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

Resistance exercise and low-level laser therapy improves grip strength and morphological aspects in the ankle joint of Wistar rats with experimental arthritis

Rheumatoid arthritis (RA) is an inflammatory disease mainly affecting synovial joints. Photobiomodulation through low-level laser therapy (LLLT) and resistance exercise may improve the inflammatory process. Therefore, we analyzed the effects of resistance exercise, LLLT, and the combination of both treatments on hind paw grip strength and ankle joint histomorphometric aspects of Wistar rats subjected to experimental RA. A total of 64 male Wistar rats were divided into eight groups: control, control LLLT, control exercise, control LLLT and exercise, arthritis, arthritis LLLT, arthritis exercise, and arthritis LLLT and exercise groups. The experimental RA was induced by a complete Freund's adjuvant injection into the knee joint cavity. Climbing exercises and LLLT (660 nm; 5 J/cm² per point) were performed as the treatment. In addition, muscle strength was evaluated using the grip strength test, and morphometric evaluations were performed on the ankle joint. Generalized mixed models and multivariate analysis of variance tests were used for statistical analysis. Statistical significance was set at a p-value of .05. Arthritis LLLT, exercise, and LLLT and exercise had positive effects on grip strength between the groups (F[7.56] = 5.8, p < .004) and within the groups (F[4.3] = 9.9, p < .002) throughout the evaluations. Morphometry revealed degenerative lesions in the ankle joint as subintima with angiogenesis, inflammatory cells, flocculated articular cartilage, chondrocyte disorganization, and pannus in the arthritis group (p < .001). The treated groups exhibited morphological characteristics similar to those of the control group. LLLT and resistance exercise restored muscle strength and morphological aspects of the ankle joint in rats with experimentally induced RA.

The association between rheumatoid arthritis and reduced estimated cardiorespiratory fitness is mediated by physical symptoms and negative emotions: a cross-sectional study

OBJECTIVES

Persons with rheumatoid arthritis (RA) have lower cardiorespiratory fitness (CRF) than healthy individuals. We sought to identify variables explaining the association between RA status and reduced CRF.

METHODS

RA patients recruited from two Norwegian hospitals and blood donors recruited as controls filled in questionnaires about physical activity, physical symptoms, and psychological factors. Estimated CRF (eCRF) was calculated from non-exercise models. The relationship between RA status and reduced eCRF was explored with structural equation modelling. The latent variables physical symptoms (based on morning stiffness, joint pain, and pain in neck, back, or hips) and negative emotions (based on Hospital Anxiety and Depression Scale's Depression score and Cohen's perceived stress scale) were included as possible mediators between RA status and eCRF in separate and combined models adjusted for age and sex.

RESULTS

Two-hundred-and-twenty-seven RA patients and 300 controls participated. The patients were older and had lower eCRF than controls (age- and sex-adjusted mean difference: 1.7 mL/kg/min, p=0.002). Both latent variables were significant mediators of the association between RA and reduced eCRF when included in separate models. The latent variables mediated 74% of the total effect of RA on eCRF in the combined model. Standardized coefficients: direct effect of RA -0.024 (p=0.46), indirect effect through physical symptoms -0.034 (p=0.051), and indirect effect through negative emotions -0.034 (p=0.039).

CONCLUSION

Both physical symptoms and negative emotions mediated the association between RA and reduced eCRF with similar effect sizes. To successfully increase CRF in RA patients, both physical and psychological factors should be addressed. Key Points • The RA patients in the present study had 1.7 mL/kg/min lower mean estimated cardiorespiratory fitness (CRF) compared to healthy controls. • Mediation analysis demonstrated that physical symptoms and negative emotions mediated 74% of the total negative effect of RA on estimated CRF in a combined, adjusted model. • This suggests that both physical and psychological factors should be addressed when supporting RA patients in improving their CRF.

Protocol for a multi-center randomized controlled trial to evaluate the benefits of exercise incentives and corticosteroid injections in osteoarthritis of the knee (MOVE-OK)

BACKGROUND

Knee osteoarthritis (KOA) is a high-priority problem among the aging population. While exercise has been shown to be beneficial in management of the disease, scalable and low-cost interventions to improve exercise in this population are lacking. Recent controversy over the value of corticosteroid injections for palliation has also arisen. Therefore, we designed a randomized, double-blind, placebo-controlled clinical trial with a 2-period crossover design to study (1) behavioral incentives to promote exercise and (2) corticosteroid injections to reduce pain and improve function in patients with KOA when compared to lidocaine only.

METHODS

The study design is a pragmatic factorial and crossover randomized clinical trial. Patients with KOA who are deemed eligible by their provider to receive knee injections and are able to walk without assistive devices will be recruited from clinical practices at four sites within the Veterans Affairs (VA) Health System in the USA. In total, 220 participants will be randomized to receive social incentives with gamification (i.e., incorporation of game elements) to promote exercise and compared to controls that receive a Fitbit but no incentive. Each patient will also be assigned to receive a blinded corticosteroid injection and a lidocaine-only injection in random order. The primary outcomes are the change in average daily step counts from baseline and the change in Knee Osteoarthritis Outcome Score (KOOS) from baseline. The study team will continuously collect step count, heart rate, and sleep data using activity monitors and patient-reported outcomes using the Way to Health (WTH) platform at two four-week intervals over eight months of follow-up. Mixed effects regression incorporating all available data points will be used for analysis.

DISCUSSION

The "Marching on for Veterans with Osteoarthritis of the Knee" (MOVE-OK) trial will take a pragmatic approach to evaluate (1) whether incentives based on behaviorally enhanced gamification can improve physical activity in this patient population and (2) whether corticosteroids injections reduce pain and disability in patients with KOA. Results of this trial will help to direct clinical practice and inform management guidelines.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05035810 . Registered on 5 September 2021.

Correlates of physical activity in adults with spondyloarthritis and rheumatoid arthritis: a systematic review

Physical activity (PA) is a primary non-pharmacological treatment option for those living with rheumatoid arthritis (RA) and spondyloarthritis (SpA). The aim of this systematic literature review was to summarize and present an updated synthesis of the factors associated with PA in the RA and SpA populations. A tailored search of PubMed (inc. Medline), Web of Science, Embase, APA PsycNET, and Scopus was conducted for research published between 2004 and June 2019. Methodological quality was assessed using The National Institutes of Health (NIH) Quality Assessment Tools for Observational Cohort and Cross-sectional Studies, Case–Control Studies, and Controlled Intervention Studies. Forty RA and eleven SpA articles met the inclusion criteria. Methodological quality was generally fair to good, with two RA studies rated as poor. Correlates are discussed in the sociodemographic, physical, psychological, social, and environmental categories. Environmental factors were not measured in any RA study. In individuals living with RA, consistent positive associations were found between PA and high-density lipoprotein, self-efficacy, and motivation. Consistent negative associations were found for functional disability and fatigue. In individuals with SpA, consistent positive associations were found between PA and quality of life, and consistent negative associations with functional disability. Physical and psychological factors are most consistently related with PA parameters in those living with RA and SpA. Many variables were inconsistently studied and showed indeterminant associations. Studies with prospective designs are needed to further understand the factors associated with PA in these populations, especially in those living with SpA.

Quality of life and life-space mobility after total knee arthroplasty in patients with rheumatoid arthritis: a pilot case-controlled study

[Purpose] The purpose of this study was to identify factors inhibiting improvement in the quality of life after total knee arthroplasty in patients with rheumatoid arthritis. [Participants and Methods] This was a pilot case-control study. The sample comprised of five participants with rheumatoid arthritis and 11 participants with osteoarthritis, who underwent total knee arthroplasty. We compared the groups in terms of physical function, walking ability, Japanese Knee Osteoarthritis Measure, and Life-Space Assessment. Measurements were taken before surgery and at four weeks and five months post-surgery. All patients underwent rehabilitation for five months postoperatively, first as inpatients, and then as outpatients after discharge. [Results] In the period from 4 weeks to 5 months post-surgery, physical function improved similarly in both groups in terms of muscle strength and walking ability. Despite the patients with rheumatoid arthritis being younger, their self-health assessment score by the Japanese Knee Osteoarthritis Measure and measures of life-space mobility by Life-Space Assessment were lower. [Conclusion] It is important to consider exercise therapy, and gait instruction to alleviate anxiety about health status and improve the quality of life and life-space mobility in patients with rheumatoid arthritis who undergo total knee arthroplasty.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Evaluation of Optical and Radar Based Motion Capturing Technologies for Characterizing Hand Movement in Rheumatoid Arthritis-A Pilot Study

In light of the state-of-the-art treatment options for patients with rheumatoid arthritis (RA), a detailed and early quantification and detection of impaired hand function is desirable to allow personalized treatment regiments and amend currently used subjective patient reported outcome measures. This is the motivation to apply and adapt modern measurement technologies to quantify, assess and analyze human hand movement using a marker-based optoelectronic measurement system (OMS), which has been widely used to measure human motion. We complement these recordings with data from markerless (Doppler radar) sensors and data from both sensor technologies are integrated with clinical outcomes of hand function. The technologies are leveraged to identify hand movement characteristics in RA affected patients in comparison to healthy control subjects, while performing functional tests, such as the Moberg-Picking-Up Test. The results presented discuss the experimental framework and present the limiting factors imposed by the use of marker-based measurements on hand function. The comparison of simple finger motion data, collected by the OMS, to data recorded by a simple continuous wave radar suggests that radar is a promising option for the objective assessment of hand function. Overall, the broad scope of integrating two measurement technologies with traditional clinical tests shows promising potential for developing new pathways in understanding of the role of functional outcomes for the RA pathology.

Effects of Aerobic and Resistance Exercise in Older Adults With Rheumatoid Arthritis: A Randomized Controlled Trial

OBJECTIVE

To evaluate the effect of a moderate-to-high-intensity, aerobic and resistance exercise with person-centered guidance in older adults with rheumatoid arthritis (RA), through a randomized controlled multicenter trial.

METHODS

Older adults (ages 65-75 years) with RA (n = 74) were randomized to either a 20-week exercise intervention at a gym (n = 36) or to home-based exercise of light intensity (n = 38). Assessments were performed at baseline, at 20 weeks, and at 12 months. The primary outcome was the difference in the Health Assessment Questionnaire disability index (HAQ DI) score, and the secondary outcomes were the differences in physical fitness assessed by a cardiopulmonary exercise test, an endurance test, the timed up and go test, the sit to stand test, and an isometric elbow flexion force measurement.

RESULTS

No significant differences between the groups were found for the primary outcome, HAQ DI score. Within the intervention group there was a significant improvement in the HAQ DI score when compared to baseline (P = 0.022). Aerobic capacity (P < 0.001) and 3 of 4 additional performance-based tests of endurance and strength significantly improved (P < 0.05) in the intervention group when compared to the control group. In the intervention group, 71% of patients rated their health as much or very much improved compared to 24% of patients in the control group (P < 0.001). At the 12-month follow-up, there were no significant differences in change between the 2 groups on the HAQ DI score. A significant between-group difference was found for change in an endurance test (P = 0.022).

CONCLUSION

Aerobic and resistance exercise with person-centered guidance improved physical fitness in terms of aerobic capacity, endurance, and strength in older adults with RA.

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

Objective:

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

Methods:

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

Results:

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

Conclusion:

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

Challenges in the treatment of Rheumatoid Arthritis

Rheumatoid Arthritis (RA) is a chronic inflammatory disease characterized by a heterogeneous clinical response to the different treatments. Some patients are difficult to treat and do not reach the treatment targets as clinical remission or low disease activity. Known negative prognostic factors, such as the presence of auto-antiantibodies and joint erosion, the presence of a genetic profile, comorbidities and extra-articular manifestations, pregnancy or a pregnancy wish may concur to the treatment failure. In this review we aimed at identify difficult to treat RA patients and define the optimal therapeutic and environmental targets. Genetic markers of severity such as HLA-DRB1, TRAF1, PSORS1C1 and microRNA 146a are differently associated with joint damage; other gene polymorphisms seem to be associated with response to biologic disease modifying anti-rheumatic drugs (bDMARDs). The presence of comorbidities and/or extra-articular manifestations may influence the therapeutic choice; overweight and obese patients are less responsive to TNF inhibitors. In this context the patient profiling can improve the clinical outcome. Targeting different pathways, molecules, and cells involved in the pathogenesis of RA may in part justify the lack response of some patients. An overview of the future therapeutic targets, including bDMARDs (inhibitors of IL-6, GM-CSF, matrix metalloproteinases, chemokines) and targeted synthetic DMARDs (filgotinib, ABT-494, pefacitinib, decernotinib), and environmental targets is addressed. Environmental factors, such as diet and cigarette smoke, may influence susceptibility to autoimmune diseases and interfere with inflammatory pathways. Mediterranean diet, low salt intake, cocoa, curcumin, and physical activity seem to show beneficial effects, however studies of dose finding, safety and efficacy in RA need to be performed.

Sedentary behaviour in rheumatoid arthritis: definition, measurement and implications for health

RA is a chronic autoimmune disease characterized by high grade-inflammation, and associated with elevated cardiovascular risk, rheumatoid-cachexia and functional impairment. Sedentary behaviour (SB) is linked to heightened inflammation, and is highly pervasive in RA, likely as a result of compromised physical function and persistent fatigue. This high sedentarity may exacerbate the inflammatory process in RA, and hold relevance for disease-related outcomes. The aim of this narrative review is to provide an overview of the definition, measurement and health relevance of SB in the context of RA. Contradictions are highlighted with regard to the manner in which SB is operationalized, and the significance of SB for disease outcomes in RA is outlined. The advantages and disadvantages of SB measurement approaches are also discussed. Against this background, we summarize studies that have reported SB and its health correlates in RA, and propose directions for future research.

Validity of the Nurses' health study physical activity questionnaire in estimating physical activity in adults with rheumatoid arthritis

Background

Patients with rheumatoid arthritis (RA) demonstrate reduced aerobic capacity, excess cardiovascular risk, mobility limitations and are less physically active than their healthy peers. Physical activity may decrease RA disease activity through its anti-inflammatory effects and psychological and health benefits. To successfully manage RA symptoms and reduce cardiovascular risks associated with RA through increased physical activity (PA), accurate physical activity assessments are critical. Accelerometry is an objective physical activity measure, but not widely used. Validity of the Nurses’ Health Study physical activity questionnaire II (NHSPAQ) has not been determined for estimation of physical activity in RA. This study examined NHSPAQ validity in adults with RA compared to accelerometry-based metabolic equivalents determined (METs) and results of performance tests. We hypothesized NHSPAQ scores would correlate moderately (0.4–0.5) with accelerometer physical activity estimates.

Methods

Thirty-five adults with RA (mean age [SD] 62 (Williams et. al, Health Qual Life Outcomes10:28, 2012) years, 28 females (80%) recruited from a hospital-based clinic registry participated in a one-week accelerometry trial. Medical data was compiled. Participants completed the NHSPAQ, a self-paced 20-m walk test, and modified timed step test. Participants wore an accelerometer for 7 consecutive days, then completed a physical activity log and another NHSPAQ. Metabolic equivalents (METs) were derived from NHSPAQ and accelerometers using standardized formulas. NHSPAQ METs were correlated with accelerometer METs and data from performance measures.

Results

Average disease duration was 21 years (SD = 11), 63% patients took biologics. The average weekly METs reported were 29 (SD = 33) and accelerometer METs were 33 (SD = 22). NHSPAQ METs correlated moderately with accelerometer-derived METs (r = 0.48 95% CI (0.15–0.70). Self-reported PA correlated moderately with Step Test performance (r = 0.50 95% CI (0.18–0.72).

Conclusion

Patients with RA exhibit low physical activity levels. General fitness measures were moderately correlated with physical activity levels. A moderate significant correlation existed between NHSPAQ and accelerometry METs. These preliminary data suggest the NHSPAQ may be useful to describe physical activity levels in this population.

Patients' conceptions of their own influence on good treatment response to biological therapy in chronic inflammatory arthritis

BACKGROUND

Biological therapies are common in the treatment of patients with chronic inflammatory arthritis (CIA). However, despite the fact that many patients respond well to their biological therapies, there are still a number of nonresponders. In order to design the best care for patients, it is important to understand how they conceive their own role in their treatment response.

OBJECTIVE

To explore how patients with CIA conceive their own influence on a good treatment response to biological therapy.

METHODS

This study had an exploratory and descriptive design with a phenomenographic approach. Interviews were conducted with 25 patients (11 women and 14 men) aged 17-79 years, with CIA who were undergoing biological therapy and who had low disease activity or were in remission.

RESULTS

Patients with CIA undergoing biological therapy conceived their own influence on good treatment response in terms of adherence, physical activity, mental attitude, social support, and self-awareness. Adherence was described as the foundation for the patients' own influence on good treatment response. Physical activity, mental attitude, and social support reflected three essential ways of understanding patients' influence on good treatment response where the patients spoke about physical strength, mental strength, and social strength. Self-awareness reflected a comprehensive way of influencing good treatment response in which patients balanced their physical, mental, and social resources in partnership with health care professionals.

CONCLUSION

Patients conceived that they had a responsibility for adhering to the treatment as well as achieving balance in life in order to ensure good treatment response. Self-awareness was essential for maintaining a good treatment response, and this reflected the patients' awareness of the complexity of living their lives with a chronic illness.

Impact of a multidisciplinary approach in enteropathic spondyloarthritis patients

Spondyloarthritis (SpA) and inflammatory bowel disease (IBD) are chronic autoinflammatory diseases that partially share the genetic predisposition and the unchecked inflammatory response linking the gut to the joints. The coexistence of both conditions in patients and the increased cross-risk ratios between SpA and IBD strongly suggest a shared pathophysiology. The prevalence of Enteropathic-related Spondyloarthritis (ESpA) in IBD patients shows a wide variation and may be underestimated. It is well accepted that the management of joint pain requires rheumatological expertise in conjunction with gastroenterologist assessment. In this view, we aimed at assessing, in a prospective study performed in a combined Gastro-Intestinal and Rheumatologic "GI-Rhe" clinic: (1) the prevalence of ESpA and other rheumatologic diseases in IBD patients with joint pain; (2) the features of the ESpA population; and (3) the diagnostic delay and the potential impact of the combined assessment. From November 2012 to December 2014, IBD patients with joint pain referring to a dedicated rheumatologist by the IBD-dedicated gastroenterologist were enrolled. Clinical and biochemical evaluations, joint involvement and disease activity assessment, diagnostic delay, and treatment were recorded. IBD patients (n=269) with joint pain were jointly assessed in the "GI-Rhe" Unit. A diagnosis of ESpA was made in 50.5% of IBD patients with joint pain. ESpA patients showed a peripheral involvement in 53% of cases, axial in 20.6% and peripheral and axial in 26.4% of cases. ESpA patients had a higher prevalence of other autoimmune extra-intestinal manifestations and received more anti-TNF treatment compared with IBD patients. A mean diagnostic delay of 5.2 years was revealed in ESpA patients. Patients with joint disease onset in the 2002-2012 decade had reduced diagnostic delay compared with those with onset in the 1980-1990 and 1991-2001 decades. Diagnostic delay was further reduced for patients with joint onset in the last two years in conjunction with the establishment of the GI-Rhe clinic. Multidisciplinary approach improved management of rheumatic disorders in IBD patients allowing a more comprehensive care.

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.