Benefits of exercise in rheumatoid arthritis

Objective measurement of sedentary time and physical activity in people with rheumatoid arthritis: protocol for an accelerometer and activPALTM validation study

BACKGROUND

The accurate measurement of sedentary time and physical activity in Rheumatoid Arthritis (RA) is critical to identify important health consequences and determinants of these behaviours in this patient group. However, objective methods have not been well-validated for measurement of sedentary time and physical activity in RA.

AIMS

Specific objectives are to: 1) validate the ActiGraph GT3X+ accelerometer and activPAL3μTM against indirect calorimetry and direct observation respectively, and define RA-specific accelerometer cut-points, for measurement of sedentary time and physical activity in RA; 2) validate the RA-specific sedentary time accelerometer cut-points against the activPAL3μTM; 3) compare sedentary time and physical activity estimates in RA, using RA-specific vs. widely-used non-RA accelerometer cut-points.

METHODS

Objective 1: People with RA will wear an ActiGraph GT3X+, activPAL3μTM, heart rate monitor and indirect calorimeter, whilst being video-recorded undertaking 11 activities representative of sedentary behaviour, and light and moderate intensity physical activity. Objectives 2 and 3: People with RA will wear an ActiGraph GT3X+ and activPAL3μTM for 7 days to measure free-living sedentary time and physical activity.

DISCUSSION

This will be the first study to define RA-specific accelerometer cut-points, and represents the first validation of the ActiGraph accelerometer and activPALTM, for measurement of sedentary time and physical activity in RA. Findings will inform future RA studies employing these devices, ensuring more valid assessment of sedentary time and physical activity in this patient group.

Factors of importance for reducing fatigue in persons with rheumatoid arthritis: a qualitative interview study

OBJECTIVE

Physical activity plays an important role in the treatment of persons with rheumatoid arthritis (RA) and is the non-pharmacological intervention with the strongest evidence to reduce fatigue. However, physical activity can be challenging for persons who are fatigued. The aim of this study was to investigate factors of importance for reducing fatigue in persons with RA.

DESIGN

This is a qualitative interview study based on semistructured, indepth individual interviews. Interviews were analysed using qualitative content analysis.

PARTICIPANTS

Participants were 12 people with RA recruited from a previous randomised controlled trial of a person-centred treatment model focusing on health-enhancing physical activity and daily balance to lessen fatigue in persons with RA.

SETTING

Interviews were conducted in a hospital setting.

RESULTS

The analysis resulted in one theme: an intellectual and embodied understanding that sustainable physical activity is important to handle fatigue. This included five categories describing barriers and facilitating factors for sustainable physical activity: mentally overcoming the fatigue in order to be active, making exercise easy, reaching for balance, receiving support to be physically active and dealing with RA disease to be physically active.

CONCLUSION

The participants in this study expressed that physical activity was important in handling fatigue, but also that this insight could only come from personal experience. The use of a person-centred ethic in physiotherapy coaching for patients with fatigue appears to promote sustainable physical activity behaviours by facilitating patients' resources to overcome barriers to physical activity.

Exercise participation has increased in patients with Rheumatoid Arthritis: A cross-sectional comparison between two Dutch RA cohorts

Objective:

This study evaluates exercise participation in patients with rheumatoid arthritis (RA) and the percentage of patients that meet the recommended level of physical activity (at least 150 minutes per week moderate-intensity physical activity) in two cross-sectional questionnaires in 2013 and 2016 in two Dutch RA cohorts.

Methods:

In 2013, a cross-sectional study was performed among 740 patients with RA from seven outpatient clinics from the Dutch DREAM registry. Subsequently in 2016, 498 patients with RA of the outpatient clinic of the Bernhoven Hospital (member of the DREAM registry) participated in a similar study. In both years, patients filled in an identical questionnaire about exercise participation (frequency and duration). In 2016, items about self-efficacy to become more physically active were added to the questionnaire.

Results:

In 2016, patients with RA spent significantly more minutes per week in exercise activities compared to 2013: 180 (150–450) and 120 (60–225) minutes per week, respectively (P<0.001). The percentage of patients with RA who met the recommended physical activity level increased from 25% in 2013 to 57% in 2016. Almost half (44%) of the non-exercisers reported feeling confident to become more physically active.

Conclusion:

Compared to 2013, RA patients participated in 2016 more frequently and spent more minutes per week in exercise activities. This resulted in a higher percentage of patients who met the recommended physical activity level. A personalized physical activity program, with a focus on identifying barriers and setting personal goals, might further increase the physical activity level of patients with RA.

Effects of exercise and physical activity promotion: meta-analysis informing the 2018 EULAR recommendations for physical activity in people with rheumatoid arthritis, spondyloarthritis and hip/knee osteoarthritis

Objective

To evaluate the effectiveness of exercise and physical activity (PA) promotion on cardiovascular fitness, muscle strength, flexibility, neuromotor performance (eg, balance) and daily PA in people with rheumatoid arthritis (RA), spondyloarthritis (SpA) and hip/knee osteoarthritis (HOA/KOA).

Methods

systematic review (SR) and meta-analysis (MA) were performed searching the databases PubMed/Medline, CENTRAL, Embase, Web of Science, Emcare and PsycInfo until April 2017. We included randomised controlled trials (RCTs) in adults (≥18 years) with RA, SpA and HOA/KOA, investigating the effects of exercise or PA promotion according to the public health PA recommendations by the American College of Sports Medicine. The time point of interest was the first assessment after the intervention period. If suitable, data were pooled in a MA using a random-effects model presented as standardised mean difference (SMD).

Results

The SR included 63 RCTs, of which 49 (3909 people with RA/SpA/HOA/KOA) were included in the MA. Moderate effects were found of aerobic exercises and resistance training on cardiovascular fitness (SMD 0.56 (95% CI 0.38 to 0.75)) and muscle strength (SMD 0.54 (95% CI 0.35 to 0.72)), respectively, but no effect of combined strength/aerobic/flexibility exercises on flexibility (SMD 0.12 (95% CI -0.16 to 0.41)). PA promotion interventions produced a small increase in PA behaviour (SMD 0.21 (95% CI 0.03 to 0.38)).

Conclusion

Exercises and PA promotion according to public health recommendations for PA improved cardiovascular fitness, muscle strength and PA behaviour, with moderate effect sizes in people with SpA, RA and HOA/KOA.

Trial registration number

CRD42017082131.

Perceived Versus Performance Fatigability in Patients With Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic, inflammatory disease that affects 1% of the general population. Fatigue is a common complaint of patients with RA, however their perceived fatigue may be more exacerbated than objective measures of fatigue may indicate. The assessment of fatigue is made complex due to inconsistent and vague terms used to define fatigue, and the task dependence of fatigability. Fatigue is defined as a state of exhaustion and decreased strength, while fatigability indicates an individual's susceptibility to fatigue. In order to offer some clarity to the manifestation of fatigue in clinical populations, in this review we outline that fatigue should be described with subsections that are related to the symptom, such as: perceived fatigability and performance fatigability. Where perceived fatigability indicates the subjective state of the individual and thus involves the individual's subjective measure of fatigue, performance fatigability would be measured through clinical and laboratory-based assessments that quantify the functional decline in performance. This review describes RA and the various neuromuscular changes associated with the disease that can lead to alterations in both perceived and performance fatigue. From there, we discuss fatigue and RA, how fatigue can be assessed, effects of exercise interventions on RA symptoms and fatigue, and recommendations for future studies investigating subjective and objective measures of fatigability.

What evidence is used to underpin the design of strength-based exercise interventions evaluated in randomised controlled trials for rheumatoid arthritis? A systematic review protocol

INTRODUCTION

Healthcare researchers designing strength-based exercise interventions must choose an appropriate dose to test before evaluating its effect using a definitive/phase-III randomised controlled trial (RCT). Compared with early phase testing employed by pharmaceutical trials, it is questionable whether exercise-based trials employ the same rigour for establishing tolerated dosage. Consequently, it is unclear if participants are initially prescribed optimal doses of exercise, which may potentially impact on study outcomes. Using trials of strength-based exercise interventions in adults with rheumatoid arthritis (RA) as an exemplar, the aims of this review are to (1) identify the proportion of RCTs that use phase I/II trials with dose escalation methodology for setting prescription parameters, (2) determine type and level of evidence used to justify prescription parameters of strength-based exercise interventions evaluated by RCTs, (3) explore consistency and applicability of the evidence underpinning prescription parameters in RCTs and (4) explore if a relationship exists between risk of bias for RCTs evaluating strength-based interventions and the level of evidence used to underpin prescription parameters.

METHODS AND ANALYSIS

Focusing on RCT's evaluating strength-based exercise interventions in adults with RA published after 2000, the following databases will be searched: Allied and Complementary Medicine Database, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, Excerpta Medica Database, Medline and Physiotherapy Evidence Database. For each RCT, we will identify the evidence used to underpin prescription parameters. Both trial and underpinning evidence will have key information about the intervention extracted using the template for intervention description and replication checklist. Risk of bias will be assessed according to Cochrane. Levels of evidence will be assessed against the Oxford Centre for Evidence-Based Medicine and relationships between RCT and underpinning evidence explored and described narratively. Two independent assessors will be involved throughout data selection and extraction with recourse to a third reviewer should agreement not be reached.

ETHICS AND DISSEMINATION

No ethical issues are identified. Dissemination will be via publication.

PROSPERO REGISTRATION NUMBER

CRD42018090963.

Keeping physically active with rheumatoid arthritis: semi-structured interviews to explore patient perspectives, experiences and strategies

BACKGROUND

Regular physical activity is safe and beneficial for people with rheumatoid arthritis (RA) but the majority of people with RA are less active than the general population and have a higher risk of co-morbidities. Exploring strategies used by physically active people with RA could inform effective methods to support those who are less active.

OBJECTIVE

To explore the perspectives, experiences and strategies employed by people with RA who successfully engage with regular physical activity.

DESIGN

Individual semi-structured interviews and thematic analysis.

PARTICIPANTS

A purposive sample of physically active people with RA.

RESULTS

Twelve females and three males participated (mean age 56, range 29 to 80; mean disease duration 13 years, range 10 months to 46 years). Analysis revealed eight constructs clustered into three themes. Theme 1: 'the individual' incorporated constructs of symptoms, feelings and role; theme 2: 'management' incorporated medical and self-management; theme 3: 'physical activity' incorporated constructs of type of physical activity, including barriers or facilitators. Participants reported a long history of physical activity prior to diagnosis and good support networks. All participants recognised that physical activity was key to their RA management, acknowledged the benefits from engaging in physical activity and were able to overcome barriers. Participants had strong beliefs that physical function would decline without regular physical activity.

CONCLUSIONS

People with RA who successfully maintain physical activity are motivated by a desire to manage symptoms, resist functional decline and maintain health and independence. These findings should be explored with a wider range of people with RA.

Possible Modulation of Vascular Function Measures in Rheumatoid Arthritis by Homocysteine

The effect of homocysteine on cardiovascular diseases is still equivocal, especially in rheumatoid arthritis patients. In this investigation, the association between homocysteine with blood flow and vascular resistance in rheumatoid arthritis was examined. Serum levels of homocysteine were determined in thirty-one rheumatoid arthritis patients and nineteen apparently healthy subjects using ELISA. Additionally, strain-gauge plethysmography was used to determine both forearm blood flow and vascular function at rest and after occlusion. Forearm occlusion blood flow (patients: 21.9 ± 6.55 versus control: 25.5 ± 6.10ml/100mL/min) was lower (p < 0.05) while occlusion vascular resistance (patients: 4.77 ± 2.08 versus controls 3.05 ± 0.96U) was greater (p < 0.01) in rheumatoid arthritis than in the controls. Level of serum homocysteine was similar (p = 0.803) in rheumatoid arthritis group and healthy group. In addition, level of serum homocysteine was correlated with resting blood flow (r = −0.41; p < 0.02) and resting vascular resistance (r = 0.31, p < 0.05) in the patients group. The study confirms altered vascular function in rheumatoid arthritis. Uniquely, the results show that homocysteine was related to resting, but not postischemia, vascular measures. These relationships indicate that homocysteine might impact the vasculature in rheumatoid arthritis.

Ten weeks of high-intensity interval walk training is associated with reduced disease activity and improved innate immune function in older adults with rheumatoid arthritis: a pilot study

Background

Rheumatoid arthritis (RA) is a chronic inflammatory disease in which adults have significant joint issues leading to poor health. Poor health is compounded by many factors, including exercise avoidance and increased risk of opportunistic infection. Exercise training can improve the health of patients with RA and potentially improve immune function; however, information on the effects of high-intensity interval training (HIIT) in RA is limited. We sought to determine whether 10 weeks of a walking-based HIIT program would be associated with health improvements as measured by disease activity and aerobic fitness. Further, we assessed whether HIIT was associated with improved immune function, specifically antimicrobial/bacterial functions of neutrophils and monocytes.

Methods

Twelve physically inactive adults aged 64 ± 7 years with either seropositive or radiographically proven (bone erosions) RA completed 10 weeks of high-intensity interval walking. Training consisted of 3 × 30-minute sessions/week of ten ≥ 60-second intervals of high intensity (80–90% VO_2reserve) separated by similar bouts of lower-intensity intervals (50–60% VO_2reserve). Pre- and postintervention assessments included aerobic and physical function; disease activity as measured by Disease Activity score in 28 joints (DAS28), self-perceived health, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR); plasma interleukin (IL)-1β, IL-6, chemokine (C-X-C motif) ligand (CXCL)-8, IL-10, and tumor necrosis factor (TNF)-α concentrations; and neutrophil and monocyte phenotypes and functions.

Results

Despite minimal body composition change, cardiorespiratory fitness increased by 9% (change in both relative and absolute aerobic capacity; p < 0.001), and resting blood pressure and heart rate were both reduced (both p < 0.05). Postintervention disease activity was reduced by 38% (DAS28; p = 0.001) with significant reductions in ESR and swollen joints as well as improved self-perceived health. Neutrophil migration toward CXCL-8 (p = 0.003), phagocytosis of Escherichia coli (p = 0.03), and ROS production (p < 0.001) all increased following training. The frequency of cluster of differentiation 14-positive (CD14⁺)/CD16⁺ monocytes was reduced (p = 0.002), with both nonclassical (CD14^dim/CD16^bright) and intermediate (CD14^bright/CD16^positive) monocytes being reduced (both p < 0.05). Following training, the cell surface expression of intermediate monocyte Toll-like receptor 2 (TLR2), TLR4, and HLA-DR was reduced (all p < 0.05), and monocyte phagocytosis of E. coli increased (p = 0.02). No changes were observed for inflammatory markers IL-1β, IL-6, CXCL-8, IL-10, CRP, or TNF-α.

Conclusions

We report for the first time, to our knowledge, that a high-intensity interval walking protocol in older adults with stable RA is associated with reduced disease activity, improved cardiovascular fitness, and improved innate immune functions, indicative of reduced infection risk and inflammatory potential. Importantly, the exercise program was well tolerated by these patients.

Trial registration

ClinicalTrials.gov, NCT02528344. Registered on 19 August 2015.

The role of self-efficacy in pain intensity, function, psychological factors, health behaviors, and quality of life in people with rheumatoid arthritis: A systematic review

Objective: The aim of this study was to systematically review and critically appraise the role of self-efficacy in pain intensity, function, psychological factors, health behaviors, and quality of life in people with rheumatoid arthritis, based on the analyses of longitudinal studies. Methods: An electronic search of PubMed, AMED, CINAHL, PsycINFO, and PubPsych was carried out from inception to July 2017. Study selection was based on longitudinal studies which have explored the role of self-efficacy in rheumatoid arthritis. The Newcastle-Ottawa Scale adapted version was used to evaluate the risk of bias, whereas the Grading of Recommendations Assessment, Development and Evaluation evaluated the quality of the evidence per outcome. Results: A total of 11 articles met the inclusion criteria. Our results suggest an association between higher self-efficacy and greater goal achievement, positive affect, acceptance of illness, problem-solving coping, physical function, physical activity participation, and quality of life. Inversely, there was also an association between higher self-efficacy and lower pain intensity, depressive symptoms, and anxiety. Conclusions: The findings of this systematic review suggest that self-efficacy might have a positive effect on the prognosis of this condition, although further longitudinal studies are needed.

Collagen-induced arthritis as an animal model of rheumatoid cachexia

BACKGROUND

Rheumatoid arthritis is characterized by chronic polyarticular synovitis and presents systemic changes that impact quality of life, such as impaired muscle function, seen in up to 66% of the patients. This can progress to severely debilitating state known as rheumatoid cachexia-without loss of fat mass and body weight-for which there is little consensus in terms of diagnosis or treatment. This study aims to evaluate whether the collagen-induced arthritis (CIA) animal model also develops clinical and functional features characteristic of rheumatoid cachexia.

METHODS

Male DBA1/J mice were randomly divided into 2 groups: healthy animals (CO, n = 11) and CIA animals (n = 13). The clinical score and edema size, animal weight and food intake, free exploratory locomotion, grip strength, and endurance exercise performance were tested 0, 18, 35, 45, 55, and 65 days after disease induction. After euthanasia, several organs, visceral and brown fat, and muscles were dissected and weighed. Muscles were used to assess myofiber diameter. Ankle joint was used to assess arthritis severity by histological score. Statistical analysis were performed using one-way and two-way analyses of variance followed by Tukey's and Bonferroni's test or t-test of Pearson and statistical difference were assumed for a P value under 0.05.

RESULTS

The CIA had significantly higher arthritis scores and larger hind paw edema volumes than CO. The CIA had decreased endurance exercise performance total time (fatigue; 23, 22, 24, and 21% at 35, 45, 55, and 65 days, respectively), grip strength (27, 55, 63, 60, and 66% at 25, 35, 45, 55, and 65 days, respectively), free locomotion (43, 57, 59, and 66% at 35, 45, 55, and 65 days, respectively), and tibialis anterior and gastrocnemius muscle weight (25 and 24%, respectively) compared with CO. Sarcoplasmic ratios were also reduced in CIA (TA: 23 and GA: 22% less sarcoplasmic ratio), confirming the atrophy of skeletal muscle mass in these animals than in CO. Myofiber diameter was also reduced 45% in TA and 41% in GA in CIA when compared with the CO. Visceral and brown fat were lighter in CIA (54 and 39%, respectively) than CO group.

CONCLUSIONS

The CIA model is a valid experimental model for rheumatoid cachexia given that the clinical changes observed were similar to those described in patients with rheumatoid arthritis.

Aponeurosis influences the relationship between muscle gearing and force

Aponeuroses are connective tissues found on the surface of pennate muscles and are in close association with muscle fascicles. In addition to transmitting muscle forces to the external tendon, aponeurosis has been hypothesized to influence the direction of muscle shape change during a contraction. Muscle shape changes affect muscle contractile force and velocity because they influence the gear ratio with which muscle fascicles transmit force and velocity to the tendon. If aponeurosis modulates muscle shape changes, altering the aponeurosis' radial integrity with incisions should alter gearing. We tested the hypothesis that incising the aponeurosis would lead to decreased gearing across force conditions with an in situ preparation of the turkey lateral gastrocnemius muscle. We found that multiple full-length incisions in the aponeurosis altered the relationship between gearing and force relative to the intact aponeurosis condition. Specifically, after multiple aponeurosis incisions, gear ratio decreased by 19% in the high-force contractions compared with the intact condition. These results suggest that aponeuroses influence muscle shape change and can alter muscle contractile force and speed through their effect on muscle gearing. NEW & NOTEWORTHY Muscle gearing is determined by muscle shape change during a contraction and varies with the force of contraction. Variable gearing influences muscle force and speed, but how gearing is modulated is not well understood. Incising the aponeurosis before and after contractions demonstrates that aponeurosis plays a role in modulating gearing.

Digital health: a new dimension in rheumatology patient care

The new digital health innovations have opened up several opportunities to help the clinicians, patients and other caregivers of rheumatology healthcare system in maximizing efficiencies resulting in better patient outcomes. In the global context, digital health technology has the potential to bridge the distance gap between all the key stakeholders involved in rheumatology health care. In this review, we update on the recent advances in the field of digital health and highlight unique features of these technologies which would help in routine care. Application of technology in any form to enable, facilitate or enhance the quality of care is the foundation of digitised care. The components could be smartphone apps, sensors, video, social media platforms or messenger platforms, wearables or a combination of these enabling healthcare delivery and overcoming the constraints of distance, location and time. Digital therapeutics have started evolving and an important step in this direction is the involvement of FDA in the approval process. Speciality specific apps, personalised patient education as per disease status, remote specialist consultations or virtual health coach to guide on lifestyle modifications are some of the developments which have been facilitated by increased digitization in all walks of life. Assisted care with the help of robots rendering care in the hospitals or an intelligent robot guiding a patient by voice and visual sense at home are already at the threshold of entering the mainstream of patient care. Wearable devices equipped with powerful sensors are coming handy in keeping a watch on patient symptoms all the time and providing useful insights on disease progression, clinical response or complications. In chronic care such as rheumatology the implications, possibilities and benefits seem unprecedented. Real time data analytics and artificial intelligence are helping the clinicians, healthcare systems and policy makers optimise the resources and improve patient outcomes. Digitization of healthcare has gained momentum in the recent years and it is envisaged that it could be a catalyst to change, bridge the quality of care and most important democratise the healthcare access across the globe. However, more data, efficacy and objective results are needed which would be fulfilled by ongoing observational studies, clinical trials, systematic review and meta-analysis to further establish the role of digital health in the realms of patient care.

A survey of physiotherapists' current management and the promotion of physical activity, in people with rheumatoid arthritis

Purpose: Establishing physiotherapists' management of people with rheumatoid arthritis, in addition to their promotion of physical activity, is important to ascertain if there are educational needs in this area. Materials and methods: Physiotherapists from three Irish Chartered Physiotherapy clinical interest groups (N = 457) were invited to participate in a cross-sectional online questionnaire hosted on SurveyMonkey^(R)™. Results: One hundred and sixty-eight (168/457; 37%) responded. Exercise prescription and education were the most frequent treatments, with 84% always/regularly providing same. Physical activity is a component of treatment with 52% always/regularly advising. In addition, 69% agree that physical activity is attainable, 68% safe, and 67% an important goal. However, 62% never recommend the appropriate guidelines, while 14% define physical activity according to frequently used definitions. There was a statistically significant association between longer years qualified and more years working with people with RA, when using guidelines to guide physical activity and exercise prescription. Low-intensity exercises were prescribed by however, 67% never provide high-intensity. Conclusions: Current practice is in line with guidelines in which, exercise therapy and education are considered as the mainstay. Promotion of physical activity is strong; however, two-thirds never recommend the appropriate guidelines, and only a minority defined physical activity correctly. The majority never prescribe high-intensity exercise. There is a need to develop education and training for physiotherapists in the promotion of physical activity in people with rheumatoid arthritis. Implications for rehabilitation Exercise therapy and education are considered as the mainstay in the physiotherapy management of people with rheumatoid arthritis. Those physiotherapists' who are qualified longer and have more experience working with people with rheumatoid arthritis use the relevant physical activity guidelines. Overall there is a need to develop education and training for physiotherapists in the promotion of physical activity in people with rheumatoid arthritis.

Decreasing muscle performance associated with increasing disease activity in patients with rheumatoid arthritis

OBJECTIVES

Increasing evidence suggests that inflammation has a detrimental effect on muscle strength. Our objective was to analyse the association between muscle performance and different disease activity levels in patients with rheumatoid arthritis (RA).

METHOD

A total of 199 consecutive outpatients were subject to cross-sectional assessment. Measurements of grip strength, endurance of the upper and lower limbs and trunk strength were combined as a muscle performance composite score (MPCS), using a standardised method. The disease activity for 28 joints (DAS28), radiographs of small joints (Larsen score), rheumatoid factor, body mass index (BMI), comorbidities and anti-rheumatic drugs were verified. Patients' questionnaires included sociodemographic information, pain level, global disease activity, the Beck Depression Inventory, the mental and physical component scores of Short Form-36 and physical activity level.

RESULTS

Of the 199 patients, 36%, 17% and 47% patients had remission, low/moderate and high DAS28, respectively. The patients in remission had significantly shorter disease duration, better parameters in terms of pain, physician's assessment, Larsen, Beck or physical component score of Short Form-36, and they were more physically active than other patients. After adjustments for age, sex, RA duration, radiographs and BMI, the decreasing MPCS associated linearly with the increasing DAS28 activity levels (linearity, P <0.001).

CONCLUSION

Poorer MPCS is clearly associated with higher disease activity in patients with RA. Muscle performance is a modifiable risk factor. The findings suggest evaluating muscle performance in clinical practice as a part of patient care.

Rheumatoid Arthritis: A Brief Overview of the Treatment

Rheumatoid arthritis (RA) is a chronic, inflammatory, systemic autoimmune disease, affecting the joints with varying severity among patients. The risk factors include age, gender, genetics, and environmental exposure (cigarette smoking, air pollutants, and occupational). Many complications can follow, such as permanent joint damage requiring arthroplasty, rheumatoid vasculitis, and Felty syndrome requiring splenectomy if it remains unaddressed. As there is no cure for RA, the treatment goals are to reduce the pain and stop/slow further damage. Here, we present a brief summary of various past and present treatment modalities to address the complications associated with RA.

Physical Activity as a Vital Sign: A Systematic Review

Introduction

Physical activity (PA) is strongly endorsed for managing chronic conditions, and a vital sign tool (indicator of general physical condition) could alert providers of inadequate PA to prompt counseling or referral. This systematic review examined the use, definitions, psychometric properties, and outcomes of brief PA instruments as vital sign measures, with attention primarily to studies focused on arthritis.

Methods

Electronic databases were searched for English-language literature from 1985 through 2016 using the terms PA, exercise, vital sign, exercise referral scheme, and exercise counseling. Of the 838 articles identified for title and abstract review, 9 articles qualified for full text review and data extraction.

Results

Five brief PA measures were identified: Exercise Vital Sign (EVS), Physical Activity Vital Sign (PAVS), Speedy Nutrition and Physical Activity Assessment (SNAP), General Practice Physical Activity Questionnaire (GPPAQ), and Stanford Brief Activity Survey (SBAS). Studies focusing on arthritis were not found. Over 1.5 years of using EVS in a large hospital system, improvements occurred in relative weight loss among overweight patients and reduction in glycosylated hemoglobin among diabetic patients. On PAVS, moderate physical activity of 5 or more days per week versus fewer than 5 days per week was associated with a lower body mass index (−2.90 kg/m²). Compared with accelerometer-defined physical activity, EVS was weakly correlated (r = 0.27), had low sensitivity (27%–59%), and high specificity (74%–89%); SNAP showed weak agreement (κ = 0.12); GPPAQ had moderate sensitivity (46%) and specificity (50%), and SBAS was weakly correlated (r = 0.10–0.28), had poor to moderate sensitivity (18%–67%), and had moderate specificity (58%–79%).

Conclusion

Few studies have examined a brief physical activity tool as a vital sign measure. Initial investigations suggest the promise of these simple and quick assessment tools, and research is needed to test the effects of their use on chronic disease outcomes.

Community-based intervention to promote physical activity in rheumatoid arthritis (CIPPA-RA): a study protocol for a pilot randomised control trial

Rheumatoid arthritis (RA) is a chronic, inflammatory condition which may cause pain, stiffness and fatigue. People who have RA have reduced levels of physical activity due to these symptoms. Interventions targeting physical activity behaviour in this population have had limited efficacy. This paper describes a protocol for a pilot randomised controlled trial (RCT) of a theory-based intervention delivered in a community setting designed to promote physical activity in people who have RA. The aim of the pilot study is to assess the impact of the intervention on moderate-intensity physical activity in people with RA. The objectives are to obtain reliable estimates regarding recruitment rates; participant retention, protocol adherence and generate potential effect size estimates to inform sample size calculations for a main trial on physical activity participation. Semi-structured interviews will be conducted with a selected sample of participants to explore their experiences. Participants will be recruited from direct referrals from the rheumatology clinics in a public hospital. Participants meeting inclusion criteria will be randomised into a 6 week physical activity intervention (four sessions delivered over a 6-week period by a trained physiotherapist) or a control group (physical activity information leaflet). Results of the pilot study will provide data to determine if a larger RCT is feasible. Qualitative data will inform intervention design and delivery. The findings will be disseminated to health professionals, in peer-reviewed journals and conference presentations.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Quality of life in patients with established rheumatoid arthritis: A phenomenographic study

Objective:

Patients with rheumatoid arthritis perceive reduced quality of life in several domains, such as physical health, level of independence, environment and personal beliefs, compared with the healthy population. There is an increasing interest in quality of life in clinical and medical interventions. Few studies have explored patients’ individual conceptions of quality of life, and interviews can thus complement quantitative studies. There is a need for a deeper understanding of the patients’ experiences of quality of life, with regard to living with a long-term condition such as rheumatoid arthritis. The aim of this study was to explore the variation of ways in which patients with established rheumatoid arthritis understand the concept of quality of life.

Methods:

The study had a qualitative design with a phenomenographic approach, which was used to describe variations in how individuals experience their quality of life. The study is based on interviews with 22 patients with established rheumatoid arthritis enrolled in the BARFOT (better anti-rheumatic pharmacotherapy) study.

Results:

The concept of quality of life could be understood in three different ways: (1) independence in terms of physical functioning and personal finances, (2) empowerment in how to manage life and (3) participation as an experience of belonging in a social context.

Conclusion:

The different conceptions of quality of life reflect the complexity in the concept, including physical, psychological and social aspects. This complexity is important to have in mind when health professionals support patients in enhancing their quality of life.

Hand exercises for patients with rheumatoid arthritis: an extended follow-up of the SARAH randomised controlled trial

OBJECTIVES

The Stretching And strengthening for Rheumatoid Arthritis of the Hand (SARAH) randomised controlled trial evaluated the effectiveness of a hand exercise programme and demonstrated it was clinically effective and cost-effective at 12 months. The aim of this extended follow-up was to evaluate the effects of the SARAH programme beyond 12 months.

METHODS

Using postal questionnaires, we collected the Michigan Hand Questionnaire hand function (primary outcome), activities of daily living and work subscales, pain troublesomeness, self-efficacy and health-related quality of life. All participants were asked how often they performed hand exercises for their rheumatoid arthritis. Mean difference in hand function scores were analysed by a linear model, adjusted for baseline score.

RESULTS

Two-thirds (n=328/490, 67%) of the original cohort provided data for the extended follow-up. The mean follow-up time was 26 months (range 19-40 months).There was no difference in change in hand function scores between the two groups at extended follow-up (mean difference (95% CI) 1.52 (-1.71 to 4.76)). However, exercise group participants were still significantly improved compared with baseline (p=0.0014) unlike the best practice usual care group (p=0.1122). Self-reported performance of hand exercises had reduced substantially.

CONCLUSIONS

Participants undertaking the SARAH exercise programme had improved hand function compared with baseline >2 years after randomisation. This was not the case for the control group. However, scores were no longer statistically different between the groups indicating the effect of the programme had diminished over time. This reduction in hand function compared with earlier follow-up points coincided with a reduction in self-reported performance of hand exercises. Further intervention to promote long-term adherence may be warranted.

TRIAL REGISTRATION NUMBER

ISRCTN89936343; Results.

Exercise Training and Epigenetic Regulation: Multilevel Modification and Regulation of Gene Expression

Exercise training elicits acute and adaptive long term changes in human physiology that mediate the improvement of performance and health state. The responses are integrative and orchestrated by several mechanisms, as gene expression. Gene expression is essential to construct the adaptation of the biological system to exercise training, since there are molecular processes mediating oxidative and non-oxidative metabolism, angiogenesis, cardiac and skeletal myofiber hypertrophy, and other processes that leads to a greater physiological status. Epigenetic is the field that studies about gene expression changes heritable by meiosis and mitosis, by changes in chromatin and DNA conformation, but not in DNA sequence, that studies the regulation on gene expression that is independent of genotype. The field approaches mechanisms of DNA and chromatin conformational changes that inhibit or increase gene expression and determine tissue specific pattern. The three major studied epigenetic mechanisms are DNA methylation, Histone modification, and regulation of noncoding RNA-associated genes. This review elucidates these mechanisms, focusing on the relationship between them and their relationship with exercise training, physical performance and the enhancement of health status. On this chapter, we clarified the relationship of epigenetic modulations and their intimal relationship with acute and chronic effect of exercise training, concentrating our effort on skeletal muscle, heart and vascular responses, that are the most responsive systems against to exercise training and play crucial role on physical performance and improvement of health state.

Association of human leukocyte antigen DRB1 with anti-cyclic citrullinated peptide autoantibodies in Saudi patients with rheumatoid arthritis

BACKGROUND

The genetic association between human leukocyte antigen (HLA)-DRB1 alleles and the risk of development of autoantibodies has been investigated, but there are few studies from the Gulf region.

OBJECTIVES

To investigate the association between the HLA-DRB1 shared epitope and the risk for development of autoantibodies in rheumatoid arthritis (RA) patients in a Saudi population.

DESIGN

Analytical cross-sectional study.

SETTING

Tertiary care hospital in Riyadh, Saudi Arabia.

PATIENTS AND METHODS

We enrolled consecutive Saudi RA patients attending the rheumatology clinic between January and April 2015. Previously published data on HLA typing on unmatched healthy controls were used for comparison. HLA typing was performed using sequence-specific oligonucleotide probes (SSOP). Rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP) antibodies, and antinuclear antibodies (ANA) were also measured. Logistic regression analysis was used to study the autoantibodies as possible explanatory variables for the presence of the HLA-DRB1 shared epitope.

MAIN OUTCOME MEASURE(S)

The association between the presence of the shared epitope and the risk of developing anti-CCP antibodies, ANA, and RF.

RESULTS

In 76 patients with RA, carrying the shared epitope was associated with a significantly higher risk of having RA [OR=2.65, 95% CI (1.42-4.94), P=.0009]. However, only HLA-DRB1*04:05 was significantly as.sociated with RA [OR=3.73, 95% CI (1.61-8.96), Pc=.016]. In the logistic regression analysis, only anti-CCP was significantly associated with the shared epitope [OR=14.51, 95% CI (1.53-137.49), P=.02].

CONCLUSIONS

Our analysis indicates that the presence of the HLA-DRB1 shared epitope is strongly associated with the development of anti-CCP antibodies in Saudi patients with RA.

LIMITATIONS

A larger sample size is needed to confirm our finding.

Perceived Barriers, Facilitators and Benefits for Regular Physical Activity and Exercise in Patients with Rheumatoid Arthritis: A Review of the Literature

Rheumatoid arthritis (RA) is an autoimmune disease, which not only affects the joints but can also impact on general well-being and risk for cardiovascular disease. Regular physical activity and exercise in patients with RA have numerous health benefits. Nevertheless, the majority of patients with RA are physically inactive. This indicates that people with RA might experience additional or more severe barriers to physical activity or exercise than the general population. This narrative review provides an overview of perceived barriers, benefits and facilitators of physical activity and exercise in RA. Databases were searched for articles published until September 2014 using the terms 'rheumatoid arthritis', 'physical activity', 'exercise', 'barriers', 'facilitators', 'benefits', 'motivation', 'motivators' and 'enablers'. Similarities were found between disease-specific barriers and benefits of physical activity and exercise, e.g. pain and fatigue are frequently mentioned as barriers, but reductions in pain and fatigue are perceived benefits of physical activity and exercise. Even though exercise does not influence the existence of barriers, physically active patients appear to be more capable of overcoming them. Therefore, exercise programmes should enhance self-efficacy for exercise in order to achieve long-term physical activity and exercise behaviour. Encouragement from health professionals and friends/family are facilitators for physical activity and exercise. There is a need for interventions that support RA patients in overcoming barriers to physical activity and exercise and help sustain this important health behaviour.

The challenging interplay between rheumatoid arthritis, ageing and comorbidities

Background

The incidence of rheumatoid arthritis (RA) is expected to increase over the next 10 years in the European Union because of the increasing proportion of elderly people. As both RA and ageing are associated with emerging comorbidities such as cardiovascular disease, malignancies and osteoporosis, these factors will have a profound effect on the management of RA. In addition, both increasing age and comorbidities may independently alter commonly used RA-specific outcome measures.

Discussion

Age-related decline in immune cell functions (immunosenescence), such as a decrease in T-cell function, may contribute to the development of RA, as well as comorbidity. The chronic immune stimulation that occurs in RA may also lead to premature ageing and comorbidity. The interplay between RA, ageing and (emerging) comorbidities is interesting but complex. Cardiovascular disease, lung disease, malignancies, bone and muscle wasting and neuropsychiatric disease all occur more frequently in RA patients as compared to the general population. It is unclear how RA should be managed in ‘today’s world of multiple comorbidities’. Evidence that treatment of RA improves comorbidities is currently lacking, although some promising indirect observations are available. On the other hand, there is limited evidence that medication regularly prescribed for comorbidities, such as statins, might improve RA disease activity. Both ageing and comorbidity have an independent effect on commonly used outcome measures in the RA field, such as the Health Assessment Questionnaire (HAQ) and the clinical disease activity index (CDAI). Prospective studies, that also account for the presence of comorbidity in (elderly) RA patients are therefore urgently needed. To address gaps in knowledge, future research should focus on the complex interdependencies between RA, ageing and comorbidity. In addition, these findings should be integrated into daily clinical practice by developing and testing integrated and coordinated health care services. Adaptation of management recommendations is likely required.

Summary

The elderly RA patient who also deals with (emerging) comorbidities presents a unique challenge to treating clinicians. A paradigm shift from disease-centered to goal-oriented approach is needed to develop adequate health care services for these patients.

In Patients with Established RA, Positive Effects of a Randomised Three Month WBV Therapy Intervention on Functional Ability, Bone Mineral Density and Fatigue Are Sustained for up to Six Months

Functional ability is often impaired for people with rheumatoid arthritis (RA), rendering these patients highly sedentary. Additionally, patients with RA often take medication known to negatively affect bone mass. Thus improving functional ability and bone health in this group of patients is important. The aim of this study was to investigate the effects of whole body vibration (WBV) therapy in patients with stable, established RA. Thirty one females with RA were randomly assigned to a control group (CON, n = 15) who continued with their normal activities or a WBV group (n = 16) who underwent a three month WBV therapy intervention, consisting of 15 minutes of intermittent vibration, performed twice per week. Patients were assessed at baseline, three months, and three months post intervention for functional ability using the modified Health Assessment Questionnaire; for RA disease activity using the Clinical Disease Activity Index, for quality of life using self-report fatigue and pain scores; for physical activity profiles using accelerometry, and for BMD and body composition using DXA. Patients in both groups were matched for all variables at baseline. After the intervention period, functional ability was significantly improved in the WBV group (1.22(0.19) to 0.92(0.19), p = 0.02). Hip BMD was significantly reduced in the CON group (0.97(0.05) to 0.84(0.05) g.cm(-2), p = 0.01), while no decreases were seen in the WBV group (1.01(0.05) to 0.94(0.05) g.cm(-2), p = 0.50). Despite no change in RA disease activity in either group at either follow up, fatigue levels were improved in the WBV group (4.4(0.63) to 1.1(0.65), yet remained unchanged in the CON group at both follow ups (p = 0.01). Ten minute bouts of light to moderate physical activity were significantly reduced in the CON group after the intervention (2.8(0.61) to 1.8(0.64) bouts per day, p = 0.01), and were preserved in the WBV group (3.1(0.59) to 3.0(0.61) bouts per day, p = 0.70). Intermittent WBV shows promise for sustained improvements in functional ability, for attenuating loss of bone mass at the hip, as well as for decreasing fatigue in patients with established RA.

TRIAL REGISTRATION

Pan African Clinical Trials Registry PACTR201405000823418.

Mobile internet service for self-management of physical activity in people with rheumatoid arthritis: evaluation of a test version

Objectives

Life-long adherence to health-enhancing physical activity (PA) is a major challenge for people with rheumatoid arthritis (RA). Our aim was to evaluate the utilisation of and experiences with a RA-specific, mobile internet PA support service, ‘tRAppen’, developed through a co-design process.

Methods

28 participants with RA formed 3 web communities and tested tRAppen for 6 weeks. A mixed-method design was used to combine different types of data. Log data and questionnaire data were analysed quantitatively, while data from telephone interviews were analysed with a directed content analysis.

Results

25 of the 28 participants used tRAppen. Log data indicated that a majority of them registered their PA, sent likes and posted comments to peers, set personal goals and made exercise plans. tRAppen was rated as easy and fun to use, and fairly informative and supportive for PA, and was highly recommended for people with RA. The interview analysis resulted in the following 6 categories describing the utilisation of and experiences with tRAppen: (1) experiences in general, (2) feasibility of features, (3) value as support for PA, (4) enjoyment, (5) ideas for improvements and (6) additional factors.

Conclusions

tRAppen is the first co-designed mobile internet service developed specifically for the self-management of PA in people with RA. The results are promising and indicate that tRAppen may be useful for supporting a physically active lifestyle in a subpopulation at certain risk of poor health. It will now be revised, launched and continuously updated in an iterative process involving its future users.

Energy expenditure and nutritional complications of metabolic syndrome and rheumatoid cachexia in rheumatoid arthritis: an observational study using calorimetry and actimetry

OBJECTIVE

Altered energy expenditure may contribute to the nutritional complications of RA, metabolic syndrome (MS) and rheumatoid cachexia (RC). The main aim of this study was to evaluate whether the altered resting energy expenditure (REE) and physical activity (PA)-related energy expenditure (EE) are related to the duration of RA and inflammatory activity and nutritional complications in RA.

METHODS

Among patients with well-characterized RA (duration, activity: DAS28 ESR), we measured REE by indirect calorimetry, and PA-EE by actimetry (SenseWear Armband). MS was defined according to the International Diabetes Federation criteria and RC from DXA body composition analysis. The relations between the characteristics and nutritional complications, and EE were analysed by linear regression.

RESULTS

Fifty-seven patients were included [73% women, age 57 (10) years] with a wide range of disease duration: 3.8 (3.0) years, and DAS28 ESR: 3.9 (1.4). The mean REE was 1486 (256) kcal/day, associated with the DAS28 ESR (β = +0.21, P = 0.02 after adjusting for gender and fat free mass). The prevalence of MS and RC was, respectively, 24 and 18%, and they were unrelated to each other. The patients with MS and/or RC had double the longstanding RA score (P < 0.05), twice the homeostasis model assessment of insulin resistance values (P = 0.052) and halved levels of PA (P < 0.05 for metabolic equivalent tasks (METs) and number of steps/day). Two modifiable factors were associated with the presence of MS and/or RC: a low level of PA as METs [exp(B) = 0.03, P = 0.009] and the use of glucocorticoids [exp(B) = 4.08, P = 0.046].

CONCLUSION

Low levels of PA and treatment by glucocorticoids are associated with the nutritional complications of RA, suggesting the potential for therapeutic interventions.

‘It might hurt, but still it’s good’: People with rheumatoid arthritis beliefs and expectations about physical activity interventions

Many people who have rheumatoid arthritis report low levels of physical activity. We conducted 17 interviews with people who have rheumatoid arthritis to gain insight into how they view physical activity and to explore how their levels of activity may be increased. Interviews were transcribed verbatim and analysed using thematic analysis. Four main themes were generated: being active, barriers and facilitators, information and advice, and supporting physical activity. A lack of information about being active fostered negative emotions limiting physical activity participation. Improved provision of physical activity advice is warranted to promote physical activity in people who have rheumatoid arthritis.

The beneficial effects of Tai Chi exercise on endothelial function and arterial stiffness in elderly women with rheumatoid arthritis

Background

Rheumatoid arthritis (RA) has been known to be associated with increased risk of cardiovascular disease (CVD). The aim of this study was to investigate the effects of Tai Chi exercise on CVD risk in elderly women with RA.

Method

In total, 56 female patients with RA were assigned to either a Tai Chi exercise group (29 patients) receiving a 3-month exercise intervention once a week or a control group (27 patients) receiving general information about the benefits of exercise. All participants were assessed at baseline and at 3 months for RA disease activity (Disease Activity Score 28 and Routine Assessment of Patient Index Data 3), functional disability (Health Assessment Questionnaire), CVD risk factors (blood pressure, lipids profile, body composition, and smoking), and three atherosclerotic measurements: carotid intima-media thickness, flow-mediated dilatation (FMD), and brachial-ankle pulse wave velocity (baPWV).

Results

FMD, representative of endothelial function, significantly increased in the Tai Chi exercise group (initial 5.85 ± 2.05 versus 3 months 7.75 ± 2.53 %) compared with the control group (initial 6.31 ± 2.12 versus 3 months 5.78 ± 2.13 %) (P = 1.76 × 10⁻³). Moreover, baPWV, representative of arterial stiffness, significantly decreased in the Tai Chi exercise group (initial 1693.7 ± 348.3 versus 3 months 1600.1 ± 291.0 cm/s) compared with the control group (initial 1740.3 ± 185.3 versus 3 months 1792.8 ± 326.1 cm/s) (P = 1.57 × 10⁻²). In addition, total cholesterol decreased significantly in the Tai Chi exercise group compared with the control group (−7.8 ± 15.5 versus 2.9 ± 12.2 mg/dl, P = 2.72 × 10⁻²); other changes in RA-related characteristics were not significantly different between the two groups. Tai Chi exercise remained significantly associated with improved endothelial function (FMD; P = 4.32 × 10⁻³) and arterial stiffness (baPWV; P = 2.22 × 10⁻²) after adjustment for improvement in total cholesterol level.

Conclusion

Tai Chi exercise improved endothelial dysfunction and arterial stiffness in elderly women with RA, suggesting that it can be a useful behavioral strategy for CVD prevention in patients with RA.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-015-0893-x) contains supplementary material, which is available to authorized users.

Recommendations for assessing and preventing falls in adults of all ages with rheumatoid arthritis

Rheumatoid arthritis (RA) is a debilitating disease that affects younger as well as older adults. It is associated with a high risk of injurious falls due to problems such as lower-limb muscle weakness, balance impairment, swollen and tender joints, pain, and fatigue. Falls are typically associated with older people; hence, many professionals do not recognise the risks for younger persons with diseases such as RA. Falls can lead to devastating consequences, such as fatalities, hip fractures (with 50% of those affected never regaining their previous level of mobility and 30% dying within 1 year), or loss of independence and confidence. Research has shown that many people are either unaware or deny their risk of falling. Therefore, it is important that health professionals, such as community nurses, are aware of the risk factors, methods of assessment, and evidence-based preventative measures, so that falls can be avoided in this population. This article presents research and practice implications for community nurses to enable them to assess, treat, and appropriately refer adults with RA who are also at risk of falls.

Effects of Whole-Body Cryotherapy in Comparison with Other Physical Modalities Used with Kinesitherapy in Rheumatoid Arthritis

Whole-body cryotherapy (WBC) has been frequently used to supplement the rehabilitation of patients with rheumatoid arthritis (RA). The aim of this study was to compare the effect of WBC and traditional rehabilitation (TR) on clinical parameters and systemic levels of IL-6, TNF-α in patients with RA. The study group comprised 25 patients who were subjected to WBC (−110°C) and 19 patients who underwent a traditional rehabilitation program. Some clinical variables and levels of interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) were used to assess the outcomes. After therapy both groups exhibited similar improvement in pain, disease activity, fatigue, time of walking, and the number of steps over a distance of 50 m. Only significantly better results were observed in HAQ in TR group (p < 0.05). However, similar significant reduction in IL-6 and TNF-α level was observed. The results showed positive effects of a 2-week rehabilitation program for patients with RA regardless of the kind of the applied physical procedure.

Painful Choices: A Qualitative Exploration of Facilitators and Barriers to Active Lifestyles Among Adults With Osteoarthritis

Research has indicated physical activity and exercise can effectively attenuate biopsychosocial osteoarthritis-related symptoms in adults, more so than other management strategies; however, both leisure and structured physical activity are scarcely recommended by health care providers, and remain rarely adopted and adhered to in this patient population. Using qualitative interviews, the present study investigated potential facilitators and barriers to physical activity for adults with osteoarthritis. Fifteen participants (30-85 years of age) with osteoarthritis engaged in semi-structured interviews, which focused on experiences with physical activity/exercise, daily osteoarthritis management, and experiences with health professionals' recommendations. Analysis of the interview transcripts revealed that pain relief, clear health-related communication, and social support facilitated physical activity. Physical pain, psychological distress, and inadequate medical support were the most frequently expressed barriers. The present study supports the biopsychosocial nature of osteoarthritis, which may have important implications for advancing exercise as an effective and long-term intervention strategy in aging adults with osteoarthritis.

Insights on the role of physical activity in patients with rheumatoid arthritis

Patients with rheumatoid arthritis (RA) are physically inactive, and trials have been undertaken to examine the effect of physical activity on pain, disease activity, functional ability and quality of life (QoL) in RA. The aim of this study was to explore the relationship between physical activity and disease-activity in RA and in healthy controls. Our findings showed that fewer RA patients had a professional occupation compared with controls, but patients and controls were similar with respect to the sedentary extent of their job. Physical exercise was inversely associated with disease activity (DAS-28), stiffness visual analog scale (VAS), patient global VAS and SF-36, but not associated with Health Assessment Questionnaire (HAQ), pain VAS, fatigue VAS, global health and the Arthritis Ipact Measurement Scale (AIMS), suggesting that pain and fatigue are important barriers to physical activity. Our findings suggest that this is more pronounced in RA patients who do not participate in regular physical activity, and so physical exercise should be recommended as part of comprehensive RA care.

Identifying barriers to smoking cessation in rheumatoid arthritis

OBJECTIVE

The aim of this study was to investigate disease-related issues that make smoking cessation challenging for patients with rheumatoid arthritis (RA). There is currently a lack of research on tailoring smoking cessation interventions for RA patients. Qualitative exploration is a necessary first step in planning targeted interventions.

METHODS

A qualitative mixed-methods study was undertaken. Participants attended either a focus group or an individual interview and completed a set of standardized questionnaires. The sample consisted of 36 RA patients: 24 current smokers and 12 ex-smokers. The transcripts were analyzed thematically using a critical realist approach to inductively identify themes.

RESULTS

Five key barriers to smoking cessation that are faced by RA patients were identified. First, participants were unaware of the relationship between smoking and RA and therefore did not perceive this as a reason to quit. Second, smoking was used as a distraction from pain. Third, participants found it difficult to exercise and therefore were unable to use exercise as an alternative distraction. Fourth, smoking was used as a coping mechanism for the frustrations of living with RA. Fifth, participants felt unsupported and isolated from other RA patients.

CONCLUSION

Disease-related issues may hinder smoking cessation for RA patients. Through an understanding of patients' perspectives there is an opportunity to plan an effective targeted intervention that may increase the chance of smoking cessation in RA patients where smoking may adversely influence disease progression and comorbidities.

Developing a Tailored Smoking Cessation Intervention for Rheumatoid Arthritis Patients

PURPOSE

Smoking is associated with an increased risk of comorbidities in rheumatoid arthritis (RA) and may reduce the efficacy of anti-rheumatic therapies. Smoking cessation is therefore an important goal in RA. Our previous qualitative research identified five RA-related barriers to smoking cessation: lack of support; limited knowledge of the relationship between smoking and RA; uncontrolled pain; inability to exercise; and using smoking as a coping strategy. The aim of this article is to describe the process of developing a smoking cessation intervention for RA patients based on these themes.

METHODS

A comprehensive review of the literature on smoking cessation was undertaken. A tailored smoking cessation programme was designed to address each RA-specific barrier. A meeting was convened with key staff of Arthritis New Zealand to develop a consensus on feasible design to deliver a smoking cessation programme based on existing best practice and smoking cessation resources, and tailored within existing Arthritis New Zealand service delivery frameworks.

RESULTS

A three-month intervention was designed to be delivered by trained arthritis educators, with the following key components: nicotine replacement therapy for eight weeks; a telephone or face-to-face interview with each patient to determine their individual specific RA-related barriers to smoking cessation; and individualized education and support activities which addressed these barriers. The intervention also included three follow-up telephone calls; a support website; and 12 weekly smoking cessation advice emails.

CONCLUSIONS

A RA-specific smoking cessation invention was developed, matching support to specific issues within each patient's experience. A pilot study is in progress to evaluate the programme's efficacy. Copyright © 2015 John Wiley & Sons, Ltd.

Perceptions of physical activity engagement among adults with rheumatoid arthritis and rheumatologists

AIM

Physical activity (PA) among adults with rheumatoid arthritis (RA) is suboptimal. This study assessed PA motivations and perceptions in adults with RA and rheumatologists.

METHODS

Patients and rheumatologists participated in structured interviews led by a behavioral scientist. Sessions were audiotaped, transcribed and coded.

RESULTS

Twenty-three patients (mean age = 63 [standard deviation = 10], 96% female) and seven rheumatologists (57% male, 29% fellows) participated. Nine themes emerged: communication with the rheumatologist, environment/access, symptom management, social support, mental health, breaking inactivity cycles, integrating PA into routines, staying in control and challenge/intimidation. Highly active patients viewed PA differently than low active patients. The need to compete with RA-free individuals may impede PA.

CONCLUSION

Understanding how patients conceptualize PA will enable clinicians to formulate PA strategies to motivate patients.

A simple step test to estimate cardio-respiratory fitness levels of rheumatoid arthritis patients in a clinical setting

Purpose. Exercise tests represent an important clinical tool to evaluate cardio-respiratory fitness and to predict future adverse cardiovascular events. However, use of such tests in patients with rheumatoid arthritis (RA) is relatively uncommon despite well-established evidence that low exercise capacity and high CVD mortality are features of this disease. Therefore, this study examined the validity and reliability of a sub-maximal step test for use in RA patients. Methods. Thirty patients (24 females) (mean ± SD age 53 ± 10 years) performed a sub-maximal step test on two occasions to estimate the criterion measure of cardio-respiratory fitness (V.O2max). A further maximal cycling test provided a direct fitness measurement (V.O2 peak). Pearson correlation coefficient, intraclass correlation coefficient (ICC), Bland and Altman plots, and 95% limits of agreement (LOA) were used to determine the validity and reliability of the sub-maximal test. Results. Estimated V.O2max correlated well with directly measured V.O2 peak (r = 0.79, LoA ±5.7 mL·kg⁻¹·min⁻¹). Test-retest reproducibility for estimated V.O2max was excellent (ICC = 0.97, LoA ±2.2 mL·kg⁻¹·min⁻¹). Conclusion. The sub-maximal step test studied here represents a valid and reproducible method to estimate cardio-respiratory fitness in RA patients. This test may be useful for the assessment and management of CVD risk in a clinical setting.

Health care providers' recommendations for physical activity and adherence to physical activity guidelines among adults with arthritis

Introduction

Physical activity is beneficial for reducing pain and improving health-related quality of life among people with arthritis. However, physical inactivity is prevalent among people with arthritis. Health care providers’ recommendations act as a catalyst for changes in health behavior. However, information about the effectiveness of such recommendations is limited in the arthritis literature. We examined the association between providers’ recommendations for physical activity and adherence to physical activity guidelines for adults with arthritis and whether adults’ age influenced this association.

Methods

We used combined data of adult respondents aged 45 years or older with provider-diagnosed arthritis (N = 10,892) from the 2011 Behavioral Risk Factor Surveillance System to conduct a retrospective, cross-sectional study. We used a multivariable logistic regression model to examine the association between health care providers’ recommendations and adherence to physical activity guidelines among adults with arthritis.

Results

Adults with arthritis who received health care providers’ recommendations for physical activity were more likely (odds ratio, 1.22; 95% confidence interval, 1.12–1.32) to adhere to physical activity guidelines than those who did not, after controlling for relevant covariates. Adults’ age did not influence the association between providers’ recommendations and adherence to physical activity (odds ratio, 1.00; 95% confidence interval, 0.99–1.00), after controlling for covariates.

Conclusion

Health care providers’ recommendations are associated with adherence to physical activity guidelines among adults with arthritis. Providers should recommend physical activity to adults with arthritis.

Rheumatoid arthritis and cardiovascular disease

BACKGROUND

Rheumatic disease and heart disease share common underpinnings involving inflammation. The high levels of inflammation that characterize rheumatic diseases provide a "natural experiment" to help elucidate the mechanisms by which inflammation accelerates heart disease. Rheumatoid arthritis (RA) is the most common of the rheumatic diseases and has the best studied relationships with heart disease.

METHODS

A review of current literature on heart disease and RA was conducted.

RESULTS

Patients with RA have an increased risk of developing heart disease that is not fully explained by traditional cardiovascular risk factors. Therapies used to treat RA may also affect the development of heart disease; by suppressing inflammation, they may also reduce the risk of heart disease. However, their other effects, as in the case of steroids, may increase heart disease risk.

CONCLUSIONS

Investigations of the innate and adaptive immune responses occurring in RA may delineate novel mechanisms in the pathogenesis of heart disease and help identify novel therapeutic targets for the prevention and treatment of heart disease.

Swedish version of the multi dimensional health assessment questionnaire -- translation and psychometric evaluation

BACKGROUND

Health assessment measurements for patients with Rheumatoid arthritis (RA) have to be meaningful, valid and relevant. A commonly used questionnaire for patients with RA is the Stanford Health Assessment Questionnaire Disability Index (HAQ), which has been available in Swedish since 1988. The HAQ has been revised and improved several times and the latest version is the Multi Dimensional Health Assessment Questionnaire (MDHAQ). The aim of this study was to translate the MDHAQ to Swedish conditions and to test the validity and reliability of this version for persons with RA.

METHODS

Translation and adaption of the MDHAQ were performed according to guidelines by Guillemin et al. The translated version was tested for face validity and test-retest in a group of 30 patients with RA. Content validity, criterion validity and internal consistency were tested in a larger study group of 83 patients with RA. Reliability was tested with test-retest and Cronbach´s alpha for internal consistency. Two aspects of validity were explored: content and criterion validity. Content validity was tested with a content validity index.Criterion validity was tested with concurrent validity by exploring the correlation between the MDHAQ-S and the AIMS2-SF. Floor and ceiling effects were explored.

RESULTS

Test-retest with intra-class correlation coefficient (ICC) gave a coefficient of 0.85 for physical function and 0.79 for psychological properties. Reliability test with Cronbach´s alpha gave an alpha of 0.65 for the psychological dimension and an alpha of 0.88 for the physical dimension of the MDHAQ-S.The average sum of the content validity index for each item was of the MDHAQ-S was 0.94. The MDHAQ-S had mainly a moderate correlation with the AIMS2-SF, except for the social dimension of the AIMS2-SF, which had a very low correlation with the MDHAQ-S.

CONCLUSIONS

The MDHAQ-S was considered to be reliable and valid, but further research is needed concerning sensitivity to change.

Concurrent validation of activity monitors in patients with rheumatoid arthritis

BACKGROUND

Physical activity is frequently reported in rheumatology but it is difficult to measure objectively outside the gait laboratory. A new generation of activity monitors offers this potential but it has not yet been evaluated in patients with rheumatoid arthritis. This study aimed to evaluate three types of activity monitors in patients with rheumatoid arthritis.

METHODS

The Step-N-Tune, Activ4Life Pro V3.8, and the Intelligent Device for Energy Expenditure and Activity activity monitors were tested concurrently in 12 patients with rheumatoid arthritis as well as in a healthy control group of 12 volunteers. Participants walked at a self selected speed for two minutes and were filmed for later review. Temporal and spatial gait parameters were also validated against the GAITRite walkway and the total number of steps recorded by each activity monitor was compared to a gold standard derived from half speed video replays.

FINDINGS

Activity monitor performance varied between devices but all showed poorer performance when used in the group with rheumatoid arthritis. Bland-Altman plots demonstrated wider 95% limits of agreement in the group with rheumatoid arthritis and a systematic decrease in agreement between activity monitors and the gold standard with decreasing functional ability.

INTERPRETATION

Despite some variation between devices, all the activity monitors tested performed reasonably well in healthy young volunteers. All except the Activ4Life showed a marked decrease in performance in patients with rheumatoid arthritis, suggesting Activ4Life could be the most suitable for use in this patient group. The marked between group difference in functional ability, and systematic decrease in device performance with deteriorating gait, indicate that activity monitors require specific validation in target clinical populations.

Assessment of foot and ankle muscle strength using hand held dynamometry in patients with established rheumatoid arthritis

Background

The foot and ankle are frequently affected in patients with rheumatoid arthritis (RA). One of the negative consequences of RA on the physical function of patients is a decrease in muscle strength. However, little is known about foot and muscle strength in this population. The aim of the study was to evaluate significant differences in foot and ankle muscle strength between patients with established RA against age and sex-matched controls using hand-held dynamometry.

Methods

The maximal muscle strength of ankle plantarflexion, dorsiflexion, eversion and inversion was assessed in 14 patients with RA, mean (SD) disease duration of 22 (14.1) years, and 20 age and sex-matched control participants using hand-held dynamometry.

Results

Significant differences were observed in muscle strength between the two groups in plantarflexion (p = 0.00), eversion (p = 0.04) and inversion (p = 0.01). No significant difference was found in dorsiflexion (p > 0.05). The patients with RA displayed a significantly lower plantarflexion-dorsiflexion ratio than the control participants (p = 0.03).

Conclusions

The results from this study showed that the RA patients displayed a significant decrease in ankle dorsiflexion, eversion and inversion when compared to the non-RA control group suggesting that foot and ankle muscle strength may be affected by the pathological processes in RA. This study is a preliminary step for the measurement of muscle impairments within the RA population.

Stages of change, barriers, benefits, and preferences for exercise in RA patients: a cross-sectional study

OBJECTIVES

To determine the distribution of exercise stages of change in a rheumatoid arthritis (RA) cohort, and to examine patients' perceptions of exercise benefits, barriers, and their preferences for exercise.

METHODS

One hundred and twenty RA patients who attended the Rheumatology Unit of a University Hospital were asked to participate in the study. Those who agreed were administered a questionnaire to determine their exercise stage of change, their perceived benefits and barriers to exercise, and their preferences for various features of exercise.

RESULTS

Eighty-nine (74%) patients were finally included in the analyses. Their mean age was 58.4 years, mean RA duration 10.1 years, and mean disease activity score 2.8. The distribution of exercise stages of change was as follows: precontemplation (n = 30, 34%), contemplation (n = 11, 13%), preparation (n = 5, 6%), action (n = 2, 2%), and maintenance (n = 39, 45%). Compared to patients in the maintenance stage of change, precontemplators exhibited different demographic and functional characteristics and reported less exercise benefits and more barriers to exercise. Most participants preferred exercising alone (40%), at home (29%), at a moderate intensity (64%), with advice provided by a rheumatologist (34%) or a specialist in exercise and RA (34%). Walking was by far the preferred type of exercise, in both the summer (86%) and the winter (51%).

CONCLUSIONS

Our cohort of patients with RA was essentially distributed across the precontemplation and maintenance exercise stages of change. These subgroups of patients exhibit psychological and functional differences that make their needs different in terms of exercise counselling.

A review of the use of dual-energy X-ray absorptiometry (DXA) in rheumatology

The principal use of dual-energy X-ray absorptiometry (DXA) is to diagnose and monitor osteoporosis and therefore reduce fracture risk, associated morbidity, and mortality. In the field of rheumatology, DXA is an essential component of patient care because of both rheumatologists’ prescription of glucocorticoid treatment as well as the effects of rheumatological diseases on bone health. This review will summarize the use of DXA in the field of rheumatology, including the concern for glucocorticoid-induced osteoporosis, as well as the association of osteoporosis with a sampling of such rheumatologic conditions as rheumatoid arthritis (RA), systemic lupus erythematosus, ankylosing spondylitis, juvenile idiopathic arthritis, and scleroderma or systemic sclerosis. Medicare guidelines recognize the need to perform DXA studies in patients treated with glucocorticoids, and the World Health Organization FRAX tool uses data from DXA as well as the independent risk factors of RA and glucocorticoid use to predict fracture risk. However, patient access to DXA measurement in the US is in jeopardy as a result of reimbursement restrictions. DXA technology can simultaneously be used to discover vertebral fractures with vertebral fracture assessment and provide patients with a rapid, convenient, and low-radiation opportunity to clarify future fracture and comorbidity risks. An emerging use of DXA technology is the analysis of body composition of RA patients and thus the recognition of “rheumatoid cachexia,” in which patients are noted to have a worse prognosis even when the RA appears well controlled. Therefore, the use of DXA in rheumatology is an important tool for detecting osteoporosis, reducing fracture risk and unfavorable outcomes in rheumatological conditions. The widespread use of glucocorticoids and the underlying inflammatory conditions create a need for assessment with DXA. There are complications of conditions found in rheumatology that could be prevented with more widespread patient access to DXA.