Benefits of exercise in rheumatoid arthritis

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

BACKGROUND

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Impact of Multimorbidity Patterns on Changes in Physical Activity and Physical Capacity Among Older Adults Participating in a Year-Long Exercise Intervention

This study investigated the impact of multimorbidity patterns on physical activity and capacity outcomes over the course of a year-long exercise intervention, and on physical activity 1 year later. Participants were 314 physically inactive community-dwelling men and women aged 70-85 years, with no contraindications for exercise at baseline. Physical activity was self-reported. Physical capacity measurements included five-time chair-stand time, 6-minute walking distance, and maximal isometric knee-extension strength. The intervention included supervised and home-based strength, balance, and walking exercises. Multimorbidity patterns comprised physician-diagnosed chronic disease conditions as a predictor cluster and body mass index as a measure of obesity. Multimorbidity patterns explained 0%-12% of baseline variance and 0%-3% of the change in outcomes. The magnitude and direction of the impact of unique conditions varied by outcome, time point, and sex. Multimorbid older adults with no contraindications for exercise may benefit from multimodal physical training.

Can we achieve pain stratification in musculoskeletal conditions? Implications for clinical practice

In the last few years there has been an increased appreciation that pain perception in rheumatic and musculoskeletal diseases (RMDs) has several mechanisms which include nociceptive, inflammatory, nociplastic and neuropathic components. Studies in specific patient groups have also demonstrated that the pain experienced by people with specific diagnoses can present with distinctive components over time. For example, the pain observed in rheumatoid arthritis has been widely accepted to be caused by the activation of nociceptors, potentiated by the release of inflammatory mediators, including prostaglandins, leukotrienes and cytokine networks in the joint environment. However, people with RA may also experience nociplastic and neuropathic pain components, particularly when treatments with disease modifying anti-rheumatic drugs (DMARDs) have been implemented and are insufficient to control pain symptoms. In other RMDs, the concept of pain sensitisation or nociplastic pain in driving ongoing pain symptoms e.g. osteoarthritis and fibromyalgia, is becoming increasingly recognised. In this review, we explore the hypothesis that pain has distinct modalities based on clinical, pathophysiological, imaging and genetic factors. The concept of pain stratification in RMD is explored and implications for future management are also discussed.

Effect of blood flow restriction with low-intensity resistance training in patients with osteoarthritis and rheumatoid arthritis: a systematic review and meta-analysis based on randomized controlled trials

PURPOSE

This study evaluated the effects of blood flow restriction with low-intensity resistance training (BFR + LIRT) on pain, adverse events, muscle strength, and function in patients with osteoarthritis (OA) and rheumatoid arthritis (RA) through a systematic review and meta-analysis.

METHODS

This study adhered to the guidelines of the Preferred Reporting Items for Systematic Review and Meta-Analyses 2020 (PRISMA 2020) and applied the A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR2) standards to ensure the high quality of the systematic review. A comprehensive literature search was conducted until August 2023 using four selected keywords (osteoarthritis, rheumatoid arthritis, blood flow restriction training, and resistance training) across five search engines (PubMed, Embase, Web of Science, CENTRAL, and PEDro).

RESULTS

Ten studies were analyzed. The results showed that BFR + LIRT had similar effects on pain, risk of adverse events, muscle strength, self-reported function, and physical function compared with resistance training (RT).

CONCLUSION

This systematic review and meta-analysis further support the potential of BFR + LIRT in the disease management of patients with OA or RA. According to this analysis, BFR + LIRT had a lower risk of adverse events than high-intensity resistance training (HIRT) and may be a safer training modality. BFR + LIRT offers greater advantages in improving physical function than LIRT and was able to provide similar benefits to HIRT without increasing the training load. These findings suggest that BFR + LIRT is a safe and effective strategy for treating patients with OA or RA. However, owing to the limited number of studies covered in this analysis, additional higher-quality studies are needed to strengthen this conclusion.

Using theory of change to co-create a programme theory for a telerehabilitation intervention for pain management in people with haemophilia

BACKGROUND

Improved approaches for chronic pain management are a clinical and research priority for people with haemophilia (PWH). Involving people with lived experience in the design of a complex rehabilitation intervention strengthens the credibility and plausibility of the intervention, particularly in relation to rare disorders. Here we describe using a 'Theory of Change' (ToC) dialogue-based stakeholder process to create a programme theory for a telerehabilitation intervention.

METHODS

An online workshop was convened and stakeholders received a briefing document in advance. Five stakeholders took part (3 PWH and 2 physiotherapists). At the workshop the group first agreed the overall aim of the intervention. Discussions then identified the resources, activities, barriers and enablers needed to achieve this outcome. All discussions were recorded and annotated by the workshop moderator. Behaviour change techniques were mapped for inclusion in the theory.

RESULTS

A programme theory and narrative report were produced. All stakeholders reviewed these for clarity and to ensure a true reflection of the workshop discussions. Agreement was based on how meaningful, well-defined, do-able, plausible, credible, and testable each component was. Stakeholders highlighted the importance of issues unique to PWH. Key components included the need for physiotherapists to be knowledgeable of the condition, a range of exercises that were inclusive of all abilities, and the need for people to feel safe and supported whilst taking part.

CONCLUSIONS

Co-developed theory based approaches to intervention design offer an inclusive and transparent way to develop novel and meaningful interventions for people with complex health conditions. The ToC is wholly transparent in its design and content. Together with the identified behaviour change techniques, the theory informs the protocol for a feasibility study evaluating a telerehabilitation intervention. Importantly, it allows the opportunity to revise, adapt and improve the programme theory for further implementation and evaluation.

"It's very saddening, you keep on wondering when the symptoms will be over": A qualitative study exploring the long-term chikungunya disease impact on daily life and well-being, 6 years after disease onset

BACKGROUND

Long-term chikungunya is a mosquito-borne disease, characterized by disabling rheumatic symptoms persisting for years, after infection with the chikungunya virus. Previous studies focused on assessing the well-being of affected individuals from a quantitative perspective using generic instruments, and have reported physical and psychological impairment. However, a common critique is that generic instrument's structured responses and pre-defined health domains selected by health professionals, may not capture the full extent of well-being impairment experienced by patients. This study aimed to explore in-depth to which extent long-term chikungunya disease impacts daily living and the physical, psychological, and social well-being from the experiences and perspective of affected individuals.

METHODOLOGY/PRINCIPAL FINDINGS

Using open-ended questions, in-depth interviews were conducted with 20 purposively selected individuals with long-term chikungunya disease, in Curaçao. Interview audio-recordings were transcribed verbatim. The data were thematically analyzed. Living with persistent rheumatic symptoms affected the participant's daily living and well-being in several ways: experience of physical impact (restricted physical functioning and limitations in activities of daily life); experience of psychological impact (altered emotional state, fear of walking and running, psychosocial aspects of footwear adaptations, and uncertainty about disease progression and future health); and experience of social impact (social isolation and impaired relational maintenance, social dependency, challenges of social support, at-work productivity loss, and giving up leisure activities after work).

CONCLUSIONS/SIGNIFICANCE

This study, the first of its kind, indicated that the adverse impact of long-term chikungunya disease is currently underreported. The persistent rheumatic symptoms had a negative effect on functional ability, which in turn impacted broad aspects of daily life and well-being, beyond what is captured by generic instruments. In the view of the findings, physical exercise programs including manual therapy, aerobics, resistance and stretching exercises, and orthopaedic footwear interventions in a multidisciplinary patient-centred approach may improve physical function and subsequently overall well-being.

Causality of occupational exposure on rheumatoid arthritis and ankylosing spondylitis: a two-sample mendelian randomization study

Objective

This study aimed to explore the potential causal link between three specific types of occupational exposure on rheumatoid arthritis (RA) and ankylosing spondylitis (AS).

Method

A Two-sample Mendelian randomization (TSMR) analysis, comprising univariate MR (UVMR) and multivariate MR (MVMR) analyses, was performed to investigate the potential causal association between three types of occupational exposures, jobs involving mainly walking or standing (JWS), jobs involving heavy manual or physical work (JMP), and jobs involving shift work(JSW) on RA and AS. Genetic variants for genome-wide association studies (GWAS) of occupational exposure and AS were obtained from the UK Biobank. GWAS summary data for RA were obtained from FinnGen Biobank analysis. For UVMR, six methods of Inverse Variance Weighted (IVW), MR-Egger, Weighted Mode, Weighted Median, Simple Mode, MR pleiotropy residual sum, and outlier (MR-PRESSO) were used for the analysis. The MVMR was analyzed using the IVW model as well as the MR-Egger model.

Results

The UVMR suggested no causal relationship between the three occupational exposure and RA [IVW: P=0.59,0.21,0.63] or AS [IVW: P=0.43,0.57,0.04], as did the bidirectional MR [IVW: P=0.73,0.70,0.16], [IVW: P=0.65,0.68,0.74]. Although unadjusted MVMR suggested a causal relationship between JMP and AS [IVW: OR = 1.01, 95% CI = 1.00- 1.02, p = 0.02], the adjusted MVMR denied this relationship and concluded that there was no causal relationship between the other occupational exposure and either RA or AS.

Conclusion

Our MR analysis did not establish a direct causal relationship between certain occupational exposures and either RA or AS.

Relative importance of inflammation and cardiorespiratory fitness for all-cause mortality risk in persons with rheumatoid arthritis: the population-based Trøndelag Health Study

OBJECTIVE

Inflammation and reduced cardiorespiratory fitness (CRF) are associated with increased mortality rates in rheumatoid arthritis (RA). We aimed at directly comparing the relative importance of inflammation and reduced CRF as mediators of all-cause mortality in persons with RA compared with controls, quantifying direct and indirect (mediated) effects.

METHODS

Persons with (n=223, cases) and without (n=31 684, controls) RA from the third survey of the Trøndelag Health Study (HUNT3, 2006-2008) were included. Inflammation was quantified using C reactive protein (CRP) and estimated CRF (eCRF) was calculated using published formulae. All-cause mortality was found by linkage to the Norwegian Cause of Death Registry, with follow-up from inclusion in HUNT3 until death or 31 December 2018. Data were analysed using standardised equation modelling, permitting complex correlations among variables.

RESULTS

Persons with RA had increased all-cause mortality rates (24.1% vs 9.9%, p<0.001). Both eCRF (p<0.001) and CRP ≥3 mg/L (p<0.001) were mediators of this excess mortality, rendering the direct effect of RA non-significant (p=0.19). The indirect effect of RA mediated by eCRF (standardised coefficient 0.006) was approximately three times higher than the indirect effect mediated by CRP (standardised coefficient 0.002) in a model adjusted for other mortality risk factors.

CONCLUSION

Even with CRP concentrations <3 mg/L in all patients with RA, excess mortality mediated by low CRF would still play an important role. Improved inflammation control in RA does not necessarily lead to better CRF. Therefore, our study strongly supports recommendations for development and implementation of exercise programmes aimed at improving CRF in persons with RA.

Physical Exercise and Occupational Therapy at Home to Improve the Quality of Life in Subjects Affected by Rheumatoid Arthritis: A Randomized Controlled Trial

BACKGROUND

Rheumatoid arthritis (RA) is a chronic autoimmune inflammatory disease that affects synovial membranes and typically causes joint pain and swelling. The resulting disability of RA is due to the erosion of cartilage and bone from the inflamed synovial tissue. Occupational therapy is a strategy and technique to minimize the joints' fatigue and effort. At the same time, physical exercise reduces the impact of systemic manifestations and improves symptoms in RA. This study investigates the role of a 30-day joint economy intervention (integration of physical exercise and occupational therapy) at home on the quality of life of subjects with RA.

METHODS

One hundred and sixty outpatients with RA were enrolled in a single-center trial with PROBE design and were divided into the intervention group (IG), which combined joint protection movements and physical exercise to maintain muscle tone at home, and the control group (CG). Both groups included 80 patients. In all patients, data from the disease activity score (DAS 28), health assessment questionnaire (HAQ), and short-form health survey (SF-12) "Italian version" were collected. In addition, to IG, a brochure was distributed, and the joint economy was explained, while to CG, the brochure only was distributed. The comparison between groups was made using Fisher's exact test for contingency tables and the z-test for the comparison of proportions. The non-parametric Mann-Whitney U test was used to compare quantitative variables between groups. The Wilcoxon signed-ranked test was used for post-intervention versus baseline comparisons.

RESULTS

Among the recruited patients, 54% were female. The mean age was 58.0 (42.4-74.7) for the CG and 54.0 (39.7-68.3) for the IG. Patients included in the IG had a higher cumulative illness rating scale for the evaluation of severity and comorbidity index (2.81 vs. 2.58; 2.91 vs. 2.59, respectively), as well as morning stiffness (33.8 vs. 25.0), even if not significant compared with CG patients. Our results indicate that, after 30 days of joint economy intervention at home, the DAS28 erythrocyte sedimentation rate (esr) and DAS28 C-reactive protein (crp), HAQ, and SF-12 mental component score were significantly improved (p = 0.005, p = 0.004, p = 0.009, and p = 0.010, respectively).

CONCLUSIONS

Our findings show that the combination of physical exercise and occupational therapy positively affects patients' quality of life with RA considering disease activity, global health status, and mental health.

Association between Nutritional Status, Lifestyle Habits, and Disease Activity in Dalmatian Patients with Rheumatoid Arthritis

The aim of this study was to evaluate body composition, handgrip strength, quality of life, disease duration and activity and lifestyle habits in patients with rheumatoid arthritis (RA) and to evaluate possible associations between all of the abovementioned factors. Seventy-five stable RA patients were included. Data on sociodemographic data, disease activity, quality of life, nutritional risk, body mass composition, anthropometric parameters, and clinical and laboratory parameters were collected for each study participant. The results showed that the mean score of the disease activity score (DAS28) was 5.4, the mean score of the health assessment questionnaire-disability index (HAQ-DI) was 1.19, and the mean disease duration in our population was 13.9 years. Our studied population had a long disease duration and high disease activity. Positive predictors of muscle mass in RA patients were daily caloric intake, fat-free mass, bone mass, basal metabolic rate, total body water, weight, body mass index (BMI), height, and muscle strength. There were no significant negative predictors. Positive predictors of muscle strength in RA patients were daily caloric intake, basal metabolic rate, predicted muscle mass, fat-free mass, bone mass, weight, total body water, metabolic age, hemoglobin, BMI, and number of exercises per week. In contrast, negative predictors of muscle strength were number of comorbidities, number of swollen joints, DAS, number of tender joints, erythrocyte sedimentation rate (ESR), and duration of RA. An association was also found between bone mineral density and both muscle mass and muscle strength. A structured nutritional approach in terms of multidisciplinary collaboration between rheumatologist, dietitian and physical medicine specialist is needed in the Dalmatian RA population.

Pain and physical activity levels among Rheumatoid Arthritis patients between the ages of 18 to 50 years in South Africa

Background

Little epidemiological research on rheumatoid arthritis (RA) has been done in Africa, suggesting that it is an uncommon illness. In rural South Africa, RA has an overall prevalence of 0.07% and a prevalence of 2.5% in urban areas; therefore, it is not as uncommon as perceived by the lack of research. Patient-centred programmes to improve physical function have been lacking and, as a result, the prior assumption was that physical activity should be avoided.

Objectives

To determine pain and physical activity levels among RA patients between the ages of 18 to 50 years in South Africa.

Methods

A combination of two questionnaires were used, namely, the Global Physical Activity Questionnaire (2002) and the Pain Outcomes Questionnaire (2003). The collated questionnaires were distributed by rheumatologists and on social media platforms to RA patients between the ages of 18 to 50 years old living in South Africa. This study had a sample size of 105 participants, with participation occurring through the online Google forms platform.

Results

One hundred and five participants with RA were recruited with an average age of 38±9 years. Most of the participants were females (93.3%). Seventy-two percent of the sample was classified as physically active, where work, leisure and travel activities were considered. No significant correlation between pain and physical activity was evident (r=0.10; p=0.311). Results showed significant correlations between pain and personal grooming (r=0.30; p=0.002), pain and ambulation (r=0.60; p=0.000), and pain and stair climbing (r=0.60; p=0.000).

Conclusion

Physical activity has proven to have multiple benefits for those suffering with RA. In this South African sample of RA patients, the majority were classified as physically active, and pain did not affect the activity levels of the involved participants. This study opens further research questions regarding RA prevalence in South Africa, and the type and intensity of physical activity that would be beneficial for RA.

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

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

[Translation of the 2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis and linguistic validation in German-speaking countries with healthcare professionals]

BACKGROUND

Regular physical activity is beneficial for people with rheumatic diseases and one of the cornerstones in its management. Based on the international recommendations of the World Health Organization for the general population, the "2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis" provide evidence-based recommendations on the prescription, performance, and implementation of physical activity exercises in this population for the first time.

AIM

Translation of the 2018 EULAR recommendations into German and linguistic validation in Germany, Austria and Switzerland.

METHODS

A professional translation of the EULAR recommendations into the German language was performed and revised by German-speaking experts from all three countries. The translation was validated by healthcare professionals consisting of rheumatologists, occupational therapists, physiotherapists, nurses, and medical assistants in a field test. In each of the three countries, eight structured interviews were conducted on comprehensibility, wording, completeness, and feasibility. The experts then discussed changes until consensus was reached and indicated the level of agreement with the final translation.

RESULTS

The translation of the EULAR recommendations was substantially revised. Based on the results of the cognitive test, formulations were adapted in order to increase comprehensibility. The level of agreement between 10 (SD 0.0) and 8.9 (SD 1.5) was very high.

DISCUSSION

The final German version of the EULAR recommendations is comprehensible and accepted across all three German-speaking countries. It can help to improve the structure and clarity of the handling of physical activity and promote physical activity for healthcare providers and patients.

Implementation of automated behavior metrics to evaluate voluntary wheel running effects on inflammatory-erosive arthritis and interstitial lung disease in TNF-Tg mice

BACKGROUND

Although treatment options and algorithms for rheumatoid arthritis (RA) have improved remarkably in recent decades, there continues to be no definitive cure or pharmacologic intervention with reliable long-term efficacy. For this reason, the combination of medications and healthy lifestyle modifications are essential for controlling joint disease, and extra-articular manifestations of RA, such as interstitial lung disease (ILD) and other lung pathologies, which greatly impact morbidity and mortality. Generally, exercise has been deemed beneficial in RA patients, and both patients and clinicians are motivated to incorporate effective non-pharmacologic interventions. However, there are limited evidence-based and specific exercise regimens available to support engagement in such activities for RA patients. Here, we provided the continuous opportunity for exercise to mice and implemented automated recording and quantification of wheel running behavior. This allowed us to describe the associated effects on the progression of inflammatory-erosive arthritis and ILD in the tumor necrosis factor transgenic (TNF-Tg) mouse model of RA.

METHODS

Wild-type (WT; males, n=9; females, n=9) and TNF-Tg (males, n=12; females, n=14) mice were singly housed with free access to a running wheel starting at 2 months until 5 to 5.5 months of age. Measures of running included distance, rate, length, and number of run bouts, which were derived from continuously recorded data streams collected automatically and in real-time. In vivo lung, ankle, and knee micro-computed tomography (micro-CT), along with terminal micro-CT and histology were performed to examine the association of running behaviors and disease progression relative to sedentary controls.

RESULTS

TNF-Tg males and females exhibited significantly reduced running distance, rate, length, and number of run bouts compared to WT counterparts by 5 months of age (p<0.0001). Compared to sedentary controls, running males and females showed increased aerated lung volumes (p<0.05) that were positively correlated with running distance and rate in female mice (WT: Distance, ρ=0.705/rate, ρ=0.693 (p<0.01); TNF-Tg: ρ=0.380 (p=0.06)/ρ=0.403 (p<0.05)). Talus bone volumes were significantly reduced in running versus sedentary males and negatively correlated with running distance and rate in TNF-Tg mice (male: ρ=-903/ρ=-0.865; female: ρ=-0.614/ρ=-0.594 (p<0.001)). Histopathology validated the lung and ankle micro-CT findings.

CONCLUSIONS

Implementation of automated wheel running behavior metrics allows for evaluation of longitudinal activity modifications hands-off and in real-time to relate with biomarkers of disease severity. Through such analysis, we determined that wheel running activity increases aerated lung volumes, but exacerbates inflammatory-erosive arthritis in TNF-Tg mice. To the end of a clinically relevant model, additional functional assessment of these outcomes and studies of pain behavior are warranted.

The experiences and beliefs of people with severe haemophilia and healthcare professionals on pain management, and their views of using exercise as an aspect of intervention: a qualitative study

PURPOSE

To explore the experiences, views and beliefs of people with severe haemophilia and healthcare professionals (HCPs) on approaches for pain management, as well as their views on exercise being used as an aspect of management.

METHODS

Taking a qualitative inquiry approach using focus groups and semi-structured interviews, participants included people with severe haemophilia living with chronic pain and haemophilia HCPs. Data were analysed using reflexive thematic analysis.

RESULTS

Fourteen men with haemophilia with a median age of 47 (range 23-73) and six haemophilia HCPs agreed to participate. Of the people with haemophilia, 11 attended two focus groups and three were interviewed over telephone. Healthcare professionals were interviewed face-to-face. Two themes were conceptualised from the data: (i) haemophilia management and pain management is discordant (imbalance between good haemophilia care but poor pain management, historical medico-social influences on pain management, the need for trust); (ii) uncertain about exercise but clear on what matters (conflicting views on exercise, the need for proof of safety, personalised care).

CONCLUSIONS

Options for effective pain management remain limited and what is used is heavily influenced by beliefs and experience. Exercise as a treatment option in pain management is conceptually acceptable for people with haemophilia. Effective pain management requires understanding of individual beliefs and fears, and a personalised approach supported by knowledgeable, trusted clinicians.Implications for rehabilitationMusculoskeletal joint pain and its relationship with bleeding in people with haemophilia continues to be a management challenge.Current pain management strategies are of limited effectiveness with little evidence of an approach that reflects the multi-modal pain experience.Whilst exercise and rehabilitation approaches are conceptually possible for people with severe haemophilia, barriers remain regarding perception of overall safety and effectiveness.People with severe haemophilia may consider exercise as part of a pain management strategy if it is individualised, and they are supported to do it by clinicians who understand them and their haemophilia.

Positive Outcomes of Comprehensive Exercise Program on Restoration of Functional Level and Quality of Life in a Patient With Rheumatoid Arthritis: A Case Report

A relatively recurrent inflammatory disease that is autoimmune, affecting the tissue that lines the joints and tendons, is rheumatoid arthritis (RA). Genome-wide association research has discovered additional genetic markers. The cornerstones of current RA care strategies include anti-inflammatory pharmaceuticals, disease-modifying anti-rheumatic drugs, joint protection and energy conservation, exercise, assistive devices, splinting, orthotics, and surgical treatment. Cardiovascular ailment is still the leading cause of mortality, and those with autoimmune diseases are far more likely to have cardiovascular disease. We present a case of RA with a history of hypothyroidism, hypertension, and diabetes mellitus. She has also taken Ayurveda treatment panchakarma for the same. Physiotherapy interventions included resistance training and aerobic exercises, which showed appreciable results on the Numeric Pain Rating Scale and Multidimensional Health Assessment Questionnaire.

Exercise intervention on cardiorespiratory fitness in rheumatoid arthritis patients with high cardiovascular disease risk: a single-arm pilot study

OBJECTIVE

In patients with rheumatoid arthritis (RA) with cardiovascular disease risk, it is unknown whether exercises are safe, improve cardiorespiratory fitness and reduce disease-related symptoms and cardiovascular-disease (CVD) risk factors. We aimed to investigate in RA patients with CVD risk: (1) safety of medium to high-intensity aerobic exercises, (2) potential changes of cardiorespiratory fitness and (3) disease activity and CVD risk factors in response to the exercises.

METHODS

Single-arm pilot-exercise intervention study including 26 consecutive patients (21 women) with > 4% 10-year risk of CVD mortality according to the Dutch Systematic Coronary Risk Evaluation. Aerobic exercises consisted of two supervised-sessions and five home-sessions per week for 12 weeks. Patients were required to exercise at intensities between 65 and 85% of their maximum heart rate. To assess safety, we recorded exercise related adverse events. Before and after the exercises, cardiorespiratory fitness was assessed with a graded maximal oxygen-uptake exercise test, while disease activity was evaluated via the Disease Activity Score-28 (DAS28) using the erythrocyte segmentation rate (ESR). Resting blood pressure, ESR and total cholesterol were assessed as CVD risk factors.

RESULTS

Twenty out of 26 patients performed the 12-week exercises without any adverse events. According to patients, withdrawals were unrelated to the exercises. Exercises increased cardiorespiratory fitness (pre: 15.91 vs. post: 18.15 ml.kg^-1 min^-1, p = 0.003) and decreased DAS28 (pre: 2.86 vs. post: 2.47, p = 0.04). No changes were detected in CVD risk factors.

CONCLUSION

A 12-week exercise intervention seems to be safe and improves cardiorespiratory fitness and disease activity in patients with RA with a high risk for cardiovascular diseases. Key Points 1. Rheumatoid arthritis patients with high cardiovascular disease risk were able to perform a maximum exercise test and a 12-week aerobic-based medium-to-high intensity exercise intervention. 2. The exercise intervention improved cardiorespiratory fitness and disease activity in rheumatoid arthritis patients with high cardiovascular disease risk. 3. Cardiorespiratory fitness levels were still low post-exercise intervention (i.e. 18.15 ml.kg-1min-1 compared to the 20.9 ml.kg-1min-1 baseline mean of the RA patients without CVD risk).

Acute effects of exercise on pain symptoms, clinical inflammatory markers and inflammatory cytokines in people with rheumatoid arthritis: a systematic literature review

Background

Exercise is advocated in the treatment of rheumatoid arthritis (RA). However, uncertainty around the acute effects of exercise on pain and inflammation may be stopping people with RA from exercising more regularly.

Objectives

To determine the acute effects of exercise on pain symptoms, clinical inflammatory markers, and inflammatory cytokines in RA.

Design

A systematic review of the literature.

Data sources and methods

Five databases were searched (PubMed, Cochrane Library, CINAHL, Scopus and SPORTDiscus); inclusion criteria were studies with acute exercise, a definite diagnosis of RA and disease characteristics assessed by clinical function (i.e., disease activity score, health assessment questionnaire and self-reported pain), clinical markers associated with inflammation (i.e., c-reactive protein (CRP) and erythrocyte sedimentation rate (ESR)), and inflammatory cytokines (i.e., interleukin 6 (IL-6) and tumour necrosis factor alpha (TNF-α)).

Results

From a total of 1544 articles, initial screening and full text assessment left 11 studies meeting the inclusion criteria. A total of 274 people were included in the studies (RA = 186; control = 88). Acute bouts of aerobic, resistance, and combined aerobic and resistance exercise did not appear to exacerbate pain symptoms in people with RA.

Conclusion

Post-exercise responses for pain, clinical inflammatory markers and inflammatory cytokines were not different between people with or without RA. Exercise prescription was variable between studies, which limited between-study comparisons. Therefore, future investigations in people with RA are warranted, which combine different exercise modes and intensities to examine acute effects on pain symptoms and inflammatory markers.

Registration

The PROSPERO international prospective register of systematic reviews - CRD42018091155.

Regulation of mi-RNAs Target Cancer Genes Between Exercise and Non-exercise in Rat Rheumatoid Arthritis Induction: Pilot Study

Introduction:

Rheumatoid arthritis is associated with various cancers. Many studies have investigated physical exercise interventions as health improvements to ameliorate the risk of cancer during rheumatoid arthritis diagnosis. Recently, microRNAs were used as biomarkers for health assessment and cancer prediction in rheumatoid arthritis patients.

Methods:

The effects of exercise interventions on serum microRNAs were investigated in pristane-induced arthritis (PIA) rat models. Twelve Sprague-Dawley male rats were divided into 4 groups including non-exercise without PIA (N-EX), non-exercise with PIA (N-EX + PIA), exercise without PIA (EX) and exercise with PIA (EX + PIA). Blood samples were collected at the end of the study period to analyze miRNA biomarkers and target cancer gene predictions.

Results:

Four significant Rattus norvegicus (rno-microRNAs) may purpose as tumor suppressors were identified as potential target cancer gene candidate expressions within the 4 comparative interventional exercise groups. One rno-microRNA and target cancer gene candidate was up-regulated and 3 rno-microRNAs and their target cancer genes were down-regulated.

Conclusions:

Exercise interventions affected rno-miRNAs regulated target cancer gene candidates ITPR3, SOCS6, ITGA6, and NKX2-1 as biomarkers for cancer prognosis in rheumatoid arthritis diagnosis.

Bioinformatics Analysis of Exercise-Related Biomarkers in Diabetes

Background

Exercise is a regular behavioral activity that not only helps to lose weight but also reduces the risk of cardiovascular and cerebrovascular diseases. Diabetes is a common disease that plagues human health. It is shown that regular exercise can improve the insulin sensitivity of diabetic patients and have an important function in adjuvant therapy.

Methods

We downloaded the GSE101931 dataset from the Gene Expression Omnibus (GEO) database, 10 samples were obtained from the GSE101931 dataset, including 5 before exercise and 5 postexercise samples, and GEO2R was used to screen the differentially expressed genes (DEGs) exhibited by a heat map. Then, the enrichment analysis of DEGs in Gene Ontology (GO) function was analyzed by Metascape, and the Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway of DEGs was also analyzed by gene set enrichment analysis (GSEA). Next, the protein-protein interaction (PPI) network maps were drawn, and the hub genes were identified through Metascape. Finally, the expressions of the hub genes in the dataset were analyzed.

Results

Totally, 116 upregulated DEGs and 1017 downregulated DEGs were identified from these data. These DEGs were mainly enriched in the platelet-derived growth factor receptor signaling pathway and mRNA processing. Then, the GSEA analysis showed that 6 KEGG pathways were associated with postexercise prediabetic samples, namely, ABC transporters, focal adhesion, MAPK signaling pathway, prion diseases, melanogenesis, and gap junction. Afterward, three hub genes (HSPA8, STIP1, and HSPH1) were highly expressed after exercise through the box plot analysis.

Conclusion

A myriad of research results confirms that there is a certain connection between exercise and diabetes, which provides a favorable basis for emerging exercise into the treatment of diabetic patients.

Comparison of the Impacts of a Dynamic Exercise Program vs. a Mediterranean Diet on Serum Cytokine Concentrations in Women With Rheumatoid Arthritis. A Secondary Analysis of a Randomized Clinical Trial

Background

Rheumatoid arthritis (RA) is a disease characterized by a chronic inflammatory state. High pro-inflammatory cytokine levels are associated with disease activity. Exercise and the Mediterranean diet (MD) exert anti-inflammatory effects; however, their impacts on inflammation in RA patients remains unknown. This study aimed to compare the effects of six-months of dynamic exercise program (DEP) vs. MD on pro- and anti-inflammatory cytokine serum concentrations.

Methods

Secondary analysis of a randomized clinical trial in which 90 women with RA were randomly assigned to the DEP (n = 30), MD (n = 30), or control group (n = 30). All patients received pharmacological treatment. Serum concentrations of pro-inflammatory (TNF-α, TNF-β, IL-1β, IL-6 pg/mL) and anti-inflammatory (IL-10, IL-Ra pg/mL) cytokines were measured at baseline and after 6 months using the Luminex technique.

Results

After 6 months of follow-up, we found an improvement of the median percentages changes concentrations of TNF-α (DEP, -12.3; MD, -13.3; control, 73.2; p = 0.01), TNF-β (DEP, -67.4; MD, -54.9; control, 0; p = 0.04), and IL-6 (DEP, -19.9; MD, -37.7; control, 45.5; p = 0.04) in the DEP and MED groups in comparison with control group. IL-1Ra concentrations increased only in the MD group (13.8) compared to levels in the control group (-31.7), p = 0.04. There were no statistically significant differences between DEP and MD groups. Only n = 27 participants in the DEP group, n = 26 in the MD group, and n = 21 in the control group completed the follow-up.

Conclusion

The DEP and the MD have potential effects in the concentrations of pro-inflammatory cytokines compared with those in a control group. Only the MD elevated the concentration of IL-Ra.

Clinical Trial Registration

[ClinicalTrials.gov], identifier [NCT02900898].

Interventions to Improve Physical Capability of Older Adults with Mild Disabilities: A Case Study

Ageing is related to changes in physical health, including loss of mobility and muscle function. It can lead to impaired physical capability and reduced quality of life. The purpose of this study was to investigate whether a physical activity rehabilitation program (PARP) could improve range of joint motion (ROM), grip strength, and gait speed of older adults with mild disabilities. Forty older adults in a long-term care center in Taiwan joined as human participants and were split into control and experimental groups. The participants in the experimental group joined a PARP for eight weeks. The ROM of bodily joints, grip strength, and gait speed of all participants were measured both before and after the eight-week period. The results showed that all the ROMs, grip strength, and gait speed of the participants in the experimental group increased significantly after attending the program. The improvement of the ROMs for male and female participants in the experimental group ranged from 3.8% to 71% and from 7.8% to 75%, respectively. Male participants had greater improvement on gait speed (50%) than their female counterparts (22.9%). Female participants, on the other hand, had greater improvement on grip strength (25.4%) than their male counterparts (20.3%). The ROM, grip strength, and gait speed of the control group, on the other hand, did not change significantly during the same period. The results showed that the PARP adopted in this study was effective in increasing the ROM, grip strength, and gait speed of those who had joined the PARP. This study shows that an eight-week PARP without the use of gym machines was beneficial in reducing sarcopenia in elderly people with mild disabilities.

The effect of exercise on cytokines: implications for musculoskeletal health: a narrative review

The physiological effects of physical exercise are ubiquitously reported as beneficial to the cardiovascular and musculoskeletal systems. Exercise is widely promoted by medical professionals to aid both physical and emotional wellbeing; however, mechanisms through which this is achieved are less well understood. Despite numerous beneficial attributes, certain types of exercise can inflict significant significant physiological stress. Several studies document a key relationship between exercise and immune activation. Activation of the innate immune system occurs in response to exercise and it is proposed this is largely mediated by cytokine signalling. Cytokines are typically classified according to their inflammatory properties and evidence has shown that cytokines expressed in response to exercise are diverse and may act to propagate, modulate or mitigate inflammation in musculoskeletal health. The review summarizes the existing literature on the relationship between exercise and the immune system with emphasis on how exercise-induced cytokine expression modulates inflammation and the immune response.

Interaction effect of systemic inflammation and modifiable rheumatoid cachexia risk factors on resting energy expenditure in patients with rheumatoid arthritis

Background

In rheumatoid cachexia (RC), high resting energy expenditure (REE) is associated with loss of muscle mass driven by proinflammatory cytokines. The objectives of this study were to investigate parameters associated with RC, and the interaction between systemic inflammation and modifiable risk factors for RC on REE.

Methods

Thirty-five rheumatoid arthritis (RA) and nineteen non-RA controls comparable in age, sex, race and BMI underwent measures of REE by indirect calorimetry. Clinical, dietary, body composition and physical function data were collected. Homeostasis model assessment for insulin resistance (HOMA-IR) and serum interleukin-6 (IL-6) were used as parameters of IR and systemic inflammation, respectively. Regression models tested association between REE and dependent variables, including pre-specified interaction tests involving HOMA-IR and IL-6 and dietary intake of protein per weight (PPW) and IL-6.

Results

RA subjects were mostly women (94%) and had a median age of 54 years (50.5, 70) and BMI of 30.5 kg/m2 (26.1, 36.9). We observed a significant interaction effect between PPW and serum IL-6 on REE among RA subjects in the multiple regression model among RA. The upper tertile of PPW demonstrated a significant negative correlation between REE and IL-6 (β=-19.97, 95% CI [-35.41, -4.54], p=0.01). The lower tertile of PPW demonstrated a significant positive correlation between REE and IL-6 (β=42.24, 95% CI [4.25, 80.23], p=0.03).

Conclusions

While IR can lead to muscle catabolism, IR was not significantly associated with REE in RA individuals. Higher dietary protein intake could attenuate the effect of systemic inflammation on REE in RA patients.

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

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

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Call for action: incorporating wellness practices into a holistic management plan for rheumatoid arthritis-going beyond treat to target

This expert opinion article explores the strategy of adopting a holistic approach to the management of rheumatoid arthritis (RA) by incorporating the wellness practices of exercise, optimised sleep, optimised nutrition, mindfulness, social connectedness and positive emotions into the management plan. The aim is to attain optimal health for each patient beyond that achievable by limiting disease management to pharmacological treatment to attain the lowest achievable composite scores of disease activity, as recommended with the current treat-to-target approach, and addressing the recent recognition of pain control as a key patient-reported outcome. Incorporating wellness practices into a busy clinical setting requires creativity and customisation based on the individual practice setting and the individual needs of each patient. Such practices can help people living with RA to achieve optimum wellness through the introduction of measures-according to individual need-designed to improve the aspects of life most impacted for that person, thereby complementing treat-to-target and pain control strategies with pharmacological agents. Clinicians must consider wellness practices in addition to treat-to-target pharmacological agents for the holistic management of people with RA.

Participation in physical activity decreased more in people with rheumatoid arthritis than the general population during the COVID-19 lockdown: a cross-sectional study

The COVID-19 pandemic and social distancing restrictions have significantly reduced population-wide physical activity (PA) levels. However, the impact of the pandemic and relevant restrictions on PA participation, and any potential barriers to it, in people with rheumatoid arthritis (RA) are not clear. Furthermore, we are unsure if any such PA changes have affected their body weight, mental wellbeing, and/or quality of life (QoL). Thus, the aim of this study was to examine the impact of the lockdown on PA participation in people with RA, versus people without RA. Participants (n = 128; RA = 27, non-RA = 101) completed a self-administered online survey, which included questions on PA, body weight, mental wellbeing and QoL. PA participation during lockdown was significantly lower among RA versus non-RA participants (p < 0.001). Additionally, a similar profile of results was found where more RA participants vs non-RA participants reported reduced habitual PA (59% vs 33%) and increased body weight (59% vs 35%). Mental wellbeing scores were similarly low in both groups during lockdown (RA: 20.8 ± 4.2; non-RA: 22.2 ± 3.4, p = 0.080). Matched group comparisons identified similar trends to full sample analyses. In the first months of the lockdown, more people with RA reported decreased PA participation and increased body weight than their non-RA counterparts. Access to exercise equipment and facilities appears to be the main cause for these results. Looking beyond COVID-19, specific PA promotion for people with RA will be required to prevent a pandemic of inactivity.

What non-pharmacological treatments do people with polymyalgia rheumatica try: results from the PMR Cohort Study

Polymyalgia rheumatica (PMR) is common. The mainstay of treatment, glucocorticoids, are associated with significant adverse effects and many patients remain on high doses for a number of years. Little is known about the use of other, non-pharmacological therapies as adjuncts in PMR. The PMR Cohort Study is an inception cohort study of patients diagnosed with PMR in primary care. This analysis presents data on the use and perceived impact of non-pharmacological therapies from a long-term follow-up survey. Non-pharmacological treatments were classified as either diet, exercise, or complementary therapies. Results are presented as adjusted means, medians, and raw counts where appropriate. One hundred and ninety-seven participants completed the long-term follow-up questionnaire, of these 81 (41.1%) reported using non-pharmacological therapy. Fifty-seven people reported using a form of complementary therapy, 35 used exercise and 20 reported changing their diet. No individual non-pharmacological therapy appeared to be associated with long-term outcomes. The use of non-pharmacological therapies is common amongst PMR patients, despite the paucity of evidence supporting their use. This suggests that people perceive a need for treatment options in addition to standard glucocorticoid regimens. Further research is needed to understand patients’ aims when seeking additional treatments and to strengthen the evidence base for their use so that patients can be guided towards effective options.

Cardiorespiratory fitness and physical activity in people who have rheumatoid arthritis at an increased risk of cardiovascular disease: a cross-sectional study

Lower cardiorespiratory fitness (CRF) and physical activity (PA) associate with higher cardiovascular disease (CVD) risk, but the relationship between CRF and PA in people who have rheumatoid arthritis (RA) at an increased CVD risk (CVD-RA) is not known. The objectives of this study were to determine the levels of CRF and PA in people who have CVD-RA and to investigate the association of CRF with PA in people who have CVD-RA. A total of 24 consecutive patients (19 women) with CVD-RA (> 4% for 10-year risk of fatal CVD development as calculated using the Systematic Coronary Risk Evaluation)-were included in the study. CRF was assessed with a graded maximal exercise test determining maximal oxygen uptake (VO_2max). PA was assessed with an accelerometer to determine the amount of step count, sedentary, light and moderate-to-vigorous physical activity (MVPA) minutes per day. Mean age of patients was 65.3 ± 8.3 years. CRF mean values were 16.3 ± 1.2 ml·kg^-1 min^-1, mean step count per day was 6033 ± 2256, and the mean MVPA time was 16.7 min per day. Significant positive associations were found for CRF with step count (B = 0.001, P = 0.01) and MVPA time (B = 0.15, P = 0.02); a negative association was found for CRF with sedentary time (B =  - 0.02, P = 0.03). CRF is low and is associated with step count, sedentary time and MVPA time in people who have RA at an increased CVD risk.

Current status and influencing factors of fatigue in patients with rheumatoid arthritis: A cross-sectional study in China

AIM

This study aimed to explore the level and influencing factors of fatigue in patients with rheumatoid arthritis.

METHODS

This cross-sectional study was conducted in 243 patients with rheumatoid arthritis from April 2016 to March 2017. The Bristol Rheumatoid Arthritis Fatigue Multi-Dimensional Questionnaire, Arthritis Self-Efficacy Scale-8, Visual Analogue Scale for pain, physical function subscale of Short Form 36-Item Health Survey, Hospital Anxiety and Depression Scale, Perceived Social Support Scale, Pittsburgh Sleep Quality Index and a self-designed demographic and disease-related information questionnaire were used to collect the data. Stepwise linear multiple regression was used to clarify the impact of statistically significant variables (P < 0.05) in the independent sample t test, one-way ANOVA and correlation analysis on the level of fatigue.

RESULTS

Stepwise linear multiple regression analyses showed that disease activity, self-efficacy, physical function, pain, depression, duration of morning stiffness and anxiety were major factors influencing fatigue in patients with rheumatoid arthritis, which explained 59.5% of the total variance.

CONCLUSION

Our study demonstrated a moderate level of fatigue in Chinese patients with rheumatoid arthritis. In clinical practice, nurses should explore individualized intervention programmes based on related predictors of fatigue to help patients relieve fatigue.

Cardiovascular Risk in Rheumatoid Arthritis: Literature Review

Rheumatoid arthritis (RA) is the most common inflammatory arthritis disease with a worldwide prevalence of 1-3%. RA patients are at higher risk of atherosclerosis than their matched age-sex controls. Cardiovascular diseases (CVDs) account for a 50% risk of increased mortality and morbidity in RA. The pattern of CVD in RA patients differs from that in the general population; RA patients are more likely to have silent ischemic heart disease, sudden death, heart failure, and die early. RA patients tend to have a 5-10 years reduction in their life span than their matched healthy population. Traditional (classical) CV risk factors work separately or synergistically with the underlying inflammation to increase CVD risk in RA. Moreover, inflammation is defined as an independent CVD risk factor. This literature review aims to discuss the traditional CVD risk factors and their association with inflammation in RA.

Physical Exercise: A Novel Tool to Protect Mitochondrial Health

Mitochondrial dysfunction is a crucial contributor to heart diseases. Alterations in energetic metabolism affect crucial homeostatic processes, such asATP production, the generation of reactive oxygen species, and the release of pro-apoptotic factors, associated with metabolic abnormalities. In response to energetic deficiency, the cardiomyocytes activate the Mitochondrial Quality Control (MQC), a critical process in maintaining mitochondrial health. This process is compromised in cardiovascular diseases depending on the pathology's severity and represents, therefore, a potential therapeutic target. Several potential targeting molecules within this process have been identified in the last years, and therapeutic strategies have been proposed to ameliorate mitochondria monitoring and function. In this context, physical exercise is considered a non-pharmacological strategy to protect mitochondrial health. Physical exercise regulates MQC allowing the repair/elimination of damaged mitochondria and synthesizing new ones, thus recovering the metabolic state. In this review, we will deal with the effect of physical exercise on cardiac mitochondrial function tracing its ability to modulate specific steps in MQC both in physiologic and pathologic conditions.

[Sports and exercise therapy in inflammatory rheumatic diseases]

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

Muscle deterioration due to rheumatoid arthritis: assessment by quantitative MRI and strength testing

OBJECTIVES

RA patients often present with low muscle mass and decreased strength. Quantitative MRI offers a non-invasive measurement of muscle status. This study assessed whether MRI-based measurements of T2, fat fraction, diffusion tensor imaging and muscle volume can detect differences between the thigh muscles of RA patients and healthy controls, and assessed the muscle phenotype of different disease stages.

METHODS

Thirty-nine RA patients (13 'new RA'-newly diagnosed, treatment naïve, 13 'active RA'-persistent DAS28 >3.2 for >1 year, 13 'remission RA'-persistent DAS28 <2.6 for >1 year) and 13 age and gender directly matched healthy controls had an MRI scan of their dominant thigh. All participants had knee extension and flexion torque and grip strength measured.

RESULTS

MRI T2 and fat fraction were higher in the three groups of RA patients compared with healthy controls in the thigh muscles. There were no clinically meaningful differences in the mean diffusivity. The muscle volume, handgrip strength, knee extension and flexion were lower in all three groups of RA patients compared with healthy controls.

CONCLUSION

Quantitative MRI and muscle strength measurements can potentially detect differences within the muscles between RA patients and healthy controls. These differences may be seen in RA patients who are yet to start treatment, those with persistent active disease, and those who were in clinical remission. This suggests that the muscles in RA patients are affected in the early stages of the disease and that signs of muscle pathology and muscle weakness are still observed in clinical remission.

Phenolic Compounds Impact on Rheumatoid Arthritis, Inflammatory Bowel Disease and Microbiota Modulation

Non-communicable chronic diseases (NCDs) are nowadays the principal cause of death, especially in most industrialized nations. These illnesses have increased exponentially with the consumption of diets very high in fat and sugar, not to mention stress and physical inactivity among other factors. The potential impact of suboptimal diets on NCDs’ morbidity and mortality rates brings to the forefront the necessity for a new way of improving dietary habits. The literature provides extensive scientific work that presents evidence that phenolic compounds from diets have antioxidant, anti-inflammatory and antiproliferative activities that impact human health. Gut microbiota modulation by some phenolic compounds leads to favorable changes in abundance, diversity, and in the immune system. However, polyphenol’s limited bioavailability needs to be overcome, highlighting their application in new delivery systems and providing their health benefits in well-established ways such as health maintenance, treatment or adjuvant to conventional pharmacological treatments. In this context, novel dietary approaches, including new food supplements, have emerged to prevent diseases and preserve health.

Therapeutic exercises and rehabilitation in axial spondyloarthropathy: Balancing benefits with unique challenges in the Asia-Pacific countries

The burden of axial spondyloarthropathy (axSpA) in the Asia-Pacific region is substantial. The management of axSpA has been revolutionized with the advent of biological therapy where the disease activity, functional disability and negative psychological affect can be mitigated to a great extent. On the other hand, exercise remains an essential component of the treatment of axSpA at all stages, which is often discounted or underused. This is compounded by a gap in demand and supply between increasing number patients with axSpA and paucity of trained specialists and rehabilitation personnel in the Asia-Pacific countries. The acceptability and uptake of therapeutic exercise is strikingly poor in this region because of multiple factors such as lack of awareness among health professionals and the general population, poor healthcare infrastructure, lack of resources and limited accessibility to rehabilitation services. Health authorities and professional bodies in these countries need to work in tandem to expand healthcare facilities, encourage training opportunities and promote safe and effective exercise interventions which is accessible to the general population and individuals with axSpA. Adequate patient education, optimum control of disease activity and strict adherence to therapeutic exercise is essential to predict the best clinical outcome. In this narrative review we have appraised the impact of therapeutic exercise in this era of biological therapies in axSpA and have explored the challenges of rehabilitation services in the Asia-Pacific countries. Overall, the available quality of evidence is mixed, acknowledging the beneficial role of exercise and optimum usage and protocols pertaining to axSpA specific exercises and therefore further research is warranted.

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

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

Association of Pain, Severe Pain, and Multisite Pain with the Level of Physical Activity and Sedentary Behavior in Severely Obese Adults: Baseline Data from the DieTBra Trial

The study aimed to assess the prevalence of pain, severe pain, and pain in four or more regions associated with physical activity and sedentary behavior, as well as other associated factors in severely obese adults (Body Mass Index ≥ 35 kg/m2). Baseline data from the DieTBra Trial were analyzed. The outcome variables were pain (yes/no) and pain in four or more sites (yes/no), as identified by the Brazilian version of the Nordic Musculoskeletal Questionnaire, along with the presence of severe pain (yes/no), identified based on the Numerical Pain Rating Scale (≥8). The main independent variables were moderate to vigorous physical activity (MVPA), light physical activity, and sedentary behavior, assessed by triaxial accelerometry. The variables were analyzed using multiple hierarchical Poisson regression. In 150 individuals (men, 14.67%; and women, 85.33%), with a mean age of 39.6 ± 0.7 years, there was a high prevalence of pain (89.33%), severe pain (69.33%), and pain in four or more regions (53.33%). The associated factors were shorter MVPA time with pain (p = 0.010); arthritis/arthrosis (p = 0.007) and the use of muscle relaxants (p = 0.026) with severe pain; and economic class C (p = 0.033), and economic class D (p = 0.003), along with arthritis and arthrosis (p = 0.025) with pain in four or more sites. There were no significant associations between sedentary behavior and any of the three outcomes analyzed. These findings indicate that, in severely obese individuals, shorter MVPA time is associated with a higher prevalence of pain. Future studies on physical activity intervention may contribute to the reduction in the prevalence and severity of pain in adults with severe obesity.

Low-Load Resistance Training With Blood-Flow Restriction in Relation to Muscle Function, Mass, and Functionality in Women With Rheumatoid Arthritis

OBJECTIVE

To evaluate the effects of a low-load resistance training program associated with partial blood-flow restriction in patients with rheumatoid arthritis (RA).

METHODS

Forty-eight women with RA were randomized into 1 of 3 groups: high-load resistance training (HL-RT; 70% 1 repetition maximum [1RM]), low-load resistance training (30% 1RM) with partial blood-flow restriction training (BFRT), and a control group. Patients completed a 12-week supervised training program and were assessed for lower-extremity 1RM, quadriceps cross-sectional area (CSA), physical function (timed-stands test [TST], timed-up-and-go test [TUG], and Health Assessment Questionnaire [HAQ]), and quality of life (Short Form 36 health survey [SF-36]) at baseline and after the intervention.

RESULTS

BFRT and HL-RT were similarly effective in increasing maximum dynamic strength in both leg press (22.8% and 24.2%, respectively; P < 0.0001 for all) and knee extension (19.7% and 23.8%, respectively; P < 0.0001 for all). Quadriceps CSA was also significantly increased in both BFRT and HL-RT (9.5% and 10.8%, respectively; P < 0.0001 for all). Comparable improvements in TST (11.2% and 14.7%; P < 0.0001 for all) and TUG (-6.8% [P < 0.0053] and -8.7% [P < 0.0001]) were also observed in BFRT and HL-RT, respectively. Improvements in both groups were significantly greater than those of the control group (P < 0.05 for all). SF-36 role physical and bodily pain and HAQ scores were improved only in BFRT (45.7%, 22.5%, and -55.9%, respectively; P < 0.05 for all). HL-RT resulted in 1 case of withdrawal and several cases of exercise-induced pain, which did not occur in BFRT.

CONCLUSION

BFRT was effective in improving muscle strength, mass, function, and health-related quality of life in patients with RA, emerging as a viable therapeutic modality in RA management.

Benefits of exercise in patients with rheumatoid arthritis: a randomized controlled trial of a patient-specific exercise programme

BACKGROUND

Patients with rheumatoid arthritis (RA) tend to be more overweight, take less physical exercise, exhibit decreased cardiorespiratory fitness and demonstrate reduced muscle strength compared with age- and sex-matched controls. Impaired cognitive function in RA is an important associated factor, although it has been less well-recognized. The aim of this study was to investigate the effects of a specifically designed exercise programme on body composition, aerobic capacity, muscle strength and cognition in RA.

METHODS

Sixty-six patients with RA were randomized to a specifically designed, personalized exercise programme or standard care. Assessments included body composition, fitness, grip strength and cognitive testing, in addition to disease related measures.

RESULTS

Significant improvements in C-reactive protein (p = 0.025), fatigue scores (p = 0.047) and truncal fat (p = 0.004) were observed in the exercise group compared with controls. Median waist circumference was significantly reduced (94.0 to 91.4 cm, p < 0.0001). Improvements were also seen in aerobic capacity (23.2 to 27.6 ml/kg/min, p = 0.002) and in median right (12.0 to 13.0 kg, p = 0.025) and left grip strength (8.0 to 10 kg, p = 0.005). Cognitive function improved in the exercise group, with median Montreal Cognitive Assessment score 25.5 at 0 months compared to 28.0 at 3 months (p = 0.001).

CONCLUSION

This study demonstrates that exercise has a significant and positive impact on cognitive function in RA. Furthermore, physical activity is safe and effective in chronic inflammatory joint disease and is recommended as a vital component in the holistic management of these patients.Key Points• A dedicated physical exercise programme is feasible and safe in patients with rheumatoid arthritis (RA).• Physical exercise helps reduce fatigue scores and improves cardiovascular fitness in stable RA patients.• Physical exercise has a positive impact on cognition in patients with RA.• A structured exercise programme should be an integral part of chronic disease management protocols for patients with RA.

Associations of Handgrip Strength with Prevalence of Rheumatoid Arthritis and Diabetes Mellitus in Older Adults

Background

The purpose of this study was to investigate the association between handgrip strength and prevalence of rheumatoid arthritis and diabetes in older adults.

Methods

A total of 4,186 participants 65 years of age and older was included in the study, which utilized data from the fifth Korea National Health and Nutrition Examination Survey. Pearson’s chi-square tests were used to explore the relationship between frequency of participation in physical activity and handgrip strength. The relationships between handgrip strength and prevalence of rheumatoid arthritis and diabetes were determined by logistic regression.

Results

Older adults with higher handgrip strength participated more frequently in walking (right hand, 3.71 day/wk; left hand, 3.80 day/wk), strength (right hand, 1.40 day/wk; left hand, 1.43 day/wk), and flexibility exercises (both hands, 2.08 day/wk) than those with lower handgrip strength (right hand, 2.83 day/wk and left hand, 2.81 day/wk for walking; right hand, 0.18 day/wk and left hand, 0.22 day/wk for strength; right hand, 1.17 day/wk and left hand, 1.24 day/wk for flexibility). Higher handgrip strength was associated with reduced prevalence of rheumatoid arthritis (right hand: odds ratio [OR], 0.29; 95% confidence interval [CI], 0.16–0.52; P<0.05; left hand: OR, 0.20; 95% CI, 0.10–0.38; P<0.05) and diabetes (right hand: OR, 0.71; 95% CI, 0.57–0.89; P<0.05; left hand: OR, 0.71; 95% CI, 0.58–0.88; P<0.05).

Conclusion

Enhanced handgrip strength was significantly associated with lower prevalence of rheumatoid arthritis and diabetes in older adults. Participating in physical activity should be recommended to older adults for maintaining handgrip strength.

The time course and mechanisms of change in biomarkers of joint metabolism in response to acute exercise and chronic training in physiologic and pathological conditions

PURPOSE

The benefits of exercise across the lifespan and for a wide spectrum of health and diseases are well known. However, there remains less clarity as to the effects of both acute and chronic exercise on joint health. Serum biomarkers of joint metabolism are sensitive to change and have the potential to differentiate between normal and adverse adaptations to acute and chronic load. Therefore, the primary objective of this review is to evaluate how serum biomarkers can inform our understanding of how exercise affects joint metabolism.

METHODS

A comprehensive literature search was completed to identify joint biomarkers previously used to investigate acute and chronic exercise training.

RESULTS

Identified biomarkers included those related to joint cartilage, bone, synovium, synovial fluid, and inflammation. However, current research has largely focused on the response of serum cartilage oligomeric matrix protein (COMP) to acute loading in healthy young individuals. Studies demonstrate how acute loading transiently increases serum COMP (i.e., cartilage metabolism), which is mostly dependent on the duration of exercise. This response does not appear to be associated with any lasting deleterious changes, cartilage degradation, or osteoarthritis.

CONCLUSION

Several promising biomarkers for assessing joint metabolism exist and may in future enhance our understanding of the physiological response to acute and chronic exercise. Defining 'normal' and 'abnormal' biomarker responses to exercise and methodological standardisation would greatly improve the potential of research in this area to understand mechanisms and inform practice.

Combination of COX-2 inhibitor and metformin attenuates rate of admission in patients with rheumatoid arthritis and diabetes in Taiwan

Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory autoimmune disease associated with increased prevalence of type 2 diabetes mellitus (T2DM). Here, we investigated the effect of the combination of cyclooxygenase (COX)-2 inhibitors and metformin on the rate of admission in patients with RA and T2DM and compared it with that of only COX-2 inhibitors.In total, 1268 subjects with RA and T2DM under COX-2 inhibitor and metformin therapy were selected from the National Health Insurance Research Database of Taiwan, along with 2536 patients as 1:2 sex-, age-, and index year-matched controls without metformin therapy. Cox proportional hazard analysis was used to compare the rate of admission during the 10 years of follow-up.At the end of the follow-up, 72 enrolled subjects (1.89%) had admission, including 9 from the combination group (0.71%) and 63 from the COX-2 inhibitor group (2.48%). The combination group was associated with a lower rate of admission at the end of follow-up (P < .001). Cox proportional hazard regression analysis revealed the lower rate of admission for subjects under combination therapy (adjusted hazard ratio of 0.275; 95% confidence interval = 0.136-0.557, P < .001).Patients with RA and T2DM receiving the combination of COX-2 inhibitors and metformin were associated with lower admission rate than those on COX-2 inhibitors alone, and this effect may be attributed to the decrease in the levels of proinflammatory factors.

Factors influencing physical activity in patients with early rheumatoid arthritis: A mixed-methods study

Objective:

The goal of this study was to provide a greater understanding of physical activity in patients with early rheumatoid arthritis. The aim was twofold: first to explore if physical activity was associated with factors in the clinical picture of rheumatoid arthritis in this patient group, and second, to explore factors influencing physical activity in patients with early rheumatoid arthritis.

Methods:

A total of 66 patients with early rheumatoid arthritis were included in the study. A sequential explanatory mixed-methods design was used, where quantitative data from a questionnaire were analysed with Mann–Whitney, post hoc Kruskal–Wallis and χ² test in order to detect differences between groups, and find possible associations between physical activity and independent variables, such as disease activity, health-related quality of life and physical function. Qualitative data were collected in a follow-up questionnaire with open-ended questions that focused on factors influencing physical activity.

Results:

Associations between physical activity, disease activity and health-related quality of life were seen in patients with early rheumatoid arthritis together with strong negative correlations between physical activity and physical function. Patients on sick leave showed the strongest associations between disease-related variables and lower levels of physical activity. The findings from the qualitative analysis showed that physical limitations, awareness as a motivational factor and external environment factors influenced physical activity in patients with early rheumatoid arthritis.

Conclusion:

The results showed a complex underlying motive where physical, psychological and environmental factors influenced the physical activity in patients with early rheumatoid arthritis. In order to provide more effective health interventions, it is important to consider the complex nature of practicing physical activity, where a person-centred approach should be considered. Factors such as physical limitations, economic aspects and time for practicing physical activity should be included in the person-centred approach.

The impact of cardiorespiratory fitness on classical cardiovascular disease risk factors in rheumatoid arthritis: a cross-sectional and longitudinal study

Rheumatoid arthritis (RA) is associated with an increased risk of cardiovascular disease (CVD). Advanced measures of cardiorespiratory fitness (CRF) are associated with CVD risk factors. The present study aimed to examine whether CVD risk factors can predict clinic-based measures of CRF, using the Siconolfi step test and to determine if exercise can improve RA patients' cardiovascular health. Sixty-five RA patients (46 females, age 58 ± 11 years) completed assessments of CRF, CVD risk factors, body composition and RA characteristics. Ten patients participated in a follow-up 8-week exercise intervention. CRF was low (22 ml kg^-1 min^-1) and associated with higher diastolic blood pressure (r = - 0.37, p = 0.002), higher global CVD risk (r = - 0.267,  p = 0.031) and worse body composition profile (body fat, r = - 0.48, p < 0.001; waist, r = - 0.65, p < 0.001; hip, r = - 0.58, p < 0.001). Regular exercise significantly improved CRF (p = 0.021), lower body strength (p < 0.001), agility (p < 0.001), systolic blood pressure (p = 0.021), body fat (p = 0.018), waist circumference (p = 0.035), hip circumference (p = 0.016), disease activity (p = 0.002), disability (p = 0.007) and QoL (p = 0.004). Elevated diastolic blood pressure and worse body composition profile are strong predictors of clinic-based measures of CRF. CRF is an important determinant of CVD risk and warrants inclusion in the routine assessment of RA patients. Regular exercise can improve CRF and CVD risk factors without any exacerbation of disease activity and should be offered as part of routine care.

Long-Term Physical Activity and Subsequent Risk for Rheumatoid Arthritis Among Women: A Prospective Cohort Study

OBJECTIVE

To evaluate the effects of long-term physical activity on subsequent risk of rheumatoid arthritis (RA) in a prospective cohort study.

METHODS

This study investigated physical activity and RA risk among women from the Nurses' Health Study II (1989-2015). Physical activity exposures and covariates were prospectively obtained using biennial questionnaires. Two rheumatologists independently reviewed the medical records of women who self-reported a new diagnosis of RA on biennial questionnaires and who screened positive for RA based on a supplemental survey. All incident RA cases met the 1987 American College of Rheumatology (ACR) or 2010 ACR/European League Against Rheumatism (EULAR) classification criteria for RA. The primary analysis investigated the long-term cumulative average number of hours spent in recreational physical activity 2-8 years prior to the RA diagnosis, a time span chosen to reduce the potential for reverse causation bias, since early RA affects physical activity prior to diagnosis. Estimated Cox regression hazard ratios (HRs) with 95% confidence intervals (95% CIs) were used to assess the risk of RA serologic phenotypes (all, seropositive, or seronegative) in relation to physical activity categories. The analyses were adjusted for body mass index (BMI) at age 18 years and time-varying potential confounders, and the mediating effect of updated BMI on the interaction between physical activity and RA risk was quantified.

RESULTS

Among the 113,366 women analyzed, 506 incident RA cases (67.0% with seropositive RA) were identified during 2,428,573 person-years of follow-up. After adjustment for confounders, including smoking, dietary quality, and BMI at age 18 years, increasing cumulative average total hours of recreational physical activity was associated with a reduced risk of RA, as follows: HR 1.00 for <1 hour/week (reference), HR 1.00 (95% CI 0.78-1.29) for 1 to <2 hours/week, HR 0.92 (95% CI 0.72-1.17) for 2 to <4 hours/week, HR 0.84 (95% CI 0.63-1.12) for 4 to <7 hours/week, and HR 0.67 (95% CI 0.47-0.98) for ≥7 hours/week (P for trend = 0.02). The proportion of the effect between physical activity and RA mediated by updated BMI was 14.0% (P = 0.002) for all RA and 20.0% (P = 0.001) for seropositive RA.

CONCLUSION

Higher levels of physical activity were associated with reduced RA risk. These results add to the literature implicating metabolic factors in the pathogenesis of RA.

Types of pain and their psychosocial impact in women with rheumatoid arthritis

Rheumatoid arthritis (RA) is a systemic inflammatory autoimmune disease predominantly affecting middle-aged women. Very commonly, pain is a manifestation of active disease and because untreated RA can result in joint deformities, the current evaluation of pain has largely focused on inflammation. In addition, treatment has centered on the premise of reducing disease activity with the hopes of halting worsening damage, preventing future deformities, and ultimately providing pain relief for the patient. Yet research shows that all patients with RA, but women in particular, often suffer from increased mechanical pain and fibromyalgia, as well as anxiety, depression, sleep disturbances, sexual dysfunction, and disability, which add to the burden of the illness. Determining and addressing alternative pain triggers as well as understanding the psychosocial burden of RA is key in treating patients, especially in those who may not improve with traditional pharmacotherapy.