Slowing of bone loss in patients with rheumatoid arthritis by long-term high-intensity exercise: results of a randomized, controlled trial

OBJECTIVE

Patients with rheumatoid arthritis (RA) are more at risk for the development of osteoporosis and osteoporotic fractures than are their healthy peers. In this randomized, controlled, multicenter trial, the effectiveness of a 2-year high-intensity weight-bearing exercise program (the Rheumatoid-Arthritis-Patients-In-Training [RAPIT] program) on bone mineral density (BMD) was compared with usual care physical therapy, and the exercise modalities associated with changes in BMD were determined.

METHODS

Three hundred nine patients with RA were assigned to an intervention group, either the RAPIT program or usual care physical therapy. The primary end points were BMD of the hip and spine. The exercise modalities examined were aerobic fitness, muscle strength, and, as a surrogate for those effects not directly measured by the RAPIT program, attendance rate.

RESULTS

The data on the 136 RAPIT participants and 145 usual care participants who completed the study were analyzed. The mean rate of decrease in hip BMD, but not in lumbar spine BMD, was smaller in patients participating in the RAPIT program when compared with that in the usual care group, with a mean decrease of 1.6% (95% confidence interval [95% CI] 0.8-2.5) over the first year and 0.5% (95% CI 1.1-2.0) over the second year. The change in hip BMD was significantly and independently associated with changes in both muscle strength (multivariate odds ratio [OR] 1.75, 95% CI 1.07-2.86) and aerobic fitness (OR 1.79, 95% CI 1.10-2.90), but not with the attendance rate (OR 1.00, 95% CI 0.99-1.00).

CONCLUSION

A long-term high-intensity weight-bearing exercise program for RA patients is effective in slowing down the loss of BMD at the hip. The exercise modalities associated with this effect are muscle strength and aerobic fitness.

Exercise therapy after coronary artery bypass graft surgery: a randomized comparison of a high and low frequency exercise therapy program

BACKGROUND

Postoperative exercise therapy aims at recovering, as soon as possible, independence in the basic physical activities; but the type, intensity, and therefore the costs of the programs, vary widely. The aim of this study was to compare the effectiveness of a low frequency (once daily, not in the weekend) program with a high frequency (twice daily, including the weekend) one and to assess whether the latter would yield sufficient benefit for the patient to justify higher costs in material and personnel (physiotherapists) after uncomplicated coronary artery bypass graft (CABG) surgery.

METHODS

Two-hundred and forty-six patients were randomly allocated to either a low or high frequency exercise program. Endpoints were the functional level as measured by the achievement of five activity milestones, the patient's independence (functional independence measures [FIM]) as assessed by a structured interview, the amount of daily physical activity (activity monitor), and patient satisfaction (questionnaire). Except for patient satisfaction, all measurements were done in the first week after surgery.

RESULTS

Patients with the high frequency exercise program achieved functional milestones faster than patients with the low frequency exercise program (p = 0.007). The frequency of the exercise program had no influence on functional independence as measured with the FIM or quantity of physical activity. The satisfaction degree was greater in the high frequency group (p = 0.032), although the low frequency group was not dissatisfied.

CONCLUSIONS

A high frequency exercise program leads to earlier performance of functional milestones and yields more satisfaction after uncomplicated CABG surgery and this should lead to an earlier discharge. On the other hand, if the shortage of physiotherapists remains unchanged or even increases, the low frequency program also yields excellent functional results, albeit at the cost of a somewhat longer hospital stay: but it would allow a sensible redistribution of the physiotherapists activity towards complicated and, therefore, more demanding patients.

Systematic review of quantitative clinical gait analysis in patients with dementia

INTRODUCTION

Diminished mobility often accompanies dementia and has a great impact on independence and quality of life. New treatment strategies for dementia are emerging, but the effects on gait remains to be studied objectively. In this review we address the general effects of dementia on gait as revealed by quantitative gait analysis.

METHODS

A systematic literature search with the (MESH) terms: 'dementia' and 'gait disorders' in Medline, CC, Psychlit and CinaHL between 1980-2002. Main inclusion criteria: controlled studies; patients with dementia; quantitative gait data.

RESULTS

Seven publications met the inclusion criteria. All compared gait in Alzheimer's Disease (AD) with healthy elderly controls; one also assessed gait in Vascular Dementia (VaD). The methodology used was inconsistent and often had many shortcomings. However, there were several consistent findings: walking velocity decreased in dementia compared to healthy controls and decreased further with progressing severity of dementia. VaD was associated with a significant decrease in walking velocity compared to AD subjects. Dementia was associated with a shortened step length, an increased double support time and step to step variability.

DISCUSSION

Gait in dementia is hardly analyzed in a well-designed manner. Despite this, the literature suggests that quantitative gait analysis can be sufficiently reliable and responsive to measure decline in walking velocity between subjects with and without dementia. More research is required to assess, both on an individual and a group level, how the minimal clinically relevant changes in gait in elderly demented patients should be defined and what would be the most responsive method to measure these changes.

Adherence and satisfaction of rheumatoid arthritis patients with a long-term intensive dynamic exercise program (RAPIT program)

OBJECTIVE

To evaluate adherence and satisfaction of patients with rheumatoid arthritis (RA) in a long-term intensive dynamic exercise program.

METHODS

A total of 146 RA patients started an intensive (strength and endurance training for 75 minutes, twice a week, for 2 years) exercise program (Rheumatoid Arthritis Patients In Training) aimed at improving physical fitness. Program attendance and satisfaction were examined. Additional assessments at baseline were done to find possible predictors of attendance.

RESULTS

Median (interquartile range) age and disease duration of the patients were 54 (45-61) and 5 (3-10) years, respectively. After 2 years, 118 (81%) patients still participated in an exercise class. The median attendance rate of all patients was 74%. Low attendance was weakly associated with high disease activity, low functional ability, and low quality of life at baseline but not with the severity of joint damage at baseline. At the end, 78% of all participants would (strongly) recommend the program to other RA patients.

CONCLUSION

Adherence and satisfaction of RA patients with an intensive dynamic exercise program over a prolonged time can be high. Disease severity parameters do not strongly predict the compliance of participants in an intensive exercise program.

Is a long-term high-intensity exercise program effective and safe in patients with rheumatoid arthritis? Results of a randomized controlled trial

OBJECTIVE

There are insufficient data on the effects of long-term intensive exercise in patients with rheumatoid arthritis (RA). We undertook this randomized, controlled, multicenter trial to compare the effectiveness and safety of a 2-year intensive exercise program (Rheumatoid Arthritis Patients In Training [RAPIT]) with those of physical therapy (termed usual care [UC]).

METHODS

Three hundred nine RA patients were assigned to either the RAPIT program or UC. The primary end points were functional ability (assessed by the McMaster Toronto Arthritis [MACTAR] Patient Preference Disability Questionnaire and the Health Assessment Questionnaire [HAQ]) and the effects on radiographic progression in large joints. Secondary end points concerned emotional status and disease activity.

RESULTS

After 2 years, participants in the RAPIT program showed greater improvement in functional ability than participants in UC. The mean difference in change of the MACTAR Questionnaire score was 2.6 (95% confidence interval [95% CI] 0.1, 5.2) over the first year and 3.1 (95% CI 0.7, 5.5) over the second year. After 2 years, the mean difference in change of the HAQ score was -0.09 (95% CI -0.18, -0.01). The median radiographic damage of the large joints did not increase in either group. In both groups, participants with considerable baseline damage showed slightly more progression in damage, and this was more obvious in the RAPIT group. The RAPIT program proved to be effective in improving emotional status. No detrimental effects on disease activity were found.

CONCLUSION

A long-term high-intensity exercise program is more effective than UC in improving functional ability of RA patients. Intensive exercise does not increase radiographic damage of the large joints, except possibly in patients with considerable baseline damage of the large joints.

Measuring physical activity in patients after surgery for a malignant tumour in the leg. The reliability and validity of a continuous ambulatory activity monitor

A continuous ambulatory activity monitor allows objective measurement of the amount and intensity of physical activity. We examined the reliability and validity of this device in the assessment of seven aspects of function over a period of 24 hours in 20 patients who had undergone limb salvage or amputation for a tumour in the leg. The test-retest reliability was determined by undertaking identical assessments on two separate days. The measurements were compared with other indicators of functional status and quality of life in order to determine the validity of the monitor. Its reliability was satisfactory, with intraclass correlation coefficients ranging from 0.65 to 0.91. Significant correlations were seen between the 'time spent walking' and the Musculoskeletal Tumor Society rating scales and the Rand-36 physical functioning score. There was also a significant association between the 'movement intensity during walking' and the Musculoskeletal Tumor Society score. The satisfactory reliability and validity of the monitor shows considerable promise for its use as a device for measuring physical activity objectively in patients after surgery for limb-salvage or an amputation.

Measuring physical activity in patients after surgery for a malignant tumour in the leg

A continuous ambulatory activity monitor allows objective measurement of the amount and intensity of physical activity. We examined the reliability and validity of this device in the assessment of seven aspects of function over a period of 24 hours in 20 patients who had undergone limb salvage or amputation for a tumour in the leg.

The test-retest reliability was determined by undertaking identical assessments on two separate days. The measurements were compared with other indicators of functional status and quality of life in order to determine the validity of the monitor.

Its reliability was satisfactory, with intraclass correlation coefficients ranging from 0.65 to 0.91. Significant correlations were seen between the ‘time spent walking’ and the Musculoskeletal Tumor Society rating scales and the Rand-36 physical functioning score. There was also a significant association between the ‘movement intensity during walking’ and the Musculoskeletal Tumor Society score. The satisfactory reliability and validity of the monitor shows considerable promise for its use as a device for measuring physical activity objectively in patients after surgery for limb-salvage or an amputation.

The value of a continuous ambulatory activity monitor to quantify the amount and intensity of daily activity in patients with rheumatoid arthritis

OBJECTIVE

To examine the reliability, validity, and responsiveness of a continuous ambulatory activity monitor in patients with rheumatoid arthritis (RA).

METHODS

Forty-one patients with RA, participating in a randomized controlled trial examining the effect of an intensive exercise program, were assessed by means of the Dynaport ADL (activities of daily living) monitor (AM). The time spent on activities (locomotion, standing, and active sitting) during 24 hours and the intensity of trunk movement during these activities were recorded. To determine test-retest reliability 20 patients were reassessed with the AM one week after the first assessment. Construct validity of the AM was determined by comparing the AM results with physical fitness measures (muscle strength, endurance, joint mobility), disease activity, and functional status. As well, 37 patients were assessed 18 months after the first assessment to determine responsiveness.

RESULTS

All AM measurements showed satisfactory test-retest reliability (ICC 0.63-0.76). AM measures were significantly associated with physical fitness, functional status, and disease activity, indicating construct validity of the AM. The AM could discriminate between patients with improvement and deterioration in physical fitness, indicating sufficient responsiveness of AM variables.

CONCLUSION

This study shows the value of an ambulatory activity monitor to quantify both the amount and intensity of physical activity of patients with RA during a day in their own environment. The ambulatory activity monitor seems to be a promising instrument for research into rehabilitation of patients with RA.

Control of maximal and submaximal vertical jumps

PURPOSE

It was investigated to what extent control signals used by human subjects to perform submaximal vertical jumps are related to control signals used to perform maximal vertical jumps.

METHODS

Eight subjects performed both maximal and submaximal height jumps from a static squatting position. Kinematic and kinetic data were recorded as well as electromyographic (EMG) signals from eight leg muscles. Principal component analysis was used analyze the shape of smoothed rectified EMG (SREMG) histories. Jumps were also simulated with a forward dynamic model of the musculoskeletal system, comprising four segments and six muscles. First, a maximal height jump was simulated by finding the optimal stimulation pattern, i.e., the pattern resulting in a maximum height of the mass center of the body. Subsequently, submaximal jumps were simulated by adapting the optimal stimulation pattern using strategies derived from the experimental SREMG histories.

RESULTS

SREMG histories of maximal and submaximal jumps revealed only minor differences in relative timing of the muscles between maximal and submaximal jumps, but SREMG amplitude was reduced in the biarticular muscles. The shape of the SREMG recordings was not much different between the two conditions, even for the biarticular muscles. The simulated submaximal jump resembled to some extent the submaximal jumps found in the experiment, suggesting that differences in control signals as inferred from the experimental data could indeed be sufficient to get the observed behavior.

CONCLUSIONS

The results fit in with theories on the existence of generalized motor programs within the central nervous system, the output of which is determined by the setting of parameters such as amplitude and relative timing of control signals.

Dynamic exercise therapy for rheumatoid arthritis

OBJECTIVES

To assess the effects of dynamic exercise therapy in improving joint mobility, muscle strength, aerobic capacity and daily functioning in patients with rheumatoid arthritis (RA). In addition, possible unwanted effects such as an increase in pain, disease activity and radiological progression were studied.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal trials register, the Cochrane Controlled trials Register, Medline, Embase and SCISEARCH databases up to may 1997 in order to controlled trials on the effect of exercise therapy.

SELECTION CRITERIA

Randomized trials on the effect of dynamic exercise therapy in RA patients with an exercise program fulfilling the following criteria: a) intensity level such that heart rates exceeded 60% of maximal heart rate during at least 20 minutes, b) exercise frequency of two session per week, and c) duration of intervention of greater than six weeks

DATA COLLECTION AND ANALYSIS

Two blinded reviewers independently selected eligible studies, rated the methodological quality and extracted data.

MAIN RESULTS

Six out of 30 identified controlled trials met the inclusion criteria. Four of the six included studies fulfilled at least seven out of 10 methodological criteria. Due to heterogeneity in outcome measures, data could not be pooled. The results suggest that dynamic exercise therapy is effective at increasing aerobic capacity and muscle strength. No detrimental effects on disease activity and pain were observed. The effects of dynamic exercise therapy on functional ability and radiological progression are unclear.

REVIEWER'S CONCLUSIONS

Dynamic exercise therapy has a positive effect on physical capacity. Research on the long-term effect of dynamic exercise therapy on radiological progression and functional ability is needed.

Dynamic exercise therapy in rheumatoid arthritis: a systematic review

The aim of this systematic review was to determine the effectiveness of dynamic exercise therapy in improving joint mobility, muscle strength, aerobic capacity and daily functioning in patients with rheumatoid arthritis (RA). In addition, possible unwanted effects such as an increase in pain, disease activity and radiological progression were studied. A computer-aided search of the MEDLINE, Embase and SCISEARCH databases was performed to identify controlled trials on the effect of exercise therapy. Randomized trials were selected on the effect of dynamic exercise therapy in RA patients with an exercise programme fulfilling the following criteria: (a) intensity level such that heart rates exceeded 60% of maximal heart rate during at least 20 min; (b) exercise frequency > or = 2 a week; and (c) duration of intervention > or = 6 weeks. Two blinded reviewers independently selected eligible studies, rated the methodological quality and extracted data. Six out of 30 identified controlled trials met the inclusion criteria. Four of the six included studies fulfilled > or = 7/10 methodological criteria. Because of heterogeneity in outcome measures, data could not be pooled. The results suggest that dynamic exercise therapy is effective in increasing aerobic capacity and muscle strength. No detrimental effects on disease activity and pain were observed. The effects of dynamic exercise therapy on functional ability and radiological progression are unclear. It is concluded that dynamic exercise therapy has a positive effect on physical capacity. Research on the long-term effect of dynamic exercise therapy on radiological progression and functional ability is needed.