Effects of exercise on fatigue, aerobic fitness, and disease activity measures in persons with rheumatoid arthritis

Bringing the Walk with Ease Programme to the UK: a mixed-methods study to assess the relevance, acceptability, and feasibility of implementation for people with arthritis and musculoskeletal conditions

Developed in the United States (US), Walk With Ease (WWE) is a popular evidence-based, 6-week community walking programme for adults with arthritis, delivered in either an instructor-led or self-directed format. While WWE has expanded into communities across the USA, it is relatively unknown in other countries across the globe. This study, in collaboration with community and patient partners, aimed to examine the relevance, acceptability and feasibility of introducing WWE into a UK context. After initial cultural adaptation, participants were recruited into the study. Eligible (≥18 years, doctor diagnosed arthritis (confirmed or self-report), self-reported joint symptoms in last 30 days, BMI ≥25 kg/m2, and <150 min/week of moderate/vigorous PA) and consented participants were randomized into two groups: WWE programme or usual care. A mixed-methods analysis approach integrated quantitative data (physical performance assessment; baseline and post-six week programme questionnaire) and qualitative data (narrative interviews exploring participants' pre- and post-WWE experiences and stakeholders' perceptions). Of 149 participants, the majority were women (70%) aged ≥60 years (76%). Among the 97 receiving the programme, 52 chose instructor-led; 45 chose self-directed. Participants found WWE relevant and acceptable-99% indicating they would recommend WWE to family/friends. Within both WWE formats, mixed differences representing improvement were observed at 6 weeks from baseline for physical performance and arthritis symptoms. Emergent themes included improved motivation, health, and social well-being. WWE is a relevant and acceptable walking programme with scope for wider implementation to support UK health and well-being policy strategies.

Effects of physical exercise and body weight on disease-specific outcomes of people with rheumatic and musculoskeletal diseases (RMDs): systematic reviews and meta-analyses informing the 2021 EULAR recommendations for lifestyle improvements in people with RMDs

BACKGROUND

A European League Against Rheumatism (EULAR) taskforce was convened to develop recommendations for lifestyle behaviours in rheumatic and musculoskeletal diseases (RMDs). This paper reviews the literature on the effects of physical exercise and body weight on disease-specific outcomes of people with RMDs.

METHODS

Three systematic reviews were conducted to summarise evidence related to exercise and weight in seven RMDs: osteoarthritis, rheumatoid arthritis, systemic lupus erythematosus, axial spondyloarthritis (axSpA), psoriatic arthritis, systemic sclerosis and gout. Systematic reviews and original studies were included if they assessed exercise or weight in one of the above RMDs, and reported results regarding disease-specific outcomes (eg, pain, function, joint damage). Systematic reviews were only included if published between 2013-2018. Search strategies were implemented in the Medline, Embase, Cochrane Library of systematic reviews and CENTRAL databases.

RESULTS

236 articles on exercise and 181 articles on weight were included. Exercise interventions resulted in improvements in outcomes such as pain and function across all the RMDs, although the size of the effect varied by RMD and intervention. Disease activity was not influenced by exercise, other than in axSpA. Increased body weight was associated with worse outcomes for the majority of RMDs and outcomes assessed. In general, study quality was moderate for the literature on exercise and body weight in RMDs, although there was large heterogeneity between studies.

CONCLUSION

The current literature supports recommending exercise and the maintenance of a healthy body weight for people with RMDs.

[Sports and exercise therapy in inflammatory rheumatic diseases]

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

The effect of physical exercise on rheumatoid arthritis: An overview of systematic reviews and meta-analysis

AIMS

To determine which outcomes will be improved by different exercise interventions and the evidence quality for each intervention.

DESIGN

Overview of systematic reviews and meta-analysis.

DATA SOURCES

PubMed, Cochrane, Web of Science, CINAHL, and Embase. Published from the establishment of the database to 3 September 2019.

REVIEW METHODS

AMSTAR 2 and PRISMA were used to evaluate methodological and reporting quality. Evidence quality of the effect of each intervention was assessed according to GRADE guidelines. Meta-analysis of original studies was conducted for comparison of systematic reviews and to explore the effect of different exercise interventions on the same outcome.

RESULTS

Ten systematic reviews were included in the overview. A significant improvement was seen in: aerobic exercise for aerobic capacity; strength training for erythrocyte sedimentation rate and 50-foot walking time; aerobic exercise combined with strength training for aerobic capacity, physical function, and fatigue; hand exercise for hand function.

CONCLUSIONS

For the maximum benefit of rheumatoid arthritis (RA) patients, different exercise methods should be selected according to the symptoms. For RA patients, any exercise is better than no exercise, but the intensity, frequency, and period of exercise for better results are not determined.

IMPACT

What problem did the study address is which outcomes will be improved by different exercise interventions. For maximum benefit for RA patients, different exercise methods should be selected according to symptoms. The research summarized the evidence of exercise rehabilitation of RA and will help RA patients or their caregivers choose the appropriate type of exercise, which will play a positive role on the rehabilitation of patients with RA.

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

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

Relationship between Physical Activity and Fatigue in Adults with Cystic Fibrosis

Purpose: We examined the relationship between the amount of physical activity and level of fatigue in adults with cystic fibrosis (CF). Method: Participants were recruited from the Toronto Adult Cystic Fibrosis Centre at St. Michael's Hospital. Participants completed the Habitual Activity Estimation Scale, the Multidimensional Fatigue Inventory, and the Depression subscale of the Hospital Anxiety and Depression Scale, in that order. Descriptive statistics and linear and multiple regressions were computed. Results: Over a 6-month period, 51 individuals were approached, and 22 (10 men, 12 women) participated in this study. The participants' median age was 33, and forced expiratory volume in 1 second (FEV₁) was 64% predicted. When holding both FEV₁ and depression constant, a significant negative correlation was found between total active hours per weekday and general fatigue (β=-0.735, p=0.03); there was a negative trend between total active hours per weekday and physical fatigue (β=-0.579, p=0.09). Conclusions: This study is the first to demonstrate that among adults with CF, a higher level of physical activity is associated with a lower level of general and physical fatigue when controlling for lung function and level of depression. Physical activity may be used as a means of mitigating the levels of general and physical fatigue in people with CF.

Physical activity and autoimmune diseases: Get moving and manage the disease

Physical activity, by definition, is any skeletal muscle body movement that results in energy expenditure. In the last few decades, a plethora of scientific evidences have accumulated and confirmed the beneficial role of physical activity as a modifiable risk factor for a wide variety of chronic diseases including cardiovascular diseases (CVDs), diabetes mellitus and cancer, among others. Autoimmune diseases are a heterogeneous group of chronic diseases, which occur secondary to loss of self-antigen tolerance. With the advent of biological therapies, better outcomes have recently been noted in the management of autoimmune diseases. Nonetheless, recent research highlights the salient role of modifiable behaviors such as physical inactivity on various aspects of the immune system and autoimmune diseases. Physical activity leads to a significant elevation in T-regulatory cells, decreased immunoglobulin secretion and produces a shift in the Th1/Th2 balance to a decreased Th1 cell production. Moreover, physical activity has been proven to promote the release of IL-6 from muscles. IL-6 released from muscles functions as a myokine and has been shown to induce an anti-inflammatory response through IL-10 secretion and IL-1β inhibition. Physical activity has been shown to be safe in most of autoimmune diseases including systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), multiple sclerosis (MS), inflammatory bowel diseases (IBD), as well as others. Additionally, the incidence of RA, MS, IBD and psoriasis has been found to be higher in patients less engaged in physical activity. As a general trend, patients with autoimmune diseases tend to be less physically active as compared to the general population. Physically active RA patients were found to have a milder disease course, better cardiovascular disease (CVD) profile, and improved joint mobility. Physical activity decreases fatigue, enhances mood, cognitive abilities and mobility in patients with MS. In SLE patients, enhanced quality of life and better CVD profile were documented in more physically active patients. Physically active patients with type 1 diabetes mellitus have a decreased risk of autonomic neuropathy and CVD. Both fibromyalgia and systemic sclerosis patients report decreased disease severity, pain, as well as better quality of life with more physical activity. Further, SSc patients improve their grip strength, finger stretching and mouth opening with increased level of exercise. The purpose of this paper is to review the clinical evidence regarding the safety, barriers to engagement, and impact of physical activity on autoimmune diseases.

Rapamycin Maintains the Chondrocytic Phenotype and Interferes with Inflammatory Cytokine Induced Processes

Osteoarthritis (OA) is hallmarked by a progressive degradation of articular cartilage. Besides risk factors including trauma, obesity or genetic predisposition, inflammation has a major impact on the development of this chronic disease. During the course of inflammation, cytokines such as tumor necrosis factor-alpha(TNF-α) and interleukin (IL)-1β are secreted by activated chondrocytes as well as synovial cells and stimulate the production of other inflammatory cytokines and matrix degrading enzymes. The mTORC1 inhibitor rapamycin is a clinical approved immunosuppressant and several studies also verified its chondroprotective effects in OA. However, the effect of blocking the mechanistic target of rapamycin complex (mTORC)1 on the inflammatory status within OA is not well studied. Therefore, we aimed to investigate if inhibition of mTORC1 by rapamycin can preserve and sustain chondrocytes in an inflammatory environment. Patient-derived chondrocytes were cultured in media supplemented with or without the mTORC1 inhibitor rapamycin. To establish an inflammatory environment, either TNF-α or IL-1β was added to the media (=OA-model). The chondroprotective and anti-inflammatory effects of rapamycin were evaluated using sulfated glycosaminoglycan (sGAG) release assay, Caspase 3/7 activity assay, lactate dehydrogenase (LDH) assay and quantitative real time polymerase chain reaction (PCR). Blocking mTORC1 by rapamycin reduced the release and therefore degradation of sGAGs, which are components of the extracellular matrix secreted by chondrocytes. Furthermore, blocking mTORC1 in OA chondrocytes resulted in an enhanced expression of the main chondrogenic markers. Rapamycin was able to protect chondrocytes from cell death in an OA-model shown by reduced Caspase 3/7 activity and diminished LDH release. Furthermore, inhibition of mTORC1 preserved the chondrogenic phenotype of OA chondrocytes, but also reduced inflammatory processes within the OA-model. This study highlights that blocking mTORC1 is a new and promising approach for treating OA. Low side effects make rapamycin an attractive implementation to existing therapeutic strategies. We showed that rapamycin's chondroprotective property might be due to an interference with IL-1β triggered inflammatory processes.

Treatment Guidelines for Rheumatologic Manifestations of Sjögren's Syndrome: Use of Biologic Agents, Management of Fatigue, and Inflammatory Musculoskeletal Pain

OBJECTIVE

The Sjögren's Syndrome Foundation clinical practice guidelines (CPGs) are designed to improve quality and consistency of care in Sjögren's syndrome by offering recommendations for management.

METHODS

Management questions for the systemic manifestations of Sjögren's syndrome were posed by the CPG committee with input from patients and rheumatologists. Clinical questions were assigned to a topic review group that performed systematic reviews and data extraction and drafted guidelines. Quality of evidence and strength of recommendation were rated using the American Society of Clinical Oncology's modification of the Grading of Recommendations Assessment, Development, and Evaluation. Guideline recommendations were reviewed by a consensus expert panel (CEP) composed of 30-40 clinicians from academia and community practices, as well as registered nurses and patients, using a modified Delphi process. A CEP agreement level of 75% was set as a minimum for adoption of a guideline recommendation.

RESULTS

Consensus was achieved for 19 recommendations; for 11 additional modules, available data were insufficient to allow a recommendation to be formulated. Of the 19 recommendations, 15 required 1 Delphi round, 2 required 2 rounds, and 2 required 3 rounds.

CONCLUSION

Key recommendations include a decision tree for the use of oral disease-modifying antirheumatic drugs for inflammatory musculoskeletal pain, use of self-care measures and advice regarding exercise to reduce fatigue, and the use of rituximab in selected clinical settings for oral and ocular dryness and for certain extraglandular manifestations, including vasculitis, severe parotid swelling, inflammatory arthritis, pulmonary disease, and mononeuritis multiplex. The CPG committee strongly discouraged the use of tumor necrosis factor inhibitors for sicca symptoms and for the majority of clinical contexts in primary Sjögren's syndrome.

Exercise as medicine - evidence for prescribing exercise as therapy in 26 different chronic diseases

This review provides the reader with the up-to-date evidence-based basis for prescribing exercise as medicine in the treatment of 26 different diseases: psychiatric diseases (depression, anxiety, stress, schizophrenia); neurological diseases (dementia, Parkinson's disease, multiple sclerosis); metabolic diseases (obesity, hyperlipidemia, metabolic syndrome, polycystic ovarian syndrome, type 2 diabetes, type 1 diabetes); cardiovascular diseases (hypertension, coronary heart disease, heart failure, cerebral apoplexy, and claudication intermittent); pulmonary diseases (chronic obstructive pulmonary disease, asthma, cystic fibrosis); musculo-skeletal disorders (osteoarthritis, osteoporosis, back pain, rheumatoid arthritis); and cancer. The effect of exercise therapy on disease pathogenesis and symptoms are given and the possible mechanisms of action are discussed. We have interpreted the scientific literature and for each disease, we provide the reader with our best advice regarding the optimal type and dose for prescription of exercise.

Calprotectin levels in patients with rheumatoid arthritis to assess and association with exercise treatment

Rheumatoid arthritis (RA) is a chronic, inflammatory, and autoimmune disease that can cause permanent joint damage. In our study, we aim to analyze the change in calprotectin levels following the low-density exercise levels applied to the patients with RA. Twenty-eight patients with RA and 30 healthy controls were included in this study. To evaluate the activity of disease in RA, scores of disease activity that has increased (DAS-28) are figured. Calprotectin, nitric oxide (NO), white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and rheumatoid factor (RF) levels are tested as the laboratory evaluation. Calprotectin, NO, CRP, ESR, WBC, and RF levels were significantly higher in the patient group compared to the control group (p < 0.01, p < 0.001, p < 0.01, p < 0.01, p < 0.01, and p < 0.05, respectively). In correlation analysis applied to the patient group with RA, there has been determined a positive relation with calprotectin, and DAS-28, CRP, NO, RF, and WBC (p < 0.001, p < 0.05, p < 0.001, p < 0.05, and p < 0.05, respectively). In result of the low-density exercise treatment applied to patients with RA for 8 weeks, there has been determined a significant decrease in calprotectin, DAS-28, NO, CRP, ESR, and RF levels (p < 0.05, p < 0.001, p < 0.01, p < 0.05, p < 0.05, and p < 0.05, respectively). As a result, a significant relation is found between RA disease activity and calprotectin levels and other inflammatory parameters. At the same time, it shows that calprotectin which is a significant indicator of local inflammation can be used as a good identifier in following up exercise treatment.

Inflammatory mediators in osteoarthritis: A critical review of the state-of-the-art, current prospects, and future challenges

Osteoarthritis (OA) has traditionally been defined as a prototypical non-inflammatory arthropathy, but today there is compelling evidence to suggest that it has an inflammatory component. Many recent studies have shown the presence of synovitis in a large number of patients with OA and demonstrated a direct association between joint inflammation and the progression of OA. Pro-inflammatory cytokines, reactive oxygen species (ROS), nitric oxide, matrix degrading enzymes and biomechanical stress are major factors responsible for the progression of OA in synovial joints. The aim of this review is to discuss the significance of a wide range of implicated inflammatory mediators and their contribution to the progression of OA. We also discuss some of the currently available guidelines, practices, and prospects. In addition, this review argues for new innovation in methodologies and instrumentation for the non-invasive detection of inflammation in OA by modern imaging techniques. We propose that identifying early inflammatory events and targeting these alterations will help to ameliorate the major symptoms such as inflammation and pain in OA patients.

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.

Fatigue in chronic inflammation - a link to pain pathways

Fatigue is a frequent symptom in several inflammatory diseases, particularly in rheumatic diseases. Elements of disease activity and cognitive and behavior aspects have been reported as causes of fatigue in patients with rheumatoid arthritis. Fatigue could be associated with activity of inflammatory rheumatism. Indeed, biologic agents targeting inflammatory cytokines are effective in fatigue. Fatigue is also associated with pain and depressive symptoms. Different pathways could be involved in fatigue and interact: the immune system with increased levels of pro-inflammatory cytokines (interleukin-1 and -6 and tumor necrosis factor alpha), dysregulation of the hypothalamic-pituitary-adrenal axis and neurological phenomena involving the central and autonomic nervous systems. A pro-inflammatory process could be involved in pain and behavioral symptoms. Inflammation could be a common link between fatigue, pain, and depression.

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.

Improving physical activity in arthritis clinical trial (IMPAACT): study design, rationale, recruitment, and baseline data

Over 21 million Americans report an arthritis-attributable activity limitation. Knee osteoarthritis (OA) and rheumatoid arthritis (RA) are two of the most common/disabling forms of arthritis. Various forms of physical activity (PA) can improve a variety of health outcomes and reduce health care costs, but the proportion of the US population engaging in the recommended amount of PA is low and even lower among those with arthritis. The Improving Motivation for Physical Activity in Arthritis Clinical Trial (IMPAACT) is a randomized clinical trial that studied the effects of a lifestyle PA promotion intervention on pain and physical function outcomes. The IMPAACT intervention was based on a chronic care/disease management model in which allied health professionals promote patient self-management activities outside of traditional physician office encounters. The program was a motivational interviewing-based, individualized counseling and referral intervention, directed by a comprehensive assessment of individual patient barriers and strengths related to PA performance. The specific aims of IMPAACT were to test the efficacy of the IMPAACT intervention for persons with arthritis (N=185 persons with RA and 155 persons with knee OA) in improving arthritis-specific and generic self-reported pain and Physical Function outcomes, observed measures of function, and objectively measured and self-reported PA levels. Details of the stratified-randomized study design, subject recruitment, and data collection are described. The results from IMPAACT will generate empiric evidence pertaining to increasing PA levels in persons with arthritis and result in widely applicable strategies for health behavior change.

Phase I/II randomized trial of aerobic exercise in Parkinson disease in a community setting

OBJECTIVES

To (1) investigate effects of aerobic walking on motor function, cognition, and quality of life in Parkinson disease (PD), and (2) compare safety, tolerability, and fitness benefits of different forms of exercise intervention: continuous/moderate intensity vs interval/alternating between low and vigorous intensity, and individual/neighborhood vs group/facility setting.

METHODS

Initial design was a 6-month, 2 × 2 randomized trial of different exercise regimens in independently ambulatory patients with PD. All arms were required to exercise 3 times per week, 45 minutes per session.

RESULTS

Randomization to group/facility setting was not feasible because of logistical factors. Over the first 2 years, we randomized 43 participants to continuous or interval training. Because preliminary analyses suggested higher musculoskeletal adverse events in the interval group and lack of difference between training methods in improving fitness, the next 17 participants were allocated only to continuous training. Eighty-one percent of 60 participants completed the study with a mean attendance of 83.3% (95% confidence interval: 77.5%-89.0%), exercising at 46.8% (44.0%-49.7%) of their heart rate reserve. There were no serious adverse events. Across all completers, we observed improvements in maximum oxygen consumption, gait speed, Unified Parkinson's Disease Rating Scale sections I and III scores (particularly axial functions and rigidity), fatigue, depression, quality of life (e.g., psychological outlook), and flanker task scores (p < 0.05 to p < 0.001). Increase in maximum oxygen consumption correlated with improvements on the flanker task and quality of life (p < 0.05).

CONCLUSIONS

Our preliminary study suggests that aerobic walking in a community setting is safe, well tolerated, and improves aerobic fitness, motor function, fatigue, mood, executive control, and quality of life in mild to moderate PD.

CLASSIFICATION OF EVIDENCE

This study provides Class IV evidence that in patients with PD, an aerobic exercise program improves aerobic fitness, motor function, fatigue, mood, and cognition.

Effect of cardiovascular training on fitness and perceived disease activity in people with ankylosing spondylitis

OBJECTIVE

Several studies suggest that patients with ankylosing spondylitis (AS) have an increased risk of cardiovascular disease. This study aimed to evaluate the effects of a 12-week, individually monitored, with moderate heart rate level intensity cardiovascular training on cardiovascular fitness and perceived disease activity in AS patients.

METHODS

Patients diagnosed with AS according to the modified New York criteria were randomized to either cardiovascular training or attention control. The training group performed 3 cardiovascular training units per week. All participants attended 1 weekly usual care flexibility training session. Attention control contained regular discussion groups on coping strategies. Adherence was self-monitored. Assessments were performed at baseline and after the intervention period of 3 months. Physical fitness was the primary end point, measured in watts using a submaximal bicycle test following the physical work capacity 75% protocol. All analyses controlled for sex, age, body mass index,baseline fitness and physical activity levels, and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI).

RESULTS

Of 106 AS patients enrolled, 40% were women and the mean ± SD age was 49 ± 12 years. A total of 74.6% of the training group reported exercising at least 3 times a week. At the 3-month followup, the fitness level in the training group was significantly higher than in the control group (mean ± SE 90.32W ± 4.52W versus 109.84W ± 4.72W; P = 0.001), independent of other covariates. The mean BASDAI total score was 0.31 points lower (P = 0.31) in the training group, reaching significance for the peripheral pain subscore (1.19; P = 0.01) but not for back pain or fatigue.

CONCLUSION

Cardiovascular training, in addition to flexibility exercise, increased fitness in AS patients and reduced their peripheral pain.

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.

Risk factors for falls in adults with rheumatoid arthritis: a prospective study

OBJECTIVE

To investigate the association between potential risk factors and falls in community-dwelling adults with rheumatoid arthritis (RA).

METHODS

We followed patients for 1 year of followup in a prospective cohort study with monthly falls calendars and telephone calls. Lower extremity muscle strength, postural stability, number of swollen and tender joints, functional status, history of falling, fear of falling, pain, fatigue, medication, and use of steroids were assessed as risk factors for falls.

RESULTS

A total of 386 women and 173 men with RA (n = 559) ages 18-88 years completed baseline assessments and 535 participants (96%) completed 1-year followup. Bivariate logistic regression showed that falls risk was not associated with age or sex. Multivariate logistic regression revealed that a history of multiple falls in the previous 12 months was the most significant predictive risk factor (odds ratio [OR] 5.3, 95% confidence interval [95% CI] 2.3-12.3). The most significant modifiable risk factors were swollen and tender lower extremity joints (OR 1.7, 95% CI 1.1-2.7), psychotropic medication (OR 1.8, 95% CI 1.1-3.1), and fatigue (OR 1.13, 95% CI 1.02-1.2).

CONCLUSION

Adults with RA are at high risk of falls. In clinical practice, high-risk fall patients with RA can be identified by asking whether patients have fallen in the past year. Important risk factors highlighted in this study include swollen and tender lower extremity joints, fatigue, and use of psychotropic medications.

Non-pharmacological interventions for fatigue in rheumatoid arthritis

BACKGROUND

Fatigue is a common and potentially distressing symptom for people with rheumatoid arthritis with no accepted evidence based management guidelines. Non-pharmacological interventions, such as physical activity and psychosocial interventions, have been shown to help people with a range of other long-term conditions to manage subjective fatigue.

OBJECTIVES

To evaluate the benefit and harm of non-pharmacological interventions for the management of fatigue in people with rheumatoid arthritis. This included any intervention that was not classified as pharmacological in accordance with European Union (EU) Directive 2001/83/EEC.

SEARCH METHODS

The following electronic databases were searched up to October 2012, Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; AMED; CINAHL; PsycINFO; Social Science Citation Index; Web of Science; Dissertation Abstracts International; Current Controlled Trials Register; The National Research Register Archive; The UKCRN Portfolio Database. In addition, reference lists of articles identified for inclusion were checked for additional studies and key authors were contacted.

SELECTION CRITERIA

Randomised controlled trials were included if they evaluated a non-pharmacological intervention in people with rheumatoid arthritis with self-reported fatigue as an outcome measure.

DATA COLLECTION AND ANALYSIS

Two review authors selected relevant trials, assessed risk of bias and extracted data. Where appropriate, data were pooled using meta-analysis with a random-effects model.

MAIN RESULTS

Twenty-four studies met the inclusion criteria, with a total of 2882 participants with rheumatoid arthritis. Included studies investigated physical activity interventions (n = 6 studies; 388 participants), psychosocial interventions (n = 13 studies; 1579 participants), herbal medicine (n = 1 study; 58 participants), omega-3 fatty acid supplementation (n = 1 study; 81 participants), Mediterranean diet (n = 1 study; 51 participants), reflexology (n = 1 study; 11 participants) and the provision of Health Tracker information (n = 1 study; 714 participants). Physical activity was statistically significantly more effective than the control at the end of the intervention period (standardized mean difference (SMD) -0.36, 95% confidence interval (CI) -0.62 to -0.10; back translated to mean difference of 14.4 points lower, 95% CI -4.0 to -24.8 on a 100 point scale where a lower score means less fatigue; number needed to treat for an additional beneficial outcome (NNTB) 7, 95% CI 4 to 26) demonstrating a small beneficial effect upon fatigue. Psychosocial intervention was statistically significantly more effective than the control at the end of the intervention period (SMD -0.24, 95% CI -0.40 to -0.07; back translated to mean difference of 9.6 points lower, 95% CI -2.8 to -16.0 on a 100 point scale, lower score means less fatigue; NNTB 10, 95% CI 6 to 33) demonstrating a small beneficial effect upon fatigue. For the remaining interventions meta-analysis was not possible and there was either no statistically significant difference between trial arms or findings were not reported. Only three studies reported any adverse events and none of these were serious, however, it is possible that the low incidence was in part due to poor reporting. The quality of the evidence ranged from moderate quality for physical activity interventions and Mediterranean diet to low quality for psychosocial interventions and all other interventions.

AUTHORS' CONCLUSIONS

This review provides some evidence that physical activity and psychosocial interventions provide benefit in relation to self-reported fatigue in adults with rheumatoid arthritis. There is currently insufficient evidence of the effectiveness of other non-pharmacological interventions.

Biomechanical factors in osteoarthritis

Biomechanical factors play an important role in the health of diarthrodial joints. Altered joint loading - associated to obesity, malalignment, trauma or joint instability - is a critical risk factor for joint degeneration, whereas exercise and weight loss have generally been shown to promote beneficial effects for osteoarthritic joints. The mechanisms by which mechanical stress alters the physiology or pathophysiology of articular cartilage or other joint tissues likely involve complex interactions with genetic and molecular influences, particularly local or systemic inflammation secondary to injury or obesity. Chondrocytes perceive physical signals from their environment using a variety of mechanisms, including ion channels, integrin-mediated connections to the extracellular matrix that involve membrane, cytoskeletal and intracellular deformation. An improved understanding of the biophysical and molecular pathways involved in chondrocyte mechanotransduction can provide insight into the development of novel therapeutic approaches for osteoarthritis.

Effects of different local cryotherapies on systemic levels of TNF-α, IL-6, and clinical parameters in active rheumatoid arthritis

Cryotherapies are frequently used to supplement the rehabilitation of patients with rheumatoid arthritis (RA) owing to their analgesic and anti-inflammatory effects. Forty patients with active RA were recruited and received 10 days of comprehensive therapy with different local cryotherapies. None of the respondents were subjected to biological treatment. They were divided into two groups according to the therapy received: nitrogen vapour at -160 °C (group I) or cold airflow at -30 °C (group II). Levels of tumour necrosis factor α (TNF-α), interleukin 6 (IL-6), disease activity score (DAS28), and functional variables were used to assess the outcomes. After the therapy, both groups exhibited similar improvements. Significant reduction in TNF-α level (nitrogen: p < 0.01; cold air: p < 0.05) and no change in IL-6 were observed. DAS28, the clinical severity of pain, duration of morning stiffness, degree of self-reported fatigue, and health assessment questionnaire (HAQ) scores improved significantly. In addition, the active range of knee extension, time, and the number of steps in the 50-m walk test also clearly got better in both groups. The 10-day comprehensive therapies including different local cryotherapies for the patients with RA cause significant decrease in TNF-α systemic levels, meaningly improve DAS28, HAQ scores, and some functional parameters, but do not change IL-6 levels. However, there were no differences in the effectiveness of either cryotherapy.

Association Between Measures of Fatigue and Health-Related Quality of Life in Rheumatoid Arthritis and Osteoarthritis

OBJECTIVE

To assess the relationship between fatigue and health-related quality of life (HR-QOL) among people with osteoarthritis (OA) and rheumatoid arthritis (RA).

METHODS

Community-dwelling people with OA, and OA patients on the waiting list for joint replacement surgery, were recruited. RA patients were recruited from rheumatologists' public and private outpatient clinics. Respondents completed a questionnaire containing demographic detail, the Fatigue Severity Scale (FSS), the Multidimensional Assessment of Fatigue (MAF), the SF-36, Western Ontario and McMaster Universities Osteoarthritis Index, and the Health Assessment Questionnaire (HAQ).

RESULTS

There were 137 OA and 52 RA respondents. Neither age nor sex was significantly associated with fatigue for OA or RA. The mean FSS score was 3.36 for RA and 3.63 for OA. Fifty percent of respondents with RA and 58% of those with OA met the FSS >3 cut-point for fatigue. Mean MAF Global Fatigue Index was 20.8 for OA and 20.1 for RA. Correlations between health status and fatigue indicated that for both OA and RA those with greater fatigue reported worse health status.

CONCLUSIONS

Few studies have measured the impact of fatigue among respondents with OA, despite it affecting a large proportion of the population. Fatigue was significantly correlated with poorer HR-QOL among OA respondents, suggesting that fatigue is a significant issue in OA as well as RA.

Effects of an enjoyable nurse-led intervention to promote movement in poststroke inpatients

It is important to have the stroke survivors move as soon as possible to improve disability as well as related problems such as fatigue, sleep, and depression. However, there were few reports on a movement intervention for the inpatients who were in the rehabilitation unit just after taking acute care. An enjoyable intervention was developed that promoted movement focusing on plegic limbs and looked more like a game or a play; the game was designed to be a group activity that could be led by nurses. Twenty participants participated in 30- to 40-min sessions, 3 times a week for 2 weeks. Functional status (cognitive, motor, and total), fatigue, sleep, and depression were measured. Except for the cognitive function, all outcomes were significantly improved in the experimental group as compared to those in the control group. Safe and enjoyable nursing interventions should be developed and implemented to improve disability and related problems for the poststroke inpatients.

Fatigue in systemic lupus erythematosus

Systemic lupus erythematosus is a chronic inflammatory autoimmune disease often characterized by fatigue, with significant effects on physical functioning and wellbeing. The definition, prevalence and factors associated with fatigue, including physical activity, obesity, sleep, depression, anxiety, mood, cognitive dysfunction, vitamin D deficiency/insufficiency, pain, effects of medications and comorbidities, as well as potential therapeutic options of fatigue in the systemic lupus erythematosus population are reviewed. Due to variability in the reliability and validity of various fatigue measures used in clinical studies, clinical trial data have been challenging to interpret. Further investigation into the relationships between these risk factors and fatigue, and improved measures of fatigue, may lead to an improvement in the management of this chronic inflammatory disease.

Effects of a group-based exercise and educational program on physical performance and disease self-management in rheumatoid arthritis: a randomized controlled study

BACKGROUND

Evidence supports the use of educational and physical training programs for people with rheumatoid arthritis (RA).

OBJECTIVE

The purpose of this study was to evaluate the effects of a group-based exercise and educational program on the physical performance and disease self-management of people with RA.

DESIGN

This was a randomized controlled trial.

SETTING

The study was conducted at a rehabilitation center in the Netherlands.

PARTICIPANTS

Thirty-four people diagnosed with RA participated in the study. Participants were randomly assigned to either an intervention group (n=19) or a waiting list control group (n=15).

INTERVENTION

The intervention in this study was an 8-week, multidisciplinary, group therapy program for people with RA, consisting of physical exercise designed to increase aerobic capacity and muscle strength (force-generating capacity) together with an educational program to improve health status and self-efficacy for disease-self-management.

MEASUREMENTS

The main outcome measures were maximum oxygen uptake (Vo(2)max), muscle strength of the elbow and knee flexors and extensors, health status, and perceived self-efficacy. All data were recorded before intervention in week 1, after intervention in week 9, and at follow-up in week 22.

RESULTS

The intervention group showed significant improvement (12.1%) in Vo(2)max at week 9 compared with the control group (-1.7%). Although significant within-group changes were found over time for muscle strength of the upper and lower extremities and health status that favored the intervention group, no between-group changes were found regarding these outcomes.

LIMITATIONS

An important limitation was the small number of participants included in our study, which may have resulted in a lack of power.

CONCLUSIONS

The present group-based exercise and educational program for people with RA had a beneficial effect on aerobic capacity but not on muscle strength, health status, or self-efficacy.

Benefits of exercise in rheumatoid arthritis

This paper aims to highlight the importance of exercise in patients with rheumatoid arthritis (RA) and to demonstrate the multitude of beneficial effects that properly designed exercise training has in this population. RA is a chronic, systemic, autoimmune disease characterised by decrements to joint health including joint pain and inflammation, fatigue, increased incidence and progression of cardiovascular disease, and accelerated loss of muscle mass, that is, “rheumatoid cachexia”. These factors contribute to functional limitation, disability, comorbidities, and reduced quality of life. Exercise training for RA patients has been shown to be efficacious in reversing cachexia and substantially improving function without exacerbating disease activity and is likely to reduce cardiovascular risk. Thus, all RA patients should be encouraged to include aerobic and resistance exercise training as part of routine care. Understanding the perceptions of RA patients and health professionals to exercise is key to patients initiating and adhering to effective exercise training.

Randomised controlled trial examining the effect of exercise in people with rheumatoid arthritis taking anti-TNFα therapy medication

Abstract

Methods/Design

Six hundred and eighteen individuals with RA, on anti-TNFα therapy medication, will be randomised into one of 3 groups: a land-based exercise group; a water-based exercise group or a control group. The land and water-based groups will exercise for one hour, twice a week for eight weeks. The control group will receive no intervention and will be asked not to alter their exercise habits for the duration of the study. The primary outcome measure, the Stanford Health Assessment Questionnaire Disability Index (HAQ-DI) which measures functional ability, and secondary measures of pain, fatigue and quality of life, will be assessed at baseline, eight and 24 weeks by an independent assessor unaware of group allocation. Changes in outcome from 0 to 8 weeks and 0 to 24 weeks in the 'land-based exercise group versus control group' and the 'water-based exercise group versus control group' will be examined. Analysis will be conducted on an intention to treat basis.

Discussion

This trial will evaluate the effectiveness of group exercise therapy on land or in water, for people with RA taking anti-TNFα therapy medication. If these exercise groups are found to be beneficial, they could be conducted in local community facilities thus making these forms of exercise more easily accessible for individuals and potentially reduce the burden on health services.

Trial Registration

This trial is registered with ClinicalTrials.gov (a service of the United States National Institutes of Health) identifier: NCT00855322.

Women's experiences of sexual health when living with rheumatoid arthritis--an explorative qualitative study

Background

The ICF core sets for patients with Rheumatoid Arthritis (RA) acknowledge sexual function and intimate relationships as important since the patients' sexual health can be affected by the disease. About 36-70% of all RA-patients experience a reduced sexual health, and their perceived problems are directly or indirectly caused by their disease. Physiotherapy is often used as non-pharmacological treatment for RA. Mobility treatment, pain reduction, and physical activities are often included in physiotherapy for patients with RA. The aim of the study was to explore sexual health in relation to physiotherapy in women living with RA.

Method

An explorative qualitative interview study with a phenomenological approach was performed. The study consisted of ten interviews with women with RA. The analysis was performed according to Giorgi.

Results

The main theme that emerged in the material was that the body and the total life situation affected sexual health. Three categories were included in the theme: 1) sexual health - physical and psychological dimensions, 2) Impacts of RA, and 3) Possibilities to increase sexual health - does physiotherapy make a difference?

Conclusions

Sexual health was affected by RA in different ways for the informants. Possibilities to improve sexual health were improved partner communication and physiotherapy. Physiotherapy can play an active role in improving sexual health for patients with RA.

Fatigue in patients with diabetes: a review

OBJECTIVE

Fatigue is a common and distressing complaint among people with diabetes and likely to hinder the ability to perform daily diabetes self-management tasks. A review of the literature about diabetes-related fatigue was conducted with an eye toward creating a framework for beginning to conduct more focused studies on this subject.

METHODS

A literature search containing the terms diabetes, fatigue, tiredness, and symptoms was conducted to search for literature that addressed diabetes-related fatigue.

RESULTS

Diabetes presents many potential pathways for fatigue, but focused studies on this symptom are rare. Furthermore, research on diabetes-related fatigue is limited by fatigue's nonspecific symptoms and because fatigue researchers have yet to agree on standardized definition, measurement, or diagnostic criteria. Additionally, few diabetes randomized clinical trials included measurement of patient-reported outcomes, such as symptoms or health-related quality of life in their study designs, although one that did provided some meaningful finding that symptom-focused education improved self-management practices, Hb(A1c) levels, quality of life, and symptom distress.

CONCLUSION

There is a need to standardize the definition, measurement, and diagnostic criteria of fatigue in diabetes. We present a model that can guide focused studies on fatigue in diabetes. The model capitalizes on the multidimensional phenomena (physiological, psychological, and lifestyle) associated with fatigue in diabetes.

Collaboration with patients in the design of patient-reported outcome measures: capturing the experience of fatigue in rheumatoid arthritis

OBJECTIVE

Patient-reported outcome measures (PROMs) need to include concepts and language relevant to patients and be easily understood. These studies aimed to develop draft PROMs to measure rheumatoid arthritis (RA) fatigue and its impact by collaborating with patients to identify language and experiences, create draft PROM items, and test them for comprehension, with decisions supported throughout by a patient research partner.

METHODS

In study 1, interview transcripts of RA patients describing their fatigue (n = 15) were subjected to content and inductive thematic analysis to identify fatigue language and experiences. In study 2, 3 focus groups of RA patients (n = 17) explored these and developed the wording for visual analog scales (VAS) and identical numerical rating scales (NRS), then a draft multi-item questionnaire was developed with the patient research partner. Study 3 comprised 15 RA patients who completed the PROMs during cognitive interviewing to explore understanding.

RESULTS

Studies 1 and 2 identified key patient terminology (fatigue, exhaustion) and 12 potential fatigue concepts (Cognition, Coping, Duration, Emotion, Energy, Frequency, Impact, Planning, Quality of Life, Relationships, Sleep, and Social Life). Patients' proposals were clarified into draft screening VAS/NRS for fatigue severity, effect, and coping, plus a draft 45-item questionnaire. Study 3 showed that 14 questions required clarification or revision of response options.

CONCLUSION

Collaboration with patients enabled development of draft RA fatigue PROMs grounded in the patient data, strengthening face and content validity and ensuring comprehension. The draft conceptual framework that emerged has resulted in draft PROMS ready for item reduction, and testing of construct and criterion validity and reliability.

Sex differences in the relations of positive and negative daily events and fatigue in adults with rheumatoid arthritis

Fatigue is a common, disabling symptom for individuals with rheumatoid arthritis (RA). This study 1) examined sex differences in the relations between daily changes in positive and negative interpersonal events and same-day and next-day fatigue and 2) tested positive affect and negative affect as mediators of the associations between changes in interpersonal events and fatigue. Reports of fatigue, number of positive and negative interpersonal events, and positive and negative affect were assessed daily for 30 days via diaries in 228 men and women diagnosed with RA. Days of higher than average daily positive events were associated with both decreased same-day fatigue and increased next-day fatigue, but only among women. Sex differences in same-day relations between positive events and fatigue were mediated by increases in positive affect. For both sexes, days of higher than average daily negative events related to increased same-day and next-day fatigue, and the same-day relations between negative events and fatigue were mediated by increases in negative affect. A more nuanced understanding of similarities and differences between men and women in the associations between changes in interpersonal events and fatigue may inform future interventions for RA fatigue.

PERSPECTIVE

This article presents an examination of sex differences in the links between changes in daily interpersonal events and fatigue in chronic pain patients. The findings can help clinicians target the psychosocial factors that potentially can ameliorate their patients' experience of fatigue.

Dynamic exercise programs (aerobic capacity and/or muscle strength training) in patients with rheumatoid arthritis

BACKGROUND

An up-to-date overview of the effectiveness and safety of dynamic exercise therapy (exercise therapy with a sufficient intensity, duration, and frequency to establish improvement in aerobic capacity and/or muscle strength) is lacking.

OBJECTIVES

To assess the effectiveness and safety of short-term (< three months) and long-term (> three months) dynamic exercise therapy programs (aerobic capacity and/or muscle strength training), either land or water-based, for people with RA. To do this we updated a previous Cochrane review (van den Ende 1998) and made categories for the different forms of dynamic exercise programs.

SEARCH STRATEGY

A literature search (to December 2008) within various databases was performed in order to identify randomised controlled trials (RCTs).

SELECTION CRITERIA

RCTs that included an exercise program fulfilling the following criteria were selected: a) frequency at least twice weekly for > 20 minutes; b) duration > 6 weeks; c) aerobic exercise intensity > 55% of the maximum heart rate and/or muscle strengthening exercises starting at 30% to 50% of one repetition maximum; and d) performed under supervision. Moreover, the RCT included one or more of the following outcome measures: functional ability, aerobic capacity, muscle strength, pain, disease activity or radiological damage.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected eligible studies, rated the methodological quality, and extracted data. A qualitative analysis (best-evidence synthesis) was performed and, where appropriate, a quantitative data analysis (pooled effect sizes).

MAIN RESULTS

In total, eight studies were included in this updated review (two additional studies). Four of the eight studies fulfilled at least 8/10 methodological criteria. In this updated review four different dynamic exercise programs were found: (1) short-term, land-based aerobic capacity training, which results show moderate evidence for a positive effect on aerobic capacity (pooled effect size 0.99 (95% CI 0.29 to 1.68). (2) short-term, land-based aerobic capacity and muscle strength training, which results show moderate evidence for a positive effect on aerobic capacity and muscle strength (pooled effect size 0.47 (95% CI 0.01 to 0.93). (3) short-term, water-based aerobic capacity training, which results show limited evidence for a positive effect on functional ability and aerobic capacity. (4) long-term, land-based aerobic capacity and muscle strength training, which results show moderate evidence for a positive effect on aerobic capacity and muscle strength. With respect to safety, no deleterious effects were found in any of the included studies.

AUTHORS' CONCLUSIONS

Based on the evidence, aerobic capacity training combined with muscle strength training is recommended as routine practice in patients with RA.

Effects of a home-based exercise program on quality of life, fatigue, and depression in patients with ankylosing spondylitis

The aim of this trial was to investigate the effects of a 12-week home-based exercise program (HEP) on quality of life (QOL) and fatigue in patients with Ankylosing Spondylitis (AS). Forty-three patients with AS were included in this study. Group 1 was given a HEP; Group 2 served as the control group. The functional capacity (Bath Ankylosing Spondylitis Functional Index), disease activity (Bath Ankylosing Spondylitis Disease Assessment Index), fatigue (Multidimensional Assessment of Fatigue Scale), depression (Beck Depression Inventory scores), and QOL (Short Form 36) of all participants were evaluated. There were significant improvements for all the parameters in two groups after the treatment. The improvements for all the parameters were better in the exercise group than in the control group. Home-based exercise programs are very effective in improving QOL and reducing fatigue. Because of these advantages, HEP should be advised for the management program in AS in addition to medical treatments.

Determination of the minimal clinically important difference for seven fatigue measures in rheumatoid arthritis

OBJECTIVE

To estimate the minimal clinically important difference (MCID) of seven measures of fatigue in rheumatoid arthritis.

STUDY DESIGN AND SETTING

A cross-sectional study design based on interindividual comparisons was used. Six to eight subjects participated in a single meeting and completed seven fatigue questionnaires (nine sessions were organized and 61 subjects participated). After completion of the questionnaires, the subjects had five one-on-one 10-minute conversations with different people in the group to discuss their fatigue. After each conversation, each patient compared their fatigue to their conversational partners on a global rating. Ratings were compared to the scores of the fatigue measures to estimate the MCID. Both nonparametric and linear regression analyses were used.

RESULTS

Nonparametric estimates for the MCID relative to "little more fatigue" tended to be smaller than those for "little less fatigue." The global MCIDs estimated by linear regression were: Fatigue Severity Scale, 20.2; Vitality scale of the MOS-SF36, 14.8; Multidimensional Assessment of Fatigue, 18.7; Multidimensional Fatigue Inventory, 16.6; Functional Assessment of Chronic Illness Therapy-Fatigue, 15.9; Chalder Fatigue Scale, 9.9; 10-point numerical Rating Scale, 19.7, for normalized scores (0-100). The standardized MCIDs for the seven measures were roughly similar (0.67-0.76).

CONCLUSION

These estimates of MCID will help to interpret changes observed in a fatigue score and will be critical in estimating sample size requirements.

Temperament and fatigue management in persons with chronic rheumatic disease

BACKGROUND

In persons with chronic conditions, fatigue is often a disruptive symptom with a devastating impact on overall well-being. Descriptions of experiences with fatigue contribute to advancing knowledge and improving health outcomes.

AIM

To describe the influence temperament has on fatigue representation, self-care strategies, and strategy success.

METHOD

A secondary analysis of an existing database of personal characteristics and symptom experiences of adults with chronic rheumatic diseases was conducted. All participants who reported fatigue at least once during the first week of participation in the study were included. Relationships were examined among demographic variables, temperamental dispositions, and symptom representation.

RESULTS

Significant relationships were demonstrated between perceived symptom seriousness, interference and helpfulness of selected strategies, and both demographic variables and temperamental dispositions.

CONCLUSIONS

When choosing interventions for the individual experiencing fatigue, be aware of demographic data and use assessment techniques to promote positive health practices.

Rheumatoid arthritis, cardiovascular disease and physical exercise: a systematic review

This systematic review investigates the effectiveness of exercise interventions in improving disease-related characteristics in patients with rheumatoid arthritis (RA). It also provides suggestions for exercise programmes suitable for improving the cardiovascular profile of RA patients and proposes areas for future research in the field. Six databases (Medline, Cochrane Library, CINAHL, Google Scholar, EMBASE and PEDro) were searched to identify publications from 1974 to December 2006 regarding RA and exercise interventions. The quality of the studies included was determined by using the Jadad scale. Initial searches identified 1342 articles from which 40 met the inclusion criteria. No studies were found investigating exercise interventions in relation to cardiovascular disease in RA. There is strong evidence suggesting that exercise from low to high intensity of various modes is effective in improving disease-related characteristics and functional ability in RA patients. Future studies are required to investigate the effects of exercise in improving the cardiovascular status of this patient population.

Predictors of exercise and effects of exercise on symptoms, function, aerobic fitness, and disease outcomes of rheumatoid arthritis

OBJECTIVE

To determine the effects of participation in a low-impact aerobic exercise program on fatigue, pain, and depression; to examine whether intervention groups compared with a control group differed on functional (grip strength and walk time) and disease activity (total joint count, erythrocyte sedimentation rate, and C-reactive protein) measures and aerobic fitness at the end of the intervention; and to test which factors predicted exercise participation.

METHODS

A convenience sample of 220 adults with rheumatoid arthritis (RA), ages 40-70, was randomized to 1 of 3 groups: class exercise, home exercise using a videotape, and control group. Measures were obtained at baseline (T1), after 6 weeks of exercise (T2), and after 12 weeks of exercise (T3).

RESULTS

Using structural equation modeling, overall symptoms (latent variable for pain, fatigue, and depression) decreased significantly at T3 (P < 0.04) for the class exercise group compared with the control group. There were significant interaction effects of time and group for the functional measures of walk time and grip strength: the treatment groups improved more than the control group (P <or= 0.005). There were no significant increases in measures of disease activity. Fatigue and perceptions of benefits and barriers to exercise affected participants' amount of exercise, supporting previous research.

CONCLUSION

This study supported the positive effects of exercise on walk time and grip strength, and demonstrated that fatigue and perceived benefits/barriers to exercise influenced exercise participation. Furthermore, overall symptoms of fatigue, pain, and depression were positively influenced in this selective group of patients with RA ages 40-70 years.

Quality of life in chronic musculoskeletal pain

This chapter reviews the impact of chronic musculoskeletal pain on patients' health-related quality of life. In addition to the physical health consequences, chronic musculoskeletal pain can have a profound negative impact on an individual's emotional and social well-being. Although efforts in the health sector are obviously of crucial importance in the management of chronic musculoskeletal pain, a high level of patient and societal involvement is key to reducing the burden of this condition. Patients should work in partnership with health-care professionals, actively participating in their care. Family members should encourage their loved ones to be as independent as possible. The employer of a person with chronic musculoskeletal pain has a vital role in returning him or her to work as soon as possible. Removing all barriers to the use of preventive and therapeutic services will help us to reduce the burden of musculoskeletal pain conditions on both patients and society.

Reconditioning in patients with rheumatoid arthritis

Rheumatologists traditionally have recommended to rheumatoid arthritis (RA) patients that they avoid dynamic and weight-bearing exercises because of concerns about aggravating joint inflammation and accelerating joint damage in such patients. These restrictions may lead to inadequate levels of physical activity and deconditioning.

OBJECTIVE

To review the literature on tolerance and benefits of conditioning training, including dynamic and weight-bearing activities in RA patients.

MATERIALS AND METHODS

Medline and Cochrane databases were searched with the keywords RA, rehabilitation, physical therapy, exercise, reconditioning, and rest.

RESULTS

Rest therapy is more deleterious than beneficial in most patients with RA and may lead to deconditioning. Dynamic and aerobic exercises do not aggravate joint inflammation and do not accelerate joint damage in such patients. The important goal of reconditioning patients with RA is the prevention of functional decline. Conditioning programs designed to prevent widespread morbidities in healthy subjects are attainable by most RA patients, but an individualized approach to exercise is required.

CONCLUSION

RA patients need to be persuaded about the effectiveness and safety of moderate and even high-intensity exercise.