Effects of community-deliverable exercise on pain and physical function in adults with arthritis and other rheumatic diseases: A meta-analysis

Patient-reported improvements in health are maintained 2 years after completing a short course of cognitive behaviour therapy, exercise or both treatments for chronic widespread pain: long-term results from the MUSICIAN randomised controlled trial

OBJECTIVES

The MUSICIAN study has previously shown short-term benefit but only marginal cost-effectiveness for two non-pharmacological interventions for chronic widespread pain (CWP). We wished to determine their long-term effectiveness and cost-effectiveness.

METHODS

A 2×2 factorial randomised controlled trial based in primary care in the UK. People were eligible if they were aged ≥25 years with CWP for which they had consulted their general practitioner. The interventions were a 6-month telephone cognitive behaviour therapy (tCBT) and/or a tailored exercise programme, in comparison to usual care. The primary outcome was patient-reported change in health.

RESULTS

884 persons were eligible, 442 were randomised and 81.7% were followed up 24 months post-treatment. In comparison to usual care (positive outcome 12.8%), tCBT (35.4%; OR 3.7 95% CI (1.8 to 8.0)), exercise (29.3%; OR 2.8 95% CI (1.3 to 6.0)) and both interventions (31.2%; OR 3.1 95% CI (1.3 to 6.0)) were significantly more effective. There was only a small decrease in effectiveness over time for individual and combined treatments. Those with more intense/disabling pain, higher distress and those who exhibited passive coping at baseline were more likely to have a positive outcome with tCBT than persons without these characteristics. tCBT was associated with the greatest increase in quality of life and lowest costs. Cost per quality adjusted life year was £3957-£5917 depending on method of analysis.

CONCLUSIONS

A short course of tCBT for people with CWP was effective long-term and was highly cost-effective. Exercise was also effective but delivered positive outcome for fewer patients at greater cost, and there was no advantage for patients receiving both interventions.

TRIAL REGISTRATION NUMBER

ISRCTN67013851.

Physical exercise as non-pharmacological treatment of chronic pain: Why and when

Chronic pain broadly encompasses both objectively defined conditions and idiopathic conditions that lack physical findings. Despite variance in origin or pathogenesis, these conditions are similarly characterized by chronic pain, poor physical function, mobility limitations, depression, anxiety, and sleep disturbance, and they are treated alone or in combination by pharmacologic and non-pharmacologic approaches, such as physical activity (aerobic conditioning, muscle strengthening, flexibility training, and movement therapies). Physical activity improves general health, disease risk, and progression of chronic illnesses such as cardiovascular disease, type 2 diabetes, and obesity. When applied to chronic pain conditions within appropriate parameters (frequency, duration, and intensity), physical activity significantly improves pain and related symptoms. For chronic pain, strict guidelines for physical activity are lacking, but frequent movement is preferable to sedentary behavior. This gives considerable freedom in prescribing physical activity treatments, which are most successful when tailored individually, progressed slowly, and account for physical limitations, psychosocial needs, and available resources.

The steps to health randomized trial for arthritis: a self-directed exercise versus nutrition control program

BACKGROUND

Despite the established benefits of exercise for adults with arthritis, participation is low. Safe, evidence-based, self-directed programs, which have the potential for high reach at a low cost, are needed.

PURPOSE

To test a 12-week, self-directed, multicomponent exercise program for adults with arthritis.

DESIGN

Randomized controlled trial. Data were collected from 2010 to 2012. Data were analyzed in 2013 and 2014.

SETTING/PARTICIPANTS

Adults with arthritis (N=401, aged 56.3 [10.7] years, 85.8% women, 63.8% white, 35.2% African American, BMI of 33.0 [8.2]) completed measures at a university research center and participated in a self-directed exercise intervention (First Step to Active Health(®)) or nutrition control program (Steps to Healthy Eating).

INTERVENTION

Intervention participants received a self-directed multicomponent exercise program and returned self-monitoring logs for 12 weeks.

MAIN OUTCOME MEASURES

Self-reported physical activity, functional performance measures, and disease-specific outcomes (arthritis symptoms and self-efficacy) assessed at baseline, 12 weeks, and 9 months.

RESULTS

Participants in the exercise condition showed greater increases in physical activity than those in the nutrition control group (p=0.01). Significant improvements, irrespective of condition, were seen in lower body strength, functional exercise capacity, lower body flexibility, pain, fatigue, stiffness, and arthritis management self-efficacy (p values<0.0001). More adverse events occurred in the exercise than nutrition control condition, but only one was severe and most were expected with increased physical activity.

CONCLUSIONS

The exercise program improves physical activity, and both programs improve functional and psychosocial outcomes. Potential reasons for improvements in the nutrition control condition are discussed. These interventions have the potential for large-scale dissemination. This study is registered at Clinicaltrials.gov NCT01172327.

Developing Community-Based Rehabilitation Programs for Musculoskeletal Diseases in Low-Income Areas of Mexico: The Community-Based Rehabilitation for Low-Income Communities Living With Rheumatic Diseases (CONCORD) Protocol

BACKGROUND

The negative impact of musculoskeletal diseases on the physical function and quality of life of people living in developing countries is considerable. This disabling effect is even more marked in low-socioeconomic communities within developing countries. In Mexico, there is a need to create community-based rehabilitation programs for people living with musculoskeletal diseases in low-socioeconomic areas. These programs should be directed to prevent and decrease disability, accommodating the specific local culture of communities.

OBJECTIVE

The objective of this paper is to describe a research protocol designed to develop, implement, and evaluate culturally sensitive community-based rehabilitation programs aiming to decrease disability of people living with musculoskeletal diseases in two low-income Mexican communities.

METHODS

A community-based participatory research approach is proposed, including multi and transdisciplinary efforts among the community, medical anthropology, and the health sciences. The project is structured in 4 main stages: (1) situation analysis, (2) program development, (3) program implementation, and (4) program evaluation. Each stage includes the use of quantitative and qualitative methods (mixed method program).

RESULTS

So far, we obtained resources from a Mexican federal agency and completed stage one of the project at Chankom, Yucatán. We are currently receiving funding from an international agency to complete stage two at this same location. We expect that the project at Chankom will be concluded by December of 2017. On the other hand, we just started the execution of stage one at Nuevo León with funding from a Mexican federal agency. We expect to conclude the project at this site by September of 2018.

CONCLUSIONS

Using a community-based participatory research approach and a mixed method program could result in the creation of culturally sensitive community-based rehabilitation programs that promote community development and decrease the disabling effects of musculoskeletal diseases within two low-income Mexican communities.

The Relationship Between Physical Activity Levels and Pain in Children with Juvenile Idiopathic Arthritis

Objective.

Pain and reduced physical activity levels are common in children with juvenile idiopathic arthritis (JIA). Currently, there is no consensus about the role of physical activity in managing pain in JIA. The purpose of our study was to assess the relationship between physical activity level and pain in children ages 11 to 18 years with JIA.

Methods.

A random sample of 50 patients with JIA were approached by mailed questionnaires. Physical activity was determined using the Physical Activity Questionnaire (PAQ). Pain measures included the Numerical Rating Scale (pain severity), SUPER-KIDZ body diagram (number of painful areas), and the Child Activities Limitations Inventory-21 (pain interference). Generalized linear models were used to assess the relationship between physical activity and pain, as well as the roles of sex and age.

Results.

The response rate was 84%. Thirty-four respondents completed the questionnaire package. The median age was 15 years. The mean PAQ score was 2.16/5. Physical activity declines with increasing age in youth with JIA (r = 0.53, p = 0.0014). Lower physical activity is associated with greater pain interference (r = 0.39, p = 0.0217) and more severe pain (r = 0.35, p = 0.0422).

Conclusion.

Children with JIA report significantly less activity than healthy children based on PAQ scores, with physical activity declining throughout adolescence. Physical activity is inversely related to pain interference and severity in children with JIA. Our findings suggest that physical activity interventions may play an important role in the management of pain in JIA.

Fit and Strong! Plus: design of a comparative effectiveness evaluation of a weight management program for older adults with osteoarthritis

Osteoarthritis (OA) is the most common chronic condition and principal cause of disability among older adults. The current obesity epidemic has contributed to this high prevalence rate. Fortunately both OA symptoms and obesity can be ameliorated through lifestyle modifications. Physical activity (PA) combined with weight management improves physical function among obese persons with knee OA but evidence-based interventions that combine PA and weight management are limited for this population. This paper describes a comparative effectiveness trial testing an evidence-based PA program for adults with lower extremity (LE) OA, Fit and Strong!, against an enhanced version that also addresses weight management based on the evidence-based Obesity Reduction Black Intervention Trial (ORBIT). Adult participants (n=400) with LE OA, age 60+, overweight/obese, and not meeting PA requirements of ≥ 150 min per week, are randomized to one of the two programs. Both 8-week interventions meet 3 times per week and include 60 min of strength, flexibility, and aerobic exercise instruction followed by 30 min of education/group discussion. The Fit and Strong! education sessions focus on using PA to manage OA; whereas Fit and Strong! Plus addresses PA and weight loss management strategies. Maintenance of behavior change is reinforced in both groups during months 3-24 through telephone calls and mailed newsletters. Outcomes are assessed at baseline, and 2, 6, 12, 18, and 24 months. Primary outcomes are dietary change at 2 months followed by weight loss at 6 months that is maintained at 24 months. Secondary outcomes assess PA, physical performance, and anxiety/depression.

Differences in Effectiveness of the Active Living Every Day Program for Older Adults With Arthritis

Objective:

The authors explored whether demographic and psychosocial variables predicted differences in physical activity for participants with arthritis in a trial of Active Living Every Day (ALED).

Method:

Participants (N = 280) from 17 community sites were randomized into ALED or usual care. The authors assessed participant demographic characteristics, self-efficacy, outcome expectations, pain, fatigue, and depressive symptoms at baseline and physical activity frequency at 20-wk follow-up. They conducted linear regression with interaction terms (Baseline Characteristic × Randomization Group).

Results:

Being female (p ≤ .05), less depressed (p ≤ .05), or younger (p ≤ .10) was associated with more frequent posttest physical activity for ALED participants than for those with usual care. Higher education was associated with more physical activity for both ALED and usual-care groups.

Discussion:

ALED was particularly effective for female, younger, and less depressed participants. Further research should determine whether modifications could produce better outcomes in other subgroups.

Social participation restriction among US adults with arthritis: a population-based study using the International Classification of Functioning, Disability and Health

OBJECTIVE

To examine arthritis impact among US adults with self-reported doctor-diagnosed arthritis using the International Classification of Functioning, Disability and Health (ICF) framework (including the impairments, activity limitations, environmental, and personal factors domains and social participation restriction [SPR] as the outcome) overall and among those with and without SPR, and to identify the correlates of SPR.

METHODS

Cross-sectional 2009 National Health Interview Survey data were analyzed to examine the distribution of the ICF domain components. Unadjusted and multivariable-adjusted prevalence ratios (PRs) and 95% confidence intervals (95% CIs) were estimated to identify the correlates of SPR. Analyses using SAS, version 9.2 survey procedures accounted for the complex sample design.

RESULTS

SPR prevalence was 11% of adults with arthritis (5.7 million). After initial multivariable adjustment by ICF domain, serious psychological distress (impairments domain; PR 2.5 [95% CI 2.0-3.2]), ≥5 medical office visits (environmental domain; PR 3.4 [95% CI 2.5-4.4]), and physical inactivity (personal domain; PR 4.8 [95% CI 3.6-6.4]) were most strongly associated with SPR. A combined measure (key limitations [walking, standing, or carrying]; PR 31.2 [95% CI 22.3-43.5]) represented the activity limitations domain. After final multivariable adjustment incorporating all ICF domains simultaneously, the strongest associations with SPR were key limitations (PR 24.3 [95% CI 16.8-35.1]), ≥9 hours of sleep (PR 1.6 [95% CI 1.3-2.0]), and income-to-poverty ratio <2.00 and severe joint pain (PR 1.4 [95% CI 1.2-1.6] for both).

CONCLUSION

SPR affects 1 of 9 adults with arthritis. This study is the first to use the ICF framework in a population-based sample to identify specific functional activities, pain, sleep, and other areas as priorities for intervention to reduce negative arthritis impacts on disability, including SPR. Increased use of existing clinical and public health interventions is warranted.

Risk factors for falls in older adults with lower extremity arthritis: a conceptual framework of current knowledge and future directions

PURPOSE

As the numbers of Canadians aged 65 years and over increases over the next 20 years, the prevalence of chronic conditions, including arthritis, will rise as will the number of falls. Although known fall-risk factors are associated with hip and knee osteoarthritis (OA), minimal research has evaluated fall and fracture risk and/or rates in this population. Thus, the purpose was to summarize research on fall and fracture risk in older adults with hip or knee OA and to develop a conceptual framework of fall-risk screening and assessment.

METHOD

The International Classification of Functioning, Disability and Health, clinical practice guidelines for fall-risk screening, and a selected literature review were used.

RESULTS

Gaps exist in our knowledge of fall and fracture risk for this population. Muscle performance, balance, and mobility impairments have been identified, but little is known about whether personal and environmental contextual factors impact fall and fracture risk. Physical activity may help to prevent falls, but non-adherence is a problem.

CONCLUSION

A need exists to assess fall risk in older adults with hip and knee OA. Promoting regular physical activity by focusing on disease- and activity-specific personal contextual factors may help direct treatment planning.

Compromised access to prescriptions and medical care because of cost among US adults with arthritis

INTRODUCTION

Study objectives were to: 1) determine the magnitude of three outcomes (prescription unaffordable, care delayed and needed care not obtained) related to cost-attributable compromised medical care access among US adults ≥18 years with and without arthritis and 2) identify US adults with arthritis with the highest levels of these outcomes.

MATERIALS AND METHODS

We analysed 2009-2011 US National Health Interview Survey data and estimated prevalence of outcomes by arthritis status and, among people with arthritis, by socio-demographic, medical care access and health status characteristics. Unadjusted and multivariable (MV) adjusted (prevalence ratios) PRs quantified associations between each outcome and arthritis status, and, among people with arthritis, selected characteristics. Number and proportion of adults with arthritis without health insurance coverage were estimated.

RESULTS

Outcomes were more prevalent (statistically-significant) among those with arthritis than those without: prescription unaffordable = 14% (9%), care delayed = 14% (11%) and needed care not obtained = 11% (8%). Outcomes were marginally more likely (statistically significant) among adults with arthritis than those without (range MV PRs = 1.2-1.3). Among those with arthritis, the uninsured had the highest prevalence of, and were most likely to have, each outcome (MV PRs: prescription unaffordable = 3.6 (95% confidence interval [CI] = 3.6-4.4), delayed care = 4.7 (95% CI = 3.9-5.7) and needed care not obtained = 5.9 (95% CI = 4.7-7.5) (referent: those with both public and private coverage)). An estimated 4.5 million adults with arthritis were uninsured.

CONCLUSIONS

Cost-attributable compromised access is common among US adults with arthritis; they are also slightly more likely than those without arthritis to have compromised care. Compromised access is highest among the uninsured. For those with limited access, convenient, inexpensive and proven community-based strategies that improve physical and psychosocial health may be especially practical.

Efficacy, safety and mechanism of action of modified-release prednisone in rheumatoid arthritis

Glucocorticoids (GCs) provide a powerful and widely used anti-inflammatory and disease-modifying therapy for rheumatoid arthritis (RA). However, concerns about adverse effects are driving efforts to find 'safer' GC or GC analogues. One novel approach has been to change the timing of GC delivery, targeting the early hours of the morning to suppress the observed circadian peak in interleukin-6 (IL-6). The CAPRA-1 study has shown that this produces a clinically useful beneficial improvement in morning stiffness and mechanistic studies have shown that this correlates with a strong suppression of the IL-6 early morning peak. With no obvious additional adverse reactions, this improvement in the therapeutic ratio offers additional treatment options in RA, and perhaps in other inflammatory diseases that show circadian variation in symptoms.

An evaluation of a postoperative rehabilitation program after spinal surgery and its impact on outcome

STUDY DESIGN

This study invited patients to evaluate the content and style of a rehabilitation program used as an intervention in a multicenter, factorial, randomized controlled trial of the postoperative management of spinal surgery patients.

OBJECTIVE

To determine the acceptability and content of the rehabilitation program.

SUMMARY OF BACKGROUND DATA

The use of rehabilitation after spinal surgery is sporadic, and the evidence for its benefit is mixed. A randomized controlled trial was conducted to determine whether functional outcome of spinal surgery could be improved by a postoperative rehabilitation program and/or an educational booklet provided at hospital discharge, each compared with usual care.

METHODS

Patients randomized to postoperative rehabilitation began the course 6 weeks after surgery. At the end of the course of 12 classes, patients completed an evaluation of content, style, and length using forced choice and open questions. Patients not attending the final class completed the evaluation at their 3-month review.

RESULTS

Compliance with rehabilitation was poor, with 41% of subjects failing to attend any classes and 16% attending less than half. Compliance with the evaluation was 100% for the 105 patients attending 1 or more classes. The length, content, and approach to the classes were rated positively, and patients gave the class a median rating of 9 of 10, range 5 to 10, with 91% rating the classes as 7 or above.

CONCLUSION

Compliance with a postoperative rehabilitation program was disappointing, but the program was assessed positively and of benefit by those who attended. Issues were raised in relation to timing and location of classes.

A public health approach to addressing arthritis in older adults: the most common cause of disability

Arthritis is highly prevalent and is the leading cause of disability among older adults in the United States owing to the aging of the population and increases in the prevalence of risk factors (e.g., obesity). Arthritis will play a large role in the health-related quality of life, functional independence, and disability of older adults in the upcoming decades. We have emphasized the role of the public health system in reducing the impact of this large and growing public health problem, and we have presented priority public health actions.

Health-related quality of life among older adults with and without functional limitations

OBJECTIVES

We examined factors that influence health-related quality of life (HRQOL) among individuals aged 50 years and older with and without functional limitations.

METHODS

We analyzed data from the 2009 Behavioral Risk Factor Surveillance System to assess associations among demographic characteristics, health care access and utilization indicators, modifiable health behaviors, and HRQOL characterized by recent physically and mentally unhealthy days in those with and those without functional limitations. We defined functional limitations as activity limitations owing to physical, mental, or emotional health or as the need for special equipment because of health.

RESULTS

Age, medical care costs, leisure-time physical activity, and smoking were strongly associated with both physically and mentally unhealthy days among those with functional limitations. Among those without functional limitations, the direction of the effects was similar, but the size of the effects was substantially smaller.

CONCLUSIONS

The availability of lower cost medical care, increasing leisure-time physical activity, and reducing rates of cigarette smoking will improve population HRQOL among older adults with and without functional limitations. These factors provide valuable information for determining future public health priorities.

A public health perspective on physical activity after total hip or knee arthroplasty for osteoarthritis

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are common treatments for osteoarthritis (OA) with good-to-excellent outcomes. As the US population ages, rates of OA and THA/TKA will continue to rise. People with OA and THA/TKA are less active than those without arthritis or arthrosplasty, respectively. With the numerous documented health benefits obtained from physical activity, it is imperative from a public health perspective that patients are sufficiently active to maintain health after surgery. Increasing moderate-intensity physical activity is a safe, efficacious, and cost-effective mechanism for improving health and reducing health care costs in this population. The return to leisure/sporting activities after THA/TKA is not as well studied as other aspects of functional recovery. In particular, no evidence-based guidelines for physical activity after THA/TKA are available. Most recommendations have been derived from cross-sectional surveys of orthopedic surgeons. Based on the literature, the general consensus for recommendations appears to be to: 1) return to low- to moderate-intensity activities and no-, low-, or intermediate-impact activities within 3 to 6 months postoperatively, 2) discourage high-impact activities, 3) avoid high-contact athletic activities, and 4) educate rather than dissuade patients from resuming leisure/sporting activities. Sports medicine physicians are in an ideal position to counsel patients in regard to leading active lifestyles. The physician can evaluate and treat any remaining functional limitations postoperatively, as well as prescribe the appropriate dose (ie, type, intensity, frequency, and duration) of physical activity. The 2008 Physical Activity Guidelines for Americans can help guide physicians in prescribing the appropriate dose of activity. Finally, physicians can refer patients to evidence-based, community-delivered group exercise and/or behavioral change interventions that are approved by the Centers for Disease Control and Prevention for people with arthritis.

Effectiveness of two evidence-based programs in participants with arthritis: findings from the active for life initiative

OBJECTIVE

Arthritis is the leading cause of disability in the US. Strong evidence suggests that physical activity (PA) is beneficial to those with arthritis. This study examined whether changes in PA and PA-related outcomes from two general evidence-based PA programs (Active Choices [AC] and Active Living Every Day [ALED]) differed in participants with and without arthritis.

METHODS

Active for Life was a 4-year, multicenter, translational initiative that evaluated the effects of AC and ALED on PA and PA-related outcomes. Participants self-reported arthritis, PA, depressive symptoms, perceived stress, and satisfaction with body appearance and function. A subset of participants completed functional fitness tests.

RESULTS

Participants (n = 2,413 AC, n = 3,191 ALED) completed at least one outcome measure; 619 ALED participants completed at least one functional fitness test. Significant improvements in all PA and PA-related outcomes were seen for people with and without arthritis with the exception of depressive symptoms and perceived stress, which only improved in ALED participants. In general, effect sizes were similar for those with and without arthritis.

CONCLUSION

ALED and AC, both general behavioral PA programs, produced positive and meaningful changes in PA and a number of PA-related behaviors in participants with and without arthritis, pointing to the potential appropriateness of these evidence-based programs for people with arthritis.

Physiatric approaches to pain management in osteoarthritis: a review of the evidence of effectiveness

SUMMARY Osteoarthritis (OA), which is highly prevalent in the general population, is one of the leading causes of pain and physical disability. A large number of nonpharmacological interventions are available for the management of pain in patients with OA. These include education and self-management, weight reduction, various forms of exercises, physical agents/modalities, complementary therapies, manual therapy, unloading strategies such as braces and orthoses, and balneotherapy. The aim of this article is to assess the evidence of effectiveness of nonpharmacological interventions pertaining to physiatry to identify best practices for pain management in OA.

Physical activity coaching of patients with rheumatoid arthritis in everyday practice: a long-term follow-up

OBJECTIVES

To investigate the long-term effects on perceived general health, disease activity, pain, activity limitation and cognitive behavioural factors of a one-year coaching programme performed in ordinary physical therapy practice to promote the adoption of health-enhancing physical activity in patients with early rheumatoid arthritis (RA).

METHODS

A total of 228 patients with early RA, from 10 rheumatology clinics in Sweden, were randomly assigned to an intervention group (IG; n = 94) or a control group (CG; n = 134). The IG was coached by physical therapists during the first year to adopt health-enhancing levels of physical activity (30 minutes/day, moderately intensive, ≥ 4 days/week). No coaching was given during the subsequent year between post-intervention and follow-up. Follow-up assessment consisted of a postal questionnaire on physical activity and of visual analogue scales for ratings of general health perception and pain. The Health Assessment Questionnaire Disability Index (HAQ) and the Disease Activity Score in 28 joints (DAS 28) were collected at regular medical check-ups.

RESULTS

Sixty-five (69%) participants in the IG and 92 (69%) in the CG completed the entire study period by filling in the follow-up questionnaire on physical activity two years after baseline. The intervention seemed to lack any significant influence on long-term outcome. However, different patterns of change in physical activity behaviour were observed in the two groups.

CONCLUSIONS

No long-term improvement in perceived general health or other outcomes were found in the follow-up. This may partly be because the intervention lacked several important behavioural elements for physical activity maintenance.