Effects of concurrent strength and endurance training in women with early or longstanding rheumatoid arthritis: Comparison with healthy subjects

Therapy for the Rheumatoid Hand

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

Improving the estimation of countermovement jump height from force plate recordings by considering the interaction between multiple procedural steps: An optimisation approach

Force plates are used as standalone measurement systems in research and practice to evaluate metrics such as jump height. Calculating jump height involves multiple procedural steps, but previous investigations aiming to improve calculation procedures have only considered the influence of a single procedural step in isolation. The purpose of this study was to investigate if considering the interacting influence of multiple procedural steps in conjunction would impact the accuracy of jump height calculated from force plate recordings. An optimisation procedure was used to determine the combination of filter type, filter order, filter cut-off, integration start point and instant of take-off, that would minimize the root mean squared difference between force plate calculated jump height and a kinematic criterion. The best filter approach was a fifth order Butterworth filter with a 6 Hz cut-off frequency or a third order Chebyshev filter with a 5 Hz cut-off frequency. The best starting point for integration was approximately 0.25 s prior to the onset of the jump and the instant of take-off was best identified by finding the first instant that the force-time signal decreased by the magnitude of system weight. The presented optimisation technique provides an improved quantitative approach to develop standard procedures.

Effects of different physical training protocols on inflammatory markers in Zymosan-induced rheumatoid arthritis in Wistar rats

Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by inflammation and involvement of the synovial membrane, causing joint damage and deformities. No effective drug treatment is available, and physical exercise has been utilized to alleviate the inflammatory processes. This study aimed to investigate the effects of different exercise training protocols on Zymosan-induced RA inflammatory markers in the right knee of Wistar rats. The rodents were subjected to aerobic, resisted, and combined physical training protocols with variations in the total training volume (50% or 100% of resistance and aerobic training volume) for 8 weeks. All physical training protocols reduced cachexia and systemic inflammatory processes. The histological results showed an increase in the inflammatory influx to the synovial tissue of the right knee in all physical training protocols. The rats that underwent combined physical training with reduced volume had a lower inflammatory influx compared to the other experimental groups. A reduction in the mRNA expression of inflammatory genes and an increase in anti-inflammatory gene expression were also observed. The physical training protocol associated with volume reduction attenuated systemic and synovial inflammation of the right knee, reducing the impact of Zymosan-induced RA in rats.

Changes in hand grip strength and body weight after a dynamic exercise program and Mediterranean diet in women with rheumatoid arthritis: a randomized clinical trial

BACKGROUND

In patients with rheumatoid arthritis (RA) exercise improves muscle strength and decreases fat mass, whereas the consumption of a Mediterranean diet (MD) also has been associated with higher grip strength. Therefore, it is important to explore the combined effects of these interventions on hand grip strength and weight in RA.

OBJECTIVE

To determine the combined effect of an MD and a dynamic exercise program (DEP) on hand grip strength in women with RA.

METHOD

In a randomized clinical trial, 106 women with RA were included and assigned to the DEP-MD, DEP and MD groups. Weight, body circumferences, Disease Activity Score-28, Health Assessment Questionnaire Disability Index [HAQ-DI], and hand grip strength were measured at baseline and 24 weeks after the interventions.

RESULTS

After 24 weeks, hand grip strength showed a significant increase in the DEP group (median 2 kg) compared with DEP-MD (median 0.5 kg) and MD (median -0.5 kg) groups (p = 0.03). In the MD group weight and waist circumference showed a significant decrease (-2.2 kg and -4.3 cm) compared with DEP-MD (0.85 kg and 1.9 cm) and DEP (0.35 kg and 0.5 cm) groups (p < 0.01). Finally, a significant decrease was observed in the HAQ-DI after treatment in the DEP-MD group of -0.5 and the DEP group of -0.25 compared with the MD group with no change (p = 0.03).

CONCLUSION

In women with RA, in addition to pharmacological treatment, DEP increases hand grip strength and an MD decreases weight and waist circumferences, while the combination of DEP and MD improves disability.

Investigation of the effectiveness of aerobic exercise training in individuals with ankylosing spondylitis: Randomized controlled study

OBJECTIVE

To investigate the effect of the addition of aerobic training to spinal mobility exercises on disease-specific outcomes and functional exercise capacity, aerobic capacity and respiratory muscle strength of ankylosing spondylitis (AS) patients.

METHODS

The study included 31 volunteers (mean age: 44.90 ± 11.52 years) diagnosed with AS. The demographic characteristics and disease-related data of all subjects were recorded, then, the Bath AS Disease Activity Index (BASDAI), Bath AS Metrology Index (BASMI) and Bath AS Disease Function Index (BASFI), the 6-minute walk test, the Bruce Treadmill Test and spirometry were used, respectively. The intervention group attended a 12-week program of aerobic exercise sessions, plus supervised spinal mobility exercises, 3 days a week. The control group performed the supervised spinal mobility exercises only, 3 times a week, for 12 weeks.

RESULTS

There was a significant improvement in BASDAI (p = .002), BASMI (p = .021), 6 DYT (p = .036), VO₂ max (p = .000), MIP (p = .005) and MEP (p = .022) results in the intervention group after 12 weeks of training. In the comparisons of the pre-treatment and post-treatment differences, BASDAI (p = .032) decreased and VO₂ (p = .001) max increased, showing significant improvements in the intervention group and these values were maintained.

CONCLUSION

It is striking that improvements in all parameters except BASFI were achieved in the aerobic training group. These results demonstrate that an aerobic exercise program should be included in an individual exercise prescription for the management of AS.

Effects of strength vs. endurance training and their combination on physical performance characteristics in female horseback riders

BACKGROUND

The purpose of this study was to investigate effects of strength (S), endurance (E) and concurrent strength and endurance (SE) training on neuromuscular and cardiorespiratory characteristics during the 12-week volume-equated protocols in female horseback riders.

METHODS

Subjects (N.=44) (29.4±8.9 yrs) were assigned to S (N.=11), E (N.=11), SE (N.=13) and control (C) (N.=9) groups. Training consisted of progressive S, E or SE training 3x/week and riding exercise 4-6x/week. The measurements included maximal isometric bilateral leg press force (MVCLP) and EMG of VL and BF muscles, rapid isometric force production (0-500ms), maximal force of trunk extensor/flexors (MVCE/MVCF), countermovement-jump (CMJ), maximal oxygen uptake (VO2max), cycling-time (Timemax), blood lactate (L) and heart rate (HR) in the bicycle-ergometer test.

RESULTS

Only group S showed significant increases of 9% in MVCLP (P<0.01) and 3% in MVCE (P<0.05) forces. None of the groups showed significant increases in CMJ, rapid isometric force production or EMG. Timemax in the ergometer test increased significantly in S (P<0.05), SE (P<0.05) and E (P<0.01) with significant increases in VO2max in E (P<0.05) and SE (P<0.01).

CONCLUSIONS

The present strength-training program led to the significant gain in maximal strength in S but not in SE, maybe due to some interference effects produced by the actual endurance training and riding related endurance training. All groups increased significantly Timemax but VO2max increased only in E and SE. It would be useful for female horseback riders to perform combined SE training and to perform S training periodically to insure gains in strength, when needed.

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

OBJECTIVE

The aim of this study was to compare the feasibility and effectiveness of neuromuscular electrical stimulation (NMES) with that of high-intensity volitional resistance training for improving muscle structure and function and physical function in patients with rheumatoid arthritis (RA). We also compared pre-intervention and post-intervention values of myocyte characteristics.

METHODS

In this 2-group, single-blind, randomized pilot study, adult patients with RA were assigned to 36 sessions of NMES (n = 31 patients) or volitional training (n = 28 patients) over 16 weeks. Outcome measures included muscle structure and function (quadriceps muscle area, density, and strength), physical function (performance-based and patient-reported), feasibility (increased pain, increased disease activity, attrition, and adherence), and myocyte characteristics (area, proportion of type I or II muscle fibers, and intramyocellular lipid content). Analysis of covariance was used to compare groups.

RESULTS

The intervention intensity in the NMES group was less than half that in the volitional exercise group (31% versus 77% of maximum effort). Both groups experienced significant improvements in muscle structure and function (P < 0.001 to 0.019). Improvements in muscle characteristics and physical function were not different between groups. Exercise did not result in serious adverse events or increases in pain and disease activity. Attrition was 29% in the NMES group and 7% in the volitional exercise group.

CONCLUSION

Both NMES and high-intensity volitional resistance training can be used as effective approaches to improving muscle structure and function in patients with RA. NMES may be a viable alternative for improving muscle function in patients in whom high-intensity resistance exercise may not be tolerated or is contraindicated, but attrition must be considered when using this approach.

Health Professionals' Perceptions of the Effects of Exercise on Joint Health in Rheumatoid Arthritis Patients

OBJECTIVES

Although exercise is an important factor in the management of rheumatoid arthritis (RA), research indicates that patients perceive that health professionals (HPs) are uncertain about the place of exercise in treatment and its relationship with joint damage. The present study investigated the perceptions of HPs regarding the effects of exercise on joint health in RA patients.

METHODS

A questionnaire investigating perceptions of exercise and joint health was distributed via professional networks and websites. Confirmatory factor analysis (CFA) was used to analyse questionnaire data and develop a focus group interview guide. Focus groups were conducted with multidisciplinary teams (MDTs) of rheumatology HPs and analysed using framework analysis.

RESULTS

A total of 137 rheumatology HPs (95 female; 27-65 years of age) completed questionnaires. CFA showed that a four-factor model provided a marginally acceptable fit. Analysis of four focus groups (n = 24; 19 female; 30-60 years of age) identified five themes relating to HPs' perceptions of exercise and joint health in RA patients: 'Exercise is beneficial', 'Concerns about damage to joints', 'Patients have barriers to exercise', 'HP knowledge differs' and 'Patients may think service delivery is vague'.

CONCLUSIONS

HPs were highly aware of the benefits and importance of exercise for RA patients. However, to remove the patient perception that HPs lack certainty and clarity regarding exercise it is important to ensure: (i) consistent promotion of exercise across the whole MDT; (ii) clear provision of information regarding rest, joint protection and exercise; (iii) HP education to ensure consistent, accurate knowledge, and understanding of the potential for conflicting advice when promoting exercise as part of an MDT. Copy © 2016 John Wiley & Sons, Ltd.

Exercise as medicine - evidence for prescribing exercise as therapy in 26 different chronic diseases

This review provides the reader with the up-to-date evidence-based basis for prescribing exercise as medicine in the treatment of 26 different diseases: psychiatric diseases (depression, anxiety, stress, schizophrenia); neurological diseases (dementia, Parkinson's disease, multiple sclerosis); metabolic diseases (obesity, hyperlipidemia, metabolic syndrome, polycystic ovarian syndrome, type 2 diabetes, type 1 diabetes); cardiovascular diseases (hypertension, coronary heart disease, heart failure, cerebral apoplexy, and claudication intermittent); pulmonary diseases (chronic obstructive pulmonary disease, asthma, cystic fibrosis); musculo-skeletal disorders (osteoarthritis, osteoporosis, back pain, rheumatoid arthritis); and cancer. The effect of exercise therapy on disease pathogenesis and symptoms are given and the possible mechanisms of action are discussed. We have interpreted the scientific literature and for each disease, we provide the reader with our best advice regarding the optimal type and dose for prescription of exercise.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Indicators of walking speed in rheumatoid arthritis: relative influence of articular, psychosocial, and body composition characteristics

OBJECTIVE

To explore the contributions from and interactions between articular swelling and damage, psychosocial factors, and body composition characteristics on walking speed in rheumatoid arthritis (RA).

METHODS

RA patients underwent the timed 400-meter long-corridor walk. Demographics, self-reported levels of depressive symptoms and fatigue, RA characteristics, and body composition (using whole-body dual X-ray absorptiometry, and abdominal and thigh computed tomography) were assessed and their associations with walking speed explored.

RESULTS

A total of 132 RA patients had data for the 400-meter walk, among whom 107 (81%) completed the full 400 meters. Significant multivariable indicators of slower walking speed were older age, higher depression scores, higher reported pain and fatigue, higher swollen and replaced joint counts, higher cumulative prednisone exposure, nontreatment with disease-modifying antirheumatic drugs, and worse body composition. These features accounted for 60% of the modeled variability in walking speed. Among specific articular features, slower walking speed was primarily correlated with large/medium lower-extremity joint involvement. However, these articular features accounted for only 21% of the explainable variability in walking speed. Having any relevant articular characteristic was associated with a 20% lower walking speed among those with worse body composition (P < 0.001), compared with only a 6% lower speed among those with better body composition (P = 0.010 for interaction).

CONCLUSION

Psychosocial factors and body composition are potentially reversible contributors to walking speed in RA. Relative to articular disease activity and damage, nonarticular indicators were collectively more potent indicators of an individual's mobility limitations.

An outsourced health-enhancing physical activity programme for people with rheumatoid arthritis: exploration of adherence and response

OBJECTIVES

The aims of this study were to document adherence to and changes in health-enhancing physical activity (HEPA) levels and self-reported and assessed functioning and to explore aspects of adherence and response during the first year of an outsourced 2-year HEPA programme in people with RA.

METHODS

Two-hundred and twenty patients participated in this observational cohort study, which included daily physical activity, twice-weekly circuit training and biweekly support group meetings. Self-reported data included current (past week) and maintained (past 6 months) HEPA levels, sociodemographics and disease-related and psychosocial factors. Tests of aerobic capacity and muscle function were performed and anthropometric data were collected.

RESULTS

Eighty-eight per cent of the participants completed 1 year assessments. Self-reported current and maintained HEPA increased. General health perception and a number of other self-reported disease-related and psychosocial factors improved, while exercise self-efficacy declined. Aerobic capacity, timed standing and grip strength improved and waist circumference decreased. The mean number of circuit training sessions performed was 48, the mean number of days with HEPA was 189 and the mean number of support group meetings attended was 9. Better adherence to circuit training improved general health, and better adherence to group meetings improved timed standing. Exercise self-efficacy improved among those adhering more to circuit training or support group meetings.

CONCLUSION

The outsourced HEPA programme had high retention and reasonable adherence. A number of health outcomes improved. Relationships between adherence to the programme components and response were not clear-cut and need further attention.

TRIAL REGISTRATION

ISRCTN register; http://www.controlled-trials.com. Trial registration number ISRCTN25539102.

Effect of concurrent training, flexible nonlinear periodization, and maximal-effort cycling on strength and power

Although there is considerable research on concurrent training, none has integrated flexible nonlinear periodization and maximal-effort cycling in the same design. The purpose of this investigation was to test outcome measures of strength and power using a pretest-posttest randomized groups design. A strength and endurance (SE) group was compared with a strength, endurance, and maximal-effort cycling (SEC) group. Both groups used a flexible nonlinear periodization design. Thirteen male and 7 female students (mean ± SD: age, 22.5 ± 4.1 years; height, 173.5 ± 12.4 cm; weight, 79.4 ± 20.2 kg; strength training experience, 2.4 ± 2.2 years) participated in this study. Groups were not matched for age, height, weight, strength training experience, or sex, but were randomly assigned to an SE (n = 10) or SEC (n = 10) group. All training was completed within 45 minutes, twice per week (Monday and Wednesday), over 12 consecutive weeks. Both groups were assigned 6.75 total hours of aerobic conditioning, and 13.5 hours of free weight and machine exercises totaling 3,188 repetitions ranging from 5 to 20 repetition maximums. The SEC group performed 2 cycling intervals per workout ranging from 10 to 45 seconds. Pretest and posttest measures included chest press and standing broad jump. Analysis of variance showed that there were no significant differences between the SE and SEC groups on measures of chest press or standing broad jump performance (p, not significant). Paired sample t-tests (p = 0.05) showed significant improvement in strength and power in all groups (pretest to posttest), except for SE jump performance (p, not significant). In conclusion, adding maximal-effort cycling does not provide additional strength or power benefits to a concurrent flexible nonlinear training program. However, an exercise professional can take confidence that a concurrent flexible nonlinear training program can increase strength and power in healthy individuals.

How to simultaneously optimize muscle strength, power, functional capacity, and cardiovascular gains in the elderly: an update

The purpose of the present study was to review the scientific literature that investigated concurrent training adaptations in elderly populations, with the aim of identifying the optimal combination of both training program variables (i.e., strength and endurance) to avoid or minimize the interference effect in the elderly. Scielo, Science Citation Index, MEDLINE, Scopus, SPORTDiscus, and ScienceDirect databases were searched. Concurrent training is the most effective strategy by which to improve neuromuscular and cardiorespiratory functions as well as functional capacity in the elderly. The volume and frequency of training appears to play a critical role in concurrent training-induced adaptations in elderly subjects. Furthermore, new evidence indicates that the intra-session exercise order may influence the magnitude of physiological adaptations. Despite the interference effect on strength gains that is caused by concurrent training, this type of training is advantageous in that the combination of strength and endurance training produces both neuromuscular and cardiovascular adaptations in the elderly. The interference phenomenon may be observed in elderly subjects when a moderate weekly volume of concurrent training (i.e., three times per week) is performed. However, even with the occurrence of this phenomenon, the performance of three concurrent training sessions per week appears to optimize the strength gains in relative brief periods of training (12 weeks). Moreover, performing strength prior to endurance exercise may optimize both neuromuscular and cardiovascular gains.

Association of self-efficacy and outcome expectations with physical activity in adults with arthritis

Background and Purpose. The purpose of this study is to determine whether higher baseline levels of (a) self-efficacy for physical activity, (b) self-efficacy for arthritis self-management, and (c) outcome expectations for exercise are associated with higher physical activity levels following an exercise intervention for adults with arthritis. Methods. A secondary analysis of the intervention cohort (n = 130) within a randomized controlled trial of the People with Arthritis Can Exercise program was performed. Multiple linear regression evaluated the relationship between physical activity at a time point three months after the completion of an exercise intervention and three main explanatory variables. Results. After controlling for baseline physical activity, neither self-efficacy for arthritis self-management nor outcome expectations for exercise related to three-month physical activity levels. There was a relationship between three-month physical activity and self-efficacy for physical activity. Conclusions. Future research is needed to evaluate the ability of self-efficacy-enhancing programs to increase physical activity in adults with arthritis.

Evidence-based risk assessment and recommendations for physical activity: arthritis, osteoporosis, and low back pain

We systematically reviewed the safety of physical activity (PA) for people with arthritis, osteoporosis, and low back pain. We searched PubMed, MEDLINE, Sport Discus, and the Cochrane Central Register of Controlled Trials (1966 through March 2008) for relevant articles on PA and adverse events. A total of 111 articles met our inclusion criteria. The incidence for adverse events during PA was 3.4%-11% (0.06%-2.4% serious adverse events) and included increased joint pain, fracture, and back pain for those with arthritis, osteoporosis, and low back pain, respectively. Recommendations were based on the Appraisal of Guidelines for Research and Evaluation, which applies Levels of Evidence based on type of study ranging from high-quality randomized controlled trials (Level 1) to anecdotal evidence (Level 4) and Grades from A (strong) to C (weak). Our main recommendations are that (i) arthritic patients with highly progressed forms of disease should avoid heavy load-bearing activities, but should participate in non-weight-bearing activities (Level 2, Grade A); and (ii) patients with osteoporosis should avoid trunk flexion (Level 2, Grade A) and powerful twisting of the trunk (Level 3, Grade C); (iii) patients with acute low back pain can safely do preference-based PA (i.e., PA that does not induce pain), including low back extension and flexion (Level 2, Grade B); (iv) arthritic patients with stable disease without progressive joint damage and patients with stable osteoporosis or low back pain can safely perform a variety of progressive aerobic or resistance-training PAs (Level 2, Grades A and B). Overall, the adverse event incidence from reviewed studies was low. PA can safely be done by most individuals with musculoskeletal conditions.

Physical activity maintenance in patients with rheumatoid arthritis: a qualitative study

Objective:

To describe the experience of physical activity maintenance in patients with rheumatoid arthritis.

Design:

A qualitative salutogenic-oriented interview study.

Setting:

A rheumatology outpatient clinic.

Subjects:

A purposive sample of 16 physically active patients (mean age 50, range 37–67) diagnosed with rheumatoid arthritis on average 21 years previously (range 4–46 years).

Methods:

In-depth interviews were conducted using a semi-structured interview guide to illuminate how the phenomenon ‘physical activity maintenance’ was experienced by patients with rheumatoid arthritis. The interviews were analysed using systematic text condensation, inspired by Giorgi’s descriptive phenomenological methodology.

Results:

The analysis revealed three categories: (1) knowing and enjoying the body; (2) responsibility and challenges; (3) autonomy and social belonging. On the basis of these categories, the essential meaning of the phenomenon of physical activity maintenance for patients with rheumatoid arthritis was summarized into ‘striving for a transparent body and participation’, pointing to experiences of sensations of wellbeing, liberation from restrictions and social participation on equal terms with non-arthritis populations.

Conclusion:

This study demonstrates that physical activity in patients with rheumatoid arthritis may be understood as a resource to resist disability and to feel and stay healthy while creating and sustaining meaningfulness in life.

Cardiorespiratory fitness and cardiovascular risk in patients with ankylosing spondylitis: a cross-sectional comparative study

OBJECTIVE

To investigate the associations between cardiorespiratory fitness (CRF) and the level of cardiovascular (CV) risk factors in patients with ankylosing spondylitis (AS) and controls.

METHODS

In a cross-sectional comparative study, CRF was measured with a maximal treadmill test for estimation of peak oxygen uptake. Metabolic syndrome (MS), body composition, traditional CV risk factors, and inflammatory markers were assessed. Multivariable linear regression models were used to study the associations between CRF and CV risk factors. All models were adjusted for age, sex, and smoking, and for inflammation when C-reactive protein (CRP) level or erythrocyte sedimentation rate (ESR) were not already included as dependent variables.

RESULTS

A total of 126 patients (mean ± SD age 47.9 ± 10.8 years) and 111 controls (mean ± SD age 52.1 ± 11.1 years) were included. There were significant inverse associations between CRF and body mass index, waist circumference, triglycerides, CRP level, and ESR (P < 0.001-0.03) for patients and controls. Also, significant associations were found between CRF and high-density lipoprotein (HDL) cholesterol (β = 0.03, P < 0.001) and blood pressure (BP; β = -0.9 for systolic and β = -0.6 for diastolic; P < 0.01) in controls, but these associations were not found in patients (β = 0, P = 0.69 for HDL cholesterol; β = -0.04, P = 0.87 for systolic pressure; and β = -0.14, P = 0.34 for diastolic pressure) (additional adjustments for medication). Higher CRF was associated with a lower risk for MS in both patients (odds ratio [OR] 0.91, P = 0.03) and controls (OR 0.89, P = 0.01).

CONCLUSION

CRF was associated with favorable levels of CV risk factors and lower risk of MS in both AS patients and controls. However, established findings of an association between CRF and BP and HDL cholesterol in healthy adults were not confirmed in AS patients.

Physical fitness in patients with ankylosing spondylitis: comparison with population controls

BACKGROUND

Although flexibility traditionally has been the main focus for physical therapy in patients with ankylosing spondylitis (AS), there is now evidence for an increased risk of cardiovascular diseases (CVDs) in this group.

OBJECTIVE

The purposes of this study were: (1) to compare physical fitness (cardiorespiratory fitness, muscular capacity, flexibility, and balance) in patients with AS and controls and (2) to explore associations between physical fitness and disease activity in the patient group.

DESIGN

This was a cross-sectional study.

METHODS

The physical fitness variables were cardiorespiratory fitness (treadmill test for estimation of peak oxygen uptake [V(O(2))peak]), muscular capacity (push-ups test), balance (30-second single-leg stand and walking in a figure-of-eight pattern), and flexibility (Bath Ankylosing Spondylitis Metrology Index [BASMI]). The Ankylosing Spondylitis Disease Activity Score (ASDAS) was used to assess disease activity. Group differences and associations were tested with the chi-square test for categorical variables, the Mann-Whitney U test for ordinal variables, and analysis of covariance for continuous variables.

RESULTS

One hundred forty-nine of 250 of the invited patients with AS and 133 of 329 of the invited controls were included in the study. The mean ASDAS score of the patient group was 2.3 (range=0.5-4.7), and the median disease duration was 23 years (range=7-55). The patient group had significantly lower V(O(2)) peak values, with a mean difference of -2.7 mL·kg(-1)·min(-1) (95% confidence interval=-4.3, -1.1), and higher BASMI scores, with a mean difference of 1.6 (95% confidence interval=1.5, 1.8), compared with the control group. No group differences were found in balance or muscular capacity. In the patient group, significant inverse associations were found between ASDAS scores and V(O(2))peak and muscular capacity.

LIMITATIONS

The response rate was lower in the control group (40.4%) than in the patient group (59.6%).

CONCLUSION

The lower cardiorespiratory fitness and reduced flexibility in the AS group indicate that physical therapy programs should include cardiorespiratory fitness exercises as a basic component to reduce the risk of cardiovascular disease.

Effects of a group-based exercise and educational program on physical performance and disease self-management in rheumatoid arthritis: a randomized controlled study

BACKGROUND

Evidence supports the use of educational and physical training programs for people with rheumatoid arthritis (RA).

OBJECTIVE

The purpose of this study was to evaluate the effects of a group-based exercise and educational program on the physical performance and disease self-management of people with RA.

DESIGN

This was a randomized controlled trial.

SETTING

The study was conducted at a rehabilitation center in the Netherlands.

PARTICIPANTS

Thirty-four people diagnosed with RA participated in the study. Participants were randomly assigned to either an intervention group (n=19) or a waiting list control group (n=15).

INTERVENTION

The intervention in this study was an 8-week, multidisciplinary, group therapy program for people with RA, consisting of physical exercise designed to increase aerobic capacity and muscle strength (force-generating capacity) together with an educational program to improve health status and self-efficacy for disease-self-management.

MEASUREMENTS

The main outcome measures were maximum oxygen uptake (Vo(2)max), muscle strength of the elbow and knee flexors and extensors, health status, and perceived self-efficacy. All data were recorded before intervention in week 1, after intervention in week 9, and at follow-up in week 22.

RESULTS

The intervention group showed significant improvement (12.1%) in Vo(2)max at week 9 compared with the control group (-1.7%). Although significant within-group changes were found over time for muscle strength of the upper and lower extremities and health status that favored the intervention group, no between-group changes were found regarding these outcomes.

LIMITATIONS

An important limitation was the small number of participants included in our study, which may have resulted in a lack of power.

CONCLUSIONS

The present group-based exercise and educational program for people with RA had a beneficial effect on aerobic capacity but not on muscle strength, health status, or self-efficacy.

Fatigue in systemic lupus erythematosus: an association with reduced physical fitness

Systemic lupus erythematosus (SLE) is an autoimmune disease that is characterized by fatigue; however, little research has been performed to identify non-pharmacological strategies, such as physical exercise, that can be employed in the prevention and treatment of fatigue in patients with SLE. Moreover, it is not clear whether physical fitness (defined here as cardiovascular fitness and muscle strength) and functional capacities are related to SLE-associated fatigue. Here, we review the studies, mechanisms and results that relate to SLE-associated fatigue. The main findings indicate that SLE patients have lower cardiovascular capacity than healthy subjects. Physical fitness, muscle strength and functional capacity are also lower in patients with SLE than in healthy individuals. The effects of exercise programs in reducing symptoms of fatigue in SLE patients remain unclear.

Benefits of exercise in rheumatoid arthritis

This paper aims to highlight the importance of exercise in patients with rheumatoid arthritis (RA) and to demonstrate the multitude of beneficial effects that properly designed exercise training has in this population. RA is a chronic, systemic, autoimmune disease characterised by decrements to joint health including joint pain and inflammation, fatigue, increased incidence and progression of cardiovascular disease, and accelerated loss of muscle mass, that is, “rheumatoid cachexia”. These factors contribute to functional limitation, disability, comorbidities, and reduced quality of life. Exercise training for RA patients has been shown to be efficacious in reversing cachexia and substantially improving function without exacerbating disease activity and is likely to reduce cardiovascular risk. Thus, all RA patients should be encouraged to include aerobic and resistance exercise training as part of routine care. Understanding the perceptions of RA patients and health professionals to exercise is key to patients initiating and adhering to effective exercise training.

Psychological interventions for rheumatoid arthritis: examining the role of self-regulation with a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To examine the efficacy of psychological interventions for rheumatoid arthritis (RA), and to determine whether self-regulation interventions demonstrate efficacy superior to that of other psychological treatments.

METHODS

Only randomized controlled trials testing a face-to-face psychological intervention among patients with RA were included. Two independent investigators extracted pertinent study data, rated each study on a scale of methodologic quality, and assessed each treatment condition for its inclusion of 5 behavior-change techniques derived from self-regulation theory (goal setting, planning, self-monitoring, feedback, and relapse prevention).

RESULTS

Twenty-seven trials were included, and cumulative effect sizes were calculated for the 5 outcomes. Significant effect sizes (Hedges' g) were found at posttreatment for physical activity (0.45), pain (0.18), disability (0.32), depressive symptoms (0.23), and anxiety (0.17). At followup (range 2-14 months), significant effect sizes were obtained for physical activity (0.36), pain (0.13), disability (0.15), and depressive symptoms (0.32). Comparative analyses revealed that interventions utilizing more self-regulation techniques reduced depressive symptoms and anxiety significantly more than interventions utilizing fewer such techniques. Additionally, depressive symptoms were reduced significantly more among recently diagnosed RA patients than among those with longstanding RA.

CONCLUSION

Psychological interventions are beneficial for many patients with RA, particularly when it comes to increasing physical activity levels. Intervention techniques derived from self-regulation theory appear to play a role in reducing depressive symptoms and anxiety among patients with RA.

Perceptions of the effects of exercise on joint health in rheumatoid arthritis patients

OBJECTIVES

Exercise is important in RA management. However, RA patients are less active than the general population. This qualitative study explores the perceptions of patients regarding the effects of exercise on joint health.

METHODS

A purposive sample of 12 female and 6 male RA outpatients [age: 23-76 years; disease duration: 2.5 months to 33 years; HAQ score: 0-2.13] participated in four moderated focus groups. The main questions addressed were: (i) How do you feel exercise affects your joints?; and (ii) What affects your exercise behaviour? Transcriptions were independently analysed with 455 meaning units identified. An inductive, thematic analysis was conducted using established techniques. Discussion with a third analyst contributed to consensus validation.

RESULTS

Sixteen constructs emerged, clustering into five themes, reflecting the issues relating to exercise and joint health in RA patients. Emergent themes were: 'health professionals showing a lack of exercise knowledge', 'not knowing what exercise should be done', 'worry about causing harm to joints', 'not wanting to exercise as joints hurt' and 'having to exercise because it is helpful'.

CONCLUSIONS

RA patients demonstrated awareness of the advantages of exercise for their joints, both experientially and through education. However, they perceived that health professionals lacked certainty and clarity regarding specific exercise recommendations and the occurrence of joint damage. Thus, to enhance patient-centred exercise prescription in the RA population, uncertainties surrounding joint health, pain symptoms and exercise specificity need to be addressed, alongside continual emphasis of exercise benefits.

Item Response Theory Analysis of Two Questionnaire Measures of Arthritis-Related Self-Efficacy Beliefs from Community-Based US Samples

Using item response theory (IRT), we examined the Rheumatoid Arthritis Self-efficacy scale (RASE) collected from a People with Arthritis Can Exercise RCT (346 participants) and 2 subscales of the Arthritis Self-efficacy scale (ASE) collected from an Active Living Every Day (ALED) RCT (354 participants) to determine which one better identifies low arthritis self-efficacy in community-based adults with arthritis. The item parameters were estimated in Multilog using the graded response model. The 2 ASE subscales are adequately explained by one factor. There was evidence for 2 locally dependent item pairs; two items from these pairs were removed when we reran the model. The exploratory factor analysis results for RASE showed a multifactor solution which led to a 9-factor solution. In order to perform IRT analysis, one item from each of the 9 subfactors was selected. Both scales were effective at measuring a range of arthritis SE.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Effect of concurrent endurance and circuit resistance training sequence on muscular strength and power development

The purpose of this study was to examine the influence of the sequence order of high-intensity endurance training and circuit training on changes in muscular strength and anaerobic power. Forty-eight physical education students (ages, 21.4 +/- 1.3 years) were assigned to 1 of 5 groups: no training controls (C, n = 9), endurance training (E, n = 10), circuit training (S, n = 9), endurance before circuit training in the same session, (E+S, n = 10), and circuit before endurance training in the same session (S+E, n = 10). Subjects performed 2 sessions per week for 12 weeks. Resistance-type circuit training targeted strength endurance (weeks 1-6) and explosive strength and power (weeks 7-12). Endurance training sessions included 5 repetitions run at the velocity associated with Vo2max (Vo2max) for a duration equal to 50% of the time to exhaustion at Vo2max; recovery was for an equal period at 60% Vo2max. Maximal strength in the half squat, strength endurance in the 1-leg half squat and hip extension, and explosive strength and power in a 5-jump test and countermovement jump were measured pre- and post-testing. No significant differences were shown following training between the S+E and E+S groups for all exercise tests. However, both S+E and E+S groups improved less than the S group in 1 repetition maximum (p < 0.01), right and left 1-leg half squat (p < 0.02), 5-jump test (p < 0.01), peak jumping force (p < 0.05), peak jumping power (p < 0.02), and peak jumping height (p < 0.05). The intrasession sequence did not influence the adaptive response of muscular strength and explosive strength and power. Circuit training alone induced strength and power improvements that were significantly greater than when resistance and endurance training were combined, irrespective of the intrasession sequencing.

Rheumatoid cachexia: a clinical perspective

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

Exercise therapy in juvenile idiopathic arthritis

BACKGROUND

Exercise therapy is considered an important component of the treatment of arthritis. The efficacy of exercise therapy has been reviewed in adults with rheumatoid arthritis but not in children with juvenile idiopathic arthritis (JIA).

OBJECTIVES

To assess the effects of exercise therapy on functional ability, quality of life and aerobic capacity in children with JIA.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews (The Cochrane Library), MEDLINE (January 1966 to April 2007), CINAHL (January 1982 to April 2007), EMBASE (January 1966 to October 2007), PEDro (January 1966 to October 2007), SportDiscus (January 1966 to October 2007), Google Scholar (to October 2007), AMED (Allied and Alternative Medicine) (January 1985 to October 2007), Health Technologies Assessment database (January 1988 to October 2007), ISI Web Science Index to Scientific and Technical Proceedings (January 1966 to October 2007) and the Chartered Society of Physiotherapy website (http://www.cps.uk.org) were searched and references tracked.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of exercise treatment in JIA.

DATA COLLECTION AND ANALYSIS

Potentially relevant references were evaluated and all data were extracted by two review authors working independently.

MAIN RESULTS

Three out of 16 identified studies met the inclusion criteria, with a total of 212 participants. All the included studies fulfilled at least seven of 10 methodological criteria. The outcome data of the following measures were homogenous and were pooled in a meta-analysis: functional ability (n = 198; WMD -0.07, 95% CI -0.22 to 0.08), quality of life (CHQ-PhS: n = 115; WMD -3.96, 95% CI -8.91 to 1.00) and aerobic capacity (n = 124; WMD 0.04, 95% CI -0.11 to 0.19). The results suggest that the outcome measures all favoured the exercise therapy but none were statistically significant. None of the studies reported negative effects of the exercise therapy.

AUTHORS' CONCLUSIONS

Overall, based on 'silver-level' evidence (www.cochranemsk.org) there was no clinically important or statistically significant evidence that exercise therapy can improve functional ability, quality of life, aerobic capacity or pain. The low number of available RCTs limits the generalisability. The included and excluded studies were all consistent about the adverse effects of exercise therapy; no short-term detrimental effects of exercise therapy were found in any study. Both included and excluded studies showed that exercise does not exacerbate arthritis. The large heterogeneity in outcome measures, as seen in this review, emphasises the need for a standardised assessment or a core set of functional and physical outcome measurements suited for health research to generate evidence about the possible benefits of exercise therapy for patients with JIA. Although the short-term effects look promising, the long-term effect of exercise therapy remains unclear.

Facteurs dont il faut tenir compte dans la création d’un guide d’activité physique pour les Canadiens qui ont un handicap physiqueCet article est tiré d’un supplément intitulé Advancing physical activity measurement and guidelines in Canada: a scientific review and evidence-based foundation for the future of Canadian physical activity guidelines (Favoriser les lignes directrices et la mesure de l’activité physique au Canada: examen scientifique et justification selon les données probantes pour l’avenir des lignes directrices de l’activité physique canadienne) publié par Physiologie appliquée, nutrition et métabolisme et la Revue canadienne de santé publique. On peut aussi mentionner Appl. Physiol. Nutr. Metab. 32 (Suppl. 2F) ou Can. J. Public Health 98 (Suppl. 2)

This paper provides a brief overview of the epidemiological data regarding Canadians with physical disabilities, with a particular emphasis on health status. A literature review is then presented, focusing on activity levels and the physiological and health-related quality of life benefits of activity for people with four different physical disabilities (arthritis, fibromyalgia, spinal cord injury, and multiple sclerosis). The unique physical activity barriers faced by people with physical disabilities are discussed. The paper concludes with recommendations for the development of a physical activity guide for Canadians with physical disabilities.

Rheumatoid arthritis, cardiovascular disease and physical exercise: a systematic review

This systematic review investigates the effectiveness of exercise interventions in improving disease-related characteristics in patients with rheumatoid arthritis (RA). It also provides suggestions for exercise programmes suitable for improving the cardiovascular profile of RA patients and proposes areas for future research in the field. Six databases (Medline, Cochrane Library, CINAHL, Google Scholar, EMBASE and PEDro) were searched to identify publications from 1974 to December 2006 regarding RA and exercise interventions. The quality of the studies included was determined by using the Jadad scale. Initial searches identified 1342 articles from which 40 met the inclusion criteria. No studies were found investigating exercise interventions in relation to cardiovascular disease in RA. There is strong evidence suggesting that exercise from low to high intensity of various modes is effective in improving disease-related characteristics and functional ability in RA patients. Future studies are required to investigate the effects of exercise in improving the cardiovascular status of this patient population.

Considerations for the development of a physical activity guide for Canadians with physical disabilitiesThis article is part of a supplement entitled Advancing physical activity measurement and guidelines in Canada: a scientific review and evidence-based foundation for the future of Canadian physical activity guidelines co-published by Applied Physiology, Nutrition, and Metabolism and the Canadian Journal of Public Health. It may be cited as Appl. Physiol. Nutr. Metab. 32(Suppl. 2E) or as Can. J. Public Health 98(Suppl. 2)

This paper provides a brief overview of the epidemiological data regarding Canadians with physical disabilities, with a particular emphasis on health status. A literature review is then presented, focusing on activity levels and the physiological and health-related quality of life benefits of activity for people with four different physical disabilities (arthritis, fibromyalgia, spinal cord injury, and multiple sclerosis). The unique physical activity barriers faced by people with physical disabilities are discussed. The paper concludes with recommendations for the development of a physical activity guide for Canadians with physical disabilities.