis.

Results

The results make it clear that even though the patients declared that physical activity is essential for them to deal with their disease, most of the participants affirmed that they significatively reduced their levels of physical activity during the pandemic.

Conclusions

Physical activity should be promoted in people, even in difficult times, to improve disease outcomes, well‐being and mental health.

Implications for Nursing Management

Knowing the experiences of these patients enables nursing managers to develop interventions that ensure the delivery of comprehensive nursing care regarding physical activity and health status, in future situations like this pandemic.

Protocol for a multi-center randomized controlled trial to evaluate the benefits of exercise incentives and corticosteroid injections in osteoarthritis of the knee (MOVE-OK)

BACKGROUND

Knee osteoarthritis (KOA) is a high-priority problem among the aging population. While exercise has been shown to be beneficial in management of the disease, scalable and low-cost interventions to improve exercise in this population are lacking. Recent controversy over the value of corticosteroid injections for palliation has also arisen. Therefore, we designed a randomized, double-blind, placebo-controlled clinical trial with a 2-period crossover design to study (1) behavioral incentives to promote exercise and (2) corticosteroid injections to reduce pain and improve function in patients with KOA when compared to lidocaine only.

METHODS

The study design is a pragmatic factorial and crossover randomized clinical trial. Patients with KOA who are deemed eligible by their provider to receive knee injections and are able to walk without assistive devices will be recruited from clinical practices at four sites within the Veterans Affairs (VA) Health System in the USA. In total, 220 participants will be randomized to receive social incentives with gamification (i.e., incorporation of game elements) to promote exercise and compared to controls that receive a Fitbit but no incentive. Each patient will also be assigned to receive a blinded corticosteroid injection and a lidocaine-only injection in random order. The primary outcomes are the change in average daily step counts from baseline and the change in Knee Osteoarthritis Outcome Score (KOOS) from baseline. The study team will continuously collect step count, heart rate, and sleep data using activity monitors and patient-reported outcomes using the Way to Health (WTH) platform at two four-week intervals over eight months of follow-up. Mixed effects regression incorporating all available data points will be used for analysis.

DISCUSSION

The "Marching on for Veterans with Osteoarthritis of the Knee" (MOVE-OK) trial will take a pragmatic approach to evaluate (1) whether incentives based on behaviorally enhanced gamification can improve physical activity in this patient population and (2) whether corticosteroids injections reduce pain and disability in patients with KOA. Results of this trial will help to direct clinical practice and inform management guidelines.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05035810 . Registered on 5 September 2021.

Effects of physical exercise and body weight on disease-specific outcomes of people with rheumatic and musculoskeletal diseases (RMDs): systematic reviews and meta-analyses informing the 2021 EULAR recommendations for lifestyle improvements in people with RMDs

BACKGROUND

A European League Against Rheumatism (EULAR) taskforce was convened to develop recommendations for lifestyle behaviours in rheumatic and musculoskeletal diseases (RMDs). This paper reviews the literature on the effects of physical exercise and body weight on disease-specific outcomes of people with RMDs.

METHODS

Three systematic reviews were conducted to summarise evidence related to exercise and weight in seven RMDs: osteoarthritis, rheumatoid arthritis, systemic lupus erythematosus, axial spondyloarthritis (axSpA), psoriatic arthritis, systemic sclerosis and gout. Systematic reviews and original studies were included if they assessed exercise or weight in one of the above RMDs, and reported results regarding disease-specific outcomes (eg, pain, function, joint damage). Systematic reviews were only included if published between 2013-2018. Search strategies were implemented in the Medline, Embase, Cochrane Library of systematic reviews and CENTRAL databases.

RESULTS

236 articles on exercise and 181 articles on weight were included. Exercise interventions resulted in improvements in outcomes such as pain and function across all the RMDs, although the size of the effect varied by RMD and intervention. Disease activity was not influenced by exercise, other than in axSpA. Increased body weight was associated with worse outcomes for the majority of RMDs and outcomes assessed. In general, study quality was moderate for the literature on exercise and body weight in RMDs, although there was large heterogeneity between studies.

CONCLUSION

The current literature supports recommending exercise and the maintenance of a healthy body weight for people with RMDs.

Effect of resistance exercise on serum leptin levels in a prospective longitudinal study of women patients with rheumatoid arthritis

Background

Exercise has an anti-inflammatory effect and reduces fat mass. Leptin has been known to be proinflammatory adipokines mainly produced by adipocytes. However, few studies have investigated the association between exercise and changes in serum leptin levels of patients with RA. This study evaluated the effect of an individualized resistance exercise on inflammatory markers including leptin as well as muscle strength and exercise capacity in patients with rheumatoid arthritis (RA).

Methods

A total of 42 age- and sex-matched participants were assigned to a resistance exercise program (60 min, once a week for 12 weeks, and self-exercise twice a week) or to a control group. Muscle strength, exercise capacities, and inflammatory markers such as cytokines and adipokines were assessed at baseline and at 12 weeks follow-up. Longitudinal changes in muscle strength, exercise capacity, cytokines, and adipokines between groups were tested with repeated measures analysis of variance or using the generalized estimating equation, with adjustment for baseline disease activity score 28-C response protein as a covariate.

Results

A total of 37 of 42 female patients with RA completed this prospective intervention study. Grip strength improved significantly in the exercise group (P < 0.05), while no between-group changes were found. Quadriceps contraction power (P for group-time interaction = 0.035 for the right side and P for group-time interaction = 0.012 for the left side) and 6-minute walking distance (P for group-time interaction = 0.021) were all improved significantly in the exercise group compared with the control group. In addition, serum leptin levels were significantly decreased in the exercise group compared with the control group (P for group-time interaction = 5.22 × 10⁻⁵), but not the other cytokines or adipokines. The change in serum leptin levels correlated with the changes in fat mass (Rho = 0.491, P= 0.015) and visceral fat area (Rho = 0.501, P= 0.013).

Conclusion

In addition to muscle strength and exercise capacity, the 12 weeks of individualized resistance exercise reduced serum leptin levels in keeping with body fat mass or visceral fat area, suggesting that serum leptin levels might be a surrogate marker of exercise in RA.

The effect of exercise training programs with aerobic components on C-reactive protein, erythrocyte sedimentation rate and self-assessed disease activity in people with ankylosing spondylitis: A systematic review and meta-analysis

AIM

To examine the effect of exercise training programs with aerobic components on C-reactive protein, erythrocyte sedimentation rate and self-assessed disease activity in people with ankylosing spondylitis compared to non-aerobic rehabilitation.

METHODS

A systematic review was undertaken of PubMED, Cochrane Library, Embase and Web of Science databases. Articles evaluating the effect of exercise training programs with aerobic components on C-reactive protein, erythrocyte sedimentation rate or Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) in adults (>17 years) with ankylosing spondylitis were included. Control groups were defined as non-aerobic rehabilitation, including usual care or physiotherapy.

RESULTS

Thirteen articles met inclusion criteria for qualitative and meta-analysis, involving 366 participants undertaking exercise and 361 controls. Exercise programs included modalities such as running, aerobic walking and swimming, and were between 3 weeks and 3 months in duration. Exercise programs significantly reduced C-reactive protein (weighted mean difference [WMD]: -1.09; 95% CI: -2.08 to -0.10; P = .03; n = 5) and BASDAI (WMD: -0.78; 95% CI: -0.98 to -0.58; P < .001; n = 13) compared to non-aerobic rehabilitation. BASDAI subgroup analysis revealed greater improvements compared to usual care than structured physiotherapy. Exercise programs did not reduce erythrocyte sedimentation rate (WMD: 0.16; 95% CI: -2.15 to 2.47; P = .89; n = 4).

CONCLUSION

Exercise training programs with aerobic components reduced C-reactive protein and improved self-assessed disease activity in people with ankylosing spondylitis. Further research is required to investigate the effects of differing aerobic exercise modes, intensities and durations.

State of Knowledge on Molecular Adaptations to Exercise in Humans: Historical Perspectives and Future Directions

For centuries, regular exercise has been acknowledged as a potent stimulus to promote, maintain, and restore healthy functioning of nearly every physiological system of the human body. With advancing understanding of the complexity of human physiology, continually evolving methodological possibilities, and an increasingly dire public health situation, the study of exercise as a preventative or therapeutic treatment has never been more interdisciplinary, or more impactful. During the early stages of the NIH Common Fund Molecular Transducers of Physical Activity Consortium (MoTrPAC) Initiative, the field is well-positioned to build substantially upon the existing understanding of the mechanisms underlying benefits associated with exercise. Thus, we present a comprehensive body of the knowledge detailing the current literature basis surrounding the molecular adaptations to exercise in humans to provide a view of the state of the field at this critical juncture, as well as a resource for scientists bringing external expertise to the field of exercise physiology. In reviewing current literature related to molecular and cellular processes underlying exercise-induced benefits and adaptations, we also draw attention to existing knowledge gaps warranting continued research effort. © 2021 American Physiological Society. Compr Physiol 12:3193-3279, 2022.

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:

[Aerobic exercise and fatigue indices in rheumatoid arthritis patients in the health resort care setting]

Fatigue is one of the most common symptoms of rheumatoid arthritis (RA). There is strong evidence that physical activity is an effective way to reduce fatigue.

OBJECTIVE

To evaluate the effectiveness of aerobic exercise (walking) to reduce fatigue in RA patients in the health resort setting.

MATERIAL AND METHODS

The study involved 102 female patients with RA (age 54.38±11.3 years, body mass index 20-29 kg/m², DAS28-ESR ≤3.2, with severe fatigue of VAS ≥50) who received 21 days of health resort treatment. The health-improving and therapeutic complex includes dosed physical activity, aerobic exercises (walking). Visual analog scale (VAS0-100) and Bristol Rheumatoid Arthritis Fatigue Scale-Numerical Rating Scale (BRAF-NRS V2) were used to assess fatigue, and the 50-meter walking test was used to evaluate the functional status of patients.

RESULTS

A correlation between walking duration and the number of steps at a distance of 50 m (p<0.001) as well as between these indices and fatigue (p<0.001) was shown. A positive effect of a standard three-week medical rehabilitation program for patients with RA on fatigue NRS severity (p=0.003) and NRS effect (p=0.037), as well as on patients' functional status (reduced time spent on the 50-meter test, p=0.01) was demonstrated. When comparing groups of RA patients with low (group 1, <5000-6000 steps per day) and optimal (group 2, ≥7000-8000 steps per day) aerobic exercise, positive results were noted in the short term (at 3 weeks) (p<0.001).

CONCLUSION

Aerobic exercise is a promising intervention for treating fatigue in rheumatoid arthritis patients. Medical rehabilitation in a resort setting is the best starting point to encourage performing regular physical activity, as well as the best way to develop exercise programs tailored to rheumatoid arthritis patients.

Evaluation of a multidisciplinary care model to improve quality of life in rheumatoid arthritis: a randomised controlled trial

BACKGROUND AND PURPOSE

Health-Related Quality of Life (HR-QOL) is an important patient-reported domain in patients with rheumatoid arthritis (RA). The uptake of multidisciplinary team (MDT) care in RA is generally low, due to initial high demand for resources. We hypothesised that whilst pharmacological treatments are effective in controlling disease activity, a multipronged intervention in an MDT may have a positive impact on HR-QOL.

METHODS

This was a single-centre randomized parallel group, single-blind controlled trial of MDT vs. usual care in an established RA clinic. Data were collected through face-to-face questionnaires, medical records review, and joint counts by a blinded assessor at 0, 3 and 6 months. Adult RA patients were randomly assigned in a single visit to a 6-member MDT (rheumatologist, nurse, social worker, physiotherapist, occupational therapist, and podiatrist) or usual care. MDT providers prescribed medications and counselled patients on managing flares, medication adherence, coping, joint protection, exercise, footwear. The primary outcome was minimal clinically important difference (MCID) in HR-QOL (increase in European QOL-5-Dimension-3-Level, EQ-5D-3L by 0.1) at six months.

RESULTS

140 patients (86.3% female, 53.4% Chinese, median (IQR) age 56.6 (46.7, 62.4) years); 70 were randomized to each arm. Median (IQR) disease duration was 5.5 (2.4, 11.0) years and disease activity in 28 joints (DAS28) was 2.87 (2.08, 3.66). 123 patients completed the study. Twenty-six (40.6%) MDT vs. 23 (34.3%) usual care patients achieved an MCID in EQ-5D-3L, OR 1.3 (0.6, 2.7). In multivariable logistic regression, baseline EQ-5D-3L was the only predictor of achieving MCID. There was more disease modifying anti-rheumatic drug escalation in MDT (34.4% vs. 19.4%). Patients with high disease activity were more likely to achieve MCID in the MDT arm.

CONCLUSIONS

A single visit by stable patients with low disease activity to an MDT failed to achieve MCID in the EQ-5D-3L; however, did achieve small but significant improvements in the EQ-5D-3L, DAS28, pain, coping and self-efficacy. To be sustainable, MDT care should be targeted at patients with high disease activity or those with a new diagnosis of RA.

TRIAL REGISTRATION

The study is registered on ClinicalTrials.gov, identifier: NCT03099668.

Fatigue in inflammatory rheumatic diseases: current knowledge and areas for future research

Fatigue is a complex phenomenon and an important health concern for many people with chronic inflammatory rheumatic diseases, such as rheumatoid arthritis, psoriatic arthritis, primary Sjögren syndrome and systemic lupus erythematosus. Although some clinical trials have shown the benefits of cognitive behavioural therapy in fatigue management, the effect of this approach is relatively modest, and no curative treatment has been identified. The pathogenesis of fatigue remains unclear. Despite many challenges and limitations, a growing body of research points to roles for the immune system, the central and autonomic nervous systems and the neuroendocrine system in the induction and maintenance of fatigue in chronic diseases. New insights indicate that sleep, genetic susceptibility, metabolic disturbances and other biological and physiological mechanisms contribute to fatigue. Furthermore, understanding of the relationships between psychosocial factors and fatigue is increasing. However, the interrelationships between these diverse mechanisms and fatigue remain poorly defined. In this Review, we outline various biological, physiological and psychosocial determinants of fatigue in inflammatory rheumatic diseases, and propose mechanistic and conceptual models of fatigue to summarize current understanding, stimulate debate and develop further research ideas.

Management of fatigue with physical activity and behavioural change support in vasculitis: a feasibility study

OBJECTIVE

Patients with ANCA-associated vasculitis (AAV) experience high levels of fatigue, despite disease remission. This study assessed the feasibility and acceptability of a definitive randomized controlled trial of a behavioural-based physical activity intervention to support fatigue self-management in AAV patients.

METHODS

AAV patients in disease remission with fatigue (Multidimensional Fatigue Inventory-20 general fatigue domain ≥14) were randomly allocated to intervention or standard care in this single-centre open-label randomized controlled feasibility study. The intervention lasted 12 weeks and comprised eight face-to-face physical activity sessions with a facilitator and 12 weekly telephone calls. Participants were encouraged to monitor their physical activity using a tracker device (Fitbit). Standard care involved sign-posting to fatigue websites. The primary outcome was feasibility of a phase III trial assessed against three stop/go traffic light criteria, (recruitment, intervention adherence and study withdrawal). A qualitative study assessed participant views about the intervention.

RESULTS

A total of 248 patients were screened and 134 were eligible to participate (54%). Stop/go criteria were amber for recruitment; 43/134 (32%, 95% CI: 24, 40) eligible participants randomized, amber for adherence; 73% of participants attended all eight physical activity sessions, but only 11/22 (50%, 95% CI: 29, 71%) completed the intervention as per the intended schedule, and green for study withdrawal; 2/43 participants withdrew before 24 weeks (5%, 95% CI: 0, 11). Qualitative results suggested the intervention was acceptable.

CONCLUSION

This study suggests a behavioural-based physical activity intervention targeting fatigue self-management was acceptable to patients with AAV, although recruitment and protocol adherence will need modification prior to a definitive trial.

CLINICAL TRIAL REGISTRATION NUMBER

ISRCTN11929227.

Usability testing of tablet-based cognitive behavioral intervention application to improve a simple walking activity for older adults with arthritis fatigue

The purpose of this study was to test usability of a tablet-based cognitive behavioral intervention ("Tab-CBI") application. Tab-CBI was designed to improve a simple walking activity for older adults with arthritis fatigue. Two phases of usability evaluation were conducted: phase I with 5 older adults to identify any initial design issues and phase II with 10 older adults to examine if Tab-CBI was seamlessly integrated into their daily living. Participants perceived that Tab-CBI was easy, light, and intuitive to use and helped them walking. They reported two key benefit as a motivator to make more active in walking and improved confidence of self-management of fatigue. They referred video recordings and videoconferencing communications as two preferable features. There were also comments for improvement, for example, a challenge for holding a tablet when videoconferencing communications. Participants comments were incorporated into a final version of Tab-CBI to prepare for a future pilot study.

[Sports and exercise therapy in inflammatory rheumatic diseases]

Physical therapy has always been a pillar of the treatment of inflammatory rheumatic diseases in addition to targeted drug treatment; nevertheless, it is only established in the treatment guidelines for a few diseases. Within the last two decades the discovery of myokines has uncovered the physiological correlations of the anti-inflammatory effect of physical activity. For rheumatoid arthritis and spondylarthritis, several randomized controlled trials provide sufficient evidence to make well-founded recommendations. For connective tissue diseases (CTD) the data situation is clearly sparser but nevertheless shows that the positive effects of physical activity prevail. In the following article the authors present the most important clinical studies on sport and inflammatory rheumatic diseases and from these derive possible therapeutic recommendations.

Different types of physical activity are positively associated with indicators of mental health and psychological wellbeing in rheumatoid arthritis during COVID-19

Nationwide lockdowns during SARS-CoV-2 (COVID-19) can compromise mental health and psychological wellbeing and limit opportunities for physical activity (PA), particularly in clinical populations, such as people with rheumatoid arthritis (RA), who are considered at risk for COVID-19 complications. This study aimed to investigate associations between PA and sedentary time (ST) with indicators of mental health and wellbeing in RA during COVID-19 lockdown, and examine the moderation effects of self-isolating. 345 RA patients completed an online questionnaire measuring PA (NIH-AARP Diet and Health Study Questionnaire), ST (International Physical Activity Questionnaire-Short Form), pain (McGill Pain Questionnaire and Visual Analogue Scale), fatigue (Multidimensional Fatigue Inventory), depressive and anxious symptoms (Hospital Anxiety and Depression Scale), and vitality (Subjective Vitality Scale) during the United Kingdom COVID-19 lockdown. Associations between PA and ST with mental health and wellbeing were examined using hierarchical multiple linear regressions. Light PA (LPA) was significantly negatively associated with mental fatigue (β = - .11), depressive symptoms (β = - .14), and positively with vitality (β = .13). Walking was negatively related to physical fatigue (β = - .11) and depressive symptoms (β = - .12) and positively with vitality (β = .15). Exercise was negatively associated with physical (β = - .19) and general (β = - .12) fatigue and depressive symptoms (β = - .09). ST was positively associated with physical fatigue (β = .19). Moderation analyses showed that LPA was related to lower mental fatigue and better vitality in people not self-isolating, and walking with lower physical fatigue in people self-isolating. These findings show the importance of encouraging PA for people with RA during a lockdown period for mental health and wellbeing.

Benefits and promotion of physical activity in rheumatoid arthritis

PURPOSE OF REVIEW

The aim of this article is to describe the benefits of physical activity and exercise on rheumatoid arthritis disease activity, functioning, and symptoms; and offer recommendations for promotion of physical activity and exercise among people with rheumatoid arthritis.

RECENT FINDINGS

In addition to well-known benefits of exercise such as improving cardiovascular health and metabolic syndrome and reducing obesity, exercise has consistently shown rheumatoid arthritis-specific benefits. Exercise and increases in physical activity improve clinically measured disease activity, reduce symptoms such as fatigue and pain, and improve function and mental health. In spite of these benefits, most people with rheumatoid arthritis are inactive. Patient barriers to engaging in physical activity may include fears of joint damage, rheumatoid arthritis symptoms, and lack of understanding that physical activity improves the symptoms that may be barriers. However, the greatest barrier to healthy levels of physical activity among individuals with rheumatoid arthritis appears to be the lack of direction from healthcare providers.

SUMMARY

Exercise is safe and highly beneficial for people with rheumatoid arthritis. Because receiving recommendations from healthcare providers may be the factor most strongly associated with engaging in physical activity or exercise, providers are encouraged to give patients positive messages about the benefits of physical activity and the extremely low risks of harm.

Sustained Long-Term Efficacy of Motivational Counseling and Text Message Reminders on Daily Sitting Time in Patients With Rheumatoid Arthritis: Long-Term Follow-up of a Randomized, Parallel-Group Trial

OBJECTIVE

To evaluate the 18-month postintervention efficacy following a 4-month individually tailored behavioral intervention on daily sitting time in patients with rheumatoid arthritis (RA).

METHODS

In an observer-blinded randomized trial, 150 RA patients were included. During 4 months, the intervention group (n = 75) received 3 motivational counseling sessions and tailored text messages aimed at increasing light-intensity physical activity through reduction of sedentary behavior. The control group (n = 75) maintained their usual lifestyle. The primary outcome was change from baseline to 18 months postintervention in objectively measured daily sitting time (using ActivPAL). Secondary outcomes included changes in clinical patient-reported outcomes and cardiometabolic biomarkers. A mixed-effect repeated measures analysis of covariance model in the intent-to-treat population was applied.

RESULTS

At 22 months follow-up from baseline, 12 participants were lost to follow-up. Compared to baseline, sitting time in the intervention group decreased 1.10 hours/day, whereas it increased by 1.32 hours/day in the control group, a between-group difference of -2.43 hours/day (95% confidence interval [95% CI] -2.99, -1.86; P < 0.0001) favoring the intervention group. For most secondary outcomes, between-group differences favored the intervention: visual analog scale (VAS) pain -15.51 mm (95% CI -23.42, -7.60), VAS fatigue -12.30 mm (95% CI -20.71, -3.88), physical function -0.39 Health Assessment Questionnaire units (95% CI -0.53, -0.26), total cholesterol -0.86 mmoles/liter (95% CI -1.03, -0.68), triglycerides -0.26 mmoles/liter (95% CI -0.43, -0.09), and average glucose -1.15 mmoles/liter (95% CI -1.39, -0.91).

CONCLUSION

The 4-month postintervention results showed that patients in the intervention reduced their daily sitting time and improved patient-reported outcomes and total cholesterol levels compared to the control group. Eighteen months after intervention, patients in the intervention group were still significantly less sedentary than controls. Findings suggest that a behavioral approach is beneficial for promoting long-term physical activity and health in patients with RA.

Mental Health and Psychological Wellbeing in Rheumatoid Arthritis during COVID-19 - Can Physical Activity Help?

In response to the COVID-19 pandemic, many countries have adopted community containment to manage COVID-19. These measures to reduce human contact, such as social distancing, are deemed necessary to contain the spread of the virus and protect those at increased risk of developing complications following infection with COVID-19. People with rheumatoid arthritis (RA) are advised to adhere to even more stringent restrictions compared to the general population, and avoid any social contact with people outside their household. This social isolation combined with the anxiety and stress associated with the pandemic, is likely to particularly have an impact on mental health and psychological wellbeing in people with RA. Increasing physical activity and reducing sedentary behaviour can improve mental health and psychological wellbeing in RA. However, COVID-19 restrictions make it more difficult for people with RA to be physically active and facilitate a more sedentary lifestyle. Therefore, guidance is necessary for people with RA to adopt a healthy lifestyle within the constraints of COVID-19 restrictions to support their mental health and psychological wellbeing during and after the COVID-19 pandemic.

The effect of physical exercise on rheumatoid arthritis: An overview of systematic reviews and meta-analysis

AIMS

To determine which outcomes will be improved by different exercise interventions and the evidence quality for each intervention.

DESIGN

Overview of systematic reviews and meta-analysis.

DATA SOURCES

PubMed, Cochrane, Web of Science, CINAHL, and Embase. Published from the establishment of the database to 3 September 2019.

REVIEW METHODS

AMSTAR 2 and PRISMA were used to evaluate methodological and reporting quality. Evidence quality of the effect of each intervention was assessed according to GRADE guidelines. Meta-analysis of original studies was conducted for comparison of systematic reviews and to explore the effect of different exercise interventions on the same outcome.

RESULTS

Ten systematic reviews were included in the overview. A significant improvement was seen in: aerobic exercise for aerobic capacity; strength training for erythrocyte sedimentation rate and 50-foot walking time; aerobic exercise combined with strength training for aerobic capacity, physical function, and fatigue; hand exercise for hand function.

CONCLUSIONS

For the maximum benefit of rheumatoid arthritis (RA) patients, different exercise methods should be selected according to the symptoms. For RA patients, any exercise is better than no exercise, but the intensity, frequency, and period of exercise for better results are not determined.

IMPACT

What problem did the study address is which outcomes will be improved by different exercise interventions. For maximum benefit for RA patients, different exercise methods should be selected according to symptoms. The research summarized the evidence of exercise rehabilitation of RA and will help RA patients or their caregivers choose the appropriate type of exercise, which will play a positive role on the rehabilitation of patients with RA.

Comparison of the effectiveness of pilates exercises, aerobic exercises, and pilates with aerobic exercises in patients with rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis (RA) is a rheumatic disease characterized by erosive synovitis and polyarthritis. Exercise is known to improve many symptoms in RA patients.

AIM

This study was designed to compare the effects of pilates exercises, aerobic exercises, and combined training including pilates with aerobic exercises on fatigue, depression, aerobic capacity, pain, sleep quality, and quality of life.

METHODS

Thirty voluntary RA patients were included in this study. Patients were divided into three groups equally, and treatment was applied to each group for 8 weeks. Pilates exercises were practiced to the first group, aerobic exercises were practiced to the second group, and combined training was performed to the third group. Fatigue, depression, aerobic capacity, pain, sleep quality, and quality of life were evaluated using Fatigue Severity Scale (FSS), Beck Depression Inventory (BDI), 6-minute walk test (6MWT), McGill Pain Questionnaire- Short Form (MPQ-SF), Pittsburg Sleep Quality Index (PSQI), and Rheumatoid Arthritis Quality of Life (RAQoL), respectively.

RESULTS

The results of the present study showed significant improvements for the first group on fatigue, depression, aerobic capacity, and quality of life (p < 0.05). Improvements in all parameters except for pain were obtained for the second and third groups (p < 0.05). In addition, there was no statistically significant difference among the treatment groups in assessments (p > 0.05).

CONCLUSION

Pilates exercises may have similar effects to aerobic exercises in patients with RA. Addition of clinical pilates exercises to the routine treatment of RA may enhance the success of rehabilitation. Trial registration NCT03836820.

The impact of lifestyle behaviours, physical activity and smoking on morbidity and mortality in patients with rheumatoid arthritis

Rheumatoid arthritis (RA) is associated with pain, disability and increased risk of developing comorbidities and premature mortality. While these poor outcomes have improved in line with advances in the treatment of RA, they still persist to some degree today. Physical activity and smoking are two areas of patients' lives where changes may have a substantial impact on the poor outcomes associated with RA. Physical activity in RA has been well studied, with many randomised trials indicating the benefits of physical activity on pain and disability. A number of observational studies have assessed the impact of smoking on RA, also indicating the benefits of quitting smoking on RA-related outcomes, but with less consistent findings, potentially due to epidemiological challenges (e.g. collider bias, recall bias). There are also a number of barriers preventing patients making these positive lifestyle changes, such as lack of time and motivation, lack of knowledge and advice, as well as disease-specific barriers, such as pain and fatigue.

Fatigue in inflammatory arthritis

Fatigue is highly prevalent in inflammatory arthritis, and people living with the symptom have described it as overwhelming and a challenge to manage. In this article, we explore the experience, impact and non-pharmacological management of fatigue from a multi-disciplinary perspective. We start by presenting qualitative evidence from people living with fatigue, including the physical, cognitive and emotional nature of the symptom and its impact on daily life. This is followed by discussion of current conceptual models of mechanisms and factors that may cause and maintain fatigue, within and between individuals. We then address the issue of fatigue measurement and modes of assessment, which is an integral aspect of management and evaluating support provision. This leads to a review of the research evidence for non-pharmacological interventions to reduce fatigue severity and impact. Finally, we consider implementation of this evidence in clinical practice and we introduce some key practical tools and techniques.

High-Intensity Exercise Improves Fatigue, Sleep, and Mood in Patients With Axial Spondyloarthritis: Secondary Analysis of a Randomized Controlled Trial

OBJECTIVE

Although exercise is recommended in the treatment of axial spondyloarthritis (axSpa), the focus has been on flexibility, and the effect of high-intensity exercises is unknown. The purpose of this study was to investigate the effect of high-intensity exercises on fatigue, sleep, and mood in patients with axSpA.

METHODS

In this secondary analysis of a randomized controlled trial, participants were recruited from outpatient clinics at 4 hospitals in Scandinavia. A total of 100 patients with axSpA were randomized to either an exercise group (n = 50) or a control group (n = 50). High-intensity exercise was provided 3 times per week for 3 months and supervised by a physical therapist. The controls received no intervention. Measurements were self-reported at baseline, 3 months, and 12 months: fatigue, using the Fatigue Severity Scale (range = 0-7, 7 = worst, ≥5 = severe); vitality, using the RAND 36-item short-form health survey (SF-36, range = 0-100, 100 = best); sleep, using the Pittsburgh Sleep Quality Index (range = 0-21, 21 = worst, >5 = poor quality); mood, using the General Health Questionnaire 12 (range = 0-36, 36 = worst); and general health, using the EUROQoL (range = 0-100, 100 = best).

RESULTS

A total of 38 participants (76%) in the exercise group followed ≥80% of the exercise protocol. At 3 months, there was a significant beneficial effect on fatigue (mean group differences = -0.4, 95% CI = -0.7 to -0.1), vitality (5.0, 95% CI = 1.1 to 10.5), mood (-2, 95% CI = -3.7 to -0.04), and general health (9.0, 95% CI = 3.3 to 14.7) but no effect on sleep (-1.1, 95% CI = -2.1 to 0.2). Compared with the control group, the exercise group had a reduced rate of severe fatigue and poor sleep. No differences were seen between the groups at 12 months.

CONCLUSIONS

A 3-month exercise program had a beneficial effect on fatigue, sleep, mood, and general health in patients with axSpA at the end of the intervention; however, no long-term effects were seen.

IMPACT

High-intensity cardiorespiratory and strength exercises should be considered as important in exercise programs for patients with axSpA.

Relationship Between Pain and Sedentary Behavior in Rheumatoid Arthritis Patients: A Cross-Sectional Study

OBJECTIVE

Despite the known benefits of physical activity, high numbers of individuals with rheumatoid arthritis (RA) remain physically inactive and sedentary. Little is known about the determinants of sedentary behavior (SB) in RA. This cross-sectional study was undertaken to examine a range of pain characteristics and RA-related symptoms and their relationship with objectively measured SB.

METHODS

In total, 76 adults with RA wore an activPAL4 accelerometer (PAL Technologies) over a 7-day period. Pain characteristics (pain intensity, painful joint count, nonarticular pain), fatigue, sleep, depression, anxiety, and disease activity were assessed. Analyses were first conducted to evaluate correlations with sedentary time. The independent contribution of pain characteristics to variation in SB was analyzed with multivariable linear regression (adjusted for demographic data and disease activity).

RESULTS

Participants with valid accelerometer data (n = 72) spent a mean ± SD of 533.7 ± 100.1 minutes/day in SB. Positive associations with daily SB were found for pain intensity (r = 0.31, P < 0.01) and number of painful joints (r = 0.24, P < 0.05) but not nonarticular pain. In multivariable analyses, pain characteristics were not independently associated with SB. Analyses indicated that disease activity had an indirect association with SB mediated by pain intensity. Other correlates of daily SB included anxiety and depression but not fatigue or sleep.

CONCLUSION

Results suggest that while pain and other RA-related factors do play a role in SB, they do not appear to have a significant influence after accounting for other variables. Future research should investigate SB and the role of factors unrelated to the symptoms of RA.

Exercise and inflammation

Based on current knowledge deriving from studies in animals and humans (the general population and patients with non-communicable diseases), there is biological plausibility that exercise may have anti-inflammatory effects. This may be particularly important for patients with chronic inflammatory rheumatic and musculoskeletal diseases (RMDs). The present review discusses the current state-of-the-art on exercise and inflammation, explores how exercise can moderate inflammation-dependent RMD outcomes and the most prevalent systemic manifestations and addresses the relationship between the dosage (particularly the intensity) of exercise and inflammation. We conclude that present data support potential beneficial effects of exercise on inflammation, however, the evidence specifically in RMDs is limited and inconclusive. More targeted research is required to elucidate the effects of exercise on inflammation in the context of RMDs.

The role of non-pharmacological interventions in the management of rheumatoid-arthritis-related fatigue

Non-pharmacological interventions may be beneficial in the management of rheumatoid arthritis related fatigue. A narrative review was undertaken, with a focus upon research published in the past 6 years. Seven studies were identified, four focusing upon physical activity, two on psychosocial interventions and one that investigated aromatherapy and reflexology. Findings supported previous evidence that physical activity and psychosocial interventions have potential to produce small to moderate reductions in fatigue related to rheumatoid arthritis. Reflexology and aromatherapy interventions also appeared promising. Limitations to the evidence included lack of consistency in fatigue measurement, and minimal data on long-term outcomes and cost effectiveness. The wide range of physical activity interventions prevent specific recommendations. For psychosocial interventions the strongest evidence is for group-based cognitive behavioural approaches. There was lack of consideration given to fatigue mechanisms and intervention design. Due to the complexity of fatigue, future research exploring personalized approaches is warranted.

A biopsychosocial network model of fatigue in rheumatoid arthritis: a systematic review

Fatigue in RA is prevalent, intrusive and disabling. We propose a network model of fatigue encompassing multiple and mutually interacting biological, psychological and social factors. Guided by this model, we reviewed the literature to offer a comprehensive overview of factors that have been associated with fatigue in RA. Six categories of variables were found: physical functioning, psychological functioning, medical status, comorbidities and symptoms, biographical variables and miscellaneous variables. We then systematically reviewed associations between fatigue and factors commonly addressed by rheumatology health professionals. Correlations of fatigue with physical disability, poor mental well-being, pain, sleep disturbance and depression and anxiety were ∼0.50. Mostly these correlations remained significant in multivariate analyses, suggesting partly independent influences on fatigue and differences between individuals. These findings indicate the importance of research into individual-specific networks of biopsychosocial factors that maintain fatigue and tailored interventions that target the influencing factors most relevant to that person.

Implementation of Physical Activity into routine Clinical pracTice in Rheumatic Musculoskeletal Disease: The IMPACT-RMD study protocol and rationale

Background:

Physical activity is an important intervention for improving disease-related symptoms and systemic manifestations in rheumatic and musculoskeletal disease (RMDs). However, studies suggest that RMD patients report that the lack of individualized and consistent information about physical activity from managing doctors and healthcare professionals, acts as a barrier for engagement. On the other hand, managing doctors and healthcare professionals report lack of knowledge in this area and thus lack of confidence to educate and advise RMD patients about the beneficial effects of physical activity. The aim of the present study therefore, is to develop two e-Learning courses for RMD doctors and health professionals: a) the first one to provide consistent information about the collective benefits of physical activity in RMDs and b) the second on how to implement physical activity advice in routine clinical practice.

Methods:

An international collaboration of seven countries, consisting of one academic institution and one patient organization from each country, will co-develop the two e-Learning courses. The final e-Learning courses will primarily target to improve – through physical activity advice – RMD symptoms which are important for patients.

Discussion:

The main result of this study will be to co-develop two e-Learning courses that can be used by managing RMD doctors and healthcare professionals to be made aware of the overall benefits of physical activity in RMDs as well as how to implement physical activity advise within their practice.

The impact of rehabilitation frequency on the risk of stroke in patients with rheumatoid arthritis

BACKGROUND

Patients with rheumatoid arthritis are at higher risk of developing stroke due to augmented systemic inflammation. While regular exercise has been shown to reduce inflammation in human subjects, the purpose of our study is to determine whether increased frequency of rehabilitation is protective against stroke or not.

METHODS

A total of 16,224 rheumatoid arthritis patients with a catastrophic illness certificate were identified in our database from 2000 to 2006, and 663 of them developed stroke before the end of 2013. After statistically matching for age, sex, and the time interval between the diagnosis of rheumatoid arthritis and stroke, 642 patients without stroke were identified as the control group. Analyses with Student's t test and Chi-square test were done to compare the clinical characteristics of patients with and without stroke, and logistic regression analysis was then performed to evaluate the odds ratio of stroke.

RESULTS

Higher odds ratio of stroke was revealed in patients with hypertension, diabetes mellitus, and moderate degree of rheumatoid arthritis disease severity. Furthermore, more than 40 rehabilitation sessions per year reduced the risk of developing stroke in patients with moderate disease severity.

CONCLUSIONS

Physical activities brought by more rehabilitation sessions are beneficial and should be encouraged in patients with rheumatoid arthritis, particularly for those with higher disease activity but not taking biologic agents.

The Role of Physical Activity and Sedentary Behavior in Predicting Daily Pain and Fatigue in Older Adults: a Diary Study

Background

Little attention has been paid to within-person daily associations among light physical activity (PA), moderate-to-vigorous physical activity (MVPA), and sedentary behavior (SB) with subsequent bodily pain and fatigue. Daily reports of pain and fatigue are less likely to be affected by recall bias and to conflate days of high and low pain/ fatigue into one overall score.

Purpose

The purpose of this study was to examine daily within-person associations between pain, fatigue, and physical health and ascertain whether such associations are moderated by individual differences in these variables.

Methods

Participants were 63 community-living older adults (female n = 43, mean age = 70.98 years). Questionnaires measured typical levels of PA, SB, bodily pain, fatigue, and physical health. Subsequently, on a daily basis over a 1-week period, participants' levels of light PA, MVPA, and SB were measured using accelerometers. Participants completed a questionnaire rating their pain and fatigue at the end of each day.

Results

Multilevel modeling revealed positive within-person associations between daily light PA, dailyMVPA, and pain, as well as negative within-person associations between daily SB and pain. For individuals with higher typical levels of fatigue, there was a negative association between daily light PA, MVPA, and fatigue. For individuals with better levels of physical health, there was also a negative association between daily MVPA and fatigue. For those with higher typical levels of fatigue and better levels of physical health, there was a positive association between daily SB and fatigue. No such interaction effects were found between high levels of typical pain and PA or SB.

Conclusions

Our findings indicate that efforts to promote daily PA in older adults might be more effective for those who report high typical levels of fatigue and physical health, compared to those who report high levels of daily physical pain.

[Promotion of physical activity for older patients with rheumatism : Characteristics of inflammatory rheumatic diseases against the background of physical activity recommendations]

Due to the wide range of positive effects and the clear evidence of effectiveness, physical activity is one of the most important treatments for inflammatory rheumatic diseases. Because of the frequent overlap of disease and age-related aspects in older patients, the implementation of the German national physical activity recommendations has to be checked and accompanied by physicians. To get the older patients in motion, a patient-centered approach is required that takes the individual health problem(s) and the current context of life into account. This article provides an overview of the activity-related characteristics of older patients with inflammatory rheumatic diseases. Against this background a simple strategy is provided for promoting physical activity during medical consultation, which takes the characteristics of older patients with rheumatism into consideration. In this way, physicians can integrate a targeted, resource and time-saving economic strategy into consultations that is in concordance with the national physical activity recommendations.

Aerobic Exercise and Fatigue in Rheumatoid Arthritis Participants: A Meta-Analysis Using the Minimal Important Difference Approach

OBJECTIVE

To use the minimal important difference (MID) versus the standardized mean difference (SMD) approach in order to provide more robust and clinically relevant information regarding the association between land-based aerobic exercise and changes in self-reported fatigue among adults with rheumatoid arthritis (RA).

METHODS

Data from a previous meta-analysis of 5 randomized controlled trials that represented up to 298 participants per study were utilized to calculate 9 effect sizes, using the MID approach. Data used to obtain the MID were derived from previously reported anchor-based values specific to each fatigue instrument in adults with RA. Results were pooled using a random-effects model.

RESULTS

Aerobic exercise resulted in statistically significant reductions in self-reported fatigue (MID effect size -0.34 [95% confidence interval (95% CI) -0.58, -0.10]; P = 0.006). Results were similar when effect sizes were collapsed so that only 1 effect size represented each study (MID effect size -0.39 [95% CI -0.76, -0.03]; P = 0.04).

CONCLUSION

Land-based aerobic exercise is associated with statistically significant reductions in fatigue; however, based on previous cut points, it may be unlikely that a substantial number of participants with RA could obtain clinically relevant reductions in fatigue. Additional studies are needed, especially in those individuals with RA who have elevated levels of fatigue.

Developing a group intervention to manage fatigue in rheumatoid arthritis through modifying physical activity

Background

Fatigue is a major symptom of rheumatoid arthritis (RA). There is some evidence that physical activity (PA) may be effective in reducing RA fatigue. However, few PA interventions have been designed to manage fatigue and there is limited evidence of end-user input into intervention development. The aim of this research was to co-design an intervention to support self-management of RA fatigue through modifying PA.

Methods

A series of studies used mixed methodological approaches to co-design a fatigue management intervention focused on modifying PA based on UK Medical Research Council guidance, and informed by the Behaviour Change Wheel theoretical framework. Development was based on existing evidence, preferences of RA patients and rheumatology healthcare professionals, and practical issues regarding intervention format, content and implementation.

Results

The resulting group-based intervention consists of seven sessions delivered by a physiotherapist over 12 weeks. Each session includes an education and discussion session followed by supervised PA chosen by the participant. The intervention is designed to support modification and maintenance of PA as a means of managing fatigue. This is underpinned by evidence-based behaviour change techniques that might support changes in PA behaviour. Intervention delivery is interactive and aims to enhance capability, opportunity and motivation for PA.

Conclusion

This study outlines stages in the systematic development of a theory-based intervention designed through consultation with RA patients and healthcare professionals to reduce the impact of RA fatigue. The feasibility of future evaluation of the intervention should now be determined.

Motivational Counseling and Text Message Reminders: For Reduction of Daily Sitting Time and Promotion of Everyday Physical Activity in People with Rheumatoid Arthritis

Most patients with rheumatoid arthritis tend to be physically inactive and spend more time in sedentary behaviors compared with the general population. This inactive lifestyle can lead to serious health consequences, for example, increased risk of cardiovascular disease. For this reason, there is an interest in increasing participation in physical activity in patients with rheumatoid arthritis. The relatively new approach of reducing sedentary behavior and replacing it with light-intensity physical activity has been shown to be feasible and effective in promoting physical activity in patients with rheumatoid arthritis. However, methods to facilitate this behavior have not yet been fully explored.

The Experience of people with rheumatoid arthritis living with fatigue: a qualitative metasynthesis

OBJECTIVES

To identify, appraise and synthesise qualitative studies on the experience of living with rheumatoid arthritis (RA)-related fatigue.

METHODS

We conducted a qualitative metasynthesis encompassing a systematic literature search in February 2017, for studies published in the past 15 years, in PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, SveMed, PsychINFO and Web of Science. To be included, the studies had to report the experience of living with fatigue among adults with RA. The analysis and synthesis followed Malterud's systematic text condensation.

RESULTS

Eight qualitative articles were included, based on 212 people with RA (69% women) and aged between 20 and 83 years old. The synthesis resulted in the overall theme 'A vicious circle of an unpredictable symptom'. In addition, the synthesis derived four subthemes: 'being alone with fatigue'; 'time as a challenge'; 'language as a tool for increased understanding' and 'strategies to manage fatigue'. Fatigue affects all areas of everyday life for people with RA. They strive to plan and prioritise, pace, relax and rest. Furthermore, they try to make use of a variety of words and metaphors to explain to other people that they experience that RA-related fatigue is different from normal tiredness. Despite this, people with RA-related fatigue experience feeling alone with their symptom and they develop their own strategies to manage fatigue in their everyday life.

CONCLUSIONS

The unpredictability of RA-related fatigue is dominant, pervasive and is experienced as a vicious circle, which can be described in relation to its physical, cognitive, emotional and social impact. It is important for health professionals to acknowledge and address the impact of fatigue on the patients' everyday lives. Support from health professionals to manage fatigue and develop strategies to increase physical activity and maintain work is important for people with RA-related fatigue.

Real world long-term impact of intensive treatment on disease activity, disability and health-related quality of life in rheumatoid arthritis

Background

The emphasis on treating rheumatoid arthritis (RA) intensively reduces disease activity but its impact in routine care is uncertain. We evaluated temporal changes in disease activities and outcomes in a 10-year prospective observational cohort study of patients in routine care at one unit.

Methods

The Guy’s and St Thomas’ RA cohort was established in 2005. It involved most RA patients managed in this hospital. Clinical diagnoses of RA were made by rheumatologists. Patients were seen regularly in routine care. Each visit included measurement of disease activity scores for 28 joints (DAS28), health assessment questionnaire scores (HAQ) and EuroQol scores. Patients received intensive treatments targeting DAS28 remission.

Results

In 1693 RA patients mean DAS28 scores fell from 2005 to 15 by 11% from 4.08 (95% CI: 3.91, 4.25) in 2005 to 3.64 (3.34, 3.78); these falls were highly significant (p < 0.001). DAS28 components: swollen joint counts fell by 32% and ESR by 24%; in contrast tender joint counts and patient global assessments showed minimal or no reductions. The reduction in DAS28 scores was predominantly between 2005 and 2010, with no falls from 2011 onwards. Associated with falls in mean DAS28s, patients achieving remission increased (18% in 2005; 27% in 2015) and the number with active disease (DAS28 > 5.1) decreased (25% in 2005; 16% in 2015). In 752 patients seen at least annually for 3 years, persisting remission (68 patients) and intermittent remission (376 patients) were associated with less disability and better health related quality of life. Over time biologic use increased, but they were used infrequently in patients in persistent remission.

Conclusions

Over 10 years an intensive management strategy in a routine practice setting increased combination DMARD and biologic use: disease activity levels declined; this association is in keeping with a causal relationship. Patients who achieved remission, even transiently, had better functional outcomes than patients never achieving remission.

Electronic supplementary material

The online version of this article (10.1186/s41927-019-0054-y) contains supplementary material, which is available to authorized users.

Supervised walking improves cardiorespiratory fitness, exercise tolerance, and fatigue in women with primary Sjögren's syndrome: a randomized-controlled trial

OBJECTIVE

The aim of this study was to evaluate the safety and effectiveness of a supervised walking program in women with primary Sjögren's syndrome (pSS).

METHODS

Forty-five sedentary women fulfilling the American European Consensus Criteria for pSS were randomized to a training group (TG, n = 23) or control group (CG, n = 22). Patients in the TG were submitted to supervise walking three times a week for 16 weeks. The patients of the CG were instructed to not perform any kind of regular physical exercise. Physical fitness [maximum oxygen uptake (VO2max) and distance], EULAR Sjögren's Syndrome Disease Activity Index (ESSDAI), hematological tests, and Medical Outcomes Study 36 (SF-36) were assessed at baseline and week 16. In addition, EULAR Sjögren's Syndrome Patient Reported Index (ESSPRI), Functional Assessment of Chronic Illness Therapy Fatigue Subscale (FACIT-fatigue), and Beck Depression Inventory (BDI) were measured prior to intervention, after 8 and 16 weeks. Patient global assessment of response to therapy was completed at the final assessment. An intent-to-treat analysis was performed.

RESULTS

After 16 weeks, the mean change of VO2max (ml/kg/min), distance, and FACIT-fatigue were higher in the TG than in the CG (p = 0.016, p = 0.043 and p = 0.030, respectively). Improved cardiorespiratory fitness was associated with improvements in fatigue scores and physical components of quality of life (SF-36). Furthermore, improved fatigue scores were associated with reduced depression and improvements in the physical and mental components of SF-36. Overall, 95.4% of patients in the TG rated themselves as clinically improved versus 62% of the patients in the CG (p = 0.049). There was no flare in disease activity and no serious adverse events with exercise.

CONCLUSIONS

This supervised walking program was demonstrated to be feasible and safe with improvements in cardiorespiratory fitness, exercise tolerance, fatigue, and patient perception of improvement in pSS patients.

TRIAL REGISTRATION

Clinical Trials.gov ID, number NCT02370225.