Neuromuscular Electrical Stimulation Compared to Volitional Exercise for Improving Muscle Function in Rheumatoid Arthritis: A Randomized Pilot Study

Adipokines in Rheumatoid Arthritis: Emerging Biomarkers and Therapeutic Targets

Rheumatoid arthritis (RA) is a chronic inflammatory disease manifested by joint involvement, extra-articular manifestations, and general symptoms. Adipose tissue, previously perceived as an inert energy storage organ, has been recognised as a significant contributor to RA pathophysiology. Adipokines modulate immune responses, inflammation, and metabolic pathways in RA. Although most adipokines have a pro-inflammatory and aggravating effect on RA, some could counteract this pathological process. The coexistence of RA and sarcopenic obesity (SO) has gained attention due to its impact on disease severity and outcomes. Sarcopenic obesity further contributes to the inflammatory milieu and metabolic disturbances. Recent research has highlighted the intricate crosstalk between adipose tissue and skeletal muscle, suggesting potential interactions between these tissues in RA. This review summarizes the roles of adipokines in RA, particularly in inflammation, immune modulation, and joint destruction. In addition, it explores the emerging role of adipomyokines, specifically irisin and myostatin, in the pathogenesis of RA and their potential as therapeutic targets. We discuss the therapeutic implications of targeting adipokines and adipomyokines in RA management and highlight the challenges and future directions for research in this field.

Non-pharmacological treatment in difficult-to-treat rheumatoid arthritis

Although the management of rheumatoid arthritis (RA) has improved remarkably with new pharmacological therapies, there is still a significant part of patients not reaching treatment goals. Difficult-to-treat RA (D2TRA) is a complex entity involving several factors apart from persistent inflammation, thereafter requiring a holistic management approach. As pharmacological treatment options are often limited in D2TRA, the need for non-pharmacological treatments (NPT) is even more pronounced. The mechanism of action of non-pharmacological treatments is not well investigated, NPTs seem to have a complex, holistic effect including the immune, neural and endocrine system, which can have a significant additive benefit together with targeted pharmacotherapies in the treatment of D2TRA. In this review we summarize the current knowledge on different NPT in rheumatoid arthritis, and we propose a NPT plan to follow when managing D2TRA patients.

Inflammatory Arthritis and the Effect of Physical Activity on Quality of Life and Self-reported Function: A Systematic Review and Meta-analysis - The ENHANCE Study

OBJECTIVE

Although physical activity (PA) is an evidence-based intervention that reduces disease-related symptoms and comorbidity in rheumatoid arthritis (RA), PA's effect on self-reported function and Quality of Life (QoL) has not been analyzed. This study synthesizes the evidence for the effectiveness of PA on QoL and self-reported function in adults with RA, spondyloarthritis (SpA), and psoriatic arthritis (PsA).

METHODS

The databases PubMed, Embase, CINAHL, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched to identify relevant randomized controlled trials (RCTs). Screening, risk of bias assessment (using RoB 2.0 tool), and data extraction were independently performed by two or more of the authors. The meta-analyses were conducted with a random-effects model.

RESULTS

The systematic review included 55 RCTs and the meta-analysis included 37 RCTs. In 55 studies included, 76% investigated RA, 20% investigated SpA, and 4% investigated PsA. In RA effects were found on QoL and function compared to inactive controls, effects not sustained in comparison to active controls. In SpA the effects of PA on QoL were in favor of the control group. Effects on function were found compared to inactive controls and sustained in fatigue and pain when compared to active controls. In PsA no effects on QoL were found but on function compared to inactive controls. The effect size was below 0.30 in the majority of the comparisons.

CONCLUSION

PA may improve QoL and self-reported function in RA, SpA, and PsA. However, larger trials are needed, especially in SpA and PsA.

The Effects of Electrical Stimulation Program on Navicular Height, Balance, and Fear of Falling in Community-Dwelling Elderly

INTRODUCTION

Intrinsic foot muscle weakness is a crucial cause of balance deficit in the elderly, which leads to a limited range of motion from the fear of falling and subsequently decreases the quality of life. Muscle strengthening via transcutaneous electrical stimulation (TENS) is an effective intervention; however, its effects on elderly people have rarely been reported. This study was conducted to investigate the effects of TENS on navicular height, balance, and fear of falling.

METHOD

In this study, forty-eight participants aged 65-75 years were included and were randomly divided into two groups: the TENS and control groups. Before and after 4 weeks of training, navicular height, balance, and fear of falling were measured.

RESULT

After 4 weeks of training, navicular height significantly increased in both groups (p < 0.05); however, the increase was higher in the TENS group (p = 0.035). The TENS group had a better improvement in balance in all four directions-front, back, left, and right (p < 0.05). However, postural balance improvements in the control group were observed in three directions only-front, back, and left (p < 0.05)-without any significant difference between the two groups. Furthermore, the TENS group decreased the scale of fear of falling after 4 weeks of training (p = 0.039).

CONCLUSION

In summary, the results of this study can be used as part of the muscle strengthening via ES for decreasing the risk of falls or fear of falling in the elderly.

Exercise therapy for sarcopenia in rheumatoid arthritis: A meta-analysis and meta-regression of randomized controlled trials

OBJECTIVE

Rheumatoid arthritis and age are associated with high sarcopenia risk. Exercise is an effective treatment for preventing muscle mass loss in older adult populations. It remains unclear whether exercise affects muscle mass in people with rheumatoid arthritis. Thus, this meta-analysis investigated the effect of exercise on muscle mass gain in patients with rheumatoid arthritis.

DATA SOURCES

PubMed, EMBASE, the Cochrane Library, the Physiotherapy Evidence Database (PEDro), the China Knowledge Resource Integrated Database, and Google Scholar were systematically searched until June 2021.

METHODS

The present study was conducted according to the guidelines recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. Randomized controlled trials (RCTs) that reported the effects of exercise on muscle mass for rheumatoid arthritis were identified. The included RCTs were subject to meta-analysis and risk of bias assessment. Subgroup and random-effects meta-regression analyses were performed to identify any heterogeneity (I²) of treatment effects across studies.

RESULTS

We included nine RCTs with a median PEDro score of 6/10 (range: 4/10-8/10). The weighted mean effect size for muscle mass was 0.77 (95% CI: 0.30-1.24; P = 0.001; I² = 77%). Meta-regression analyses indicated that the disease duration significantly explained variance of treatment effects across studies (β = -0.006, R² = 69.7%, P = 0.005).

CONCLUSIONS

Exercise therapy effectively increased muscle mass in patients with rheumatoid arthritis. Treatment effects may be attenuated in those who have had rheumatoid arthritis for a relatively long time.

Effect of electromyostimulation on intramyocellular lipids of the vastus lateralis in older adults: a randomized controlled trial

BACKGROUND

Excessive intramyocellular lipid (IMCL) accumulation is a primary cause of skeletal muscle insulin resistance, especially in older adults, and interventions that reduce IMCL contents are important to improve insulin sensitivity. Electromyostimulation (EMS)-induced changes in IMCL content in older adults remain unknown. The purpose of this study was to clarify the effects of a single bout of EMS on the IMCL content of the vastus lateralis muscle in older adults.

METHODS

Twenty-two physically active, non-obese older men and women were randomly assigned to an EMS intervention group (69.0 ± 5.2 years, n = 12) or a control group (68.4 ± 3.5 years, n = 10). EMS was applied to the vastus lateralis (7 s on and 7 s off) for 30 min; control participants sat quietly for 30 min. IMCL content within the vastus lateralis was quantified with ¹H-magnetic resonance spectroscopy (n = 7 per group). Fasting plasma glucose and insulin values were determined from blood samples collected before and after the EMS intervention.

RESULTS

EMS induced a significant reduction in plasma glucose (93.1 ± 9.6 to 89.5 ± 9.1 mg/dL, p < 0.01), but not IMCL content (15.7 ± 15.7 to 15.8 ± 13.1 mmol/kg wet weight, p = 0.49) or insulin (5.4 ± 2.4 to 4.7 ± 2.7 μIU/mL, p = 0.18). In the control group, no changes in IMCL content in the vastus lateralis was observed after prolonged quiet sitting.

CONCLUSION

EMS intervention for 30 min induces changes in plasma glucose, but no changes in IMCL content in older adults.

TRIAL REGISTRATION

University hospital Medical Information Network (UMIN) Center ID: UMIN000020126 . Retrospectively registered on December 222,015. https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000023242.

The effects of mindfulness-based stress reduction therapy combined with intensive education on the effectiveness of the care and the awareness rate in patients with arthritis and diabetes

OBJECTIVE

To explore the effect of mindfulness-based stress reduction (MBSR) therapy combined with intensive education on the effectiveness of the care and the awareness rate in patients with diabetes and arthritis.

METHODS

A total of 94 patients with diabetes and arthritis admitted to our hospital were recruited as the study cohort and randomly divided into two groups, with 47 patients in each group. Both groups underwent routine nursing interventions. The control group underwent an eight-week-long intensive education program, while the observation group was additionally cared for with MBSR for 8 weeks. The two groups were assessed using the Symptom Checklist 90 (SCL-90), the Hamilton Anxiety Scale (HAMA-14), the Hamilton Depression Scale (HAMD-17), the Simple Coping Style Questionnaire (SCSQ), the diabetes specificity quality of life scale (DSQL), and their cortisol levels and awareness/satisfaction rates.

RESULTS

The SCL-90 scores were lower in both groups after 8 weeks of nursing (P < 0.05), and the scores in the observation group were lower than the scores in the control group (P < 0.05). The observation group exhibited lower HAMA-14, HAMD-17, and negative coping scores (P < 0.05) and higher positive coping scores than the control group (P < 0.05). The DSQL scores and the cortisol levels in the observation group at 2, 4, 6, and 8 weeks after the nursing were lower than they were in the control group (P < 0.05). The satisfaction rate with the nursing methods, the nursing effectiveness, and the awareness rate with regard to regular review, knowledge of pathogenesis, and clinical manifestations in the observation group were higher than they were in the control group (P < 0.05).

CONCLUSION

MBSR therapy combined with intensive education can improve patients' symptoms, reduce their anxiety/depression, improve their coping levels, quality of life, and cortisol levels as well as their satisfaction/awareness rates in diabetic patients with arthritis.

A systematic review exploring the evidence reported to underpin exercise dose in clinical trials of rheumatoid arthritis

We aimed to evaluate the evidence reported to underpin exercise dose in randomised controlled trials (RCTs) using strengthening exercise in RA. We searched six different databases between 1 January 2000 and 3 April 2019. We included RCTs, where a main component of the intervention and/or control used strengthening exercise. Evidence sources cited to underpin dose were judged for their quality, consistency and applicability. Thirty-two RCTs were reviewed. Four (12.5%) piloted the intervention without using dose-escalation designs to determine optimal dose-response. Twenty (62.5%) reported no evidence underpinning dose. Where reported, quality, consistency and applicability of the underpinning evidence was a cause for methodological concern. The majority of RCTs did not report the evidence underpinning dose. When reported, the evidence was often not applicable to the clinical population. Frequently, the dose used differed to the dose reported/recommended by the underpinning evidence. Our findings illustrate exercise dose may not be optimised for use with clinical populations prior to evaluation by RCT.

Skeletal muscle fat in individuals with rheumatoid arthritis compared to healthy adults

OBJECTIVE

To compare skeletal muscle fat (SMF), intermuscular adipose tissue (IMAT) and subcutaneous adipose tissue (SAT) between individuals with rheumatoid arthritis (RA), and healthy individuals of the same age, and healthy individuals at least 10 years older than those with RA.

METHODS

Two cross-sectional studies. In the first study, RA subjects were matched by age, sex, and BMI with healthy adults. In the second, RA subjects were matched by sex and BMI to adults 10-20 years older. SMF, IMAT and SAT were measured with Computed Tomography images of the mid-thigh region. We used parametric or non-parametric related-sample tests to compare fat accumulation between RA subjects and healthy adults.

RESULTS

In the first study SMF was significantly higher in the RA cohort compared to their age-matched healthy counterparts (mean difference = -3.5 HU (95% -6.2, -0.9), p = 0.011), but IMAT and SAT were similar between cohorts. In the second study, SMF, IMAT and SAT were not significantly different between the RA and matched older healthy cohorts. In both studies, there were no significant differences in mid-thigh muscle area between RA subjects and healthy adults.

CONCLUSION

SMF accumulation in RA was higher than in healthy individuals of similar age, sex, BMI. Accumulation of fat within and around the muscles in RA was not different compared to the matched healthy older individuals, indicating that muscle fat accumulation in RA might mimic a pattern not different from healthy aging.

Dose-Response Relationship Between Neuromuscular Electrical Stimulation and Muscle Function in People With Rheumatoid Arthritis

BACKGROUND

Neuromuscular electrical stimulation (NMES) is a viable intervention for improving impaired muscle function in individuals with rheumatoid arthritis (RA). However, there is limited evidence about the dose-response relationship between NMES and muscle function in these individuals.

OBJECTIVE

The objectives of this study were to investigate the dose-response relationship between NMES and muscle function in individuals with RA and to establish the minimal NMES training intensity for promoting improvements.

DESIGN

This study was a secondary analysis of data obtained before and after an NMES intervention in a randomized study.

METHODS

The study took place at a research clinic. Only adults diagnosed with RA were included. The intervention consisted of 36 NMES treatment sessions for the quadriceps muscles over 16 weeks. Muscle function was measured before and after the intervention; quadriceps cross-sectional area and muscle quality were assessed using computed tomography, and strength was measured with an isokinetic dynamometer. NMES training intensity was calculated as a percentage by dividing NMES-elicited quadriceps muscle torque by the maximum voluntary isometric contraction. Improvements in muscle function were calculated using paired-sample t tests. The dose-response relationship was determined using curve estimation regression statistics. The minimum NMES training intensity was defined as that sufficient to significantly improve all muscle function measures.

RESULTS

Twenty-four people (48 legs) participated (75% women; mean [SD] age = 58 [8] years; mean body mass index = 32 [7] kg/m2). Quadriceps cross-sectional area, muscle quality, and strength improved after the intervention. Associations between NMES training intensity and muscle quality (r2 = 0.20) and strength (r2 = 0.23) were statistically significant, but that between NMES training intensity and muscle cross-sectional area was not (r2 = 0.02). The minimum NMES training intensity necessary to improve all measures of muscle function ranged from 11% to 20% of the maximum voluntary isometric contraction.

LIMITATIONS

The relatively small sample size was a limitation.

CONCLUSIONS

The minimum NMES training intensity for significant gains in muscle function was ∼15%. Higher NMES intensities may promote better muscle quality and strength in individuals with RA.