Oxygen cost of walking, physical activity, and sedentary behaviours in rheumatoid arthritis

Gait Rehabilitation for Early rheumatoid Arthritis Trial (GREAT): lessons learnt from a mixed-methods feasibility study and internal pilot trial

Background

People with rheumatoid arthritis experience foot and lower limb pain due to active synovitis, resulting in impaired lower limb function. Earlier intervention may help with prevention of functional decline. The aims of this research were to develop and evaluate a new gait rehabilitation intervention for people with early rheumatoid arthritis, evaluate its feasibility, and to test whether or not gait rehabilitation plus usual care is more clinically and cost-effective than usual care alone.

Design and methods

We undertook a single-arm, repeated-measures, pre- and post-intervention, mixed-methods feasibility study with embedded qualitative components. We planned to undertake a pragmatic, two-arm, multicentre, superiority randomised controlled trial, with health economic evaluation, process evaluation and internal pilot.

Setting and participants

Participants with early rheumatoid arthritis (< 2 years post diagnosis) were identified from early arthritis and rheumatology outpatient clinics and referred for intervention in either podiatry or physiotherapy clinics.

Intervention(s)

Participants were randomised to a gait rehabilitation programme (Gait Rehabilitation Early Arthritis Trial Strides) involving a six-task gait circuit. Sessions were underpinned by motivational interviewing to facilitate behaviour change, supported by trained physiotherapists or podiatrists for a minimum of two sessions. Both groups received their normal usual care from the rheumatology multidisciplinary team.

Main outcome measures

Outcome measures for the feasibility study were intervention acceptability, adherence using the Exercise Adherence Rating Scale and fidelity using the Motivational Interviewing Treatment Integrity Scale. The main outcome measure for the internal pilot/randomised controlled trial was the Foot Function Index disability subscale. Outcomes were measured at baseline, 3 months, 6 months and 12 months. Other outcomes: intervention acceptability questionnaire, Exercise Adherence Rating Scale, exercise treatment beliefs via the Theory of Planned Behaviour Questionnaire, intervention fidelity (Motivational Interviewing Treatment Integrity Scale), health-related quality of life (EuroQol-5 Dimensions, five-level score).

Results

Thirty-five participants were recruited for feasibility and 23 (65.7%) completed 12-week follow-up. Intervention acceptability was excellent: 21/23 were confident that it could help and would recommend it and 22/23 indicated it made sense to them. Adherence was good, with a median (interquartile range) Exercise Adherence Rating Scale score of 17/24 (12.5-22.5). Twelve participants' and nine therapists' interviews confirmed intervention acceptability, identified perceptions of benefit, but highlighted some barriers to completion. Motivational Interviewing Treatment Integrity Scale scores demonstrated good fidelity. The trial did not progress from internal pilot to full main trial as a result of low recruitment and high attrition, after 53 participants were recruited from 9 sites over 12 months. Process evaluation confirmed good intervention acceptability and adherence, and fair fidelity. Evaluation of clinical and cost-effectiveness was not possible.

Limitations

Significant delays were experienced with the impact of coronavirus disease 2019, regulatory approvals, contracts and site readiness, resulting in few sites opening in time and low recruitment capacity. Foot and/or ankle pain prevalence was lower than anticipated, resulting in a low potential participant pool and a low conversion rate from screening to enrolment.

Conclusions

The Gait Rehabilitation Early Arthritis Trial Strides intervention was acceptable to people with early rheumatoid arthritis and intervention clinicians, safe, with good levels of adherence by participants, and fair intervention fidelity. The randomised controlled trial stopped early following failure to meet recruitment targets. Gait Rehabilitation Early Arthritis Trial Strides is a promising intervention that could be adapted for future evaluations. A definitive trial of the Gait Rehabilitation Early Arthritis Trial Strides gait rehabilitation intervention still needs to be done.

Funding

This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number 15/165/04.

Associations of physical activity levels with fatigue in people with inflammatory rheumatic diseases in the LIFT trial

Objectives

The overall aim of the current study was to quantify physical activity levels in inflammatory rheumatic diseases (IRDs) and to explore their role in fatigue.

Methods

We conducted a secondary analysis of data from the Lessening the Impact of Fatigue in IRDs (LIFT) trial of the personalized exercise program (PEP) intervention for fatigue. Participants with IRDs were recruited from 2017 to 2019 and the current analysis used fatigue, measured by the Chalder Fatigue Scale (CFS) and the Fatigue Severity Scale (FSS), and accelerometer measured physical activity data collected at baseline and at the 6-month follow-up. Physical activity levels were quantified and associations with fatigue and effects of PEP investigated.

Results

Of the 337 included participants, 195 (68.4%) did not meet the current recommendations for moderate-vigorous physical activity (MVPA). In baseline cross-sectional analysis, many dimensions of physical activity were associated with fatigue. After mutual adjustment, overall physical activity (vector magnitude) was associated with CFS [-0.88 (95% CI -0.12, -1.64)] and distribution of time spent at different activity intensities was associated with FSS [-1.16 (95% CI -2.01, -0.31)]. Relative to usual care, PEP resulted in an increase in upright time, with trends for increases in step count and overall physical activity. People who increased overall physical activity (vector magnitude) more had greater improvements in CFS and FSS, while those who increased step count and MVPA more had greater improvements in FSS.

Conclusion

Increasing physical activity is important for fatigue management in people with IRDs and further work is needed to optimize PEPs to target the symptoms and impact of fatigue.

Trial registration

ClinicalTrials.gov (http://clinicaltrials.gov), NCT03248518.

A 5 item version of the Workplace Activity Limitation Scale successfully identifies impaired work productivity in rheumatoid arthritis patients: A split-sample factor analysis approach

BACKGROUND

There is a growing interest in studying the effects of arthritis on a person's work productivity using a growing variety of outcome indicators.

OBJECTIVES

To develop a valid and reliable shortened version of the Workplace Activity Limitation Scale 12 (WALS-12) for assessing work productivity limitations in rheumatoid arthritis (RA) patients.

METHODS

A cross-sectional study involving 277 RA patients was conducted. An exploratory factor analysis on WALS-12 was used for item reduction on the first sample. Then confirmatory factor analysis (CFA) was run to establish the best fit indices of the reduced version. On the second sample, CFA and linear discriminant analysis were performed to assess the diagnostic performance and discriminant ability of the reduced form. A Bland-Altman method was used to find the agreement between the WALS-12 and the reduced one.

RESULTS

The WALS-12 was reduced to 5 items. The Cronbach α was 0.817, with a composite reliability of 0.715. The Spearman rho correlation coefficient ranged between 0.675 and 0.795 for WALS-5, which was higher for the scale items with their domains than the correlation of WALS-5 with the domains of Work Limitations Questionnaire-25. Also, the root square of the average variant extracted from WALS-5 was 0.802. WALS-5 showed excellent discriminant ability with an area under the curve of 0.98 (P < .001), sensitivity of 97%, specificity of 82%, and accuracy of 94%. The reduced version WALS-5 was in agreement with the original version WALS-12.

CONCLUSIONS

WALS-5 is a valid and reliable tool to assess the work productivity limitations in RA patients.

The challenges of measuring physical activity and sedentary behaviour in people with rheumatoid arthritis

The importance of sufficient moderate-to-vigorous physical activity as a key component of a healthy lifestyle is well established, as are the health risks associated with high levels of sedentary behaviour. However, many people with RA do not undertake sufficient physical activity and are highly sedentary. To start addressing this, it is important to be able to carry out an adequate assessment of the physical activity levels of individual people in order that adequate steps can be taken to promote and improve healthy lifestyles. Different methods are available to measure different aspects of physical activity in different settings. In controlled laboratory environments, respiratory gas analysis can measure the energy expenditure of different activities accurately. In free-living environments, the doubly labelled water method is the gold standard for identifying total energy expenditure over a prolonged period of time (>10 days). To assess patterns of physical activity and sedentary behaviour in daily life, objective methods with body-worn activity monitors using accelerometry are superior to self-reported questionnaire- or diary-based methods.

Characteristics of participants and decliners from a randomized controlled trial on physical activity in patients with rheumatoid arthritis: a retrospective register-based cross-sectional study

OBJECTIVE

A randomized controlled trial [Joint Resources - Sedentary Behaviour (JR-SB) intervention] aimed to reduce sedentary behaviour and increase light-intensity physical activity in patients with rheumatoid arthritis (RA) through motivational counselling and text messages. Since a large proportion of invited patients declined to participate, this study aims to compare sociodemographic, clinical, and lifestyle factors between included patients and patients declining to participate (non-participants) in the JR-SB study and to investigate which characteristics were associated with participation.

METHOD

A register-based cross-sectional study was conducted. All patients invited to participate in the JR-SB study were identified in the DANBIO registry, from which patients' clinical and lifestyle data were also retrieved. Data on sociodemography and comorbidity were extracted from national registers. Differences between participants and non-participants were determined by an independent t-test or a chi-squared test. Logistic regression analyses adjusted for various confounders tested the association of patient characteristics with the likelihood of participation in the JR-SB study.

RESULTS

A total of 467 (58%) declined participation in the JR-SB study. Non-participants were older and less educated, more were smokers, fewer performed regular physical activity, and more had comorbidity compared to participants. Regression analyses showed that a higher educational level and absence of comorbidity in particular were associated with participation in the JR-SB study.

CONCLUSION

Patients with RA who are less educated and with certain types of comorbidity are less motivated to participate in a physical activity intervention. The findings may inform the recruitment process and implementation of physical activity interventions in rheumatology clinical practice.

Barriers and facilitators to physical activity in people with an inflammatory joint disease: a mixed methods study

Background

Physical activity has been shown to be of great benefit to people with an inflammatory joint disease (IJD), however people with an IJD have been shown to be very inactive compared to the general population. The aims of this study were to explore 1) whether the transition from a National Health Service (NHS)-run exercise programme into exercising in the community could be achieved successfully; and 2) the barriers and facilitators during the transition period.

Methods

This study adopted a complementary mixed-methods study design including a qualitative approach using focus groups and a prospective cohort study. Descriptive statistics were used to summarise the cohort study data. All variables were assessed for normality of distribution using the Sharpiro-Wilk test. Paired t-tests or Wilcoxon tests were undertaken for two consecutive assessment timepoints; one-way repeated measures ANOVAs or Friedman’s tests for three consecutive assessment timepoints. Micro-interlocutor analysis was used to analyse the focus group data. Areas of congruence and incongruence were explored by confirming the statistical results against the qualitative results. The adapted ecological model of the determinants of physical activity was then used as a framework to describe the findings.

Results

A successful transition was defined as still exercising in the community 6-months post discharge from the NHS-run Inflammatory Arthritis Exercise Programme. This was self-reported to be 90% of the cohort. An individual barrier to physical activity in people with an IJD was found to be the unpredictable nature of their condition. Other barriers and facilitators found were similar to those found in the general population such as recreation facilities, locations, transportation and cost. Other facilitators were similar to those found in people living with other chronic long-term conditions such as the importance of peer support.

Conclusions

90% of the cohort data were defined as a successful transition. People with an IJD have similar barriers and facilitators to exercise as the general population and those living with other chronic long-term conditions. A barrier which appears to be unique to this population group is that of the unpredictable nature of their condition which needs to be considered whenever tailoring any intervention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05847-z.

Gait rehabilitation for foot and ankle impairments in early rheumatoid arthritis: a feasibility study of a new gait rehabilitation programme (GREAT Strides)

Background

Foot impairments in early rheumatoid arthritis are common and lead to progressive deterioration of lower limb function. A gait rehabilitation programme underpinned by psychological techniques to improve adherence, may preserve gait and lower limb function. This study evaluated the feasibility of a novel gait rehabilitation intervention (GREAT Strides) and a future trial.

Methods

This was a mixed methods feasibility study with embedded qualitative components. People with early (< 2 years) rheumatoid arthritis (RA) and foot pain were eligible. Intervention acceptability was evaluated using a questionnaire. Adherence was evaluated using the Exercise Adherence Rating Scale (EARS). Safety was monitored using case report forms. Participants and therapists were interviewed to explore intervention acceptability. Deductive thematic analysis was applied using the Theoretical Framework of Acceptability. For fidelity, audio recordings of interventions sessions were assessed using the Motivational Interviewing Treatment Integrity (MITI) scale. Measurement properties of four candidate primary outcomes, rates of recruitment, attrition, and data completeness were evaluated.

Results

Thirty-five participants (68.6% female) with median age (inter-quartile range [IQR]) 60.1 [49.4–68.4] years and disease duration 9.1 [4.0–16.2] months), were recruited and 23 (65.7%) completed 12-week follow-up. Intervention acceptability was excellent; 21/23 were confident that it could help and would recommend it; 22/23 indicated it made sense to them. Adherence was good, with a median [IQR] EARS score of 17/24 [12.5–22.5]. One serious adverse event that was unrelated to the study was reported. Twelve participants’ and 9 therapists’ interviews confirmed intervention acceptability, identified perceptions of benefit, but also highlighted some barriers to completion. Mean MITI scores for relational (4.38) and technical (4.19) aspects of motivational interviewing demonstrated good fidelity. The Foot Function Index disability subscale performed best in terms of theoretical consistency and was deemed most practical.

Conclusion

GREAT Strides was viewed as acceptable by patients and therapists, and we observed high intervention fidelity, good patient adherence, and no safety concerns. A future trial to test the additional benefit of GREAT Strides to usual care will benefit from amended eligibility criteria, refinement of the intervention and strategies to ensure higher follow-up rates. The Foot Function Index disability subscale was identified as the primary outcome for the future trial.

Trial registration

ISRCTN14277030

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01061-9.

Physical Activity and Sedentary Behavior in People With Inflammatory Joint Disease: A Cross-Sectional Study

OBJECTIVE

To determine whether patients with inflammatory joint disease (IJD) meet current guidelines on physical activity, and to determine which factors influence physical activity levels and sedentary behavior (SB) in patients with IJD.

METHODS

This was a cross-sectional study of 137 patients with a medical diagnosis of an IJD prior to commencing an NHS-run inflammatory arthritis exercise program. Physical activity and SB were measured objectively using a thigh-worn physical activity monitor for 7 consecutive days. Activity levels were subdivided into low physical activity (LPA) and moderate-to-vigorous physical activity (MVPA). First, activity levels were analyzed against current guidelines of 150 minutes of MVPA per week. Second, time spent in SB, LPA, and MVPA was analyzed against possible determinants.

RESULTS

In total, 29% of patients with IJD met current physical activity guidelines. Patients on average spent 10 hours per day in SB. Poor physical fitness measured by the 6-minute walk test was the only significant predictor (P = 0.019) of high SB (R2  = 4.7%). Attending an exercise facility in the community (P = 0.034) and low role limitations due to physical health (P = 0.008) predicted high levels of LPA, following a backward multiple regression (R2  = 8.0%). Low role limitations due to emotional problems (P = 0.031), higher physical fitness (P = 0.002), and healthier exercise attitudes and beliefs (P = 0.021) predicted meeting current physical activity guidelines, following a backward conditional logistic regression, explaining between 22.2% and 31.7% of variance.

CONCLUSION

Patients with IJD are inactive and spent much time in SB. Good general health predicts high activity levels. No disease-specific factors were found to determine SB, LPA, or MVPA.

Impact of Reducing Sitting Time in Women with Fibromyalgia and Obesity: A Randomized Controlled Trial

BACKGROUND

Sitting time has negative effects on health, increasing the risk of obesity, osteoporosis, diabetes, and cancer. Thus, primary health care education interventions aimed to reduce sitting time and sedentary behavior could have beneficial effects on people's health and wellbeing. The purpose of this study was to assess the effectiveness of an intervention based on reducing sitting time to decrease cardiometabolic risk on a sample of women diagnosed with fibromyalgia and moderate obesity.

METHODS

Randomized controlled trial to evaluate the effectiveness of an intervention to decrease cardiometabolic risk in 84 participants. Sedentary behavior was monitored using an accelerometer before and at 3-month follow-up.

RESULTS

Compared with the control group, body mass index decreased, and the number of steps taken increased, in the intervention group 3 months after the intervention. No significant differences were found in the rest of the variables measured.

CONCLUSION

The intervention group decreased sitting time after the intervention. Group activities and support from primary care may be useful to improve treatment adherence. RCT registration: NCT01729936.

Physical activity and sedentary behavior in women with rheumatoid arthritis: a comparison of patients with low and high disease activity and healthy controls

Objective: In rheumatoid arthritis (RA) patients, low levels of physical activity (PA) and high levels of sedentary behavior (SB) may play a role in enhancing cardiovascular risk. We do not know how long-term control of disease activity impacts upon daily PA levels and if treated patients attain PA levels seen in healthy controls. We therefore compared habitual levels of PA and SB between female RA patients with low disease activity achieved by anti-tumor necrosis factor (TNF) therapy, those with active arthritis (aRA) and non-RA controls.

Methods: We carried out a cross-sectional comparison of 40 RA patients on anti-TNF therapy for >2 years with DAS28<3.2 (tRA), 32 patients on conventional disease modifying anti-rheumatic drugs with DAS28>3.2 (aRA) and 34 healthy controls (C) with the groups matched for age and body mass index. PA was assessed using the ActiGraph accelerometer to determine step count and time spent in moderate-to-vigorous physical activity (MVPA), light activity and sedentary time.

Results: Daily step count was 72% higher in tRA and 40% higher in C in comparison to aRA (p<0.01). Sedentary time (as a proportion of wear time) was 10% less in tRA than aRA (p=0.03), while light activity time was 18% higher (p=0.014). Both RA groups had 40% lower MVPA time than C (p=0.001). Only half of either RA group fulfilled current WHO guidelines for PA compared with 82% of controls.

Conclusion: RA patients who had long-term disease suppression were more physically active with less SB compared to RA patients with active disease. They had similar light PA and SB to controls although lower MVPA. Behavioral change interventions are likely to be needed in order to restore moderate exercise, further reduce SB and to meet guidelines for daily PA.

Sedentary behaviour in rheumatoid arthritis: definition, measurement and implications for health

RA is a chronic autoimmune disease characterized by high grade-inflammation, and associated with elevated cardiovascular risk, rheumatoid-cachexia and functional impairment. Sedentary behaviour (SB) is linked to heightened inflammation, and is highly pervasive in RA, likely as a result of compromised physical function and persistent fatigue. This high sedentarity may exacerbate the inflammatory process in RA, and hold relevance for disease-related outcomes. The aim of this narrative review is to provide an overview of the definition, measurement and health relevance of SB in the context of RA. Contradictions are highlighted with regard to the manner in which SB is operationalized, and the significance of SB for disease outcomes in RA is outlined. The advantages and disadvantages of SB measurement approaches are also discussed. Against this background, we summarize studies that have reported SB and its health correlates in RA, and propose directions for future research.

Physical inactivity and sedentary behavior: Overlooked risk factors in autoimmune rheumatic diseases?

This review aims to (1) summarize the estimates of physical inactivity and sedentary behavior in autoimmune rheumatic diseases; (2) describe the relationship between physical (in)activity levels and disease-related outcomes; (3) contextualize the estimates and impact of physical inactivity and sedentary behavior in autoimmune diseases compared to other rheumatic diseases and chronic conditions; and (4) discuss scientific perspectives around this theme and potential clinical interventions to attenuate these preventable risk factors. We compiled evidence to show that estimates of physical inactivity and sedentary behavior in autoimmune rheumatic diseases are generally comparable to other rheumatic diseases as well as to other chronic conditions (e.g., type 2 diabetes, cardiovascular diseases, and obesity), in which a lack of physical activity and excess of sedentary behavior are well-known predictors of morbimortality. In addition, we also showed evidence that both physical inactivity and sedentary behavior may be associated with poor health-related outcomes (e.g., worse disease symptoms and low functionality) in autoimmune rheumatic diseases. Thus, putting into practice interventions to make the patients "sit less and move more", particularly light-intensity activities and/or breaking-up sedentary time, is a simple and prudent therapeutic approach to minimize physical inactivity and sedentary behavior, which are overlooked yet modifiable risk factors in the field of autoimmune rheumatic diseases.

Association of Light-Intensity Physical Activity With Lower Cardiovascular Disease Risk Burden in Rheumatoid Arthritis

OBJECTIVE

To characterize physical activity (PA) in individuals with rheumatoid arthritis (RA) and to determine the associations between PA participation at light to moderate intensities and cardiovascular disease risk factors, disability, and disease activity.

METHODS

The cross-sectional study used data from 2 RA cohorts. PA was measured using an accelerometry-based activity monitor, recording minutes/day spent in sedentary (≤1 metabolic equivalent [MET]), very light (1.1-1.9 METs), light (2-2.9 METs), and moderate activities (≥3 METs). Cardiovascular markers included body mass index, blood pressure, insulin resistance, and lipid profile. Disability and disease activity were measured using the Health Assessment Questionnaire (HAQ) and the Disease Activity Score in 28 joints (DAS28), respectively. Associations between PA at each intensity level and health markers were assessed by multiple linear regression models, adjusted for age, sex, and cohort.

RESULTS

Ninety-eight subjects (mean ± SD age 58 ± 9 years, 85% female) were included. Subjects spent 9.8 hours/day being sedentary, 3.5 hours/day engaged in very light PA, 2.1 hours/day engaged in light PA, and 35 minutes/day engaged in moderate PA. Only 17% were physically active (≥150 minutes/week of moderate PA in 10-minute bouts). Regression models showed that very light, light, and moderate PA were inversely associated with most cardiovascular disease risk factors and HAQ and DAS28 scores (R(2) Δ range 0.04-0.52, P < 0.05). The associations between PA and cardiovascular disease markers were either equivalent or stronger at very light and light intensities, as compared to moderate intensity.

CONCLUSION

Individuals with RA are mostly active at very light and light intensities. PA at these intensity levels associates favorably with cardiovascular markers and lower disability and disease activity in RA.

Understanding walking activity in multiple sclerosis: step count, walking intensity and uninterrupted walking activity duration related to degree of disability

In multiple sclerosis (MS), physical activity (PA) is most commonly measured as number of steps, while also walking intensity and walking activity duration are keys for a healthy lifestyle. The aim of this study was to investigate (1) the number of steps persons with MS (PwMS) take; (2) the number of steps they take at low and moderate intensity; and (3) their walking activity duration for 2, 3, 6, 10, 12 and 14 uninterrupted minutes; all related to the degree of disability. 64 PwMS participated, distinguished in a mild (n = 31) and moderate MS subgroup (n = 34) based on their ambulatory dysfunction (Disease Steps). Standardized clinical tests were performed, and step data from the StepWatch Activity Monitor were collected for seven consecutive days. The results showed that (1) step count in PwMS was lower than PA recommendations, and is negatively influenced by a higher disability degree. (2) No walking was registered during 77 % of the day. PwMS are making steps for 22 % at low and only 1 % at moderate intensity. (3) Both MS subgroups rarely walk for more than six uninterrupted minutes, especially not at moderate intensity. PwMS need to be encouraged to make steps at moderate intensity, and to make steps for longer periods of time (minimal ten uninterrupted minutes).

Sedentary behaviour in patients with rheumatoid arthritis: A qualitative study

Background

Despite increasing interest in investigating sedentary behaviour (SB) in the general population and in patients with rheumatoid arthritis (RA), there is little documentation of the subjective experiences of SB in patients with RA. This study aimed to examine how patients with RA describe their daily SB.

Methods

Fifteen patients with RA (10 women and 5 men) from 23 to 73 years of age and with a disease duration ranging from 4 to 27 years were interviewed following a semi-structured interview guide. Data were analysed using the content analysis method described by Graneheim.

Results

SB appeared in three categories covering: 1) A constant battle between good and bad days; SB could be a consequence of RA in terms of days with pronounced pain and fatigue resulting in many hours of SB. 2) Adaptation to everyday life; living with the unpredictability of RA included constant modification of physical activity level causing increase in SB, especially during periods of disease flare. Prioritizing and planning of SB also functioned as part of self-management strategies. 3) It has nothing to do with my arthritis; for some patients, SB was not related to RA, but simply reflected a way of living independent of the disease.

Conclusions

SB is perceived, motivated, and performed differently in patients with RA. An individually tailored approach may be essential in understanding and encouraging patients’ motivation towards sustainable change in SB and activity patterns.

Let me Google that for you: a time series analysis of seasonality in internet search trends for terms related to foot and ankle pain

BACKGROUND

The analysis of internet search traffic may present the opportunity to gain insights into general trends and patterns in information seeking behaviour related to medical conditions at a population level. For prevalent and widespread problems such as foot and ankle pain, this information has the potential to improve our understanding of seasonality and trends within these conditions and their treatments, and may act as a useful proxy for their true incidence/prevalence characteristics. This study aimed to explore seasonal effects, general trends and relative popularity of internet search terms related to foot and ankle pain over the past decade.

METHODS

We used the Google Trends tool to obtain relative search engine traffic for terms relating to foot and ankle pain and common treatments from Google search and affiliated pages for major northern and southern hemisphere English speaking nations. Analysis of overall trends and seasonality including summer/winter differences was carried out on these terms.

RESULTS

Searches relating to general foot pain were on average 3.4 times more common than those relating to ankle pain, and twice as common as searches relating to heel pain. Distinct seasonal effects were seen in the northern hemisphere, with large increases in search volumes in the summer months compared to winter for foot (p = 0.004, 95 % CI [22.2-32.1]), ankle (p = 0.0078, 95 % CI [20.9-35.5]), and heel pain (p = 0.004, 95 % CI [29.1-45.6]). These seasonal effects were reflected by data from Australia, with the exception of ankle pain. Annual seasonal effects for treatment options were limited to terms related to foot surgery and ankle orthoses (p = 0.031, 95 % CI [3.5-20.9]; p = 0.004, 95 % CI [7.6-25.2] respectively), again increasing in the summer months.

CONCLUSIONS

A number of general trends and annual seasonal effects were found in time series internet search data for terms relating to foot and ankle pain. This data may provide insights into these conditions at population levels.

The efficacy of motivational counseling and SMS-reminders on daily sitting time in patients with rheumatoid arthritis: protocol for a randomized controlled trial

Background

Patients with RA (Rheumatoid Arthritis) are more sedentary than the general population. Reduction of Sedentary Behaviour (SB) has been suggested as a mean for improvement of health in patients with chronic diseases and mobility problems. Short-term intervention studies have demonstrated that SB can be reduced by behavioural interventions in healthy populations. However, it remains unexplored whether it is valid for patients with RA also.

Therefore, the aim of this trial is to investigate the efficacy of an individually tailored, theory-based motivational counseling intervention on reducing daily sitting time in sedentary patients with RA. Additionally, to explore whether a reduction in daily sitting time is associated with reduced pain and fatigue, self-reported physical function, self-efficacy, improved health-related quality of life (HR-QoL) and cardiovascular biomarker levels, and finally to assess the cost-effectiveness of the intervention.

Methods/Design

For this parallel group randomized trial, 150 patients with RA and at least 5 hours of sitting time per day, will be recruited from a rheumatology outpatient clinic, and block-randomized to the intervention group or the control group receiving usual care. The intervention includes: 1) individual motivational counseling (in total 3 sessions) on reduction of daily sitting time in combination with 2) individual Short Text Message Service (SMS) reminders over a 16-week intervention period. Primary outcome is change in daily sitting time (minutes) from baseline to 16 weeks measured objectively using an ActivPAL® Activity Monitor. Secondary outcomes include fatigue, pain, physical function, HR-QoL, self-efficacy, costs and cost-effectiveness. Furthermore, anthropometric measures will be included as well as measurement of blood pressure and serum lipids. All outcomes are assessed at baseline and repeated after 16 weeks. Follow-up assessments are made at 6 and 18 months post-intervention.

Discussion

The intervention is simple, non-invasive and may be implemented at low costs. If the study confirms the positive results expected, the intervention might be implemented in clinical practice and potentially transferred to other clinical populations.

Trial registration

ClinicalTrial.gov registration number: NCT01969604. Date of registration: 17 October 2013.

Dynamic plantar loading index detects altered foot function in individuals with rheumatoid arthritis but not changes due to orthotic use

BACKGROUND

Altered foot function is common in individuals with rheumatoid arthritis. Plantar pressure distributions during gait are regularly assessed in this patient group; however, the association between frequently reported magnitude-based pressure variables and clinical outcomes has not been clearly established. Recently, a novel approach to the analysis of plantar pressure distributions throughout stance phase, the dynamic plantar loading index, has been proposed. This study aimed to assess the utility of this index for measuring foot function in individuals with rheumatoid arthritis.

METHODS

Barefoot plantar pressures during gait were measured in 63 patients with rheumatoid arthritis and 51 matched controls. Additionally, 15 individuals with rheumatoid arthritis had in-shoe plantar pressures measured whilst walking in standardized footwear for two conditions: shoes-only; and shoes with prescribed custom foot orthoses. The dynamic plantar loading index was determined for all participants and conditions. Patient and control groups were compared for significant differences as were the shod and orthosis conditions.

FINDINGS

The patient group was found to have a mean index of 0.19, significantly lower than the control group's index of 0.32 (p>0.001, 95% CI [0.054, 0.197]). No significant differences were found between the shoe-only and shoe plus orthosis conditions. The loading index was found to correlate with clinical measures of structural deformity.

INTERPRETATION

The dynamic plantar loading index may be a useful tool for researchers and clinicians looking to objectively assess dynamic foot function in patients with rheumatoid arthritis; however, it may be unresponsive to changes caused by orthotic interventions in this patient group.

Determinants of sedentary behavior, motivation, barriers and strategies to reduce sitting time in older women: a qualitative investigation

Sedentary behavior defined as time spent non-exercising seated or reclining posture has been identified has a health risk and associated with frailty and disablement for older adults. Older adults are the most sedentary segment of society. To date no study has investigated the determinants of sedentary behavior in older adults. This study reports a qualitative investigation of the determinants of sedentary behavior, strategies and motivator to reduce sitting time by structured interviews in a group of community dwelling older women (N = 11, age 65 and over). Older women expressed the view that their sedentary behavior is mostly determined by pain which acts both as an incentive to sit and a motivator to stand up, lack of energy in the afternoon, pressure from direct social circle to sit and rest, societal and environmental typecasting that older adult are meant to sit, lack of environmental facilities to allow activity pacing. This qualitative investigation highlighted some factors that older adults consider determinants of their sedentary behavior. Some are identical to those affecting physical activity (self-efficacy, functional limitations, ageist stereotyping) but some appear specific to sedentary behavior (locus of control, pain) and should be further investigated and considered during intervention design. Tailored interventions that pay attention to the pattern of sedentary behavior of individuals appear to be supported by the views of older women on their sedentary behavior.